VA Clinical Ladder

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by PMFB-RN PMFB-RN, RN Member Nurse

Specializes in burn ICU, SICU, ER, Trauma Rapid Response. Has 16 years experience.

After years working in military and private hospitals ICU, ER & transport I have recently been hired as the Rapid Response nurse for a large VA hospital (well large by VA standards, it's actually quite small, like 275 beds). I was shocked when we went through the orientation class on the VA clinical ladder. They have Nurse I, level I, II & II, Nurse II, Nurse III, & Nurse IV. Nurse IV is for like the head nurse in a hospital. Nurse III is supposed to be for managers and others who have created a "change in practice", for example the RN who started the PICC team is a Nurse III. Nurse II is SUPPOSED to be a unit level competent RN who can care for any of the patient types in that unit, serve as charge and orientate new nurses.

What was shocking to me is that to move up through the levels depends on your nursing degree and projects you do. Like in services for skin care committee etc. No place in the promotion scheme is weather you are a good nurse taken into account.

We all work with those nurses who we know are not very good, the kind you hate to follow because the rooms are a mess, the patients haven't been given their PRNs for pain or hypertension or whatever, the patients say things to you like "I haven't seen my nurse in hours", or "your the first one to do that today" when you listen to heart and lung sounds during your normal assessments.

In the VA those nurses are on exactly equal foot for promotion to Nurse II as the awesome RN whose patients are always well cared for. In the nurse performance evaluation there isn't even a place to take high quality nursing into account. As I have worked in the hospital and responded to Rapid Response calls it is very noticeable who is on top of things and whose patients are getting great nursing care and whose are not. However it is impossible to tell weather the nurse is a Nurse I, Nurse II, or even Nurse III by he care they are providing for their patients.

This is exactly the opposite of every hospital I have ever worked in. Has anyone else noticed this in the VA or is my hospital unique?



Specializes in ICU, ER. 46 Posts

I just had this exact conversation with a nurse!! How funny.

You are correct; I feel your pain. You will find that the hospital is filled with Nurse IIIs who couldn't nurse their way out of a wet paper bag, let alone formulate a coherent sentence. But, even they are some of the sweetest people you will ever meet.

Unfortunately, you will not be informed of their rank. You will not be privy to the special secret rank system. But, we all know who they are.

At one time, in the early 2000's, my unit posted the vacation schedule that had the rank and step of the nurses. It was interesting that the performance did nor correlate with Rank/Step. That list quickly went away when someone realized they made the mistake

Good luck.



Has 1 years experience. 12 Posts

Actually you can find out their rank and salary. It's public information, part of what alot of government agency are calling "transparency". I can't recall the actual site, but just google "federal employee salaries" . It's there..



5 Posts

I have certainly noticed the same at my facility, and we have a few very questionable nurses that will probably hob-nob with the right people and work their way up the ladder. I have a MSN and run the wound/ostomy program for the entire facility and am still fighting my way up the ladder. There is no easy formula. But the benefits are great!

deliverator, MSN, RN, NP

Specializes in Family medicine, Cardiology, Spinal Cord Injury. Has 13 years experience. 111 Posts

Hopefully to revive a long silent topic and with the same issues on promotion for nurses in the Dept of Veterans Affairs.

I've worked at the Long Beach VA since July of 2011. While there, I've gotten my BSN, and now I'm currently working on my MSN and FNP. Before starting at the VA, I've had experience working as a telemetry nurse for 2 years. I'm a hard worker and the patients and my coworkers attest to that. However, several nurses that I started with, who were fresh out of BSN nursing school with no experience, are now Nurse IIs and Nurse IIIs. We have Nurse IIs with two year degrees as well.

What my nurse manager, who has no clue how to be a nurse manager, keeps telling me is that I have to come up with some BS performance improvement project for the ward, that has to have measurable outcomes (percentage change), and is evidenced based. And then, I have to write my own performance evaluation, and I write it honestly (which doesn't get you promoted). And then, once a year, my evaluation goes before some stupid board that decides whether you move up a grade, or stay at your current grade. It seems to me, providing the best patient care isn't rewarded. Only those who spend time working on projects ( which tend to be the younger, single people without kids), or who are all buddy buddy with the nurse managers, are the ones that get promoted. I've noticed that a lot of PI projects are just rehashes of previous PIs that were done.

I'm kind of fed up with working at the VA, even if it is guaranteed employment for life. The work culture is stagnant and promotions are based more on favoritism than on hard work. As what was posted in the OP posts.

I bet that when finish my MSN and get my FNP license, I still won't be considered for Nurse II. And according to HR, the VA won't hire NPs without at least 1 years experience. And even if I do work part time for a year as an NP and apply for the job, I will be brought on as a NP at the Nurse I level since I haven't been boarded for Nurse II. NPs that come from external applications are hired on a Nurse IIIs.

Ok, I'm done with my rant. I have midterms for my MSN coming up this weekend I need to be studying for.


jeckrn, BSN, RN

Specializes in EMT, ER, Homehealth, OR. Has 17 years experience. 1,868 Posts

You will find this in many civilian facilities also. Remember the saying when it comes to healthcare, those who can will, and those who can't teach/lead.


CraigB-RN, MSN, RN

Specializes in Critical Care, Emergency, Education, Informatics. Has 40 years experience. 1,224 Posts

You'll find that in many facilities both civilian and VA, just doing your job well isn't a criteria for a clinical ladder. For each level there is well spelled out criteria. Where the system fails is your pretty much responsible for documenting that your meeting those criteria.

A clinical ladder is just that, a ladder to advancement that benefits the organization. Clinical ladders are designed to recognize the people who are working above and beyond their day to day job.

Level 2 is doing something for the unit

Level 3 is for the hospital

The other levels are for the region and the VA itself. That being said the 4 and 5 aren't permanent

Now there are ways to get credit for being good at your job, but they generally involve sharing your skills and knowledge. Find the experts in your facility who will be willing to help you with these the performance appraisals.



370 Posts

Do you have a union? I don't know if all VAs have one. If so, contact your rep and ask for assistance. Some managers are great at helping get things done for proficiencies and giving you time for it. Others are clueless. You can also contact the head of the board that denied you the promotions and ask for clarification and reasons for the denial. You can also appeal the decision. I feel your frustration.


Specializes in Primary Care; Child Advocacy; Child Abuse; ED. Has 24 years experience. 526 Posts

You have to be in the right department within the VA. I had the struggle getting into the VA but was offered a temporary position. So the DON hired me into his new float team and told me that I could go into another position once the manager and myself agreed. I worked hard and kept my ear to the ground trying to get into a department where people were happy and I also had an opportunity for advancement. The dept that I worked in majority of the time left little room for advancement but others told me to come to pact. So I asked questions to the nurses there and their manager gives opportunity for advancement. So that is where I went. They are giving me opportunities to do things that the board wants to see. I guess in May I will see if this pays off [emoji4][emoji40]🤔



54 Posts

the Nursing Professional Standards Boards at each hospital aren't a make or break for promotion, you appeal back to them and then you appeal to VACO and the National board looks at your write up. I agree with having union help. there is also an intranet site for NPSB and VACO nursing that have samples and what the board looks at for promotion.



Has 5 years experience. 6 Posts

I just graduated with a Doctorate in pharmacy PharmD, RnBSN, BSc {Finnace} with 5yrs nursing experience, worked part time whilst in pharmacy school from Hospital to LTC and Homehealth with dialysis ,just got hired as a VA Nurse Manager.Still to take the pharmacy board .I am writing to find out what should be the minimum Nurse level acceptable and if my Doctorate degree in pharmacy PharmD can serve as a doctorate in a health related field .I also need some advice on the Nurse process standard write up paper



Has 6 years experience. 96 Posts

I just graduated with a Doctorate in pharmacy PharmD, RnBSN, BSc {Finnace} with 5yrs nursing experience, worked part time whilst in pharmacy school from Hospital to LTC and Homehealth with dialysis ,just got hired as a VA Nurse Manager.Still to take the pharmacy board .I am writing to find out what should be the minimum Nurse level acceptable and if my Doctorate degree in pharmacy PharmD can serve as a doctorate in a health related field .I also need some advice on the Nurse process standard write up paper

Why not be a clinical pharmacist? The VA has a great residency program for PharmDs. In hindsight, I wish I'd done that, lol.