Professional Documents
Culture Documents
Nurs 208 Final Evaluation
Nurs 208 Final Evaluation
I declare that this is my original work and the sources used are acknowledged.
1. COMPETENT AND SAFE PRACTICE WITHIN A PROFESSIONAL, LEGAL, AND ETHICAL FRAMEWORK
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1. 1 Comply with regulatory standards, relevant legislation and the practice settings policies and
procedures.
J.C. : Comply with regulatory standard and protocol by bringing the MAR to patient's desk when we give medication and follow the procedure when
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1. 2 Act in a responsible, ethical and accountable manner.
J.C. : When patient needed lone time or with family member, I make sure they receive their privacay.
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1. 3 Determine how the three factor and practice decision-making frameworks influence client care.
J.C. : The three factor fame-work which is client, nurse and the environment, I make sure these three frame-work are applied to everyday practice
and that I try my best to link and benefit from it. Nurse and client needs to build therapeutic relationship by also considering environmental factors
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1. 4 Use evidence informed practice and a theory-based approach to care.
J.C. : Evidence informed practice is to identify what will benefit the patient as well as to do no harm by applying appropriate intervention. I try my
best to provide therapeutic care and understand the situation that they are in, as well respect their choice if they refuse medication.
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1. 5 Carry out safety-based practices and risk management principles to ensure client safety and a
safe environment.
J.C. : Safety based practice is applied in clinical setting as well as everyday life. We cannot assume when and where the environment is unsafe,
however our approach is to prevent patient from falling by making sure the brakes are on when they are transferring from wheelchair to bed and
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1. 6 Ask questions and clarify the plan of care, unclear orders or directions, and whenever uncertain.
J.C. : If there is any doubt in giving PRN med or giving care outside scope of practice, I would always follow up with nurse or clinical teacher to make
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1. 7 Demonstrate professional behavior by seeking assistance in situations in which there is unsafe,
J.C. : When I was overwhelmed with patient care, I seek help with fellow student. A situation when patient was embarassed in giving taking shower
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1. 8 Demonstrate understanding about the role of the nurse within health care.
J.C. : I try to demonstrated professionalism and understand that role as nurse, our primary focus is to provide comfort and best care possible even in
an unpleasant situation. I must keep in mind that communication is key and patient education is needed when there is conflict between nurse and
patient
Teacher comments for COMPETENT AND SAFE PRACTICE WITHIN A PROFESSIONAL, LEGAL, AND ETHICAL FRAMEWORK :
During the clinical experience Anne has demonstrated competent and safe practice in a professional, legal and ethical framework through
her clinical time spent working with patients needing rehabilitation at St. Johns Rehab. Anne has practiced her care using the practice
settings policies and procedures and consistently acts in a responsible, ethical and accountable manner while providing patient care. She
has demonstrated understanding about the role of the nurse and nursing student within the health care system.
During Annes clinical progress, she has demonstrated much growth and development in connecting what she has learned in the
classroom setting to her patient care in clinical, thus demonstrating a good understanding of how to use evidence-informed practice and a
theory-based approach to nursing care. As Anne has stated above, she has had the opportunity to apply her knowledge regarding patient
safety, assessment data collection, wound care knowledge and important nursing considerations for medication administration to guide
her decisions for nursing care.
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2. 1 Participate in team sharing and discussions.
J.C. : During post conference, we shared our thoughts the effectiveness and some of side of effects in giving narcotics since most narcotics are given
PRN. We also discussed how it be overdosed and cause a harm to patients. We also talked about different wound care.
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2. 2 Document clearly, accurately, concisely in a timely manner using written and electronic methods.
J.C. : I have documented using SOAPIE notes but sometimes I get stuck on how I should document especially in Implementation and Plan. I feel like
sometimes they overlap. However, I make sure it's documented before the shift change and that I would write down briefly on my piece of note to
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2. 3 Report relevant information to the appropriate personnel.
J.C. : I have reported any unacceptable behaviour of patient to the charge nurse or discussed any misconduct or doubt about nurse's behaviour to
clinical teacher.
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2. 4 Use communication techniques with the client and the inter-professional health care team.
J.C. : I have collaborated with the nurse's, OT's and PT's if they was any question to patient care. One patient was delayed in OT therapy
appointment due to new admission so I collaborated with OT to make sure the appointment is moved to another time so the patient does not feel rush.
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2. 5 Ensure privacy and confidentiality according to the Personal Health Information Protection Act
(PHIPA).
J.C. : I would always ensure privacy and confidentially in giving care such as wound care, bed bath, catherization, and during shower. I also make
sure that I would not discuss patient's information or care outside the scope of practice.
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2. 6 Use technology to retrieve and share information including research, data and other information.
J.C. : I used internet search to look up medication information and utilize medical dictionary. There are different text we can use in nursing station if
Anne has continued to work with the paper documentation system at St. Johns Rehab and has achieved competence in writing nursing
notes using the SOAPIE method as well an imputing vital sign data, ADL flow sheet tasks, pain assessments and shift reports into the
proper documentation areas. She is able to document clearly and accurately, in a timely manner. Anne has demonstrated the ability to
effectively communicate with the Clinical Instructor, her peers and fellow staff members of the multi-disciplinary team, in order to provide
safe and effective care to her clients and reports relevant information to the appropriate personnel. Throughout the semester I have
appreciated Annes initiative to be in charge of her own learning, by keeping the Clinical Instructor informed of her learning needs and
progress goals. Because of this, I believe Anne was able to achieve optimal experience and competence with many aspects of nursing
care.
Anne has consistently maintained the privacy and confidentiality of the client's at St. Johns Rehab, according to PHIPA.
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3. 1 Use effective communication techniques.
J.C. : Effective communication technique is key in nursing practice and trying to find out what the need and want of patient is also important.
However, sometimes it's hard to get message across especially if patient speaks minimal english. In this care, I would use gestures by pointing out
the object and use simple words. Sometimes when their family member come for visit, we can communication with family member to find out what
patient wants.
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3. 2 Establish therapeutic caring, compassionate, and culturally safe relationships with clients and
J.C. : This is where critical thinking comes in to play. Patient wanted home food and was getting tired of eating hospital food. When the family
member came, I would bring it up to the family member to bring some home made food and keep it in the fridge in patient lounge and when patient
wants them we label it and bring the food to patient. This way patient feels like they are in so much hospital care with food that they don't want but
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3. 3 Demonstrate therapeutic use of self to foster client well-being.
J.C. : I have utilized therapeutic use of self and client's well being by building support, feeling empathy and trying to engage in their lifestyle as if they
are yours. I try to put my self into their shoes and the difficult moment they are experiencing.
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3. 4 Use self-awareness to identify the effects that beliefs, values, and personal experiences have on
relational practice.
J.C. : I have told few of my patient who was having difficulty coping and managing therapy regime and when patient was feeling depressed about
how they look. I have expressed my empathy by giving an example of my situation when I had difficulty coping and how i managed to overcome. I
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3. 5 Collaborate with clients and members of the inter-professional health care team and consult
appropriately.
J.C. : I have consulted with nurse when patient refuse to take medication and that we explained what the consequence will be if patient refuse to take
them.
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3. 6 Support the diversity of clients and the inter-professional health care team.
J.C. : When patient rings a call bell for help, I would walk up to the patient desk even when I'm not assigned to it or when they are in the same room I
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3. 7 Display sensitivity and respect for clients cultural, religious, and other beliefs and values
J.C. : When i went up to patient desk, the patient was praying so I waited until she/he was done and went along with my care.
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3. 8 Provide effective client education.
J.C. : When patient was admitted to the unit couple of days ago, it was his first time taking a shower. He had chest brace on and his mobility level is
very slow and careful. I advised him how he should go about in taking a shower without falling and hurting himself. He was standing the whole time
and refused my care but I stayed with him in the shower room just so that he is safe.
It has been great to see Annes confidence grow in regards to her clinical competence. She has grown from someone who was somewhat
shy and hesitant to begin care for her client, into a competent nurse professional who can provide care to her clients independently using
therapeutic communication techniques. I have appreciated Annes kindness and gentleness while working with her clients and her ability
to demonstrate use of self to foster client well-being. Anne is always sure to introduce herself to the client, collaborate care with them and
walk them through whatever procedure she is doing; ensuring they are comfortable. Overall Anne provides care to her clients that is
therapeutic, compassionate and culturally safe.
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4. 1 Apply appropriate conflict resolution skills in therapeutic client and other interactions.
J.C. : When patient was uncomfortable and felt insecured when I was giving care because I was a student, I got the nurse to monitor me and instruct
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4. 2 Evaluate and refine leadership skills to develop solutions and create a positive work
environment.
J.C. : I had a plan in getting the patient ready for the therapy and the nurse kept on pushing me that I need to get this patient ready asap so I
completely forgot to wash him when I was helping the patient to put the clothes on. The nurse came in and ask if I washed him, I said "no". She gave
me the look and just walked away. So I quickly gave the patient a shower and get him ready for therapy.
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4. 3 Provide feedback to peers and accept feedback from peers and members of the inter-
J.C. : During post conference or during our care, I gave feedback when one of our student colleague wasn't giving proper care and that I would help
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4. 4 Advocate for clients, self, others, and quality practice environment.
J.C. : My role as nurse, my main goal is give proper care and that in whatever circumstance they are in, I would advocate for them. One patient was
feeling very emotional one day and wanted to go out for fresh air. I took him outside and we had a small talk. He really appreciated the time.
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4. 5 Support clients rights for self-determination and choice.
J.C. : When patient refused medication, I would explain to them what are the consequence in not taking it and the benefit in taking the drug. If patient
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4. 6 Respond appropriately to unsafe, unacceptable, and unprofessional behaviours.
J.C. : I had forgotten to give 1000 medication and left for the break. That day I was bombarded with all three patient that I completely forgot to give
1000 medication for one of my patient. Luckily my instructor noticed and gave the medication to patient. I would always keep in mind to administer all
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4. 7 Collaborate and consult when implementing health care and nursing practices that are in the
best interests of the public and protect the public through collaboration and consultation.
J.C. : I have collaborated with all the nursing team for any issues or concerns regarding the patient.
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4. 8 Contribute to the creation of quality practice solutions and strategies.
J.C. : I noticed that each hospitals have different policies and protocol. Sometimes there can be things that I don't agree with but I would still follow
their procedure. If I have any doubts or suggestions, I would first discuss as our team and consult with nursing team member.
Anne respects the rights of others and she participates in a collaborative manner with peers and staff. She seeks assistance from the
appropriate members of the multidisciplinary team and the clinical instructor, if she is unsure and then will perform the task independently.
Although it can be difficult as a nursing student to feel comfortable and confident with this nursing competency, I believe that Anne knows
when to advocate for her patient to provide the best possible care and as her confidence and competence as a growing nurse professional
grows she will no doubt be a great leader and advocate.
5. PLANS OF CARE: MEET CLIENTS NEEDS AND MUTUALLY AGREED EXPECTED OUTCOMES
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5. 1 Incorporate the clients unique needs and expected outcomes into holistic and client-centred
plans of
care.
J.C. : I convinced one of my patient to take shower, when he insisted to take shower for a week.
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5. 2 Develop theory-based plans of care that are holistic and client centered and are articulated
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5. 3 Use knowledge, skill and judgment to assess clients, prioritize needs and outcomes.
J.C. : I have prioritized my time in accordance to their therapy schedule. I make sure to tell the patient that I need to take of other patient and will be
back to take care of them just so that they don't feel like I am ignoring them
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5. 4 Collaborate in the evaluation and modification of plans of care.
J.C. : I have collaborated in reporting process when nurse gives shift report
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5. 5 Safely and competently implement and evaluate nursing assessments and nursing interventions
J.C. : I have demonstrated and implemented nursing assessment in reference to what the previous nurse performed previously and created my own
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5. 6 Use the Three-Factor and practice decision-making frameworks to guide practice.
J.C. : I would always keep in mind that nurse, client and environment is important in giving care and that building a therapeutic relationship with nurse
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5. 7 Prioritize nursing care and nursing interventions in order to manage workload, time, and physical
resources.
J.C. : I have prioritized my nursing care in accordance to their OT, PT therapy. I realized that time management is critical when you have more than
three patients.
Teacher comments for PLANS OF CARE: MEET CLIENTS NEEDS AND MUTUALLY AGREED EXPECTED OUTCOMES :
By the end of the semester, Anne has demonstrated competence in working with a 3-patient assignment on a busy rehabilitation unit. Anne
receives her patient assignment when she arrives to clinical each morning and then collects data from each clients chart, MAR and
KARDEX to create a Daily Organizational Care Plan (DOCP). Through the development of a good DOCP Anne has demonstrated very good
organization and prioritization of care throughout the 12-hour shift. Anne has learned how to perform head-to-toe assessments, take vital
signs, administer medications including PRN narcotics for pain management, give Sc and IM injections, provide wound care, and remove
sutures and staples. Anne was able to perform the required nursing assessments, data interpretation and critical thinking necessary to
competently and safely carry out each of these nursing skills.
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6. 1 Collaborate with clients and members of the inter-professional health care team to assess
clients, determine health needs, and to achieve mutually agreed expected outcomes.
J.C. : When providing special wound care and staple removal on sutures, we collaborated as team observe and implement complex care.
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6. 2 Contribute as a member of the inter-professional health care team to respond to the changing
J.C. : When we give flu shot to patients, we had to wait until the doctor is in the unit so when unexpected or allergic reaction occurs, we have the
J.C. : When administering PRN medication, I would confirm with nurse first so it's appropriate to patient's symptom
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6. 4 Use teamwork, consensus building, and conflict resolution skills to meet expected client
outcomes.
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6. 5 Use effective, collaborative, and consultative strategies to meet clients needs within a changing
environment.
J.C. : When one of my patient was going through difficult moment due to changes in her body image and the fact that she has to live like that for the
rest of her life, I put my empathy towards her in giving positive advice and encouragement.
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6. 6 Interact with members of the health care team respecting their unique role and competencies.
J.C. : I understand everyone has their own way of giving care. I tried my best to adapt to his/her style of nursing and also give my advice on how I
By the end of the clinical placement it is evident that Anne has become an integral part of the interprofessional health care team. She has
taken charge in caring for a 3-patient assignment while consulting and collaborating with the staff nurse to ensure that mutually agreed
and expected outcomes were achieved for each client. It is clear that Anne understands the importance of communicating with the team
members in regards to her client's status and changes so that safe care is provided. Anne would receive report from the staff at the
beginning of the shift and then discuss with the staff what aspects of care she would be responsible for, which usually included the
collection of assessment data, ADLs, medication administration, any nursing tasks such as wound care and documentation. Throughout
the shift Anne would seek out assistance and consult with other members of the health care team when she needed to and would report
relevant data to the appropriate personal. As a nursing student, Anne has demonstrated the ability to work effectively as a member of the
health care team so that she can carry out holistic plans of care for each of her clients.
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7. 1 Act in the best interests of clients and protect clients from harm through collaboration and
consultation with members of the inter-professional health care team and through competent and safe
practice.
J.C. : When our unit was in code blue status, it was great to see all nursing team member gather up to get this patient alert and it was also great to
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7. 2 Engage in ongoing reflective practice to identify strengths, areas for improvement; and, integrate
J.C. : Every week when I sign off for weekly K4Y, the instructor comments on my performance. I would reflect back on what I did that week and
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7. 3 Create, implement, and evaluate a learning plan consistent with the Quality Assurance program
(CNO).
J.C. : When I reflect back on my experience that week and as I was creating a weaknesses and strengths, I realized which area I need to focus and I
also realized that there were so many areas that needs to be improved on. The learning plan will help me reflect back on my area of improvement.
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7. 4 Seek out learning opportunities and feedback that foster professional development; and,
J.C. : I am always open to learn new things and take on challenge. When patient rings a bell for assistance, I would take the initiative to help even
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7. 5 Use nursing research to foster professional development.
J.C. : I have utilized medical surgical book and wound care management book to give proper care
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7. 6 Use a theory-based approach and evidence-informed practice.
J.C. : When I am giving care to patients, I would always keep in mind to do no harm and to promote good health teaching method
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7. 7 Apply knowledge of changes to the health care system, technology, and in society as these
J.C. : Applying changes such as taking the MAR to patient's desk, using SOAPIE notes in documentation, two person check for injection as well as
proper count with narcotics at the end of shift was all new to me but overall it was great experience how thorough and precise it was to see.
It is evident that Anne engages in self-reflection through the constant improvement on her daily organizational care plan and in her
progress to care for a 3-patient assignment effectively and efficiently. She considers what could be done the same or differently during the
next clinical experience and adjusts her plans of care to demonstrate improvement. Based on the progress that Anne has made over the
semester, I am confident that she will be able to take the prioritization skills she has developed and easily transition into working in the
Pre-grad setting.
Anne seeks out learning opportunities and feedback from the Clinical Instructor, peers and staff so that she can continue to improve in her
nursing knowledge and skills. This has been evident throughout the semester as Anne has shown much growth and development in
therapeutic communication with her patients, collaborative practice with the healthcare team and general competence with performing
nursing tasks such as wound care, suture/staple removal and her ability to translate her assessment data into decisions guided by critical
thinking.
Anne has completed her self-evaluation and obtained peer feedback based on this clinical experience and previous learning plan. Anne has
identified three new learning goals and has created a new Learning Plan for the next clinical experience.
Anne, I encourage you to continue to engage in ongoing reflective practice to identify your strengths, areas for improvement and integrate
the feedback into your practice so that you can continue to learn and grow as a competent nurse professional!
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8. 1 Use critical thinking and problem-solving skills to inform decision-making in all aspects of nursing
care.
J.C. : I noticed my critical thinking skills and my interaction with patient was improving. When in doubt, I would always confirm with nurses' and
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8. 2 Use critical thinking, problem-solving and decision-making skills to assess clients and to
determine nursing diagnoses, expected outcomes, nursing interventions, and evaluative criteria.
J.C. : Sometimes your critical thinking skills needs to go above and beyond the boundaries. I noticed that what we go about in nursing intervention
for certain diagnosis does not always apply everyday practice but we need modify our intervention using our critical thinking skills
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8. 3 Evaluate critical thinking, problem-solving, and decision-making skills and design a plan to
improve
these.
J.C. : I think critical thinking skills gradually improves as more experience comes along.
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8. 4 Integrate knowledge from a variety of nursing, health, and other theory into nursing practice to
J.C. : I've got to experience my patient going for OT, PT therapy and apply some knowledge there as they perform different therapy.
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8. 5 Prioritize effectively.
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8. 6 Demonstrate professionalism and accountability.
J.C. : I have tried my best to display professionalism and accountability for my actions and that I would always introduce myself to patient first and
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8. 7 Use the practice decision-making and the nurse-client-environment frameworks to inform and
guide practice.
J.C. : Giving patient centered care, using therapeutic relationship method is a guide to nursing care. I would respect, advocate for my patient
During clinical time Anne has been given the opportunity to take the nursing theory learned in the class room and apply it into actual
nursing practice. She has been learning what it means to care for a client in need of rehabilitation from either orthopedic surgery or a
traumatic event such as MVC or burn injury and apply her critical thinking skills. Annes growth and development in this area of her
nursing practice is evident in many ways such as her ability to:
Taking vital signs and assess the data to determine that the patient is stable or unstable and report these finding to the appropriate
personal
Consider the values of blood pressure and pulse before administering blood pressure medication
Be sure to give a medications like Pantoloc or Synthyroid before a meal
Assess pain using the PQRSTU method and identify what medication(s) would be appropriate for effective pain management
Ensure that a client with mobility issues has a safe environment to maneuver around in and has the appropriate assistive devices
Adapt to the changing needs of her client and re-prioritize effectively
Throughout the clinical experience Anne has also been working on the development of her critical thinking and decision making skills
through the development of her daily organizational care plan (DOCP) as she has learned to competently plan and prioritize care needs for
a 3-client case load.
I still need to improve on critical thinking process when unexpected situation comes and time management.
Good work!