Patient Care Services Performance Criteria and Appraisal Form for Clinical Nurse (CN) I, II, III, and IV

Name: Department: Date:

 Self-Appraisal  Manager Appraisal by

Directions:

1. Indicate (above) if this is a self-appraisal or manager appraisal.

2. If the behaviors described below can be verified through either observation or clinical narrative (written or verbal). The evaluator enters her/his initials
in the box adjacent to the performance criteria.
3. To be signed off, the behavior needs to be consistently demonstrated.
4. The descriptions are cumulative, e.g. the performance of CN II must also include meeting the criteria for NC I and CN II.

Principles:

1. Nurses change over time in three general aspects of performance:

a. Movement from reliance on abstract principles to use of past concrete experience as paradigms to guide decisions.
b. Perceptions of situation change: from equally relevant parts to where only certain parts are relevant/salient
c. From detached observer to involved performer.
2. Change in performance, not the passage of time, is the defining characteristic for promotion/advancing through the levels
3. The levels are not discreet. A person might be demonstrating elements of more than one level at any one time.
4. All levels to be within the California Nursing Practice Act (http://www.rn.ca.gov/pdfs/regulations/npr-i-15.pdf)
 Clinical Nurse I
Job Description Advanced Beginner
Summary for Clinical
Nurse (CN) I-IV Focus is on learning 80% of
patient population, procedures,
documentation, setting
priorities, and time
management. Supervised by
preceptor or RNS/delegate.
This is an entry level
orientation position for an RN
with less than 6 months
experience. Must be promoted
to CN II within 6 months.
Clinical Nurse II
Competent
Able to consistently complete
full patient assignment with
patients of varying Stability
levels. Advocates for his/her
patients while recognizing and
appropriately responding to
changes in patient’s condition
Learning the patient population
that are not routinely admitted
to the unit.
Delegation to and monitoring
supervision of ancillary staff
during shift.
Clinical Nurse III
Proficient
Has a perceptual understanding
of the overall clinical situation
based upon a deep background
and knowledge of the patient
population.
Manages complex and novel
situations. Responds to
emergencies quickly and
accurately.
Shares knowledge and expertise
through on-unit teaching and
participation in unit or
department
committees/councils.
Clinical Nurse IV
Expert
Has an intuitive grasp of each
situation and zeros in on the
accurate region of the problem
without wasteful consideration
of a large range of unfruitful,
alternative diagnoses and
solutions, i.e. responds
instantaneously.
Contributes to the profession
of nursing.
Assists unit management to
monitor and maintain quality
care.
Performance Expectations

Initials

Initials

Initials

Initials
CN I CN II CN III CN IV

Section 1 Identifies obvious Attentively listens to Anticipates patients and Provides the patient and
physical or emotional patient and family families concerns and family with new coping
The Helping Role: discomforts. concerns, and issues and initiates strategies.
Establishes a Healing collaborates with them to discussion.
Environment and Consults with preceptor determine interventions if Advocates strongly for
Therapeutic or RSN to determine needed. Demonstrates flexibility in the patient’s wishes.
Relationship appropriate practice to support needs,
interventions. Guides patient and family beliefs and values of the
through illness phases by individual patient and
providing information and family.
emotional support.
Empowers patient and
family to discover their
strengths and to make
choices about their care.
Performance Expectations

Initials

Initials

Initials

Initials
CN I CN II CN III CN IV

Section 2 Consistently completes Recognizes and acts on Uses trending data to Identifies warning
all parts of the nursing data which needs further analyze effects of signs/trends of changing
Diagnostic and admission assessment assessment. treatments and detect patient condition before
Monitoring including risk Adapts assessment early deterioration overt changes in vital
Functions assessments. Correctly interview and data signs.
operates equipment collection to Can identify obvious and
used for patient accommodate culturally covert phsycial and Remains open to what
assessment to obtain diverse patients and psychosocial problems for the situation presents.
accurate data. families. Delegates a broad range of patients. i.e. unexpected new
appropriate aspects of clinical problems.
Monitors the patient data collection to ancillary
following procedures staff and follows-up with
and treatments as such staff to obtain
ordered. results.

Interprets assessment Determines the relevant

data to identify obvious medical and nursing
nursing problems and level of
problems/diagnosis. stability.

Reports data to RSN Recognizes and acts based

and/or MD using SBAR on the assessment and
parameters and
monitoring frequency
based on level of stability.

Patient handoffs focus on

urgent/impending needs,
teaching and discharge
planning, and stability
level.
Performance Expectations

Initials

Initials

Initials

Initials
CN I CN II CN III CN IV

Section 3 Initiates and updates Collaborates with Identifies patient and Creates unique plans of
plans of care in patient/family and team family strengths and care for complex/novel
Administers and consultation with to develop integrated and incorporates into the plan situations.
Monitors preceptor or RSN. individualized plans of of care.
Therapeutic care. Able to read the patient
Interventions/ Attends interdisciplinary Participates in Advance and respond
Regimens rounds with preceptor Participates in rounds with Care Planning discussions instantaneously: knows
or RSN. other members of the to empower the what to do, how to do
healthcare team and patient/family to reach what is needed.
Consults with preceptor report on nursing issues goals of care.
and RSN when changes and concerns.
in plan of care are Adapts medical and
indicated. Acts to prevent hospital nursing plans of care in
acquired complications response to patient’s
Performs protocols and such as pressure ulcer, needs and changing
procedures as ordered UTI, wound infection, condition.
and according to CLABSI, aspiration.
hospital policy.

Correctly and safely

operates equipment
used in patient care
procedures.
Performance Expectations

Initials

Initials

Initials

Initials
CN I CN II CN III CN IV

Section 4
Teaching Coaching
Function:

Patient and family Identifies learning needs
teaching and barriers using the
admission assessment
tool. Initiates teaching
plans.
Offers written materials
to patient regarding
medications,
procedures, and/or
illness.
At or before discharge,
teaches needed aspects
of home care.
Explains rationale to
patient and family for
procedures and what to
expect.
Explains medications
including purpose,
administration, dose, and
effects.
Discusses impact of illness
on patient’s life.
Ensures at discharge that
the patient comprehends
the follow-up care
including medication
administration.
Offers information on
Stanford resources and/or
community resources
related to illness and
home care as needed.
Capitalizes on a patient’s In consultation with
readiness to learn. patients/families,
develops/revises
Anticipates potential teaching tools and
teaching and discharge materials for use with
needs and incorporates same patient population
into teaching plan. on unit, throughout the
Individualizes teaching organization, and/or in
plans in collaboration with the community; or
patient. teaches formal patient
education classes at
Helps patient and families Stanford or in the
to identify how to make community
lifestyle changes
respecting their informed
choice.
Participates in community
health fairs to promote
health and wellness.
Performance Expectations

Initials

Initials

Initials

Initials
CN I CN II CN III CN IV

Staff Teaching Identifies own learning Informally teaches Teaches all unit staff in Teaches in areas of
needs and seeks individual staff on new or areas of expertise, e.g. in expertise outside of
relevant education changed policies/ super-user role or acts as assigned unit. And/or
procedures as needed a preceptor to students or assists managers by
new staff nurses; and/or is coordinating and
a mentor to staff nurses. implementing on-unit
orientation/training
programs

Section 5 Reports changes in Recognizes changes in the Anticipates potential Sees what is salient in
patient condition to patient condition and problems and acts to the situation and
Effective preceptor/RSN. notifies MD, Stroke Code, prevent the problem by responds immediately.
Management of Recognizes absence of or RRT as indicated. Uses performing emergency
Rapidly Changing pulse or respirations, Chain of Command to interventions and calling Performs skillfully under
Situations and unresponsiveness insure patient’s condition MD. pressure.
and calls a Code Blue. is addressed.
Performs aspects of Gives directions to others Conducts de-briefing
cardiopulmonary Provides information to during the event: acts as sessions with staff
resuscitation correctly. code team regarding the nursing team leader. involved in emergency
patient history Provides emotional to evaluate process and
support and information outcomes
to family regarding the
event.
Performance Expectations

Initials

Initials

Initials

Initials
CN I CN II CN III CN IV

Section 6 Follows policies, Monitors self and others Checks daily electronic Conducts literature
procedures and for compliance to policy, reports and insures all searches for new
Monitoring and standards of practice. procedure and needed aspects of care standards and evidence
Ensuring the Quality Maintains documentation. and documentation are in the unit’s patient
of Healthcare confidentiality of patient completed. population and brings to
Practices information. Recognizes when policies appropriate
and procedures need to Follows up with staff who council/committee
Recognizes and acts on be updated to meet new have not completed structure.
unsafe patient or standards/evidence or required regulatory
environmental changing needs and may documentation to ensure Ensures that policies are
situations. make recommendations compliance by end of followed by other staff
Completes a SAFE report to manager. shift. in relation to
in a timely manner Participates in problem compliance with
when error is found or Recognizes inappropriate analysis sessions and regulatory bodies
committed and outdated assists in identifying
orders/interventions and strategies to prevent
seeks clarification and/or future errors.
change.
Participates on unit or
Reports patient care and hospital based committee
environmental issues to or council structures to
unit management for insure health care
ongoing follow-up. practices are based in
current evidence
Performance Expectations

Initials

Initials

Initials

Initials
CN I CN II CN III CN IV

Section 7 Responds to patient Prioritizes care based on Ability to respond to Senses the needs of all
requests/ situations as medical and/or nursing problems from many patients in the unit as
Organization and they arise. Consults with urgency, goals of care. directions: patient care, well as the capabilities
Work-role preceptor or RSN for Offers to assist other unit environment, of nurses assigned to
Competencies help in determining nursing staff to complete interpersonal situations. care for them:
priorities. care. Reassigns workload Recognizes when
according to job greater expertise is
Seeks education for skill Seeks education in areas classification and required and intervenes.
and/or knowledge related to patient competency level.
deficits related to care population to maintain Takes a lead role to
of assigned patients. and improve Participates in unit or spearhead change,
Takes and uses feedback competencies. hospital including follow through
from preceptor and committee/council to completion.
RSNs As a team member, helps structure as a means of
to maintain team spirit addressing systems Assists others on unit to
Uses the C-I-Care and positive unit morale. problems prepare for crucial
principles in all conversations when
interactions. Recognizes and reports Is an early adaptor to there is a conflict
situations of harassment change. Helps others to
Learns hospital email become engaged
system and reads email
at least weekly. During times of conflict,
uses crucial conversation
skills to maintain open
lines of communication