Exemplary Professional Practice: Accountability, Competence and Autonomy EP15 Nurses at all levels engage in periodic formal performance reviews that include a self-appraisal and peer feedback process for assurance of competence and continuous professional development. EP15a: Provide an example, with supporting evidence, of clinical nurses using periodic formal performance review that includes a self-appraisal and peer feedback process to enhance competence or professional development. Introduction In their 2014 position statement on professional role competence, the American Nurses Association wrote that “the public has the right to expect registered nurses to demonstrate professional competence throughout their careers... the employer is responsible and accountable to provide an environment conducive to competent practice. Assurance of competence is the shared responsibility of the profession, individual nurses, professional organizations, credentialing and certification agencies, employers, and other key stakeholders.” One way to ensure the competence of clinical nurses and to promote their professional development is through formal performance review. The importance of the annual performance review is codified in Massachusetts General Hospital (MGH) and MGH Department of Nursing policies:

• The 2016 MGH Human Resources “Performance Evaluation” policy (attachment EP 15a.a) states “it is expected that the process of Performance Evaluation be an ongoing dialogue that occurs informally on a day-to-day basis. The written Performance Evaluation is only one step in this process. It is required that every employee receives this written evaluation of his/her work performance on at least an annual basis. The evaluation shall be based on the employee’s work performance and on expectations/standards communicated to the employee by management.”

• The Department of Nursing policy titled, “Registered Nurse Annual Performance

Evaluation” (attachment EP 15a.b), states that “nurses who are organizationally accountable for this process (i.e. “nurse manager”) evaluate Registered Nurses.” The required components of each performance appraisal are: self-evaluation, peer review and manager evaluation. In reviewing these three components the nurse manager and the employee develop and agree on professional development goals for the upcoming year.

Elements of the Performance Appraisal The Performance Appraisal for the clinical nurse occurs in a face-to-face meeting between the clinical nurse and his/her Nursing Director (ND) and is comprised of:

• Self-evaluation including a review of the past years goals and their status • Goals for the next year • Standards of Behavior—MGH Mission, Credo and Boundaries/Confidentiality

Agreement • Nursing Director’s evaluation and comments • Peer Review • Clinical Narrative

Each element of the Performance Appraisal process is described below. Self-evaluation and Review of the Past Year’s Goals Self-evaluation allows clinical nurses to reflect on their performance over the past year focusing on times of growth and accomplishment as well as identification of challenges and opportunities. The format for the self-evaluation focuses on five areas of clinical practice:

• Clinician/Patient Relationship • Collaboration/ Communication/Teamwork • Clinical Knowledge and Decision-Making • Professional Development • Quality and Safety, Practice Improvement and Innovation, and Efficiency.

These themes reflect components of Nursing & Patient Care Services’ Professional Practice Model and Clinical Recognition Program and the accountability and responsibility of clinical nurses to continually pursue their professional development. Clinical nurses rate themselves on a scale from 1 (unacceptable) to 5 (exceeds expectations) for each element. The ability to reflect on the past year allows clinical nurses to review their past year’s goals and the status of those goals. This level of review ensures accountability for goal attainment and if the goals were not attained, a chance to dialogue with the ND on why they were not achieved and what support is required to achieve them. Employee Goals for the Coming Year Given the unique role nurses play in healthcare and society, nurses constantly strive to develop and challenge themselves to learn as a way to grow in their practice. Through goal setting, the clinical nurse is able to identify opportunities for professional development, to ensure competence in the delivery of care, and to improve the care of patients on their units and across the hospital. The ND and clinical nurse mutually agree on the goals for the coming year.

Standards of Behavior—MGH Mission, Credo and Boundaries/Confidentiality Agreement All MGH employees annually attest that they will adhere to the hospital’s mission, credo, and boundaries and confidentiality agreements. In doing this, employees commit to the well-being of our patients by providing high-quality, compassionate and culturally-sensitive care and to adhere to all MGH policies and procedures. All MGH employees annually attest that they will uphold their ethical and legal responsibilities to maintain the confidentiality of patients and their health information. Peer Review Peer review is defined by the American Nurses Association as, “the process by which practicing registered nurses systematically assess, monitor, and make judgments about the quality of nursing care provided by peers as measured against professional standards of practice.” The MGH Nursing Peer Review tool requires the clinical nurse to ask a colleague to complete a peer review on one of three themes: clinical knowledge and decision-making, clinician/patient relationship, and teamwork and collaboration. These themes were adopted from the Nursing and Patient Care Services (N&PCS) Clinical Recognition Program. The peer evaluator is asked to select one theme they identify as strengths in the clinical nurse’s practice and one theme where there is a practice development opportunity. The form is signed by both the peer evaluator and the clinical nurse being reviewed. Clinical Narrative Clinical narratives are a component of the N&PCS Professional Practice Model and once a year, clinical nurses across N&PCS submit a narrative as part of their annual performance appraisal. Inclusion of the narrative is an opportunity for the clinical nurse to reflect on and discuss his/her practice with their ND through the story of a patient. The occassion for the ND to listen and engage with the clinical nurse on the care of their patient begins a conversation which allows the performance appraisal to come alive and opportunities to ensure competence and professional development may be identified during this discussion. Nursing Director’s Evaluation and Comments The ND carefully reviews the clinical nurse’s self-evaluation and their rating for each area of clinical practice as well as the previous year’s goals and the goals for the coming year. They then give their own rating for each area of clinical practice and comment on the clinical nurse’s performance over the past year. The clinical nurse is then able to write any comments they have based on the performance appraisal.

The following example of a formal performance review of a clinical nurse illustrates that self-appraisal and peer feedback can contribute to the ongoing process to enhance the nurse’s competence and professional development. Example Karen Rosenblum, RN, BSN, is a Clinical Nurse and Attending Registered Nurse (ARN) on the Psychiatry Unit (Blake 11). The ARN is a unit-based clinical nurse who, through leadership and coordination, ensures continuity from admission to discharge, by facilitating the plan of care with the nurse caring for the patient, the patient and family, and the interprofessional team. Approximately one month prior to her evaluation date (November 20, 2016), Rosenblum was notified by her ND, Tina Stone, RN, MSN, PMHCNS-BC, that her performance appraisal was due and sent her the performance appraisal documents. Stone asked Rosenblum to return the completed forms to her at least one week prior to her scheduled appraisal (attachment 15a.c). In her self-assessment of the five clinical practice areas, Rosenblum ranked herself in each area a 5. A 5 is defined as “exceeding expectations, the employee’s performance is outstanding and extends beyond expectations.” In reviewing her achievement of her 2016 goals:

• Maintain and hope to improve the ARN driven quality metrics (reduced length of stay; increased pre-noon discharges)

• Continue her education toward achieving certification.

Rosenblum noted that while her goal to improve the ARN-driven metrics had been met, she had not yet achieved her professional development goal of achieving professional certification. She hoped to achieve this goal in the coming year and added it to her 2017 goals. Rosenblum completed her Healthstream modules on MGH Standards of Behavior (includes Mission, Credo and Boundaries) on October 25, 2016 and the Confidentiality Agreement on November 2, 2016. Rosenblum asked her colleague, Clinical Nurse Denise Studley, RN, BSN, RN-BC, to be her peer reviewer. Studley described Rosenblum. as someone “who has always been able to share her knowledge of the patients and their conditions with the residents, interns and nursing staff.” Studley also noted that Rosenblum “is always willing to help out whenever we need her. She will assist staff with ADLs, restraint issues, and discharges when they are complex and the staff nurse needs assistance.” Studley reinforced the need for Rosenblum to attain her goal of enhancing her professional development by taking a professional certification exam. Studley wrote that “clinical knowledge and decision-making are truth strengths of Rosenblum. Staff go to Rosenblum because of her vast knowledge of psychiatric nursing and clinical issues. I

believe she should take the opportunity to sit for the certification exam in psychiatric nursing.” Stone supported Rosenblum’s assessment that her practice “exceeded expectations.” She noted that Rosenblum has continued to help all of the teams focus on the goals of admission for each patient which continues to contribute to a decreased length of stay (around 9 days) and a marked increase in pre-noon discharges. Stone also commented on Rosenblum’s impact on quality improvement measures as well as taking on the role of co-chair of the ARN group. Stone and Rosenblum discussed steps that she needed to do to achieve the goal of professional certification. Rosenblum noted that her participation on the RN substance abuse education pilot is the incentive she needed to achieve certification as a Certified Addictions Registered Nurse. Stone and Rosenblum agreed on the following goals for 2017 which would continue to support her professional development:

• Participate in the RN substance abuse education committee. • Sit for the Certified Addictions Registered Nurse exam. • Co-chair the ARN group • Serve on the Peer Review Revision Process Team which will give feedback to

nurse leaders on opportunities to improve Nursing’s peer review forms and process.

Rosenblum shared her narrative with Stone which focused on her care of RM, a 34-year-old woman who suffered from depression, alcohol and opiate use disorder, and a seizure disorder. RM was admitted to Blake 11 with suicidal ideation following significant alcohol use. When she meets RM, Rosenblum’s skill and empathy are evident when she recognizes that RM is embarrassed that she was been re-admitted. Rosenblum immediately puts her at ease by reassuring her “We are not here to judge, but rather to help during this difficult time.” Rosenblum’s role as the ARN allows her to provide consistency for RM as she works to adjust and engage in the therapeutic milieau. Rosenblum used her skill and humor to encourage RM’s participation, “I would use humor to point out her reluctance to participate. This was an effective way to connect with RM who struggled with the dichotomy of her high functioning successful self and her current situation of being a patient on an inpatient psychiatric unit.” Her alliance with RM is tested as the team began to plan for RM’s discharge, a subject that she and her parents had struggled with. Rosenblum wrote “I challenged her resistance. I understood that she was not acknowledging her own anxieties rather externalizing them. I challenged her negative thinking. I challenged her fears and offered support.” At the family meeting prior to discharge, Rosenblum recognized RM’s parents’ anxiety and fear that RM would repeat past behaviors. Again Rosenblum shows her skill by writing, “I was comfortable being direct in addressing their fears in the meeting and did

not avoid the difficult conversations...I had established a rapport with RM that was both compassionate and firm.” RM was successfully discharged home and Rosenblum continued to speak with her as she transitioned. Rosenblum worked with RM on managing her AA meetings and finding a long term care substance abuse program in her town. Rosenblum offered support and advice to RM and, as she transitioned to a new normal, RM felt a new emotion, hope. “She thanked me for being available to answer all of her questions and being a support during and after her hospitalization.” Stone and Rosenblum discussed her narrative and her skill in managing a complex, treatment adverse patient as well as her frightened parents. Together, they identified the importance of her role as an ARN in providing continuity for the patient and the team during the patient’s stay and her transition home. The above example demonstrates how the annual performance appraisal enhances the clinical nurse’s reflection, achievement of goals and professional development. References American Nurse Association Statement on Competence (2014) Silver Springs, MD American Nurses Association (1988) Peer Review Guidelines. Silver Springs, MD.

Massachusetts General Hospital Clinical Nurse Annual Performance Evaluation Form

Employee ID#: 3017973 Department:Blake 11 Employee Name: Karen Rosenblum

Name and Title of Evaluator:Tina Stone Effective Date of evaluation: 11/20/16

Level 5 Exceeds expectations: The employee's performance is outstandinq and extends beyond expectations. Level4 Fully meets expectations: Performance meets expectations. Level 3 Acceptable with room for further development: Performance meets expectations. Some further development

necessary before the full expectations of the position are realized. Level 2 Needs improvement: Performance not meeting expectations. Improvement necessary. Level 1 Unacceptable: The employee's performance in this area is unacceptable. Immediate improvement must occur.

Employee Director Clinical Practice Standards Self Assessment

Assessment Rating (1-5) Rating (1-5)

1. Clinician / Patient Relationship • Provides competent, compassionate patient 5 § & family-centered nursing care

• Assesses and identifies unique and diverse needs of each patient, and develops patient specific plan of care

• Advocates for patients and families2. Collaboration/Communication/Teamwork • Collaborates with all members of the health 5 §

care team to ensure the best possibleoutcomes for patients

• Interacts effectively with colleagues andemployees throughout the organization.

• Effectively articulates own perspective whiletaking into consideration conflicting viewsand/or positions

Attendance:

re Meets standards r Needs improvement

C Unacceptable

3. Clinical Knowledge and Decision Making • Utilizes evidence based practice 5 §

• Seeks out and accesses resources and expert colleagues to ensure the highest standards of clinical care

4. Professional Development • Maintains and updates clinical knowledge 5 § and skills based on current education,research and evidence

• Identifies specific learning needs and goalsand develops a plan to meet them

• Collaborates with unit based nursingleadership to identify developmental needsand level of practice (Clinical RecognitionProgram and Certification)

5. Quality and Safety • Participates in problem solving, process 5 § Practice Improvement and Innovation improvement and advancing quality patientEfficiency outcomes i.e. falls reduction, patient

satisfaction • Contributes and adapts effectively to

change • Reports and participates in the examination

of errors/incidents/near misses and shares learning

• Effectively and efficiently utilizes resources

Last Updated: 11/10/15

Employee Director MGH Performance Appraisal Summary Self Assessment

Assessment

Overall Rating (take total score and divide by 5): 5 5

Goals/Develooment Section

Goals for the previous year

1. Maintain and hope to improve the ARN driven quality metrics (reduced LOS, increased pre noon discharges) 2. Ongoing continued education with an eye toward certification

Were goal(s) achieved?: Yes [ ] No [ Some were achieved, but not all [ x ] N/A [

Incorporating feedback from the self-evaluation, peer review and manager's assessment, the following mutually agreeable goals have been established for the coming year:

1. Participate in the RN substance abuse education and take CARN exam 2. Ongoing growth in the ARN role, serve as ARN co-chair, serve on the Peer Review Revision Process Team

Comments Section

Evaluator's Comments:

Karen is an outstanding psychiatric nurse serving in the ARN role on Blake 11. She continues to provide expert

guidance to patients and families. She has continued to help all of the teams to focus the goals of admission for

each patient which continues to contribute to a decreased length of stay (ALOS around 9 days) and a marked

increase in pre-noon discharges (45%). Karen continues to impact and sustain the quality improvements measures

that were established when we became an innovation unit. It is a pleasure to work with and supervise Karen. She is

an expert Advanced clinician and highly regarded by her peers. I continue to support Karen in her efforts to expand

her influence outside of Blake 11 and am thrilled she has been asked to consider co-chairing the ARN group. Karen

is also planning to participate in the RN Substance Abuse education pilot and sit for CARN certification.

Employee's Comments:

My goal is to continue to work closely with multidisciplinary teams to meet goals of inpatients and their families. I

will stay actively involved in developing and implementing treatment plans for difficult patients.

The signatures indicate that the employee and evaluator have discussed the information contained in this form.

For electronic submission of the completed performance appraisal, the employee and the evaluator names may be

typed. This will serve as the employee's and evaluator's signature, indicating that the information contained on this

form has been discussed. The evaluator will also copy the employee on the electronic submission of the

performance appraisal sent to mghperformanceappraisals@partners.org.

_Karen Rosenblum RN ________ _

Employee's Signature or Typed Name if submitting

electronically

_ Christina Stone RN ________ _

Evaluator's Signature or Typed Name if submitting

electronically

Last Updated: 11/10/15

_11/20/2016 _________ _

Date

_11/20/2016 ________ _

Date

MGH Nursing Peer Review Tool - Staff Nurse

Nursing Peer Review (NPR) "is the pr cess by which practicing registered nurses systematically assess, monitor, and make judgments, about t e quality of nursing care provided by peers as measured against

professional stand rds of practice" (American Nurses Association).

ulation and enhances individua[accoun!ability for patient outcomes.

Clinical Knowledge and Dejision MakingClinician Patient Relationship Collaboration/Teamwork

D Strength C8J Opportunity D Strength D Opportunity C8J Strength D Opportunity

• Select 1 Theme from above and write a brief description

Collaboration and Teamwork comes naturally to Karen. Karen has always been able to share her knowledge of the patients and their conditions with the residents, interns and nursing staff. Karen has advanced psychiatric nursing experience that supports the newer nurses and those of us who work part time and are newer to psychiatric nursing.

1 Karen is also always willing to help out whenever we need her. She will assist staff with AD Ls restraint issue and discharges when they are complex and the staff nurses need assistance.

• Select 1 Theme from above and write a brief description

Clinical Knowledge and Decision making are a true strength of Karens. Staff go to Karen because of her vast knowledge of psychiatric nursing and clinical issues. Because of this, I believe that she should take the opportunity to sit for the

1 certification exam in psychiatric nursing. She would easily pass the certification exam with her clinical espertise and

! expert knowledge.

Version: 3.30.17

:

CC:rrtifiratr of C!rontpletton

This is to Certify Karen Rosenblum

has completed the course "MGH Standards of Behavior"

10/25/2016

8HeolthStream

Healthstream.com/HSAPP /Transcript/Certificate?courselnstanceld=c044c500-... 4/13/2017

QL:rttif irntr of QI:01npletton

This is to Certify Karen Rosenblum

has completed the course "PHE Confidentiality Agreement"

11/2/2016

.HealthStream

healthstream.com/HSAPP/Transcript/Certificate?courseinstanceid=a2098db5... 4/13/2017

Clinical Narrative

November 1, 2016 Karen Rosenblum RN

R.M. is a 34 year old woman with a history of depression, alcohol use disorder,

opiate use disorder and a seizure disorder who was re admitted to Blake 11 sixmonths after her initial Blake 11 hospitalization. She endorsed suicidal ideation inthe context of significant alcohol use. She had successfully completed her graduate

degree in Psychology and had been living and teaching in LA until her addiction to

opiates forced her to return to her parent's home in the Boston area about eightmonths ago. She initially came to Blake 11 with her parents for worseningdepression with suicidal ideation and opiate use. R.M. shared with me she was no

longer using opiates but her alcohol use had increased significantly. She felt isolated

at her parent's home and because of her seizure disorder she was unable to driveand stopped going to her appointments. R.M. reported that she became increasinglydepressed and her alcohol use had increased significantly. About nine days prior tocoming to MGH R.M overdosed on sleeping pills, clonazapam, lorazapam, tizanidine

and alcohol. She wrote a suicide note and was shocked when she woke up. The night

prior to admission R.M broke up with a man she had been seeing, had a "breakdown", told her parents and decided to come to the ED

I remember when I first saw R.M. in the dayroom of Blake 11. I recognized her from

her prior admission to Blake 11 and immediately reintroduced myself as the

Attending Registered Nurse (ARN). She remembered me as well, yet I sensed that

she felt embarrassed about another admission stating "I am back. .. " allowing her speech to fade off and then looking down at the ground. I sensed how bad she was

feeling about herself. I reassured her that we were not here to judge but rather to

help her during this difficult time. She smiled, seemed reassured and we briefly

spoke about what brought her to the hospital.

I reminded R.M. that my role as ARN would include being a member of her treatment team and her "nurse for the stay". The ARN's relationship was in addition

to her assigned RN. I would work with the various disciplines as we developed a

treatment plan for her hospitalization and would help move the plan forward and

keep the team focused on her goals as she moved toward discharge. As discharge neared I would be certain all the pieces were in place so that she would have a smooth transition as she left the hospital. R.M. seemed to understand that my role

was to help her successfully navigate the hospitalization and I would act as a liason between she and the team should any questions/concerns come up outside of our

daily team rounds meeting.

This is my role for all of the 24 inpatients on Blake 11. Each day I round formally on

as many patients as I can and juggle the demands of four different interdisciplinary

teams. I prioritize to best meet the needs of all of the patients while maximizing the

and addressed some of her own issues around emotional stability as she worked

toward discharge.

During my frequent check ins I offered support to RM. as she struggled with the

idea of discharge. I challenged her resistance. I understood that she was not

acknowledging her own anxieties but rather externalizing these negative feelings. I

gently confronted her and offered ideas where she placed blame. One example was

her fear of isolation. RM. was blaming the team for sending her back to the same

environment that she came from; her parent's home where she was alone all day

while they worked and where she was drinking. She blamed the team for setting up

programs when she could not drive. I reminded RM. that in fact she had taken cabs

to the liquor store to buy alcohol. I offered the productive solution of taking a cab

( or even Uber) to an AA meeting once or twice a day until her long -term program

was firmly in place. I continued to challenge her negative thinking. I used humor and

a direct and supportive approach. But most importantly I challenged her fears and

offered support. I understood that leaving the safe environment of the hospital can

be frightening. I normalized her feelings and shared that the team understood that

she (and her parents) may have some anxiety about discharge. This was normal and

did not necessitate that she stay longer.

Due to my strong alliance with RM., the social worker requested that I be present at

the second family meeting that was scheduled on the day of discharge. As the ARN I

often work with the families of our patients. The families get to know the ARN when

they visit the unit on a regular basis as the ARN is a regular and consistent RN on the

unit who is present and active in the milieu. I knew RM.'s parents so it made sense

that I attend the family meeting on the day of discharge.

RM. was angry with the team for setting up a discharge date. She felt it was too soon

and expressed to the team that we did not understand her. She refused to pack prior

to her family meeting hoping that her discharge would be postponed. The Social

Worker, Resident MD and I all met briefly prior to the meeting. We had a clear plan

for discharge as we had reviewed with RM. and we were ready to discuss and

address any concerns with the family and the patient. We anticipated the meeting

would be difficult due to the patient and family's resistance. Her RN felt it was in the

best interest of the patient for the staff who had developed a consistent and trusting

relationship to be present at the family meeting. Because of this, RM.'s nurse chose

not to go to the meeting. I reviewed the treatment plan with her RN and reassured

her that although this may be a challenging discharge I was confident that it was

going to be successful.

It was evident at the start of the meeting that RM.'s parents were anxious about her

returning to their home and fearful that she would repeat past behaviors. I was

comfortable being direct in addressing their fears in the meeting and did not avoid

the difficult conversations. I established a rapport with R.M. during her

hospitalization that was both compassionate and firm. I knew that I needed to

provide the same balance of limits and compassion when speaking to RM.'s family

flow of the unit. This includes facilitating early discharges, as well as working with

each team to develop effective interdisciplinary treatment plans to manage the

acutely ill and sometimes behaviorally dysregulated patients.

In RM.'s case I understood quickly what my role would include. Based on her personality traits I knew immediately that frequent check-ins, regular attendance at

her daily rounds and helping her at discharge would all be part of my role as the

Blake 11 ARN. I understood her potential to "split" the different staff on the team

and divide them as "good" and "bad" This was not intentional but rather part of her

coping skills she had developed over the years. RM. had a significant trauma history and these behaviors developed as a way to cope. They were a result of her trauma.

Understanding and recognizing these coping strategies are an important part of

being an effective psychiatric nurse. Because I was available every weekday I could

help her with the consistency that was so important to her care and be instrumental

in not allowing her to struggle with different team members, disciplines or nurses

that she was assigned to each day. These behaviors would detract from her overall

goals and help her move toward sobriety. I could also be available to the RN

assigned to RM. to help each nurse better understand R.M's goals and help R.M

achieve these goals by working on the treatment plan and not undermining the plan

by struggling with an assigned nurse.

Initially, RM. was reluctant to participate in the milieau. The team recommended

that she attend groups and work on her sobriety plan. Each day she busied herself

with visitors and isolated herself in her room. She often had a reason as to why she

missed the groups. Perhaps R.M. was not feeling well as she was adjusting to her sober self. After two days she was able to acknowledge to the group that she did

believe she was an alcoholic. This was a difficult but important part of her treatment

plan. By the third day on Blake 11 RM. began to attend a few groups. It was slow at

first but she was willing to come out of her room more. Her assigned nurse and I

often had to remind her when it was group time. I would use humor as I pointed out

her reluctance to participate. This was an effective way to connect with R.M. who

struggled with the dichotomy of her high functioning successful self and her current

situation of being a patient on an inpatient psychiatric unit. But she was a person.

She was bright, intelligent and had a good sense of humor. Humor was a good way to

connect with her and at the same time be gently firm and direct about her care.

And then it was time to plan a family meeting and discuss a discharge plan.

This did not go well. The social worker on the team met with RM. and her parents.

Her parents struggled with the social worker and had unrealistic expectations about

how long R.M. would stay on Blake 11. R.M. and her parents were angry with the

team for discussing discharge. R.M. was not working on her sobriety plan. She did

not want to work toward discharge. She feared returning to her parent's home

where she was lonely and isolated and drank. Her parents feared for her safety and

were anxious about her coming home. R.M. met with the psychologist on the team

during the meeting. As a team we answered many of their questions and continued to reiterate the importance of RM.'s "buy in" to the follow up treatment plan. During

the meeting I intentionally was clear and direct with my communication, and I emphasized the importance of clear and direct communication within their family. I

felt that modeling this behavior was an important part of the meeting as well. The

meeting progressed as we had planned and RM. and her parents felt more

comfortable with the many follow up appointments and programs that were in

place. R.M. even agreed to schedule an AA meeting for that evening to provide her

the structure that had benefitted her during her hospitalization.

I believed that RM. and her family were well prepared for discharge. I shared this

with RM. I knew that we had developed an alliance and that she benefitted from the

ongoing structure and boundaries that I provided for her during her hospitalization.

It was evident to me that RM. not only saw me as a trusted member of the team but

she felt safe sharing her feelings and concerns with me.

RM. and her family left shortly after the meeting and RM. felt ready to move her

care into the community.

The following day I spoke to RM. As a trusted member of her treatment team she

wanted to share her progress with me. She also wanted to share her fears that

things may not work (her pattern of negative thinking). She sought me out for my direct and clear feedback and my ability to gently remind her that she needs to

participate in her own care. RM. told me that although she did attend an AA meeting

the previous night she was feeling overwhelmed with how to access the long term

program near her home. I offered her support and discussed ways to help her bridge

her care. I reminded her that the program intake appointment was approaching and

she still had to go through a screening process. I commended her strength to attend

the AA meeting and encouraged her to continue to get her needed structure through

at least one AA meeting a day but that two would be ideal. I knew the value of

pushing her to reach her goals and teaching her to believe in her true self. She

benefitted from my honest and direct approach. I also reviewed her other

appointments and supports and reminded her that she was still on waiting lists for

other long term programs that she had applied to months earlier.

RM. called me again the following day. She was still attending AA meetings but

learned that she would probably not get in to the day program at the nearby

hospital. I continued to encourage AA meetings as well as Healthy Recovery and

suggested she be open to a sponsor. I continued to be firm and direct and was

careful to maintain the role of caregiver and maintain these boundaries. I shared

that the value of the sponsor would be to offer her support and guidance as she

continued on the journey toward sobriety.

RM. called again the following day. Her connection to me was evident. She had some

questions regarding her medications. I coordinated with the MDs on her inpatient

team to fill out paperwork so RM. could get one of her medications in a formulation

with which she was more comfortable. I returned her call later that afternoon. I

knew it was important to get back to her in a timely manner in order to maintain her trust. I was happy that she continued to benefit from the support and reassurance I

offered even after she left the hospital. I understood she trusted me because I

continued to be direct and clear with my responses. This therapeutic dialog is what R.M. responded best to during and after her hospitalization.

During our last conversation R.M. shared that she had indeed been accepted to a

long term program that would be starting the following week! R.M. was looking

forward to beginning this new chapter of her life. And the program provided transportation! R.M. was feeling more hopeful than she had in a long time. She

thanked me for being available to answer all of her questions and being a support

for her both during and after her hospitalization.

I hope that things continue to move in the right direction for R.M ....

MASSACHUSETTS GENERAL HOSPITAL Department of Nursing

TITLE: REGISTERED NURSE ANNUAL PERFORMANCE EVALUATION

Overview:

This policy is to be used in conjunction with the Massachusetts General Hospital (MGH) Human Resources Performance Evaluation policy. Nurses who are organizationally accountable for this process (i.e. “nurse manager”) evaluate the Registered Nurse (RN). This process applies to nurses at all levels of the organization.

The required components of each annual performance evaluation are: 1) Self-evaluation

• The Registered Nurse (RN) completes a self-evaluation with goals, and may include aclinical narrative.

2) Peer review• The RN requests a peer review from a colleague.• The peer review includes two aspects of a nurse’s practice: recognizing practice strength

and identifying a practice development opportunity to assist a peer in developing goals toenhance or advance an aspect of nursing practice.

3) Manager evaluation• The nurse manager reviews the RN’s self-evaluation and peer review and completes

his/her own assessment.

It is through the process of the nurse manager and the employee reviewing these three components of the annual performance evaluation that leads to the mutual development of the nurse’s clinical and professional goals for the upcoming year.

In addition to the annual performance evaluation, each year, topics are chosen and included as part of the Annual Regulatory Compliance Training program. The topics include, but are not limited to, job expectations, local, state or federal regulations, standards, rules of participation, accreditation or licensure requirements. The employee is expected to demonstrate initial and ongoing knowledge of, and compliance with all areas, including each of the selected topics. Documentation of the employee’s compliance with the Annual Regulatory Compliance Training Program is completed, at a minimum of one time per year.

Approved by Nursing Executive Operations Team, 8/2009 Approved by Nursing Executive Operations Team, 7/2012 Approved by Nursing Executive Operations Team, 5/2017