Clinical Nurse Advancement

Clinical Practice

• Develops solid nurse/patient relationships
• Demonstrates the ability to care proficiently for patient populations within their unit setting
• Works with patients, their significant others and health care team to identify goals and plans of care including transition of care
• Makes sound decisions by analyzing and integrating all patient data and nursing principles
• Evaluates patient care outcomes and revises plan of care as needed
• Prioritizes needs of individual patients in relation to other unit activities
• Advocates for patients

Evidence-Based Practice

• Uses current literature in daily clinical practice
• Makes clinical decisions based on documented findings

Education

• Identifies own learning needs
• Takes initiative for professional development beyond standard requirements
• Attends in-services/presentations beyond the unit specific requirements
• Identifies patient’s learning needs
• Utilizes appropriate patient teaching methods and teaching materials to address patient learning needs

Leadership

• Consistently models high standards of nursing practice
• Presents self in a professional manner
• Demonstrates accountability in one’s practice
• Offers and accepts assistance to/from colleagues
• Demonstrates the ability to reflect on one’s own practice
• Demonstrates effective and professional communication
• Identifies issues and problem solves issues to ensure resolution
• Supports colleagues, shares expertise, and serves as a role model, preceptor, and/or mentor
• Promotes teamwork and a positive work environment
• Promotes the development of collaborative relationships with peers and other health professionals through open, clear, and concise communication
• Develops positive relationships with interdisciplinary colleagues
• Participates in process improvement

Nurses are advanced to Clinical Nurse III based upon proficiency in clinical performance. You are eligible for advancement following a minimum of two years’ nursing practice experience, one year of which must be on your current unit at BID Needham.

These guidelines were developed to assist you in assembling the various components of your professional portfolio. The information is meant only to serve as a guide and should not stifle your own creativity in putting together your portfolio.

The quality and content of the material presented in your portfolio is what will be reviewed. Please be sure all information is typed or written legibly. It is suggested that you start your portfolio early so that there is time to obtain all of the necessary components and feedback. Applications are accepted and reviewed monthly on a rolling basis. You will be contacted by a member of the committee shortly after the monthly meeting in which your portfolio was reviewed.

You are encouraged to submit your portfolio electronically online to Heidi Alpert. Alternately, you may submit hard copies (2) of your portfolio to Heidi Alpert.

Required Documentation/Checklist (it is recommended that you assemble your portfolio in the following order):

• Application for Clinical Nurse Advancement
• Two letters of reference written by peer colleagues (see Guidelines for Letter of Recommendation)
• Director endorsement via a narrative summary of most recent performance evaluation
• Self-evaluation of professional performance
• One Clinical Exemplar
• Minimum of 3 professional goals
• Professional Resume or Curriculum Vitae

Please be sure that your portfolio is complete prior to submission. An incomplete portfolio may impede your advancement. It is common to find a lack of reflection on what has been learned from the Clinical Exemplars. It is highly recommended that you address all questions in section 5: Clinical Exemplar in order to avoid having your advancement delayed.

Application for Clinical Nurse Advancement

Write a brief statement, approximately two paragraphs, introducing yourself to the Review Committee. Please include any facts, beliefs, values, or behaviors that you think characterize yourself and your nursing practice. How would you describe yourself and your work? How will clinical advancement support your career goals?

Letters of Reference

In seeking letters of reference from colleagues, it is best to ask someone who can speak to your clinical practice. Two letters of reference are needed from a Clinical Nurse with at least two years experience at BID Needham or an advanced practice nurse (NP or CNS). The colleague should describe your practice. He/she should use specific examples whenever possible to describe your relationships with patients and peers, your communication skills, and evidence of your clinical leadership. See Guidelines for Letter of Recommendation.

Narrative Summary of Most Recent Performance Evaluation by Director

Performance appraisal of the candidate by the nursing director must be completed within six months preceding application or updated to reflect an accurate evaluation of the applicant’s current nursing practice. A narrative summary must be included highlighting the applicant’s strengths in clinical practice and/or professional activities.

Self-Evaluation of Professional Performance

A self-evaluation is a tool used to reflect on your current professional practice and progression to date.

• Your self-evaluation represents an opportunity for you to review and reflect on your past accomplishments, current activities, future interests, strengths, and areas for improvement.
• Evaluate your practice since your date-of-hire or last evaluation.
• You can structure the narrative of your self-evaluation in whatever way is most meaningful to you.
• Please be candid with yourself in describing areas for improvement.

Clinical Exemplar

Please describe and critique your current nursing practice in a Clinical Exemplar. A Clinical Exemplar is a description of a patient care situation that is significant to you and reflects your current practice. It may be a clinical situation that went unusually well, an incident in which there was breakdown (i.e., things did not go as planned), a situation that is very typical, or a situation that you think captures the essence of nursing. If you have difficulty identifying a clinical incident, it is often times helpful to ask a colleague or your director for ideas about a pertinent clinical situation in which you were involved.

Present your account as a story, rather than an analytic case study.

Include the following:

• The context of the incident (e.g., shift, time of day, staff resources)
• A description of what happened
• What your concerns were at the time
• What you were thinking about as it was taking place
• What you were feeling during and after the incident

Show what you learned from this experience by answering the following questions within the description of your Clinical Exemplar or in summary at the end:

• Why was this incident significant to you?
• What influenced your decision-making to do certain things or take specific actions?
• What courses of action were considered but not pursued?
• What happened that was unexpected?
• What new knowledge or insights were gained from this experience and describe how this has impacted your current practice

The Clinical Exemplar does not have to be lengthy: 3-4 typed pages (double-spaced) is usually sufficient. You can take as much space as you feel is necessary to tell your story.

Professional Goals

Please ensure that your goals are:

• Realistic and reflect aspirations for the future that stretch your capabilities
• Measurable - use action verbs
• Achievable within a timeframe
• Feasible within the framework of your professional role

Examples of Goals:

• I will attend a workshop on sepsis and present a summary to my unit of what I learned within two months.
• I will achieve my CEN within the next six months.
• I will develop an information sheet for caring for patients with chest tubes within three months.
• I will join a hospital committee this year and bring information back to the staff within one week after each monthly meeting.

Goals should be specific.

Professional Resume or Curriculum Vitae

A professional resume describes what you have achieved and how you have prepared yourself for the role you are seeking. It includes formal education and professional work experience beginning with your most recent experience in each area. It also provides an opportunity for you to identify publications, presentations of papers, honors received, and professional associations of which you are a member. A resume is a useful and convenient mechanism for presenting yourself and your accomplishments.

References

• Benner, P. (1984). From novice to expert, excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley Publishing Company, 1984.
• Benner, P. (1987). Clinical judgment: how expert nurses use intuition. AJN, 87(1), 23-31.
• Benner, P., Tanner, C., & Chesla, C. (1997). Becoming an expert nurse. AJN, 97(6).

Clinical Nurse Advancement Program Application »

The letter of recommendation for advancement to Clinical Nurse III should be provided by a Clinical Nurse with at least two years of experience at BID Needham or an Advanced Practice Nurse (NP or CNS) who can speak to the applicant’s practice. Below are some guidelines to assist in writing a recommendation.

The letter should reflect the following areas of practice and include specific examples of how the applicant demonstrates expertise in each of the following areas:

• Clinical Practice: Describe how the individual is proficient in clinical practice, advocates for patients, makes sound clinical decisions.
• Evidence Based Practice: Describe how the individual uses current literature in their practice.
• Education: Describe how the individual identifies own learning needs, takes initiative for their professional development beyond standard requirements, and attends in-services. Please include how their practice incorporates patient education.
• Leadership: Describe how the individual models high standards of nursing practice, presents self professionally, is involved in process improvement for patient care, and precepts and mentors staff. Supports colleagues, demonstrates interdisciplinary collaboration, and promotes team work.

Please feel free to contact Heidi Alpert x33879 or any other member of the CN III Review Board for assistance.

Remember to include examples.

I was so glad 3 o’clock finally came and I was giving report to the evening charge nurse. It had been a long but good day in the ED. Just as we were wrapping up report, the dreaded EMS radio went off. I answered and Needham Fire came on line. “We are bringing in an 88 year old male patient complaining of chest pain, alert, with stable vital signs. IV started and 324 aspirin given. We are at your back door; just coming from across the street.” That last statement was the key. The evening charge nurse and I looked at each other and said, “gotta be Mr. P”. I know we both had the same thought: “How many times has he been here for this chest pain?” And lo and behold there was Mr. P on the stretcher.

I stayed to help get Mr. P triaged; this was fairly quick for me since I had taken care of him so many times. Mr. P stated that he awoke this a.m. with chest pain and it just had not gone away. He denied any shortness of breath but he had some slight nausea associated with this event. Of course most of Mr. P’s history is known to the ED staff but just in case, Mr. P keeps his cherished index cards, which documents his history, in his upper shirt pocket. Mr. P does have some short term memory loss but he never forgets his index cards! He also has a history of coronary artery disease and hypertension which has been worked up in the past and has been managed with medications. I stayed just long enough to get him tucked in and off I went as I was done for the day.

At 0700 the next morning, Mr. P was still on the “dash”. He had been admitted to our OBS unit over night. The night shift informed me that Mr. P ruled out, as both sets of troponins and both EKGs were within his normal limits. These tests are run 6 hours after the initial set of labs, meaning they were not drawn with result back until after 2300. The night ED team decided to admit him to the OBS unit instead of sending him home so late knowing that he lived alone. The plan from report was to discharge him this morning. I assigned myself to be Mr. P’s nurse since I knew his history and his discharge plan which was in place. I was also in charge for the day. The day shift MD, Dr. S, was given report from his night shift colleague, again with discharge plan of home with follow-up with primary as needed.

I started my day by first assessing my other patient, and then headed down to Mr. P’s room. The room was dim and Mr. P was awake, but he did not acknowledge me when I went in. I asked Mr. P how he slept and he said “OK” but still he did not feel well. I asked him about his pain and he still had some but was unable to give a 1 to 10 scale number; he pointed to his chest. Upon my assessment, he was pale and warm to touch. Temperature was low-grade 100.4, he was in a sinus rhythm with regular respirations and lungs were clear upon auscultation. Blood pressure was also within normal limits. When I assessed his abdomen, he was slightly tender with positive bowel sounds and he continued to complain of slight nausea. I knew something was off. Mr. P. was not Mr. P. There seemed to me to be a slight change in his mental awareness. He surely did not have his Mr. P smile and he was just “not right”. So many thoughts were running through my head, “why does he have this low grade temp”, “why when I pressed on his abdomen did he grimace ever so slightly?” Mr. P had not complained of any abdominal pain - only his chest pain. I had an uneasy feeling that we were missing something.

As Dr. S was getting ready to print the discharge instructions for Mr. P, I updated him on Mr. P’s condition. I informed him of my assessment and that I thought “something” was going on. What was I missing? The attending said a low grade temp was not of concern and it was ok to send him home with this as all of his other vital signs were within normal limits and his cardiac work-up was negative. Dr. S said Mr. P did not voice any complaints to him and he looked “ok”. He then went on to say that Mr. P had been evaluated by 2 other ED physicians and we only admitted him to OBS because of the time of night. It would have been very easy for me to go along with the discharge plan. He did have a negative work-up and, yes, he could have been sent home last night but he wasn’t. I knew I could not let Mr. P be discharged. I went on to say that I had taken care of Mr. P so many times and I knew him well and he was not himself. I felt that a hospital admission was needed. I was not going to let this go. It is a testament to my practice and professionalism that Dr. S quickly responded to my concerns regarding Mr. P. Without hesitation Dr. S went and re-assessed Mr. P. Upon his reassessment Dr. S. also noticed that Mr. P. grimaced when he palpated his abdomen and Mr. P verbalized that his “stomach hurt”. Not sure what was causing this pain Dr. S called the hospitalist to arrange for Mr. P’s admission.

Mr. P was admitted to the floor and within 24 hours he was transferred to the ICU as his condition deteriorated. As I continued to follow Mr. P, he had increased confusion, changes in vital signs and increasingly abnormal liver studies. He was diagnosed with cholangitis. Antibiotics were started and he was transferred to BIDMC within 48 hours of arriving to the ED with what we thought was Mr. P’s usual chest pain. Mr. P underwent an ERCP with a sphincterotomy and a biliary stent was placed for a small intra-hepatic bile abscess. Mr. P’s post procedure hospitalization was uneventful and he was discharged home 3 days later.

I chose this story for several reasons. I made a difference in Mr. Ps’ care. I trusted my gut and persisted in articulating my concerns. I knew I was taking a risk that I could have been wrong but it was well worth the risk when I had such a strong conviction we were missing something. I was willing to have Mr. P admitted and have a negative work-up than for him to be discharged and return critically ill. This incident with Mr. P. taught me a great lesson that I now incorporate into my nursing practice. Each and every patient visit must be treated uniquely. Knowledge of the patient’s past medical history is important, but it is equally important to maintain your objectivity and to make no assumptions. As well as I may know a patient, I must always be cautious not to draw a conclusion too soon. The joy of working in a community hospital is that we get to know our patients extremely well. This special knowledge base allows me to recognize subtle changes in my patients that otherwise might be missed.

My experience with Mr. P reinforced my core belief that I always need to be my patient’s advocate. I realized Mr. P was unable to express his concerns or fear about his discharge. He was also unable to communicate his pain and change of condition. I needed to be his voice. As a profession we must speak up and communicate our assessments effectively, including changes in our patient’s condition and evaluation of our patient’s needs. I have the great pleasure and privilege of continuing to care for Mr. P. FYI, I am happy to report that his index cards have now been updated!