Develops nursing care plan based on an articulated evidence-based plan for a patient with complex nursing needs

Clinical Evaluation Criteria

1. F: Incorporates Franciscan Values and the American Nurses Association, Code of Ethics for Nurses in  academic and practice settings.

 

1. Creates a caring community
   1. *Respect the patient’s dignity
   2. Provide person-centered care
   3. Actively listen to patients and others.
   4. *Demonstrate personal responsibility by arriving on time and informing the clinical instructor of the absence
   5. Prepare self to provide patient care
   6. *Use professional communication in interactions with patients, inter-professional staff, instructor, and peers
2. Showing compassion
   1. Support patient’s decision-making regarding healthcare needs
   2. Allow the patient to direct their care.
   3. Support staff with patient care decision-making
3. Reverencing creation
   1. *Values diversity
   2. Does not allow personal biases to influence patient care
   3. Protects the environment by managing resources in patient care
4. Making peace
   1. Identifies sources of conflicts
   2. Forgives others
5. Examine how professional values direct decision making in the clinical setting:
   1. *Forthright with peer, staff, and instructor.
   2. Practices safe technique even when not being observed
   3. Accepts responsibility for errors and tries to take appropriate corrective action
   4. Respectful of faculty, staff, and peers
   5. Recognizes personal, staff, and organizational biases and the potential influences on the care of a patient with a mental illness
   6. Based on identified weakness and strengths in providing patient care, determines goals and strategies to improve clinical performance

 

1. R: Uses research and evidence-based practice as a basis for planning and providing care.

 

1. Develops nursing care plan based on an articulated evidence-based plan for a patient with complex nursing needs
2. Uses current and reliable resources (nursing literature, textbooks, and credible web sites) to explain the rationale of nursing actions

 

1. A1: Practice according to the ANA Nursing: Scope and standards of practice and the CONHS Standards of Conduct; abides by the legal standards as defined by state nurse practice acts, and federal regulations.

 

1. Utilizes the nursing process in the planning and delivery of care for a patient with complex nursing needs:
   1. Assessment: collects comprehensive data pertinent to the patient’s health or situation using clinical agency identified assessment tools and identify normal from anticipated abnormal patient assessments
   2. Diagnosis: analyzes data to determine the nursing diagnosis or issue using appropriate nursing classification language
   3. Outcome Identification: identifies expected outcomes for a plan individualized to the patient or situation
   4. Planning: evaluates the articulated plan of care and identifies the rationale for strategies
   5. Implementation: implements the identified plan
   6. Evaluation: evaluates progress toward attainment of outcomes
2. *Protects patient confidentiality in academic discussions (verbal and written)
3. *Protects institutional confidentiality in academic discussions (verbal and written)
4. *Abides by NCSBN guide on social media
5. Acts to prevent unsafe, illegal, or unethical care practices.

 

1. N1: Provides developmentally appropriate nursing care across the continuum of healthcare environments.

 

1. Identifies the developmental level of patient
2. Individualizes care based on the developmental level of patient
3. Adapts nursing skills to match patient population
4. The priority of activities reflects patients’ needs
5. Applies safeguards and decision-making support tools embedded in patient care technologies and information systems to support a safe practice environment for both patients and healthcare workers
6. Demonstrates the application of psychomotor skills for the efficient, safe, and compassionate delivery of patient care.

 

1. C1: Collaborates and communicates with the patient and the healthcare team to maximize health outcomes.

 

1. *Validates nursing plan of care with the instructor and/or primary nurse
2. Explains treatments and procedures to patient and family as appropriate
3. Keeps patient informed of the plan of care
4. *Keeps the primary nurse and clinical instructor informed of patient response to the plan of care and any changes to the plan of care
5. Compares/contrasts the roles and perspectives of the nursing profession with other professionals on the healthcare team.

 

1. I: Uses information management and the application of patient care technology to provide quality care.

 

1. Explains the rationale for the use of patient care technology
2. Demonstrates skills in the use of patient care technology according to agency protocol   
3. Uses EHR to communicate effectively with members of the health care team
4. Documents clinically relevant information in a timely manner
5. Understands the use of Clinical Information Systems (CIS) to document interventions related to achieving nurse-sensitive outcomes.
6. Uses information and communication technologies in preventative care.

 

1. S: Demonstrates leadership by influencing others to optimize physical, emotional, and spiritual safety and provide quality care.

 

1. *Collaborates with the inter-professional team to provide safe and effective care and implement unit safety initiatives, policies, and procedures
2. *Places the patient’s concerns and safety first:
   1. Accessible and prompt in answering patient’s requests;
   2. Prioritize patient’s care needs
   3. Notify the instructor and primary nurse when leaving the unit and makes arrangements for patient care needs to be met
3. Collaborates with the patient regarding spiritual needs, incorporates into the plan of care, and identifies professionals who are specialists in spiritual care and makes referrals
4. Reviews and revises inter-professional plan as appropriate
5. Identifies and adapts environment to promote a sense of peace such as lighting, music, roommate, etc.
6. Engages the patient in dialogue that promotes a sense of well-being by:
   1. Providing a presence
   2. Determining the meaning of pain
   3. Therapeutic sense of self
   4. Uses a variety of appropriate non-verbal communication strategies that “grounds” or “centers” the patient, such as touch, silence, presence, humor, and active listening
   5. Effectively uses therapeutic communication
7. Assists the patient to continue or engage in his/her meaningful spiritual rituals and routines
8. Manages personal emotional responses when the patient’s beliefs or actions may lead to a harmful effect
9. Identifies and acts on barriers to communication
10. Participates in quality and patient safety initiatives, recognizing that these are complex system issues, which involve individuals, families, groups, communities, populations, and other members of the healthcare team.
11. Promotes factors that create a culture of safety and caring.
12. Promotes the achievement of safe and quality outcomes of care for diverse populations.

 

1. C2: Provides culturally competent and holistic nursing care to diverse patients.

• Assesses the patient’s use of complementary, alternative, and integrative health practices
• Assesses spirituality in patient care
• Assesses patient’s cultural practices in a respectful and sensitive manner
• Identifies the patient’s cultural influences on acute illness behaviors
• Considers the whole person (mind, body, spirit, and environment) when planning and providing care

 

1. A2: Advocates for health promotion and disease prevention strategies.

• Assesses patient’s perceptions of needs and utilizes strategies that promote health
• Identifies factors that contribute to health disparities
• Supports patients’ decisions and motivates patients to follow through with actions
• Participates in patient-centered activities that promote health and prevent disease
• Provides information to empower patients to make informed decisions

 

1. N2: Demonstrate knowledge of health care policy, finance, and regulatory environments to improve patient outcomes.

• Understands the implications of payer source
• Identifies economic and health literacy barriers to improve the patient’s ability to navigate the health care system
• Acts on identified barriers to improving patient outcomes
• Identifies community resources for a patient with complex health care needs who is being discharged

* Indicates a critical behavior that must be followed at all times.  Violation of a critical behavior may result in immediate clinical failure.