1. Name and Credentials Current Unit Level Applying for 1

2. Exemplary Professional Practice Describe and provide examples of how you are a leader within Mary Washington Healthcare (MWHC). How have you grown as a professional nurse and how has your practice changed with this growth? Describe your philosophy or values of nursing practice and how you integrate this philosophy or the values into your professional nursing practice. 2

3. Transformational Leadership 3 Describe your unit/organizational project and how it has provided value to your unit or to MWHC and what the next steps of this project will be. Describe how you have participated in setting professional standards/policies using evidence- based practice at the unit or organizational level.

4. Structural Empowerment Describe a successful preceptor/preceptee relationship you have had as the preceptor. What made the relationship successful? Did you have any barriers or challenges? Describe your teaching activities and what was taught. How did you decide the need for this activity? What MWHC Pillar did this involve – quality, service, safety, finance? Describe your journal club. Who was involved in the club and what was the impact to your unit? 4

5. New Knowledge, Innovations and Improvements Describe your leadership role in outcome activities (PDCA, a change initiative, or QI project). How did you identify the need for this activity? What were your metrics you measured? What MWHC Pillar did this involve- quality, service, safety, finance? What were your findings and were you surprised by them? Are there any next steps for this activity? 5

6. Summary 6