Clinical Self-Evaluation Tool

Evaluator: de Oliveira Morais, Carolina (carolinavito@usf.edu) Completed Date:04/09/2023

Evaluatee: Neavins, Cynthia(cneavins@usf.edu) Rotation:Complex Health - Med Surg. 02/11/23-04/08/23

5-Outstanding: Exceeds Standards

Exhibits above average performance of nursing care for this level student. The student is proactive, self-directed, and consistently engaged in
learning; needs minimal guidance; is knowledgeable; and appropriately incorporates knowledge with skills. Student is proactive and
self-directed in approach to learning.

4-Satisfactory: Meets Standards

Exhibits average performance of nursing care for this level student. Functions with minimum guidance. Demonstrates adequate knowledge and
requires minimum assistance in applying knowledge to skills. Recognizes learning opportunities but may require assistance in utilizing them.

3-Minimal
Exhibits minimal performance of nursing care for this level student. Functions safely with moderate guidance. Demonstrates minimal knowledge
and requires moderate assistance in applying knowledge to skills. Requires some direction in recognizing and utilizing learning opportunities.
Often focuses on the task or own behavior, not on the patient.

2-Unsatisfactory
Requires intense guidance for the performance of activities at a safe level. Clinical performance reflects difficulty in the provision of nursing
care. Demonstrates gaps in necessary knowledge and requires frequent or almost constant assistance in applying knowledge to skills. Requires
frequent and detailed instructions regarding learning opportunities. Focuses primarily on the task or own behavior, not on the patient.

1-Unsafe to Practice
Is unsafe to practice without constant, intense guidance. Frequently lacks necessary knowledge and skills and unable to integrate these into
practice. Requires constant detailed instructions regarding learning opportunities and is often unable to utilize them. Attempts activity or
behavior, yet is unable to complete. Focuses entirely on the task or own behavior, not the patient.
Course

Answer: NUR 3225L COMPLEX HEALTH NURSING I CLINICAL

Semester

Answer: Spring

Year

2023

Select Evaluation Type

Answer: Summative

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 Clinical Self-Evaluation Tool
Standard 1: Patient-Centered Care
1. Performs a comprehensive assessment including patient values, preferences, and needs.
2. Develops an individualized plan of care with a focus on the nursing process.
3. Provides care with sensitivity and respect for the diversity of the human experience.
4. Delivers care based on knowledge of pathophysiology and pharmacotherapy.
5. Identifies potential barriers to active involvement of patients in their own health care process.

Answer: 5 Outstanding: Exceeds Standards (Comment Required)

I consistently receive compliments from my patients and their family while taking care of them; they often express being grateful,
comfortable and cared. I work accordingly with their values, preferences and needs, and always respect their decisions. In the instances I
had obstinate patients, I managed to communicate efficiently and explain the reason of prescribed orders or, the importance of it, and we
managed to find common ground. I'm proud of myself in my ability to care and support my patients and develop good communication and
rapport with them. Wherever I felt like I have a barrier I try my best to come up with a strategy that can benefit both sides. When I have
patients unable to communicate in a certain way, I do what's in my power to overcome the barrier, such as translating, trying to find
someone that speak their language and if not, the ability of staff providing an interpreter. I had a patient unable to normally speak as
consequence of a stroke and half body paralysis, and I found that just by attentively listening to what he was trying to say, reading his
body language, using simple language and questioning with yes or no helped me to try and provide the care he needed; in the end
everything worked great. I ensure patient teaching accordingly to their condition, specially when they have low level of literacy or have
some type of mental impairment or declined mental cognition, such as dementia. Once a nurse came to give my patient who had dementia
his meds, she explained what meds they were, what they did and why he needed, following to leave the meds with him in a cup after he
said he understood. One minute after she left he was asking me what the meds were for, what each one was for this and for that. I
explained and he couldn't understand why he needed it, so I proceeded by explained his condition; he understood and was ready to take
it until he wasn't and we had to go through the same conversation 2 times again until he finally took them. I maintained my calm and
patient and followed his pace until he was ready, staying with him until he took all his meds properly, still explaining the reason behind
each one as he was taking it. My group is not allowed to directly call or seek the provider or other healthcare personnel to discuss patient
issues, but wherever they need support in a matter, are in distress, unhappy with a situation, need a different approach, I try to be the
bridge between them and the assigned nurse, communicating these factors and advocating for them the best I can, as I'm the one taking
care of them for the whole day.
Standard 2: Teamwork and Collaboration
1. Demonstrates awareness of own strengths and limitations as a team member.
2. Initiates requests for help from other team members as appropriate.
3. Communicates effectively with patients, family members, and other members of the healthcare team.
4. Identifies potential complications related to handoffs or transitions of care.

Answer: 4 Satisfactory: Meets Standards

I know what skills I'm able to perform by myself and which ones I need assistance, and I'm always open to receive help and learn from my
nurse partners because I want to provide the best care possible for my patients. I believe communication is key for great patient outcomes
so I have no qualms in communicating my capabilities as a nurse student. I let patients and their family be aware of my position there and
if they do not feel comfortable with me performing a skill or overall caring for them, I respect and leave. If they do agree, I make sure to
inform everything I pretend to do and the reason behind it. I inform my nurse partner and team members working with me of what I've
done to ensure patient care is being documented and to avoid patient's harm and discomfort. I'm especially very proud of my clinical
group with the way we are so good in communicating and helping each other wherever it's needed; I can say for sure that we never feel
desperate or overworked in clinical because we got each others back always, and having this great teamwork only contributes to great
and positive patient outcomes. I had a patient in need of wound care and dressing changes; that was the first time I had the opportunity
to practice this skill and had no idea how to even begin. I immediately communicated with my instructor and my other team member who
had previous experience in wound care to assist me. This patient was full of wounds and pressure ulcers, very frail, weak and he definitely
was not properly care for I don't know how long. In the end, two more team members got into the scene to help give my patient a full bath
and oral care, and I cannot stress how happy he was just to receive the care that he was supposed to be receiving all this time. After that,
my team member and my instructor guided me beautifully through the supplies and in how to care for the wounds. This is just one of the
hundreds of instances where we demonstrated great team work in clinical setting.

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 Clinical Self-Evaluation Tool
Standard 3: Evidence-Based Practice and Quality Improvement
1. Utilizes evidence-based literature to support clinical decision making as demonstrated in written clinical assignments.
2. Differentiates clinical opinion from evidence-based practice to determine best clinical practice.
3. Promotes and practices quality, cost-effective delivery of care.
4. Identifies potential areas for quality improvement in the clinical setting.
5. Participates in measures to improve patient outcomes as appropriate.

Answer: 4 Satisfactory: Meets Standards

I improved significantly during this clinical rotation, specially on writing my NPWs. I apply with me most of my knowledge and evidence
based practice to all my clinical assignments. When caring and planning patient care, I ensure I stay concise and follow best practiced
always. When I'm unsure, I seek guidance and discuss measures that can be implemented for the greater patient quality care. I seek help
from my instructor, teammates, and healthcare personnel to further improve, and I always observe and participate in care practices,
measures and planning.
Standard 4: Safety
1. Identifies strategies to reduce the risk of harm or poor patient outcomes in the delivery of care.
2. Delivers medication (as appropriate) in a timely and safe manner including understanding the specific indications for the medication
and potential side effects.
3. Communicates effectively between team members or to clinical faculty when giving patient report.
4. Uses appropriate resources to improve organization and/or time management.

Answer: 4 Satisfactory: Meets Standards

In order to properly identify and reduce risk of harm and poor patient outcomes in delivered care, I always communicated effectively to
nurses on patient care, safety, current status, appropriate and inappropriate practices. I always gave appropriate end of shift report on my
patient to assigned nurse in every clinical before leaving my unit. I always paid close attention to identify and avoid potential patient risks
and harms. When performing skill that I am not fully comfortable with, I had someone to watch, assist and guide me to ensure my patient
safety. I did not have any opportunity to pass medications as it was not allowed in my clinical site so that's a skill I did not performed. I
encountered at various moments unsafe environments, messy and dirty rooms, needles on floor/chair, medication vials and pills laying
around patients rooms, medication errors, discrepancy on chart assessments and my personal assessments on patients and so on; in all of
those moments I made sure to report to my nurse and if it was on my ability to change/fix issue, I to measures to fix it.
Standard 5: Informatics
1. Navigates the electronic health record where appropriate.
2. Documents clearly, concisely, and accurately in the electronic medical record where appropriate.
3. Protects confidentiality of all protected health information.

Answer: 4 Satisfactory: Meets Standards

I use the hospital chart system appropriately and as instructed to us in order to gather important patient information to properly care for
them before first seeing them and then during the day to check any new orders and changes in their status. I always make sure to log off
when I'm done with the system and do not let anyone besides me see patient's chart/information and use the hospital system on my login.
My clinical group were not instructed and teached in chart on patient's record, so we do not perform this action. Patient's information,
status, have to be reported back to nurses.

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 Clinical Self-Evaluation Tool
Standard 6: Professionalism
1. Demonstrates core professional values (caring, altruism, autonomy, integrity, human dignity, and social justice).
2. Maintains professional behavior and appearance.
3. Demonstrates expected behaviors and completes tasks in a timely manner.
4. Engages in self-evaluation and assumes responsibility for learning.
5. Arrives to clinical setting on time.
6. Demonstrates evidence of preparation for clinical learning experiences.
7. Maintains a positive attitude while interacting with patients, family members, faculty, peers, or members of the healthcare team.
8. Accepts individual responsibility for actions.

Answer: 5 Outstanding: Exceeds Standards (Comment Required)

I'm a very resilient person, and can easily shape myself to different situations. I believe this helps me to care and do my job in clinical
setting despite any adverse factor. I cared for patients with backgrounds, beliefs and actions that I don't agree with a couple of times and
in all moments I maintained my professionalism and performed what I was supposed to perform at my position. Dealing with child
predators or sexual harassers in general is not easy for me, especially for being a women in the field. I had to maintain my professionalisms
in various instances and even when I was offered to care for a different patient, I refused; this is part of the job and I won't have the ability
to choose who I'm caring for. Nursing is not just caring because, but also despite of.I pushed myself to have the experience and learn how
to deal with those situations. I provided care and support just like I would to any other person. I always present myself with a positive
attitude to patients, their family and staffs.I present myself with proper appearance and behavior to all clinical days, I'm always 30 min
early and I complete all my tasks in time and in a organized matter every clinical day. I come to clinical prepared with all the required
equipment needed to provide care for patients. I make sure to always look for learning opportunities and I maintain responsibility for my
patient's care.

Neavins, Cynthia reviewed the above evaluation on 4/14/2023 7:49:00PM and has provided the following comment:

Carol, you are very resilient and have learned to communicate confidently and appropriately. You have grown this semester and it has been
as an absolute please to have you in my clinical course. You provide safe evidence-based practices and have managed to prioritize
effectively. Your professionalism is positive with all team members, peers and patients. Please continue to grow and learn everything within
your reach. I wish you the best.

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