Career AwardsInaugural Rich Payne Leadership AwardInaugural Palliative Care Nursing Awards Physician Nomination Form Step 1 of 9 - Nominator Information 0% 1/9 Nominator's Information As nominator, please tell us about yourself. Name* First Last Title Organization Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email Address* 2/9 Nominee's Information Please fill out this form with your nominee's information.Award Category Early Career (0-7 years) Mid Career (8-19 years) Senior (20+ years) Name* First Last Title* Organization Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email Address* 3/9 Nominee's CV Please provide a current CV for the nominee at the PDF, JPG, DOC or TXT format Drop files here or Select files Accepted file types: pdf, jpg, doc, txt, Max. file size: 50 MB. 4/9 TECHNICAL COMPETENCE Please provide a description of the nominee's excellence in TECHNICAL COMPETENCE*Competence is a baseline requirement. It encompasses both technical knowledge of the best means of care as well as skill in determining how best to deploy care with individual patients. The ‘art’ and science of medicine and nursing comes into play. Please consider specific examples of board certifications, advance trainings/certificates received and/or new or novel curriculum developed, etc (500 words or less) 5/9 PERSONAL INTEGRITY Please provide a description of the nominee's excellence in PERSONAL INTEGRITY*Personal integrity means that combination of personality traits and virtues most conducive to good end-of-life care. Humility is a key virtue.That means knowing what one does not know, a willingness to shift modes of treatment when an earlier course proves inefficacious, and a sharing of uncertainty with colleagues. Friendship with patients, though not always possible, is an advantage. Dying can be lonely, and often only the clinician is in a position to be a steadfast companion. Availability is hardly less important, but it requires openness to inconvenience and schedule disruption. A willingness to make house calls to avoid unnecessary visits to hospitals or physician offices is an important mark of availability. Most fundamentally, patients need to know they will not be abandoned. Come what may, the clinician must be there until the very end. Notes for items to consider in this section can include but not limited to: specific examples of other awards or recognitions from other organizations received by nominee, quotes from patients or care givers of loved one, examples of an “extra layer of care” provided, etc. (500 words or less) 6/9 FAMILY AND FRIENDS Please provide a description of the nominee's excellence in ACTIVE ENGAGEMENT OF FAMILY AND FRIENDS*Most patients have family and friends, and how a patient fares will be affected by their relationship with them. The family needs its own assessment and dialogue initiated. While a clinician may not be well placed to help resolve all problems or tensions between patients and families, it is useful to be aware of them. (500 words or less) 7/9 DOCTOR/PATIENT DIALOGUE Please provide a description of the nominee's excellence in CLINICIAN/PATIENT DIALOGUE*As far as possible, a dying person should be actively engaged in his or her care. Minimally, this means understanding the likely nature, course, and trajectory of treatment. The clinician should let the patient know what to expect and what is being done to help. The physician should also seek the patient’s informed involvement in decision-making. A clinician’s first task should be to assess the patient to gain a sense of what to say and not say – that is, what kind of a dialogue it is likely to be, and how to change it if it is initially not promising. Dialogue involves more than just communicating information; it is as much about listening. Notes for items to consider in this section can include but not limited to: specific examples of trainings that the nominee has completed, titles of any publications or articles authored by applicant in this arena, awards for communication or empathy, specific patient or caregiver quotes, etc. (500 words or less) 8/9 TEAM WORK Please provide a description of the nominee's excellence in TEAM WORK*Few clinicians work alone and, especially with end-of-life care, cooperation among caregivers is crucial. There will be different people providing different kinds of care, so coordination and full engagement among them is important. This is particularly so with regard to nurses and nursing assistants. Often, nurses have the greatest knowledge of the patient’s day to day experience and family concerns. This is true in all settings, and especially in home care. Continuity of care is especially important, and the principal clinician caring for the patient has a special responsibility to make certain the patient knows who is in charge and that his or her personal physician will be there when needed. For all these reasons, the ability to work well with a team is an important ingredient of good care. Notes for items to consider in this section can include but not limited to: specific examples of team trainings that applicant developed or participated in, quotes from colleagues, awards for team work, titles of any publications or articles authored by the applicant in this arena, examples of other committees or initiatives led by nominee, etc. (500 words or less) 9/9 SUMMARY SUMMARY*Provide a brief (250 words or less) summary of the leadership and impact the nominee has as a role model for other physicians and nurses and for those in the community they serve. Nominating individuals are encouraged to provide as many specific examples of how this particular nominee exhibits exemplary characteristics in each category appropriate for their stage of career and experience. General statements about the importance of each of these arenas are commonly assumed by the selection committee for all nominees. Δ Dr Richard Payne Palliative Care Leadership Award Nomination Form Step 1 of 9 - Nominator Information 0% 1/9 Nominator's Information Please fill out this form as the nominator suggesting a nominee for the 2022 Awards. Name* First Last Title Organization Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email Address* 2/9 Nominee's Information Please fill out this form with your nominee's information.Award Category Dr Richard Payne Palliative Care Leadership Award Name* First Last Title* Organization Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email Address* 3/9 Nominee's CV Please provide a current CV for the nominee at the PDF, JPG, DOC or TXT format Drop files here or Select files Accepted file types: pdf, jpg, doc, txt, Max. file size: 50 MB. 4/9 TECHNICAL COMPETENCE Please provide a description of the nominee's excellence in TECHNICAL COMPETENCE*Competence is a baseline requirement. It encompasses both technical knowledge of the best means of care as well as skill in determining how best to deploy care with individual patients. The ‘art’ of medicine as well as the ‘science’ of medicine comes into play. (500 words or less) 5/9 PERSONAL INTEGRITY Please provide a description of the nominee's excellence in PERSONAL INTEGRITY*Personal integrity means that combination of personality traits and virtues most conducive to good end-of-life care. Humility is a key virtue. That means knowing what one does not know, a willingness to shift modes of treatment when an earlier course proves inefficacious, and a sharing of uncertainty with colleagues. Friendship with patients, though not always possible, is an advantage. Dying can be lonely, and often only the physician is in a position to be a steadfast companion. Availability is hardly less important but requires openness to inconvenience and schedule disruption. A willingness to make house calls to avoid unnecessary visits to hospitals or physician offices is an important mark of availability. Most fundamentally, patients need to know they will not be abandoned. Come what may, the physician must be there until the very end. (500 words or less) 6/9 FAMILY AND FRIENDS Please provide a description of the nominee's excellence in ACTIVE ENGAGEMENT OF FAMILITY AND FRIENDS*Most patients have family and friends, and how a patient fares will be afected by their relationship with them. The family needs its own assessment and dialogue initiated. While a physician may not be well placed to help resolve all problems or tensions between patients and families, it is useful to be aware of them. (500 words or less) 7/9 DOCTOR/PATIENT DIALOGUE Please provide a description of the vulnerable population that your nominee is serving*Vulnerable populations, including the economically disadvantaged, racial and ethnic minorities, LGBTQ people, people experiencing homelessness, rural populations and others often do not have access to quality palliative care. In 500 words or less please describe the population that your nominee is serving, the roles they have taken on and how long they have been serving this community. Please provide a description of the nominee's excellence in CLINICIAN/PATIENT DIALOGUE*As far as possible, a dying person should be actively engaged in his or her care. Minimally, this means understanding the likely nature, course, and trajectory of treatment. The physician should let the patient know what to expect and what is being done to help. The physician should also seek the patient’s informed involvement in decision-making. A physician’s first task should be to assess the patient to gain a sense of what to say and not say – that is, what kind of dialogue it is likely to be, and how to change it if it is initially not promising. Dialogue involves more than just communicating information; it is as much about listening. (500 words or less) 8/9 TEAM WORK Please describe how your nominee expresses leadership skills and qualities*Leadership in serving vulnerable populations is crucial in creating the quality and access to care that all human beings need and deserve. Such leaders also serve as important role models and mentors that will attract quality and motivated clinicians to this important work. In 500 words or less please address your nominees skills, virtues, behaviors and commitments that have helped provide quality palliative care to this population.Please provide a description of the nominee's excellence in TEAM WORK*Few physicians work alone now and, especially with end-of-life care, cooperation among caregivers is crucial. There will be different people providing different kinds of care, and coordination among them is important, particularly with nurses and nursing assistants. Continuity of care is especially important, and the principal physician caring for the patient has a special responsibility to make certain the patient knows who is in charge and that the personal physician will be there when needed. On occasion, as with home care, it will be the nurse who provides the care, usually guiding and advising the physician. The ability to work well with a team is an important ingredient of good care. (500 words or less) 9/9 SUMMARY Please provide a description of the vulnerable population or populations that your nominee is serving*Vulnerable populations, including the economically disadvantaged, racial and ethnic minorities, LGBTQ people, people experiencing homelessness, rural populations, refugees, immigrants and closed populations such as prisons often do not have access to quality palliative care. Please describe the population that your nominee is serving, the roles they have taken on and how long they have been serving this community.(500 words or less)Please describe your nominee’s leadership skills and qualities*Leadership in serving vulnerable populations is crucial in creating the quality and access to care that all human beings need and deserve. Such leaders also serve as important role models and mentors that will attract quality and motivated clinicians to this important work. Please address this nominee’s skills, virtues, behaviors and commitments that have helped provide quality palliative care to this population and/or policy changes resulting from the leadership intervention. (500 words or less) Δ Nursing Nomination Form Step 1 of 9 - Nominator Information 0% 1/9 Nominator's Information Please fill out this form as the nominator suggesting a nominee for the 2023 Nursing Awards. Name* First Last Title Organization Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email Address* 2/9 Nominee's Information Please fill out this form with your nominee's information.Award Category Inpatient and/or Outpatient Nurse Hospice and/or Home Care Nurse Name* First Last Title* Organization Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email Address* 3/9 Nominee's CV Please provide a current CV for the nominee at the PDF, JPG, DOC or TXT format Drop files here or Select files Accepted file types: pdf, jpg, doc, txt, Max. file size: 50 MB. 4/9 TECHNICAL COMPETENCE Please provide a description of the nominee's excellence in evidence based practice of palliative nursing care*The nurse integrates evidence of best practices in palliative care to insure the highest quality of care for patients and families. The nominee applies evidence based practice through their own care and also leads efforts within their organization or community to insure the highest quality of care. Evidence based practice includes all domains of palliative care as established by the NCP Clinical Practice Guidelines for Quality Palliative Care.. (500 words or less) 5/9 PERSONAL INTEGRITY Please provide a description of the nominee's excellence in personal ethics and integrity*The nominee exemplifies a model of clinical practice based on the nursing professional code of ethics and acts with integrity. The nurse provides leadership in the many ethical challenges in palliative nursing care including supporting patients and families in health care decisions, honoring values, and respecting diversity.(500 words or less) 6/9 FAMILY AND FRIENDS Please provide a description of the nominee's excellence in compassionate relationships with the family*Recognizing that family, as defined by the patient, is central in the support of seriously ill patients and those facing the end of life, the nominee provides competent and compassionate support of the family. (500 words or less) 7/9 DOCTOR/PATIENT DIALOGUE Please provide a description of the nominee's excellence in Empathic, human centered communication*The nurse recognizes that communication is the foundation of nursing practice and relationships with patients, families and colleagues. The nominee exhibits communication that supports patients and families and communication with colleagues to foster cohesive, patient centered care. (500 words or less) 8/9 TEAM WORK Please provide a description of the nominee's excellence in Interprofessional team collaboration and leadership*The nominee demonstrates excellence in interprofessional care and provides leadership to insure that care is coordinated and brings the strengths of all disciplines to support patient and family care. These efforts strengthen quality physical, psychosocial and spiritual care. The nominee also promotes self care for the team . (500 words or less) 9/9 SUMMARY Please provide a description of the nominee's excellence in the application of diversity, equity and inclusion*The nurse demonstrates commitment to diversity, equity and inclusion. Examples may include the nurse’s own practice as well as efforts to insure that these critical elements are integrated in the organization and that care is responsive to the most vulnerable populations. Δ