Please mail the completed application to: Mail: Jewish Hospital Nursing Education 200 Abraham Flexner Way Louisville, KY 40202 Attn: Sarah Woolwine

Thank you for your interest in the KentuckyOne Health Louisville Area Facilities: Jewish Hospital, Sts. Mary & Elizabeth Hospital, Frazier Rehab Institute, and Our Lady of Peace Nurse Extern Program. The Nurse Extern Program is a 6 week academic program and offers 3 credit hours through Bellarmine University. You do not have to be a student at Bellarmine to apply. If you are chosen for the extern program, KentuckyOne Health will cover the cost of tuition for you. You must be in an Associates or Bachelors degree program to qualify. The program is designed to increase your nursing knowledge and skills as well as acquaint you with our Nursing Departments. It will facilitate your transition from student to nurse. You will have the opportunity to meet other students and work with our nurses in the clinical areas. In addition, KentuckyOne Health will provide a stipend of $12 per hour. KentuckyOne Health was formed when two major Kentucky health care organizations came together in early 2012. KentuckyOne Health combines the Jewish and Catholic heritages of the two former systems Jewish Hospital & St. Mary s HealthCare and Saint Joseph Health System. In late 2012, the organization formed a partnership with the University of Louisville Hospital James Graham Brown Cancer Center. The nonprofit system is committed to improving the health of Kentuckians by integrating medical research, education, technology and health care services wherever patients receive care. KentuckyOne Health has more than 200 locations including hospitals, physician groups, clinics, primary care centers, specialty institutes and home health agencies, with nearly 15,000 employees across the state of Kentucky and southern Indiana. KentuckyOne Health is the largest health system in Kentucky and has more than 2,700 licensed beds. Jewish Hospital opened in 1905 with a mission to provide all patients with the highest quality care and a strong emphasis on research and education. Today, Jewish Hospital is a 462- bed, internationally renowned, high- tech tertiary referral center located in downtown Louisville, developing leading- edge advancements in the minimally invasive surgery, hand and microsurgery, heart and lung care, emergency care, orthopedics, neuroscience, and organ transplantation. Noted for numerous medical "firsts" in Kentucky, the nation and the world, Jewish Hospital is the site of the nation's first four hand transplants, and the world's first and second successful AbioCor Implantable Replacement Heart transplant. Sts. Mary & Elizabeth Hospital (SMEH) is a 331- bed, full- service hospital, founded by the Sisters of Charity of Nazareth in 1874. SMEH offers a full range of orthopedic, cardiac, medical imaging, surgical and emergency services, a wound healing center, sleep disorders center and has three medical plazas on campus to provide office space for a wide array of physicians representing a number of

specialties. Additionally, SMEH is home to Jewish Bariatric Care, the region s only weight- loss management program utilizing the Lap- Band System and The Women s Center, a state- of- the- art diagnostic facility specifically for women. Founded by the SCN s in 1951, Our Lady of Peace is dedicated to treating individuals and their families with an array of 21 different psychiatric inpatient, outpatient and partial programs for patients with emotional, behavioral and psychiatric disorders and chemical dependencies. Approximately 75 percent of patients are children and adolescents with emotional and behavioral disorders or who have physical and developmental disabilities such as brain injury, autism, mental retardation and fetal alcohol syndrome. A team of psychiatrists, social workers, nurses, recreational therapists, play therapists and others strive each day to help patients regain their confidence, rebuild trust and develop the skills they need to function successfully in the world. Our vision is to be the premier, integrated, comprehensive health system in the Commonwealth providing high- quality care close to home reducing the incidence of disease and eliminating inequities in access. The organization s health care heroes touch lives across the state of Kentucky. We offer easy access to expert care in every specialty, by caring for people in their own neighborhoods through community hospitals, outpatient centers, mobile occupational health clinics, and physician offices. We believe you can become our next health care hero. Enclosed you will find an application packet and additional information regarding the Nurse Extern Program. Admission to the Nurse Extern Program is highly competitive, and not all applicants will be accepted. Priority will be given to KentuckyOne Health scholarship students and current employees. To be considered, your application must be complete. You must be available for the entire program. Current KentuckyOne Health employees must be able to meet the 2 or 3 day/week extern commitment in addition to their KentuckyOne Health staff commitment. If you have any questions regarding the program, contact Sarah Woolwine at 502.587.4194. Please mail the completed application to: Mail: Jewish Hospital Nursing Education 200 Abraham Flexner Way Louisville, KY 40202 Attn: Sarah Woolwine We must receive your completed application and it must include the following:

Application Official Skills Checklist Current Official Transcript (unless you are an accepted Educational Loan Student) Reference Sheet from your nurse manager if you are a current employee Cover Letter and Resume Two letters of recommendation Copy of current CPR card Sincerely, Sarah Woolwine, RN, MSN, PCCN Nurse Extern Program Coordinator KentuckyOne Health (Jewish Hospital, Sts. Mary & Elizabeth Hospital, and Our Lady of Peace) Important Dates for the 2014 Program April 1 Application Deadline, all applications must be postmarked by March 31 st. May 27, 28, 29, and June 2 Orientation - Please note that depending on the facility, you may be expected to attend additional orientation classes during the first two weeks of the program. Orientation days will vary for each facility. Once chosen for the program, you will be provided with a complete calendar. July 9 - Last day of program. Clinical will be on Tuesdays and Wednesdays from 6:45am- 7:00pm. There will not be make- up days.

Academic Nurse Extern Program Fact Sheet Introduction KentuckyOne Health Louisville will again be offering a Summer Nurse Extern program. This 6 week program is affiliated with Bellarmine University and will provide 3 credit hours on satisfactory completion; however you can be enrolled in ANY accredited nursing program. This program will enable the nursing student to supplement school experience with patient care management, organizational, and time management skills under the guidance of a RN preceptor and clinical faculty. It will also provide the opportunity to identify a specific area of clinical interest. The student will set goals and objectives based on personal needs with the clinical faculty. Program Objectives Develop an understanding of staff nurse role and other health provider roles at KentuckyOne Health in the Louisville area. Increase patient care management, organizational and time management skills. Demonstrate greater proficiency with clinical skills. Experience professional growth. Experience increased self- confidence in caring for the adult patient. Application Completed application must be received by the application deadline. Must submit the enclosed Official Skills Checklist, completed by a clinical instructor from the student s school. Must submit a resume with a cover letter. Must submit two letters of recommendation, one from a faculty member, and if you are a current employee one from a nurse on your unit. Must submit a current Official Transcript with application, unless you are an accepted Educational Loan Student. Current employees must submit the enclosed Reference Sheet filled out by your nurse manager. Must submit a copy of a current CPR card. Qualifications Preference will be given to KentuckyOne Health educational loan students and current employees. Must be in an Associates or Bachelors degree program. Current employees must provide reference from Nurse Manager. Enrolled in an accredited School of Nursing (GPA at least 3.0). Must be entering the last year of a nursing program.

Must graduate in December or May following the summer program. Summer Work Experience The program is planned for 24 hours per week, 12 hour shifts, 6:45am - 7pm, on Tuesday and Wednesdays, over eight weeks. Emphasis will be on increasing knowledge and skill in the clinical area to facilitate transition to the RN role. The student will receive a stipend ($12 per hour) for the summer program. The scholarship student must be able to meet the 2 or 3 day/week extern commitment in addition to their KentuckyOne Health staff commitment on their unit if they are a KentuckyOne Health employee. Post Summer Graduation After the summer program, the extern student will be hired into a pool extern position or another available position. The KentuckyOne Health employee will continue in their previous staff position on their unit after the summer program or may elect to transfer to a pool extern position if available.

Name (First, MI, Last): EXTERN APPLICATION APPLICANT INFORMATION Mother s Maiden Name: SSN: Phone: Current address: City: State: ZIP Code: School of Nursing: Email: Expected Date of Graduation: ADN BSN (Please check one) EMPLOYMENT INFORMATION Currently Employed by KentuckyOne Health: (Please check one) If yes, Facility: Department: How long? Current Employer: HOSPITAL PREFERENCE (PLEASE NOTE THAT PLACEMENT WILL BE BASED CURRENT AREA OF EMPLOYMENT, DATE OF SURVEY RETURN, YOUR CLINICAL INTEREST, AND UNIT AVAILABILITY.) 1 st Choice: Frazier Jewish Our Lady of Peace Sts. Mary & Elizabeth 2 nd Choice: Frazier Jewish Our Lady of Peace Sts. Mary & Elizabeth 3 rd Choice: Frazier Jewish Our Lady of Peace Sts. Mary & Elizabeth

JEWISH HOSPITAL/FRAZIER REHAB UNIT PREFERENCE (Please indicate your top five choices in order of preference, with 1 being the number 1 choice.) Abdominal Transplant (3 East) Vascular and Chest Pain (6/7 Towers) Cardiopulmonary and VAD (5 Tower) Emergency Department General Medical Surgical (5 West or 6 East) General Telemetry (4 West) ICU Medical (ICU B&C) ICU Transplant (ICU F) ICU Neuro (ICU G) ICU Cardiac (ICU A) Orthopedics/Medical Surgical (9 Frazier) Spinal Cord Rehab (Frazier) Post- Op CABG (7/8 Heart & Lung) Surgical (6 West) Pediatric/Adult General Rehab (Frazier) Neuroscience and Stroke (5 East) Stroke and Brain Injury Rehab (Frazier) STS. MARY & ELIZABETH HOSPITAL UNIT PREFERENCE (Please indicate your top five choices in order of preference, with 1 being the number 1 choice.) Intermediate Cardiac Medical Surgical Oncology/Stroke Telemetry Orthopedics ICU/CCU Emergency Dept. OUR LADY OF PEACE (Please indicate your top choices in order of preference, with 1 being the number 1 choice.) Adolescent Extended Care 8-11 yrs and 12-18 yrs Male Adolescent Forensic Innovations: Brain Injury/Autistic/MRDD for Older Adolescent Innovations: Brain Injury/Autistic/MRDD for Younger Children

1. What types of patients have you had the most experience with in your school clinicals or in your work setting? 2. What type of patients have you had the least experience with in your school clinicals or in your work setting? 3. What areas of your practice would you like to improve during the externship program? (ex: procedures, Assessment skills, patient care skills, organizational skills, time management skills). 4. Describe previous work experience (not school- related experience). 5. Do you anticipate scheduling conflicts (ex: summer classes) with a summer program? Explain. 6. Please list additional comments, questions or concerns about the externship program. Have you had a Hepatitis vaccine? Have you had a TB Skin Test within the last 6 months? CPR Expiration date After you complete the application, you will receive additional details regarding unit placement. We will process the applications as quickly as possible upon receipt. We feel this is an exciting and rewarding opportunity for students. We look forward to your participation. Please mail the completed application to: Mail: KentuckyOne Health Nursing Education 200 Abraham Flexner Way Louisville, KY 40202 Attn: Sarah Woolwine If you have any questions regarding the program, contact Sarah Woolwine at 502.587.4194.

EXTERN REFERENCE SHEET If current team member, please have your manager/supervisor complete: Date: Team Member Name: Department/Unit: Facility: Length of time in area: Attendance Skills Teamwork Poor Average Good Excellent Does team member have discipline issues? If so, please explain: If employee was PRN, commitments were met each month? Yes No Pick three words to describe this team member: When this team member completes the educational program, would you want to keep him/ her in your unit/ department? Yes No Additional Comments: Manager/ Supervisor Signature:

Extern Skills Checklist Instructions (Complete and return by Application Deadline) The Kentucky Board of Nursing now requires that we have a record of the skills taught and validated by your school of nursing prior to your participation in the Academic Nurse Externship at KentuckyOne Health Louisville. Enclosed is a skills checklist. Please complete the Student Self- Assessment sections of the checklist. Indicate, with a checkmark, if you have been taught the skill, if you have performed the skill, and if you feel competent to perform the skill. To be considered for the program, we must have the Extern Skills Checklist with Student Self Assessment completed AND your most recent clinical instructor s signature on the last page. Please have your most recent clinical instructor sign the last page of your checklist to validate that you have had the course content and skills in your nursing program. Your summer clinical experience will be based on the skills you have been taught and performed in your school of nursing. NOTE Do not write in the sections of the checklist marked Educators Plan or Preceptor. Those sections will be completed in the summer during the program. We look forward to working with you this summer. Thank you for your assistance. If you have questions, please call Sarah Woolwine at 502.587.4194. Please mail the completed application to: Mail: KentuckyOne Health Nursing Education 200 Abraham Flexner Way Louisville, KY 40202 Attn: Sarah Woolwine

KentuckyOne Health Nursing Education Nurse Extern Skills Checklist Name: Unit: Date: Listed below are skills that you may be called upon to perform as a KentuckyOne Health extern. Please complete the ASSESSMENT PORTION so that the clinical faculty and nursing staff can individualize your learning experience. The checklist will be reviewed throughout the program. This form is to be returned at the completion of the program. An RN must supervise and co- sign all procedures performed by a Nurse Extern. ASSESSMENT A.) Completes Initial Assessment Form Educated? Performed? Competent? Teach Practice Perform Initials/Date B.) Assesses patient and records/ communicates deviations from normal C.) Recognizes and reports abnormal diagnostic data D.) Recognizes pathophysiology of patients as evidence of care plan E.) Recognizes cultural & religious needs as evidence in plan of care PLANNING A.) Lists pertinent information in the nursing history and on the PCAR (Kardex) B.) Incorporates care plan in patient care and documentation (ICIP) C.) Prioritizes care to best meet all patient s needs D.) Enters Goals/ Interventions in ICIP IMPLEMENATION A.) Catheterization Educated? Performed? Competent? Teach Practice Perform Initials/Date Educated? Performed? Competent? Teach Practice Perform Initials/Date 1.) F/C Male 2.) F/C Female 3.) Change drainage bag 4.) Maintains TUR drip 5.) External Cath

IMPLEMENATION B.) Insertion, care of, removal of the following tubes: 1. N/G Tube 2. Feeding Tubes 3. Administer tube feedings 4. Check tube placement 5. Check residual 6. G- Tube C.) Maintains and documents I & O D.) Enemas 1. Fleets 2. Cleansing Enema E.) Specimen Collection/ Labeling/ Charting Educated? Performed? Competent? Teach Practice Perform Initials/Date 1. 24 hour urine 2. Clean catch midstream 3. Cath specimen 4. Specimen obtained from F/C 5. Stool 6. Sputum 7. Throat 8. Wound Culture F.) Ostomy Care G.) Trach Care 1. Cleaning 2. Changing Ties 3. Suctioning 4. Inline suctioning

IMPLEMENATION H.) Pre- op Care Educated? Performed? Competent? Teach Practice Perform Initials/Date 1. Pre- op teaching 2. Completes pre- op checklist I.) Post- op Care 1. Obtains pertinent information from OR/PACU nurse 2. Cares for wounds/drains dressing 3. Prevents post- op complications J.) Care of Patient in Isolation K.) Uses Universal Precautions L.) Assists with the following: 1. Central line 2. Bone marrow biopsy 3. Liver biopsy 4. Lumbar puncture 5. Other M.) Code Blue 1. Calling a code 2. Checking emergency cart 3. Placing patient on the monitor 4. Call pediatric Code Blue N. Application of Heat and Cold 1. Ice pack 2. K pad 3. Davol 4. Hemovac

IMPLEMENATION O.) Suction Equipment, Care of Educated? Performed? Competent? Teach Practice Perform Initials/Date 1. Wall Controlled 2. Jackson Pratt 3. Davol 4. Hemovac P.) Chest Tubes 1. Care of patient 2. Chest drainage system 3. Measuring and recording drainage 4. Assist with removal Q.) Respiratory 1. Nasal 02 2. Portable 02 3. N/T Suctioning 4. Ambu Bag R.) Restraint- Care of patient/ documentation S.) Medication Responsibilities 1. Oral 2. I.M. 3. I.V. 4. Sub Q 5. Eye drops 6. Interdermal 7. Suppositories 8. Use of Pyxis Med Station

IMPLEMENATION 9. Calls for missing dose Educated? Performed? Competent? Teach Practice Perform Initials/Date 10. Adheres to the 5 rights 11. Documents on MAR 12. IV Pumps 13. Saline lock 14. Central lines 15. Care of IV sites 16. Changes IV tubing 17. Labeling of bags 18. Documentation using Med- Admin 19. TPN 20. Monitors patient with blood product 21. Monitors patient with epidural cath 22. Monitors patient with P.C.A. T.) Blood Glucose Monitoring 1. Performs procedure 2. Quality control checks U.) Equipment 1. Hypothermia blanket 2. Portable bed scale V.) Body Mechanics

IMPLEMENATION W.) Patient Education 1. Explains to patients and others hospital schedules and routines on admission 2. Explains to patients and significant others test/procedures 3. Gives information in appropriate language 4. Documents patient teaching (ICIP) Educated? Performed? Competent? Teach Practice Perform Initials/Date 5. Utilizes resources (CareNotes, Mosby s) X.) Transfer Patient 1. Gives information report to appropriate person 2. Documents transfer and completes transfer checklist Y.) Receives a Patient 1. Orients to room and unit 2. Obtains report 3. Documents patients arrival and condition Z.) Discharge of Patient 1. Completes D/C summary 2. Post mortem care DOCUMENTATION AND EVALUATION A.) Recognizes the patient s response to nursing/medical care and documents in the nurses notes (ICIP) B.) Reviews and analyzes appropriate patient data and updates care plan daily Educated? Performed? Competent? Teach Practice Perform Initials/Date

C.) Participates in Care Management Rounds D.) Uses approved abbreviations E.) Updates PCAR (Kardex) F.) Utilizes ICIP Documentation system PROFESSIONALISM A.) Communicate effectively with others B.) Demonstrates professional dress and appearance OTHER SKILLS A.) Arrhythmia recognition with assistance B.) Lead Placement Educated? Educated? Performed? Competent? Teach Practice Perform Initials/Date Performed? Competent? Teach Practice Perform Initials/Date

COMMENTS To participate in the academic summer nurse extern program at KentuckyOne Health, validation of course content and skills of the student is required. Please have your most recent clinical instructor at your school of nursing validate your skills assessment with their signature below. Faculty Signature Position School of Nursing Signature of Student