The"Clinical"Practicum:"" Guidelines"for"Success"

School&of&Nursing& TheClinicalPracticum: GuidelinesforSuccess Adult9GerontologyClinicalNurseSpecialist & PrimaryCareAdult9Gerontology NursePractitioner 201592016 1

TableofContents 1.Introduction... 3 2.Selection of Clinical Preceptors and Sites... 3 3.The Student: Responsibilities and Accountability... 3 Scheduling of Clinical Hours... 4 Paperwork...4 Preceptor Interview...4 Scheduling of Clinical Hours...4 Attendance...5 Attire and Behavior...5 Clinical Objectives......5 Preparation for Clinical Practicum...6 Guidelines for Clinical Preparation...6 4.Clinical Faculty Responsibility... 7 5.Documentation of the Clinical Encounter... 7 6.The Clinical Site Visit... 8 The studentis responsible for:... 8 The clinical faculty is responsible for:... 9 The preceptor is responsible for:... 9 7. Problem/Conflict Management... 9 8. Pogram Requirements... 11 9. Health Examination... 12 10. Personal Health History... 13 11. Mid-Clinical Evaluation... 14 12. NP Student Clinical Evaluation... 15 13. NP Clinical Skills & Procedures Documentation... 17 14. Student Evaluation of Site & Preceptor... 19 2

3 1. Introduction Thismanualservesasaguidetoestablishguidelines,facilitatestudentroledevelopment, andprovidematerialsforusebyclinicalnursespecialist(cns)andnursepractitioner(np) studentsduringtheirclinicalpreceptorshipexperiences. 2. SelectionofClinicalPreceptorsandSites Developingaskilledpractitionerdependsuponbothacademiclearningintheclassroom andappropriateexperiencesinclinicalpractice.clinicalnursespecialistsandnurse practitionerwillberequiredtoidentifyandcontactpreceptors.asagraduatestudent, developingtheskillstopromoteyourselfareveryimportantandonewaytoenhancethis experienceistohavestudentsworktodeveloptheirclinicalpracticerelationships. Ultimatelystudentsaremorecomfortablewithsites,preceptors,andlocationsthatthey haveprocuredthansitesthatwecanprovide. Onceyouhaveidentifiedyourpotentialsiteandpreceptoryoushouldcontactthefaculty leadforyourcourse.pleaseprovidethemdetailedinformationaboutthesitesothatthey maydetermineitsappropriateness.onceapprovedbyyourcoursefacultyyouwillneedto contactbobbitowne.bobbitowneistheofficialcoordinatorforthegraduateprogram andwillworkwiththesitetoobtainanaffiliationagreementpermittingyoutodoyour clinicalhoursinthatfacilityandwiththatpreceptor.studentsshouldbegintheirsearchat least3monthspriortothedesiredclinicaldate.thiswillensureadequatetimetoevaluate theclinicalsite,ascertainpreceptorcredentialsandgathertheappropriateinformation neededtoformalizeacontractualagreementbetweentheuniversityandthefacilityifone doesnotalreadyexist. 3. TheStudent:ResponsibilitiesandAccountability Studentsentertheclinicalarenaformentoringandclinicalpreceptorshipwhentheyhave progressedtoaspecificpointintheireducatione.g.completedsciences,theoretical,and assessmentcourses.itisimportantforstudentstounderstandtheirrolesand responsibilitiesasastudent.whenassignedtoorselectingaclinicalsiteandpreceptor,the studentisexpectedtofulfillbasicrequirements.meetingtheclinicalrequirementswill assistthestudentinoptimizingthelearningexperience.withinthepartnershipsbetween thestudentandcoursefacultyandpreceptor,therearerolesthateachpartnermustfulfill. Clinical'Placement'RequestCompleteandsubmitclinicalplacementrequestformbythedate assigned.therequestformsareavailableontheprogramwebsite.itisveryimportantfor thestudenttoconsideranyrestrictionstheyneedtoplaceontheirclinical time/placements.forinstance,transportationconcerns,familyresponsibilities,specific days,andworkcommitmentsshouldallbeconsideredwhenselectingclinicalplacements. Minimally,studentsshouldexpecttospend4hoursperdayataclinicalsite.An8hour clinicaldayisthemosttypicalscenarioandmayencompassavarietyofclinicalcare,client rounds,procedures,homevisits,chartreviewsandotherexperiences.

Necessary'PaperworkAllstudentsareresponsibleforsubmittingupdatedhealthforms, immunizationrecords,cprcertification,nursinglicenses,criminalbackgroundchecksand otheritemsasrequiredbytheemuschoolofnursing.individualclinicalsitesmayalso havespecificrequirementsthatmustbemet.studentswillnotbeallowedtoparticipate inclinicalexperienceswithoutcompletionoftheappropriatepaperwork.students willberequiredtoverifythattheircertificationisgoodfortheentiresemester.ifanyofthe necessarypaperworkexpiresmidsemester,thestudentisexpectedtoupdatetheirrecords immediately. Preceptor'InterviewSomepreceptorsrequireaninterviewwiththestudentseeking placementwiththem.thepurposeoftheinterviewisto: 1.Providethepreceptorwithanunderstandingofthelevel,ability,andpersonality ofthestudent 2.Enablethepreceptortoassessifthestudentswouldbeagoodfitfortheclinical siteandthepopulationitserves. Typicalquestionsfromthepreceptormayinclude: 1. Whydoyouwantmeasapreceptor?Whatareyourexpectations?Whatareyour primaryclinicalobjectivesforthissemester? 2. WhydoyouwanttobeaCNSorNP?Whatareyourfuturegoals? 3. TellmewhataCNSorNPis?Howwillyouexplainthisroletoaclient? 4. Whatareyourstrengths/weakness? 5. Howdoyouhandlemistakes? 6. Howoftendoyouliketohavefeedback?Doyoupreferaformalevaluationor informalevaluation?doyouprefera wrap9up attheendofeveryday? 7. Whathoursdoyouexpecttobehere?Whendoyouwishtostart?Doyouhave certaindaysthatyouareavailable? 8. Alongwithprovidingprimarycare,Ialsocanprovideotherexperiencessuchas grandrounds,homevisits,etc.doyouwanttoparticipate? 9. Howlonghaveyoubeenanurse?Whattypesofpatientsdoyouprefertocare for? Scheduling'of'Clinical'Hours' Clinical'practicum'hours'are'to'be'scheduled'at'the'convenience'and'availability'of'the' preceptor.studentsare&not&to&ask&preceptorstoconformtoaschedulethatmeetstheir personalandemploymentneeds.thestudent spersonalandworkschedulesareexpected toaccommodateparticipationintherequirednumberofclinicalhoursprescribedbythe clinicalcourse.studentsandpreceptorsneedtoagreeonthedaysandtimesthatthe studentwillbeintheclinicalagencypriortobeginningthepracticumexperience.when determiningthehours,itiswisetoscheduleseveral contingency days.thesearedays thatcanbeusedas make9up timeintheeventthatthepreceptororstudentisunavailable i.e.,ill,theclinicisclosed,orweathereventsmaketravelhazardous.clinical'hours'must' be'completed'within'the'semester'that'students'are'registered.' 4

AttendancePerformanceofclinicalhoursatthenegotiatedtimesanddaywiththe preceptorisrequired.carefulattentiontoattendclinicalonthedayswhichthepreceptor canaccommodatethestudentisimportant.often,specificdaysoftheweekarechosenby thepreceptorduetoclientavailability,clientmix,ortheavailabilityofextraexamination rooms.itisthestudent sresponsibilitytomonitorthenumberofhourscompleted,and planoncompletingtherequiredhourswithinthesemester.thestudentisresponsiblefor adjustinghis/herpersonalandemploymentcommitmentssothattherequirednumberof clinicalhourscanbecompleted.ifthestudentdoesnotcompletetherequirednumberof clinicalhoursforthesemester,he/shecannotexpectthepreceptortocontinuethe preceptingrelationship.extensionoftheclinicalperiodwiththepreceptorcannotbe assumedbutisgrantedonlybyagreementwiththepreceptor,clinicalagencyand school/collegeofnursing.exceptionsrelatedtounexpectedillnessofthestudent/family andorpreceptorshouldbediscussedwithcoursefacultyandthepartiesinvolved. When'the'student'cannot'attend'clinical'on'a'day'that'is'scheduled,'the'preceptor'and' clinical'faculty'must'be'notified'immediately.thestudentshouldobtaincontact information(telephonenumberoremailaddress)fromthepreceptoranddiscussthe procedurefornotifyingthepreceptorandfacultyforunexpectedabsences.failuretonotify thepreceptorasnegotiated,priortothebeginningofthescheduledclinicaldayis unacceptableandmayplacethestudentandclinicalplacementinjeopardy.thestudent shouldpresentthefacultyandpreceptorwithaplantocompletethelostclinicaltime. Attire'and'Behavior'StudentsarerepresentativesoftheEasternMichiganUniversitySchool ofnursingandmustpresentthemselvesasambassadorsoftheirprograms.studentsare expectedtoberespectfultopreceptors,faculty,staff,patients,andtheirfamilies.reportsof unprofessionalbehaviorwillresultinthestudentbeingcounseledandpossiblysubjectto review.interactionswithclients,staff,otherhealthprovidersandstudentsarelearning opportunitiesforthestudenttorolemodelnursepractitionerexpertise.theclinical preceptorshipsaredesignedtoprovideadvancedpracticenursingexperiencesbutinthe earlysemestersofclinicalitisnotuncommonforstudentstofallbackintoacomfortable staffnurse role.studentsarehighlyencouragedtoobservetheirpreceptor sinteractions withsupportstaffandothersasitrelatestoapnpractice. StudentsshoulddressprofessionallyandcarrytheirEasternMichiganUniversitySchoolof Nursingidentificationbadgedenotingstatusasanursepractitionerstudent.Work identificationbadgesshouldnotbewornduringclinicalpreceptorships.someclinicalsites mayrequirethatlabcoatsorotherspecializedgarbareworninclientcareareas.students aretodiscusstheappropriatedressattirewiththeirpreceptorpriortothefirstclinical day. Clinical'ObjectivesItistheresponsibilityofthestudenttoconstructandprovidethe preceptorwithstudent9specificclinicalobjectivesfortheclinicalpracticum.thepreceptor isprovidedwithacopyofthecoursedescriptionandobjectivesinaletterthatdr.bumpus distributeswhenthepreceptorconfirmstheiragreementforstudentplacement.the 5

studentshouldreflectanddevelopindividuallearningobjectivesthatwillmeetand facilitatehis/herlearningneedsandpreviousclinicalnursingexperience(e.g.assessment ofabnormalheartsounds,skillsacquisition9clinicaluseofthemicroscopeorphlebotomy, suturing,etc.)thatarenotexplicitinthecourseorclinicalobjectives.guidelinesfor developingclinicalobjectivesinclude: 1.Thestudentwillwritespecificclinicalobjectivesaccordingtoindividuallearningneeds. TheseobjectivesshouldbediscussedwiththepreceptorEACHWEEK.Theobjectives shouldalsobesubmittedtotheclinicalfacultywhensoapnotesaresubmitted. 2.ExamplesofclinicalobjectivesincludeAPNskills,diagnosticreasoning,diagnostic labeling,interventions,evaluationmethods,andrecordaudits. 3.Clinicalobjectivesmustbemeasurableandevaluatedattheendoftheclinicalday. Writtenobjectivesdonotprovidelearningfeedbackunlessevaluationoccurs.Ifthe objectiveisnotcompleted,itmaybeusedinsubsequentclinicaldaysuntilitismet. 4.Clinicalobjectivesshouldreflectthelevelofcompetencythestudentwouldliketo achieveattheendofthepracticum,e.g.,minimalcompetency,proficient,etc. 5.Clinicalobjectivesshouldbecongruentwithandcomplementthecourseobjectives. 6.Amethodforevaluationofindividualobjectivesshouldbeplannedandcompleted. 7.Specificclinicalobjectivesshouldbesufficientlylimitedinnumbersothatappropriate attentioncanbedirectedtowardeach.typically293objectivesperclinicaldayisadequate. Preparation'for'Clinical'Practicum Theclinicalpracticumextendsthelearningenvironment oftheclassroomtointegratetheoreticalconceptswithclinicalpractice.studentsshould preparefortheclinicalpracticumbydevelopingindividuallearningobjectives,as previouslydiscussed.studentsshouldprepareforclinicalbyreadingcoursetextsand professionaljournals,andusingotheraudiovisualandelectroniclearningaidsas necessary.thepreceptormayrecommendadditionalmaterialsandtopicsforreviewprior tothefirstclinicalday.thestudentshouldreviewthecommonclinicalproblemsrelevant totheclinic spopulation.follow9upreadingofcurrentreferencematerialfollowingthe clinicaldayprovidesthestudentwiththeopportunitytoincreasethebreadthofscientific andclinicalknowledgefromthatgainedintheclinicalarena. Guidelines for clinical preparation 1.Studentsareexpectedtohavefullknowledgeofentrancerequirementsforclinical, includingcredentials,dress,location,timing,securityclearances,etc.,beforeschedulingthe firstclinicaldayattheagency. 2.Studentsareresponsiblefortheirownhealthrecordsandotherrequirements,suchas currentcprcertificationandimmunizations,inordertofulfilltheclinicalrequirementson 6

thefirstday.inaccordancewithschoolandagencypolicy,studentswithoutappropriate clearancewillnotbeallowedtoentertheclinicalsetting. 3.Wheneverpossible,discussionwithotherstudentswhohavethesameorsimilar placementsmaybebeneficial. 4.Onthefirstclinicalday,discussquestionsaboutcomputeraccess,theprocedurefor preceptorco9signingdocuments,eatingandparkingarrangements,andthecommunication withotherdisciplines. 5.Learnsomethingaboutthepreceptor,whenpossible,inordertoacknowledgethe preceptor sbackgroundandbroadenthestudent seducationalexperience. 4. ClinicalFacultyResponsibility Eachstudentwillhaveaclinicalfacultymemberassignedtothemforthedurationofthe semester.theroleoftheclinicalfacultyistofacilitatethestudent slearningviapersonal observationofthestudent sclinicalskillsandclinicalconferences.pairingofclinicalfaculty withastudentalsoprovidessensitivitytothestudent slifeexperiences,expertise,unique perspectives,learningpreferences,andcareergoals.theclinicalfacultyalsoactsasarole modelforthenumerousdimensionsofthenursepractitionerrole. Theclinicalfacultymemberisresponsibleforthecompletionofstudentsitevisits, assessingthestudent ssoapnotes,clinicalobjectivesandprogressionintheclinical sequence,communicationswiththepreceptorviatelephone,emailsoronsitevisits,andfor providingtimelyandconstructivefeedbacktothestudent.theclinicalfacultyalso communicatesregularlywiththecoursefacultyandtrackcoordinatorsregardingstudent progressandachievement. Studentsshouldcontacttheclinicalfacultyimmediatelyifconcernsariseabouttheclinical preceptorshipexperienceortheirabilitytosuccessfullyadheretotheoriginalagreements madewiththepreceptor.also,thestudentshouldseekadvicefromtheclinicalfaculty shouldchallengesoccurattheclinicalsitethatthestudentcannotreasonablyresolvedon theirown. Theclinicalfacultywillhaveamidtermandfinalconferencewitheachstudenttoreview academic/clinicalprogress,setobjectivesfortheremainingorupcomingsemester,and provideconstructivefeedback. 5. DocumentationoftheClinicalEncounter 7

Eachclinicalencounterperformedbythestudentmustbedocumentedintheclient s record.documentationshouldbeconsistentwithcurrentbillingandcodingguidelinesand adheretothecurrentnationalandfacilitystandardsofcare.typically,soapnotesarethe preferredformatofdocumentationusingpaper,electronic,digitalortapedmethods. However,manyagenciesnowhavetemplates,checksheetsandotherformatstodocument theclinicalencounter.beforesubmittingsoapnotesforreviewbytheclinicalfaculty, thestudentishighlyencouragedtodiscusstheformat/method. AllSOAPnotesmustbecoLsignedbythepreceptor.Itishighlyencouragedthatthe preceptorsdomorethansimplysignthenote.manyfacilitiesnowhavestipulations regardingthemeaningi.e.,legalandreimbursementdesignations,ofapreceptorsignature andhavedevelopedtheirownpoliciesonco9signing.followingaresomesuggested wordingthatmaybeusediftheagencydoesnothaveguidelinesinplace. Agreewiththeabove.Signed. Agreewiththeabove.Alsoinclude9999999.Signed. Agreewiththeabovedocumentation.Presentduringvisit.Signed. Ihavereviewedthehistoryandphysicalfindingsandrepeatedpertinentphysicalexam elementsnecessarytodevelopthediagnosisandplansigned. Allclientvisitsmustalsoberecordedintheelectronicclinicallog(ProjectConcert).Thislog isusedtodocumentthebreadthanddepthofthestudent sclinicalexperiences.the clinical,courseandprogramfacultyalsousethelogasatooltoassessandevaluatethe appropriatenessofclinicalplacementandtheincreasingindependenceofthestudent s clinicalskills.thesummativedatafromthelogwillbeusedinthestudent scareer portfoliothatisdevelopedinthefinalsemesterofcoursework. 6. TheClinicalSiteVisit Clinicalsitevisitsarecompletedatdesignatedintervalsthroughoutthestudent sprogram ofstudy.thesitevisitfacilitatestheclinicalfaculty sunderstandingofstudentprogressvia directobservationoftheirclinicalskills,enablesthestudenttodemonstratetheirexpertise andtoconferencewiththeirclinicalfacultymember,andallowsthepreceptortoshare theirexperiencesregardingthestudent saccomplishmentandtheirpreceptingwiththe clinicalfaculty.thememberoftheteamplaysanimportantroleinasuccessfulsitevisitas notedbelow. The'student'is'responsible'for: 1.Coordinatingthedateofthesitevisitwiththeclinicalfacultymember,providing importantcontactnumbersthatcanbeusedwhilethefacultymemberisenroutetothesite shouldsomethingoccur,andconfirmingthesitevisitonedaypriortotheevent. 2.Ascertainingwiththepreceptorthatclient swillbeavailablethedayofthesitevisitand selectingseveralthatcanbeseenbythestudent. 8

3.Introducingthefacultymembertothepreceptorandsupportstaff,providinga tour of thefacilityifappropriate,discussingchartingprocedures,andhowclientsareselectedfor thestudent. 4.Remindingthepreceptorthattheclinicalfacultywillbearrivingforasitevisitandthat thefacultywillneedseveralminutesoftheirtimetodiscussthestudent sprogress. The'clinical'faculty'is'responsible'for:'' 1. Observingthestudentduring2clinicalencounters.Thiswillincludeobservingoral summariesgiventothepreceptorandanysubsequentclientmanagement. 2. Observingthestudent sinteractionswiththeenvironsofthesite:preceptor,clinical staff,supportstaff,clientsandtheirsupportpersons,useoftechnologyatthesiteand others. 3. Conferencingwiththepreceptorregardingthestudent sabilitiesandprogress,learning goalsandsuggestedchanges. 4. Providingconstructivefeedbackregardingtheencountersandthewholeofthesitevisit aswellasmakingrecommendationstofacilitateclinicalexpertise. 5. Completingthesitevisitevaluationandsharingtheresultswiththestudent. The'preceptor'is'responsible'for:'' 1. Providingappropriatesitevisitclientsforthestudents. 2. Providingfeedbacktothestudentandtheclinicalfacultyregardingthestudent s experiencesandabilitiesatthesite. 3. Providingfeedbackonthestudent sdocumentationofclientvisits,attendance, professionalism,andothercomponentsofthenursepractitionerrole. 4. Completionoftheappropriatestudentevaluationsforclinical. Thesitevisitdayshouldbeconductedasanormalclinicaldayforboththestudentandthe preceptor.althoughthestudentisusuallynervousattheprospectofbeingobserved,the facultyandpreceptorarewellawareofthisandtrytoplacethestudentatease.also,itis importantthattheclinicalfacultyobservetheflowoftheclinicatlarge,theinteractionof thestaffwiththevariouscareproviders,theclientmixandthestudent sinteractions withinallofthesearenas.thisassistsinnotonlyevaluatingthestudentbutascertaining theappropriatenessoftheclinicalsiteforthecurrentand/orfuturestudents. 7.Problem/ConflictManagement 9

Thepotentialforconflictanddisagreementininterpersonalrelationshipsiscommonand shouldbeanticipated.intheclinicalsetting,preceptorsareunderpressuretobe productivewhichmayconstraintimethatcanbefullydevotedtoteaching.otherfactors, suchaslevel,ability,communicationstyleandmotivationofthestudentcoupledwiththe uniquenessofthepreceptor sclientloadcanprovidefertilegroundforconflict.itisthe student s,preceptor sandfacultyresponsibilitytousetheappropriateresourcesfor problem9solvingwhileoptimizinglearningexperiences. Examplesofpotentialconflictsituationsinclude: 1.Placementofastudentwithpreceptorwithaconflictofinterestthatispersonal,family relatedorviajoballiances. 2.Culturaldifferencesbetweenthestudentandpreceptorincommunicationtoclientsand otherproviders. 3.Inappropriatematchingofstudentcompetencelevelwithpreceptorexpectations. 4.Inexperienceofpreceptorincopingwithstudent sunacceptablebehaviors. Preceptorisnotprovidingexpectedlevelofmentorshiporclinicalcare. Interventionstrategiesforconflictresolutionaredependentupontheurgencyofthe matter.ininstanceswhereanimmediateresponseisneeded,theclinicalfacultyshouldbe notifiedfirst.ifthereisnoresponse,thennotificationofeitherthecoursefacultyand/or programcoordinatorshouldbedoneimmediately. 10

EasternMichiganUniversity SchoolofNursing ProgramRequirements AllstudentsmustprovidethefollowinginformationtotheSchoolofNursingOffice,311Marshall.Please sendtobobbitowne,coordinatorat734948796949(fax)oremailtortowne1@emich.edu. CPR PersonalHealth Insurance ProfessionalLiability Insurance Optional 1.Areportofcurrentphysicalexamination(formenclosed) 2.Completionofimmunizationrecord(formenclosed)thatprovidesproofof immunity(evidencedbytiter)orimmunizationforthefollowing: a.rubella b.rubeola c.mumps d.varicellazoster (*Historyofanyoftheabovediseasesisnotsufficientproofofimmunity) 3.Proofoftetanusvaccinationwithinthepastfiveyears. 4.ProofofhavingatleastthefirstofthreeHepatitis9Binjectionsorapositivetite titerresultorsubmissionofasigneddeclinationform(enclosed). 5.AnnualdocumentationthatthestudentisfreefromTuberculosis. FreedomfromTBisevidencedby:1)negativeTBskintest,2)current negativechestx9ray,or3)negativechestx9rayinthepastwithcurrent documentationbyhealthcareproviderthatstudentisfreefromtb **A7paneldrugscreenwillberequiredbysomeaffiliatedclinicalagencies. DocumentationofcurrentAdult,Child,Infant,TwoPersonCPRcertification fortheprofessionalrescuer. ProofofPersonalHealthInsuranceisrequired. ProofofProfessionalLiabilityInsurance(1,000,000eachincident3,000,000 aggregate)isoptional.youcancontactthenursingserviceorganization (www.nso.com),marshaffinitygroup(www.proliability.com)oranyother nursingliabilityinsuranceprovider. CriminalBackgroundCheck:Formattached.Youmustorderandpayforthis.Accessthewebsite: www.myvci.com/emuandthecostis$30.oo NursingLicense:Copyofunexpired,non9restrictednursinglicense. NOSTUDENTWILLBEABLETOBEGINCLINICALCONTACTHOURSWITHOUTMEETINGTHESE REQUIREMENTS Ihaveread,understand,andagreetotheaboveEMUprogramrequirements.Ihavemadeapersonalcopyof theserequirementsformyownreference.failuretocompletetheseprogramrequirementswillresultinmy notbeingabletoattendclinicalnursingcourses. StudentSignature PrintedStudentName Date 11

EASTERNMICHIGANUNIVERSITY HEALTHEXAMINATION **TOBECOMPLETEDBYMD,NURSEPRACITIONER,ORPHYSICIAN SASSISTANT** Name Last First Middle Date 1.Explainanysignificantfamilyorpersonalhistory: 2.Height BloodPressure Hb Weight Pulse Urinalysis Alb. Sugar 3.Pleasecompletethefollowingbyindicatingnormalwithacheck.Explainabnormalfindings: A. Vision VisualAcuity:Right20/ Left20/ B.Hearing C.Eye,Ear,Nose,Throat D.Neck,Thyroid E.Heart F.Lungs G.Breasts H.Abdomen,Hernia I.NervousSystem JBoneandJoint K.Genito9Urinary L.Skin 4.Immunizationgiven:(Datesrequiredorneedtogetimmunization/titer) *Note:Studentswillbeunablegotoclinicalsiteswithoutdatesgivenortiters. TetanusToxoid Date1 Date2 Tdap RubeolaVac. Date1 Date2 TiterResult MumpsVac. Date1 Date2 TiterResult VaricellaZoster Date1 Date2 TiterResult RubellaVac. Date1 Date2 TiterResult *Rubellavaccinemustbeafter1969orwillneedRubellatiterasproofofimmunity HepatitisBVac. Threeshot series: Date1 Date2 Date3 *IfstudentdeclinesHepatitisB.Vac.pleasedocumentdeclination,andhavestudentsignaswell. TuberculinSkinTest: Date Positive Negative *Ifskintestis positive,thenchestx9rayisrequired. ChestX9ray: Date Positive Negative 5.Isstudentcapableofregularphysicalactivity? Ifnot,pleaseexplain: 6.Summaryoffindings: HealthCareProvider(M.D.,NursePractitioner,Physician sassistant),pleasesignanddate: Name Signature Pleaseprint Address Date 12

EASTERNMICHIGANUNIVERSITY SchoolofNursing Thissidetobecompletedbystudents: I. Enrollmentfor Student# Semesteryear II. Name Last First Middle Address Street City State Zip III. Age Birthday PERSONTOBENOTIFIEDINCASEOFEMERGENCY: Address Name Phone Relationship PersonalHistory: HaveyoulivedwithorbeenincontactwithanyonehavingTuberculosisinthepasttwoyears? Ifyes,pleaseexplain: Doyouhave/haveyoueverhad: RheumaticFever Tuberculosis ScarletFever KidneyInfection HeartDisease Convulsions Diabetes PersistentorMigraine Headaches Asthma HighBloodPressure HayFever Anemia Pneumonia ThyroidTrouble MentalIllness Ulcers Ifyes,pleaseexplain: PastImmunizations: (Alsosee#4 Polio Date onotherside) Smallpox Date Diphtheria Date Haveyoueverbeenhospitalized? Forwhatandwhen? Doyouhaveanyallergies? Ifso,specify: Areyouallergictoanydrugs? Ifso,specify: Doyouhaveanyphysicalimpairment? Ifyes,pleasespecify: **Student ssignature 13

Eastern(Michigan(University( Mid2Clinical(&(Site(Evaluation( PrimaryCareAdult/GerontologyNursePractitionerProgram Student Course Term Preceptor Site Pleasecircletheappropriateresponsetoeachofthestatements. SA(=(Strongly(Agree((((((((((A(=(Agree((((((((((D(=(Disagree((((((((((SD(=(Strongly(Disagree( NO=Not(Observed( 1. Historytakingskillsarewelldeveloped. SA( A( D( SD( NO( 2. Physicalexamskillsarewelldeveloped. SA( A( D( SD( NO( 3. Collecteddataispresentedinacompleteand organizedmanner. 4. Managementofcommonacuteproblemsis appropriateforpatientneedsandstudentlevel ofpreparation. 5. Consistentlyaddresshealthpromotionissuestoage andgender. SA( A( D( SD( NO( SA( A( D( SD( NO( SA( A( D( SD( NO( 6. Patientteachingiswelldone. SA( A( D( SD( NO( 7. Agoodworkingrelationshipwithpatientsis developed. SA( A( D( SD( NO( StudentStrengths: StudentLimitations: OtherComments: Preceptor/FacultySignature&Date: (circleone) StudentSignature&Date: Please&Return&to:SherryBumpus,EasternMichiganUniversity,340MarshallBuilding,Ypsilanti,MI48197;sherry.bumpus@emich.edu;office: 734I487I2279;Fax734I487I6946

NP Student Clinical Evaluation Student s Name: # of Hours Completed: Preceptor s Name: Course Title & #: COMPETENCY AREA: Scientific Foundation 1. Critically analyzes data and evidence for improving advanced nursing practice. 2. Integrates knowledge from the humanities and sciences within the context of nursing science. 3. Translates research and other forms of knowledge to improve practice processes and outcomes. 4. Develops new practice approaches based on the integration of research, theory, and practice knowledge. COMPETENCY AREA: Leadership 1. Assumes complex and advanced leadership roles to initiate and guide change. CONSIDERABLE CONSIDERABLE Fairly CONSISTENT in meeting Fairly CONSISTENT in meeting CONSISTENT & Self directed in meeting CONSISTENT & Self directed in meeting 2. Provides leadership to foster collaboration with multiple stakeholders (e.g., patients, community, integrated health care teams,and policy makers) to improve health care. 3. Demonstrates leadership that uses critical and reflective thinking. 4. Advocates for improved access, quality, and cost effective health care. 5. Advances practice through the development and implementation of innovations incorporating principles of change. 6. Communicates practice knowledge effectively both orally and in writing. 7. Participates in professional organizations and activities that influence advanced practice nursing and/or health outcomes of a population focus. COMPETENCY AREA: Quality 1. Uses best available evidence to continuously improve quality of clinical practice. 2. Evaluates the relationships among access, cost, quality, and safety and their influence on health care. 3. Evaluates how organizational structure, care processes, financing, marketing and policy decisions impact quality of health care. 4. Applies skills in peer review to promote a culture of excellence. 5. Anticipates variations in practice and is proactive in implementing interventions to ensure quality. COMPETENCY AREA: Practice Inquiry 1. Provides leadership in the translation of new knowledge into practice. 2. Generates knowledge from clinical practice to improve practice and patient outcomes. 3. Applies clinical investigative skills to improve health outcomes. 4. Leads practice inquiry, individually or in partnership with others. CONSIDERABLE CONSIDERABLE Fairly CONSISTENT in meeting Fairly CONSISTENT in meeting CONSISTENT & Self directed in meeting CONSISTENT & Self directed in meeting 5. Disseminates evidence from inquiry to diverse audiences using multiple modalities. 6. Analyzes clinical guidelines for individualized application into practice. COMPETENCY AREA: Technology and Information Literacy 1. Integrates appropriate technologies for knowledge management to improve health care. 2. Translates technical and scientific health information appropriate for various users needs. CONSIDERABLE Fairly CONSISTENT in meeting CONSISTENT & Self directed in meeting 2a. Assesses the patient s and caregiver s educational needs to provide effective, personalized health care. 2b. Coaches the patient and caregiver for positive behavioral change. 3. Demonstrates information literacy skills in complex decision making. 4. Contributes to the design of clinical information systems that promote safe, quality, and cost effective care. 5. Uses technology systems that capture data on variables for the evaluation of nursing care.

COMPETENCY AREA: Policy 1. Demonstrates an understanding of the interdependence of policy and practice. 2. Advocates for ethical policies that promote access, equity, quality, and cost. 3. Analyzes ethical, legal, and social factors influencing policy development. 4. Contributes in the development of health policy. 5. Analyzes the implications of health policy across disciplines. 6. Evaluates the impact of globalization on health care policy development. COMPETENCY AREA: Health Delivery Systems 1. Applies knowledge of organizational practices and complex systems to improve health care delivery. 2. Effects health care change using broad based skills including negotiating, consensus-building, and partnering. 3. Minimizes risk to patient and providers at the individual and systems level. 4. Facilitates the development of health care systems that address the needs of culturally diverse populations, providers, and other stakeholders. 5. Evaluates the impact of health care delivery on patients, providers, other stakeholders, and the environment. 6. Analyzes organizational structure, functions, and resources to improve the delivery of care. 7. Collaborates in planning for transitions across the continuum of care. COMPETENCY AREA: Ethics 1. Integrates ethical principles in decision making. 2. Evaluates the ethical consequences of decisions. 3. Applies ethically sound solutions to complex issues related to individuals, populations, and systems of care. COMPETENCY AREA: Independent Practice 1. Functions as a licensed independent practitioner. 2. Demonstrates the highest level of accountability for professional practice/ 3. Practices independently managing previously diagnosed and undiagnosed patients. 3a. Provides the full spectrum of health care services to include health promotion, disease prevention, health protection, anticipatory guidance, counseling, disease management, palliative and end of life care. 3b. Uses advanced health assessment skills to differentiate between normal, variations of normal and abnormal findings. 3c. Employs screening and diagnostic strategies in the development of diagnoses. 3d. Prescribes medications within the scope of practice. 3e. Manages the health/illness status of patients and families over time. 4. Provides patient-centered care recognizing cultural diversity and the patient or designee as a full partner in decision making. 4a. Works to establish a relationship with the patient characterized by mutual respect, empathy, and collaboration. 4b. Creates a climate of patient-centered care to include confidentiality, privacy, comfort, emotional support, mutual trust, and respect. 4c. Incorporates the patient s cultural and spiritual preferences, values, and beliefs into health care. 4d. Preserves the patient s control over decision making by negotiating a mutually acceptable plan of care. Student Strengths: CONSIDERABLE CONSIDERABLE CONSIDERABLE CONSIDERABLE Fairly CONSISTENT in meeting Fairly CONSISTENT in meeting Fairly CONSISTENT in meeting Fairly CONSISTENT in meeting Areas for development/improvement: CONSISTENT & Self directed in meeting CONSISTENT & Self directed in meeting CONSISTENT & Self directed in meeting CONSISTENT & Self directed in meeting Preceptor s Signature/Date : Student Signature/Date: Please Return to: Sherry Bumpus, Eastern Michigan University, 340 Marshall Building, Ypsilanti, MI 48197; sherry.bumpus@emich.edu; office: 734-487-2279; Fax 734-487-6946

NP CLINICAL SKILLS & PROCEDURES CHECKLIST* NAME: # 1. PROCEDURE (e.g. suturing) CONFIDENT & INDEPENDENT FAIRLY CONFIDENT MINIMAL SUPERVISION NEEDED SKILL LEVEL SUPERVISION NEEDED PERFORMED ONCE & WITH SUPERVISION NEVER PERFORMED OR NOT APPLICABLE PRECEPTOR SIGNATURE & DATE (PROCEDURE AND SKILL LEVEL TO BE SIGNED OFF BY PRECEPTOR WHEN COMPLETED) 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. *Checklist should be customized by each NP program and can be continued after the student enters advanced practice to document newly acquired expertise.

NAME: # PROCEDURE 16. CONFIDENT & INDEPENDENT FAIRLY CONFIDENT MINIMAL SUPERVISION NEEDED SKILL LEVEL SUPERVISION NEEDED PERFORMED ONCE & WITH SUPERVISION NEVER PERFORMED OR NOT APPLICABLE PRECEPTOR SIGNATURE & DATE (PROCEDURE AND SKILL LEVEL TO BE SIGNED OFF BY PRECEPTOR WHEN COMPLETED) 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. *Checklist should be customized by each NP program and can be continued after the student enters advanced practice to document newly acquired expertise. Please Return to: Sherry Bumpus, Eastern Michigan University, 340 Marshall Building, Ypsilanti, MI 48197; sherry.bumpus@emich.edu; office: 734-487-2279; Fax 734-487-6946

STUDENT EVALUATION OF CLINICAL PRACTICUM and SITE INSTRUCTIONS: Please evaluate your clinical practicum site for this semester. Answer each statement by circling the number that most accurately reflects your evaluation of the clinical practicum. Please use the scale defined below: 1 = Strongly Disagree 3 = Neither disagree or agree, or not applicable 5 = Strongly Agree 2 = Disagree 4 = Agree 1. The clinical site provided adequate practice opportunities for growth as an advanced practice nurse. 2. This clinical site has resources to support a student practicum. 3. This clinical site has procedure and protocol manuals, educational materials, and personnel to adequately support a student in advanced practice nursing. 4. I was able to use a theoretical model to guide my practice in the clinical site with little or no difficulty. 5. The clinical preceptor was sensitive to my need for guidance. 6. The clinical preceptor was able to allow for latitude for my developing autonomy. 7. I was stimulated by the clinical preceptor to confront new problems and situations to prepare me for advanced practice. 8. The clinical site director, preceptor (circle one) assisted me to fulfill the objectives of the course of study for which this clinical practicum was organized. 9. The clinical site personnel did not utilize my services as a worker except as contracted in my clinical contract. 10. I was evaluated fairly and objectively by my clinical preceptor. 11. I would recommend this preceptor to my peers for practicum experience. 12. I would recommend this clinical site to my peers for practicum experience. 13. Patients are variable in age, diagnoses, and numbers. 14. Diagnostic test results are readily accessible. 15. The philosophy of the personnel was directed toward quality care, health promotion, and disease prevention. 16. Opportunities were readily available for my participation in management of care for patients. 17. My overall evaluation of this clinical practicum site is: (Indicate as below) Excellent (5) Good (4) Fair (3) Poor (2) Would not recommend (1) Name of Clinical Preceptor : Name of Student: Faculty: Name of Clinical Site: Dates Date: FOR COMMENTS, PLEASE USE ADDITIONAL PAGE Please Return to: Sherry Bumpus, Eastern Michigan University, 340 Marshall Building, Ypsilanti, MI 48197; sherry.bumpus@emich.edu; office: 734-487-2279; Fax 734-487-6946