EVALUATION OF CLINICAL PERFORMANCE TOOL

Psychiatric Nursing - 2012

FIRELANDS REGIONAL MEDICAL CENTER SCHOOL OF NURSING

Sandusky, Ohio

Student: _Samantha Paris___________	Final Grade: Satisfactory/Unsatisfactory

Semester: Summer	Date of Completion: _________________________________

Faculty:	Katherine Vanderpool, MSN, RN; Amy Rockwell, MSN, RN	Faculty Signature: __________________________________

Teaching Assistant: Frances Brennan, MSN, RN

DIRECTIONS FOR USE:

Each week the students evaluate themselves based on the competencies using the performance code on page 2. The performance code includes the terms Satisfactory (S), Needs Improvement (NI), Unsatisfactory (U), and Not Available (NA). The instructor will initial if in agreement with the student’s evaluation. If there is a discrepancy in the performance code evaluation between the student and the instructor, a note is written on the comment section by the instructor with the rationale for the evaluation.

All clinical competencies are critical to meeting the objectives of the course. If the final performance code is unsatisfactory in any one of the competencies, a grade of unsatisfactory is given. If a pattern of unsatisfactory performance occurs after performing the competency satisfactorily, this also constitutes a grade of unsatisfactory. An unsatisfactory as a final score in any single competency results in a clinical course grade of unsatisfactory; this is a failure of the course. The terms Satisfactory and Unsatisfactory will be used in evaluating the final grade or clinical course performance.

METHODS OF EVALUATION:
ABSENCE (Refer to Attendance Policy)
Nursing Process Assignments
Date	Number of hours	Make up
Observation
Nursing Skills
Teaching Plan
Care Map
Care Plan
Process Recordings
Self-evaluation of Clinical Performance
Faculty’s Name	Initials
Katherine Vanderpool MSN, RN
Fran Brennan MSN, RN	FB

PERFORMANCE CODE

SATISFACTORY CLINICAL PERFORMANCE

Satisfactory (S):	Safe; accurate each time, efficient, coordinated; confident, focuses on the patient; some expenditure of excess energy; within a reasonable time period; appropriate affective behavior; occasional supporting cues; minimal instructor feedback related to written clinical work.

Needs Improvement (NI):	Safe; accurate each time; skillful in parts of behavior; focuses more on the skill and self rather than the patient; inefficient, uncoordinated, anxious, worried, flustered at times; expends excess energy within a delayed time period, frequent verbal and occasional physical directive cues in addition to supportive cues; instructor feedback required in several areas of clinical written work.

UNSATISFACTORY CLINICAL PERFORMANCE

Unsatisfactory (U):	Failure to achieve the course competency, safe but needs instructor reminders constantly, not always accurate, unskilled, inefficient, considerable expenditure of excess energy, anxious, disruptive or omitting behaviors, focus on skills and/or self, continuous verbal and frequent physical cues, unsafe, performs at risk to patient/clients/others, unable to function, incomplete, erroneous, faulty, illegible clinical written work, no feedback sought from instructor or response to feedback not evident in submitted written work. If the student does not self-rate a competency the competency is graded “U.” A “U” in a competency must be addressed in writing by the student in the Evaluation of Clinical Performance tool. The student response must include how the competency has been or will be met at a satisfactory level. If the student does not address the “U,” the faculty member (s) will continue to rate the competency unsatisfactory.

OTHER

Not available (NA):	The clinical experience which would meet the competency was not available

Written Assignments	Date
Grade
Date
Grade
Date
Grade
Individual Client Profiles	7/9-10/12
S
7/16/27
S
8/1/12
S
Process Recording (1)
Process Recording (2)
Geriatric Assessment and Education Plan
Concept Map	7/9-10/12
S
7/16/12
S
NA
NA
Psychotropic Medication Presentation
Community Mental Health Resource Presentation

Objective	Individual Client Profile & Clinical Experience

1. Apply the principles of psychiatric theory in the care of adolescent to geriatric clients with mental illness. (1,2,5,7)*
Date (Write in your clinical dates)	7/2/12	7/5/12	7/9/12-7/10/12	7/16-7/17	7/31/12-8/1/12	7/11/12	7/20/12	8/1/12
Weeks of Clinical	OR 1 So.	OR S.C.	Week 1	Week 2	Week 3	AA	Comm.	GA	Make up	Final
Competencies:

a.	Demonstrate an understanding of the relationship

between mental health, physical health, and

environment for those clients diagnosed with a

mental disorder.

NA	NA	NI/S	NI/S	S	S	S
na
b. Correlate prescribed therapies, psychotherapy, and

alternative therapies in relation to the client’s

mental disorder.

NA	NA	NI/S	NI/S	S	S	S
na
c. Provide culturally and spiritually competent care

within the scope of nursing that meets the needs of

assigned clients from diverse cultural, racial and

ethnic backgrounds.

NA	NA	NI/S	NI/S	S	S	S
na
d. Assess the environment as therapeutic for the

mental health client.

NA	NA	NI/S	NI/S	S	S	S
na
e. Identify appropriate methods that will assist the

client to regain independence and achieve self care.

NA	NA	NI/S	NI/S	S	S	S
na
f. Recognize normal versus non-normal behavior

patterns in terms of developmental milestones.

(Erickson)

NA	NA	NI/S	NI/S	S	S	S
na
Criteria met/Individual Clinet Profile & Medication Profile/Care/concept Map	KV	KV	KV	KV	FB

Clinical Location	Orientation-class-1 South FRMC	St. Charles Orientation	St. Charles Haynes Unit	St. Charles

ACU	Frmc 1 SOUTH	Sandusky artisans group	Nord Center

Comments

Objective	Individual Client Profile & Geriatric Assessment

2. Synthesize psycho-pathology, health assessment data, and the nursing process concepts to plan and care for clients with mental illness. (1,2,3,4,5,7)*

Date	7/2/12	7/5/12	7/9/12	7/16/12
Weeks of Clinical	OR 1 So.	OR S.C.	Week 1	Week 2	Week 3	AA	Comm.	GA	Make up	Final
Competencies:

a. Complete a health history which includes past and

current history of mental and medical health issues

and chief reason for hospitalization.	NA	NA	NI/S	NI/S	s	s	s
na
b. Identify the individual client’s symptoms related to

the psychiatric diagnosis.	NA	NA	NI/S	NI/S	s	s	s
na
c. Demonstrate ability to identify the client’s use of

coping/defense mechanisms.	NA	NA	NI/S	NI/S	s	s	s
na
d. Collaborate with the client in formulating

positive short term and long term objectives

for hospitalization.	NA	NA	NI/S	NI/S	s	s	s
na
e. Select priority nursing diagnoses based upon

assessment, psychopathology, identified client

objectives and chief concern.	NA	NA	NI/S	NI/S	s	s	s
na
f. Validate actual nursing diagnosis through the use

of defining characteristics.	NA	NA	NI/S	NI/S	s	s	s
na
g. Implement specific interventions to achieve stated

objectives for clients assigned.	NA	NA	NI/S	NI/S	s	s	s
na

Criteria met via Individual Client Profile, Med Profile, Care/concept Map

KV	KV	KV	KV	FB
Comments

7/27/12 Competencies met. KV

Objective	*Individual Client Profile & Geriatric Assessment

2. Synthesize psycho-pathology, health assessment data, and the nursing process concepts to patient centered plan and care for clients with mental illness. (1,2,3,4,5,7)*

Date (Write in your clinical dates)	7/2/12	7/5/12	7/9/12	7/16/12
Weeks of Clinical	OR 1 So.	OR S.C.	Week 1	Week 2	Week 3	AA	Comm.	GA	Make up	Final
Identify education needs for an assigned mental

health client. *	NA	NA	NI/S	NI/S	s	s	s
na
Formulate individualized teaching objectives

reflecting identified educational needs, based on

patient values and preferences. (Geriatric

Assessment)	NA	NA	NI/S	NI/S	S NA	s	s
na
Develop an appropriate patient centered

educational plan for assigned client(s).*	NA	NA	NI/NA	NI/S	s	s	s
na
d. Evaluate the effectiveness of the education plan.*	NA	NA	NI/S	NI/S	s	s	s
na
Formulate a patient centered care/concept map

demonstrating the bio-psychosocial interactions of

assigned clients. (Individual Client Profile).	NA	NA	NI/S	NI/S	s	s	s
na
Engage in discussions for evidence-based

psychiatric nursing practice. (Journal Presentation)	NA	NA	NI/NA	NI/NA	s	na	na
na
Criteria met via Individual Client Profile, Med Profile, and Care/concept Map	KV	KV	KV	KV	FB

Comments

Week 1 Education and teaching need: My client this week needed education regarding diet and exercise. He was stated that he was unhappy with his weight, and hypertension and sleep apnea. I educated regarding the DASH Diet, and told him that walking was good exercise and its free since he does not have access to finances for a gym membership. I educated him that getting his weight within normal limits and improving his diet would help control his medical issues such as the sleep apnea and hypertension. He was receptive to this education and was able to verbalize understanding. KV Nice Job!!! Please attach the education handouts with your Individual Client Profile . 7/15/12 7/27/12 NOT Completed KV Completed 7/28/12 KV

Week 2: My client this week’s teaching need was related to his medications. He was not very receptive to his medication regimen. I sat down with him and explained what each drug does using my psych drug guide. He was much more receptive to taking them after I explained the need for each one as well that if he did not like the way the medications made him feel that there are many other medication regimens that could be tried. KV

Week 3: My education piece for this was in regards to my patients hygeine and participation with ADLS. I had to take a lot of cueing to get her to assist with ADLS but I was able to explain to her that she needed to help. I also explained also that complying with meds would help her feel better and give her more energy. She was receptive to this teaching and was able to assist with her care, and also took her meds. Great Job!!! FB

Objective	Individual Client Profile & Process Recording

Refine basic verbal and non-verbal communication skills when interacting with clients, families, and members of the health care team. (2,3,5,7)*

Date	7/2/12	7/5/12	7/9/12	7/16/12	8/1/12
Weeks of Clinical	OR 1 So.	OR S.C.	Week 1	Week 2	Week 3	AA	Comm.	GA	Make up	Final
a. Integrate professionally appropriate and

therapeutic communication skills in interactions

with client’s, families, and significant others.	NA	NA	NI/NI	NI/S	s	s	s
na
b. Communicate professionally with the health care

team.	NA	NA	NI/S	NI/S	s	s	s
na
c. Identify barriers to effective communication

(Process recording).	NA	NA	NA/NA	NI/NA	S NA	na	na
na
d. Construct effective therapeutic responses

(Process Recording).	NA	NA	NA/NA	NI/NA	S NA	na	na
na
e. Complete a satisfactory client-nurse therapeutic

Communication (Process Recording).	NA	NA	NA/NA	NI/NA	S NA	na	na
na
KV	KV	KV	KV	FB

Comments

7/15/12 Critera met. Beginning to utilize those therapeutic communication skills. KV

7/27/12 Competencies met. KV

Objective	*Individual Client Profile, Geriatric Assessment, & Medication Presentations

4. Demonstrate knowledge of frequently prescribed medications used in treating mental illness. (1,4,5)*

Date	7/2/12	7/5/12	7/9/12	7/16/12	8/1/12
Weeks of Clinical	OR 1 So.	OR S.C.	Week 1	Week 2	Week 3	AA	Comm.	GA	Make up	Final
Demonstrate ability to discuss the uses and implications of psychotropic medications.*	NA	NI/NA	NI/S	NI/S	s	s	s
na
Identify the major classifications of psychotropic medications.*	NA	NI/NA	NI/S	NI/S	s	s	s
na
Identify common barriers to maintaining medication compliance.*	NA	NI/NA	NI/S	NI/S	s	s	s
na
Explain the effects, adverse effects, nursing interventions and safety issues, related to the use of psychotropic medications.*	NA	NI/NA	NI/NI/S	NI/S	s	s	s
na
Develop an education plan for the client and/or their family for the administration of psychotropic medication. (Individual Client Profile).	NA	NA	NI/NA	NI/S	s	s	s
na
Complete a satisfactory psychotropic medication presentation to peers. (Create-A-Game).	NA	NA	NI/NA	NA	S NA	na	na
na
KV	KV	KV

KV	FB
Comments

7/15/12 Nice job on the medication profile, just a few critical side effects that need to be addressed. KV 7/18/12 corrections noted. KV

7/27/12 Competencies met. KV

Objective	*Individual Client Profile, A.A. & Community Resource Observation

Develop an awareness of community resources and services. (5,7)*

Date	7/2/12	7/5/12	7/8/12	7/16/12
Weeks of Clinical	OR 1 So.	OR S.C.	Week 1	Week 2	Week 3	AA	Comm.	GA	Make up	Final
Competencies:

a. Identify community resources for a client with

mental illness. *	NA	NA	NI/S	NI/S	s	s	s
na
b. Propose recommendations for referrals to

appropriate community agencies. (Individual

Client Profile).	NA	NA	NI/S	NI/S	s	s	s
na
c. Complete a visit and written assignment for a

Community Agency involved in the care of a client

with mental illness. (Community Resource

Observation).	NA	NA	NA	NA	S NA	s	s
na
d. Complete a visit and written assignment for an

Alcoholics Anonymous meeting. (Alcoholics

Anonymous meeting).	NA	NA	NA	NA/NI/S

7/28/12 KV	S NA	s	s
na

KV	KV	KV	KV	FB
Comments

7/27/ Competencies met. Have reviewed the AA reflection paper. Awaiting the signature page for attendance. KV AA reflection paper completed and graded. KV 7/28/12

Objective	Clinical experience

Demonstrate satisfactory proficiency when using informatics and techniques in the assessment of clients with a mental illness diagnosis. (2,4,7)*

Date	7/2/12	7/5/12	7/9/12	7/16/12	8/1/12
Weeks of Clinical	OR 1 So.	OR S.C.	Week 1	Week 2	Week 3	AA	Comm.	GA	Make up	Final
Competencies:

Demonstrate competence in navigating the electronic health record (1 South/St. Charles)	NA	NA	NI/NA	NA	S	s	s
na
Satisfactory documentation of physical and psychiatric assessments and nursing notes utilizing the electronic health record. (1 South/St. Charles)	NA	NA	NI/NA	NA	S NA	s	s
na

KV	KV	KV	KV	FB
Comments

7/15/12

Students have the ability to review the electronic medical record but do not document in St. Charles system. KV

Objective	Journal, Process Recording, & Clinical Experience

Evaluate self-participation in patient care experiences with focus on ethical legal and professional responsibilities. (7)*

Date	7/2/12	7/5/12	7/9/12	7/16/12	8/1/12
Weeks of Clinical	OR 1 So.	OR S.C.	Week 1	Week 2	Week 3	AA	Comm.	GA	Make up	Final
Competencies:

Identify your strengths and weaknesses of care delivery.	NI/S	NI/S	NI/S	NI/S	s	s	s
na
Demonstrates effective use of strategies to reduce risk of harm to self or others.	NI/S	NI/S	NI/S	NI/S	s	s	s
na
Communicates observations or concerns related to hazards and errors to patients, families, and the health care team.	NA/NA	NA/NA	NI/NA	NI/S	s	s	s
na
Influence self-learning by questioning, requesting experiences, and seeking assistance.	NA/S	NA/S	NI/S	NI/S	s	s	s
na
Appraise self-performance in clinical setting in the Evaluation of Clinical Performance Tool.	N/S	NA/S	NI/S	NI/S	s	s	s
na
Compose feedback to instructor throughout course and at conclusion of course about techniques that promoted or impeded learning.	NA/NA	NA/S	NI/S	NI/S	s	s	s
na
Follow the standards outlined in the FRMCSN policy, “Student Conduct While Providing Nursing Care”.	NI/S	NI/S	NI/S	NI/S	s	s	s
na

KV	KV	KV	KV	FB
Comments

OR 1 SO July 2, 2012: I will try and familiarize myself with the programs and layouts of one South and use of the resources provided to make sure I can provide adequate care and communication. I will do this by reviewing the information provided to us, asking any questions that I have, and reviewing the basic intro power points. I thought for my strength this week that I showed good enthusiasm for the coming clinicals on this floor, and look forward to having clinical here.

OR St. Charles July 5, 2012: My area for improvement in regards to this facility would be to ensure I have proper communication for all the different types of “Psych” patients here. I will do this by reviewing some of the power point and the chapters in the textbook on therapeutic communication. I also plan to review the procedure and policies and the student nurse expectations so I can bring my ace game to clinical and have a beneficial experience. I believe that my strength this week would be my confidence and eager attitude to begin clinicals.

Week 1 Clinical: My area for improvement this week would be working on reviewing all the different Psych medications so that when I review the client’s medication chart I will better be able to understand how the medication is supposed to be helping them, and what adverse reactions can occur. I also need to be more assertive in communication with the patients when trying to work with a variety of patients in a group. My strength this week would be being able to have an in depth therapeutic discussion where I learned a lot and so did the patient. 7/15/12 Good goal for the next clinical experience. You did a nice job interacting with your client this week. Demonstrated good insight into his mental health and medical issues. KV

Week 2: My area for improvement this week would be to review the various psychotropic medication basics so that I am more confident and knowledgeable about them for both my patient and myself. So this way I can provide better education next time. I will review the handouts and the book, as well as the drug to facilitate this area of learning. My area of strength this week was related to being a patient advocate and facilitating a much-needed situation. My patient needed to make it to a very important appointment but was not going to be discharged before the date, and the doctor and case amnager were not facilitating him with options for him to make this appointment, so I spoke to the case manager and was able to have the appointment changed to a date after discharge for the client. You did an excellent job advocating for this client. Sam, give yourself credit when you are completing the tool. You do a great job interacting and caring for your assigned clients. KV 7/27/12

Week 3: My strength this week was communication with my chosen patient, she was very confused and hard to reach out to with a little patience I was able to get her to open up and communicate with her and effectively educate her, I was happy with my communication skills this week. My area for improvement would be confidence when working with groups, hopefully be interacting more with the other patients I will be more comfortable when working with them I will do this by taking the initiative and the time to work with patients when at work and clinical.

GREAT JOB WITH YOUR COMMUNICATION SKILLS AND GETTING THIS PATIENT TO OPEN UP! YOU WILL BECOME MORE CONFIDENT AND COMFORTABLE AS YOU GAIN EXPERIENCE! FB

EVALUATION OF CLINICAL PERFORMANCE TOOL

Psychiatric Nursing - 2012

FIRELANDS REGIONAL MEDICAL CENTER SCHOOL OF NURSING

Sandusky, Ohio

I was given the opportunity to review my final clinical ratings in each course competency. I was given the opportunity to ask questions about my clinical performance. I have the following comments to make about my clinical performance/final clinical evaluation:

(student signature)	(date)

KV/df 2012

EVALUATION OF CLINICAL PERFORMANCE TOOL

BrennaF

2012-08-09

samantha paris

Firelands Regional Medical Center