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The portfolio provides evidence of competence relative to the role of clinician, outcomes manager, client advo- cate, educator, information manager, systems analyst/ risk anticipator, team manager, healthcare professional, and lifelong learner. This article describes the CNL portfolio developed by experts from the University of Tennessee Health Science Center and Methodist LeBonheur Healthcare. Examples of portfolio docu- ments generated throughout the master’s entry CNL cur- riculum are provided, along with student experiences using the portfolio in the employment interview process.

With more than 1,400 clinical nurse leaders (CNLs) in the United States and increasing enrollment in master’s entry CNL programs, it is critical that CNLs are able to clearly articulate their value. Clarity in this regard is especially important for the newly li- censed CNL. Portfolios pro vide a format to showcase a unique understanding of patient care and frontline care systems as a dynamic record of growth and pro- fessional development. 1A portfolio is valuable in the employment process, showing the newly grad- uated CNL’s clinical experience in quality improve- ment (QI) and safety, along with strengths gained from training with content experts. A portfolio, or- ganized similarly to customary career advancement criteria, provides additional value to the CNL by dif- ferentiating the skills and knowledge of the CNL above those of a bedside nurse for potential employers. This article describes the use of portfolios in the University of Tennessee Heal th Science Center (UTHSC) MSN CNL program to document academic perfor- mance and demonstrate specialized skills to prospective employers. The benefits of portfolios to the nurse em- ployee, academic institutions , and organizations are dis- cussed. Examples from student experiences using the portfolios during the interview process are included.

Background The healthcare system in the United States has been reported as unsafe and fragmented. 2Fragmentation has been identified as contributing to preventable er- rors, unnecessary mortality, reduced quality of care, and poor outcomes. 2To meet the challenges set forth by the IOM to transform hea lthcare through address- ing levels of education for nurses, 3the AACN, along with nurse leaders from academia and practice, cre- ated the CNL role. The role was conceived to address the educational needs for nursing generalists prepared at the graduate level who could work as lateral inte- grators of outcome-based care at the microsystem level. 4The role is anticipated to reduce fragmenta- tion through incorporation of evidenced-based pa- tient care and QI strategies. 4 To prepare nurses to meet the IOM mandates, 3 important initiatives were launched. 3In 2004, AACN convened a CNL implementation taskforce JONA Vol. 42, No. 1 January 2012 47 Author Affiliations: Director of Clinical Nurse Leader Pro- gram and Associate Professor (Dr Norris), Assistant Professor (DrWebb), and Assistant Dean for Student Affairs and Associate Pro-fessor (Dr McKeon), Acute & Chronic Department; Interim Deanand Professor and Ruth Neil Murry Endowed Chair in Nursing(Dr Jacob), Primary Care and Public Health, the University ofTennessee Health Science Center, College of Nursing, Memphis;and Senior Vice President/Adm inistrator and CNO, Martin Me- morial Health Systems, Stuart, Florida, and Clinical Associate Pro-fessor, the University of Alabama, Huntsville (Ms Herrin-Griffith). The authors declare no conflict of interest.Correspondence: Dr Norris, College of Nursing, The University of Tennessee Health Science Center, 877 Madison Ave, Suite 637,Memphis, TN 38163 ( [email protected] ). DOI: 10.1097/NNA.0b013e31823c18e3 Copyright @ 201 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 1 to identify and recruit academic-practice partnership models that would implement and evaluate CNL pilot/demonstration projects. As of August 2011, there are 99 MSN CNL programs. 5In 2007, the Quality and Safety Education for Nurses (QSEN) project, funded by the RWJF, published the crucial quality and safety nursing competencies needed by prelicensure students to achieve quality patient out- comes in the practice environment. 6Quality and Safety Education for Nurses competencies encom- pass the essential knowledge, skills, and attitudes in the domains of patient-centered care, teamwork and collaboration, evidenced- based practice (EBP), QI, in- formatics, and safety. 6Phase 2 of QSEN focused on the development and evaluation of classroom, clin- ical, and simulation quality and safety learning strat- egies by 15 schools of nursing across the country.

In 2009, phase 3 addressed faculty development for teaching safety and quality in professional entry nursing programs. 6The AACN revised the Essen- tials of Baccalaureate Education for Professional Nursing Practice 7to guide baccalaureate nursing cur- ricula. The revised documen t includes greater empha- sis in patient-centered care, interprofessional teams, EBP, QI, patient safety, informatics, clinical reasoning / critical thinking, genetics and genomics, cultural sen- sitivity, professionalism, and practice across the life- span in a complex healthcare environment. 7 Implementation of the CNL role in practice has been led by Veterans Health Administration medical centers, in addition to a few early adopter health- care organizations such as Maine Medical Center in Portland, Maine. Early outcomes from the Veterans Affairs Tennessee Valle yHealthcareSystemin Nashville, Tennessee, demonstrated that CNLs had a positive impact on patient readmission rates, hospital-acquired infection rates, length of stay, and patient satisfaction. 8Remarkably, 3 years after im- plementation, outcomes of CNL practice have been sustained; additional CNL-led improvements include decreased blood transfusi ons after joint replacement surgery, increased venous thromboembolism prophy- laxis for intubated patient s, and decreased cancella- tions for elective surgery. 9 Preparation for the Role The CNL provides and manages care at the bedside or point of care to individual patients and cohorts. 4 The flexibility and broad scope of this role support employment in a variety of practice setting. 10 Imple- mentation of the CNL role is being explored by more than 175 practice institutions and employers 4; however, roles vary across settings. The CNL curriculum includes didactic and clin- ical content for preparation as an advanced nurse generalist with specific focus on nursing leadership, clinical outcomes manageme nt, and care environment management. 4In addition to graduate coursework in health assessment, pharmacology and pathophys- iology, 400 to 500 hours of clinical experiences are expected. Curriculum topics include epidemiology, EBP, health policy, finance, QI, informatics, and health- care systems complexity.

Portfolios Historically portfolios were used in non-healthcare professions including art, architecture, and finance.

Portfolios are used today by the nursing profession in academic settings and for career advancement. 11,12 The components and formatting of the portfolio have been refined over time to current electronic versions. 13-18 Because CNLs are knowledge workers, a portfolio is an effective strategy to demonstrate their unique skill set for transforming care at the bedside. In academia, the portfolio has become a collection of student work 19 providing evidence of achieved competence. 20 Practice innovations for complex patients, error reduction strategies, examples of interprofessional collaboration, and microsystem improvements are examples of CNL transformational care practices.

Portfolios that include both successful and unsuc- cessful outcomes can profile CNL problem-solving skills. Evaluations of current practices demonstrate critical synthesis 21 and command of process evalua- tion, both guiding principles for future patient care delivery. 22 Ongoing maintenance of the portfolio pro- vides the CNL with evidence of career development useful for licensure and certification renewal. 18,23 Academic and practice leaders from UTHSC and Methodist Le Bonheur Healthcare in Memphis, Tennessee, collaboratively developed the CNL port- folio with application for both the academic and practice settings. A 2-phase pilot project was used to evaluate the use of portfolios. Phase 1 addressed CNL use of a portfolio including competencies ac- quired in nursing coursework, clinical experiences, and CNL clinical immersion outcomes.

Documentation of CNL Competencies The CNL portfolio is developed at the beginning of the program in the informatics course using an elec- tronic format. During the advanced leadership and internship classes, UTHSC CNL students organize evidence of professional nursing competencies ac- quired through coursework and clinical experiences in preparation for graduation. Students complete the portfolio at the conclusion of a 315-hour CNL clin- ical immersion experience. The portfolio is organized 48 JONA Vol. 42, No. 1 January 2012 Copyright @ 201 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 1 according to the CNL role competencies established by AACN. 4Documents include examples of com- plex patient care interventions and outcomes, error reduction strategies based on systematic assessment, demonstration of interprof essional collaboration, and systematic microsystem imp rovement. A professional resume with cover letter to potential employer; a personal mission, vision, and values statement; and earned certificates, such as continuing education, are usually included in the portfolio (Table 1). For the role systems analyst/risk anticipator, students include a de-identified Microsystem Assess- ment in their portfolio to demonstrate QSEN and CNL competencies related to systematic microsys- tem improvement. At the start of the clinical immer- sion, CNLs complete a comprehensive assessment of an aspect of the healthcare system. Examples include assessment of nursing practices and protocols; per- formance of an environmental safety or safety cul- ture assessment; microsystem profile that analyzes the system’s purpose, patients, employees, processes, and patterns; microsystem core and supporting pro- cesses inventory to determine staff’s perception and rank order; and those processes that need improve- ment. Other criteria include discharge process cycle time to measure the time from the patient being dis- charged until the patient has left the unit, interdisci- plinary team observation, care transition maps to diagnose the quality of patient care transitions be- tween both healthcare practitioners and settings as care needs dictate, and medication administration interruption analysis that analyzes patterns of inter- ruptions, waits, and delays in the process of safe med- ication administration. Specific details for these and other assessments are described in a previous pub- lication. 24 The data from these assessment documents are used to identify opportunities for practice im- provement. One student led a process improvement project to reduce the patient no-show rate for a clin- ical research unit. Using QI analysis tools including Table 1. Examples of Documents/Content for Clinical Nurse Leader (CNL) Portfolio CNL Role Evidence in Portfolio Clinician Complex patient concept mapNational Database of Nursing Quality Indicators Pressure Ulcer Prevention TrainingCultural assessment Outcomes manager Care path analysis for complex acute care Community assessment projectMicrosystem Core and Supporting Processes Inventory a Discharge process cycle time b Client advocate Presentation to an official on a healthcare issue or impending bill Advance directive interview Educator Teaching project for community safety in pediatric population Health literacy teaching project: revision of patient education materials usingprinciples of health literacy Information manager Personal digital assistants at point of care competency evaluation Quality improvement project presentationMicrosystem Profile c Systems analyst/Risk anticipator Medication administration interruptions analysis d Ergonomic assessment for bariatric patients Team manager skill validation Bed huddle analysis of patient flow Interprofessional role collaboration analysisGeriatric interdisciplinary team training, team meeting analysis Professional associations Validation of Student Nurses Association membership Abstract for CNL summit presentation Demonstration of commitment aslifelong learner Distinguished visiting professor lectureshipsIHI basic safety certificationCNL certification Abbreviation: IHI, Institute of Healthcare Improvement.aMicrosystem core and supporting processes inventory = interview strategy to gain staff’s perception to rank order those processes that needimprovement.bDischarge process cycle time = measures the time from the patient being discharged until the patient has left the unit.cMicrosystem profile = analyzes the microsystem’s purpose, patients, employees, processes, and patterns.dMedication administration interruptions analysis = analyzes patterns of interruptions, waits, and delays in the process of safe medicationadministration, including recommendations to reduce interruption using evidence-based strategies. JONA Vol. 42, No. 1 January 2012 49 Copyright @ 201 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 1 process maps, cause and effect diagram, and Pareto analysis, she and her team identified myriad quality gaps resulting in a 13.2% no-show rate. Through process redesign using advanced technology and in- corporating patient preference in the scheduling pro- cess, the team reduced the no-show rate to 2.1%. The student added select de-identified project documents to her CNL portfolio, including the executive sum- mary, data tables and graphs, team meeting minutes, and a revised standard operating procedure as an ex- ample of her mastery of the QI process. For the role of a member of profession, students participating in the Clarion competition held at the University of Minnesota show evidence of interpro- fessional collaboration in their portfolio to demon- strate QSEN competencies related to teamwork and collaboration through incl usion of presentation slides and reflections on particip ating in a professional team. The Clarion competition is a n interprofessional team competition held annually and focuses on healthcare quality and safety. The intercollegiate competition provides medical, pharmace utical, nursing, and health services students across the country with the op- portunity to analyze a complex healthcare case study based on actual events. Teams present their anal- ysis and recommendations to a group of judges who evaluate the presentations; summative evaluations are provided to the teams for deeper learning. Re- flections from CNL students have included comments about the importance of communication among healthcare providers in the acute and primary care settings to prevent error; application of leadership, critical thinking, and fina ncial principles throughout the project; and validation that multidisciplinary teams work.

An Interview Tool Portfolios provide documenta tion of specialized skills that can help CNLs market themselves more effec- tively in the interview proc ess. Portfolios may provide an advantage in screening for high potential candi- dates because the tool communicates a particular level of interest in pursuing a position. 25 An electronic for- mat allows CNLs to customize their portfolio for a specific practice setting and share the portfolio by simply embedding a Web-link in the cover letter. In an informal survey of recent UTHSC gradu- ates, former students reported their professional portfolios useful during the employment process to generate and direct discussion with the nurse man- ager conducting the interview. Graduates shared that during the interview, some nurse managers were sur- prised at the level of professionalism and quality of the projects showcased in the portfolios. In general, the graduates believed the time spent collecting and organizing the data was worth the effort and agreed that it was important to keep the portfolio updated.

One student reported that after viewing her portfo- lio, the nurse manager who conducted the interview noted a need to begin collecting her own information and projects.

Conclusion Portfolios are an effective marketing and communi- cation strategy to introduce the CNL to the practice setting. In particular, portfolios developed through the academic-practice partnership help demonstrate that the CNL has successfully bridged theory with practice. 26 A well-documented portfolio can also boost a new CNL graduate’s confidence and sense of professionalism. The process of developing a port- folio provides a format for self-reflection on prac- tice, competencies, and goal planning. 11 It is likely that employers will perceive the entry-level CNL as more capable of pioneering this new role in the prac- tice setting through the presentation of a professional portfolio. Finally, the ongoing use of the portfolio format facilitates role development of the CNL as the lifelong learner, continually adapting as the needs of the healthcare system evolves and helping to be a record of personal and professional outcomes. The portfolio provides benefits for nursing insti- tutions and employers. Because of the fluidity of prac- tice settings for nurses, many need something like a portfolio to document skills and outcomes. 27 Port- folios supplement the employee’s resume and provide employers with evidence of the nurse’s commitment to continued competence. 28 The portfolio also aids the organization in annual performance appraisals to doc- ument how the employee met or exceeded standards. 25 The portfolio also offers an opportunity for the em- ployee to demonstrate a commitment to life-long learn- ing and professional development to the organization. The portfolio provides academic institutions with authentic assessments of student learning and pro- motes deeper learning as students connect learning across courses and time. Portfolios help students plan their own academic pathways as they come to under- stand knowledge deficiencies. Portfolios provide a means for monitoring stude nt skills and achievement. Electronic portfolios allow students and faculty to create, manage, and run reports on achievements using standard templates or by customizing fields to their liking. Students have the ability to merge reports and upload documents, assignments, and experiences into their portfolios. Faculty can monitor, validate, comment, and evaluate content within the portfolio.

Students have a complete catalog of experiences to share when applying to the workforce or advanced educational programs. 50 JONA Vol. 42, No. 1 January 2012 Copyright @ 201 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 1 References 1. McMullan M, Endacott R, Gray M, et al. Portfolios and as- sessment of competence: a review of the literature. J Adv Nurs . 2003;41(3):283-294. 2. Institute of Medicine. To err Is human: Building a Safer Health System 1999. 2000. Available at http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf.Accessed February 1, 2010. 3. Greiner A, Knebel E, eds. Health Professions Education: A Bridge to Quality . Washington, DC: National Academies Press; 2003. 4. American Association of Colleges of Nursing. White paper on the education and role of the clinical nurse leader. 2007; Avail-able at http://www.aacn.nche.edu/Publications/WhitePapers/ClinicalNurseLeader07.pdf. Accessed September 15, 20011. 5. American Association of Colleges of Nursing. Clinical Nurse Leader Master’s Degree Programs. 2011; Available at http://www.aacn.nche.edu/cnl/CNLWebLinks.htm. Accessed August24, 2011. 6. Cronenwett L, Sherwood G, Barnsteiner J, et al. Quality and safety education for nurses. Nurs Outlook . 2007;55(3):122-131. 7. American Association of Colleges of Nursing. The essentials of baccalaureate education for professional nursing practice.2008. Available at http://www.aacn.nche.edu/Education/pdf/BaccEssentials08.pdf. Accessed June 16, 2011. 8. Harris J, Walters S, Quinn C, Stanley J, McGuinn K. The clinical nurse leader role: a pilot evalution of an early adopter.2006. Available at http://www.aacn.nche.edu/CNL/pdf/tk/VAEvalSynopsis.pdf. Accessed January 11, 2007. 9. Hix C, McKeon L, Walters S. Clinical nurse leader impact on clinical microsystems outcomes. JNursAdm . 2009;39(2):71-76. 10. Poulin-Tabor D, Quirk R, Wilson L, et al. Pioneering a new role: the beginning, current practice and future of the clinicalnurse leader. JNursManag . 2008;16(5):623-628. 11. Williams M, Jordan K. The nursing professional portfolio: a pathway to career development. J Nurses Staff Dev . 2007;23 (3):125-131. 12. McColgan K. The value of portfolio building and the registered nurse a review of the literature. Educ Pract . 2008;18(2):64-69. 13. Dion K. Nursing portfolios: drivers, challenges, and benefits. DEAN’S Notes . 2006;27(4):1-3. 14. Casey D, Egan D. The use of professional portfolios and pro- files for career enhancement. Br J Commun Nurs . 2010;15 (11):547-552. 15. Ceely M. National registration and professional portfolios: what does it all mean? J Australas Rehab Nurses Assoc . 2010; 13(2):4-6. 16. Jasper M, Fulton J. Marking criteria for assessing practice- based portfolios at masters’ level. Nurse Educ Today . 2005; 25(5):377-389. 17. McCready T. Portfolios and the assessment of competence in nursing: a literature review. Int J Nurs Stud . 2007;44(1): 143-151. 18. Twaddell J, Johnson J. A TIME for nursing portfolios: a tool for career development. Adv Neonatal Care (Elsevier Sci) . 2007;7(3):146-150. 19. Shelton D. Chapter 23: beyond tests: other ways to evaluate learning. In: Penn B, ed. Mastering the Teaching Role . Philadelphia, PA: F.A. Davis Company; 2008:287-297. 20. Garrett B, Jackson C. A mobile clinical e-portfolio for nursing and medical students, using wireless personal digital assis-tants (PDAs). Nurse Educ Pract . 2006;6(6):339-346. 21. Joyce P. A framework for portfolio development in post- graduate nursing practice. J Clin Nurs . 2005;14(4):456-463. 22. Haase-Herrick K, Herrin D. The American Organization of Nurse Executives’ guiding principles and American Associ-ation of Colleges of Nursing’s clinical nurse leader: a lesson insynergy. JNursAdm . 2007;37(2):55-60. 23. Ball E, Daly W, Carnwell R. The use of portfolios in the assessment of learning and competence. Nurs Stand . 2000; 14(43):35-37. 24. McKeon L, Norris T, Webb S, Hix C, Ramsey G, Jacob S. Teaching clinical nurse leaders how to diagnose the clinicalmicrosystem. J Prof Nurs . 2009;25(6):373-378. 25. Oermann M. Developing a professional portfolio in nursing. Orthop Nurs . 2002;21(2):73-78. 26. Scholes J, Webb C, Gray M, et al. Making portfolios work in practice. J Adv Nurs . 2004;46(6):595-603. 27. Holmstro ¨m R. Skills passports show the way ahead. Nurs Stand . 2010;25(9):62-63. 28. Smith L. Showcase your talents with a career portfolio. Nursing (Lond) . 2011;41(7):54-56. JONA Vol. 42, No. 1 January 2012 51 Copyright @ 201 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 1 View publication statsView publication stats