NURS 253 STUDENT SELF.

ASSESSMENT
EVALUATION OF PERFORMANCE OCCUBS AT WEEK 4 and/or ongoing (it required), WEEK7 (Mldterm), Week 1t AND WEEK 15 (Final)
NOTE: Students who are experiencing difficulties that could rosult in an 'unsatisfactorF in Week 7 or Week 15 will be expected to do a self-evaluation and receive
a precoptor and faculty evaluation in Week 4 and/or week 11, and as requked.

PLEASE
E

9y, TEI"ESL 4SP.

1.

il.

iv.

vt.

vii
vilt.

tx.

S = SATISFACTORY ND= NEEDS

Week4 /S) ND U
c n w rH N A LE G AL

CIRCLE

9lIF l'll$crr

DEVELOPMENT

Model safe, competent, and ethicalpractice in

compliance with legal and regulatory frameworks
and the policies and procedures of the practice
setting.
Comply with regulatory standards, relevant legislation
and the practice setting's policies and procedures.
Act in a professional, responsible, ethical and
accountable manner.
Use the three factor and decision making frameworks
to determine strengths and limitations and when to
collaborate and consult with other professionals.
lntegrate evidence-informed practice and a theory
based approach into nursing care.
Assess practices and risk management principles and
take action to ensure safety of clients, self, and others.
Question and clarify unclear orders or directions and
when uncertain.
Question, clarify or challenge questionable orders,
decisions or actions by others.
Respond in a professional manner to situations in
which there is unsafe, unacceptable or unprofessional
behavior.
Demonstrate understanding about the role of the nurse
within health care.

\j

Comments

Preceptor siqnature and date

Student siqnature and date

week

ei

U = UNSATISFACTOHY

Comments

ND

,r'r I ,, rl

,:=
Student signature and date

Preceptorynrllur" and date

y'-\r-

Week

Student signature and date

Week14iS

(-

\rli
,r.i:

/.aa,--/

Preceptor signature and date

Comments

\*",')

aL

Comments

ND

11

i( rr --i
-,r

S: {

lt.- e S r.\' e\

<x).r tsr**r.e il,

I

-{- _,-,,i..1i
,* {_

.,.>

Student siqnature and date

Week4 S ND

-, F

<_r.,.k

u'

{i ir \ r-xi.tre, (\{.\ (-,\,..p

{:-), q--t
-)
<:\\*?^=--.,-a"
-.
\o:.t- v(,-_.{ -r.]r,.=,. qw[-*rs
---!
Preceptor siqnature and

date f

;/t1j:

*c

Comments

ACCURATE AND RELEVANT COMMUNICATION

.t-/,c't
',J/

"

:.

''',.;f,,
,
,_"

"')'---f,',-"1/t

"i

CARING RELATIONAL PRACTICE

3.

[.

il.
iv.

vt.

vil.

vil

Week 4

Comments

ND

Engage in relational practice that is caring,

compassionate and respectf ul.
Establish therapeutic caring, compassionate, and
culturally safe relationships with clients and health care
team members.
Establish a caring environment that supports clients in
meeting their needs and outcomes, managing their
illness, or experiencing a peaceful death
Demonstrate therapeutic use of self to foster client
well-being.
Utilize relational knowledge and skills, and ethical
principles to support clients and to interact with health
care providers
Use self-awareness to identify the effects that beliefs,
values, and personal experiences have on relational
practice.
Collaborate with clients, members of the
interprofessional and health care teams; and, consult
appropriately.
Uphold practices and systems that support the diversity
of clients and of the interprofessional health care team.
Provide effective client education.

Student signature and date

WeekT

iSi

,,,"\

r'l---;

Preceptor signature and date

Comments

ND

,,

-...
Jr-.

l
i .l:r:\

.--

Student signature and date

Week 11

ND

Preceptor signature and date

Comments

Student signature and date

Week 14

Student signature and date

Preceptor signature and date

Comments

Preceptor signature and date

i-

) \..! ,r.1
--:.'(
/'

plettS Of CARE:

MEET CLIENTS' NEEDS AND MUTUALLY

AGREED EXPECTED OUTCOMES
5.

i.

il.

iv.
V.

vt.

vil.

vill.

Week4 S ND U

Comments

lntegrate the nursing process into all aspects of

nursing care and across diverse practice settings.
Formulate clinicaljudgments that meet clients' unique and
changing health needs and priorities, outcomes, and overall
condition and incorporate these into evolving plans of care.
Devise evidence-informed plans of care that are holistic and
client centered.
Use clinicaljudgment to assess clients, prioritize needs,
outcomes, and nursing interventions.
Collaborate in the evaluation, refinement and modification of
plans of care.
Safely and competently perform treatments and use
techniques, and technology autonomously and in
collaboration with clients and members of the
interprofessional health care team.
Collaborate with the clients across the lifespan and with
members of the interprofessional health care team to create
a client centered plan of care that is articulated with
competence both in writing and orally.
Use awareness of own knowledge and skills, the three
factors of nurse, client and environment and the practice
decision-making framework to guide practice.
Manage workload, time, and physical resources to provide
effective, elficient and ethical care.

Student signature and

weekT "S\,

date

ND U

Preceptor signature and date

Comments

!-'l

.\
-+\

,j)

ri

!I .-,.i,";'
r- L-,r\[,i:1,.:
:

Student signature and

ND
Week 11

Student signature and

Week 14

.-_-;

.-,,:

Student signature and

Preceptor signature and date

Comments

date

sl U
(-,/

,l;-- r

'<
:
''i)<\---:f

date

Preceptor signature and date

Comments

l,I :\

date

Preceptor signature and date

.t)7 ),,.( l''i

"1i/

Week4 S ND

Comments

QUALITY ASSURANCE: CONTINUE AND IMPROVE

COMPETENCE
7.

Engage in Quality Assurance consistent with the

regulatory framework.
Act in the best interests of clients and protect clients
from harm through collaboration and consultation with

il.

ilt

tv.

vt.

other members of the interprofessional and health care

teams and by through competent and safe practice.
Commit to Quality Assurance practice to identify
strengths and areas for prolessional growth and in
accordance with the regulatory f ramework (CNO).
Create, implement, and evaluate a learning plan
consistent with the Quality Assurance program (CNO).
Assume responsibility to seek out feedback for
colleagues and peers and learning opportunities that
foster prof essional development.
Consistently review nursing research and information
about health care to improve competence and to
support clients
Develop professional responses to health care system
changes resulting from advances in research,
technology, and changes in societaland political
forces.

Student signature and di

S IND
WeekT\/-

{.,,(.
lrl--

t.'

lte

PrecePtor signature and date

Comments

a.)''-' r'-) "1i "\.

Preceptor

Student sionature and date

Week

11 S ND U

student signature and

Week 14 , S

lU

.t

/.+, t- \'

''-:)1i

'

-.

,)'

s ig

ne!qg_q!q_gate

Comments

date

Preceptor signature and date

Comments

I ;,

'-- ''- .

Student siqnature and date

,'-- i" .,": . ,lt J

Pteqeptor signature and

I

i1

\-<,

:)-,/

. '-

/,'/// )
t: )("
t

2.

t.

ii.
ilt.

lv.

V.

vi.

Communicate using strategies and technology to

effect accurate and timely information sharing
including data, research, and other information.
Contribute to team sharing and discussions.
Document clearly, accurately, concisely in a timely
manner using written and electronic methods.
Use effective communication techniques when
reporting relevant information and providing feedback
to the appropriate members of the interprofessional
heath care team.
Evaluate and refine techniques used to communicate
and share information with clients and the
interprofessional health care team.
Ensure privacy and confidentiality.
Use technology to retrieve information including
research and other date and to obtain and forward
information both within and outside the practice setting.

Preceptor signature and date

Student signature and date

WeekT, S rND

Gomments

\/

\,j

,,

., nl
"-,.\
Student signature and date

Week

ND

11

Preceptor signature and date

Comments

Student signature and date

Week

14 /'S
tj

,A-f

Preceptor signature and date

Comments

*,i,,*,\,o

Student signature and date

Preceptor signature and date

-tf.t,,"ll'

Week 4

Comments

ND

LEADERSHIP AND ADVOCACY

Act as a leader and an advocate to empower

clients, self, the interprofessional health care team
and to fufiher the professaon.
l.

Evaluate and refine leadership skills to develop

solutions, resolve conflict, create a positive work
environment and organizational culture, and to

strengthen advocacy role.

Provide feedback to peers and accept leedback from
peers and members of the interprofessional health care
team.
Advocate for clients, self, others, and quality practice
iv.

vt.

vii.
vlil.

environment.
Support clients' rights for self-determination and
choice.
Flespond appropriately to unsafe, unacceptable, and
unprofessional behaviors.
Demonstrate public protection and acting in the
interests of the public through collaboration and
consultation with other members of the
interprofessional health care teams.
Contribute to the creation of quality practice strategies
and solutions.
Assign, supervise, teach as appropriate, and provide
feedback to unregulated care providers (UCPs) in
collaboration with the interprofessional health care
team.

Student signature and date

Week

.r\ii\

\-

Preceptor signature and date

Comments

ND

\--

,-,;\i,, r1,,,
I

Student signature and date

Week

11

Preceptor signature and date

Comments

ND

Student signature and date

Week 14

-l-.-\.' li '

Preceptor signature and date

Comments

Student signature and date

Preceptor signature and date