Exceptional Resource Nurse of the Year Nomination Form Nurse nominated/title: Unit: Manager’s Signature: APP’s Signature (if applicable): Nominated by/SAP number and Title: Unit: Telephone Number Date: Nominator’s Signature Resource Group: Telephone Number Date: Resource Facilitator Signature 10 traits please circle (Yes) or (No) as it applies to the nurse you are nominating. Yes No Provides constructive feedback to engage/involve staff (timely, factual, and solution focused). Integrates specific resource (Safety, Skin, Diabetic, Pain, Value Analysis, Clinical Informatics, Retention) Yes No need/s not only on unit but also on units without a Resource Nurse in same specialty. i.e., online modules, Yes No Provides evidence and implements evidenced-based practice change/s resulting in measurable outcomes impacting the patient and family experience. Role models in collaboration with healthcare team and in mentoring new resource nurses. Yes No Yes No Attends hospital committee/specialty conferences, i.e. Infection Control Meeting Yes No Is nationally certified or has submitted a certification plan to obtain in specialty area. Is responsible for integrating best practices of the specific resource into their respective units/areas in Yes No addition to overall CLP orientation via Staff Education. Yes No Community service presentations outside of UAMS, i.e., nursing homes, health or safety fairs, schools, etc. Yes No Considered a clinical expert and serves as a support to staff in resource specialty on/off the unit. Presents at local, state or national level, i.e. ARNA, Men in Nursing, Hispanic Nurses, etc.) Yes No Provide two (2) statements (one-two paragraphs, only, including specific “Supportive” examples) from nurses who have benefitted by the nominee’s specific resource work within the past twelve months.
Exceptional Resource Nurse of the Year Nomination Form Nurse nominated/title: Unit: Manager’s Signature: APP’s Signature (if applicable): Nominated by/SAP number and Title: Unit: Telephone Number Nominator’s Signature Date: Resource Group: Telephone Number Resource Facilitator Signature Date: 10 traits please circle (Yes) or (No) as it applies to the nurse you are nominating. Yes No Provides constructive feedback to engage/involve staff (timely, factual, and solution focused). Yes No Integrates specific resource (Safety, Skin, Diabetic, Pain, Value Analysis, Clinical Informatics, Retention) need/s not only on unit but also on units without a Resource Nurse in same specialty. i.e., online modules, Yes No Provides evidence and implements evidenced-based practice change/s resulting in measurable outcomes impacting the patient and family experience. Yes No Role models in collaboration with healthcare team and in mentoring new resource nurses. Yes No Attends hospital committee/specialty conferences, i.e. Infection Control Meeting Yes No Is nationally certified or has submitted a certification plan to obtain in specialty area. Yes No Is responsible for integrating best practices of the specific resource into their respective units/areas in addition to overall CLP orientation via Staff Education. Yes No Community service presentations outside of UAMS, i.e., nursing homes, health or safety fairs, schools, etc. Yes No Considered a clinical expert and serves as a support to staff in resource specialty on/off the unit. Yes No Presents at local, state or national level, i.e. ARNA, Men in Nursing, Hispanic Nurses, etc.) Provide two (2) “Supportive” statements (one-two paragraphs, only, including specific examples) from nurses who have benefitted by the nominee’s specific resource work within the past twelve months.