Clinical Ladder Portfolio

UCLA Medical Center Department of Nursing Clinical Ladder Portfolio "Celebrate Your Clinical Expertise, Tell Us About Yourself!" REVISED 2011

Table of Contents About the Clinical Ladder... 1 Principles of the Clinical Ladder... 2 Promotion Process from Clinical Nurse II to Clinical Nurse III... 3 Clinical Ladder Promotion Step Process (Algorithm)... 4 Guidelines for Written Portfolio... 5 Complex Patient Template Sample... 6 Verbal Presentation Option of Portfolio... 7 Guidelines for Verbal Presentation... 8 Incorporate Relationship Based Care Principles in Your Chosen Scenarios.......12-14 Relationship Based Care Elements 1-6.. 1-4 Unit Clinical Expert Review Group Guidelines... 9 Critical Incident Standardized Format... 10 List of Committee Members to Assist You with the Portfolio... 11 Clinical Ladder Portfolio Summary/Menu of Choices... 15-16 Patient Care.. Planning Activities... 17.. Conducting Shift Report... 18.. Managing Multiple Resources... 19.. Incorporating Diversity: Spiritually/Clinically Culturally... 20.. Planned Impact on Patient Outcome Within Limitation... 21.. Demonstrating Critical Thinking Related to Policies and Standards of care and Clinical Guidelines.....22.. Clinical Decision Making..... 23 Leadership.. Pattern of Using Resources to Achieve Win-Win Situations... 24.. Demonstrate Calmne ss, Purposefulness and Effectiveness in Managing a Clinical Operational Situation... 25.. Organization and Efficiency... 26.. Compassion and Empathy.... 27.. Perseverance: Achieving A Beneficial Outcome In A Complex Situation Despite Obstacle..28.. Discernment: Knowing When and How to Use Interventions Among Competing Needs... 29 Staff Education.. Sharing Knowledge with Colleagues..... 30 Patient and Family Education.. Teaching Patients and Families... 31 Precepting Attributes... 32 Samples... 33 36

ABOUT THE CLINICAL LADDER The clinical ladder process for promotion of clinical nurses at UCLA Medical Center has been designed with input from nursing staff at all levels. In the early phase of development, focus group sessions were held to obtain guidance from bedside nurses to determine the principles upon which the ladder would be based. These principles reflect the values of staff nurses for clinical experience, fairness, consistency, individualism, and empowerment. The list of the eight guiding principles for the clinical ladder is clearly defined in the introductory pages of this manual. Our clinical ladder uses the Benner Model to differentiate practice from novice to expert. The Clinical Ladder Committee is composed of volunteer staff nurses, Clinical Nurse Specialists, Unit Directors and the Clinical Director of Nursing. The group strives to incorporate the values of the staff into the promotion process. The results of that work have been reviewed and revised extensively and approved throughout the Department of Nursing. The process undergoes continuous evaluation and is revised when appropriate. The CN III applicant can demonstrate his/her clinical expertise through a) Verbal presentation or b) written portfolio. Through the portfolio or verbal presentation, the CN III applicant will demonstrate clinical expertise using actual complex clinical cases. Using these complex cases, the applicant will demonstrate critical thinking, the analysis of intervention used in the course of care and the evaluation of patient outcomes. These presentations will also highlight the applicant s expertise in these roles: practitioner, teacher, advocate and leader. A group of volunteer nurses has been identified to serve as mentors through the process. Their names and most recent telephone extensions appear in this manual. Candidates for promotion are not required to utilize a mentor, but the Clinical Ladder Committee strongly recommends that a mentor be consulted in order to avoid unnecessary delays in the processing of the portfolio. In addition, consult your, Clinical Nurse Specialist, Unit Director, or CN IIIs on your unit s Expert Review Group. This program belongs to all nurses at UCLA Medical Center. Its roots are imbedded in the staff nurses whose honesty, integrity, and courage began the work. Its development is the result of collaboration among all nurses at all levels of the organization. Its future depends on its usefulness to us as a measurement of clinical expertise. 1

PRINCIPLES OF THE CLINICAL LADDER 1. The Clinical Ladder will be a process that provides recognition for clinical expertise. 2. The process for moving through the Clinical Ladder will be clearly delineated. 3. The process for moving through the Clinical Ladder will be consistent across all units. 4. There will be consistent and clear requirements for each level of the Clinical Ladder. 5. The Clinical Ladder process will strive for objectivity and fairness. 6. The Clinical Ladder process will provide more recognition of bedside clinical expertise and growth. 7. The Clinical Ladder requirements will be individualized to recognize each person s aspirations and contributions. 8. All nurses will be empowered decision-makers, regardless of Clinical Ladder level. YOU ARE THE PRIDE OF NURSING CAPTURE IT HERE! 2

PROMOTION PROCESS FROM CN II TO CN III Eligibility Eligibility is based on the following criteria: Applicant meets all bolded and asterisks items in job description/evaluation. Minimum of 6 months on the unit. No ongoing corrective actions. Portfolio If you have decided to submit a written portfolio instead of having a verbal presentation, present your complex cases in a manner in which the reviewer can discern the science and art of your assessments, diagnosis, plans, interventions and evaluations. The portfolio is divided into the following categories: Patient Care, Patient and Family Education, Staff Education, and Leadership. Utilize actual patient situations which you work with daily and present these cases to reflect your expertise. The experiences are to be within the one year period of time prior to submission of the completed portfolio. There are Clinical Nurse Specialists, Unit Directors, and CN IIIs from a variety of units who can provide assistance with the portfolio. (They are listed in this manual). We strongly encourage you to consult with one of these people prior to submitting your portfolio. Written Option: Once you complete the portfolio, submit it to the committee by leaving it in Coco McFrazier or Vanessa Adauto s mailbox in the Nursing Office. The Clinical Ladder Committee will review it for completeness and presentation. If that portion of the review is acceptable, the portfolio then goes to the unit based expert review group for evaluation related to clinical expertise. You can expect feedback from your unit-based panel of experts within a month of your portfolio s review. Verbal Option: Once you decide on this option, submit a written outline (maximum 1-2 pages) to the Committee by placing a copy in Coco McFrazier or Vanessa Adauto s mailbox in the Nursing Office. The outline will be distributed to the reviewing committee members. If it is complete, a date and time with your unit's Expert Review group and two members of the Clinical Ladder Committee will be scheduled and announced. You can expect feedback from your panel of experts within one month after your verbal presentation. 3

CLINICAL LADDER PROMOTION STEP PROCESS* Eligibility is based on 1) Meets all asterisked and bolded items in job description/evaluation, 2) Applicant must be on the unit at least 6 months and 3) No ongoing corrective action. These requirements remain in effect during the entire process including any extensions that may be granted. Step 1 Application forms and portfolio packets are available in Room B790A. The applicant may begin the process at this point. Step 2 The completed written portfolio or verbal presentation outline is submitted to Coco McFrazier s or Vanessa Adauto s mailbox in the Nursing Administration Office. The portfolio is evaluated for completeness and adherence to presentation guidelines only. (Evaluated by 2 rotating members of the Clinical Ladder Committee.) Make sure that you choose a complex patient situation. Yes Portfolio or verbal presentation outline is complete. Portfolio goes to step 3. No Portfolio or verbal presentation outline is incomplete. Applicant meets with a designated member of the Clinical Ladder Committee (person that reviewed portfolio or outline) for assistance with revisions. After portfolio or verbal presentation outline is approved by reviewers, the material goes to Step 3. Step 3 Evaluation of written portfolio or verbal presentation by Unit Based Expert Review Group. The CNS, Unit Director and 2-4 CN IIIs review the portfolio for demonstration of expertise in the specialty area. (Approval is completed by group consensus). Yes Portfolio or verbal presentation demonstrates clinical expertise. Portfolio goes to step 4. No Portfolio does not demonstrate clinical expertise. Individual feedback is given by CNS/UD identifying further work that needs to be done. Applicant has the option of making a verbal presentation or resubmitting a written portfolio to expert panel. Applicant makes needed corrections and resubmits written portfolio or verbal presentation outline. No If verbal presentation or written portfolio is not approved, a Consultation can be held with the Clinical Ladder Committee Chair or designee. A request for a 2nd expert panel will be made. A Clinical Ladder representative will attend presentation. No If the verbal or written portfolio is not accepted for the 3rd time, applicant will go back to step 1. Step 4 Promotion process is completed. Applicant is sent a notification letter from Heidi Crooks, Unit Director, and CNS informing them of promotion to CN III and the effective date of promotion. Applicant has 6 MONTHS from Step 1 to complete the entire process. Applicant may extend if they meet the requirements for Step 1. * Refer to Portfolio Presentation Guidelines and Clinical Expert Review Group Guidelines. 4

GUIDELINES FOR WRITTEN PORTFOLIO Your portfolio is a written demonstration of your clinical expertise. Therefore, it should be presented in a manner that reflects your expertise. To assist you in its preparation, the Clinical Ladder Committee has developed brief guidelines. These guidelines must be followed or the portfolio will be considered incomplete and will be returned for revisions. There are several members of the Clinical Ladder Committee who are available to assist you should you have questions, want a proof reader, or want suggestions. 1. All portfolios must be typed, without typographical, spelling or grammatical errors. 2. To maintain privacy of patients, all references to either, patients, families, or other staff must be made by using initials only. 3. The standard critical incident format should be used when describing your clinical expertise (see attached). 4. Make sure you select only complex patient situations for your portfolio. 5

Complex Patient Template - SAMPLE To be developed by unit staff, CNS and UD. Reviewed/revised a minimum of every 2 years. Unit Primary Patient Population The following is a list of sample complex patients according to the following categories: Diagnosis, Treatments/Interventions, and Psych/Social Issues. Diagnosis 1. Multi system organ failure 2. C-3 spinal cord injury/quadriplegia 3. Status epilepticus Treatments/Interventions/Events 1. Four vasoactive drip with active titration 2. Weaning 3. Code situation 4. Massive blood transfusion Psych/Social Issues 1. Withdrawal of life support 2. DNR controversy 3. Ethical issues 4. Non compliant, violent or disruptive patient/family 5. Severe agitation Continuity & Transition 1. Discharge planning 2. Community resources 3. Difficult patient placement Reviewer's Name: Review Date: 6

VERBAL PRESENTATION OPTION OF PORTFOLIO The portfolio may be completed in the form of a verbal presentation. This offers nurses a choice in how they prefer to demonstrate their expertise. The eligibility and other requirements are the same as the written portfolio. 1. All nurses must meet the same eligibility requirements as the written portfolio process. 2. Once a nurse has selected the verbal presentation option, they must communicate that decision to Coco McFrazier x79688 or Vanessa Adauto x79687. 3. The applicant is required to submit an outline of their selections from the portfolio packet to Coco or Vanessa a minimum of 2 weeks prior to the process. Two members of the Clinical Ladder Committee will review the outline for completeness. 4. Once an outline has been submitted and deemed to be complete by 2 members of the Committee, Coco or Vanessa will notify the Clinical Nurse Specialist and the Unit Director that the presentation must be done within 2 weeks. The verbal presentation will be done in the unit. The applicant will present her portfolio verbally at a set scheduled time. A question and answer period from the panel of experts and the applicant occurs at this presentation.. The applicant is then excused after the presentation. The Clinical Expert Review Group will then evaluate the presentation using the same methodology as they would if it were a written presentation. 5. The decision process for the applicant s promotion is the same as the written portfolio. 6. In the event there is no consensus, the CNS and UD will follow up with the applicant. The applicant will be required to present the section(s) that needed improvement or were missing to their unit expert group. This may be done by either written or verbal format. 7

GUIDELINES FOR VERBAL PRESENTATION We realize you may be nervous, so we do not expect perfection. 1. Professional conduct and appearance there is a saying, you are what you wear. This is a promotion process therefore, how you look counts here. Try to wear something that makes you feel and look like a professional. Professional attire is encouraged. You do not want to have to worry about what you have on and how it feels and looks. 2. Practice and prepare ahead of time. Rehearse before you come to the presentation. Lack of preparation could be your worst enemy. 3. Please refrain from reading your notes. You should be able to speak from the heart and from your valuable clinical experience. It is your story that the panel wants to hear and they want to hear it in your words. 4. The most effective tool is that you know your material and you can answer any question that is addressed to you or the portfolio. 5. Try to arrange your presentation at a time when you are refreshed and not tired. The best time would be on your day off if possible. 6. Remember even though you may know everyone on the panel, this is a professional presentation and will be viewed as such by the panel members. Assume that the panel members are not familiar with your specialty, so explain the whys quite well. The higher your expectations are the more credible you will be. 7. Try not to hurry through the presentation. The slower you speak and the clearer you articulate your thoughts again, the more credible you will be. 8. Bring something to drink. It is not uncommon to have dry mouth and difficulty talking secondary to being nervous. 9. Remember you are the expert in the clinical situation that you are presenting. After all, it happened to you and all you are doing now is recounting your story in a more formalized setting. 10. No gum chewing or eating food. 11. Presentation is limited to 1 hour maximum. However, there may be questions and answers or a lively discussion that may take longer. The panel should be an asset to your promotion process, not a hindrance. 8

NEW Clinical Ladder Portfolio Requirements Incorporate Relationship Based Care Principals in Your Chosen Scenarios PATIENT CARE (2 out of 7 categories): Planning Activities (1 of the following 7 activities) Interdisciplinary discharge planning (ex. rehab. planning) Plan of care (individualized from standard of care, and for complex patient as determined by unit) including plan for patient education Plan for a Patient Care Conference (include the problem you are trying to solve as you discuss your plan) Facilitate a unit or department based performance improvement activity related to planning activities (requires prior approval from UD/CNS) Conducting Shift Report (1 of the following activities) Two outstanding taped reports (per UD/CNS) Two outstanding verbal reports (per UD/CNS) Facilitate a unit or department based performance improvement activity related to shift report (requires prior approval from UD/CNS) Managing Multiple Resources (1 complex patient care problem demonstrating involvement of at least 3 other disciplines in the care of the patient) Manages complex patient care problem using multiple resources 3 disciplines (Interdisciplinary conference, family conference) Identifies what services patient needs and who is best person(s) to provide service Facilitate a unit or department based performance improvement activity related to managing multiple resources (requires prior approval from UD/CNS) Demonstrating Critical Thinking Related to Policies and Standards and Clinical Guidelines of Care (1 of the following activities) Facilitate and implement a revision, or development of a policy, guideline, protocol, pathway or standard of care) Make an exception to a policy or standard in the patient s best interest Facilitate a unit or department based performance improvement activity related to policies, standards of care, guidelines or protocols (requires prior approval from UD/CNS) Clinical Decision Making Critical Incident (1 complex patient care situation) Facilitate a unit or department based performance improvement activity related to Assess Intervene Revise Evaluate (requires prior approval from UD/CNS) Incorporating Diversity: Spiritual/Clinical/Cultural (1 of the following 2 activities) Critical incident (1 complex patient care situation) Facilitate a unit or department based performance improvement activity related to policies, standards of care, guidelines or protocols (requires prior approval from UD/CNS) Planned Impact on Patient Outcomes Within Limitations (1 limit from the following list) Financial (example: PCA vs. less costly method) Clinical (example: July interns) Environmental (example: physical layout, availability of equipment) Human Resources (example: qualifications of available care-givers at a given time) Facilitate a unit or department based performance improvement activity related to policies, standards of care, guidelines or protocols (requires prior approval from UD/CNS 12

PATIENT EDUCATION (1 of the following 8 activities). Teaching Patients/Families (1 of the following 8 activities) Demonstrate patient education assessment with regard to readiness to learn, learning styles, barriers to learning, or cultural issues Demonstrate interactive teaching (e.g. infant care) Utilize teaching aids (e.g. self-suctioning with mannequin) Design teaching aids or tools for individual patient or unit (e.g. poster board) Return demonstration from patient of a complex activity (as determined by unit, e.g. ostomy care) Discern best teaching method for a specific complex patient involving family members or other caregivers in teaching process Include other members of health care team in teaching strategies and activities Facilitate a unit or department based performance improvement activity related to teaching patients/families (requires prior approval from UD/CNS) STAFF EDUCATION Sharing Knowledge with Colleagues (if candidate doesn t choose Precepting they must select 2 of the remaining 10 activities) Precepting meets complete requirements for this activity. The candidate must have been a primary preceptor for a new employee for at least 72 hours Demonstrate 5 attributes for successful precepting (see page 3 of this checklist) Patient care conference (manage the conference for a complex patient situation or problem) Teaching at bedside or in unit Impromptu bedside teaching (critical incident) Rounds (manage 2 rounds) Nurse to nurse consultation, problem solving (2 episodes) Designing teaching aids or tools for staff (e.g. module or poster) Teaching in a class at NRE Teaching in skills lab Current instructor at UCLA BCLS, ACLS, NALS, PALS Facilitate a unit or department based performance improvement acitivity related to sharing knowledge with colleagues (requires prior approval from CNS/UD LEADERSHIP (2 out of 6 categories) Pattern of Using Resources to Achieve Win-Win Situations (1 of the following 2 activities) Critical Incident (1 complex patient care and/or unit operational issue) Facilitate a unit or department based performance improvement activity related to policies, standards of care, guidelines or protocols (requires prior approval from CNS/UD) Demonstrating Calmness, Purposefulness and Effectiveness in Managing a Complex Clinical/Operational Situation (1 of the following 2 activities) Critical Incident (1 complex clinical/operational situation) Facilitate a unit or department based performance improvement activity related to policies, standards of care, guidelines or protocols (requires prior approval from UD/CNS) Organization and Efficiency (1 of the following 2 activities) Critical Incident (1 complex patient care situation) Facilitate a unit or department based performance improvement activity related to policies, standards of care, guidelines or protocols (requires prior approval from UD/CNS) Perseverance: Achieving a Beneficial Outcome in a Complex Situation Despite Obstacles (1 of the following 2 activities) Critical Incident (1 complex patient care situation) Facilitate a unit or department based performance improvement activity related to policies, standards of care, guidelines or protocols (requires prior approval from UD/CNS) 13

Discernment: Knowing When and How to Use Interventions Among Competing Needs Critical Incident or incident cited by colleagues (1 complex patient care situation) Facilitate a unit or department based performance improvement activity related to policies, standards of care, guidelines or protocols (requires prior approval from UD/CNS Compassion and Empathy For PRECEPTING to be used in the portfolio, the candidate must have been a primary preceptor for a new employee for at least 72 hours. Demonstrating 5 attributes for successful precepting from the following list completely meets the requirement for: Staff Education: Sharing Knowledge with Colleagues. PRECEPTING ATTRIBUTES (need 5): Demonstrate sensitivity to preceptee s needs Acknowledge preceptee s rights Involve preceptee in establishing objectives Provide continuity in plan of action for preceptee Enhance preceptee s proficiency in performing frequent unit based skills Handle difficult preceptee problem Enhance socialization of preceptee to the unit Provide feedback Help build self confidence Confront negative behaviors and attitudes Teach by example (role model) Explain organizational dynamics Coach the preceptee Encourage winning behavior Share critical knowledge Provide appropriate information Trigger self-awareness Offer encouragement Encourage constructive alternatives Increase knowledge of resources Empower the preceptee Promote self development Understand preceptee s needs Read preceptee s non-verbal signals Identify preceptee s feelings and verify them (feedback) Encourage exploration of options Envision outcomes Provide active listening Establish partnership Determine and verify preceptee s expectations Develop preceptor-preceptee learning contract Identify special needs/issues Provide cross-culture precepting Enhance risk taking Enhance systematic problem solving and decision making Rev. 7/11 14

UCLA MEDICAL CENTER Relationship Based Care is our way of connecting to UCLA s Vision for being: The Best People, Best Practice, Best Quality. ELEMENT #1: Caring and Healing Practice 1. Core values, patient advocacy, patient safety, patient and family education and respect for patient and family preferences are consistently demonstrated in practice. 2. Caring, compassion and connection are the foundation for intentional caring in all relationships (see Nsg Guideline 1011 Nurse-Patient Interactions; Making the Connection). 3. Caring and healing practices are visible in relationships, clinical interventions and the physical setting to meet the needs of patients and their families. 4. Emotional, physical and spiritual aspects of care are incorporated into assessments, plans of care, therapeutic relationships and caring interactions. 5. All caregivers take individual responsibility to contribute to a therapeutic and healing environment for patients and their families and a healthy work environment for staff. 6. Caregivers will possess the skill and knowledge to manage their own stress, articulate personal needs and values, and balance the demands of the job with their physical and emotional health and well being. ELEMENT #2: Responsibility for Relationship, Decision-making and Nursing Plan of Care 1. Each patient deserves to have a designated RN to plan and coordinate their care. 2. The UCLA RN is responsible for establishing an individualized therapeutic relationship and individualized plan of care with the patient and family for a defined period of time determined by the Unit Director, Clinical Nurse Specialist and the RBC Unit Practice Council. 1

UCLA MEDICAL CENTER Relationship Based Care is our way of connecting to UCLA s Vision for being: The Best People, Best Practice, Best Quality. 3. The UCLA RN develops and updates an individualized plan of care based on an initial assessment and continuous reassessments of patient s preferences, biopsychosocial and spiritual needs. 4. The UCLA RN incorporates clinical reasoning, theory and evidence based policies and guidelines into their professional nursing care of patients. 5. The UCLA RN is responsible for implementing and coordinating the patient s individualized plan of care, facilitating the appropriate level of care and the timely transition to the appropriate setting for the patient. 7. Based on the plan of care all RN s lead the nursing care team in providing activities of care within the context of a caring relationship with the patient and family and the scope of their roles, responsibilities and competencies. ELEMENT #3: Schedules, Assignments and Work Allocation 1. Staff schedules and patient assignments are patient driven to ensure consistency of care and continuity of relationships. 2. The UCLA RN has the responsibility, authority and accountability for determining the kind and amount of nursing care a patient will receive, what activities of care require the knowledge of the RN and what activities of care can be delegated to other caregivers in order to provide quality care. 3. In relationship with one another, all nursing caregivers work as a team contributing their knowledge and expertise in the best interest of the patients. 4. Assignments are aligned with patient need, continuity of relationship, caregiver competency and resource management. 2

UCLA MEDICAL CENTER Relationship Based Care is our way of connecting to UCLA s Vision for being: The Best People, Best Practice, Best Quality. ELEMENT #4: Communication with the Health Care Team NOTE: During the discussions about the interface of the professional nursing practice model with other disciplines and departments a dialogue with them is recommended to promote the achievement of mutually desired results. (See also Communication principles) 1. The focus of communication is the patient, the patient s preferences, individualized plan of care, current assessments and shared interdisciplinary goals. 2. Based on an individualized relationship and plan of care, the UCLA RN communicates directly with nursing caregivers, the physician(s) and the interdisciplinary team. 3. The UCLA RN advocates for the patient and family by using the chain of command to provide timely individualized interventions for the patient. 4. All caregivers take individual responsibility for their contribution to teamwork and collaboration with a focus on patient and family. 5. Based on their professional responsibility and knowledge, individuals from each clinical discipline contribute their expertise and work collaboratively to provide the best healthcare experience and clinical outcomes possible during the hospital stay and throughout the continuum of care. ELEMENT #5: Leadership 1. Leaders engage staff to achieve the vision of UCLA by facilitating professional development, autonomy, participation, collaboration and creativity at the point of care. 2. Unit leadership owns the success of their program and fosters a clear focus on the purpose of the work-providing quality patient care-by articulating expectation for performance, modeling relationships with patients and their families by face to face contact, promoting competency development and recognizing contributions. 3

UCLA MEDICAL CENTER Relationship Based Care is our way of connecting to UCLA s Vision for being: The Best People, Best Practice, Best Quality. 3. Leaders select, evaluate and promote staff based on Relationship Based Care competencies and facilitate the development and continuous improvement of Relationship Based Care on their units. 4. The UCLA RN demonstrates proficiency in the domains of competency; clinical-technical, critical thinking and interpersonal skills. ELEMENT #6: Process Improvements 1. The Unit Practice Council, in communication with the Unit Director, the Clinical Nurse Specialist and the staff they represent, has the responsibility for unit plans specific to each of the principles and for mutual problem-solving of unit process issues. 2. Individuals take initiative and responsibility to work together to solve process issues at the unit level and to communicate issues that go beyond the scope of the unit to the Unit Director/Nurse Manager and the Clinical Nurse Specialist, who, in turn, engage in problem solving with other disciplines and departments. 3. Everyone works collaboratively and creatively to streamline the processes of care, including communication, to support consistency and continuity for patients and families. 4

UNIT CLINICAL EXPERT REVIEW GROUP GUIDELINES This information is to be used as a resource for CNSs, UDs, and clinical nurses that are part of their unit based Clinical Expert Review Group. The portfolio is reviewed in two phases: Phase I: Presentation and Completeness Phase II: Clinical Expert Review The first phase is simple and is reviewed by the Clinical Ladder Committee, not necessarily staff or managers from the applicant s home unit. The second phase, clinical expertise, is more complex, hence requires more attention related to the content of the portfolio. Each unit has a Clinical Expert Group that will conduct this review. The CN III members of this group should rotate on a 12-month schedule. The Clinical Nurse Specialist and Unit Directors are also members of this group. The following guidelines are written specifically for this group. 1. Each patient example meets unit criteria/definition for a complex patient situation as defined by the applicant's unit. 2. Directions are followed and questions answered for each section. 3. Written documentation or verbal presentation reflects clinical expertise in the following areas: Assessment, planning, implementation and evaluation of individual patient/family needs related to patient s clinical, psychological/social, spiritual needs and using multiple resources. 4. Expert Review Group members read the portfolios independent of each other prior to discussion with the other group members. 5. Expert Review Group members conduct their evaluation in an objective manner and limit their review to the portfolio only, not prior experience with any particular CN III applicant. When the unit review group decides the portfolio demonstrates clinical expertise, it is approved and the applicant goes forward to promotion. However, if the portfolio does not demonstrate clinical expertise, the applicant receives feedback ASAP from CNS, UD and assistance to either make the necessary revisions, or reconsider their level of clinical performance. Remember, this is a promotion and not every nurse is a clinical expert, but may develop the skills to become one. Promotional process can be extended on an individual basis, as requested by applicant s unit-based CNS and Unit Director. Request for extension is mailed to Clinical Ladder Committee. 9

CRITICAL INCIDENT STANDARDIZED FORMAT This format is to be used for the CN III portfolio for Critical Incidents. Additional information may be added. However, all of the items below must be included. Each Critical Incident should not exceed two pages. 1. Patient's diagnosis, situation, relevant information describing the scenario. 2. Identify the problem and contributing factors related to the incident. 3. How did you resolve the problem? a. Assessment b. Plan c. Intervention 4. How did you know that resolution was achieved? Measurement or Evaluation Outcomes 10

LIST OF COMMITTEE MEMBERS TO ASSIST YOU WITH THE PORTFOLIO Naturally, you will have questions as you read through this packet. We are here to help you make it happen. We invite you to call any of the nurses below. They are very familiar with the process and are eager to assist you. Your portfolio will be your own, but you don t have to do it alone. David Eskenazi 8 North 77857 Malou Blanco-Yarosh 8 North 77831 Wendy Holloway 8 West 77830 Dignacion Ilada 8 East 77810 David Ho 6 W 77630 Maureen Keckeisen (Mo) 8 ICU 77951 Bernardette Alvarez-Mohr 6 ICU 77640 Kathie Rodriquez 6 ICU 77640 Jannette Maneja 6 East 77610 Younghee Lee 6 East 77610 Eleanor S. Punzalon Bed Control 56922 Julie Beunik 7 CCU 77765 CeCe Healy 7 North COU 77760 Renee Appleby 7 West 77980 Cheri Neil 7 West 77982 Margo Goldman 5 West 77530 Chai-Chih Huang 5 West 77016 Supa Rodpradist 5 West 77530 Vangie Urbano 5 West 77344 Melissa Manguiat 6 North 77660 Sariya Chayutipun 5ICU 77540 Manny Punzalan 6E 77610 Jasmine Ochoa-Briones OR 78861 Dennis Gonzales 5W Peds 77530 Mark Flitcraft 4ICU 79529 11 Revised 6/10/11 cm

Department of Nursing CLINICAL LADDER PORTFOLIO Menu of Choices: Categories for Demonstrating Expert Practice The Clinical Ladder Program is a process designed to recognize and promote clinical expertise. Nurses choose among categories of competencies to compile a portfolio. The portfolio represents actual samples of a nurse's practices and outcomes. These samples document a pattern of expert practice in nursing across dimensions which include Patient Care central to nursing practice, Leadership and Patient and Family Education and Staff Education. These examples should illustrate what differentiates the expert nurse from other nurses. All written examples must have occurred within the 12 months prior to portfolio submission. Patient Care (Choose 2 categories among 7 choices): 1. Planning Activities 2. Conducting Shift Report 3. Managing Multiple Resources 4. Incorporating Diversity: Spiritual/Cultural/Clinical 5. Planned Impact on Patient Outcome Within Limitation 6. Demonstrating Critical Thinking Related to Policies, Standards of Care and Clinical Guidelines 7. Clinical Decision Making Leadership (Choose 2 categories among 4 choices): 1. Pattern of Using Resources to Achieve Win-Win Situations 2. Organization and Efficiency 3. Planned Impact on Patient Outcomes Within Limitations 4. Demonstrating Calmness, Purposefulness and Effectiveness in Managing a Clinical/Operational Situation 5. Perseverance: Achieving a Beneficial Outcome in a Complex Situation Despite Obstacles. 6. Compassion and Empathy 7. Discernment: Knowing When and How to Use Interventions Among Competing Needs 15

Staff Education (Choose 1category among 2 choices): 1. Sharing Knowledge with Colleagues 2. Precepting Staff ( see precepting attributes ) If Precepting Staff is your choice, this completes the requirement for this section. (You do not have to give another example.) Patient and Family Education (One example is needed) 1. Teaching Patients/Families 16

CLINICAL LADDER PORTFOLIO Patient Care Planning Activities Definition: Directions: An expert plans for the care of the patient in many ways, taking into consideration multiple factors, all at the same time. An excellent plan derives from an expert assessment. This outstanding planning ability contributes to patient outcomes that are substantially better and more economical (in time, resources and effort) than the results derived from less expert planning capability. Choose 1 of the following planning activities for complex patients or activities to assist in resolution of a unit based need or problem. Categories of planning activities: Interdisciplinary discharge planning (example, rehab. planning) Plan of care (individualized from standard of care, and for complex patient as determined by unit) including plan for patient education Plan for a Patient Care Conference (include the problem you are tying to resolve as you discuss your plan) Facilitate a unit or department based performance improvement activity related to Planning Activities (requires prior approval from UD/CNS). The above categories are applied to a complex patient care situation or a complex diagnosis as determined by your unit. 17

CLINICAL LADDER PORTFOLIO Patient Care Conducting Shift Report Definition: An expert shift report, designed by an expert nurse, cues the oncoming nurses to the most critical incidents and actions that the next shift must pay attention to in order to succeed. An outstanding shift report stands out in that it does more than report statistics and the meeting of standards of care. It highlights the critical decision points, assessments, etc, that are essential for this patient. It is brief, well organized, and oriented toward what the next shift needs to know. Directions: Select 2 samples of your shift reports to be reviewed by a Clinical Nurse Specialist: either your unit based CNS/UD, or a related specialty CNS. These samples will be reevaluated against standards or *guidelines set by your unit. The two samples must be related to complex care as determined by your unit. The CNS may listen to taped reports, or may let you know when s/he has observed you give 2 outstanding reports, along with the related feedback. Categories of Shift Report Activities: Two outstanding taped reports (per CNS or UD) Two outstanding verbal reports (per CNS or UD) Facilitate a unit or department based performance improvement activity related to shift report (requires prior approval from UD/CNS). *These guidelines should be readily available as a reference on your unit. 18

CLINICAL LADDER PORTFOLIO Patient Care Managing Multiple Resources Definition: Directions: An expert nurse assesses complex patient care dilemmas and seeks consultation from other disciplines to manage the care for the best outcome. In addition to consultation, an expert nurse will coordinate multiple resources and manage the interaction of care delivery so that the patient receives the most appropriate care for that situation. In this competency the competent nurse is, consulting with other disciplines, and is managing outcomes with other disciplines. Choose 1 complex patient care problem as determined by your unit. Select any one of the following categories of working in an interdisciplinary context, and show documentation of involvement of at least 3 disciplines for the best outcome for your patient. Indicate why you choose an intervention, what you did, what outcome you achieved, and whether the outcome was effective. Categories of Activities Demonstrating the Involvement of Other Disciplines in the Care of Your Patient: Manages complex patient care problem using multiple resources -- 3 disciplines (Interdisciplinary conference, family conferences) Identifies what services patient needs and who is best person(s) to provide service Examples of multiple disciplines: Pastoral Care Social Work MD Pain Management Physical Therapy Interpreters Performance Improvement Nutrition Respiratory Therapy Pharmacy Speech Discharge Facilitate a unit or department based performance improvement activity related to managing multiple resources (requires prior approval from UD/CNS). 19

CLINICAL LADDER PORTFOLIO Patient Care Incorporating Diversity: Spiritual/Clinical/Cultural Definition: An expert nurse simultaneously attends to a patient's culture, religious heritage and incorporates patient/family values within all of these circumstances, and achieves successful clinical outcomes. Directions: Document 1 critical incident which demonstrates competency in incorporating diversity. Categories of activities for managing patient outcomes within cultural dimensions: Critical incident Facilitate a unit or department based performance improvement activity related to policies, standards of care, guidelines or pathways (requires prior approval from UD/CNS). Critical Incident Format: 1. What were the patient's needs? Spiritually Clinically Culturally (ethnic) Patient/Family values 2. How did you successfully meet norms/values and beliefs? 3. How did you know you were effective? 20

CLINICAL LADDER PORTFOLIO Patient Care Planned Impact on Patient Outcome within Limitation Definition: Directions: An expert nurse must conduct interventions and achieve outcomes with patients within a limited environment. Expert nurses acknowledge limits and plan care within them. They do not design an unattainable plan, or a plan that requires an inappropriate use of resources. Expert nurses exhibit a pattern of incorporating the real environmental conditions into a plan that results in successful patient outcomes. Select 1 "limit" from the following list. Using the Critical Incident Format, show how you assessed the problem, planned for it, and achieved successful patient outcomes. Categories of Environmental Limitation: Financial (example: PCA vs. less costly method) Clinical (example: July interns) Environmental (example: physical layout, availability of equipment) Human Resources (example: qualifications of available care-givers at a given time) Facilitate a unit or department based performance improvement activity related to policies, standards of care, guidelines or pathways (requires prior approval from UD/CNS). Critical Incident Format: 1. What did you want to accomplish? 2. What were the limitations? 3. How did you achieve the outcome within the limits? How did you incorporate strategies to account for the limits? 4. How did you know it worked? 21

CLINICAL LADDER PORTFOLIO Patient Care Demonstrating Critical Thinking Related to Policies & Standards of Care and Clinical Guidelines Definition: Directions: An expert nurse has a broad knowledge and skill base, as well as a significant accumulation of experience. The expert nurse uses these attributes interactively to support her/his decisions in caring for patients. Sometimes a nurse's judgment, based on all of these outstanding attributes, will require the suspension of a common practice, the revision of a policy or the deletion of a policy. An expert nurse uses evidence-based practice to support policies, standards and guidelines. However, exceptions will be made by the expert nurse in specific instances to meet patients and families needs. Choose 1 of the following activities that demonstrates expertise in using Critical Thinking related to Standards of Care or policies. Show what the problem was; what knowledge base used; what was the expected outcome and what the outcome actually was. Facilitate and implement a revision, or development of a policy, guideline, protocol, pathway or standard of care* Make an exception to a policy or standard in the patient's best interest Facilitate a unit or department based performance improvement activity related to policies, standards of care, guidelines or pathways (requires prior approval from UD/CNS). *This may be unit, divisional, departmental or organizational policy related to patient care. 22

CLINICAL LADDER PORTFOLIO Patient Care Clinical Decision Making Assess Intervene Revise Evaluate Definition: Directions: An expert nurse is able to assess the patient care environment as a whole, integrate simultaneous observations and intuition, act, revise based on their in depth assessment, and continue to observe globally, almost at the same time. In the expert nurse, it is a simultaneous set of activities than a sequential set. As an example, a nurse will be noticing the physiological parameters, the clinical picture, the psychosocial picture, and subtle shifts in any dimension, and will be able to ascertain the effect of these shifts on the other dimensions. Interventions will be made taking all of this into consideration. Write one critical incident demonstrating expert ability in this competency for a different complex patient situation. Categories of Activities in the Clinical Decision Making: Critical incident format Facilitate a unit or department based performance improvement activity related to clinical decision making: - Asses - Intervene - Revise - Evaluate (Requires prior approval from UD/CNS). 23

CLINICAL LADDER PORTFOLIO Leadership Pattern of Using Resources to Achieve Win-Win Situations Definition: Directions: An expert nurse shows a pattern of being able to draw colleagues and other disciplines into collaborating for the best patient outcome. The expert nurse negotiates patient care and resources in such a way that patient outcomes are achieved. Expert nurses persist in conflicts; yet maintain an environment where their colleagues do not feel coerced, threatened or manipulated. An environment of collegial good will is enhanced, despite differences in points of view. Select 1 example of complex patient care and/or unit operational issue and write a critical incident resulting in positive outcomes for all involved parties. Categories of activities demonstrating Achieving Win-Win Solutions: Critical Incident Facilitate a unit or department based performance improvement activity related to policies, standards of care, guidelines or pathways (requires prior approval from UD/CNS). Critical Incident Format: 1. What was the desired outcome? 2. What were the resources you utilized? 3. How did you make it win/win? (What did each party get out of it?) 24

CLINICAL LADDER PORTFOLIO Leadership Demonstrate Calmness, Purposefulness and Effectiveness in Managing a Clinical /Operational Situation Definition: Directions: An expert nurse intervenes in complex situations with composure and confidence. The result is an environment of synergy in the midst of a chaotic environment. Expert nurses may be concerned about what they encounter, but they are in control of themselves, and purposeful in their actions. Select 1 complex clinical/operational situation. Using the Critical Incident Format, show how you achieved a synergistic environment. Categories of Activities showing Calmness, Purposefulness and Effectiveness: Critical Incident Facilitate a unit or department based performance improvement activity related to policies, standards of care, guidelines or pathways (requires prior approval from UD/CNS). Critical Incident Format: 1. What was the situation? 2. What did you do? 3. How did you create a calm environment? 4. How did you know you were effective? 25

Organization and Efficiency CLINICAL LADDER PORTFOLIO Leadership Definition: Directions: An expert nurse has the quality of efficiency in interventions. There is a sense of "just enough" for the situation. The nurse acts with conservation of energy, using enough to achieve the desired outcome. An expert nurse knows how to avoid duplicating effort, using too many steps, etc. The expert nurse gets it all done, but in the most efficient order. This is one quality that can be learned by other staff from the Clinical Nurse III, i.e. using clinical expertise and leadership behaviors to achieve good outcomes in multi-tasks. Select 1 complex patient care situation. Using the Critical Incident format, show how you used organization and efficiency to conserve in carrying out patient care. Categories of Activities Demonstrating Efficiency: Critical Incident Facilitate a unit or department based performance improvement activity related to policies, standards of care, guidelines or pathways (requires prior approval from UD/CNS). Critical Incident Format: 1. What was the situation? 2. What were the multiple tasks/assessments/situations you had to manage? A. B. C. D. 3. What did you do that conserved energy and time to get it all done? 4. How did you know what you did was effective? 26

CLINICAL LADDER PORTFOLIO Leadership Compassion and Empathy Definition: An expert nurse exhibits compassion and empathy for their patients/families under trying conditions. They show a pattern of consistency and evenness, and stand out among their peers. Their quality of empathy and compassion is so noticeable as to elicit comment at a higher frequency than one would expect. It is an integral part of the care they deliver, rather than episodic. Directions: Choose 2 of the following ways of documenting empathy and enclose in your portfolio submission. Categories of documentation of empathy and compassion: Thank you grams Satisfaction surveys (mentioned by name in 2 surveys) Personal letters from patient or family Written comments or examples from peers, social worker, physician, or other healthcare providers 27

CLINICAL LADDER PORTFOLIO Leadership Perseverance: Obstacles Achieving A Beneficial Outcome In A Complex Situation Despite Definition: Directions: An expert nurse successfully perseveres past obstacles to an outcome goal. The significant factor is overcoming obstacles and getting to the "finish line." Select 1 complex patient care situation and demonstrate how you persevered in overcoming barriers to your expected outcome. Categories of activities showing Perseverance: Critical Incident Facilitate a unit or department based performance improvement activity related to policies, standards of care, guidelines or pathways (requires prior approval from UD/CNS). Critical Incident Format: 1. What was the problem? 2. What was the outcome you wanted? 3. What were the obstacles? A. B. C. D. 4. What did you do? 5. How do you know it worked? 28