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2017 COMFORT Communication for Oncology Nurses Application - Charleston, SC
***ONCE YOU START THIS SURVEY YOU CANNOT SAVE YOUR ANSWERS AND RETURN TO IT. YOU MUST START AND COMPLETE THE SURVEY IN ONE SITTING. IF HELPFUL, PRINT THE SURVEY OUT BEFORE STARTING SO YOU CAN GAUGE YOUR TIME AND INFORMATIONAL NEEDS***

Incomplete applications will not be considered.

Questions? Email comfort@coh.org

What To Do To Complete This Application
*Reminder, you cannot save your answers and return later.

To complete this application, you will need:

1) General Contact Information for each team member (2 members required)

2) A 400 word statement of interest

3) Three institutional goals (write three goals that you will accomplish after completing the course)

4) Obtain a letter of support from an institutional administrator and have them initial the support form. You can access the support form here: https://drive.google.com/file/d/0BybNs0gR7BJ4NXJOY0JfbkxfZ3c/view?usp=sharing

The letter of support and administrator support form need to be emailed to: comfort@coh.org

I. General Applicant Information - Team Member 1
Last Name
Your answer
First Name
Your answer
Current Title/Position
Your answer
Work Phone Number
Your answer
Ethnicity (optional)
Gender (optional)
Race (optional)
Home Address
Your answer
City
Your answer
State
Your answer
Zip
Your answer
Contact Phone Number
Your answer
Email
Your answer
Degrees/Credentials
Your answer
Speciality
Your answer
Certifications
Your answer
Professional License #
Your answer
State
Your answer
Are you from a disadvantaged background?
An individual from a disadvantaged background comes from a low-income family and previously qualified for federal disadvantaged assistance for student loans, or comes from a social, cultural, or educational environment (rural or inner city) that inhibit skills to build a research career.
Do you have a disability?
How did you hear about this course?
Would you like to be included in our e-mail list to receive information about upcoming courses?
I. General Applicant Information - Team Member 2
Last Name
Your answer
First Name
Your answer
Current Title/Position
Your answer
Work Phone Number
Your answer
Ethnicity (optional)
Gender (optional)
Race (optional)
Home Address
Your answer
City
Your answer
State
Your answer
Zip
Your answer
Contact Phone Number
Your answer
Email
Your answer
Degrees/Credentials
Your answer
Speciality
Your answer
Certifications
Your answer
Professional License #
Your answer
State
Your answer
Are you from a disadvantaged background?
An individual from a disadvantaged background comes from a low-income family and previously qualified for federal disadvantaged assistance for student loans, or comes from a social, cultural, or educational environment (rural or inner city) that inhibit skills to build a research career.
Do you have a disability?
How did you hear about this course?
Would you like to be included in our e-mail list to receive information about upcoming courses?
II. Institutional Information
Employing Institution/Program
Your answer
Institution Address
Your answer
City
Your answer
State
Your answer
Zip
Your answer
Work Phone
Your answer
Work Email
Your answer
Work Setting
Required
Ethnicity of patient population
Please list percent of patient population that is categorized under each of the following ethnicities listed below. All together, the numbers you provide should add up to 100%.
Percent Hispanic
Your answer
Percent Non-Hispanic
Your answer
Race of patient population
Please list percent of patient population that is categorized under each of the following races listed below. All together, the numbers you provide should add up to 100%.
Percent African American
Your answer
Percent Asian
Your answer
Percent American Indian or Alaska Native
Your answer
Percent Caucasian
Your answer
Percent Hawaiian or Other Pacific Islander
Your answer
Percent More than one race
Your answer
III. Statement of Interest (to be completed as a team)
Please describe in the space provided why you are interested in participating in the Oncology nurse Communication project as a team and how you will apply the information in your institution.
Limit response to box provided (1400 characters & spaces).
Your answer
IV. Institutional Goals
The primary objective of this project is to provide your team with tools to increase your communication skills to support patients and families and to use those skills to develop patient-centered care programs and practices. Preparation for completing this objective begins with the development of specific goals.

As part of the application, we ask that you submit, as a team, three realistic and practical goals that you will achieve to improve communication support in your institution after attending the course. Goals are highly encouraged to include a measurable component, so that you can determine their impact within your institution. During the course you will have time to discuss and refine your goals but we want your ideas to begin germinating here.

Please limit response to box provided. Each box limited to 400 characters & spaces.

Sample Goal: To establish a monthly educational session on communication for oncology nurses and to measure satisfaction of the educational session.

Goal 1
Your answer
Goal 2
Your answer
Goal 3
Your answer
V. Pre-Course Survey (to be completed as a team)
To help you begin thinking about your institution's needs, please complete the following institutional assessment regarding current communication practices
Vision and Management Standards
Administrative executive staff support implementation of initiatives to improve communication
Required
Education resources are designated to support development of competencies and practices in communication
Required
Display/distribution of patient feedback of excellent communication (such as bulletin board with patient comments)
Required
Practice Standards (procedures, policies, care protocol)
Advance care planning support available and plan communicated
Required
Visiting Standards
Policies for treatment and care settings clearly explained (safety procedures, visiting hours)
Required
Inpatient visitor policies clearly explained to patients and family
Required
Spiritual, Religious and Cultural Standards
Interpreter available and process for referral is clear
Required
Chaplain/spiritual care provider available and process for referral is clear
Written materials available for treatment options
Written materials available in different languages
Video available to explain treatment options, procedures
Computer access with internet available for patient/families
Complementary or integrative therapies are discussed with patients
Families have access to library for additional resources
Psychosocial and Emotional Standards
Palliative care team is available and referral process is clear
Required
Providers are accessible via email for patients and families
Required
Providers are available for family meetings with patients and families
Required
Providers are available for phone conversations with patients and families
Required
Video conferencing with providers is available for patients and families
Required
Quality Improvement Standards
Routine feedback from patients, family caregivers and community partners is obtained
Required
Community Network and Partnerships
Referral process for community resources in place
Required
Staff knowledge of community resources and contact information is current
Required
VI. Across the continuum of care, please indicate your perception of communication with patients at your institution (please check the most appropriate answer)
1. At the time of diagnosis
0= Not Effective 10 = Very Effective
2. During treatment
0= Not Effective 10 = Very Effective
3. Through survivorship
0= Not Effective 10 = Very Effective
4. At recurrence
0= Not Effective 10 = Very Effective
5. Facing end of life
0= Not Effective 10 = Very Effective
6. At time of death
0= Not Effective 10 = Very Effective
7. During bereavement
0= Not Effective 10 = Very Effective
Educational Programs
Indicate if your institution has offered an educational program for healthcare professionals in each of the following oncology communication content areas in the past two years:
A. Breaking bad news
B. Health Literacy
C. Culture
D. Being present/mindfullness
E. Support for family caregivers
F. Goals of care conversations/Patient-Centeredness
G. Transition in care conversations
H. Team Communication
I. Diagnosis (assessment, evaluation of patient understanding)
J. Treatment conversations (shared decision-making)
K. Survivorship care planning
L. Recurrence conversations
M. End of life communication
N. Grief/Bereavement
Please indicate the degree of difficulty the two of you (as a team) have with the following:
1. Determining how the patient and family like information shared with them
0=Not Difficult 10=Very Difficult
2. Evaluating your own communication with patients and families
0=Not Difficult 10=Very Difficult
3. Evaluating your own communication with colleagues
0=Not Difficult 10=Very Difficult
4. Telling others when you observe or have concerns about errors of care
0=Not Difficult 10=Very Difficult
5. Keeping regular communication with other providers about patient transfers/transition of care
0=Not Difficult 10=Very Difficult
6. Sharing information during interdisciplinary team meetings
0=Not Difficult 10=Very Difficult
7. Initiating talks with patients about hospice and palliative care topics (e.g. prognisis, bad news, death)
0=Not Difficult 10=Very Difficult
8. Handling conflict among patients and family
0=Not Difficult 10=Very Difficult
9. Handling conflict among team members
0=Not Difficult 10=Very Difficult
10. Discussions with patient/family about spirituality (e.g. existential distress)
0=Not Difficult 10=Very Difficult
11. Discussions with patient/family about cultural concerns (beliefs, traditions, rituals)
0=Not Difficult 10=Very Difficult
12. Discussions with patient/family about financial concerns
0=Not Difficult 10=Very Difficult
13a. When bad news is given to the patient, are you present?
13b. When bad news is given to the patient, do you deliver the news?
13c. When bad news is given to the patient, is a colleague with you?
14a. When prognosis information is given to a patient, are you present?
14b. When prognosis information is given to a patient, do you deliver the news?
14c. When prognosis information is given to a patient, is a colleague with you?
VII. Letter of Support
Instructions: The form to send to your administrator is located here:

https://drive.google.com/file/d/0BybNs0gR7BJ4NXJOY0JfbkxfZ3c/view?usp=sharing

Please access and print this form. The successful implementation of the curriculum will depend on support and commitment from your institution. An administrator from your institution is asked to provide one letter indicating the support of and commitment to your team’s effort to advocate for improved communication. Qualified institution administrators to supply these letters include the following: Director of Nursing/Patient Care Services, Chief of Staff/Medical Director, or Institution Administrative Official. Please give the form to your chosen institutional administrator. The form explains the purpose of this letter of support. Please ask your institutional administrator to read and initial the form.

After receiving the form and letter of support from your admin, and after you have completed this online application, please email the initialed form and letter of support to comfort@coh.org

Name of Supporting Administrator
Your answer
Administrator's Email Address
Your answer
Administrator's Phone Number
Your answer
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