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Evaluation tool for Student staff nurses Name of Staff to be evaluated: Sec.

and Group: Rating 5 4 3 2 1 Excellent Very Satisfactory Satisfactory Fair Poor Description Student is able to perform the task very good with minimal supervision by the clinical instructor Student is able to perform the task well with minimal supervision by the clinical instructor Student is able to perform the task with moderate supervision by the clinical instructor Students is able to perform the task with full supervision by the clinical instructor Student is not able to perform the task even though with full supervision by the clinical instructor Date: CI:

Performance I. Assessment 1.1 Able to establish rapport and interview the client 1.2 Able to assist the patient in necessary routines of the client (e.g. accompanying to the comfort room, making client feel comfortable, giving needs.) 1.3 Shows proper attitude and conduct to the client 1.4 Able to gather necessary data 1.5 Ensures safety of the client II. Implementation 2.1 Carries out certain tasks automatically (e.g. getting vital signs) 2.2 Able to work with Doctor/Intern assigned to the patient 2.3 Able to assists certain tasks that is ordered by the doctor (Administration of medications, nebulization, ECG, suctioning, iv fluid regulation, etc.) III. Evaluation 3.1 Notifies the assigned Doctors, Interns, and Superior if any unwanted occurrences happen that is related to the client. 3.2 Documents the nursing procedures that were done. IV. Attitude 4.1 Has necessary paraphernalias in the area 4.2 Wears proper uniform in the area 4.3 Demonstrates professionalism in the area 4.4 Observes the confidentiality of patients information Actual score/Total Score =

Rating

Student Head Nurse

Clinical Instructor

Evaluation Tool for Head Nurses Name of Head Nurse to be evaluated: Sec and Group Number: Rating 5 Excellent Description Head nurse is able to demonstrate proper behavior and shows excellent leadership with minimal supervision by the clinical instructor Head nurse is able to demonstrate proper behavior and shows adequate leadership with minimal supervision by the clinical instructor Head nurse is able to demonstrate proper behavior and shows minimal leadership with moderate supervision by the clinical instructor Head nurse is able to demonstrate proper behavior and shows poor leadership with moderate supervision by the clinical instructor Head nurse is not able to demonstrate proper behavior and shows poor leadership with full supervision and guidance by the clinical instructor Date: CI:

Very Satisfactory

Satisfactory

Fair

Poor

Performance I. Knowledge 1.1 Able to make decisions appropriately for the situation 1.2 Able to brainstorm with his staff about the current condition of the patient and the appropriate nursing care. 1.3 Shows proper attitude and conduct to the staff nurses 1.4 Able to assess the staffs level of knowledge of the likely causes and risks of the clients condition 1.5 Able to collaborate with the staff nurses II. Attitude 2.1 Neat and well groomed. Follows proper decorum 2.2 Comes to duty on time 2.3 Shows Independence of decisions that are made 2.4 Respects staff nurses appropriately 2.5 Assists his/her staff nurses if necessary III. Skills 3.1 Can perform certain tasks as a leader and as a head nurse 3.2 Instructs and answers questions staff nurses on certain tasks to be done in the area 3.3 Provide adequate leadership needed in the

Rating

area Actual score/Total Score =

________________________ Staff Nurse

________________________________ Clinical Instructor