Self Assessment

2016 - 2016 - NURS 151 Practical Nursing Practice 2 Final (201508)

NURS 151 Practical Nursing Practice 2 (PN, 12-Jan-2016 - 07-May-2016)
Student : Alyssa Dela Cruz
Clinical Teacher/Preceptor : Grace Jose
Program Coordinator : Wendy Chow
Location : Cawthra Gardens Long Term Care Residence
Placement Setting : Agency
Unit/Office/Clinic : LTC
Description : From week 7 to finals, working in the long-term care
residence as a student nurse and administrating
medication for the patients.
Period : 12-Jan-2016 To 07-May-2016
Student hours : 168
Required Hours : 168
Validated hours : 156
Teacher comment for validated hours:
Teacher cancelled one 12 hour day of clinical due to poor driving conditions from snow storm the night before.

I declare that this is my original work and the sources used are acknowledged.

Abilities and Outcomes / Learning Outcomes Student Rating Teacher Rating

1. COMPETENT AND SAFE PRACTICE WITHIN A PROFESSIONAL, LEGAL, AND ETHICAL FRAMEWORK

Satisfactory Satisfactory
1. 1 Comply with regulatory standards, relevant legislation and the practice settings policies and

procedures.

A.D.C. : I always follow the regular standards, legislations and policies during clinical. I always make assurance to my work by asking my peers, my

preceptor and healthcare team members if I am not sure of something.

Satisfactory Satisfactory
1. 2 Act in a responsible, ethical and accountable manner.

A.D.C. : When I start my day for clinical, I always act responsibly to my job with guidance and provide ethical care with an accountable manner by
triple checking my work before I proceed in order to not any mistakes.

1. 3 Determine strengths and limitations and when to consult and seek assistance from other Satisfactory Satisfactory

professionals.

A.D.C. : I usually determine my strengths and weakness to know what field I can develop on and I also ask for guidance from the professionals

(preceptor and nurses working in the facility) when I get stuck or unsure about any situation.

Satisfactory Satisfactory
1. 4 Use evidence informed practice and a theory-based approach to care.

A.D.C. : I always use and provide evidence in my practice to make the situations clear to understand and to know what goals I can work on with my

patients to help with their treatment.

Satisfactory Satisfactory
1. 5 Ensure client safety and a safe environment.
A.D.C. : When I work in the long term care facility I make sure tha the environment for my patients are safe and I always make sure that I follow the
safety procedures whenever I am providing care. I always make sure that I ask for help when I can't manage or lift a patient to prevent any falls or

injuries for me and the patient.

Satisfactory Satisfactory
1. 6 Ask relevant questions to clarify understanding of the plan of care and whenever uncertain.

A.D.C. : I always ask revelant questions to clarify out the understanding of the care of plan of my patient especially when I am unsure of the drug that

I am going to administer. Medications a very important to know and understand according to the patient's diagnosis to get a the treatment that they

need.

Satisfactory Satisfactory
1. 7 Identify ethical and unsafe situations and seek appropriate assistance to resolve these.

A.D.C. : At a time there is a non ethical situation or unsafe situation I always seek guidance to know what can I do about the situation. Especially to

the gloves situation in the facility, because this situation in not safe in a way that we can contact some infection during the treatment or care of the
person.

1. 8 Demonstrate understanding about the role of the student nurse. Satisfactory Satisfactory

A.D.C. : I always make sure I demonstrated my understanding and knowledge from the lessons I learned from classes and labs to my placement and

by doing this, I can develop all this knowledge and learn from it as a student nurse.

Teacher comments for COMPETENT AND SAFE PRACTICE WITHIN A PROFESSIONAL, LEGAL, AND ETHICAL FRAMEWORK :

Student consistently demonstrated accountability in nursing practice. Student was able to consistently demonstrate preparedness for
practice, assumed responsibility for learning, and actively participated in learning. Weeks 11- 14: Student was able to care for 2 clients
independently; medication administration (teacher supervising), morning routine, ADL needs, and documentation.

2. ACCURATE AND RELEVANT COMMUNICATION

2. 1 Participate in team sharing and discussions. Satisfactory Satisfactory

A.D.C. : During post conference in our placements, I always make sure I participate in any group discussions and sharings to have a broader

understanding to other concepts of nursing and to also know what other situations can happen from the stories and views of my other classmates.

Satisfactory Satisfactory
2. 2 Document clearly, accurately, concisely in a timely manner using written and electronic methods.

A.D.C. : I always practice documentation in every clinical, I make sure I follow the rules for documentation and ask for guidance for somethings that I

am unsure of documenting, I usually use examples from the book or examples from the nursing websites to help me out develop my documentation a
clearly.

Satisfactory Satisfactory
2. 3 Report relevant information to the appropriate personnel.

A.D.C. : I always report revelant information to my preceptor firsts and as well as the other nurses working on the floor when there is a problem on

the floor or with the patients before taking an action especially if I'm not sure of.

Satisfactory Satisfactory
2. 4 Utilize communication techniques with the client and inter-professional health care team.

A.D.C. : I will aways try to give my client's to speak up to what they want during their care, and as well have a good communication with the right

people in the team and with the patient, to provide a good client-centered care.
 Satisfactory Satisfactory
2. 5 Maintain privacy and confidentiality according to the Personal Health Information Protection Act

(PHIPA)

A.D.C. : I will always keep in mind to give some privacy and confidentiality for my patients, during their care especially during their morning care
when they are all naked while gating dressed. I always keep in mind that my patients are the same person like me, they get embarrassed and have

feelings to deal with when they wanted to hide something from themselves.

Satisfactory Satisfactory
2. 6 Use technology to retrieve information including research, data and other information.

A.D.C. : I use technology to retrive any important informations for any important questions I have during the clinical settings. I try to use my e book to

follow up some of the uncertain things based on the nursing topics I have. but I should always keep in mind to research before clinical to save time.

Teacher comments for ACCURATE AND RELEVANT COMMUNICATION :

Student communicated clearly, concisely, and correctly in the written, spoken, and visual forms that met the needs of the clients. Also,
student responded to relevant information in a manner that ensured effective communication.

3. CARING RELATIONAL PRACTICE

Satisfactory Satisfactory
3. 1 Utilize effective communication techniques.

A.D.C. : From working in the long term care residence from the past weeks, I have developed my communication skills with a variety of geriatric
patients and I have seen my self grow from my shell. In the beginning of clinical I thought my first weakness was communication skills but from now it

is still a weakness and but a developing one. I have no longer struggled to find out what say right to my patients, and how to give comfort with good

communication skills. However in the future I will develop my skills more when I get into a different setting.

Satisfactory Satisfactory
3. 2 Demonstrate therapeutic caring, compassionate, and culturally safe relationships with clients

and health care team members.

A.D.C. : In my first few weeks in the facility I was demonstrating therapeutic caring to the elderly, compassionate about my work and I tried to be as

culturally aware with my clients and the health care team members to have a great relationship with them. By doing this, I can create a great bond

with the team and as well as have a good nurse-client relationship. Until now I am still therapeutically caring compassionate and culturally safe with
my patients while I provide care and treatment.

3. 3 Apply knowledge of therapeutic use of self and identify its effect on client well-being. Satisfactory Satisfactory

A.D.C. : When I am in my placement, I always try to check myself before I act to provide therapeutic use of my self and my identity to the patients for

an effect on client well-being. I use my knowledge from the things learned in my theory class and to use some of Orem's theory of self.

Satisfactory Satisfactory
3. 4 Use self-awareness to identify the effects that beliefs, values, and personal experiences have on

relational practice.

A.D.C. : I use self awareness to the effects that beliefs, values and personal experiences in relation to my practice. Being self aware is going to

provide great work for my practice and I will be able to provide a better nurse client relationships, because if you are not self aware it my effect your

work as a nurse.

Satisfactory Satisfactory
3. 5 Interact with clients and members of the inter-professional health care team; and, consult
appropriately.
A.D.C. : I interact with my clients and members of inter-professional health care team all the time to provide good communication skills and better
understanding on what the patient wants and how the work should be done according to their policy. Good communication is always the best thing to

do in order to provide good nursing practice.

Satisfactory Satisfactory
3. 6 Apply knowledge of practices and systems that support the diversity of clients and the inter-

professional health care team.

A.D.C. : I always try to use my knowledge from my nursing classes to support my care to my clients and as well as support the diversity of clients and

the inter-professional health care team.

Satisfactory Satisfactory
3. 7 Apply knowledge of clients cultural, religious, and other beliefs and values as these influence

clients choices and decisions.

A.D.C. : To provide client-centred care I always try to incorporate my client's wishes with their care because I want them to feel comfortable while
they are being taking cared for. From the CNO guidelines I have to value their choices and decisions with their care to provide client-centred care.

From this I can build trust between me and the client and have a good nurse-client relationship

Satisfactory Satisfactory
3. 8 Provide effective client education.

A.D.C. : During my care for my patient, from assessment to evaluatation I always provide some client education according to their health and

treatment. Providing client education by explaining them simple and understandable meanings of their treatment will somehow make them more

cooperative with their treatment. That's is why it is very important to provide them information on how to do a procedure, on how to eat well and etc.

Teacher comments for CARING RELATIONAL PRACTICE :

Student was able to establish sound relationships with peers, staff, clients, and teacher. Student consistently utilized well developed
communication and interpersonal skills.

4. LEADERSHIP AND ADVOCACY

Satisfactory Satisfactory
4. 1 Recognize conflicts and strategies for resolution.

A.D.C. : At a time where there is conflict during my practice I always make sure that I will ask the appropriate personnel first before doing an

action.as a novice nurse, seeking guidance is always the best way to have a better solution for any conflicts at this moment.

Satisfactory Satisfactory
4. 2 Demonstrate leadership skills that foster group work and a positive learning environment.

A.D.C. : I am not really a good leader who leads, but I always make time to help out my peers and work out things together whenever something is

not looking good. By doing this it can also help me improve my communication skills.

Satisfactory Satisfactory
4. 3 Identify opportunities to improve health care service and nursing interventions by advocating for

client, self, others, and quality practice.

A.D.C. : When an opportunity has come up, I always make sure that use it while it's there and not let come by, having to have two patients at a shift

is good step of opportunity I have because time management is my weakness from doing a lot of work as a nurse. That's is why whenever I get to see

or do a skill I haven't done before I always try to grab it, because every opportunity counts as an experience in this career.

Satisfactory Satisfactory
4. 4 Provide feedback to peers and accept feedback from peers and members of the inter-

professional health care team.

A.D.C. : During sim labs and post conferences I always try to participate and give out feedback a with my fellow nursing students and accept
feedback from my preceptors, health care team members and peers to help me improve my skills. I use this feedback to see my weakness and help

me improve them. We also have done some peer feedback forms given out to our peers to provide them what their strengths and weakness are, from

this it can provide them some information on what to develop on to further their skills in nursing.

Satisfactory Satisfactory
4. 5 Support clients rights for self-determination and choice.

A.D.C. : I always try to incorporate and support clients needs and choices to help them out with their therapy. Because it is very tough for a client to

try and become healthy if their needs are not met especially if it doesn't get some good support.

Satisfactory Satisfactory
4. 6 Respond appropriately to unsafe, unacceptable, and unprofessional behaviours.

A.D.C. : Whenever I encounter some unsafe, unacceptable and unprofessional behaviours I always seek for guidance and support or let someone

know about it right away, so that it can not be done and omitted in the future.

Satisfactory Satisfactory
4. 7 Consult and collaborate when carrying out health care and nursing practices that are in the best
interests of the public and protect the public through collaboration and consultation.

A.D.C. : I make sure that I always collaborate with the health care teams for any nursing practices for the public and also for my clients as well.

Teacher comments for LEADERSHIP AND ADVOCACY :

- Student was able to demonstrate leadership skills related to peer interactions. Student Consistently demonstrated
professional nursing behavior.

5. PLANS OF CARE: MEET CLIENTS NEEDS AND MUTUALLY AGREED EXPECTED OUTCOMES

Satisfactory Satisfactory
5. 1 Incorporate the unique needs and expected outcomes into individual clients plans of care.

A.D.C. : As a student nurse I always make sure that I met the unique needs for my clients, because they have the choice to do what they want for
their treatment. It is helpful for me and the client to get the possible outcomes of what we want from their treatment, when they get to have that

support from us and have the needs that they want.

Satisfactory Satisfactory
5. 2 Develop theory-based plans of care that are holistic and client centered and are articulated

competently in writing and orally.

A.D.C. : I always try my best to develop a theory-based care plans for my patient by researching their diagnosis and their medications first and trying

to organize and make things clearer for me to understand. By making a concept map, it will help me figure out the risks and goals that I can work with

my patients.

Satisfactory Satisfactory
5. 3 Use knowledge, skill and judgment to assess clients, prioritize needs and outcomes.

A.D.C. : By creating a concept map, which is a tool to organize and set priorities for the patient's needs to achieve their goals. I use this tool by using
my theory based knowledge to judge my client's treatments based on their assessments and from this it will create a better learning for me and a

good nursing care for my client.

Satisfactory Satisfactory
5. 4 Provide information that contributes to the evaluation and refinement of plans of care.

A.D.C. : I try to provide information that contributes for re evaluatation and refinement of care plans according to my patient's condition. When it's a

developer in care of a conflict in care I always try to look for the cause of its effect in order to find out the reason of the condition.
 Satisfactory Satisfactory
5. 5 Safely and competently carry out nursing assessments and nursing interventions that are theory-

based and within skill abilities.

A.D.C. : I try my best to safely and competently carry out nursing assessments and nursing interventions with theory based practice by the use of my
nursing textbooks especially the Heath assessment textbook and the fundamentals of nursing textbook.

5. 6 Carry out nursing care that reflects the practice decision-making framework. Satisfactory Satisfactory

A.D.C. : I always try to follow the decision making frame work whenever I'm doing any nursing care plans for my patient. Finding the problem before

implementing something is always good to provide great quality care.

Satisfactory Satisfactory
5. 7 Complete nursing care responsibilities and nursing interventions in an organized and timely

manner.

A.D.C. : I always plan my days ahead to get my things organize and have it done in the timely manner. it is very important to have things organized

and timed well to get great quality care for the clients. I always use a care plan whenever I go to my clinical and plan my research before going to

work.

Teacher comments for PLANS OF CARE: MEET CLIENTS NEEDS AND MUTUALLY AGREED EXPECTED OUTCOMES :

Student practiced within the ethical guidelines of the care facility, expectations of Humber College, and the CNO.

6. COLLABORATIVE PRACTICE: INTERPROFESSIONAL HEALTH CARE TEAM

Satisfactory Satisfactory
6. 1 Work with clients and members of the inter-professional health care team to assess clients,

determine health needs, and to achieve mutually agreed expected outcomes.

A.D.C. : Before my shift starts, I always make sure I come in on time to get the night shift reports from the night shift nurses and because of this

collaboration it will help me to determine the needs of my client and achieve the goals that is set for that day. organization and working collaboratively

with the health care team is really an asset because as a nurse you can not do it all alone.

Satisfactory Satisfactory
6. 2 Contribute as a member of the inter-professional health care team to respond to the changing

needs and expected outcomes of clients.

A.D.C. : As a team member I always try to contribute to the team based on the knowledge I have, by taking care of my patient and providing current
information about my patient to the other healthcare providers.

Satisfactory Satisfactory
6. 3 Seek out assistance and consult with members of the inter-professional health care team.

A.D.C. : I always seek out some assistance whenever it is appropriate for the situation. I consult with my peers and other health care team members

so that there is another opinion, and from that we can collaborate and choose the right move. Collaboration is very helpful to situations that are very

difficult.

Satisfactory Satisfactory
6. 4 Use teamwork, consensus building, and conflict resolution skills.

A.D.C. : teamwork is the key to help out clients to get their goals. One nurse can't handle all the job so collaboration with the health care team is very

ideal in situations in the hospital or in a long tern care facility. I always ask for help when needed, and collaborate with the team based on my nursing

theory.
 Satisfactory Satisfactory
6. 5 Describe effective, collaborative, and consultative strategies to meet clients needs within a

changing environment.

A.D.C. : whenever the patient needs to consult with anyone in the team because to their situation, I will try to help them arrange that according to
their schedule. I will have to talk to the therapist or who ever they need, so that they know some history with client and as well so we can work

together and meet the client's goals.

Satisfactory Satisfactory
6. 6 Interact with members of the health care team respecting their unique role and competencies.

A.D.C. : As a team member I want to get treated the same way I treat others and that is the same to the other team members. I respect any of the

team members and treat them equally to have a nice working environment for us and also for the clients.

Teacher comments for COLLABORATIVE PRACTICE: INTERPROFESSIONAL HEALTH CARE TEAM :

Student developed strong relationships both with peers, hospital staff, teacher, and clients. Student utilized effective interpersonal skills
and therapeutic communication.

7. QUALITY ASSURANCE: CONTINUE AND IMPROVE COMPETENCE

Satisfactory Satisfactory
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.

A.D.C. : I always act with my best interest whenever I am caring for my clients for them so see that I am interested helping them. I will always try to

give them their privacy and confidentiality whenever I collaborate and consult with other team members.

Satisfactory Satisfactory
7. 2 Participate in self-reflection to identify strengths, areas for improvement.

A.D.C. : I always self-reflect after my clinical to identify what were my accomplishments and my weakness throughout the day to identify the places

where can I improve on. I also have wrote my self reflection for my clinical from these pass few weeks.

Satisfactory Satisfactory
7. 3 Create, implement, and evaluate a learning plan consistent with the Quality Assurance program

(CNO).

A.D.C. : I always make sure that I create a consistent learning plan before make some plans with my client to have our goals met. a learning plan
organizes the treatment for the day and can able to focus on the first priorities. especially when planning for their medication administration.

7. 4 Seek out learning opportunities and feedback that foster professional development; and, Satisfactory Satisfactory

integrate these into practice.

A.D.C. : I always make sure that I create a consistent learning plan before make some plans with my client to have our goals met. a learning plan

organizes the treatment for the day and can able to focus on the first priorities.

Satisfactory Satisfactory
7. 5 Utilize nursing, health and other theory and literature to improve nursing practice.

A.D.C. : I always use nursing, health and nursing theories to improve my nursing practice, by using all the knowledge I got from my lectures and from
my nursing books and as well as from my preceptors.

Satisfactory Satisfactory
7. 6 Use a theory-based approach and evidence-informed practice.
A.D.C. : I always use my theory based approach and evidence-informed practice by organizing my work first and taking an assessment before
making an action, so that everything makes sense and on the right track.

Teacher comments for QUALITY ASSURANCE: CONTINUE AND IMPROVE COMPETENCE :

Student consistently sought knowledge and provided evidence based rational for decisions. Student was able to use acquired knowledge
and apply it to practice. Student increased ability to organize and prioritize related to client care.

8. USE CRITICAL THINKING, PROBLEM-SOLVING & DECISION-MAKING EFFECTIVELY

Satisfactory Satisfactory
8. 1 Utilize problem-solving skills to inform decision making in all aspects of nursing care.

A.D.C. : I use my problem-solving skills to inform any decision making in all aspects of nursing. I use the SMART goals sheet in order to help me find

all the things that I should develop more and it really a benefit from making a decision.

Satisfactory Satisfactory
8. 2 Use problem-solving and decision-making skills to assess clients and to determine nursing
diagnoses, expected outcomes, nursing interventions, and evaluative criteria.

A.D.C. : when I assess my patient I always rely on making a concept map on my shifts. By creating a concept map, it will help me find what nursing

diagnosis I can use according to my patient's medical diagnosis. from that nursing diagnosis I can be able to figure out my goals for my client, and

plan the nursing interventions to obtain the goals.

Satisfactory Satisfactory
8. 3 Use self-reflection to design a plan to improve problem-solving and decision-making skills.

A.D.C. : I self reflect on my clinical by using a LEARN note, this usually helps me find my weakness and plan ahead to develop my problem- solving

and decision making skills.

Satisfactory Satisfactory
8. 4 Utilize knowledge from variety of nursing, health, and other theory into nursing practice to

provide safe and competent care.

A.D.C. : During my practice I always utilize the knowledge I have from a variety of nursing, and other theory from my lectures and nursing textbooks

into nursing practice to provide safe and competent care.

Satisfactory Satisfactory
8. 5 Use prioritization strategies for client care.

A.D.C. : During my practice I always try to find ways on how to time manage and use prioritization strategies for my patient in order to achieve our

goals for her health during my shift. it is very important to use prioritization strategies because it use to provide good nursing care by being on time to

all their treatments and nursing care.

Satisfactory Satisfactory
8. 6 Demonstrate professionalism and accountability.

A.D.C. : I always demonstrate my professionalism during my practice, from how I communicate and with my actions. I always make sure that my

actions are made to provide a good nursing care. I know that I am always accountable in my practice so I make sure that i document every care i have
done with the patient.

8. 7 Recognize strengths and limitations and seek appropriate assistance and support. Satisfactory Satisfactory

A.D.C. : I always make sure that by making a self- reflections according to my practice in every clinical, I will recognize my strengths and weakness.

By recognizing my strength and weakness I will be able to improve my weakness by reviewing and by seeking some guidance and support from my

preceptor.
Teacher comments for USE CRITICAL THINKING, PROBLEM-SOLVING & DECISION-MAKING EFFECTIVELY :

Student successfully cared for 2 clients for several weeks. Student was able to apply analytical, interpersonal, and technical skills to
implement a safe effective plan of care.

9. SIM number of hours

9. 1 SIM number of hours

A.D.C. : 6

G.J. : 6

Teacher comments for SIM number of hours :

Student had no significant issues in SIM, completed all hours, and assignments.

Student Final Summary with Strategies for Continued Growth

From the beginning of the semester, I was not really confident in starting to work with actual patients. My main concern was to have a good
communication with them because I really struggled in lab with my communication skills last semester. This semesters I have found new weakness,
and that is setting priorities and time management with a larger amount of patients during my shift. Setting priorities and managing time is the very
important role in this practice, because from this two concepts I can be able to attain set goals and provide a good nursing care and treatment for my
patient. I need to review my health assessment, theory lectures and books in order to develop my standing to become a better nurse in the future.

Teacher Final Summary with Strategies for Continued Growth

You did an awesome job in clinical keep up the great work! Please continue to practice your nursing skills, develop your critical thinking by reading
your nursing theory books, and improve on your problem solving skills by communicating with the inter-professional team. Well Done!

Student's References

Nursing Lectures, CNO guidelines.

Lewis, S. L., Heitkemper, M. M., Dirksen, S. R., & OBrien, P. G. (current ed.). Medical - Surgical Nursing in Canada: Assessment and Management of
Clinical Problems (current ed.). Toronto: Mosby Elsevier.
Potter, P., Perry, A. G. (2014). In Ross-Kerr, J., Wood, M., Astle, B., & Duggleby, W. (Eds), Canadian fundamentals for nursing (current ed). Toronto:
Mosby.
Touchy, T. A., Jett, K. F., Boscart, V., & McCleary, L. (current ed.). Ebersole and Hess Gerontological Nursing and Healthy Aging (current ed.).
Toronto: Elsevier.
Jarvis, C. In Browne, A., MacDonald-Jenkins, J., & Lucktkar-Flude, M. (Eds.), Physical
Examination and Health Assessment: Canadian Edition. Toronto: Elsevier.
Lilley, L. L., Harrington, S., Snyder, J. S., & Swart, B. Pharmacology for
Canadianhealth care practice.. Toronto: Mosby Elsevier.

Grade Satisfactory Unsatisfactory

Referred to Clinical Excellence Committee (CEC)

Program Coordinator Feedback

The Program Coordinator has reviewed the evaluation Yes No

Student Sign Off

I met with my Clinical Teacher/Preceptor and discussed my evaluation Yes No

In general this evaluation accurately reflects my performance Yes No