503 Psychiatric and Mental Health Nursing Clinical Performance Appraisal

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1 503 Psychiatric and Mental Health Nursing Clinical Performance Appraisal Clinical Objective 1: Develop communication skills that facilitate accurate problem identification and development of a therapeutic relationship with clients/patients and families. Differentiates between therapeutic and non-therapeutic communication techniques in the nurse-patient relationship. Engages in therapeutic relationships with assigned patients. Identifies factors that may impede and/or facilitate the formation of a therapeutic relationship. Utilizes therapeutic communication skills with all patients in the milieu. Demonstrates self-awareness of factors impacting the use of therapeutic communication skills. Utilizes communication skills with health care professionals that is respectful and aimed at improving the patient s health. Employ therapeutic use of self and intentional presence to protect the value of the human relationship. Deliver competent, holistic and contextually appropriate patient-family-population-centered Demonstrate professional values in nursing practice. Clinical Nurse Leaders Competencies: Provider and Manager of Care Consistently develops therapeutic relationships with patients by establishing rapport and trust (orientation phase) ex: exhibit patience, care, understanding (working phase) ex: therapeutic responses by acknowledging feelings and difficulties, patients often open up about mental illness Therapeutic skills: active listening, open-ended questions, open posture, allows patient to guide the conversation, answering questions but deferring focus back to patient Clinical Objective 2: Implement interventions that promote optimal level of functioning in the least restrictive environment for individuals with mental illness. Demonstrates synthesis of knowledge by: Performing mental status examinations without cues Integrating knowledge of normal and abnormal findings to plan and implement appropriate interventions Evaluating interventions based on desired outcomes Prioritizing nursing diagnoses based on a synthesis of data gathered

2 Employ therapeutic use of self and intentional presence to protect the value of the human relationship. Deliver competent, holistic and contextually appropriate patient-family-population-centered Synthesize scientific evidence and innovative technologies to guide nursing practice in dynamic care environments. Demonstrate professional values in nursing practice. Nursing Technology and Resource Management Health Promotion, Risk Reduction, and Disease Prevention Illness and Disease Management Human Diversity Member of a Profession Able to perform mental status exam by recognizing mood, affect, motor activity, speech, thought process and content and intellectual functioning and utilizing it to guide interactions with patients. Able to recognize nursing diagnoses (ex ineffective coping and knowledge deficit) and implement appropriate interventions (ex: development of nurse-patient relationship, exploring stress management, education on healthy medication and symptoms) Clinical Objective 3: Demonstrate knowledge and skill in determining realistic collaborative goals and outcomes for individuals with mental illness. Develops goals and outcomes based on the psychiatric diagnosis that are age-appropriate and consistent with the patient s culture, values, and beliefs. Involves the patient, family, and other health care professionals in formulating outcomes when possible and appropriate. Considers risks, benefits, costs, and current scientific evidence in developing expected outcomes.

3 Modifies expected outcomes based on changes in the patient status or evaluation of the situation. Employ therapeutic use of self and intentional presence to protect the value of the human relationship. Deliver competent, holistic and contextually appropriate patient-family-population-centered Illness and Disease Management Human Diversity Member of a Profession Is able to collaborate with patients to determine realistic goals. Example: While running a group on depression, patients determined the direction of the discussion (patient-oriented) therefore goals were individualized and realistic. On the in patient unit, began developing informal goals with patients. Ex: how many groups they will attend, plans to prevent returning to the hospital. Clinical Objective 4: Analyze the impact of health care policy, culture, technology and ethics on healthcare Integrates cultural adaptations in plan of care Synthesizes analysis of microsystem when planning care Identifies transitions of care affecting the patient/family (Where did patient/family come from? Where will patient/family transition to? Changes that will affect the patient/ family?) Begins to develop strategies/interventions to plan care based on transitions. Deliver competent, holistic, contextually appropriate patient-family-population centered nursing Deliver competent, holistic, contextually appropriate patient-family-population centered nursing

4 Provider/Manager of Care Risk Reduction Human Diversity Individualizes care and conversations by acknowledging patient s situation and recognizing patient s culture and environment, never generalizing. Recognizes barriers to continuity of care within the health care system, utilizes resources available (discussing support groups, group homes, changing physicians, family). Speaks to patients about transitions to help them recognize what has been successful and unsuccessful and possible ways to adapt. Clinical Objective 5: Use mental health promotion and disease prevention strategies in the delivery of care to patients and their families. Identifies and incorporates teaching strategies aimed at health promotion and disease prevention for patients and their significant others. Maintains a safe and therapeutic milieu in collaboration with patients, families, and other healthcare professionals. Integrates activities into the plan of care that build or enhance social competence, self-esteem and sense of well-being. Serves as a resource for community mental health promotion and disease prevention activities. Synthesize scientific evidence and innovative technologies to guide nursing practice in dynamic care environments. Manage the structure and process of the care environment, incorporating policy, fiscal, and macrosystem concepts. Health Promotion, Risk Reduction, and Disease Prevention Consistently engages in health promoting conversations whenever appropriate (coping strategies, exercise, art therapy, diet/diabetes management) and contributes to group discussions (smoking cessation, stress management). Actively engages in art therapy and

5 conversations with patients to enhance social skills and sense of well-being. Professional and approachable demeanor allowing me to serve as a resource (engage in therapeutic relationship, patients able to approach me to ask for health advice) Clinical Objective 6: Collaborate with members of the multidisciplinary team in providing continuity of care for clients/patients and families. Actively engages in interdisciplinary conversations both formally and informally: Actively participates in team meetings Attends family conferences/meetings Initiates consultations with other disciplines based on the plan of care Maintains ongoing dialogue with assigned nurse/staff person for the purpose of coordinating care activities. Manage the structure and process of the care environment, incorporating policy, fiscal, and macrosystem concepts. Demonstrate professional values in nursing practice. Health Care Systems and Policy Member of a Profession Actively participates in group discussions to establish rapport and trust and contribute to the purpose of the group (sharing experiences with stress management, social skills; education about medication side effects, smoking cessation, coping skills). Collaborating with instructor and team to determine which group discussions would be best for the group, following up with permanent staff (therapists and counselors) to provide continuity of Clinical Objective 7: Participate in identification of system-related issues that affect the delivery of mental health care across the continuum of care Demonstrates an awareness of the continuum of mental health care in the United States. Facilities patients movement through the mental health care continuum. Identifies system gaps in the mental health care of patients.

6 Manage the structure and process of the care environment, incorporating policy, fiscal, and macrosystem concepts. Nursing Technology and Resource Management Health Care Systems and Policy Member of a Profession Recognizes gaps in continuity of care between physician and nurse with regards to charting and technology. Recognizes the barrier a psychiatric diagnosis may create in regards to treatment, therefore provides symptoms-based Recognizes the need for talk therapy and/or someone to listen in the acute care setting, able to provide this on the in-patient unit. Clinical Objective 8: Identify the potential impact of socio-cultural, political, and interpersonal factors on the development of the therapeutic relationship, and the dynamics within the treatment team. Examines the socio-cultural, political, and interpersonal factors that may impact therapeutic relationships. Analyzes the group dynamics within the treatment team and their influence on decisionmaking about patient Employ therapeutic use of self and intentional presence to protect the value of the human relationship. Deliver competent, holistic and contextually appropriate patient-family-population-centered Manage the structure and process of the care environment, incorporating policy, fiscal, and macrosystem concepts. Clinical Nurse Leaders Competencies: Nursing Technology and Resource Management Information and health Care Technologies

7 Member of a Profession Aware of unconscious bias and stereotypes within myself and the influence of socio-cultural and interpersonal factors that affect the therapeutic relationship. Practices empathy and understanding and recognizes transference and countertransferrence to improve therapeutic relationship. Recognizes the importance of communication and collaboration among the treatment team; recognizing differences between PHP and the inpatient setting. Clinical Objective 9: Demonstrate consistent professional behavior. Demonstrates respect for peers, instructor, and other health care professionals. Evaluates own practice in relation to CPA objectives and institutional and unit guidelines. Seeks formative feedback on clinical performance from clinical faculty member. Begins to demonstrate autonomy while seeking assistance when appropriate. Actively seeks new learning opportunities Demonstrate professional values in nursing practice. Information and health Care Technologies Member of a Profession Consistently demonstrates professionalism and respect among patients, peers and interdisciplinary professionals. Demonstrates autonomy by actively engaging in groups and one-on-one discussions. Actively seeks new learning opportunities (within in-patient unit and PHP) and demonstrates leadership behaviors (actively seeking to run group discussions on the unit). PRIMARY STRENGTHS: Developing a therapeutic relationship and establishing trust. Individualizes care and conversations by acknowledging patient s situation and recognizing patient s culture and environment. Practices empathy and understanding and aware of unconscious bias and stereotypes within self. Actively seeks new learning opportunities. SPECIFIC AREAS FOR IMPROVEMENT: Improvement could be made in the area of developing goals with patients and helping them work toward them. Increase communication and collaboration with permanent staff for better continuity of

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