Self-Assessment and Capability Verification



RN-Orientee Competency Checklist Vermont Assembly of Home Health Agencies

INSTRUCTIONS

Interns/New Hires:

1. Complete this form, prior to starting your clinical experience. Use the scoring key below to self-assess and rate in the first column your areas of extensive experience vs. skills that need additional practice (or review of this facility’s protocol). This process will help to identify the areas where you need additional experience, access to teaching resources, and/or lab practice.

2. Use the results of your self-assessment and discussion with your preceptor to establish learning goals and plan your direct care experiences. Use this form throughout your Internship experience to plan your assignments (based on learning needs) and for the preceptor to verify skills/procedures accomplished.

3. The completed form is documentation of competence verification and skills acquisition during transition.

Scoring Key

1 – Identified Limitation - requires direct guidance & support, little or no experience with skill

2 – Capable - familiar with skill/equipment but may need assistance, seeks help when unfamiliar with process/skill

3 – Performs independently - knowledgeable to perform these tasks safely as a result of training and experience

4 – Proficient - extensive experience in this area/skill, able to teach and mentor others

5 – Expert - All of the above; fluid performance; ensures evidence-based practice for clients, team & agency

Preceptor:

- Items listed in bold are critical elements requiring evaluation/validation within orientation competency assessment

- Critical elements that are lettered in italics - represent population specific considerations

- The first blank column is for the intern or new nurse to use for self-assessment (see #1 above). Information gleaned here and from dialogue/discussion will help with planning goals, activities, and assignments.

- Comments column - This is where you might chart dates when care is practiced with supervision. Add pertinent comments if indicated. Record N/A and initials for items that do not apply to this nurse’s role or performance.

- The final column is for Preceptor use only. The date and preceptor initials in this column confirm that the preceptor has observed the intern/orientee provide safe and effective care, delivered according to agency protocol, on the indicated date. Signing in this column verifies a score of at least 2 – Capable, for the indicated aspect of care. Completion and filing of this form indicates completion of orientation as well as verification of the nurse’s capability in the clinical setting and role expectations.

Important: Do not sign off a skill or criteria as demonstrated unless you actively verified the individual’s competence. Competence is a synthesis of skill, knowledge, and performance. The ability to transform learning into effective and relevant action is evidence of such competence.

Verification of competence may be by:

o Demonstration - novice performs task/procedure in safe, capable manner. This may include simulations, lab setting, skills stations, &/or direct care performance.

o Verbalization - novice explains process and/or planning that evidences safe, reliable knowledge base and planning for care. This may include case scenarios, discussion, description of plan

This competency assessment tool is based on the framework and model developed by Dr. Carrie Lenburg

Lenburg, C. (2009). The COPA Model: A Comprehensive Framework Designed To Promote. Nursing Education Perspectives, 30 , 312 - 317.

Lenburg, C. (1999). Redesigning Expectations for Initial and Continuing Competence For.

The Framework, concepts and methods of the competency outcomes and performance assessment (COPA) model. © 1999 Online Journal of Issues in Nursing. Sept. 30, 1999

Please refer to the VNIP Bibliography for a complete reference listing of resources contributing to the production of this work.

Competence Verification Form Name ___________________________________________________________

ID#____________________ Start Date ___________________ Unit __________________ _

|Critical Elements and Specific Subskills |Self assess|Comments, concerns, successes |Date & |

| | | |Initials |

|Practice Standard I: Incorporates relevant intervention skills in delivery of nursing care | |

|Provides for patient/colleague/self safety & protection - cleanliness, PPE, body mechanics, | | | |

|Protects self from environmental hazards, aggressive, or abusive behaviors | | | |

|Assesses problem areas at revisits | | | |

|Implements precautions and reporting for infestations of rodents, insects, or other | | | |

|Completes full physical assessment, using OASIS as indicated. | | | |

|Completes other OASIS time points (recert, resumption of care, transfer, and discharge) | | | |

|Performs comprehensive medication review & reconciliation | | | |

|Assists patient with safe transfers/ambulation | | | |

|Provides routine and high tech care interventions as prescribed | | | |

|Integrates Medical Technology in care delivery | | | |

|Initiates patient discharge plan on admission | | | |

|Practice Standard II: Communicates with patients & team in accurate, considerate, timely manner. | |

|Wears name tag; identifies self and credentials | | | |

| - Identifies patient as per protocol | | | |

| - Uses effective communication skills with patient interview | | | |

|Interacts effectively with patient, families, colleagues, etc. | | | |

| - Reports pertinent, concise info to team members | | | |

| - Responds to messages in a timely manner | | | |

|Ensures accurate and complete computer processing & documentation for assessment, treatments, meds, orders, & etc | | | |

|Utilizes various modes of communication (email, voice mail, phone call, fax, etc) | | | |

|Engages in appropriate contact with physicians, to coordinate care | | | |

|Protects confidentiality of patient and colleague information | | | |

|Completes documentation that reflects coordination of care within interdisciplinary team | | | |

|Completes documentation forms as indicated for identified incidents: | | | |

| Sentinel/Critical events; APS reporting; Incident reports; Infection control | | | |

|Practice Standard III: Employs Critical Thinking skills to achieve outcomes and solve problems | |

|Administers individualized, population specific care that supports optimal function & wellbeing | | | |

|Develops care plan in collaboration with client | | | |

|Delivers organized, well-prioritized care for patient assignment | | | |

|Uses reflective judgment in self assessment and planning | | | |

|Makes alterations in plan of care as indicated | | | |

|Practices within limits of experience and capability | | | |

|Seeks assistance and/or information correctly | | | |

|Practice Standard - Integrates the human experience of health, illness, healing in building client- provider relationships | |

|Uses statements/body language that convey an absence of bias and respect for the rights of others | | | |

|Protects patient autonomy, dignity, & rights | | | |

|Integrates caring & concern for patients, families, colleagues within all provision of care | | | |

|Assists colleagues with care delivery | | | |

|Refers concerns/issues to correct resource | | | |

|Provides care based on philosophical, multi-cultural, moral, and social justice and ethical concepts. | | | |

|Treats each patient's special needs with consideration of their uniqueness - physical limitations, communication style, | | | |

|personal history, psycho-social, belief system, language, literacy, etc. | | | |

|Practice Standard V. Manages workload and material resources effectively | |

|Organizes multitask & multi-patient assignment effectively | | | |

|Applies personal work organization skills | | | |

|Prioritizes care & tasks consistent with circumstances and available resources | | | |

|Requests assistance when unsure of process/task | | | |

|Seeks out feedback and accepts correction | | | |

|Utilizes equipment and supplies correctly | | | |

|Develops daily, weekly work plan | | | |

|Accepts changes in assignment/expectations | | | |

|Practice Standard VI: Applies leadership skills consistent with role/experience | |

|Assigns care that is consistent with role, scope of practice, & validated capabilities of recipient | | | |

|Coordinates care within the interdisciplinary team | | | |

|Gives feedback pertinent to situation | | | |

|Delivers & receives effective hand-off communications | | | |

|Interacts with others in professional manner | | | |

|Manages conflict in capable, effective manner | | | |

|Implements assertive and risk-taking behaviors that are consistent with circumstances | | | |

|Evaluates colleague performance according to agency protocols | | | |

|Maintains professional appearance & demeanor | | | |

|Complies with Policies and Procedures: Adheres to accepted Standards of Practice | | | |

|Follows Nursing Procedure Manual and Clinical Practice Guidelines – i.e. VNAA | | | |

|Utilizes Policy Manual consistently to guide practice | | | |

|Acknowledges own capability / practices within limits of knowledge, experience or capacity | | | |

|Requests assist when unsure of situation | | | |

|Seeks assistance/information correctly | | | |

|Practice Standard VII: Provides teaching in delivery of care to promote health and prevent disease | |

|Provides relevant health improvement information with consideration for age, culture, health issues & educational | | | |

|background | | | |

|Utilizes motivational interviewing for disease self-management | | | |

|Observes caregiver/patient providing treatment | | | |

|Exchanges research info/sources with colleagues | | | |

|Promotes continuous learning through questioning and dialogue | | | |

|Reflects on learning process in an active & consistent manner | | | |

|Reflects on personal nursing practice, actively & consistently | | | |

|Works effectively within preceptor program | | | |

|Practice Standard VIII: Integrates relevant knowledge and evidence-based practice for the patient populations served | |

|Seeks mastery of regulatory and clinical requirements | | | |

|Seeks out new clinical experiences to expand skill set | | | |

|Engages with systems and resources to improve delivery of patient care | | | |

|Seeks validated, evidence based practice info | | | |

|Participates in a change process; working within the framework of regulatory, quality management, safety indicators & | | | |

|organizational structures | | | |

|Stays current with new resources and knowledge | | | |

|9. Provides home care specific services as outlined by facility. | |

|Manages routine home care visit | |

|(includes critical elements that are consistently applied in all visits) | |

|Engages with patient and family in determining care needs | | | |

| - Uses effective communication skills with patient interview | | | |

| - Uses statements and body language that convey respect for others and absence of bias | | | |

|Washes hands at beginning & end of visit | | | |

|Protects cleanliness with handling of nurse bag, storage in car | | | |

|Cleanses equipment as per protocol | | | |

|Uses appropriate Multi Drug Resistant Organism protocols for care / cleaning | | | |

|Disposes of contaminated waste (pt home, sharps in home and office) | | | |

|Utilizes proper selection, application and removal of PPE | | | |

|Implements precautions for infestations of rodents, insects, or other | | | |

|Reports infestations | | | |

|Takes measures to protect self from environmental hazards | | | |

|Protects self from aggressive or abusive behaviors | | | |

|Uses correct body mechanics | | | |

|Assists patient with safe transfers/ambulation | | | |

|Assesses patient’s physical/psycho-social status continually | | | |

|Completes full physical assessment, using OASIS as indicated. | | | |

|Completes assessment for pain, depression, falls, skin breakdown | | | |

|-Interprets relevant population-specific data & physical assessment findings within plan of care | | | |

|-Integrates psychological, social, intellectual, & physical skills for the patient populations served | | | |

|Performs comprehensive medication review, reconciliation and evaluation of compliance | | | |

|- Evaluates effects and effectiveness of medications | | | |

|Documentation is complete, timely, accurate, appropriate | | | |

|- Completes majority of visit note in the home | | | |

|- Completes transfer of EMR to agency server | | | |

| | |

|Integrates patient/family teaching within all care delivery | |

|Provides relevant health improvement info consistent with age, culture, educational background | | | |

|Assesses for barriers to learning and motivation, considers educational level, cultural background | | | |

|Utilizes motivational interviewing for disease self-management | | | |

|Provides client and family with appropriate and accurate information | | | |

|Teaches patient to safely take & monitor effects of medications | | | |

|Clarifies instruction through demonstration & visual aids. | | | |

|Provides counseling about health behaviors | | | |

|Involves family/significant other in decision making/care as appropriate for age/needs of clients | | | |

|Evaluates client and family response to teaching | | | |

|Validates patient/sig. other ability to maintain well-being | | | |

|Prepares a patient mentally for prescribed procedure, treatment, &/or follow-up self care | | | |

|Evaluates client and family response to teaching | | | |

|Provides client / family with information re: | | | |

|Medications: Safely take & monitor effects, actions & side effects | | | |

|Management of pain | | | |

|Effects of diet on disease, consequences of not following diet | | | |

|Oxygen safety | | | |

|Treatment procedure (dressing change, IV administration…) | | | |

|Pressure ulcer prevention/positioning | | | |

|Disease process, management of chronic illness | | | |

|Signs and symptoms of exacerbation of illness | | | |

|Accomplishes start of care/resumption of care visits | |

|Completes assessment and patient processing for start of care | | | |

|Completes assessment, pt processing and documentation for resumption of care | | | |

|Adapts the management of health care for diverse populations and environments | | | |

|Promotes clients self care abilities as per stage of development | | | |

|Describes patient qualifiers for home care service as per payor coverage | | | |

|Identifies skilled care needs | | | |

|Describes nuances of Homebound status | | | |

|Uses the correct form for non-coverage issues | | | |

|Explains issues specific to: Medicare, Managed Medicare, Commercial: Including pre-auth. Procedure, Medicaid and Charity | | | |

|care | | | |

|Monitors supplies in the home | | | |

|Obtains supplies from outside vendor | | | |

|Delivers patient unique interventions, treatments and procedures | |

|Review Physician Orders prior to treatment | | | |

|Provides therapeutic interventions as prescribed | | | |

|- Complete Dressing changes: Clean technique | | | |

|Performs Uni-Boot application | | | |

|Collects specimens as ordered by physician (blood, sputum, urine, culture) | | | |

|Replaces indwelling Foley/Suprapubic catheter—Indicate gender/type | | | |

|Performs urinary catheter care | | | |

|Administers injection (Indicate IM and/or SubQ) | | | |

|Integrates Medical Technology in care delivery | | | |

|Follows best practice for Tele-monitoring | | | |

|Completes INR protocol | | | |

|Uploads Wound photo as per agency guidelines | | | |

|Follows best practice for Pulse Oximetry | | | |

|Completes documentation as per protocol | | | |

|Completes re-certification process for patient to receive continued care | |

|Engages with patient and family in determining care needs | | | |

|Makes alterations in plan of care as indicated | | | |

|Analyzes patient condition and notifies MD of changes in condition | | | |

|- Notify MD of data out of established parameters | | | |

|- Notify MD of patient non-compliance with the plan of care | | | |

|Initiates referrals to community agency to assist patient staying in home | | | |

|Makes referrals to appropriate disciplines within the healthcare team | | | |

|Completes re-certification assessment and documentation | | | |

|Promotes clients self-care abilities | | | |

|Completes transfer for patient admission to hospital or nursing home | |

|Prepares for visit by reviewing chart, physician orders and medications prior to visit | | | |

|Assures patient privacy and comfort | | | |

|Explains procedures and what to expect from care providers and/or treatments | | | |

|Prioritizes care & tasks based on circumstances and resources | | | |

|Reprioritizes work as patient or unit needs change | | | |

|Utilizes equipment and supplies correctly | | | |

|Maintains clean, orderly environment of care | | | |

|Accomplishes work activities in time allotted | | | |

|Protects patient autonomy, dignity, & rights | | | |

| - Advocates for the needs and values of the patient | | | |

| - Involves family and/or significant other in decision-making / care | | | |

| - Maintains professional boundary with client & family | | | |

| - Aware of patient advanced directives and Non-hospital DNR | | | |

|Assists in patient ethical/legal issues – DNR, pt. rights, advance directives, etc | | | |

|Completes discipline, agency or death at home discharge | |

|Ensures prompt arrival (or notification of expected delays) | | | |

|Provides empathetic support for patient &/or family | | | |

|Completes patient assessment | | | |

|Engages support systems for family as needed | | | |

|Adapts the management of health care for diverse populations and environments | | | |

|Completes documentation and interdisciplinary communications that are required | | | |

|Provides high tech intravenous management | |

|Applies knowledge of expected norms –VS, lab values, & assessment - in preparing for, planning, interventions | | | |

|Utilizes equipment and supplies correctly | | | |

|Develops daily, weekly work plan | | | |

|Completes IV insertion | | | |

|Accesses Central lines and implanted ports as per treatment need | | | |

|- Administer IV therapy-(peripheral, PICC line, Port, etc.) | | | |

|Administers medications via IV lines | | | |

|Ensures patient’s ability to care for lines | | | |

|Assesses competence of care provided by caregivers, clients, and other personnel | | | |

|Provides Aide supervision with Home care visit: | | | |

|Observes caregiver/patient providing treatment | | | |

|Explains incidents that require reporting and how to report | | | |

|Medication &/or Treatment errors - patient and Staff; Patient Complaints | | | |

|Provides high tech respiratory management | |

|Manages in home ventilator maintenance, settings and patient utilization | | | |

|Provides suitable respiratory therapies and treatments | | | |

|Assesses patient or care giver capability to manage the equipment and treatments | | | |

|Suctions secretions as indicated – trach, airway, nasal, oral, | | | |

|Completes trach or ventilator care | | | |

|Completes comprehensive respiratory and medication assessment | | | |

|Analyzes patient condition and notifies MD of changes in condition | | | |

|Makes referrals to appropriate disciplines within the healthcare team | | | |

|Manages equipment needs within the home environment | | | |

|Provides high tech wound management – vac dressing, etc. | |

|Completes wound care utilizing hi-tech components such as Vac dressing | | | |

|Ensures ostomy care that maintains optimal skin integrity and bowel function | | | |

|Manages fistula care as prescribed | | | |

|Explains incidents that require reporting and how to report; including but not limited to Treatment errors: Patient and | | | |

|Staff; Patient Complaints | | | |

|Utilizes appropriate form for reports and communication | | | |

|Assesses competence of care provided by caregivers, clients, and other personnel | | | |

|Provides Aide supervision with Home care visit: | | | |

|Observes caregiver/patient providing treatment when indicated | | | |

|Manages special pediatric home care needs | |

|Completes assessment with age specific adaptations | | | |

|Collaborates with patient and caregivers in developing a plan of care | | | |

|Engages interdisciplinary team in planning/ providing care | | | |

|Works effectively with colleagues | | | |

|Attends team meetings | | | |

|Assists colleagues in the delivery of patient care | | | |

|Verbalizes scope of practice for self and others | | | |

|Coordinates care within the multi-disc. team | | | |

|Gives feedback pertinent to situation | | | |

|Delivers & receives effective hand-off communications | | | |

|Applies knowledge of expected age appropriate norms –VS, lab values, & assessment - in planning interventions | | | |

|Integrates aspects of care that are unique to pediatrics | | | |

|Admits patient to hospice or palliative care | |

|Applies population & disease specific considerations in planning and delivery of care | | | |

|Completes patient assessment, documentation and explanation of transfer | | | |

|Engages family/care provider in developing ongoing plan of care | | | |

|Links patient/family/care providers with community and social services/resources | | | |

Name : Start Date Completion Date

Preceptors involved – as listed in chart below All preceptors involved in orientation of a new staff member/intern must sign and initial in this signature chart.

Initials Preceptor signature Initials Preceptor Signature

| | | | | |

| | | | | |

| | | | | |

Completion signatures:

Intern/Orientee Date

Primary Preceptor Date

Manager Date

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