St.

Paul University Philippines

Tuguegarao City, Cagayan North 3500

GRADUATE SCHOOL
Master of Science in Nursing

Dear Preceptors,

Greetings of Peace!

This is meant to evaluate the student as regards his/her practicum performance in your institution. Please find attached inventory of
effective strategies for the said practicum. Using a scale of 0-3 with 3 as the highest, may we request you to rate the students performance in
the course of his/her stay in your area. Encircle the number which best describes his/her performance.
Rest assured that your answer will be kept confidential.

Thank you,

MIRIAM D. PATTUGALAN, MSN

Practicum Adviser
 Page |2

PERFORMANCE EVALUATION TOOL

Domain 1. ATTITUDE (Personal Growth and Development)

This domain focuses on how the student serves as an effective role model of values inspired by Paulinian Education. The
students actions, statements, and interpersonal relationships with patients and other health care professionals exemplify the 5 Cs of a
Paulinian student: caritas, Christ-centered, community, commission, charism. Displays professionalism in her thoughts, words and
actions.
Strands Performance RUBRICS
Indicator
3 2 1 0

1. Student - Demonstrates Has 100% attendance Has been tardy once Has incurred 2 Has incurred more
actions punctuality and in the duration of his for the duration of his tardiness for the than 2 tardiness for
demonstrate regularity of practicum. practicum. duration of his the duration of his
paulinian attendance. practicum. practicum.
values or 5Cs.

- Maintains Always wears neat Wears neat and Failed to wear Do not wear
appropriate and complete complete uniform complete uniform complete uniform but
appearance uniform and is and is well groomed. once but well well groomed.
(wearing of always properly groomed.
uniforms, personal dressed and well
hygiene, and groomed on duty.
grooming).

- Exhibits personal Exhibits the 5 Cs; Exhibits 3 of the 5C Exhibits 2-1 of the Do not exhibit any
and professional shows outmost have; demonstrate 5Cs; sometimes one of the 5Cs; no
values towards professionalism professionalism exhibit demonstration of
other health care towards other health towards other health professionalism professionalism
professionals and care professionals care professionals. towards other health towards other health
clients. and clients. care professionals. care professionals.
 Page |3

3 2 1 0
- Exhibits smooth Always exhibit Exhibit smooth Sometimes exhibit Do not exhibit
professional and smooth professional professional and smooth professional smooth professional
social relationship and social social relationship and social and social
towards clients. relationship towards clients. relationship relationship towards
towards clients. towards clients. clients.

2. Takes pride A. Articulates and If all of the 5 If only 3 or 4 of the If only 1 or 2 of the If none of the 5
in the nobility demonstrates indicators are indicators are indicators are indicators are
of nursing acceptable evident. evident. evident. evident.
profession. philosophy on
nursing.

B. Manifests
enthusiasm and
strong commitment
in nursing as a
mission.

C. Manifests high
standards of
decorum; a model
for others to
emulate.

D. Maintains
stature and
behaviour that
upholds the dignity
of nursing.
 Page |4

E. Inspires fellow
nurses to adhere
and uphold essence
of profession.

3. Positive - Demonstrates Always demonstrate Demonstrate Sometimes Never demonstrate

outlook on openness to accept openness to accept openness to accept demonstrate openness to accept
attainment of feedback from feedback from feedback from openness to accept feedback from
personal patients, peers, and patients, peers, and patients, peers, and feedback from patients, peers, and
development. superiors to superiors. superiors. patients, peers, and superiors.
improve his superiors.
performance.
 Page |5

Domain 2. SKILLS (Enhancement of abilities)

This domain focuses on the skills and the ability that the student demonstrates accordingly that is beneficial to both clients
and self in accordance to institutions policies and regulations.
Strands Performance RUBRICS
Indicator
3 2 1 0

1. Exhibit skills A. Participates in Demonstrates all 3 Demonstrates only 2 Demonstrates only 1 Do not demonstrate
on dealing with ward endorsements. parameters. of the parameters. of the parameters. any of the
complex health parameters.
care needs and B. Utilizes
demonstrates the therapeutic
ability to communication
effectively skills.
communicate
with other health C. Participation in
care workers in a constructive peer
clinical setting. interaction.

2. Effectively A. Assesses If all of the 6 If 4-5 indicators are If 2-3 indicators are If 0-1 indicator is
implement roles patients condition indicators are evident. evident. evident.
in professional accordingly. evident.
nursing with the
use of nursing B. Able to identify
process. specific
problems/need of
clients.

C. Constructs
SMART objectives
 Page |6

for provision of
health care.

D. Appropriately
performs desired
client care in
conjunction to
goals/objectives.

E. Provides an
evaluation for
patients care and
prognosis.

F. Identifies a topic
for case study.

3. Demonstrates A. leads staff in Demonstrates Demonstrates all the Demonstrates only 1 Do not demonstrate
leadership performing care for beyond the parameters. of the parameters. any of the
abilities clients parameters. parameters.

B.

4. Demonstrates A. Is aware of Demonstrates Demonstrates all the Demonstrates only 1 Do not demonstrate
respect of culture cultural diversities beyond the parameters. of the parameters. any of the
in performing among clients. parameters. parameters.
competent care
throughout the B. Is sensitive in
whole exposure. performing proper
care based on
 Page |7

culture & lifeways

of clients.

5. Documents A. Well-organized Demonstrates all of Demonstrates only 2 Demonstrates only 1 Do not demonstrate
accurately all in his the parameters. of the parameters. of the parameters. any of the
possible plan, documentation parameters.
implementation,
evaluation and B. Adheres to
prognosis in institutions policy
health care to all on proper
clients. documentation.

C. Accurately
prepares and
accomplish needs
for documentation.
 Page |8

Domain 3. KNOWLEDGE (Effective intellectual learning)

This domain focuses on concept of Cardiology, Diabetes and Oncology Nursing regarding Preventive/Promotive,
Curative, Rehabilitative, & Palliative/End-of-Life Care as well as on Leadership & Management, Theoretical Foundations in Nursing
and Nursing Ethics.
Strands Performance RUBRICS
Indicator
3 2 1 0

1. Conducts A. Identifies clients Demonstrates all 5 Demonstrates 3-4 of Demonstrates 1-2 of Do not demonstrate
health education level of learning. parameters. the parameters. the parameters. any of the
in clients while parameters.
performing B. Delivers accurate
health care and updated content
services as per knowledge using
clients needs. appropriate
methodologies,
approaches and
strategies.

C. Explains learning
objectives, instructional
procedure and contents
while rendering proper
patient care.

D. Provides health
education showing
mastery of the topic.

E. Assures oneself to
 Page |9

remain up to date on
issues regarding health
care.

2. Recognizes A. Assesses patient Demonstrates Demonstrates all the Demonstrates only 1 Do not demonstrate
health problems carefully for beyond parameters. parameters. of the parameters. any of the
necessary for existing/actual/possible parameters.
research and health problems.
development.
B. Recognizes all
problems as a candidate
for research and
development in health
care services.

EVALUATED BY: _____________________________

DATE: _____________________________
P a g e | 10