Nursing Praxis

and Professional Caring

443 Northern Avenue
Sault Ste. Marie, ON Canada P6B 4J3

BScN Clinical Evaluation Form

Tel 705.759.2554
www.saultcollege.ca

SEMESTER COURSE CODE MIDTERM DATE FINAL DATE

III 10/29/21 10/29/21

STUDENT
2144
2084
CLINICAL EDUCATOR CLINICAL SETTING STUDENT/INSTRUCTOR COPY

Morgan Burke Barb Engel 3B Medical Student Instructor

Purpose course professor. Each objective in the supplementary plan is to address

To formally document a compilation of information indicating a pattern of
growth, development, and performance for each stated clinical practice
indicator. Sources of information include self-assessment, educator observation,
written clinical work, and feedback from agency personnel and clients.
a separate indicator that received a score of “1” or “2” from the student or
educator on the midterm evaluation.
At final evaluation, scores of three (3) in all five domains of clinical practice are
required to be assessed as successful in clinical practice. The exceptions are
those indicators assigned a score of zero (0).

Process
Clinical evaluation involves the following five (5) steps:
1. The student independently completes this form in preparation for the midterm
and final evaluations. The student must draft a learning plan (page 7) to bring
to the midterm for the clinical educator’s approval.
2. Check the numbered box that best represents the student’s performance
relative to the following scale:
0 = No information to render a score
1 = Fails to meet the stated indicator despite usual guidance and feedback
2 = Approaches the stated indicator with usual guidance and feedback
3 = Maintains the stated indicator with usual guidance and feedback
4 = Maintains the stated indicator with minimal guidance and feedback
At midterm evaluation, a score of “1” or “2” indicate failure to maintain the
stated indicator(s). The student must complete a supplementary learning
contract (page 8) that must be approved by the clinical educator and the
3. To support the assigned numerical score in each of the five (5) domains
of clinical practice (see below), the student must provide specific written
examples from this clinical experience.
4. At both midterm and final evaluations, the student and clinical educator meet
privately to review, compare, and discuss their independently completed
Clinical Evaluation Forms. The course professor can be invited to either
evaluation at the request of either the student or clinical educator.
5. At a minimum, the clinical educator communicates student progression to the
course professor within five (5) days of the midterm and final evaluations. The
midterm communication with the course professor can be verbal or written.
The final communication must be in writing.
Five clinical practice domains
A. Professional Responsibility and Accountability; B. Knowledge-Based Practice;
C. Relational Practice; D. Ethical Practice; E. Service to the Public

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A. Professional Responsibility and Accountability
Demonstrates professional practice with a commitment to ensuring safe, competent,
and ethical nursing care and progressive professional development

MIDTERM FINAL
INDICATORS
0 1 2 3 4 0 1 2 3 4

a.1 Complies with school and agency professional and behavioural policies

a.2 Arrives prepared to assume care of client

a.3 Practices within nursing professional standards

a.4 Incorporates feedback about his/her professional practice

a.5 Communicates own role, responsibilities, values, and scope of practice to others
(clients, healthcare team members) using appropriate language
a.6 Plans appropriate actions to address self-identified professional limitations,
including accessing others’ skills and knowledge appropriately through consultation
a.7 Invites the participation of clients/families/representatives as integral partners
alongside healthcare team members
a.8 Is accountable for own clinical judgements, actions and behaviours

a.9 Organizes all professional responsibilities in a timely manner

a.10 Actively participates in clinical learning opportunities

a.11 Demonstrates reflective practice

a.12 Submits all required documentation in a timely manner

a.13 Completes all Senate approved clinical hours

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Provide examples from this clinical experience to support your assigned numerical scores in this Domain:

I feel as though that I ensure safe, competent,and ethical nursing care and progressive professional development. If there is something I have not been
taught how to do I tell my nurse that I am unable to do the skill safely but I will ask my clinical instructor if it is possible for her to do it with me. Before
Clinical day I ensure I understand my clients diagnosis in order to safely and thuroughly assess my patient.

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B. Knowledge-Based Practice
Integrates current and appropriate knowledge in the provision of assigned nursing responsibilities.

MIDTERM FINAL
INDICATORS
0 1 2 3 4 0 1 2 3 4

b.1 Demonstrates safe practice grounded in knowledge, client's preferences, cultural safety,
organizational policies, and professional standards
b.2 Integrates current/relevant literature, nursing theory, and evidence to support/direct practice

b.3 Anticipates health issues relevant for each assigned client

b.4 Assesses client's health including their perception of their health

b.5 Plans evidence-informed, individualized care and intervenes based on priorities in collaboration
with the client and healthcare team
b.6 Provides substantiated rationale for care priorities

b.7 Demonstrates competence in the performance of the following fundamental nursing skills:

7.1 Foundational nursing care

7.2 Health Assessments

7.3 Appropriate comfort measures

7.4 Urinary catheterization

7.5 Medication administration

7.6 Oxygen therapy

7.7 Wound care

7.8 Enteral feedings

b.8 Evaluates outcomes of interventions and alters plan of care as necessary in collaboration with the
client and healthcare team
b.9 Assists with mobilization of information resources after consultation with clinical educator and/or
healthcare team members
b.10 Reports client’s condition to appropriate healthcare member(s) during each patient handover
(breaks, absences from unit, end-of-shift) verbally and/or in written format as appropriate
b.11 Identifies significant or potentially significant changes in client’s condition

b.12 Reports signs and symptoms, which may indicate an emergency, to appropriate healthcare team
member(s) immediately
b.13 Works with other members of the healthcare team to enable effective client outcomes

b.14
Last Documents
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b.15 Appropriate and authorized use of technology 4

Provide examples from this clinical experience to support your assigned numerical scores in this Domain:

When given a client I research the disease and possible findings before Clinical. This help me gain an understanding in what significant findings I may
find while assesing my patient or reviewing their laboratory work. I also speak to the nurse before introducing myself to the patient as this is my first
interaction with that patient and I do ot necissarily know what their normal base line is. If when I assess them and I find that the patient is now a two
person assist instead of being independant like the nurse told me this could be a significant finding that I may not have realized if I did not understand
what their normal was. In relation to finding what their normal is I dont assume that the patient I am speaking to wants their pain to be completly
diminished, it is important for me to gain an understanding of what their goal is in terms of their health inorder to create my own nursing goals and
interventions.

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C. Relational Practice
Initiates, maintains, and terminates professional relationships that are characterized by trust,
respect, authenticity, and support the dignity of others.

MIDTERM FINAL
INDICATORS
0 1 2 3 4 0 1 2 3 4

c.1 Demonstrates relational competencies (e.g., respectfulness, genuineness, compassion, empathy,

active listening, cultural humility and safety, trauma-informed care) to uphold the dignity and safety
of the client
c.2 Demonstrates client-centered orientation to one’s own practice of nursing

c.3 Describes the role of diversity (i.e. age, gender, culture, determinants of health, equity, social justice,
power imbalances) on health choices and practices
c.4 Responds to client's health choices within the context of significant others

c.5 Maintains professional interactions with clients, their significant others, clinicians, and peers

c.6 Integrates the client's unique past and current healthcare experiences into the plan of care

c.7 Promotes client autonomy

c.8 Engages in culturally safe care from the perspective of the client, integrating relevant knowledge
(e.g., Truth and Reconciliation Commission of Canada: Calls to Action)
c.9 Respects, advocates, and mobilizes actions to honour client’s individuality consistent with
organizational protocols in consultation with healthcare providers
c.10 Demonstrates honesty and integrity in all professional verbal, nonverbal, and written
communications
c.11 Maintains professional boundaries (e.g., clearly identifies role as a student nurse; refrains from self-
disclosure to meet one's own personal need)
c.12 Assessing own relational practices with clients, their significant others, and healthcare team
members
c.13 Evaluates own role in establishing culturally safe interactions

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Provide examples from this clinical experience to support your assigned numerical scores in this Domain:

My goal as a nursing student is to advocate for my client individuality and wishes as well as promote myself as a professional nursing student. I want to
promote independancy and gain a better understanding of those clients beliefs in terms of their care. By understanding my clients I am able to provide
them with a safe enviornment.

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D. Ethical Practice
Demonstrates competent professional judgement by applying ethical values and
responsibilities to facilitate the health and welfare of clients.

MIDTERM FINAL
INDICATORS
0 1 2 3 4 0 1 2 3 4

d.1 Demonstrates ethical and practice standards of the profession

d.2 Maintains ethical responsibilities and legal obligations related to maintaining privacy, confidentiality,
and security in all forms of communication, including social media
d.3 Maintains truthfulness and integrity in all professional written, verbal, and non-verbal interactions

d.4 Critically assesses responsibilities related to the use of restraints (e.g., principle of least/minimal
restraints, use of different types of restraints, etc.)
d.5 Promotes client’s choice and well-being within the obligations of the law and standards of practice

d.6 Maintains commitment to assigned clients

d.7 Seeks assistance when ethical concerns and conflicts arise

d.8 Facilitates client safety and welfare by preventing and removing harm

d.9 Describes the potential for conflict to occur and takes steps to address it including consultation
with members of the healthcare team

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Provide examples from this clinical experience to support your assigned numerical scores in this Domain:

When given a patient I am essentially taking responsibily of that patient while I am at Clinical. Therefore I will only write down findings that I have found
while assesing my patient, and alert consult health care profesionals when I feel there is potential for harm or conflict. I maintain ethical responsibility and
legal obligations by never writing my patients full name down while I have papers on hand with their health information.

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E. Service to the Public
Demonstrates public protection in collaboration with clients and other members of the intra-
and inter-professional health care team, and decision makers as appropriate.

MIDTERM FINAL
INDICATORS
0 1 2 3 4 0 1 2 3 4

e.1 Assists client to integrate new health practices relative to individual health needs, health
preferences, values, beliefs, and care expectations
e.2 Collaborates with members of the care team to address client's health needs, choices,
expectations, and equity
e.3 Outlines relevant nursing practice issues

e.4 Describes nurses' and nursing students' role in intra- and inter-professional teams

e.5 Describes the contributions of other health care providers in the provision of safe client care

e.6 Complies with safety mandates of the organization

e.7 Upholds organizational policies and practices in clinical judgements

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Provide examples from this clinical experience to support your assigned numerical scores in this Domain:

I collaborate with other health care professionals inorder to gain a better understanding of how we can help a patient with discomfort. I speak to my
patient inorder to understand their health prefrences and how I can integrate their wishes into my plan of care.

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Midterm Evaluation Summary

DATE HOURS COMPLETED HOURS OF LATENESS OR ABSENCE MIDTERM CLINICAL

Pass Fail

The student must attain a minimum rating of three (3) in all areas, excluding
those not applicable, to be assessed as successful.

AREAS FOR GROWTH RESOURCES ESTABLISHED TIMELINE

(Consider: cognitive, affective, or psychomotor learning objective) (Consider: textbooks, journal articles, organizational policies, videos, FOR ACHIEVEMENT
simulation, lab practice)

STUDENT SIGNATURE CLINICAL EDUCATOR SIGNATURE

Sending this form from your Sault College email account will serve as your signature. Typing your name in this field will serve as your signature.

Morgan Burke

A verbal report of the Midterm Evaluation Summary must be communicated by the clinical
educator to the course professor within five (5) days of the midterm evaluation.

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 TEMPLATE TO BE USED TO CREATE SUPPLEMENTARY LEARNING CONTRACT
Aim: to address only those indicators that received a score of “1” or “2” at midterm evaluation by either the student or clinical educator

STUDENT DATE INITIATED

Morgan Burke
SUPPLEMENTARY LEARNING OBJECTIVES SUPPLEMENTARY STRATEGIES, RESOURCES EVIDENCE OF ACHIEVEMENT ACHIEVEMENT OF EACH
(Specific, measurable, attainable, realistic AND EVALUATION Statements of activities that demonstrate LEARNING OBJECTIVE AT
and timely) What will be done and what resources will be achievement of learning objectives. FINAL EVALUATION
accessed to facilitate success? Who will do
Each objective is to address a separate
assessments? When? What are the criteria for
indicator that received a score of “1” or “2”
success? UNMET MET
on the midterm evaluation

Health Assesments Practice assesments routinely, and consider

Ableassesment
to effectively
outcomes
performfor
head
clients
to toe
conditions.
assesment

Reports client'ss condition to appropriate

Practice
healthcare
SBAR withmember
different situations Effectivly communicate clients well being to nurse.

Organize responisibilities in a timelyCreate

mannora plan of care and follow scheduleClients needs are met in a timely mannor

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Final Evaluation Summary

DATE HOURS COMPLETED HOURS OF LATENESS OR ABSENCE

The student must attain a minimum rating of three (3) in all areas, excluding
those not applicable, to be assessed as successful.

LEARNING PLAN OBJECTIVE SUPPLEMENTARY LEARNING CONTRACT OBJECTIVES FINAL CLINICAL

Met Unmet Met Unmet N/A Pass Fail

STUDENT SIGNATURE CLINICAL EDUCATOR SIGNATURE COURSE PROFESSOR

Sending this form from your Sault College email account will serve Typing your name in this field will serve as your signature. Typing your name in this field will serve as your signature.
as your signature.

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