Clinical Nurse Advancement

At BID Needham, the Clinical Nurse Advancement Program provides an opportunity for qualified clinical nurses who practice at the level of proficiency and beyond to apply for 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 healthcare 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
• Promotes teamwork and a positive work environment
• Demonstrates empathetic, compassionate care with patients and families
• Follows through on patient care issues

Education

• Identifies own learning needs and sets appropriate measurable goals
• Attends in-services/presentations beyond the unit specific requirements
• Utilizes appropriate patient teaching methods and teaching materials to address these learning needs
• Supports practice changes or performance improvement ideas

Evidence Based Practice

• Uses current literature in daily clinical and/or BIDN policies in daily clinical practice a basis for your clinical decisions

Leadership

• Consistently models high standards of nursing practice
• Takes initiative for and owns professional development
• 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 the development of collaborative relationships with peers and other health professionals through open, clear, and concise communication
• Participates in process improvement related to education or a practice change

For more information on this process, contact Heidi Alpert, RN, Chair of the Clinical Nurse Advancement Review Board, or any other members of the Review Board.

To be eligible for advancement to CN III, you must:

• Have a minimum of two years of nursing practice.
• Have worked in a budgeted benefits-eligible position (20 hours a week or more) in current unit/department for at least one year.
• Have been endorsed by the current unit nursing director.
• Meet criteria for Clinical Nurse III in the areas of clinical practice, evidence-based practice, education and leadership.

Along with the endorsement of your unit Nursing Director, a qualified applicant initiates their own advancement process to CN III. There is no set schedule or deadline to complete the application process. The review board is comprised of nurses who represent a variety of clinical areas. The board meets every month to review portfolios and make decisions regarding individual nurse advancement.

Ready to get started? Download an application.

The application process is based on defined criteria and requires the creation of a portfolio. We developed these guidelines to assist you in assembling the 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.

We suggest that you start your portfolio early so that you have time to obtain all of the necessary components and feedback. The review board will assess the quality and content of the material that you present in your portfolio. Please be sure that you type or legibly write all of your information.

We accept and review applications monthly on a rolling basis. A member of the committee will contact you shortly after the monthly meeting in which your portfolio was reviewed.

We encourage you to submit your portfolio electronically (online) to Heidi Alpert. Alternately, you may submit two (2) hard copies of your portfolio to Heidi Alpert.

We recommend that you assemble your portfolio in this order:

1. 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?

2. Two letters of reference by peer colleagues

In seeking letters of reference from colleagues, it is best to ask someone who can speak to your clinical practice. We require two letters of reference 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. They should use specific examples whenever possible to describe:

• Evidence of your clinical leadership
• Your communication skills
• Your relationships with patients and peers

See below for more details on guidelines for the letters.

3. Director endorsement via a narrative summary of most recent performance evaluation

You must have a performance appraisal from your nursing director that is no more than six months old, or that your nursing director updates to reflect your current nursing practice. This must include a narrative summary that highlights your strengths in clinical practice and/or professional activities.

4. Self-evaluation of professional performance

A self-evaluation is a tool that you use 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.

You should evaluate your performance from your date of hire or from your last evaluation. You can structure the narrative of your self-evaluation in whatever way is most meaningful to you. We strongly recommend that you write candidly about your areas for improvement.

5. 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
• A situation that is very typical
• A situation that you think captures the essence of nursing
• An incident in which there was a breakdown (i.e., things did not go as planned)

If you have difficulty identifying a clinical incident, 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 in your clinical exemplar:

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

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:

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

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

See below for a sample Clinical Exemplar.

6. Minimum of three professional goals

Please ensure that your goals are:

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

Examples of goals:

• I will achieve my CEN within the next six months.
• I will attend a workshop on sepsis and present a summary to my unit of what I learned within two 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.

7. 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. A resume is a useful and convenient mechanism for presenting yourself and your accomplishments. You should include:

• Formal education and professional work experience beginning with your most recent experience in each area.
• Publications, presentations of papers, honors received and professional associations of which you are a member.

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).

Please be sure that your portfolio is complete prior to submission. An incomplete portfolio may impede your advancement. Make sure that you address all questions in section 5: Clinical Exemplar in order to avoid having your advancement delayed.

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 and makes sound clinical decisions.
• Evidence Based Practice: Describe how the individual uses current literature in their practice.
• Professional Education: Describe how the individual identifies their own learning needs, takes initiative for their professional development beyond standard requirements and attends in-services.
• Patient Education: Include how their practice incorporates patient education.
• Leadership: Describe how the individual:  
  • Demonstrates interdisciplinary collaboration
  • Is involved in process improvement for patient care and precepts and mentors staff
  • Models high standards of nursing practice
  • Presents self professionally
  • Promotes teamwork
  • Supports colleagues

Remember to include specific examples.

I was so glad 3 o’clock finally came, and I was giving a report to the evening charge nurse. It had been a long but good day in the ED. Just as we were wrapping up the report, the dreaded EMS radio went off. I answered and Needham Fire came online. “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 document 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 overnight. 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 a 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 at 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.