PROFESSIONAL ADVANCEMENT LADDER …libvolume7.xyz/.../professionaladvancementnotes2.pdfSAMPLE...

SAMPLE APPLICATION CN IV

PROFESSIONAL ADVANCEMENT LADDER

CLINICAL NURSE IV

APPLICATION PACKET

~*Please consult 'with your Nurse Director before beginning the Clinical ~adder process. **

You must meet the following requirements to be eligible to advance to anRN IV:

- A Bachelor's of Science in Nursing degree or ~e matriculated in a BSN program and be actively pursuing a BSN degree

and

- A national certification in an area of nursing practice. Skill .. specific certifications such as ACLS, PALS, TNCC, NRP do not qualify.

N arne of applicant:

SAMPLE APPLICATION CN IV 2

CLINICAL LADDER APPLICATION PACKET

Clinical Nurse IV

1. DemographiclEmployment Data

Name:

Date of Hire:

Current Clinical Ladder Level:----":::::..-L-'---'-J-1-"""---"':J,-l--I-"'--"--'--~~17T.k..L....t._...------

Time in Current Specialty (Med-Surg, I CU, etc,): :2 -t- y,e til r:s C SA I't)t <\50 -abo Ve.) Identify 2 peers (at least one from your unit) who wish to recommend you for advancement:

Please use the attached forms for your Nurse Director and Peer Recommendations. Attach this form with the type written recommendations to your application packet.


MID COAST HOSPITAL

PROFESSIONAL ADVANCEMENT

PEERINURSE DIRECTOR RECOMMENDATION FORM

Part I. Recommendation

I, ~ \-{lflM (Prin your name)

, being an RN employed

with Mid Coast Hospital in good standing, hereby recommend

vOUJrJl)e(~r'S name)

of Clinical Nurse'J"

Part II. Support for Recommendation

----, for advancement to the position

Please describe the reason for your recommendation for promotion by describing' the applicant's practice in the three broad categories: Clinical Nursing Practice/Caring, Leadership and Management, and Professionalism, Growth and Development. It is requested that you type your recommendation: Be specific and feel free to add any additional information that may help the committee with this decision. .

(Please attach your typed recommendation.)

.. ,",

3


To Whom It May Concern,

I am hereby recommending _ •••• _._.-1 for advancement to Clinical Nurse IV.

_ has only been an RN at Mid Coast Hospital for 3 years and has already made quite the impression

on her patients and co-workers .... graduated with her BSN and is a Certified Medical/Surgical Nurse

through the Academy of Medical-Surgical Nurses. _s an active participant in various committees throughout our organization. These include our

4

department specific Professional Practice Councils where she is the co-chair of the Performance I

Improvement Council and the Fall Prevention sub-committee. She has helped initiate our bedside () ;( .

. ~!f p~y participating In a site visit to Lehigh Medical Center in Pennsylvania as-well as ~ / attending the ANCC Magnet Conference in 2012 where she gleaned a great deal of knowledge

surrounding this subject. Lynne has also attended leadership workshops through Maine Health that

have allowed her to improve her skillset for improving performance and achieving outcomes for our

unit. .. has also helped coordinate multiple skill fairs during her tenure on Med-Surg .

.. is highly regarded by her co-workers as seen in her previous peer reviews. Words such as

IIcaring", IIcompasslonate", "goes the extra mile" just scratch the surface of the type or person and

professional Lynne truly is. Having shadowed her myself, "Is thorough, a great communicator, organized, and is the personification of what a Med-Surg nurse should be.

I hope the Professional Advancement Committee agrees with my recommendation of_or

advancement to Clinical Nurse IV. I can't think of anyone else who is more qualified than she. It has

been my honor writing this recommendation.

Sincerely,

Matthew Hincks RN, BSN, CEN

10/2/13


MID COAST HOSPITAL


PEER/NURSE DIRECTOR RECOMMENDATION FORM

Part I. Recommendation

I, -:--: ___ ---:-_____________ , being an RN employed (Print your name)

with Mid Coast Hospital in good standing, hereby recommend

______ , for advancement to the position

-JSC-. of Clinical Nurse-Ht.--

Part II. Support for Recommendation

Please describe the reason for your recommendation for promotion by describing the applicant's practice in the three broad categories: Clinical Nursing Practice/Caring, Leadership and Management, and Professionalism, Growth and Development. It is requested that you type your recommendation. Be specific and feel free to add any additional information that may help the committee with this decision.

Signed:_ Date: f I~J /1 J --------


5

SAMPLE APPLICATION CN IV (

Peer Recommendation for Clinical Nurse IV

for

I have known ince she arrived as a new grad, fresh out of

nursing school. I remember my very first impression of her, "This nurse is going

places." She very quickly earned my confidence in her knowledge and composure

and has never let me feel otherwise. I have teased ~hat I want to adopt

her, or have one of my daughters marry her brother so I can say I am related to

her, I suppose that's why I am asked to write this recommendation for her

advancement to Clinical Nurse IV.

I know of no other person more deserving, _s certainly the type of

professional we want to present as one of our best, top of the line clinical nurses.

~as the confidence needed to help her patient know that she can care for

him with confidence. I believe she is one of the top documentors on the Medical

Surgical unit. I have to audit charts monthly for Maine Health, and ~ documentation for not only clinical issues but her education documentation is

excellent. I know she is on many professional council teams, I hope she is

included on an education team as she leads by example and could help launch the

MCH education documentation grow to a very high standard.

I have also seen _ deal with difficult patient situations and

personalities with a good deal of skill, always maintaining her respect and

professional level for the patient and family. Even at her young age, she displays

mature skill that is often learned after years of experience. I think her main

approach is keeping the patient and family up to date, and keeping

communication ongoing throughout her day.

6

SAMP~E APPLICATION CN IV (

I truly feel that one day~ould make a great leader in a management

role at MCH, I believe her future is bright and we are lucky she landed here after

graduation.

IV

9-23-2013

7


MID COAST HOSPITAL


PEER/NURSE DIRECTOR RECOMMENDATION FORM

I, I~ ______ ' being an RN employed (Print your name)

with Mid Coast Hospital in good standing, hereby reconunend

(Print your name) -:tst'-.

of Clinical Nurse-Ht:-

Part II. Support for Reconunendation

______ , for advancement to the position

Please describe the reason for your reconunendation for promotion by describing the applicant's practice in the three broad categories: Clinical Nursing Practice/Caring, Leadership and Management, and Professionalism, Growth and Development. It is requested that you type your recommendation. Be specific and feel ft'ee to add any additional infonnation that may help the committee with this decision.

Signed: _____ Date: Pla-r/r3


8


Recommendation

Advancement to Clinical Nurse IV

I, would like to recommend for advancement to clinical nurse IV. Although _ has been a nurse for a relatively short period of time, she has shown clear signs of leader$hip and commitment to the nursing profession. I had the experience of orienting _when she was hired at Mid Coast Hospital and even as a new grad, these characteristics were ever present. She possesses a combination of confidence and interpersonal skills that enable her to communicate and collaborate with other members of the health care team with ease.

It has been a pleasure to observe _ professional growth over the past years. She has a

wonderful, positive attitude about her job and her peers. She is an exceptional support person and she

always works as a team member, helping others out when and where she can.

_ clinical skills are excellent, though she is always looking for ways to learn more, whether It be through seminars or through physicians and other staff members. She performs thorough, comprehensive assessments of her patients, Identifying their physical, emotional, and spiritual needs, as well as the needs of their significant others. She is respected by physicians and other members of the health care team for her knowledge, clinical practice and ability to utilize critical thinking when problem

solving. She is assertive and able to maximize positive outcomes when conflict develops. I am Impressed

by her calm, "can do" attitude. I believe this has helped her achieve the high level of practice she

demonstrates.

_ is actively involved on the unit level as well. She is co-chair of both the Performance

Improvement Committee and the Falls Prevention Committee, as well as a member of the Bedside

Handoff Committee. She also presented the CHF/MI education at the med/surg skills lab.

I believe I can speak for her peers when I say tha_ls a valued member of the Medical Surgical

team. I highly recommend her for advancement to Clinical Nurse IV.


II. Criteria Evaluation:

Under each'heading (Clinical Nursing Process/Caring, Leadership and Management, Professionalism, Growth and Development), please check those criteria you feel you meet at least 75%. In narrative form, explain how you meet the criteria of each section. Give specific examples, stories, etc. Your stories may d~monstrate a combination of criteria and should make it clear to the committee how you meet these criteria. Length of narrative may vary, so please,attach your ~ copy. Please be prepared to come to your interview ready to talk about your narrative and keep in mind other examples that you may want to talk about.

1) Leadership.

a) The RN provides leadership in the professional practice setting and the profession.

~ i) Recognized as a professional by colleagues as demonstrated by

competent clinical skill, effective interpersonal relationships and positive image with ]:>atients, families, and colleagues.

V- ii) Actively participates in unit activities, teams, or committees (e.g., PI teams, Professional Practice Councils).

V-iii) Is recognized as a professional role model by members of the

health care team.

y/ iv) Presents one or more patient care conferences or unit-based educational programs per year.

V v) Actively participates on hospital committees, focus groups, or multidisciplinary teams.

V vi) Is a member of a local, state, or national professional nursing organization.

V vii) Recognized as a professional role model throughout the organization/community. Enhances the image of nursing.

viii) Presents one or more hospital-wide, local, state, national, or international nursing programs.

ix) Assumes a leadership role in hospital committees or actively V participates on community task forces and/or professional

organizations. x) Actively participates in professional organizations (nursing,

community, or healthcare). May be recognized as a resource within one's professional organization by serving as officer, committee chair or co-chair, or actively taking on a proj ect for the organization.

b) Research. The RN integrates research findings into practice.

V- i) Familiarizes self with sources of nursing research available.

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V ii) Assists with PI data collection on unit. V- iii) Demonstrates awareness of research projects on unit.

iv) Incorporates research specific to specialty into clinical practice. v) Problem solves for practice issues on unit by researching best

V available evidence, developing clinical questions, or research project design.

!/" vi) Coordinates data collection. vii) Serves as hospital resource for research issues. viii) Conducts and publishes or presents nursing research in

conjunction with the hospital liaison nurse researcher or other recognized research specialist. .

2) Teamwork

a) Communication and collaboration in direct patient care.

V- i) Collaborates and communicates with the patient, family members, and other health care team members to meet the patients/s needs.

V ii) Communication ensures -the continuity of care. V iii) Coordinates care delivery with outside agencies and providers. V iv) Includes time estimate for attainment of expected outcomes. V v) Troubleshoots problems with multidisciplinary care delivery.

V vi) Recognized as a resource for communication and collaboration of

care.

V vii) Integrates nursing and medical plan of care through anticipating and evaluating interventions and outcomes.

b) Collaboration. The RN collaborates with patient, family, and others in the conduct of nursing practice.

V i) Recognizes and understands the importance of involving patient,.

family and other healthcare providers in implementing patient plans.

V ii) Implements the discharge plan, involving patient, family and health care providers.

V iii) Collaborates with all members of the health care team for safe family-centered care.

V iv) Includes the patient/family in an individualized plan of care,

including expected outcomes, interventions and an awareness of patient priorities.

v) Formulates a comprehensive discharge plan involving patient, V family and health care providers. Considers available resources in

the facility and in the community.

V vi) Functions as a patient advocate as part of a multidisciplinary team.

V vii) Recognizes situations involving patient or family dissatisfaction or concern, and seeks solutions promptly.


V viii) Initiates involvement of the patient, family, an~ other healthcare _providers in the patient's plan of care.

'V ix) Serves as a patient advocate role model. V x) , Independently resolves patient or family complaints.

xi) Provides staffwith guidance in formulating a comprehensive

V discharge plan and secures the external resources necessary to meet discharge goals.

V xii) Is a role model and seen as a resource for collaboration in, complex and challenging patient care situations.

c) Communication and Collegiality. The RN interacts with and contributes to the professional development of peers and colleagues.

V i) Follows established communication, dress, and behavior guidelines.

ii) Addresses interpersonal conflicts directly with individuals

V involved, in a positive manner, utilizing supportive resources as necessary.

V iii) Functions as a team member by assisting colleagues.

V iv) Provides feedback to colleagues directly in a non-threatening relationship-preserving fashion.

v) Treats mistakes by self and others as opportunities for growth,

V thereby creating a culture in which feedback is not only safe, but expected.

~ vi) Assists the preceptor in the orientation of staff members. ,

~ vii) Sets a positive tone, even in challenging situations, by treating

others with caring and respect.

V viii) Independently communicates in a manner which permits and

resolves conflicts.

V ix) Actively promotes self-care, stress reduction, and personal balance within the unit.

V x) Demonstrates a willingness to be a team member and to work both collaboratively and inaependently.

xi) Designs and implements an individualized student or new employee orientation program.

V xii) Freely share'S clinical knowledge and skills with others in an approachable manner.

V xiii) As a resource person, assists colleagues in developing conflict' resolution and assertive communication skills.

. xiv) Recognized as a hospital resource for self care, stress reduction, centering, or other holistic self care practice.

V xv) Works to create and maintain heal thy work environments in local, regional, national, or international communities.

~ xvi) Role models highest level of professional conduct.

V xvii) Is sought out and recognized by colleagues as a role model for assisting staff to grow professionally.


xviii) Plans or conducts preceptor training. V xix) Develops mentoring relationships.

xx) Recognized as a positive, energetic, upbeat resource among

V colleagues, one who is solution-focused even under trying circumstances and who has a passion for excellent care.

V xxi) Recognized as a role model for providing and receiving direct

feedback to/from colleagues in a non-threatening, growth promoting manner.

V xxii) Unit or hospital resource in communication techniques or patient handoffs.

3) Attendance

V a) May be depended upon to work scheduled shifts. V b) Arrives to work on time.

4) Professional Nursing

a) Patient care:

V- i) Provides safe patient care according to established standards, policies and procedures.

V ii) Evaluates and communicates the appropriateness and

effectiveness of established standards, policies, and procedures.

V iii) Assists in the development of new patient care standards, policies,

and procedures in response to identified needs.

V iv) Recognized as a model of best practices; acts as a resource for peers and colleagues on best practice issues.

V v) Demonstrates advanced knowledge of therapeutic modalities and integrates this knowledge with advanced level of practice.

b) Education and self development. The RN attains knowledge and competency that reflects current nursing practice.

V i) Reads current nursing literature.

~ ii) Maintains professional records that provide evidence of'

competency and lifelong learning.

V- iii) Assumes responsibility for meeting educational needs including mandatory programs.

V iv) Obtains a minimum of 35 approved contact hours or a 3-credit hour professional development course per year.

V v) Reads current nursing literature and incorpor~tes this information

into clinical practice. /,---" vi) Reads and critiques articles from professional journals.

v--- vii) Attends conferences, workshops, seminars and shares new knowledge with colleagues.


viii) Critically analyzes research articles. Shares this information with colleagues through unit meetings, reading clubs, or other venue, and incorporates into clinical practice.

c) Professional Practice Evaluation. The RN evaluates one's own nursing practice in relation to professional practice standards and guidelines, relevant statutes, rules, and regulations.

1/" i) Recognizes own limitations and asks for assistance/direction from resource persQnipreceptor.

V ii) Evaluates areas of professional development needs and develops goals and a plan to meet them with the Nurse Director annually.

V- iii) Assumes responsibility for completion of CBO tool.

V-iv) Recognizes own limitations and asks for assistance/direction from

resource person. "

V-v) Serves as resource to eN I and II nurses, CNAs and ancillary staff

in routine clinical situations.

V vi) Develops a personal plan for professional improvement and advancement and is actively pursuing it .

V vii) . Independently analyzes developmental goals and o~t1ines a plan to meet these goals, with ongoing evaluation of progress.

V viii) Assists others to develop professionally. Is recognized as a unit or hospital resource on professional evaluatiol;1 and development.

V ix) Assumes accountability for own career through continuous self-evaluation and goal 'setting.

x) Advocates for and implements changes in clinical

V practice/standards of care based on knowledge gained through attending continuing education programs.

d) Ethics. The RN integrates ethical provisions in all areas of practiCe.

V i) Uses ANA's Code of Ethics for Nurses to guide practice.

V ii) Delivers care in a manner that preserves and protects patient autonomy, dignity, and rights.

V-iii) Maintains patient confidentiality within legal and regulatory

parameters. V iv) Reports illegal, incompetent, or im~aired practices.

V v) Recognizes ethical issues in clinical practice and seeks expert

consultation.

V vi) Underst~nds the role and scope of the Ethics Committee at Mid Coast Hospital.

'V-vii) Recognizes ethical dilemmas and helps to coordinate the

resolution process.

V viii) Takes the initiative to identify and resolve complex ethical

situation with a patient, colleague, or system, using hospital and/or community resources.


e) Participation in Shared Governance:

V i) Attends & participates in unit staff meetings. I

V ii) Knowledgeable of shared governance opportunities and responsibilities, both on the unit and-hospital-wide.

iii) Demonstrates support of the processes for shared governance and

V collective decision maldng, as well as the goals and decisions reached.

V iv) Provides positive feedback & constructive criticism through

appropriate channels and forums. V- v) Actively participates on a hospital or unit based team. ~ vi) Shares accountability for outcomes.

V vii) Serves as a resource person for program planning, development and evaluation.

V- viii) Assumes project or council leadership responsibility.

5) Care Delivery

a) Patient Safety :

i) Maintains safe and therapeutic patient care environment and V equipment which minimizes risk,.injury, error, infection, and

allows healing.

V ii) Uses best practices in communications in transferring or reporting

patient care, using SEAR and handoff communication.

V- iii) Demonstrates knowledge and skills in location, operation, care and trouble-shooting of unit equipment independently.

V-- iv) Serves as resource person to others for safe practices.

V v) Addresses "workarounds" in patient safety directly with nurse

involved; escalates issue as needed with director.

v-:-- vi) Makes safety practices a habit; adopts new safety initiatives as they are developed.

V vii) Consistently demonstrates compliance with safe practices without using workarounds.

V viii) Active in hospital- or unit"wide development, and teaching of safety practices'.

V-ix) Assists in the planning and implementation of guidelines to meet

hospital safety goals. V-- x) Models safe patient practices.

V xi) Recognized by others for expert knowledge of patient and staff safety. ,...--- xii) Assumes leadership role in one or more hospital safety goals.

b) Clinical Assessment: The RN collects comprehensive data pertinent to the patient's health or situation, cultural or spiritual needs.


V i) Perfonns and documents systematic assessments according to established criteria.

V-ii) Recognizes and responds to abnonnal diagnostic data and reports

to appropriate provider.

~ iii) Identifies actual or potential emergency· s'ituations and intervenes

safely with assistance and/or supervision.

V iv) Perfonns comprehensive assessments of patient's needs from a

holistic perspective.

~ v) Anticipates problems and intervenes appropriately to

prevent/minimize impact.

V' vi) Responds to subtle shifts in patient data or status and collaborates

with appropriate provider.

V"' vii) Independently identifies an actual or potential emergency

situation and intervenes safely.

~ viii) Perfonns in-depth, discriminating assessments utilizing advanced

knowledge and skills.

V ix) In addition, detects subtle shifts in patient status andlor needs

often before the presence of objective measurable sign's

V x) Anticipates and proactively responds to subtle shifts in patient

status and collaborates with provider. xi) Demonstrates the ability to effectively handle actual or potential

V- emergency situations calmly and directs others in such situations; is a "go to" person for difficult and emergency situations.

c) Caring

t-----' i) Develops and maintains a professional and personable relationship with patients/families.

V-ii) Develops a relationship with the patient/family that facilitates

mutual involvement in the planning of care. iii) Demonstrates ability to spend time with patient ("presence self')

V which maximizes patient's involvement: strengthens and promotes positive outcomes.

d) Critical thinking

,.....-- i) Applies critical thinking skills as a routine part of practice. Examples include:

r.......- ii) Questioning appropriateness and effectiveness of treatment;

~ iii) Sca~ng each patient's care for incongruities, lapses, and missed

opportunities; v-' iv) Seeking alternative methods to reach outcomes.

V-- v) Is aresource for critical thinking skills and complex problem resolution.


e) Documentation:

V-- i) Documentation reflects adherence to hospital and legal requirements.

IV' ii) Documentation is concise, accurate, and complete. V- iii) Uses effective time management skills to chart in real time. Iv- iv) Documents response to treatments.

V v) Participates in development, evaluation, or improvement of

documentation tools. V vi) Is recogniied as a documentation resource.

f) Population Specific Competency: All standards of practice are based on individualized cultural, age appropriate, environmentally sensitive, and population-specific factors.

V i) Meets age- and population-specific mandatory education

competencies as d€?fined by the department specific scope of service.

V ii) Provides age appropriate care in a culturally and ethnically sensitive manner.

V-iii) Provides care to patients and families from all manner of diverse

backgrounds and presentations in a non-judgmental manner. -V- iv) Recognizes the patient and family as the center of care.

V v) Identifies age, cultural, or other population specific patient problems based on assessment findings.

V vi) Is accepting and tolerant of diffe~ences posed by patients and families.

v--- vii) Seeks resources torreconciling one's own personal issues and biases.

V-- viii) Actively researches and implements care plans for patients with population-specific care needs.

V- ix) Works collaboratively with patients and families of diverse backgrounds to develop plan of care.

x) Is recognized as a unit or hospital resource on issues of cultural diversity and population specific care.

6) Resources

a) Time Utilization:

V i) Sets priorities for nursing interventions based on individua,l needs and the needs ofthe caseload.

~ ii) Is able to accomplish patient care priorities in a timely way. V- iii) Is a resource and role model for effective time management.

b) Delegation and Resource Utilization. The RN considers factors related to


safety, effectiveness, cost, and impact on practice in the planning and delivery of nursing services.

V i) Knowledgeable about Maine nursing statutes regarding the conditions under which an RN may delegate.

Iv- ii) Demonstrates fiscal responsibility.

V iii) Effectively communicates expectations, delegates and supervises

activities of the CNA and Unit Secretary. v--- iv) Manages patient assignment with available resources.

v--- v) Demonstrates flexibility, an ability to adapt to changing workload related to patient census and acuity.

vi) Functions effectively when assigned as resource nurse. V- vii) Troubleshoots issues around delegation. ~ viii) Decisions reflect an awareness of resources and priorities.

V ix) Proactively responds to changing workload related to patient

census and acuity. x) Recognized as a hospital resource on delegation; actively teaches'

others. xi) Proposes practice changes that reduce utilization of resources and

enhance patient care. xii) Mentors others in resource nurse role.

xiii) Provides creative solutions in times of stress and transition that

IV-- positively influence the unit work environment. Demonstrates ability to direct others and minimize "team" anxiety.

7) Outcomes. The RN identifies expected outcomes for a plan individualized to the patient or situation.

a) Evaluation

V i) Evaluates patient care and effectiveness ofinterventions and revises the plan of care as needed.

V-ii) Assists with identification and resolution of unit- or hospital-wide

improvement opportunities.

V-iii) Assumes leadership role in analyzing and implementing solutions

to improvement opportunities.

b) Patient Teaching

V- i) Documents teaching and evaluation of patient/family understanding.

V- ii) Demonstrates awareness of unit teaching resources.

V iii) Assists the patient and family in becoming informed consumers

about treatment and care.

V-iv) Presents information clearly and uses appropriate methods with

the patient/family.


v V) Plans and implements patient/family teaching program to meet assessed learning needs.

vi) Demonstrates effective and creative patient teaching for patients

V-- with challenging learning needs, readiness, learning ability, language barriers, or cultural differences.

vii) Develops, researches, and integrates new patient teaching tools and practices.

V viii) Coaches others in documenting and evaluating patient/family teaching.

c) Quality of Practice. The RN systematically enhances the quality and effectiveness of nursing practice.

V-i) Identifies and reports to Unit Coordin~.tor/Nurse Director or

professional practice council issues which affect daily clinical practice.

V-ii) Demonstrates an awareness of unit quality monitors, including ,.

nursing sensitive indicators, and how the unit is performing relative to most current outcome data.

V- iii) Participates in data collection for patient outcome monitors. v----- iv) Is involved in resolution processes for practice issues on unit.

V v) Works closely with team to affect lUlit changes and promote

practice changes and quality outcomes. ~ vi) Participates on hospital or unit based quality teams or committees.

V vii) Coordinates data collection, analysis, and implementation of

practice changes. viii) Collaborates in the design and implementation of performance

V- improvement indicators to advance the professional standards and practices.

V-ix) Implements nursing interventions based on advanced theoretical , knowledge scientific rationale and professional experience.

J,..-- x) Uses creativity and innovation to improve patient care delivery,


Please attach your !Y.:I!!:!! narrative explaining specifically how you meet the above checked criteria.

Feel free to add any additional information and/or documentation you feel would help this committee make this decision.

'-" ,

20

SAMP_ APPLICATION eN IV I

Xii 22 i 2 ii! _iitii21li! ad £in (

- 1 -

21

Running Head: NARRATIVE FOR CLINICAL NURSE IV APPLICATION

Narrative for Clinical NUl'se IV Application

Mid Coast Hospital

APPLICATION CN IV (

~ 2 ~

In October 2012 I advanced to Clinical Nurse III at a time in which I felt my

professional nursing career was beginning to form an identity. Since then, over the past

12 months, I have continued my journey towards professional advancement through a

variety of endeavors in the workplace and community. The following narrative will

include details of the activities that have advanced my practice from that of a Clinical

Nurse III to a Clinical Nurse IV over the past year. Additional exemplar dating back

before October 2012 can be found in my prior application for Clinical Nurse III as

many of those experiences still hold value to support achievement of the following

evaluation criteria.

Leadership

Leadership in the Professional Practice Setting and the Profession

My leadership characteristics have been recognized by many of my peers over

the past several years, dating back before the start of my professional career. While I do

not purposely set out on endeavors to serve as an appointed leader, I often find that my

passion and involvement leads me to that of a leadership role. Since advancing to

Clinical Nurse III in October 2012, my leadership experiences have continued to

advance. Over the past year I have served as an active member of the Medical Surgical

Bedside Handoff Council; co~chair of the Medical/Surgical Performance Improvement

Council; co~chair of the Medical/Surgical Fall Prevention Council; intermittent member

of the Magnet Champions Committee; and most recently a member of the Braun PCA

Advisory Council. Additionally, I served as a presenter at the 2013 Medical/Surgical

Skills Fair with a focus on care of patients with Acute Coronary Syndrome and

Congestive Heart Failure. As a member of the Medical/Surgical Bedside Handoff

Council I also traveled to Lehigh Valley Medical Center in Allentown, Pennsylvania, to

network with fellow Magnet nurses and witness an excellent performance of bedside

22

SAMP4E APPLICATION CN IV I

hand off report, I also had the opportunity to role play in our bedside handoff

educational videos, and served as the presenter for all mandatory education classes

prior to 'going-live' with the bedside handoff practice change,

- 3 -

Beyond my active involvement in professional practice as an employee at Mid

Coast Hospital, I have sought to challenge my own personal professional development.

In February 2013 I became a member of the Academy of Medical-Surgical Nurses

(AMSN), Subsequently, in April 2013, I earned the credentials of a Certified Medica1-

Surgical Registered Nurse (CMSRN) through the Medical-Surgical Nursing

Certification Board (MSNCB), Since obtaining certification, I have sought to serve as a

resource for peers who are seeking the same professional challenge by offering support

and study materials, Numerous colleagues have since voiced interest in obtaining their

specialty certification,

Over the past year I have had the fortunate opportunity to share my story and

past experiences that have fueled my passion for nursing excellence as I proudly

celebrate the Magnet Achievement of Mid Coast Hospital. After traveling to the ANCC

National Magnet Conference in Los Angeles, California in October 2012, I was asked to

share my insight on the Magnet Achievement at our monthly medical/surgical staff

meeting, and was also invited to speak at the annual Mid Coast Hospital Nurses' Day

Celebration, Lastly, the highlight achievement over the past year that epitomized my

recognition as a professiona11eader throughout our organization and community was

being asked by Deb Macleod, Chief Nursing Officer, to participate in the production of

Mid Coast Hospital's latest video advertisement, titled "Our Community, Our Health,"

Research

Over the past year I have utilized nursing research for a variety of situations, On

a personal accord I try to stay up-to-date on the latest nursing literature through my

23

(

11 -4-

monthly sUbscriptions to "MBDSURG Nursing" and "JONA" (The Journal of Nursing

Administl'ation). Additionally, Christina Stuntz, MLIS, the Health Sciences Librarian

can attest to the number of times I have used her as a valuable resource to access

nursing literature. A significant amount of literature review has occurred through my

committee work in an effort to determine best practice for nursing handoff report,

interventions to reduce patient falls, and guidelines for nursing pain assessments,

Christina also assisted me in collecting evidence based research for confirming

placement of a nasogastric tube, which stemmed from a patient care concern that I will

describe later in this narrative under the subject of 'Professional Nursing: Patient Care.'

The initial ground work performed by the Medical/Surgical Bedside Handoff

Council included data collection as our committee members conducted time studies to

evaluate the efficiency of our prior practice of 'silent nursing handoff report'. This data

serves as our benchmark to assure improvement, as we plan to conduct follow-up time

studies to evaluate the efficiency of our change in practice to that of bedside nursing

handoff report. Additionally, our council has utilized 'Survey Monkey' to poll the staff

after going live with bedside handoff to identify baniers and concerns regarding our

new practice technique. Lastly, as a member of the Medical/Surgical Performance

Improvement Committee I am well aware of our performance indicators and the

measures being taken to address deficiencies in nursing care since that is the primary

focus of our committee.

Teamwork

Communication and Collaboration in Direct Patient Care

One of the few pel'ks that have yet to deter me from my 3a-3p shift work is the

opportunity to serve as an integral part of the multidisciplinary collaboration that

occurs dul'ing the daytime hours. As the direct care nurse I often feel like I have an

24

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opportunity to serve as not only an advocate but a spokesperson for my patients in

consultation with various entities such as physical therapy, occupational therapy,

speech therapy, dietary, radiology, respiratory therapy, case management, medical

providers etc. Communication with all departments is essential to coordinating

efficient care that best serves the patients and families. I believe that any of my

colleagues would attest to my ability to collaborate and communicate with all members

of the healthcare team, including outside agencies in giving hand off report pl'ior to

patient transfers. Additionally, I support the value of including family members in the

plan of care to ensure the patient returns home with the proper knowledge and

understanding of their illness. One goal in the roll-out of bedside handoff report was to

encourage participation from family members, so they could anticipate a daily update at

change of shift if they so wished to be present.

Colla bora tion

The work I do each and everyday would not be possible without collaborating

with all members of the healthcare team. However, the most important collaboration

occurs with the patient and families as they are the key stakeholders in our mission. We

fail our patients when we do not include them in the plan of care and assist them to

understand the immediate and future implications of their illness. As a part of my daily

work flow, I ensure that each patient is updated on their plan of care for the day,

including tests, lab results, procedures etc. and document as such. I also strive to ensure

that patients receive appropriate education documents regarding their illness (I.e.

stroke, pneumonia, CHF, Coumadin education etc), and that patients are able to teach

back key safety points prior to discharge. At times I have even created personalized

discharge documents to facilitate strict adherence to the discharge instructions. In one

particular instance a provider requested that the patient check her blood glucose three

25

SAMP APPLICATION CN IV 26

- 6 -

times daily before meals for seven days following discharge and then report her glucose

levels to her Primary Care Provider for tailoring of her glycemic control. To ensure this

patient adhered to the discharge instructions, knowing that her glycemic control could

become a serious issue as her regimen had been adjusted while hospitalized, I took it

upon myself to make a simple excel spreadsheet with clear directions that would allow

her to record her mealtime glucose checks in one location, which could then be brought

to her follow-up appointment the next week. The patient was able to teach back the

importance of her glucose monitoring and how to properly record each glucose check,

in fact I believe she said "Oh, this is easy enough", ensuring the discharge instructions

were completed as directed.

There is great value in collaboration amongst all members of the healthcare

team, however, that does not go without saying that there is a time and place for each

conversation and that patient and family concerns must be prioritized. As the frontline

caregiver for each patient, I strive to serve as the greatest wealth of knowledge

regarding the plan of care by collecting a comprehensive shift report that includes

review of the patients Histol'y&Physical, physician progress notes, lab and radiology

results, and case management notes. The culmination of these facts allows me to engage

the patient in dialogue and assist them to understand the plan of care. This also allows

me to answer questions and concerns from patients and families to the best of my

ability, which often prevents interruptions for the rounding physicians and case

managers who have clearly documented the plan of care in their records. By serving as

a knowledgeable resource for patients I can maintain the efficiency of our rounding

process by minimizing interruptions in the ancillary workflow, which in turns allows

more time for each patient when the physicians and case managers are fully prese~t.

SAMP~E APPLICATION CN IV I --- -7 -

Communication and Collegiality

I have long valued the professional realm of nursing, and thus serve to hold

myself to high professional standards while in the workplace and/or when representing

Mid Coast Hospital in the community. On a few occasions since the start of my

professional career I have had to engage some of my peers in those unfortunate "crucial

conversations". I appreciate open dialogue and opportunities to discuss concerns with

peers in a non-threatening manner that often in fact leads to strengthening of our

relationship when a conversation is conducted in an appropriate manner. I think back to

a "crucial conversation" I had with a fellow colleague over a year ago regarding a

combined situation of a potentially fatal medication error with a peA that was

compounded by complete disrespectful attitude from that peer. After allowing myself

time to process the situation and attempt to understand her behavior, I sat down with

the peer to address my concerns, and our conversation quickly turned to an hour long

sharing of stories and experiences. Since then our relationship has almost blossomed

into that of a mentorship as I understand the struggles she faces as she adapts from a

novice nurse.

It was not long after I had begun my professional career that I had the

opportunity to begin precepting new graduate nurses. I enjoy the opportunities I have

had to not only orient new staff to our work environment, but also to continue thereafter

serving as a mentor to their practice. I believe my colleagues would consider me a very

approachable teammate who is always willing to offer assistance and serve as a

resource for collaboration on patient care concerns. My most recent annual evaluation

(June 2011) included the following comments from peers: "Amazing nurse and

functioning at a very high level for her years out of school"; "I see~ during shift

change asking other nurses if they need help"; "Quiet, friendly demeanor, works well

27

SAMPlE APPUCATION CN IV I

with all staff. _would be a good staff member to be developed for a leadership

- 8 -

position within the hospital"; "Has good working relationships with patients and staff in

other departments"; "Very eager to learn and receptive to suggestions"; '_is very

balanced. She is hardworking, conscientious, and a very educated nurse although she is

not too hard on herself and has a very balanced, calm personality. She could be having

the most stressful, awful day but you would never tell because she carries herself so

well. At the same time, she can easily ask for help when she needs it". Overall, I strive

to hold myself to high professional standards and serve as a resource and teammate to

my peers.

Attendance

My peers will attest to the fact that I always arrive on time to work, and stay

until my work is finished. The greatest feat in my attendance history is that in over

three years of employment at Mid Coast Hospital I have never missed a scheduled shift;

in fact, I joke that I would not know how to 'call-out' sick, as I have yet to do so in all

of my working career dating back to High Schoo1. I am also very flexible with my work

hours, and pick up extra shifts to cover holes in the schedule or come in on short notice

when called at home for additional coverage.

Professional Nursing

Patient Care

Any medical professional serves to provide safe patient care and practices in a

means to do no harm. I pride myself in providing such care and doing so to the highest

standard. All of my patients, regardless of external influences, deserve the same quality

of care day in and day out. My definition of a "bad day" at work is when time does not

allow me to provide equal quality of care to all of my assigned patients.

28

SAMP~E APPLICATION CN IV (

- 9 -

As a member of the Medical/Surgical Performance Improvement Council and

the Medical/Surgical Fall Prevention Council I have had the opportunity to review our

current policies and procedures regarding practices such as pain management and falls.

As a committee we are currently reviewing the policies and making adjustments based

on changes in our current practice. For example, chart reviews were conducted and

indicated that only 19% of nurses on the medical/surgical unit are appropriately

documenting a re-assessment of pain after an intervention has been performed. It is

apparent that a degree of this short-falling may be due to our means of documentation,

but it also triggered a review of our current policy. With this information we as a

committee are reviewing out definition of pain reassessment and time parameters as

stated in the policy to be congruent with out practice and in line with Joint Commission

Standards.

My involvement in professional practice has also played a significant role in the

development of our new standardized bedside handoff practice, and development of a

standardized post-fall assessment and huddle tool, which also serves to formulate a

root-cause analysis.

On occasion I have found myself in situations in which my knowledge of best

practice is not in line with any stated policy 01' procedure. This past winter I was caring

for a patient who had been previously hospitalized for treatment of pneumonia, then

sent to rehab and unfortunately readmitted shortly thereafter with rectal bleeding. Her

hemoglobin/hematocrit were stable, though her 01 bleed continued. Due to the recent

antibiotic treatment for pneumonia, the initial concern was for an infectious colitis such

as -c.diff. When the stool studies came back unremarkable, the gastroenterologist

indicated that he would like to perform an urgent colonoscopy. The patient was a frail

elderly lady whose nutritional intake had been poor for some time. She did not feel as

29

SAMPLf APPLICATION CN IV (

30

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though she could tolerate ingesting the golytely prep in order to proceed with the

colonoscopy. Therefore, the gastroenterologist in consultation with the hospitalist,

ordered placement of a nasogastric tube to be used to facilitate administration of the

golytely prep. The time constraints were challenging in that the decision to proceed

with the prep was made at approximately 1000 and the physician wanted to perform the

test at 1600 that same day. r quickly gathered my supplies, placed the NG tube, and

then stepped back for a moment and thought about the logistics of this plan. The

physician was essentially ordering the NG tube to hasten the administration of the

bowel prep, and while the patient was in agreement, r was concerned that regardless of

the NG tube the patient would not be able to tolerate the rate in which the physician

wanted me to instill the solution. Additionally, remembering back to my collegiate best

practice days, I remember that r had many discussions in the past about the evidence

that indicates NG tube placement should be confirmed via xray. I did not feel

comfortable proceeding with the administration of the golytely prep via NG tube

without precise confirmation of placement. After discussing my concern with the

resource nurse and other seasoned nurses on the floor, I was assured that aspiration and

auscultation of ail' were fine to confirm placement and that they had never heard of

using xray to confirm placement. However, r was not satisfied with their answers and

wanted more reassurance. Unfortunately, there was no policy on the matter either. Carol ~ o

~I enteral feedings and such. Fortunately, they provided the answer r was looking for and

Wark, the case manager for the patient that day overheard my concern and validated it

as such. She then proceeded to call rcu, where they more often use NG tubes for

indicated that based on AACN guidelines NG tube placement should be confirmed with

a portable xray. With this information, r subsequently called the provider, explained my

concerns and rational, and the xray was ordered, placement was confirmed, and r felt

comfortable proceeding with administration of the golytely prep. Unfortunately, there

SAMPY: APPLICATION CN IV ( --- - 11 -

were other issues with this situation that were of concern to me in hindsight. But from

this incident, _discussed the need for improved guidelines for practice, and

contacted Christina Stuntz to obtain literature supporting evidence based practice of

confirming NO tube placement prior to enteral administration. Since that time I had

discussed with our previous nurse manager, concerns regarding the

lack of specific policies and procedures that serve as evidence based guidelines for

care. One of the goals for the restructured Performance Improvement Council is to look

at our CUrl'ent practice and policies to evaluate the congruencies between literature that

legally supports the care in which we provide.

Education and Self Development

Over the past year I have strived to be more active in my personal pursuit of

new knowledge and staying current on evidence based practice, I routinely review my

monthly subscriptions to "MEDSURG Nursing" and "JONA" (Journal of Nursing

Administration). I have also completed critiques of two online seminars that were

presented at the 2012 Academy of Medical-Surgical Nurses (AMSN) Convention, titled

"Evidence-Based Nursing Management of Enteral Feeding" and "The Impact of

Nutritional Intake on Patient Outcomes". And most importantly, my involvement in

professional practice had led to numerous article reviews regarding best practice on

nursing handoff report, fall prevention, and pain assessments.

I have completed all mandatory education requirements annually since my start

of employment in 2010. Over the past 12 months I have earned ove!' 44 continuing

education hours, which included attendance at the ANCC National Magnet Conference;

two workshops offered by the MaineHealth Improvement Science Academy, titled

"Improving Healthcare: Achieving Outcomes that Matter" and "Coaching Teams to

Higher Performance"; and an event titled "Nursing 2013 & Beyond, Creating

31

SAMP4E APPLICATION CN IV 32 --- - 12-

Communitites of Care" sponsored by MaineHealth. These events were directly

correlated to knowledge sharing upon return to Mid Coast Hospital. In fact, it was

attendance at the ANCC National Magnet Conference that initiated our practice change

to that of bedside handoff report, and it was information obtained from the MaineHealth

Science Academy that reaffirmed the importance of developing a charter for each

professional practice council and guidelines for running effective meetings. I also had

the opportunity to attend the Transforming Care at the Bedside (TCAB) Celebration on

April 30, 2013 on behalf of the bedside handoff committee.

Professional Practice Evaluation

Each year my professional practice invol vement seemingly escalates to the

appropriate next step. I have also been successful in setting and achieving personal

professional goals. For example, over the past year I achieved my personal goals of

ad vancing to Clinical Nurse III after just over two years of practice; becoming certified

as a Medical-Surgical Registered Nurse; advancing in professional practice by serving

as the co-chair of the Medical/Surgical Performance Improvement Committee and Falls

Prevention Committee; teaching care of patients with Acute Coronary Syndrome and

Congestive Heart Failure at the 2013 Medical/Surgical Skills Fail'; and spearheading the

initiative to begin bedside handoff report in collaboration with

_after our return from the ANCC National Magnet Conference. And as stated

before, I have served as a resource for nurses interested in pursuing their

medical/surgical specialty certification by offering support and study materials. My --.-.~ .. -.. -.--

next milestones may include a goal to begin graduate classes to purs(aMasters De~re~

in Nursing, though I have not been able to narrow my interest and as~ns-te-a~ selected concentration.

- 13 -

Ethics

Ethics is a topic that impacts patient care on a routine basis and requires

understanding and adherence to Nursing Code of Ethics to ensure that personal biases

do not impede care. I was recently involved in a patient care scenario that led me to

address my ethical concerns with a higher chain of command as the situation was

intertwined at many levels. In this particular instance, a patient was admitted for

treatment of lower extremity cellulitis. During the course of his stay he received

diuresing treatment to reduce the lower extremity edema that was impairing the

resolution of his cellulitis and venous stasis wounds. Unfortunately, the diuretic therapy

subsequently triggered acute on chronic (stage IV) renal failure, which neared end-stage

failure as the patient waited for transfer to a medical facility that could provide

hemodialysis. I assumed care of this patient on a Thursday morning at 0300. At that

time his labs from the day prior indicated a creatinine of 8.0 and BUN 107 with an

upward trend. Arrangements had been made days prior for transfer to a higher level

medical center for dialysis, though the transfer was continually delayed for one reason

or another. Unfortunately, this patient succumbed to his illness and passed away that

morning at approximately 1025 under my care while still waiting for transfer to the

facility that could provide a higher level of treatment. In the days following this

incident I continually revisited the factors surrounding this situation and subsequently

felt compelled to voice my concerns on behalf of this now deceased patient and his

wife. After discussing matters with my nurse director, concerns were relayed to Barb

McCue, Director of Quality and Patient Safety, and arrangements are being made to

conduct a patient care conference with all direct care providers who were involved in

this case. As I discuss the topic of ethics, I must prohibit myself from including any

further written details of this patient care scenario, but would be willing to speak more

33

IV (

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to this story in person during the interview process to describe the ethical complexities

of this case. Another example of an ethical provision includes the story I previously

described regarding placement of the NO tube to facilitate a bowel prep for an urgent

colonoscopy. Again, I could speak more to the ethical concerns regarding this situation

in person during the interview process.

Participation in Shared Governance

At this point I feel this narrative has already highlighted nearly all my current

and most recent professional practice endeavors, both unit-specific and hospital-wide,

which demonstrates my commitment and understanding of the Shared Governance

model. As a strong proponent and supporter of the Magnet Achievement I understand

the value of shared governance, which empowers individuals at all levels to impact

change. Therefore, I not only strive to maintain my professional obligations, but I also

encourage others to serve as active members of professional practice. In addition, I

have consistently attended monthly staff meetings in accordance with our unit specific

requirements, during which time information regarding professional practice activities

are shared and discussed.

Care Delivery

Patient Safety

Patient safety is always of utmost importance. Information above has already

detailed my involvement in the promotion of safe patient care through professional

practice initiatives. In fact, the number one reason for implementing the change in

bedside handoff report was due to patient safety concerns. By changing our practice we

now have the opportunity to visualize all patients within the first 30 minutes of our

shift and ensure safety measures are in place from the moment we assume care (Le.

bed/chair alarms are on, suction is setup, pump settings are confirmed, IV sites are

34

SAMEir APp! 'FAII •• I\I.( ••••• • ii i .. 35

without sis of phlebitis etc). Since adopting the practice change of standardized beside

report, other departments have also followed suit. In fact, Eileen Delaney, Maternity

Director, expressed interest in implementing bedside handoff report on her unit and I

have discussed the idea of creating a standardized report sheet for nurses to give

handoff to skilled nursing facilities prior to transfer with

The operating room/PACU has also revised their purple handoff report sheets, which

reflect a similar format to that in which we are using on the medical/surgical unit.

Patient falls has also been at the forefront of my concern for patient safety with

the work being done on the Falls Prevention Council. As a committee we have worked

to develop and standardized post-fall assessment and huddle tools to ensure that every

patient fall receives the same degree of follow-up and investigation. Reviewing each

patient fall based on the standardized process will generate a root cause analysis to

determine the contributing factors, and thus guide our efforts for practice change.

Over the past year there have been concerns for compliance with documenting

and properly wasting controlled substances on the Medical/Surgical unit. This is not

only a serious patient safety concern, but also of concern for the licensure of individual

staff members. Part of the practice change for improving compliance with proper

documentation and wasting of controlled substances was to have the primary nurse

bring a witness to the pyxis station to perform an immediate waste upon removal of any

controlled substance. I have adhered to this practice change and have not faltered on the

wasting or documentation of any controlled substances since. In this practice change

alone, there are workarounds present that will still allow a nurse to remove the desired

medication without having an immediate waste. While this may be done due to time

constraints at the moment, it does not reinforce compliance with our standard of

SAMPL't APPLICATION CN IV I

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practice, and thus I force myself to conform to the change in practice knowing it is best

for not only my patients but for protection of my personal licensure.

Clinical Assessment

I believe the quality of my clinical assessment skills must first begin with

obtaining a comprehensive report on each patient to understand the multidisciplinary

approach to the plan of care. Understanding not only the physician's initial plan

communicated via the History&Physical, but also the daily updates detailed in the

physician's progress notes, as well as gathering data from case management and other

ancillary providers is imperative to establishing a solid foundation before proceeding

with carrying out the daily plan of care. Through my experiences I have learned, and

now teach to new nurses, that a tremendous strength in clinical practice is your ability

to recognize abnormal assessment findings. When orienting new graduate nurses I try to

reaffirm the notion that they are not expected have all the answers, but by trusting their

assessment skills and ability to recognize abnormal findings they will be able to

effectively communicate concerns to a provider who in turn will order the appropriate

workup or intervention. To this day, there are often situations in which I detect subtle

changes in assessment findings, and while I may have a suspicion as to what the

findings may indicate, I understand that my primary responsibility is to report the

abnormality to the provider so that further workup can be completed in a timely

manner. Detecting slight changes in a patient assessment not only leads to better

outcomes when early interventions are performed, but it is also important to be able to

communicate these findings in an SEAR format so that a provider, who may by chance

be outside of the hospital during the overnight hours, can comprehend the urgency of

the situation at hand. On a few occasions I have had patients rapidly decline less than

an hour into my shift, in the early morning hours, requiring urgent phone calls to

36

SAMP4E APPLICATION CN IV

providers who were not available to personally assess the patient at that time.

Fortunately, due to the background data collected via extensive research for each

patient combined with my physical assessment findings the provider appropl'iatel¥

intervened and/or appropriately transferred the patient to a higher level of care for

closer monitoring.

Caring

The thing I enjoy most about my job is the opportunity to interact with

individuals at a time of great need. Helping patients overcome some of their most

challenging days and see them return to their normal functioning self is most l'ewarding.

Occasionally, when patients feel well enough to recognize our efforts it makes

everything seem even that much better. On April 22, 2013 a patient wrote a letter of

recognition to the staff that cared for her while she was admitted and treated for

pneumonia. She wrote "To my direct caretakers;

you guys were amazing and down to earth, and just made my stay

easier. You all took great care of me. It takes a special person to work in such a

demanding line of work. I appreciate everything you did for me." I also cherish a card I

received from the daughter of a patient who passed away after a short battle with colon

caner. She wrote "Dear_ Thank you so very much for making my mother's last

days easier. It was a time when emotionally I was having a hard time knowing the end

was near. I wanted to be hel' rock. When I couldn't you stepped right in. For that my

love will always be with you." I like to think that I provide compassionate care to all

individuals, but occasionally messages such as this help reaffirm that I am in fact doing

a good job despite the many conflicting constraints in our work environment.

37

l 38

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Critical Thinking

Critical thinking is the fun part of nursing. Putting all the pieces together to

come to a logical conclusion or influence appropriate change in the plan of care. Every

patient presents a unique scenario in which the combination of history, present illness,

physical assessment, and diagnostic procedures creates a course of treatment that

hopefully sees them through to feeling better. I find that one of the most important

pieces of critical thinking is to fully understand the physicians plan of care, ensure the

consulting providers are on the same page, and actively promote achievement of patient

care goals.

I recently cared for a patient who was admitted after a referral was made from

her primary care provider for workup of symptomatic anemia with progressive dyspnea

on exertion over the past month. Throughout her hospital course she had a full cardiac

workup, which revealed elevated troponins (in a "flat" presentation), ECHO showing a

normal ejection fraction of 55-60% with moderate mitral regurgitation, and severe

anemia with her hemoglobin dropping as low as 6.1, likely related to a chronic GI

bleed. On the day I assumed care of this patient we were anxiously awaiting the arrival

of 2 units of packed red blood cells that were retrieved by the currier early that morning

from Maine Medical Center after 2 days of searching for a compatible transfusion as

this patient had multiple antibodies in her blood. Fortunately, the patient was nearly

asymptomatic, with her only residual complaints being fatigue, mild lightheadedness

upon standing, and mild dyspnea on exertion. Overnight her systolic blood pressure was

in the 90s, heart rate 70-80s, sinus rhythm. She had been started on metoprolol due to

the nature of her elevated troponins and abnormal ECHO. After some initial diuresing

she was ordered to receive one additional dose oflV lasix between the two units of

blood that day. However, after I consulted with the hospitalist that morning and

(

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discussed the patient's status we opted to hold her metoprolol until her blood pressure

improved, possibly after the 2 unit transfusion, and cancelled the order for lasix

between transfusions as the patients BUN and creatinine were elevated and with her

normal ejection fraction the provider felt she did not need further diuresing. Later that

day, prior to the start of the transfusion, the cardiologist rounded and documented in the

progress note the plan was to continue metoprolol and lasix, but noted that the patient

would not be started on and ACE or ARB due to her renal function. I did not have an

opportunity to talk with this provider on rounds, but later brought to the attention of the

hospitalist that the cardiologist's plan of care was not congruent with the changes he

had made that morning, including the lasix and metoprolol. For the next two days the

cardiologist continued to indicate in the progress note that the plan was to continue the

lash and metoprolol, likely not knowing that both those medications had been

discontinued. Each day I discussed the plan of care with the rounding hospitalist and

again addressed the concern that the cardiologist's note was not consistent with the

current plan, for which the hospitalist made note of. The critical thinking skills of a

nurse require the ability to extract data from numerous venues and ensure that the plan

of care is in line with the patient's condition. Examples such as this happen nearly on a

daily basis, which underscores the importance of collaboration amongst all healthcal'e

providers to ensure the patient is receiving consistent messages and care.

Documenta tion

Documentation is one area of nursing that I feel will always have room for

improvement, however, I feel as though I provide the most current and thorough

documentation possible within the means of our system. Personally, each patient l'ecord

for every shift I work will include a head-to-to physical assessment, documentation of

interventions completed, and a nal'1'ative summary throughout the day to "paint a

39

picture" of the events that occurred, whether benign or abnormal. I also ens.ure that

every patient receives education on the plan of care, tests or procedures, pertinent lab

results, and review medications when given and document as such. Many of my peers,

mostly the care coordinators, have commented on the thoroughness of my

documentation for both patient care and education. In fact, the manner in which I

document narrative notes throughout the course of the day can also be seen in the

practice of nurses whom I have precepted, for which the care coordinators also

recognize and appreciate as it allows them to understand and visualize what occurred

throughout the day. The reasoning behind my extensive documentation is due to the fact

that the data I record is the only information I will be able to rely upon in the future if

there is any question regarding patient care. At that time it will be essential for me to

be able to detail the events that occurred while providing care to that patient that I

would otherwise not be able to remember and lor prove true based solely upon my

memol'Y. The old saying of "If it wasn't documented, then it wasn't done" continually

resonates with me throughout the course of each day. Additionally, I do my best to

chart in real time but utilizing the computers in the patient's room as evidence supports

that is the most accurate and timely method for documentation, and it also makes the

patient feel as though I am present and spending more time in their room during each

visi t.

Population Specific Competency

While the population of Brunswick, Maine does not include a vast ethnic 01'

cultural diversity in comparison to other parts of the country, there are still differences

amongst our patient population that require special attention and consideration. One of

the greatest challenges I remember as of recent may have been providing effective

education to a patient and his wife who did not speak English as their primary language.

40

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Unfortunately, this patient had suffered a serious eVA with residual aphasia that made

communication initially a challenge until alternate communication techniques were

established to facilitate conversation as the patient declined use of the interpreter

service. Fortunately, the patient's daughter spoke English as her primary language and

was actively involved in the patient's care. While it is not necessarily ideal to have an

immediate family member serve as the pl'imary translator for major correspondence, the

situation ultimately worked out well for all parties. With appropriate adaptations and

support the patient and family were able to receive and comprehend the information

needed to safely engage in the plan of care and be prepared f01' discharge.

Resources

Time Utilization

In just over three years of nursing practice I believe I have developed strong

time management skills and have become adept with prioritization. I not only stl'ive to

ensure that patients receive equal levels and quality of care, but I do so in a manner

directed by highest priority. One peer on my most recent evaluation stated "Pt tasks are

competed before sign off, and any follow-up needs are addressed with the oncoming

nurse." Some days I am forced to accept the fact that we work in a 24 hour facility and

not everything can be completed before 3pm, in which case I appropriately pass off

tasks to the oncoming nurse, which are generally of the lowest-priority for that day.

Delegation and Resource Utilization

Growing up in a family of business owners I have an appreciation for fiscal

responsibility. At times I have not hesitated to suggest we cancel a professional practice

meeting if we are not prepared to effectively use the time allotted. I have also

encouraged use of HealthStream to stream videos and PowerPoints for mandatory

education in place of funding all staff to come in for a bl'ief mandatory session. In

41

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addition, I strive to be fiscally responsible in my own practice by reducing waste and

conserving time and resources when possible.

I believe my peers that work as Resource Nurse would attest to my flexibility in

managing varying acuity and census on the unit. I am always willing to be flexible with

my assignment during my scheduled shift, and often fill in staffing holes on short

notice for alternate shifts. In my most recent performance evaluation (June 2011),"

stated '_has cared for some very

difficult patients with complex needs. I never hesitate to assign a complicated patient to _s I know she can handle it and ask for help as needed. As a matter of fact, I

need to remind myself that_has only been an RN for one year because she does so

well!" Above all else, I strive to maintain my composure in stressful situations and

understand that as an individual I can only do so much. As long as I prioritize

effectively, the work will get done.

Outcomes

Evaluation

My clinical documentation is reflective of how I evaluate the effectiveness of

interventions and my ability to revise the plan of care as needed. I have a sufficient

understanding of our documentation system and thus make it a priority to keep the plan

of care built and up-to-date.

The details in the above narrative can attest to my assistance in resolution of

unit- and hospital-wide improvement opportunities through involvement in professional

practice. In many cases I have assumed leadership roles in these areas of developing

and implementing practice changes

42

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Patient Teaching

The attached recommendation b can speak

to my commitment to not only providing, but effectively documenting patient

education. Education is always on my "to-do" list for the day. I ensure that patients not

only receive education on the daily plan for the day including tests, procedures, and

goals, but I also review all medications when given, and confirm that appropriate

education documents have been provided to the patient and family in accordance with

core measures (Le. disease specific education such as stroke, MI, CHF, pnemonnia;

Coumadin education for all patients on Coumadin regardless of how long; and smoking

cessation information for anyone who states that they continue to smoke). I also

document appropriately to indicate whether the patient andlor family need follow-up

assessment of teach back to ensure comprehension of the presented material.

Quality of Practice

Now that I have reached the final segment of this narrative, I believe the above

information speaks to the quality and effectiveness of my nursing practice. Since

starting my career at I have strived to serve as a more

active participant and effective leader each year to create positive change in our work

environment. I do not hesitate to bring forth concerns regarding clinical practice to

appropriate parties and am always willing to assist in measures to improve practice. My

passion for Magnet Excellence in nursing, which originally attracted me to Mid Coast

Hospital, still resonates in my practice and inspires me to challenge myself and others

to continually enhance our practice day in and day out.

Conclusion

I hope the above narrative details the work I have done most recently over the

past 12 months to advance my practice from that of a Clinical Nurse III to a Clinical

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Nurse IV. In addition to my commitment to excellence and best practice, I have showed

an active commitment to professional practice through numerous unit and hospital-wide

councils, and have expanded my involvement by presenting at the Medical/Surgical

Skills Fair. On a side note, I also enjoyed supporting a fellow colleague and the Maine

Cancer Foundation by raising nearly $300 for cancer research, education, and patient

support programs in the state of Maine as a participant in the 2013 Twilight 5K race.

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