Brigham Young University Idaho Nursing Program Clinical Evaluation Tool

To be completed by Student:
Student Name: Adam King

I#: 843583849

Course code: 310C

Facility Name: Teton Post Acute Care & Rehab

Clinical Area:

Dates Attended: October 6, 2017-November 7, 2017

To be complete by Clinical facilitator/preceptor:

Clinical facilitator/preceptor name: Kaitlyn Baker

Number of hours completed:

Number of hours absent:
Mid-term assessment: Satisfactory
Unsatisfactory
Final assessment: Satisfactory
Unsatisfactory
Clinical facilitator/preceptors signature:
Kaitlyn Baker
Date: November 9, 2017

I acknowledge that I have made a duplicate of this document and other documents that I have submitted which I will retain for the duration of my course.

Students signature: Adam King Date: 11/9/17

Revised 7/18/16
Brigham Young University Idaho Nursing Program Clinical Evaluation Tool

Daily: Mid-term: Final:

Student Self Evaluation
Clinical Judgment Component
NOTICING
Focused Observation E A
Complete a self-assessment in the section of the Clinical Evaluation Tool based on your clinical experience, and meet with
your assigned clinical faculty to discuss. Use the next page to determine your self-rating and explain specifically your
rationale or give examples if you gave yourself a rating below or above the minimum requirements for your semester
level.
D B U

Recognizing deviations from

expected patterns E A D B U
Information Seeking E A D B U

INTERPRETING
Prioritizing Data: E A D B U

Making sense out of data: E A D B U

RESPONDING
Calm, Confident Manner E A D B U

Clear Communication E A D B U

Well-Planned Intervention/
Flexibility E A D B U
Being Skillful E A D B U

REFLECTING
Evaluation/Self-Analysis E A D B U

Commitment to Improvement E A D B U

Minimum requirements Jnr 1 (NURS Jnr 2 (NURS 322C & NURS Snr 1 (NURS 410C & NURS 422C) Snr 2 (NURS433C &
per semester 310C) 323C) NURS490C
Noticing B D A A
Interpreting B D A A
Responding B D A A
Reflecting B D A A

Revised 7/18/16
Brigham Young University Idaho Nursing Program Clinical Evaluation Tool
Copy permission obtained from Lasater (U:\SON\Diane\Bussard\Lasater Clinical Judgment Rubric Scoring Sheet.doc) Final document adapted from Lasater (2007a)
Table 1: Adapted Lasater Clinical Judgment Rubric
Dimension Exemplary
Effective noticing involves:
Focused observation Focuses observation appropriately
without assistance; regularly
observes and monitors a wide
variety of objective and subjective
data to uncover any useful
information and makes changes to
assessments as needed.
Recognizing deviations Recognizes subtle patterns and
from expected patterns deviations from expected patterns
in data and uses these to guide the
assessment. Makes association
between deviations to patient
disease processes.
Information seeking Assertively seeks information to
plan intervention: carefully collects
useful subjective data from
observing and interacting with the
patient and family. Determines if
more information is needed.
Effective interpreting involves:
Prioritizing data Focuses on and prioritizes the most
relevant and important data useful
for explaining the patients
condition.
Revised 7/18/16
Accomplished
Focuses observation appropriately;
regularly observes and monitors a
wide variety of objective and
subjective data to uncover any useful
information.
Recognizes subtle patterns and
deviations from expected patterns
in data and uses these to guide the
assessment.
Assertively seeks information to plan
intervention: carefully collects useful
subjective data from observing and
interacting with the patient and
family.
Focuses on the most relevant and
important data useful for explaining
the patients condition.
Developing
Regularly observes and
monitors a variety of data,
including both subjective and
objective; most useful
information is noticed; may
miss the most subtle signs.
Recognizes most obvious
patterns and deviations in data
and uses these to continually
assess.
Actively seeks subjective
information about the patients
situation from the patient and
family to support planning
interventions; occasionally does
not pursue important leads.
Generally, focuses on the most
important data and seeks further
relevant information but also
attempts to attend to less
pertinent data.
Beginning
Attempts to monitor a variety
of subjective and objective
data but is overwhelmed by
the array of data; focuses on
the most obvious data, missing
some important information.
Identifies obvious patterns and
deviations, missing some
important information; unsure
how to continue the
assessment.
Makes limited efforts to seek
additional information from
the patient and family; often
seems not to know what
information to seek and/or
pursues unrelated
information.
Makes an effort to prioritize and
focus on the most important
data, but also attends to less
relevant or useful data.
Unsatisfactory
Confused by the clinical
situation and the amount and
kind of data; observation is not
organized and important data
are missed, and/or assessment
errors are made
Focuses on one thing at a time
and misses most patterns and
deviations from expectations;
misses opportunities to refine
the assessment
Is ineffective in seeking
information; relies mostly on
objective data; has difficulty
interacting with the patient and
family and fails to collect
important subjective data
Has difficulty focusing and
appears not to know which
data are most important to
the diagnosis; attempts to
attend to all available data
Brigham Young University Idaho Nursing Program Clinical Evaluation Tool
Table 1: Adapted Lasater Clinical Judgment Rubric
Dimension Exemplary
Making sense of data Even when facing complex,
conflicting, or confusing data, is able
to (a) note and make sense of
patterns in the patients data, (b)
compare these with known patterns
(from the nursing knowledge base,
research, personal experience, and
intuition), and (c) develop plans for
interventions that can be justified in
terms of their likelihood of success.
Seeks new data as needed.
Effective responding involves:
Calm, confident manner Assumes responsibility within
current scope of practice; assesses
patients efficiently and effectively.
Reassures patient and any support
persons, adjust priorities of care
based on changes to patient
condition.
Clear communication Communicates effectively; checks
for understanding and adjusts
communication as needed; explains
interventions in a manner that all
involved are able to understand;
calms and reassures patients and
any support persons;
Well-planned Interventions are tailored for the
intervention/flexibility individual patient; monitors patient
progress closely and is able to
adjust treatment as indicated by
patient response and by worsen
patient condition.
Being skillful Shows confidence and co-
ordination of necessary nursing
skills with minimal supportive cues
from staff or faculty.
Revised 7/18/16
Accomplished
Even when facing complex,
conflicting, or confusing data, is able
to (a) note and make sense of
patterns in the patients data, (b)
compare these with known patterns
(from the nursing knowledge base,
research, personal experience, and
intuition), and (c) develop plans for
interventions that can be justified in
terms of their likelihood of success.
Assumes responsibility within
current scope of practice; delegates
team assignments; appropriately
assesses patients and reassures
reassure the patient and any
support persons.
Communicates effectively; explains
interventions; checks for
understanding calms and reassures
patients and any support persons.
Interventions are tailored for the
individual patient; monitors patient
progress closely and is able to adjust
treatment as indicated by patient
response.
Shows confidence and capability of
necessary nursing skills, requires
infrequent supportive cues from
staff or faculty.
Developing
In most situations, interprets the
patients data patterns and
compares with known patterns
to develop an intervention plan
and accompanying rationale; the
exceptions are rare or in
complicated cases where it is
appropriate to seek the guidance
of a specialist or a more
experienced nurse.
Needs to be prompted to take
responsibility. Appears to be
unsure of appropriate co-
ordination of care. Is able to
assess the patient, requires
assistance to priorities care but
is able to appropriately
reassure the patient and any
support persons.
Generally, communicates well;
explains carefully to patients and
any support persons; could be
more effective in establishing
rapport.
Develops interventions on the
basis of relevant patient data;
monitors progress regularly but
does not expect to have to
change treatments.
Displays proficiency in the use
of most nursing skills; could
improve speed or accuracy,
requires frequent verbal and/or
physical cues.
Beginning
In simple, common, or familiar
situations, is able to compare
the patients data patterns
with those known and to
develop or explain intervention
plans; has difficulty, however,
with even moderately difficult
data or situations that are
within the expectations of
students; inappropriately
requires advice or assistance.
Is reluctant to take on
responsibility; reassures
patients and families in routine
and relatively simple situations,
but becomes disorganized
easily, unable to adjust to
changes in patients conditions.
Shows some communication
ability (e.g., giving directions);
communication with patients,
and any support persons is only
partly successful; displays some
empathy.
Develops interventions on the
basis of the most obvious data;
monitors progress but is unable
to make adjustments as indicated
by the patients response.
Is hesitant or ineffective in using
nursing skills, requires
continuous verbal and frequent
physical cues.
Unsatisfactory
Even in simple, common, or
familiar situations, has difficulty
interpreting or making sense of
data; has trouble distinguishing
among competing explanations
and appropriate interventions,
requiring assistance both in
diagnosing the problem and
developing an intervention
Except in simple and routine
situations, is stressed and
disorganized, lacks control,
makes patients and families
anxious or less able to
cooperate
Has difficulty
communicating;
explanations are confusing;
directions are unclear or
contradictory; patients and
families are made confused
or anxious and are not
reassured
Focuses on developing a single
intervention, addressing a
likely solution, but it may be
vague, confusing, and/or
incomplete; some monitoring
may occur
Is unable to select and/ or
perform nursing skills
Brigham Young University Idaho Nursing Program Clinical Evaluation Tool
Table 1: Adapted Lasater Clinical Judgment Rubric
Dimension Exemplary Accomplished Developing Beginning Unsatisfactory

Effective reflecting involves:

Evaluation/self-analysis Independently evaluates and
analyzes personal clinical
performance, noting decision
points, elaborating alternatives,
and accurately evaluating choices
against alternatives. Assesses if
goals are being met.
Independently evaluates and
analyzes personal clinical
performance, noting decision points,
elaborating alternatives, and
accurately evaluating choices
against alternatives.
Evaluates and analyzes personal
clinical performance with
minimal prompting, primarily
about major events or decisions;
key decision points are
identified, and alternatives are
considered.
Even when prompted, briefly
verbalizes the most obvious
evaluations; has difficulty
imagining alternative choices;
is self-protective in evaluating
personal choices.
Even prompted evaluations are
brief, cursory, and not used to
improve performance; justifies
personal decisions and choices
without evaluating them

Commitment to Demonstrates commitment to
improvement ongoing improvement; reflects on
and critically evaluates nursing
experiences; accurately identifies
strengths and weaknesses and
develops specific plans to
eliminate weaknesses. Uses
reflective nursing practice
effectively.
Demonstrates commitment to
ongoing improvement; reflects on
and critically evaluates nursing
experiences; accurately identifies
strengths and weaknesses and
develops specific plans to eliminate
weaknesses.
Demonstrates a desire to
improve nursing performance;
reflects on and evaluates
experiences; identifies
strengths and weaknesses;
could be more systematic in
evaluating weaknesses.
Demonstrates awareness of the
need for ongoing improvement
and makes some effort to learn
from experience and improve
performance but tends to state
the obvious and needs external
evaluation.
Appears uninterested in
improving performance or is
unable to do
so; rarely reflects; is
uncritical of himself or
herself or overly critical
(given level of development);
is unable to see flaws or
need for improvement

Table 2
Resource for Students: Examples of questions from the Lasater Clinical Judgment Rubric (LCJR) that simulate deep thinking and learning so student think like a nurse.
Tanner Model Phase LCJR Dimension Example of Question
Noticing Focused observations What did you first notice about the patient?
Recognizing deviations from expected What was different than what you expected? Have you seen this before in other
patterns patients?
Information seeking What other information would be helpful? How can you get that information?
Interpreting Prioritizing data How did you prioritize the patient information/data? In other words, what was most
important for this patient now?
Making sense of the data On what did you base choice of intervention? If intuition, what kinds of data might offer
evidence to support your gut feeling?
Responding Calm, confident manner What was your approach with the patient? How comfortable did you feel?
Clear communication How did you think you gained the patients trust? What did you say to the patient? To
the family?
Well-planned interventions/flexibility What factors, including patient feedback, impacted the treatment plan?
Being skillful How did your skill compare to nursing standards of care?
Revised 7/18/16
Brigham Young University Idaho Nursing Program Clinical Evaluation Tool
Reflecting Evaluation/self-analysis What went well? What didnt go so smoothly as your planned? Why or why not?
Commitment to improvement What would you do differently if you had the opportunity?
K. Lasater / Nurse Education in Practice 11 (2011) 86e92

Students and facilitators are expected to complete an interim and a final reflection on the clinical placement.

Mid-term reflection by student: Mid-term reflection by facilitator/clinical preceptor

Adam has really been so personally motivated to his own growth. He has
I feel that I have improved greatly on my confidence. I started out extremely
shy but now I go out of my way to learn. I have a huge commitment to a difficult patient due to mental deficits and Adam has just taken it in stride.

improve. I learn so much every day, and I try to apply all of my knowledge to He has become so confident and its clear he has really grown to love his

appropriate situations. I absolutely have room to improve in information resident. Adam is right on track for continuing on in the clinical setting. He

seeking. I focus only on objective data, and I should be observing the just needs to work on making his interventions measurable and realistic

subjective too. My interventions also have room for improvement. I do great for the clinical setting.

on the obvious interventions, but I would like to start early looking outside
the box. I am thrown off easily with abnormalities during the assessment. I
would like to have flexible with my routine and able to adapt to change. I feel
like my strong point is focused observation. I do a good job of focusing on the
patient, gathering data, and completing the task.

Students name: Adam King Students signature: Adam King Date: 10/25/17

Clinical facilitator/preceptor name: Kaitlyn Baker Clinical facilitator/preceptor signature: Kaitlyn Baker Date: 10/25/17

Final reflection by student: Final reflection by facilitator/preceptor:

I have significantly improved my confidence in the real world, I show to the Adam is hardworking and is beginning to show progress in his interventions
patient that I know what Im doing which builds rapport. My goal is to and critical thinking. His assessments have vastly improved and his attention
become more organized with my assessments, even the situation changes or to detail will be a great asset to his future nursing career. He just needs to
is different in the assessment. I feel that I have obtained a great amount of

Revised 7/18/16
Brigham Young University Idaho Nursing Program Clinical Evaluation Tool
new appropriate knowledge in clinicals, and plan on applying the information make sure he continues to make his patient the priority and make his
in the future. My goal in the future is to be able to create more outside the interventions measureable. He is ready for next semester!
box interventions, instead of just the regular and most obvious ones. I plan
on improving my subjective information seeking methods, by actually getting
to know the patient and showing that I care. I have done very well in
predictable scenarios, it shows that my regular skills are sufficient and I am
competent with regular situations.

Students name: Adam King Students signature: Adam King Date: 11/9/17

Clinical facilitator/preceptor name: Kaitlyn Baker Clinical facilitator/preceptor signature: Kaitlyn Baker Date: 11/9/17

Revised 7/18/16