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  1. O'Hara, Nancy F. RN
  2. Duvanich, Mary MSN, RN
  3. Foss, Julie MSN, RN
  4. Wells, Nancy DNSc, RN


Developing a performance-based advancement system requires evaluation tools that capture essential behaviors and outcomes reflective of key nursing functions. To ensure relevance to clinical practice and enhance buy-in from nursing staff, the behaviors and outcomes were defined by a broad cross-section of nursing staff and administrators. The first article (September 2003) in this 3-part series described the foundation for and the philosophical background of the Vanderbilt Professional Nursing Practice Program (VPNPP), the career advancement program under way at Vanderbilt University Medical Center. This second article describes the development of the evaluation tools used in the VPNPP, the implementation and management of this new system, program evaluation, and improvements since the inception of the program. Additionally, the authors present the challenges and lessons we learned in development and implementation of a dynamic evaluation system that supports our career advancement program. The process of advancing within the program will be described in part 3.


The Vanderbilt Professional Nursing Practice Program (VPNPP) is a 4-tiered performance-based career advancement system that recognizes and rewards the application of clinical nursing expertise in direct patient care. During the development of the program, it became clear to the steering committee that the nursing performance appraisal process needed to be refined to support the objectives of the advancement program. Concurrent with the development of this recognition and reward system for differentiated levels of practice for nurses through the VPNPP, Vanderbilt University Medical Center (VUMC) was developing a performance development system. In this system, each employee's annual pay increase was to be based on a pay-for-performance model.


It was imperative therefore that the evaluation tools created for VPNPP be aligned with the medical center's performance development initiative to integrate the advancement program with the basic structure of the organization. The outcome was an evaluation system that monitors practice over time by gathering qualitative and quantitative data from a variety of perspectives, differentiates performance at the 4 practice levels of nursing, and quantifies performance variation within each level.


There is much in the literature pertaining to the need for and benefit of evaluation systems. A system is essential to meet regulatory guidelines. More importantly, credible and objective evaluations assist in improving employee performance, aid in individual goal setting and increase staff satisfaction and retention. Ultimately, a focus on performance improvement can be expected to result in better patient care. The literature describes many of the challenges organizations have encountered in creating and sustaining successful performance appraisal systems. 1 Foremost among the issues the VPNPP steering committee set out to address were job descriptions that did not clearly define expected behavior and inadequate evaluation tools that resulted in subjective evaluations. Additionally, staff at VUMC had not historically received performance feedback in a consistent or timely manner.


Other healthcare organizations have been challenged with the same type of environment. One such example, Miami Valley Hospital, redesigned its nursing position description and successfully created a comprehensive, unit-specific assessment of performance. Although the performance appraisal system was in concert with the advancement program, it was separate and distinct from the advancement program. 2


At VUMC, we sought to integrate the performance appraisal system with our career advancement program so that the same data collection tools used to evaluate performance for annual review also would be used to assess at which level the nurse was practicing for advancement purposes. With the implementation of the VPNPP, we initiated a process of remarkable change in the culture of nursing within the organization. By defining 4 levels of practice, we recognized the variation in practice during professional development from novice to expert clinician, and reward accordingly. The novice can feel comforted by this acknowledgement at this stage in his or her development. Interest and motivation of VUMC nurses at all levels to achieve excellence within their practice area are increasing. Nurses who have advanced in the VPNPP have become the benchmarks of excellent clinical practice for their colleagues.