ࡱ> z|y) bjbj Vdddd' 8?4s[&555"2 >[ [ [ [ [ [ [$]`D[FFFD[55Y[&JJJFv55[JF[JJBQW5P>):vTf [[<[BU'a2'aW'aW,FFJFFFFFD[D[JFFFFFF'aFFFFFFFFF :  CLINICAL LADDER PROGRAM LEVEL IV RN APPLICATION CHECKLIST NAME OF APPLICANT: _______________________ DEPT: ___________________ LOC: _________ Refer to your HNA contract for complete details on the Level IV RN. Consult with your manager/supervisor about your application prior to submission Obtain a clinical ladder application packet Time period for this application should be within 2 years Place this completed form with all supporting documentation in a three-ring binder. Each category should have its own labeled section within the binder for easy reference. Upon review of application by the Clinical Ladder Committee, the candidate must score a minimum of 90 points in order to be promoted to a level IV position Fill in the blank or enter the appropriate response within each of the following categories of requirements. APPLICANT: If you meet requirements, submit this form and required documentation to your Manager/Supervisor *Applications that have been mentored prior to submission are more likely to pass.REQUIREMENTS AND ADVANCED SKILLS CHECKLISTDOCUMENTATION REQUIREDCurrent Hawaii RN licenseN/ANumber of hours per week for which I am hired (minimum is 24 PAN hours per week/0.6 FTE).N/AAt least 2 years of clinical experience as a registered nurseN/ANational certification in a nursing specialtyAttach proof of national certification.MANAGER/SUPERVISOR TO FILL OUT BELOW: This employee has completed the above checklist and I verify the above requirements have been met: _________________________________________________________ Manager/Supervisors Signature Date _________________________________________________________ Please print name  Manager/Supervisor Upon receiving approval letter from Clinical Ladder Committee: Complete the HR Adjustment (HRAR) Form 1960 online via MyHR and attach the following: Application checklist Proof of national certification Approval letter from Clinical Ladder Committee Check status of HRAR via MyCases on MyHR Upon approval from HR: Complete and print certificate template and sign (cardstock & color print highly recommended). Celebrate and present during staff meeting, huddle, etc Print congratulatory letter and present with certificate CLINICAL LADDER PROGRAM GUIDELINES LEVEL IV Application of Nursing Process The applicant will provide narrative case studies of three (3) patients who required comprehensive care, and for whom the applicant cared within the last two (2) years. The length of each case should be a maximum of five pages. This is just a guideline. Each case study should include: Significant background information, history of the patient, why you chose this case. Remember to protect the privacy of the patient. Some type of research on the disease or reason that the patient is receiving care, preferably one-half page, maximum one page. Relevant assessment data and the identification of actual and potential patient/family problems and nursing needs (consider physiological, psychosocial, teaching, discharge planning, and case management). Expected patient outcomes or goals of care (long term and short term), the interventions you planned and implemented, and the rationale for the care. The effectiveness of your actions (consider outcomes, responses to care). Unit In-Service on Clinical Aspect of Care Select a clinical topic relevant to assigned work area. Write behavioral objectives. Present clear, concise, practical content. Evaluate effectiveness utilizing evaluation tool, post-test, or return demonstration; summarize findings. Provide documentation of the in-service presented: objectives, outline of content, evaluation, and attendance roster. The Unit/Department Supervisor or administrative representative (Clinical Nurse Specialist, Level Staff, or committee member) must observe the in-service. Quality Improvement Activity Monitor a relevant clinical problem. Define what to improve and why it is needed. Plan/Develop a problem-solving activity. Do implement change. Check/measure/assess progress. Act on next steps based on evaluation of results. Provide documentation of the QA activity that includes the above elements including data collection before and after the activity to evidence the improvement. Leadership as noted on checklist. Sample score sheet utilized by Clinical Ladder Committee when reviewing application LEVEL IV POINT BREAKDOWN TOTAL POINTSCASE PRESENTATIONS = 30 POINTS 10 points per case presentation. Choice of patient as explained by applicant (2 points). The presentation (how it was presented) (2 points). The nursing process displayed in the presentation (3 points). The research on the disease entity of the patient (3 points). Case #1 Case #2 Case #3 1. ______________ _______________ ________________ 2. ______________ _______________ ________________ 3. ______________ _______________ ________________ 4. ______________ _______________ ________________ UNIT INSERVICE ON CLINICAL ASPECT OF CARE = 30 POINTS Choice of in-service topic as explained by applicant (6 points). Objectives (6 points). Outline and content (6 points). Evaluation of in-service, including summary of findings (6 points). Evidence of participation by supervisor or administrative representative - CNS, Level Staff, or Committee member (6 points). QUALITY IMPROVEMENT PROJECT = 30 POINTS Choice of clinical unit specific problem (6 points). Evidence on how it was identified (6 points). How the correction or change was implemented (6 points). Follow-up data collection after the change was implemented (6 points). Presentation/evaluation of outcomes/findings per data (6 points). LEADERSHIP = 10 POINTS Review of performance evaluation and any other information inserted to verify leadership on the unit. Score and add total points. 90 points are needed to pass. 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