Welcome to the Application. Part 1: Organizational Information. 1. Please indicate the name of your organization/hospital.

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Moses Ross
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1 Welcome to the Application Only 1 hospitals represented by a Mentoring Champion Dyad (two team members per organization including an educator and nurse executive/administrator) will be selected for participation. (Exceptions will be considered for educatoronly or administrator only dyads.) Complete applications including all supporting materials must be submitted by February 14, 2014 to be eligible for consideration. However, applications will be considered and accepted on a rolling basis, so we encourage early submission of applications and required supporting materials.) The Dyad will need to complete all of the questions in this electronic application, plus submit a letter of support from the Chief Nurse Executive or his/her designee. To complete the application and be considered for participation a CV or Resume for each Dyad team member are also requested. Details about submission of supplemental materials are provided at the end of the application. This mentoring educational and process research project is being sponsored by the Nurse Mentoring Institute and is pending approval by the Institutional Review Board of Akron Children's Hospital. For additional questions contact the Project Manager: Louise Jakubik, PhD, RN BC Founder, Nurse Mentoring Institute President and Chief Learning Officer, Nurse Builders Louise@nursebuilders.net Or one of the Project Team members: Aris Eliades, PhD, RN, CNS Institute Assoc. Dir. and Dir. of Nursing Research Akron Children's Hospital aeliades@chmca.org Part 1: Organizational Information Please answer the following questions about your organization. 1. Please indicate the name of your organization/hospital. 2. Which best describes your institution type? National/International Academic Medical Center Regional Medical Center Community Hospital Other (please specify)

2 3. Which of the following describes your primary patient population? gfedc gfedc gfedc adult pediatric both adult and pediatric Other (please specify) 4. If your organization is a children's hospital, please indicate the type? free standing/independent free standing/part of a healthcare system housed within an adult hospital/medical center Other (please specify). Describe your organization's service(s) answer all that apply. (If not applicable, enter NA) Inpatient number of licensed beds, acute care Inpatient number of licensed beds, long term care Average daily census Average length of stay Number of outpatient clinics Average daily OPD visits Number of nurses employed. Is your hospital a Magnet Hospital? yes no 7. Is your hospital a non Magnet Hospital that is on the Magnet journey? yes no Other (please specify)

3 8. Describe the status of nursing lists and nurses' access to and computers within your organization. NOTE: Data will be collected electronically through a link provided to each Dyad for the Dyad to send to the list on the unit, service line, department or organization for the mentoring intervention. 9. Chief Nursing Officer Information Name Credentials Title Address City/Town State Zip Address Phone Number Part 2: Applicant Information EDUCATOR ONLY Please answer the following question about the Educator who will be part of the Dyad. (NOTE: Administrators who are part of the Dyad complete Part 3.) 10. Please provide your complete contact information Name Credentials Title Address City/Town State Zip Address Phone Number

4 11. Describe your current position as an educator including your scope of practice and job activities. 12. Please describe your experience with mentoring including your interest in mentoring. (This may be as a protégé, mentor, or both).

5 13. Please provide information about your nursing education and practice. Length of time working as a nurse (i.e. in years) Length of time working in your current position (i.e. in years) Length of time working for your organization (i.e. in years) Highest degree in nursing Highest degree in another field How did you hear about this program? 14. What are your personal objectives for being part of this Mentoring Champion project? Part 3: Applicant Information ADMINISTRATOR ONLY Please answer the following questions about the Administrator who will be part of the Dyad.

6 1. Please provide your complete contact information. Name Credentials Title Address City/Town State Zip Address Phone Number 1. Describe your current position as an administrator including your scope of practice and job activities.

7 17. Please describe your experience with mentoring including your interest in mentoring. (This may be as a protégé, mentor, or both). 18. Please provide information about your nursing education and practice. Length of time working as a nurse (i.e. in years) Length of time working in your current position (i.e. in years) Length of time working for your organization (i.e. in years) Highest degree in nursing Highest degree in another field How did you hear about this program?

8 19. What are your personal objectives for being part of this Mentoring Champion project? Part 4: Dyad Information Dyad interest and experience that describe why your Educator/Administrator Team will be successful project Mentoring Champions in your organizational setting. Please provide short answers limited to no more than 20 words. 20. Please describe your interest in applying for selection as a Mentoring Champion Dyad team to introduce mentoring practices and their benefits into your organization.

9 21. Describe how change is approached within your hospital (i.e. include the details on how new ideas are introduced, your governance structure, the chain of command, and policy development/change process) 22. Describe a change initiative that has recently occurred within your organization and each of your roles in that change process.

10 23. Describe an example of how the two of you (Dyad applicants) have worked together previously on projects. 24. Provide a summary of how the two of you (Dyad applicants) plan to work together for this project. Part : Supplemental Materials LETTER OF SUPPORT: **You can download the CNO Letter of Support Template on the 'mentoring certificate course' webpage as a guide." A letter of support is required from your hospital's chief nurse executive or his/her designee. For a letter of support to be accepted, it must be on institutional letter head, have a signature, and should include the contact information of the letter

11 writer. The letter should include the following: Documentation of your nursing officer's awareness and support of your Dyad's application A description of why the nursing officer feels this initiative is important for your organization Documentation of your nursing officer's level of commitment to support the change within the organizational environment and their support of your Dyad's leadership efforts to integrate mentoring practices within your organization (i.e. details about financial support for additional continuing education or other necessary resources; release time from other duties to focus on this project; clerical support; etc. Letters of support must be submitted electronically via to: Louise Jakubik, PhD, RN BC Louise@nursebuilders.net A CV or resume from both the Educator and Administrator members of the Dyad must be submitted electronically via to: Louise Jakubik, PhD, RN BC Louise@nursebuilders.net Congratulations, you have completed your application! One you have submitted your supplemental information (CV/Resumes and letter of support) you will be considered for selection in this project. Complete applications including all supporting materials must be submitted by February 14, 2014 to be eligible for consideration. An advisory group of experts convened for the purposes of this project will assess and score blinded applications according to preset criteria. Only 1 hospitals will be invited to participate. Applications will be reviewed and invitations to participate will be sent out on a rolling basis. So we encourage early submission of applications and required supporting materials You will be notified by March 3, 2014 of the outcome of your Dyad application. Thanks!

Equipping for Leadership: A Key Mentoring Practice. Eliades, Aris; Weese, Meghan; Huth, Jennifer; Jakubik, Louise D.

Equipping for Leadership: A Key Mentoring Practice. Eliades, Aris; Weese, Meghan; Huth, Jennifer; Jakubik, Louise D. The Henderson Repository is a free resource of the Honor Society of Nursing, Sigma Theta Tau International. It is dedicated to the dissemination of nursing research, researchrelated, and evidence-based