Sign-In Sheet

Lourdes Health System Career Ladder Application Summary Form Clinical Track

CATEGORY Score 1 Score 2 Score 3 SCOR E

Years of Experience SCOR E

1-5 years Score 1 6-15 years Score 2 16 or more years Score 3 # years of experience ______Continuing Education toward Degree (BSN, MSN, Doctoral in Nursing) earned this data collection period

3 credits Score 1 6 credits Score 2 9 or more credits Score 3 Credits earned this period _____ Specialty Certifications and Advanced Degrees Current National Specialty Certification Yes: Score 5 No: Score 0 (Maximum score of 5 for this relevant to your area of current practice category) Certification: ______Date Achieved: ______Degree (Bachelors/Masters/Doctoral) (Beyond required degree for position) Bachelors = 3 Masters = 5 Doctoral = 7 Date Achieved: ______Directions: Follow the guidelines below each category: maximum score of 3 per category CATEGORY Score 1 Score 2 Score 3 SCOR E

I. Professional Member of a local or national Active member of a local or Officer in a local or national professional organization; national professional nursing professional nursing Nursing may score 1 point per organization (attended >50% of organization Organizations professional organization up meetings) to a maximum of 3 points OR Receives an award from a professional nursing organization. Guidelines Must provide copy of Must provide documentation Must provide documentation membership card and verifying 50% of local meeting verifying the office held (i.e. copy document on the attendance for that individual of newsletter listing officers, “Professional Organization organization (i.e., copy of sign-in website, etc.) Verification Form” sheets) OR Submit a copy of award II. Volunteer Participate in 4 to 8 hours of Participate in >8 to 24 hours of Participated in more than 24 volunteer activities; 50% or volunteer activity; 50% or more hours of volunteer activity; 50% Activities more must be Lourdes- must be Lourdes-sponsored or more must be Lourdes- sponsored activities or activities or activities in which you sponsored activities or activities activities in which you are are representing Lourdes in which you are representing representing Lourdes Lourdes OR Global Health Ministry / Mission Trips Guidelines Must provide documentation Must provide documentation Must provide documentation verifying participation on verifying participation on verifying participation on “Volunteer Activities Volunteer Activities Verification “Volunteer Activities Verification Verification Form” Form” Form”

01/2016 Lourdes Health System Career Ladder Application Summary Form Clinical Track

III. Council and Active member of unit-based Active participation in a Lourdes Facilitator, chair/chair-elect, or committee or councils at hospital council or committee and officer on a Lourdes council or Committee Lourdes and attended > 75% attended >75% of meetings (this subcommittee and attended Involvement of meetings; may score 1 includes committees that are >75% of meetings point per council or committee interdisciplinary) Note: Peer review up to a maximum of 3 points OR does not qualify Active participant in an inter- hospital/county/state/national Council/Committee. Guidelines Document on “Council and Document on “Council and Document on “Council and Committee Verification Form” Committee Verification Form” Committee Verification Form” (including signature of (including signature of (including signature of Council/Committee Chair Council/Committee Chair) Leadership Representative)

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IV. Evidence Conducted on-going unit-level Created data collection tool, Created data collection tool, data collection for a PI/Risk collected and summarized data collected data, summarized Based Practice/PI Management project for one PI/Risk Management data for two or more PI/Risk throughout the year or through project Management projects project completion OR OR Coordinates a product trial, Collecting and submitting the according to established Quarterly PI/Risk guidelines. Management data analysis for 1 quarter.

Guidelines Must provide evidence of all Must provide copy of original data Must provide copy of original data collected for PI/Risk collection tool, and summarized data collection tool, and Management project on the data on the ‘Data Collection summarized data on the ‘Data ‘Data Collection Verification Verification Form’ Collection Verification Form’ for Form’; may score 1 point per each project project up to a maximum of 3 points OR Must provide evidence of all data collected and the data analysis on the ‘Data Collection Verification Form’; may score 1 point per project up to a maximum of 3 points

V. Research Reviewed two original Served as a reviewer for a Active participant in a nursing research articles or systematic professional media research activity where results review, /meta-analysis, or OR are to be submitted for metasynthesis article related Active participant in a nursing publication to patient-care research activity where data OR OR collection, written analysis is Coordinated and facilitated Coordinated a Journal Review completed. journal club review for the Club on the unit level Research Council’s quarterly OR Journal Club Review Active participant in a nursing research activity where data collection is completed

Guidelines Document using “Research Must provide a letter from the Must provide written evidence Evidence Appraisal Form”. publisher validating applicant as of the conduction of a research Articles must be from a peer- reviewer for a professional media project including: reviewed journal published OR - description of within the last 5 years. Attach Document using “Data Collection responsibility a copy of the article(s) Verification Form” and copy of - literature review conducted analysis - design of the study OR - results of the study (if Document Journal Club available) Review on “Research Document using “Research Evidence Appraisal Form” and Participation Form” submit a copy of participant OR sign-in sheet Document Journal Club OR Review on “Research Document using “Data Evidence Appraisal Form” and Collection Verification Form” submit a copy of participant sign-in sheet

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VI. (non-degree) Completed 12 hours of Completed 24 hours of Completed 36 hours of continuing education related to continuing education related to continuing education related to Self Development nursing beyond what is required nursing beyond what is nursing beyond what is for licensure required for licensure required for licensure OR OR Attended one regional Attended one local conference conference and presented a and presented a unit-based unit-based educational activity educational activity from from information learned (i.e., information learned (i.e., report report at staff meeting, brief in- at staff meeting, brief in-service, service, etc.) etc.)

Guidelines Document evidence of both Document evidence of both Document evidence of both required and additional required and additional required and additional education using “Continuing education using “Continuing education using “Continuing Education Verification Form” Education Verification Form” Education Verification Form” OR OR Must provide evidence of local Must provide evidence of conference attendance (i.e., regional conference attendance conference certificate) and (i.e., conference certificate) and document summary of document summary of educational activity on the educational activity on the “Conference Education “Conference Education Verification Form” Verification Form”

VII. Presented a unit-based Precepted an individual student educational activity to at least or Lourdes’ associate for 109 – Precepted an individual student Provision of 30% of unit staff or a minimum of 216 hours or Lourdes’ associate for more Education 5 associates whichever is the than 216 hours greater number (i.e., poster, OR (These PowerPoint, lecture) in addition Prepared content and educational to in-services required for presented a Nursing Grand application Rounds activities are in OR addition to the Precepted an individual student two required for or Lourdes’ associate for 72 – eligibility for the 108 hours Career Ladder)

Guidelines Document unit-based Document precepting Document precepting educational activity on experiences on the “Preceptor experiences on the “Preceptor “Education Activity Verification Verification Form” Verification Form” Form” and submit sign-in sheet OR with participants’ signatures and Document Grand Rounds on other documentation as “Education Activity Verification necessary: Form” and submit sign-in  Post-test for poster sheets with participants’ presentation signatures and program  Program Evaluation for live evaluation. or video presentation (with summary of responses)  Skills Checklist for Return Demo OR Document precepting experiences on the “Preceptor Verification Form”

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VIII. Additional Serves as unit validator for 1 Serve as unit validator for 2 Serve as a unit validator for 3 or POC training/testing skill POC training/testing skills more POC training/testing skills Activities OR OR OR Administered and read PPD Administered and read PPD Administered and read PPD testing for at least 10 testing for at least 15 associates testing 21 or more associates associates (or entire staff for OR OR departments with less than Serves as charge nurse for a Serves as charge nurse more 10 associates) minimum of 288 hours than 400 hours OR (Care Managers not eligible) (Care Managers not eligible) Serves as charge nurse for a OR OR minimum of 144 hours Participates in a unit specific Participates in a unit specific (Care Managers not eligible) project approved by the nurse project approved by the nurse OR manager (minimum of 15 hrs.) manager (minimum of 25 hrs.) Participates in a unit specific OR OR project approved by the Participates in a NICHE project Participates in a NICHE project nurse manager (minimum of approved by the NICHE approved by the NICHE 6 hrs.) coordinator (minimum of 15 coordinator (minimum of 25 OR hrs.) hrs.) Participates in a NICHE project approved by the NICHE coordinator (minimum of 6 hrs.) OR Submit a written proposal to the nurse manager which is intended to improve service and or decrease expenses. Proposal must be implemented.

Guidelines Submit a copy of “Point-of- Submit a copy of “Point-of-Care Submit a copy of “Point-of-Care Care Testing Validator Testing Validator Competency” Testing Validator Competency” Competency” signed by POC signed by POC Coordinator signed by POC Coordinator Coordinator OR OR OR Document PPD administration Document PPD administration Document PPD on the “PPD Administrator on the “PPD Administrator administration on the “PPD Verification Form” Verification Form” Administrator Verification OR OR Form” Document charge nurse hours OR Document charge nurse hours on the “Charge Nurse Document charge nurse on the “Charge Nurse Verification Form” hours on the “Charge Nurse Verification Form” Verification Form” OR OR Submit Project with Manager Document on “Clinical events Approval Form” and evidence of implementation.

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IX. Service Is recognized in writing by a patient, Assists manager / Director Receives 1 of the family, visitor, or colleague for in teaching Language of following awards: Delivery excellence in service delivery. Caring Class. - Governors Nursing (Ambassador of excellence, NRP Picker OR Excellence Award comments, Beryl Calls, etc.) Receives 1 of the following - Nursing Spectrum OR awards: Excellence Award Receives nomination for 1 of the - Nursing Excellence - Lourdes’s Champion following awards: Award Award - Nursing Excellence Award - Daisy Award - Sr. Elizabeth Corey - Daisy Award OR Award -Governors Nursing Excellence Award Submit a written proposal to - Nursing Spectrum Excellence Award the nurse manager which is - Lourdes’s Champion Award intended to improve patient - Sr. Elizabeth Corey Award satisfaction. Proposal must (max of 3 points) be implemented and proof OR of increase in pt. Coordinates an activity/project/event that satisfaction related question contributes to the unit staff morale. provided. (max of 2 points) OR OR Guardian Angel Award Submit a written proposal to the nurse manager which is intended to improve patient satisfaction. Proposal must be implemented.

Guidelines Submit copies of written recognitions. Submit sign in sheet from Submit sign in sheet Maximum of one from a colleague. class. from class. OR OR OR Submit on “Clinical events Form” Attach a copy or a picture of Attach a copy or a the award picture of the award OR Copy of Award X. Clinical Coordinates a multi-disciplinary care Presenter at a skill station Presenter at a skill conference to meet the needs of a for 2 Hospital wide or Unit station for 3 Hospital Expertise patient with complex care. Based SKILLS wide or Unit Based maximum of 3 points OR SKILLS or one SKILLS OR Serves as clinical resource at each facility Peer Review Committee Member to colleagues on assigned OR OR unit for nursing procedures Serves as clinical Presenter at a skill station for 1 Hospital or skills on at least 10 resource to colleagues wide or Unit Based SKILLS occasions on assigned unit for OR nursing procedures or Serves as clinical resource to colleagues OR skills on at least 15 on assigned unit for nursing procedures Serves as clinical resource occasions or skills on at least 5 occasions to colleagues on other units OR or departments for nursing Serves as clinical procedures or skills on at resource to colleagues least 5 occasions on other units or departments for nursing procedures or skills on at least 10 occasions Guidelines Document clinical resource activities on Document clinical resource Document clinical the “Clinical Resource Verification Form” activities on the “Clinical resource activities on the Resource Verification Form” “Clinical Resource Verification Form”

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TOTAL SCORE

Score 21-28 Score 29 - 36 Score > 36 RN II RN III RN IV LEVEL APPLYING FOR

01/2016