Practicum Evaluation Program HH/NURS 4527 9.0 Integrated Practicum School of Nursing, Faculty of Health York University

PRACTICUM EVALUATION
PROGRAM
HH/NURS 4527 9.0
Integrated Practicum
School of Nursing, Faculty of Health
York University
The Practicum evaluation is used to reflect the expected clinical performance outcomes of Collaborative students. The tool is standard within the Collaborative
program and is modified for each level of the program. It is intended for use by students for self evaluation purposes for each clinical practicum course. This
tool will also be used by Clinical Course Directors (CCD) to evaluate students in the practicum setting at midterm and end of term.
The document consists of three main parts.
Part A is comprised of a learning plan framework (to be completed by the student or student team). Students may be expected to keep additional praxis records at
the request of the CD/CCD to meet course requirements.
Part B is the practicum evaluation form that students/student teams and their CCD will complete at midterm and end of term. It is organized, based on the course
outcomes students are expected to meet in their practicum experience. For each course objective identified, indicators of performance that take into account the
applicable leveled program outcomes, and incorporate relevant College of Nurses of Ontario (CNO) Entry Level Competencies for Registered Nurses in Ontario
(2007) and Canadian Nurses Association (CNA) Codes of Ethics are listed. These indicators are to be used by students in the development of their learning plan
and to gauge their performance. They will also be used by the CCD to assess and evaluate student/student group abilities to meet course outcomes and overall
performance. Students/Student groups will be evaluated using the qualifiers defined in Appendix A of the Practicum Evaluation template document.
Part C is a summary of performance. Both students/student groups and their CCD are asked to provide summary comments about notable strengths and areas for
improvement. The CCD will also indicate whether the student/student group is passing/passed, or failing/failed the course.
Please refer to the accompanying Practicum Evaluation Guidelines and Use document for more important information regarding student
performance, evaluation, and professional behaviour. It is the students responsibility to be aware of all course requirements.
CD/CCD: Salwa Musa
Student Name/Number: Kris-Ann Simpson
Term: Winter
Part A: Learning Plan

NURS 4527 9.0 Integrated Practicum
School of Nursing, York University
Individual/Term Learning
Goals
Activities to Achieve Goals

(What will I/we do to achieve this
goal?)
*These activities should reflect or
*Also identify the course outcome

you are working toward through your
goal
Evaluation Criteria (Learning Evidences)

*Be specific
Target
Date
link to the indicators for the course

objective you are working toward
meeting
Gain knowledge and

understanding about the role and responsibility of the
discharge nurse and how
patients become a candidate for discharge.
Gain knowledge and
experience on
communicating within a
intradisciplinary team
Resources and Supports

What supports will you need to
achieve your goal?
Shadow discharge nurse -St Michaels hospital

to view the discharge
website for policies
process
and procedures
Identify hospital policies -Nurse educator
and procedures for
discharging a patient
-Identify a candidate for discharge

- Identify the roles and responsibility
Research the roles and

responsibilities of each
member of the
Shadow members of the
Identify clients as
candidates for
consultation from
members of the
intradisplinary team
Effectively communicate
with different members
of the team
Attend morning rounds
Transfer of
accountability
Documenting
-Understand
-Nurse educator
-Preceptor
-Members of the
interdisciplinary on
14CC
-Orientation booklet
-St Micheals hospital
entranet
March
7,2014
of a discharge
nurse.
-Provide evidence in portfolio
and communicate the roles and

responsibilities of different members of the
-Effectively communicate, and identify clients for
consultation
-Documentation
Ongoing
Gain knowledge and

understanding on the
admitting process from
registration to admission to
14CC.
Understand the role and

responsibilities of the
charge nurse.
Shadow a nurse in the

registration office during -Nurse educator
-Preceptor
admitting process to
-St Micheals hospital
admission onto 14CC
entranet for policies
Research policies and
and procedures
procedures
Shadow charge nurse
Research the roles and
responsibilities of the
charge nurse
-Preceptor
-St Micheals
hospital
entranet for policies
and procedures
-Orientation booklet
-Identify criteria for admission onto

-Identify policies and procedures
-documentation
-Communicate
14CC
the roles and responsibilities of the

charge nurse
-Identify when to consult with a charge nurse
-Provide documentation
March 12,
2014
Feb 28,
2014
Part B: Practicum Evaluation

Student:
Kris-An Simpson
Preceptor: Cindy Pablo/ Marinel Padernal
CCD:
Date:
Salwa Musa
April 5, 2014
Unit/Agency:
Term:
St. Micheals Hospital

Winter
Note: Person/Client may refer to: an individual, a family, a client group or a community. Please check the appropriate qualifier in the shaded box and provide
supportive narrative comments. For additional comments, please attach documentation. Thank you.
Individual Performance
Course Outcome #1: Demonstrate
accountability to the public by practicing in
accordance with professional standards of
nursing practice and the current Entry to
Practice Competencies for Registered Nurses of
the College of Nurses of Ontario. (Linked with
4th year level goal #1)
The following CNO Entry to Practice
competencies may be incorporated: 1-3,6-8,1013,41,71,74,79,82,83,85,100,101
Midterm Evaluation
Pass
Final Evaluation
Fail
Fail
Student Comments:
Student Comments:
Demonstrate professional responsibility and

accountability by being punctual to my clinical
placement. Recognize situations and seek assistance
when needed. Maintaining a professional dress code.
Demonstrate professional responsibility and

accountability by being accountable for actions and
decision making. Recognize situations when
assistance is needed. Demonstrate clear, concise
and timely, documentation.
Preceptor/CCD Comments: Pass

- Was able to shadow CCAC to determine what happen when pt get
discharged.
-Kris Ann is always punctual and dressed appropriately
- Always ask questions and does research with needed
Course Outcome #2: Enhance health and

healing in individuals, families, groups and/or
communities/populations in a variety of
traditional and non-traditional settings through
Pass
Pass
Fail
Preceptor/CCD Comments:
She is able to follow and understand her scope of practice.
She knows her limits and seeks assistance if needed.
Pass
Fail
synthesizing knowledge from nursing and other

disciplines to guide assessments, care and health
promotion. (Linked with 4th year level goals
#2,8)
competencies may be incorporated: 17, 23,24,
27,30-32,34,36,37,42-44,51-70,72
Student Comments:
Student Comments:
Provide theoretical and evidence based rationale for

nursing intervention such as administering medication
(knowing what the medication is used for and why the
patient is receiving medication). Knowing where to
access hospital policy and documents when necessary.
Able to use knowledge from pathophysiology,
pharmacology and medical surgical nursing to
understand a clients clinical picture.
Provide theoretical and evidence based rationale for

nursing intervention such as administering
medication (knowing what the medication is used
for and why the patient is receiving medication).
Knowing where to access hospital policy and
documents when necessary. Able to use knowledge
from pathophysiology, pharmacology and medical
surgical nursing to understand a clients clinical
picture. Able to build relationships and trust with
clients and members of the healthcare team of the
health care team. Able to contact members of the
healthcare team to address health challenges.
Preceptor/CCD Comments:Pass
-Research and apply knowledge and skills to provide safe nursing
care.
-Able to build therapeutic relationships with her patients.
-Able to access hospital policy and procedures
Course Outcome #3: Demonstrate praxis, in

incorporating multiple ways of knowing,
evidence-informed care, and critical-reflective
practice in the humanization of health care.
(Linked with 4th year level goals #3,8)
competencies may be incorporated: 18,19,21,22,
25,26,33,38,48,49,62,65,75,76,78
Pass
Fail

She seeks opportunity for professional growth which
enhances her competence.
She demonstrate behavior which contributes to effective
partnership with her pt./family.
Pass
Fail
Student Comments:
Student Comments:
Exercise professional judgment when deciding whether

to hold medication. Collaborate with nurses, clinical
assistants, and allied health care professionals with the
provision of care.
Exercise professional judgment when deciding

whether to hold medication. Collaborate with
nurses, clinical assistants, and allied health care
professionals with the provision of care. Able to
understand the roles and contributions of other
members of the health care team such as OT, PT,
SLP, dietian, case worker, etc.
-Using different means to acquire information and then appropriately
able to incorporate it into her practice
-RN and Kris Ann reflects at the end of her day about her practice
Course Outcome #4: Exemplify personal and

professional growth through application of skills
for lifelong learning. (Linked with 4th year level
goal #4)
competencies may be incorporated: 5,16, 92,94,
102-104
Pass
Fail
Pass
Fail
Student Comments:
Student Comments:
Completes documentation in a timely manner through

sorian. Able to recognize a change in health and
collaborates with various members of the health care
team such as preceptor, doctors, speech language
pathologist, OT/PT, and other nurses. Organizing
workload by determining which client to see first,
documenting, and prioritizing, in order to meet
responsibilities.
Able to apply theory to practice. Critically reflect

on situations to increase knowledge and skill.
Receive feedback from preceptor .Complete
documentation in a timely manner through sorien.
- Able to prioritize care to meet client needs
- Able to research and preform skills in a timely manner
-Always looking to increase knowledge and skills
Course Outcome #5: Establish and maintain

collaborative relationships with nursing
colleagues, inter-professional team members,
and clients/communities. (Linked with 4th year
level goal #5)

Able to demonstrate knowledge with her scope of practice.
She report situations which potentially unsafe for her pt.
Pass
Fail

She is able to apply critical thinking skills in her practice.
She is able to detect and document significant changes in pt.
conditions.
Pass
Fail

competencies may be incorporated: 9,20,35,4547,84,88-91,98,99
Student Comments:
Student Comments:
Advocates and intervene to ensure client safety. Uses

communication technology effectively to communicate
within an interdisciplinary team such as webexcange,
telephones. Uses critical inquiry and evidence based
practice when caring for a client. Provide care that is
client centered and respect the clients autonomy.
Advocates and intervene to ensure client safety.

Uses communication technology effectively to
communicate within an interdisciplinary team such
as web exchange, telephones. Establish professional
relationships with the health care team, built on
respect, trust and is client centered. Uses critical
inquiry and evidence based practice when caring
for a client. Provide care that is client centered and
respect the clients autonomy.
- Did a day placement with CCAC
- Able to collaborative with other nurses, doctors and other team
members to provide
Course Outcome #6: Demonstrate leadership

for the advancement of the nursing profession in
all areas of practice. (Linked with 4th year level
goal #6)
competencies may be incorporated: 4,1416,45,89,90,97
Pass
Fail

She is able to established and maintained a caring
environment and collaborate with other health care team
member.
Pass
Fail
Student Comments:
Student Comments:
Contributes to the nursing team by building relationships

with respect, trust and honesty, also respecting diversity.
Promote interprofessional collaboration through shared
problem solving and decision making. Participates in
patient safety by identifying fall risk patient and utilizing
transfer signs and arm bands.
Contributes to the nursing team by building

relationships with respect, trust and honesty, also
respecting diversity. Promote interprofessional
collaboration through shared problem solving and
decision making. Participates in patient safety by
identifying fall risk patient and utilizing transfer
signs and arm bands. Demonstrate leadership by
working independently and providing assistance
when necessary.
-Kris Ann is always willing to assist another student and other
members of her team.
- Demonstrates leadership by looking to acquire a new skills.
Course Outcome #7: Advocate for and support

healthy organizational and public policy to
promote health of individuals, families, groups,
communities and/or global populations. (Linked
with 4th year level goals #7,8)
competencies may be incorporated: 20,39,86,
87,93,95-97
Pass
Fail
Pass
Fail
Student Comments:
Student Comments:
Complete head to toe assessment examining the clients

both physical and cognitive state. Able to interpret lab
values. Maintains client confidentiality by using and
disposing of client information appropriately
Able to follow hospital policy and protocols. Know

when and where to access hospital policies. Provide
health promotion through patient teaching.
Complete head to toe assessment examining the
clients both physical and cognitive state. Able to
interpret lab values. Maintains client confidentiality
by using and disposing of client information
appropriately.
-Kris Ann is able to do teaching with her patient that is relevant and
appropriate in a hospital setting.
Course Outcome #8: Provide culturally

sensitive nursing care that honors human dignity,
diversity, and different ways of being. (Linked
with 4th year level goals #8)

She is able to show and teach her fellow student from other
school.
She delegate to CA/RN if she is busy with other pt.
Pass
Fail

She demonstrates knowledge relevant to her practice.
She demonstrate respect for her pt. privacy and
confidentiality.
Pass
Fail

competencies may be incorporated: 28,29,40,50,
73,77,78,80,81
Student Comments:
Student Comments:
Establishes therapeutic communication and relationships

with clients. Able to interpret data from assessment and
lab value and other sources to draw conclusion about the
client health status. Work with other members of the
health care team to promote the continuity of care.
Continually evaluates patient care by reassessment and
documentation. Demonstrates honestly and respect in all
professional interactions.
Establishes therapeutic communication and

relationships with clients. Able to interpret data
from assessment and lab value and other sources to
draw conclusion about the client health status.
Work with other members of the health care team to
promote the continuity of care. Continually
evaluates patient care by reassessment and
documentation. Demonstrates honestly and respect
in all professional interactions.
-Always provide care to patients that honors human dignity.
Treats patient equally
- Respects patients diversity and cultural needs

She communicates well and being respectful for them as well
as she supports pt. while coming to decisions about their
health care.
Part C: Summary of Performance

Summary of Performance: Please provide a summary of students strengths and areas requiring further development.
Midterm Evaluation
Strengths (identified by student):
Able to organize and manage time effectively up to 3 patients.
Communicating within an interdisciplinary team. Critically reflecting on
practice. Ensuring patient safety. Establishing caring and trusting
therapeutic relationship with clients and team members.
Strengths (identified by preceptor/CCD):
Kris Ann has correctly identify her strengths above. Kris Ann is warm and
soft spoken, helpful. Always looking to learn something new.
Final Evaluation
Strengths (identified by student):
Able to organize and manage time effectively up to 4-5 patients ranging from
various complexities. Able to recognize when to communicate and provide
relevant data to the interdisciplinary team when client health status changes.
Continue to ensure patient safety. Establishing caring and trusting therapeutic
relationship with clients and team members.
Strengths (identified by preceptor/CCD):
She correctly identifies her strength above. She used every opportunity that
she had to enhance her knowledge and skills. She is enthusiastic to learn and
improve her practice. She never stops looking for something new.
Areas of Development (identified by student): Organizing and managing

time effectively for up to 4 patients that range from less complex to very
complex patients. Demonstrating more leadership in regard to problem
solving and decision making as well as exercising clinical judgement.
Areas of Development (identified by student):

Continue to build on clinical judgment and problem solving.
Areas of Development (identified by preceptor/CCD):

Building on her clinical judgement. Being able time manage and organize
care for more complex patients
Areas of Development (identified by preceptor/CCD):building her clinical

judgment to more complex pt.
10
Student General Comments:
Student General Comments:
Preceptor/CCD General Comments:
Preceptor/CCD General Comments:
Preceptor
________________
(print name)
________________
(signature)
________________
(date)
Preceptor
________________
(print name)
________________
(signature)
______________
(date)
Student
________________
(print name)
________________
(signature)
________________
(date)
Student
________________
(print name)
________________
(signature)
______________
(date)
Clinical Course
Director (CCD)
________________
(print name)
________________
(signature)
________________
(date)
Clinical Course
Director (CCD)
________________
(print name)
________________
(signature)
______________
(date)
11
Clinical Course Director (CCD) Dates of site visits

Visit #1
Visit #2
Visit #3
Visit #4
___________________
(date)
___________________
(date)
___________________
(date)
___________________
(date)
___________________
(CCD Initials)
___________________
(CCD Initials)
___________________
(CCD Initials)
___________________
(CCD Initials)
End of Term: OVERALL Pass or Fail (Please Check)
___________________
(Student Initials)
___________________
(Student Initials)
___________________
(Student Initials)
___________________
(Student Initials)
Pass
Visit #5
Visit #6
Visit #7
Visit #8
_________________
(date)
_________________
(date)
_________________
(date)
_________________
(date)
__________________
(CCD Initials)
__________________
(CCD Initials)
__________________
(CCD Initials)
__________________
(CCD Initials)
__________________
(Student Initials)
__________________
(Student Initials)
__________________
(Student Initials)
__________________
(Student Initials)
Fail
Clinical Course Director ____________________ ____________________ ____________

(print name)
(signature)
(date)
Course Director ____________________ ____________________ ____________________

(print name)
(signature)
(date)
12
Appendix A: Definition of Rating Qualifiers

Rating/Qualifier
Pass
Fail
Defining Characteristics/Performance Indicators

The student is performing at a competent level and is meeting course outcomes/performance indicator for the level of the course
with occasional to minimal assistance. Specifically, the student demonstrates the following (please note that not all of the following
may apply to each indicator):
Performs safely
Identifies theoretical principles, with evidence of application of theoretical principles to clinical practice most of the time.
Application is mostly accurate
Incorporates holistic client-centered care consistently
Develops good organizational skills and prioritization
Is able to function safely in increasingly complex situations
Recognizes when supportive or directive cues are necessary and seeks assistance
Demonstrates critical reasoning and reflective practice skills with varying degrees of assistance
Unable to meet the performance indicator despite continual support. Unable to demonstrate consistent growth. Specifically the
student demonstrates the following (please note that not all of the following may apply to each indicator):
Fails to perform consistent/safe nursing care with reference to indicator
Unable to identify theoretical principles or apply theoretical principals in clinical practice
Unable to perform in a safe manner
Unable to organize or prioritize care and course related activities
Requires continual monitoring
Engages in activities or behaviours that they are unable to safely and/or correctly accomplish and/or does not seek required
assistance
Demonstrates lack of clinical judgment
13
Appendix B: Practicum Progression Plan

Student Name (Please Print):
Placement:
CCD:
Preceptor:
Date:
Student Number:
A. Summary of level of performance:

B. Clinical Course Directors (CCD) description of situation/practicum issue/concern:
a. Areas where student is meeting requirements:
b. Areas where student is observed to be experiencing difficulty:
C. Students Description of issue/concern:

a. Areas where you believe you are attaining success:
b. Areas where you perceive need improvement:
D. Plan for success (to be completed collaboratively)

Minimal expectations to
Actions required to meet course expectations (must be measurable
demonstrate competency or
consider how will knowledge gained be evaluated?)
fully address issue/concern
Referral required in NRC

Date Communicated
Yes
Communication to NPCO required

Date Communicated
Yes
Target Date
No
______________________________________________
No
______________________________________________
Date to review progress:

Student Signature:
Date:
Clinical Course Director Signature:
Date:
Course Director Signature:
Date:
14

Practicum Evaluation Program HH/NURS 4527 9.0 Integrated Practicum School of Nursing, Faculty of Health York University

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PRACTICUM EVALUATION

CD/CCD: Salwa Musa

Student Name/Number: Kris-Ann Simpson

Part A: Learning Plan

Activities to Achieve Goals

*Also identify the course outcome

Evaluation Criteria (Learning Evidences)

link to the indicators for the course

Gain knowledge and

Resources and Supports

Shadow discharge nurse -St Michaels hospital

-Identify a candidate for discharge

Research the roles and

and communicate the roles and

Gain knowledge and

Understand the role and

Shadow a nurse in the

-Identify criteria for admission onto

the roles and responsibilities of the

Part B: Practicum Evaluation

St. Micheals Hospital

Demonstrate professional responsibility and

Demonstrate professional responsibility and

Preceptor/CCD Comments: Pass

Course Outcome #2: Enhance health and

synthesizing knowledge from nursing and other

Provide theoretical and evidence based rationale for

Provide theoretical and evidence based rationale for

Course Outcome #3: Demonstrate praxis, in

Preceptor/CCD Comments: Pass

Exercise professional judgment when deciding whether

Exercise professional judgment when deciding

Course Outcome #4: Exemplify personal and

Completes documentation in a timely manner through

Able to apply theory to practice. Critically reflect

Course Outcome #5: Establish and maintain

Preceptor/CCD Comments: Pass

Preceptor/CCD Comments: Pass

The following CNO Entry to Practice

Advocates and intervene to ensure client safety. Uses

Advocates and intervene to ensure client safety.

Course Outcome #6: Demonstrate leadership

Preceptor/CCD Comments: Pass

Contributes to the nursing team by building relationships

Contributes to the nursing team by building

Course Outcome #7: Advocate for and support

Complete head to toe assessment examining the clients

Able to follow hospital policy and protocols. Know

Course Outcome #8: Provide culturally

Preceptor/CCD Comments: Pass

Preceptor/CCD Comments: Pass

The following CNO Entry to Practice

Establishes therapeutic communication and relationships

Establishes therapeutic communication and

Preceptor/CCD Comments: Pass

Part C: Summary of Performance

Areas of Development (identified by student): Organizing and managing

Areas of Development (identified by student):

Areas of Development (identified by preceptor/CCD):

Areas of Development (identified by preceptor/CCD):building her clinical

Student General Comments:

Student General Comments:

Clinical Course Director ________

Course Director