Celebrating excellence in clinical practice

The PCS Clinical Recognition Program

—by Carmen Vega-Barachowitz, SLP, and Trish Gibbons, RN, co-chairs, Clinical Recognition Steering Committee

The PCS Clinical Recognition Program is in the process of becoming a reality, and the question on every- one’s mind is: "What is the Clinical Recognition Program, and how is it going to affect me?" The Clinical Recognition Program was designed to recognize and celebrate excellence at all levels of clinical practice. It is a way to formally recognize professional clinical staff for their expertise. It is a structure and resource to help staff analyze their own practice and reflect on how it has evolved. And it is an opportunity to celebrate the excellence in practice achieved by all clinicians throughout Patient Care Services. The program involves six disciplines within Patient Care Services: Nursing, Occupational Therapy, Physical Therapy, Respiratory Care, Social Work, and Speech-Language Pathology. Staff, managers, and directors from each discipline were involved in developing the program.

The idea to create a formal clinical recognition program originated shortly after Jeanette Ives Erickson, RN, assumed leadership of Patient Care Services in 1996. After hearing from staff that there was a need to acknowledge and reward clinicians for excellent practice, Ives Erickson charged the Professional Development Committee to define a framework for a professional recognition program.

The Professional Development Committee convened in June of 1997 as part of the PCS collaborative governance structure, and was comprised of staff representing all six disciplines. The PCS vision, guiding principles, and strategic plan guided the committee’s work. Building on certain operating assumptions, the Professional Development Committee developed guiding principles for the Clinical Recognition Program.

Operating Assumptions

• Domains of practice exist for each clinical discipline.
• A credentialing system exists.
• Performance measures, or competencies, exist for each role group.
• A peer-review system contributes to the strength of the model.
• Situation-based reflective practice (e.g., clinical narratives) promote acquisition of skill and knowledge.

The Guiding Principles for the Clinical Recognition Program are:

• We recognize that clinicians’ essential contribution to clinical practice is direct care to patients and families. We value contributions to clinical practice through participation in activities beyond direct patient-care.
• We believe that clinicians acquire knowledge and skill over time in the practice of their respective disciplines. Learning is achieved through experiences with patients, through collaboration with colleagues and leadership, and through formal education. Learning is transformed into knowledge through self-reflection and analysis.
• We recognize the uniqueness of each discipline that contributes to the care and positive outcomes of patients. We recognize the need for each discipline to shape the recognition model in ways that are flexible and dynamic and reflect the values and needs of the organization, their profession, and the individual.
• We believe that clinicians’ contributions to the care of patients and families should be recognized and celebrated. The program should recognize individual performance, team contributions and organizational effectiveness.

As members of the committee began their work, they realized that in order to develop a robust framework for a recognition program, one that would be meaningful to staff, they would need to do two things: First, they would need to examine the literature and identify work done by others that should be considered in designing the framework. And then, they would need to examine and incorporate into that framework the real-life experiences of MGH clinicians.

To accomplish this task, the committee used a multi-faceted approach. They researched the field of skill acquisition (see article on page 4). They studied Dr. Patricia Benner’s research on the  development of nursing practice. They examined more than 100 narratives written by MGH clinicians that provided detailed illustrations of practice at MGH.

Through careful study of the narratives the committee identified certain themes of practice. Themes are clusters of competencies, or recurring elements found in practice. They are the competencies that staff value. The themes that emerged from this intensive review of clinical narratives were:

• clinician-patient relationship
• clinical knowledge and decision-making
• teamwork and collaboration
• movement (this theme applies only to Physical and Occupational Therapy)

In reviewing themes that emerged, it became apparent that as clinicians gain knowledge and integrate their clinical experiences, the way that they practice evolves and matures in recognizable and definable ways.

It was this revelation—understanding that practice matures in recognizable and definable ways—that led to the identification of four distinct levels of practice. Each level coincides with the journey clinicians make as they continue to gain skill, knowledge, and professional wisdom.

The four levels of practice identified by the committee are: entry-level clinician, clinician, advanced clinician, and clinical scholar. Themes of practice were then considered as they relate to each of the four levels of practice. It was at this point that each discipline had the opportunity to hold focus groups with staff, discuss the themes and levels of practice, and ensure that clinical practice at MGH was being accurately captured and described.

Through this process, the committee recognized that no level of practice is any more or less valuable than any other. Essential contributions are made by staff at every level of practice. Excellence is the goal of every clinician regardless of level.

While the same levels of practice will be used across disciplines, the program acknowledges that each discipline has its own body of work and expertise, so the skills and behaviors practiced at each level will be different for each discipline.

The work of the Professional Development Committee was completed in March, 2001. The next phase of the program began with the appointment of the Clinical Recognition Steering Committee. This group was charged with implementing, overseeing and evaluating the program. The Steering Committee is comprised of staff, clinical specialists, managers, and directors from all six disciplines. Many clinicians  who served on the Professional Development Committee sit on the Steering Committee to ensure continuity of the knowledge and wisdom gained over time.

The Steering Committee met for the first time in April, 2001. The first task was to educate ourselves on the Dreyfus Model of Skill Acquisition and its application to clinical practice. We reviewed the narratives of MGH clinicians and examined portfolios. A timeline and plan of action were established. Five workgroups were identified to carry out the work, and each group was co-chaired by clinicians from different disciplines. Consensus was the decision-making model for each workgroup, and all recommendations generated by the groups were presented to the Steering Committee before being brought to Ives Erickson for final approval. The five workgroups are:

• Clinician Leadership Workgroup

Co-chaired by Evelyn Bonander, ACSW, and Mary Ellin Smith, RN, this group was responsible for designing content and educational strategies for leadership to facilitate their knowledge and understanding of the Clinical Recognition Program so they would be better prepared to guide and counsel staff.

• Clinician Education Workgroup

Co-chaired by Ann Daniels, LICSW, and Carol Camooso Markus, RN, this group was responsible for the design and content of educational strategies to facilitate understanding of the program among clinicians.

• Structure and Process Workgroup

Co-chaired by Debra Burke, RN, and Kristin Parlman, PT, this group was responsible for developing the application and review processes, including a description of the review board and its responsibilities.

• Clinical Resource Workgroups

Co-chaired by Pat English, RRT, and Mary Ellin Smith, RN, this group was responsible for reviewing the program and materials with clinical staff to ensure that the committee was on track; and for assessing whether the educational strategies were reasonable and appropriate.

• Communications and Marketing Workgroup

Co-chaired by Carmen Vega-Barachowitz, SLP, and Marianne Ditomassi, RN, this group was responsible for increasing the visibility and understanding of MGH clinical practice at MGH both within and outside the MGH community through the development of materials and a Clinical Recognition Program ‘signature.’

The work of these groups is highlighted in other articles in this issue of Caring Headlines. As we launch this new program within PCS we are reminded of our vision and guiding principles.

The Clinical Recognition Program embodies our organizational values. Our goal is to celebrate clinical practice at all levels; and recognize, acknowledge, and reward clinicians for the excellent care they provide.

Entry-level clinician

The entry-level clinician is learning to apply newly acquired knowledge and skills to a multitude of patient-care situations.

Clinician-patient relationship

the entry-level clinician is able to establish a relationship with the patient and family and is beginning to recognize differences in how individual patients and families react to illness and treatment.

Clinical knowledge and decision-making

Clinicians at the entry level draw largely on learned facts and rules to organize care and guide their practice. As they gain experience, they are increasingly able to recognize the uniqueness of each patient situation and modify care to meet each patient’s needs.

Teamwork and collaboration

Entry-level clinicians are learning the meaning of teamwork as it applies to the clinical environment. They understand the role of other disciplines but often turn to peers for help in designing a plan of care.

Clinician

Those practicing at the clinician level have acquired broad experience in caring for patients and have often developed a sound understanding of a particular patient population.

Clinician-patient relationship

Clinician-level practitioners are strong advocates for patients and are able to personalize care for each patient and family. They are developing an awareness of, and are able to work with, complex patient-family dynamics and cultural differences.

Clinical knowledge and decision-making

Clinician-level practitioners routinely draw on learned facts and experience and an understanding of possible outcomes when designing a plan of care. They recognize patterns in clinical practice, and use this knowledge when making clinical decisions. They are confident in their own abilities, comfortable with clinical decision-making, and are able to manage competing priorities. They seek out resources as they develop and form a plan of care.

Teamwork and collaboration

Clinician-level practitioners readily collaborate with members of the patient care team and work with others to develop an integrated plan of care. They are resources to colleagues, they seek and value collegial relationships, they readily provide guidance to less experienced staff, and they willingly participate in interdisciplinary forums.

Advanced Clinician

Clinicians at the advanced clinician level have acquired in-depth knowledge about the care of a particular patient population and an appreciation for the many factors that influence care.

Clinician-patient relationship

Advanced clinicians demonstrate a deep understanding of patient and family dynamics and skillfully incorporate complex patient and family factors into the plan of care. They are open to, and accepting of, other values and routinely adjust a patient’s plan of care out of respect for cultural differences. While they are comfortable advocating for individual patients, they recognize organizational issues that affect multiple patients and readily advocate for change at the system or organizational level.

Clinical knowledge and decision-making

Advanced clinicians skillfully incorporate multiple factors into their clinical decision-making. When caring for a patient, they consider not just the possibilities (what could happen in a particular situation) but the probabilities (what is likely to happen given the clinical and organizational factors at hand). Instinctively, they use this information to continually tailor the patient’s care to ensure the best outcomes. Advanced clinicians possess a spirit of inquiry and routinely look to the clinical literature and incorporate their findings into practice. They adapt readily to changing clinical situations and are comfortable taking clinically sound risks.

Teamwork and collaboration

Advanced clinicians value the contributions of peers and colleagues and readily recommend and seek consultation with other disciplines. They promote the development of collaborative relationships with colleagues and peers by communicating in a constructive manner, and they routinely incorporate joint decision-making into practice. They are a resource to others and work with others to develop and implement improvements in practice.

Clinical Scholar

Clinicians at the clinical scholar level demonstrate exquisite foresight in planning patient care, are recognized as experts in their areas of specialization, and are adept at negotiating conflict and collaborating with others.

Clinician-patient relationship

Clinical scholars actively empower and advocate for patients and families and try to maximize patient-family participation in decision-making and goal-setting. They are effective in eliciting cultural beliefs and values from patients and integrate this knowledge into the patient’s plan of care. They intuitively use their sense of ‘self’ in the therapeutic relationship and find innovative and creative ways to engage patients and families. Their advocacy often leads them to question and get involved in re-shaping systems at the hospital and community levels.

Clinical knowledge and decision-making

Clinical scholars are reflective by nature, and readily integrate knowledge gained by reflection into their practice. They are able to respond intuitively to patient needs and comfortably engage in clinically sound risk-taking. In response to a challenging situation, they regularly identify and implement innovative approaches to meet the needs of patients and families. They routinely examine and apply relevant research and are equally comfortable evaluating their own decision-making and clinical judgment.

Teamwork and collaboration

Clinical scholars welcome new perspectives and seek out opportunities to share knowledge and insights with colleagues. They are skilled problem-solvers and are able to effectively mobilize the interdisciplinary team to provide quality patient care. They see the ‘interrelatedness’ of practice components and work with peers to elevate the standard of practice as a whole. They are interested in developing others and regularly promote the growth and creativity of peers and other team members.

Understanding the importance of having a recognizable logo for The Clinical Recognition Program, the Communications and Marketing Workgroup met with designers to try to create a graphic that would capture the concepts of: quality, excellence, pride, professionalism, warmth, teamwork, caring, collaboration, motivation, and elegance. Lorraine Silvestri, a local artist, designed the illustration on the opposite page specifically for The Clinical Recognition Program. Created in lively shades of red, yellow and blue, the committee feels it captures the goal of continually striving for excellence in clinical practice.

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Jeanette Ives Erickson

Reach for the stars! 
PCS introduces Clinical Recognition Program

—by Jeanette Ives Erickson, RN, MS, senior vice president for Patient Care

This special issue of Caring Head- lines and the roll- out of our new Clinical Recognition Program reflect the hard work and commitment of many people. Beginning with the Professional Development Committee, who identified the principles and criteria for recognizing clinical practice, and continuing with the Clinical Recognition Steering Committee (and its five subgroups), this has been a journey of enlightenment. Implementation of the Clinical Recognition Program marks an historic passage for Patient Care Services—passage into a world where clinical practice at all levels is recognized and celebrated every day!

In preparation for the roll-out of the Clinical Recognition Program, I invited the directors and leadership of Patient Care Services to attend a retreat on Thursday, January 10, 2002. The day was a forum for the Clinical Recognition Steering Committee to begin to share information and details about the program, and to field the many questions everyone has about how it will work. Hopefully, a lot of those questions will be answered here by the articles in this issue of Caring Headlines.

As I prepared for the retreat, I was drawn to an analogy between the Clinical Recognition Program and the millions of stars that make up our universe. In astrological terms, a star is an enormous, spinning ball of light held together by a strong gravitational force; at the center of this luminous body is a dense core where vast amounts of energy are produced. (Can you see where I’m going with this?)

At MGH, the stars are all of you who work so tirelessly to provide exceptional care for our patients and families. Our stars are held together by strong leadership and organizational support; and their energy, too, is boundless!

The similarities go on: in the universe as at MGH, there are countless stars, each one an integral part of a larger, inter-connected landscape; stars vary in age, size, color, and energy level; every star tells a story; they provide a consistent navigational framework—helping people to find their way.

You may be surprised to learn that stars are identified according to how they fit into four main categories. Soon, clinical practice within Patient Care Services will be able to be described in a similar way. With the implementation of the Clinical Recognition Program, all direct-care providers within Patient Care Services (Nursing, Occupational Therapy, Physical Therapy, Respiratory Care, Social Work, and Speech-Language Pathology) who do not hold managerial positions will be recognized at one of four levels of practice: entry-level clinician, clinician, advanced clinician, or clinical scholar.

Where many stars in a night sky may go unnoticed, from now on, every star in Patient Care Services will be visible and recognizable every day. 

One of the most important tenets of the Clinical Recognition Program, one which cannot be overstated, is the understanding that excellent care is delivered by clinicians at all levels of practice, and that every level of practice is valued and important.

As I’m sure you can appreciate, a great deal of time, energy, research and passion has been invested in the design and development of this program. That’s because when we answered clinicians’ call for a career advancement model, we wanted to make sure we got it right. Ours is the only multi-disciplinary clinical recognition program in the country. It was important to us to craft a model that included all disciplines within Patient Care Services to reinforce the value we place on collaboration and teamwork.

Recognizing that each discipline makes a unique contribution to patient care and that distinct domains of practice guide each discipline, great care was taken to create a program that respects and celebrates every clinician, at every level of practice, in every discipline.

The PCS Clinical Recognition Program is a way for us to formally acknowledge and celebrate excellence in practice, but it is more than that. It is an opportunity for every clinician to help shape, reflect on, and participate in the development of his or her career. And I hope it is a way for you to feel as good about your practice as I do. Please join me as Patient Care Services embarks on a new frontier, and together, we reach for the stars!

Updates

I am pleased to announce that Lauren Holm, RN, has joined our team as staff specialist supporting PCS Operations and the Partners Chief Nurse Council. Lauren will bring her planning and management expertise to initiatives including capacity-management, marketing, strategic planning, and influencing healthcare legislation.

Please join me in welcoming Adele Keeley, RN, as the new nurse manager for the Blake 7 MICU. Adele served as interim nurse manager on the unit for five months and has accepted the position on a permanent basis. Welcome.

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Skill Acquisition

An explanation of the four levels of clinical practice

—by Mary Ellin Smith, RN, co-chair, Clinical Leadership Development Workgroup

The foundation for the PCS Clinical Recognition Program comes from the Dreyfus Model of Skill Acquisition. In the mid-60s, the Dreyfus brothers, Hubert, a philosopher, and Stuart, a mathematician, became interested in how certain skills (such as playing chess and flying airplanes) were acquired. They defined skill-acquisition as the development of skilled know-how. Since the early 80s, Doctor Patricia Benner has applied this model to clinical practice and has added to our knowledge about this important work.

Skilled know-how is what enables you to drive a car, start an IV, or assess and treat a patient. Skilled know-how is not innate, it is learned through trial and error, or taught by someone who has acquired it through their own experience. It is the result of both theoretical and practical knowledge and therefore requires experience. In this case, ‘experience’ is not defined as a passage of time but as the refinement of preconceived notions, expectations, and/or theories through encounters with actual clinical situations. It is through experience that clinical knowledge is developed, and from that knowledge comes clinical expertise.

A particular perspective, type of decision-making, and level of involvement characterize each stage of skill-acquisition. An individual moves from:

• a reliance on rules to a reliance on past experience
• detached observer to engaged participant.
• perceiving a situation as made up of equally relevant parts to perceiving it as a whole in which only certain parts are relevant

The Dreyfus brothers learned that as individuals acquire skill, they pass through five stages in the development of expertise. These five stages are: novice, advanced beginner, competent, proficient and expert.

At MGH, following the review of more than 100 narratives, interviews and discussions with clinicians throughout Patient Care Services, the Professional Development Committee identified four levels of practice that correspond to the Dreyfus Model of Skill Acquisition and build on the work of Dr. Benner. They are: entry-level clinician (advanced beginner), clinician (competent), advanced clinician (proficient), and clinical scholar (expert).

Entry-level practice is characterized by rule-governed behavior and a focus on the here and now. There is tremendous trust and reliance on the experience of others. Entry-level clinicians are learning what it means to practice as a professional and becoming acclimated to the MGH practice environment.

At the advanced-clinician level, the clinician has developed a sense of ‘salience,’ the ability to read situations in such a way that some things stand out as more important than others. Practice at the advanced-clinician level is driven not just by doing things correctly, but by the desire to achieve positive outcomes.

At the clinical-scholar level the clinician intuitively understands the situation and knows what actions are necessary without having to stop and ‘figure it out.’ Clinicians at clinical-scholar level see the big picture, not just with their own patients, but with all patients in their practice area; and not just with their own issues and concerns, but with the issues and concerns of their peers, and colleagues, and those of the larger community.

The Dreyfus Model of Skill Acquisition and its application to clinical practice give us the language to describe the excellence that is embedded at all levels of clinical practice.

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Self Reflection

Self-reflection: a valuable tool in the recognition process

—by Carol Camooso Markus, RN, and Ann Daniels, LICSW, co-chairs, Clinical Education Workgroup

Reflection on practice is a way of thinking about our clinical work with patients, families and colleagues. Self-reflection promotes understanding of where we are in our practice, how our practice has evolved, and how we can develop our practice in the future.

There are many different approaches to reflection. Some clinicians may think about their practice in a broad way. They may ask themselves:

• What do I do?
• How do I do it?
• What do I do best?
• What am I not comfortable doing?
• What aspects of my work do I enjoy most?
• What is my impact on patients and those I work with?
• Do my peers come to me with questions or ask for my help?
• What does this mean to me as a professional?
• Where do I see myself in five years?
• What do I need to do to get there?

Another form of self-reflection is thinking about a recent specific clinical situation. Critical reflection on specific situations helps us recognize patterns in patient needs and identify the impact of our interventions and interactions with patients, families and team members. Reflection helps us examine our decision-making strategies. The awareness we achieve from self-reflection informs us and becomes integrated into our future actions; this is how practice develops.

Some individuals reflect ‘in the moment.’ Others might prefer to reflect when there is more ‘distance’ between them and the situation (in the car on the way home, or in some quiet spot). The ways we reflect may vary, but some form of reflection is integral to ongoing clinical development.

With the introduction of the Clinical Recognition Program, clinicians will want to think about which level best describes their current practice (entry-level, clinician, advanced clinician, clinical scholar). To assist you in determining which level best describes your practice, we have developed a self-reflection guide. This tool helps you look at your practice within the themes of clinician-patient relationship, clinical decision-making, collaboration/teamwork, (and, for physical and occupational therapists, movement). The guide is included in the informational folder you will receive in your clinical areas (see article on page 12).

The guide suggests different ways to examine your practice. For example, in the theme of clinician-patient relationship, it suggests you look at the criteria for the different levels of practice and ask yourself: what level of practice best characterizes my experience? Think about specific patient situations. Think about someone whose practice you admire. How does that individual’s practice compare to the criteria and to your own practice.

As you think about clinical knowledge and decision-making, ask yourself which level best describes how you use clinical knowledge to make decisions.

For teamwork and collaboration, ask yourself about the nature of your relationships with colleagues within and outside of your discipline, how you contribute to an interdisciplinary approach to care?

For physical and occupational therapists, there is a fourth theme: movement. This theme speaks to how you use your hands in examining and treating patients and how this movement impacts your interventions.

It’s not unusual for all clincians to have a ‘range’ of practice. When looking at the behaviors described for each theme, you may find that most of the time you practice at the clinician level. But there may be times when your practice falls into the advanced-clinician level. So how do you determine your true level of practice? One way is to think about where you ‘live’ versus where you ‘visit.’ As your practice develops, you occasionally ‘bump into’ the next level. This would be considered visiting. You want to be able to distinguish between visiting and where your practice actually lives.

You may also find that a range of practice exists between themes. For example, you may live at the clinician level for teamwork and collaboration, but you live at the advanced-clinician level for clinical decision-making.

How do you best describe your overall practice? Ask yourself where you practice most consistently in each theme. If you consistently practice at clinician level for most themes, but in one theme you practice at advanced-clinician level, your overall practice is at the clinician level.

Self-reflection and using the self-reflection guide will help you think about your practice in a new way. If you take the time to do this exercise in the spirit of true self-examination, you’ll be better prepared to describe your practice when you sit down to dialogue with your manager or director.

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Program Design

The structure and process of the Clinical Recognition Program

—by Kristin Parlman, PT, co-chair, Structure & Process Workgroup

The PCS Clinical Recognition Steering Committee was formed in July, 2001, with the charge of overseeing, implementing, and evaluating the Clinical Recognition Program. One of five workgroups that grew out of that committee, the Structure and Process Workgroup, was responsible for:

• defining the application process at the advanced-clinician and clinical-scholar levels
• determining and describing the content of the portfolio
• determining the composition and responsibilities of the review board
• describing the review process

Recognizing the value that each discipline brings to the table, the Structure and Process Workgroup was a multi-disciplinary team with representatives from all disciplines participating in the Clinical Recognition Program.

One parameter of the program states that recognition at the entry and clinician levels is determined on the unit or in the department where the clinician practices. Recognition at the advanced-clinician and clinical-scholar levels occurs through a centralized process and is initiated by the clinician when he or she feels it’s appropriate to seek recognition at one of these levels.

Application process at the advanced-clinician and clinical-scholar levels

Application to advanced-clinician and clinical-scholar levels is voluntary. Clinicians may apply after they have been employed at MGH for six months and have the endorsement of their manager or director. It is recommended that clinicians undergo a process of self-reflection and engage in a dialogue with their manager prior to obtaining that endorsement.

Applications may be submitted monthly. Clinicians can apply for either level; recognition does not have to be sequential. Once clinicians receive the endorsement of their manager, they must prepare a professional portfolio to be reviewed by a multi-disciplinary review board, and participate in an interview to discuss their clinical practice. The review board will make the final decision regarding recognition at the desired level.

Portfolio contents

Each clinician’s portfolio must contain:

• a cover letter from the clinician introducing him/herself to the review board outlining the aspects of practice he or she wishes to highlight in the portfolio.
• a letter of endorsement from the manager or director.
• a clinical narrative, or story, about a clinical event or situation that holds special meaning for the clinician and reflects his or her current practice.
• letters of support from colleagues within the applicant’s discipline as well as from other disciplines. (Three letter of support are required at the advanced-clinician level and four letters are required at the clinical-scholar level.) These letters allow colleagues to describe the applicant’s practice while commenting on any or all of the themes of practice.
• a resume/curriculum vita, chronicling the clinician’s professional accomplishments.

Clinical recognition review board

The clinical recognition review board is comprised of 12 members. The review board will have representation from all disciplines eligible for the Clinical Recognition Program. Each member represents his or her discipline and is accountable for ensuring the integrity of the program. Two members of the board from different disciplines will be identified as co-chairs. Similar to the collaborative governance model, a coach will be assigned to support the co-chairs. Members of the review board will serve for 2–3 years.

(Initially, a transition board will be appointed to recognize staff at the advanced-clinician and clinical-scholar levels. The transition board will be comprised of leadership and clinicians familiar with the program, representing all disciplines. Members will serve on the transition board until clinicians currently practicing at the advanced-clinician and clinical-scholar levels have been recognized and appointed.)

The review process

Portfolios will be reviewed and discussed by all members of the board. The co-chairs will then identify a 3-member ‘review team’ to conduct an in-depth review of the portfolio and interview the clinician. The interview will focus on clinical practice and evidence supporting appropriate themes of practice. One member of the review team will be from the clinician’s discipline. Following the interview, the review team will summarize their recommendations to the review board.

Clinicians will be notified of the review board’s decision within three months of the application date. If recognized, clinicians will receive a congratulatory letter. If not recognized, clinicians will receive a letter with recommendations regarding their portfolio and/or practice. Clinicians will have the opportunity to meet with a member of the review team to discuss the board’s decision. The goal of the review board is to help clinicians be better prepared if they need to re-apply for recognition. Clinicians may submit a re-application at any time.

Clincians must practice at the level for which they are seeking recognition for at least six months before applying. For example, advanced clinicians would have to wait at least six months after being recognized at that level before applying for the clinical-scholar level.

Managers and directors will be notified of the review board’s decision (to recognize or not) but will not receive detailed information about the reasons for the decision. Clinicians may choose to share this information; but it is the responsibility of the board to keep this information confidential.

Re-appointment and re-application

The desire to have clinicians consistently practice at their recognized level is an important aspect of this program. Decisions about re-appointment and re-application will be made over the next few years as clinician input and program-evaluation data become available.

The Employee Assistance Program

presents

"Eldercare Planning"

Presented by Barbara Moscowitz, LICSW, MGH Senior Health

Program will define available resources, and show how family members can work together to find assistance that suits everyone’s needs.

February 14, 2002

12:00–1:00pm

Wellman Conference Room

For more information, call 726-6976.

New England Regional Black Nurses Association

celebrates

National Black Nurses’ Day

with a special historical presentation, slide show, and award ceremony

February 19, 2002

5:30–6:30pm

O’Keeffe Auditorium

Reception to follow in Trustees Room, Bulfinch 225

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Program Signature

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Education

Learning more about the Clinical Recognition Program

—by Carol Camooso Markus, RN, and Ann Daniels, LICSW, co-chairs, Clinical Education Workgroup

In January 18, 2002, Jeanette Ives Erickson, RN, senior vice president for Patient Care, introduced the Clinical Recognition Program by sending a letter and brochure to every clinician’s home. The brochure provided a brief overview of the program and included a calendar of educational sessions that will be offered during February, March and April to inform staff about the Clinical Recognition Program.

In addition to the educational sessions, written information will be available in a number of formats. Each eligible clinician will receive a folder of information containing the Clinical Recognition Program brochure, a self-reflection tool describing the levels of practice for his/her discipline, and a packet of information explaining the application process for advanced clinician and clinical scholar. The folder will include instructions on how to write a clinical narrative.

The same information will be available in a notebook in every patient care area, department office, and health center. Another source for this information will be the Clinical Recognition website, which is accessible through the Patient Care Services webpage.

Educational sessions offered during February, March, and April, will provide clinicians with general information about the program and individualized assistance in understanding their participation in it. Some sessions will be centrally located; others will be offered in various inpatient and outpatient settings. Locations may vary, but the content of the sessions will be the same. Information will be provided for approximately 30 minutes; and time will be allotted afterward for questions and answers. Sessions will touch on:

• background of the program, including the work of the Professional Development Committee and how themes and levels of practice were developed
• the skill-acquisition model, which provides the theoretical framework for the program
• benefits to you and the organization
• a description of the themes and levels of practice
• how clinicians move from one level to the next
• ways to help identify your level of practice.
• resources available for assistance

Registration is not required at any session, and you may attend as many sessions as you feel would be helpful.

To maximize attendance at unit and department sessions, a designated clinical recognition resource nurse on each unit will carry a pager (from 7:30am to 5:00pm). Each designated resource nurse will be a point person to coordinate and accommodate any changes that may occur on the unit that would necessitate a change in the scheduling of educational sessions. The pager number of each resource nurse will be posted on the unit. This person may be contacted to request additional seesions, cancel a session, or answer any questions pertaining to the Clinical Recognition Program.

For clinicians who have additional questions or need more time to discuss the process, special working sessions will be offered throughout the day to respond to your individual needs. Working sessions will be offered in two-hour blocks, and you may come and go at your convenience.

For more information about educational sessions, speak to the clinical leadership in your area or contact a member of the Clinician Education Workgroup:

• Ann Daniels, LICSW, co-chair, 6-2657
• Carol Camooso Markus, RN, co-chair, 4-7306
• Jane Harker, RN, 6-8084
• Theresa Gallivan, RN, 4-1767
• Carol Mahony, OT/R, 4-0147
• Paige Nalipinski, SLP, 4-0766
• Cathy O’Malley, RN, 6-8910.

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Fielding the Issues

The PCS Clinical Recognition Program

The Fielding the Issues section of Caring Headlines is an adjunct to Jeanette Ives Erickson’s regular column. This section gives the senior vice president for Patient Care a forum in which to address questions presented by staff at meetings and venues throughout the hospital.

Question: How did the idea for the Clinical Recognition Program come about?

Jeanette: Shortly after becoming senior vice president for Patient Care Services, I began hearing from staff about their desire to have clinical practice formally recognized. The subject came up in rounds, at staff meetings, and in comments submitted with the Professional Practice Environment Survey. I charged The Professional Development Committee with creating a framework for a clinical recognition program in response to these inquiries from staff. Following a key principle of our collaborative governance model, committee members were primarily staff clinicians. I like to think that one of the many ways this program is unique is that it was both inspired by, and has been extensively shaped by, our clinical staff.

Question: How does the Clinical Recognition Program fit with other Patient Care Services initiatives and priorities?

Jeanette: The Clinical Recognition Program is a major component of our five-year strategic plan. The program and the value it places on quality patient care and clinical excellence provide a strong incentive for clinicians to stay at MGH. By design, the program communicates respect for direct-care providers. I feel very strongly that this program will help attract other qualified clinicians to MGH and help us meet our retention and recruitment goals.

Question: How will other Patient Care Services award and grant programs be affected by this program?

Jeanette: In Patient Care Services we are fortunate to have many ways of recognizing and showing our appreciation for the work of clinical staff. Respiratory Care’s Excellence in Service Award, Physical Therapy’s Mankin Award, our Family-Centered Care Awards, and the Stephanie Macaluso Award for Expertise in Clinical Practice are just a few of the ways we celebrate good practice. Recognition in Caring Headlines, fellowships, and participation in collaborative governance are other ways for clinicians to gain recognition. The Clinical Recognition Program does not seek to replace any of our existing avenues for recognition; rather, it provides another way to demonstrate the value we place on the contributions of clinical staff at all levels. The Clinical Recognition Program complements our existing award landscape.

Question: What challenges do you anticipate as the program rolls out?

Jeanette: The Clinical Recognition Program has been well thought out and is off to a strong start. However, as is true of any new program, we know there will be challenges in the months ahead. In anticipation of those challenges, we will make every effort to:

• Develop a consistent understanding and implementation of the program throughout Patient Care Services. Patient Care Services encompasses more than 3,000 individuals and many different practice areas. We will be challenged to support every clinician in her/his effort to learn about, and participate in, the program. Because it is important that each clinician understand the concepts and structure, we will offer numerous educational sessions for staff over the next few months.
• Ensure the integrity of the program while allowing for discipline-specific variations. One of the unique characteristics of this program is that it encompasses six different disciplines. As we go forward, we need to continually assess how and when to adjust aspects of the program to meet the needs of all disciplines. Each change must be considered thoughtfully so that the program’s core principles are preserved and the integrity of the program is not compromised.
• Evaluate and revise the program as it moves forward. Inevitably, we will find that elements of the program don’t work as envisioned and need to be adjusted. In fact, some key decisions regarding program structure have been delayed so that clinicians experiencing the program first-hand can help guide that decision process. As the program unfolds, I encourage all clinicians throughout Patient Care Services to share their insights about what works and suggestions about how to make it better.

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Clinical Narratives

How to write a clinical narrative

What is a clinical narrative?

A clinical narrative is a ‘story’ written by a clinician that describes, first-hand, a specific clinical event or situation. Writing narratives allows clinicians to describe or illustrate their current practice in a way that can be easily shared with colleagues. Narratives help clinicians examine and reflect on their clinical practice or analyze a particular clinical situation.

What should a narrative be about?

When writing a clinical narrative, choose a clinical event or situation that holds some special meaning for you, one that reflects your current clinical practice.

Examples might include:

• an experience with a patient or family that illustrates how your intervention made a difference in the patient’s outcome
• a clinical experience that was particularly demanding
• an event or situation that you think captures the essence of your discipline
• a situation that you commonly confront in your practice and that gave you new insight into your role as a professional clinician

Often, a single event shares several of these characteristics and can serve to showcase multiple aspects of your practice.

What information should be included?

When writing a narrative, be sure to include details and information that help the reader to visualize the situation and understand its context. Remember that the reader may be unfamiliar with your clinical role and overall approach to patient care. Use the narrative to describe yourself and your role, and to illustrate how you approached a challenging patient-care situation.

Some elements to include are:

• information about yourself including your name, title, unit, and length of time you have practiced
• information that allows the reader to put the situation in context such as a description of where the event took place, the time of day or shift on which it occurred, a description of special conditions on the unit, and details about the patient’s background
• a detailed description of what happened
• statements about what concerned you at the time
• a description of your feelings and thoughts during and after the situation
• a discussion about what, if anything, you found most demanding
• important conversations you had with the patient, family, members of the healthcare team, or other relevant parties
• reflections about why this clinical situation was important to you.

Writing a narrative

• Present your story as a first-person account (using the pronoun, ‘I’). In the interest of confidentiality, change the patient’s name and any other identifying information.
• Some people find it helpful to ‘tell’ their story into a tape recorder, then transcribe the tape and edit it, removing any unnecessary details and adding any missing elements.
• Your narrative should be 1-3 typed pages in length (with ‘comfortable’ spacing).
• Review your story with a colleague who also cared for this patient. This may help to identify additional details and information that should be included.
• Have someone who doesn’t know the patient read your narrative to see if you missed any important information or left any questions unanswered. A neutral, or uninvolved, reader can often help identify details you may have inadvertently omitted.
• Avoid using vague summary statements or general phrases that don’t fully communicate what occurred. Instead, state what happened in specific terms. This will help the reader understand the situation and appreciate your actions. For example:

Instead of saying: "I analyzed the possible dangers to the patient and took action."

Say: "Her blood pressure was dropping and her pulse rate was rising. I sensed she was going into shock. I immediately called the intern."

Instead of saying: "I provided emotional support."

Say: "I sat and talked with Mr. B about how to tell his family about the diagnosis."

• Be sure to describe what concerned you and what prompted you to take a particular action. This type of information gives readers a window into your thought process and insight into the way you make clinical judgments. "I thought the patient would be resistant, so I decided to..."

How are narratives used in the Clinical Recognition Program?

Because they provide insight into clinicians’ current level of practice, narratives are an important component of the recognition process. Clinicians seeking recognition at the Clinician level are asked to write a narrative to be reviewed and discussed with their manager or director. Those seeking recognition at the advanced clinician or clinical scholar level must include a narrative in the portfolio they submit to the Clinical Recognition Program Review Board.

Your Opinion Counts!

Staff Perceptions of the Professional Practice Environment Survey – 2002 Reminder!

Surveys are due back by February 22, 2002.

If you have not yet received a survey, call The Center for Clinical & Professional Development at 726-3111.

All individual responses will be kept confidential. Please complete and return your survey by February 22nd.

Your voice is important!

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