BACHELOR R OFF SCIENCEE IN

N NURSINGG PROGRAM M
CLINICALL ASSESSMENTT OFF STUDENTT ABILITIESS
NURSS 3009
9 CLINICALL PRACTICUM:: Mental,, Chronicc orr Rehab
b Health
h Challenges

Name of Student: Carley Mayer Unit/Agency: Trenton Hospital

Student ID: 500094271 Clinical Hours: 144 Hours Absent: 0
Date of Experience: September 2023-October 2023 Lab Hours: 0 Hours Absent: 0

NOTE: THIS CLINICAL ASSESSMENT OF STUDENT ABILITIES IS TO BE USED IN CONJUNCTION WITH THE COURSE
DOCUMENTATION FOR CLINICAL PRACTICUM: MENTAL, CHRONIC OR REHAB HEALTH CHALLENGES.

FITNESS TO PRACTICE: THE STUDENT MUST DEMONSTRATE FITNESS TO PRACTICE IN ALL INTERACTIONS IN THE
CLINICAL SETTING.

Areas of Strength Identified by Student: Patient empathy, teamwork with other students, adaptability

Areas for Future Development Identified by Student: Confidence in Assessments and Getting started with new tasks.

Faculty Comments/Critical Incidents: This nursing student initially had self-doubts, but her confidence and competencies have
grown effectively. Despite a tendency to overthink, she shows impressive adaptability in practice. Her collaboration with
experienced nurses is excellent, highlighting both her team spirit and her increasing proficiency in practical skills. Her progress
indicates promising future potential in nursing- Alex Watson R.N.

Course Learning Outcome Midterm Student Self- Final Student Self- Faculty Feedback Pass Fail
Assessment Assessment
1. Integrates relevant data, I presented my nursing Your consistent Monday
I have completed patient PASS
preparations highlight a
information, and knowledge research each Monday of education care plan to my dedication to comprehensive
from multiple sources to placement, using patient on October 11th . patient care. Drawing from
formulate safe and culturally This plan was created by various resources and directly
information from the involving the patient in care
competent nursing care plans medical surgical textbook, speaking to the patient to decisions, such as offering their
for clients and their families. medi tech system, and the determine their needs and preferred drink to meet health
wants. It used peer- goals, exemplifies a thoughtful
patient to prepare for the reviewed journals, blend of evidence-based and
patient-centered care. Your
clinical shift. This research textbooks and patient approach aligns perfectly with the
allows me to plan nursing research/history goal of integrating diverse
interventions such as insights to craft culturally
information. sensitive care plans.
increased movement,
increased fluids or Your nursing education care plan
presentation on October 11th
providing hygiene care with exemplifies a patient-centered
patient feedback, implement approach. By actively involving
the patient in determining their
this during clinical and needs and utilizing peer-reviewed
evaluate the effectiveness. I journals, textbooks, and patient
applied the nursing research, you ensured a
comprehensive and culturally
intervention of increased competent plan.
fluids on September 26th by
giving coffee x3, the
patient's preferred drink, to
my patient who needed to
increase their fluids.
I completed patient research
before working with my
assigned patient each week.
I used my mental health
textbook (Varcarolis's
Canadian Psychiatric
Mental Health Nursing, 3rd
Edition), Information in the
 Meditech system, Nanda
nursing diagnosis,
motivational interviewing in
healthcare and knowledge
from Mental Health class.
Using this research, I was
able to begin to prepare a
health teaching plan.
2. Utilize data, knowledge, I have begun my Learning In creating my nursing Your initiative in the Learning PASS
Plan and thorough assessments
and skills from year 1 and Plan, which requires patient education plan, I highlight a strong application of
year 2 when assessing, completing patient pulled in data from years your year 1 and year 2
planning, implementing, and one and two to complete knowledge. The ability to spot,
assessments. I completed a report, and reflect on abnormal
evaluating nursing care. head-to-toe assessment on bedside head-to-toe findings showcases your
September 26th and a head- assessments, take vital dedication to continuous growth.
signs, and implement a
neck and throat-focused Impressive work in creating a
range of motion exercise nursing patient education plan by
evaluation on September with my patient. To utilizing data, knowledge, and
27th. This required patient implement this plan, I was skills from year one and year two.
consent, and knowledge of Your approach, from assessment
required to assess my to evaluation, showcases your
each of the body systems patient, plan my teaching proficiency in providing
learned in year one, based on assessment and comprehensive care.
knowledge of abnormal patient interest, implement
findings from year two to my plan, gather patient
evaluate the findings, and feedback and reflect on
the ability to advise the on- and evaluate my plan.
shift nurse of abnormal
findings so required actions
could be taken. After the
assessment, I self-reflected,
considering what parts went
well and what to improve
for the next assessment.
 During shifts, when
speaking with my patients, I
have been able to practise
gathering and applying
information from the patient
to assist in nursing care.
This includes
recommendations for peer
support groups, providing
therapeutic 1:1
communication, and
discussions surrounding
journaling. Unfortunately,
there have been limited
follow-ups due to frequent
discharge. However,
patients have reported being
willing to try the suggested
interventions.

I have also begun a health

teaching plan for a patient
on the mental health unit by
using patient research and
knowledge. I will
implement, evaluate, and
follow up once the plan is
completed and placed.
3. Demonstrates effective I documented nursing notes I documented nursing Your consistent documentation in PASS
the Meditech system and
written communication, by and patient assessments on notes and patient receptiveness to peer feedback
documenting in a clear, Sept 19, 20, 26, and 27 in assessments on Oct 10,11 highlight your dedication to clear
concise timely manner and and 17 in the Meditech and concise written
the Meditech system. I
communication. Engaging with
comprehensive manner while asked for peer feedback on system. I ensured to the PSW to broaden your
adhering to documentation September 19th and document at least every documentation scope further
standards specific to practice two hours on my patients. demonstrates adaptability and
improved my nursing notes commitment to meeting practice
setting. based on this feedback to On October 12th, I also standards. Well done on
improve conciseness. I documented care for upholding and enhancing your
another patient I cared for. documentation skills.
spoke with the PSW on I reviewed the Health Your diligent documentation
September 27th, who taught Assessment Lab efforts, including nursing notes
me another place to documentation on October and patient assessments,
document in the chart and demonstrate effective written
12th to ensure communication. Maintaining
also documented there. comprehensive and regular updates every two hours
concise practice charting on your patients showcases your
commitment to clear, concise, and
I completed nursing notes and consider suggested timely charting. Additionally,
on November 1,8,14, and improvements. your proactive review of
documentation standards in the
15th in the FAIO format. Health Assessment Lab on
My clinical instructor October 12th highlights your
reviewed these entries, and I dedication to comprehensive and
concise practice charting.
actively implemented the
feedback to enhance their
quality and
comprehensiveness.

4. Uses elements of effective I provided oral teaching to On October 12th , when I Your proactive oral teaching on PASS
safe footwear effectively
oral communication to my patient on September presented my education resonated with your patient,
enhance client, family 20th regarding safe care plan to my patient, I emphasizing your skill in clear,
learning while integrating educated the patient about timely, and developmentally
footwear and the importance appropriate communication. The
appropriate educational aids; of grips on socks or slippers adding sodium to their patient's response and actions
appropriately provides to reduce fall risk. The meal. I also provided a validate the effectiveness of your
informal teaching in a timely handout, which we approach.
patient thanked me and
manner and at a completed to show Impressive work in presenting
repeated the importance of movements to assist with your education care plan on
wearing the slippers, then
developmentally and physical activity and range October 12th. Your approach of
asked for assistance in
educating the patient about
culturally appropriate level. adding them to their socks of motion. To achieve this sodium intake and providing a
to reduce the chance of teaching, I kept the session handout with physical activity
short and at my patient's tips is commendable. Keeping the
falling. The patient response session short and at the patient's
indicated their level. I also performed level, along with ongoing
understanding of my ongoing patient assessments, demonstrates your
assessments in the commitment to effective
teaching and appeared planning and reflection communication and patient-
centered teaching
acceptable to the stages of the healthcare
educational level of my teaching plan.
patient.
I have applied principles of
motivational interviewing in
my patient interactions, such
as open-ended questions,
active listening statements,
affirmations, and
summarization. These
strategies enabled me to
engage meaningfully with
patients, understanding their
preferences and abilities. As
a result, I was able to
recommend beneficial
interventions like guided
journaling and peer support.

5. Use data, knowledge and I have gathered information I used the RNAO best Drawing from textbooks, RNAO PASS
guidelines, and patient feedback,
information from multiple from my pathophysiology, practice guidelines for you've effectively tailored
sources including best pharmacology textbooks, facilitating client-centred interventions for patient care.
practice guidelines, to care to prepare for my Your eagerness to understand
and the RNAO bladder and
formulate a safe and client assessment. Using even beyond your current scope
bowel management
displays thoroughness. Your
culturally sensitive guidelines and patient input the guide, I made notes approach is a testament to crafting
individualized plan of care to implement nursing about assessing my evidence-based, individualized
for assigned clients and patient's interests, face-to- care.
interventions surrounding
families, and articulate fluid intake and bowel face interviewing and
Great job incorporating diverse
rationale for chosen nursing movement implications providing a pictorial aid, sources, including RNAO best
interventions. as the RNOA states that practice guidelines, for your client
from constipation that can this improves learning. I assessment preparation. Your
worsen in the hospital. could implement a safe
patient-centered approach,
including assessing interests and
Using this information and and individualized plan for using face-to-face interviews and
my current scope of my patient using this pictorial aids, ensures safe and
individualized care planning.
practice, I applied the information, along with Your use of various sources like
nursing intervention of the American Heart the American Heart Association,
encouraging movement and Association, Government government resources, and peer-
reviewed journals reflects your
increasing fluids to assist resources and a peer- commitment to evidence-based
with regular bowel reviewed journal. and culturally sensitive care.
movements. While not
implemented due to my
current scope of practice, I
also gained knowledge of
bowel protocols used in
hospital.
I have used multiple
sources, including
Varcarolis's Canadian
Psychiatric Mental Health
Nursing, Mediech, Nanda,
Motivational Interviewing
in healthcare, and the best
practice guidelines to begin
a nursing care plan to be
implemented with my
 patient. I have also used the
Assessment and Care of
Adults at Risk for Suicidal
Ideation and Behaviour Best
Practice RNAO guidelines
to assist in planning and
implementing conversations
with patients who may be at
risk for suicide.
6. Critically analyze and While on placement On October 12th, I was Your adaptability on September PASS
26th stands out. Observing
evaluate different nursing September 26th I attempted present when a nurse alternative methods and adjusting
approaches and modify the to provide care and was requested information your approach based on patient
plan of care, accordingly, from the patient. The nurse response showcases a patient-
refused by the patient. Later, centered mindset and the essence
based on evaluation of I observed care that was asked about their home of critical analysis in nursing.
client’s response to previous life, support and Your willingness to modify care
delivered in a way that plans based on feedback
interventions. medications. This was
differed from my approach highlights both flexibility and
helpful to watch as they commitment to improvement.
and was successful. My seemed to be asking in a
patient responded well to manner that was focused Your observation of the nurse's
this care method, and I later approach on October 12th
on building their provides valuable insights into
attempted to implement this therapeutic relationship. therapeutic relationship-building.
strategy when caring for that This nurse chose to self- The nurse's empathetic and
patient-centered approach,
specific patient. disclose a small amount of including self-disclosure,
personal information to improved the rapport. This trust
relate with the patient, to resulted in the patient seeking
During my clinical on referrals for discharge resources,
November 7th, I had the which the patient showing the effectiveness of the
opportunity to shadow my responded well and nurse's approach. Your ability to
seemed to improve the analyze and evaluate this nursing
clinical instructor as they approach reflects your
relationship. Later that understanding of the importance
conducted a Mental Status
day, the patient asked the of building trust in patient careǤ
Exam with a patient. nurse for some referrals to
Witnessing this interaction resources for discharge
gave me insights into that had not been
 interpreting patient requested previously. This
responses and acquiring seemed to directly result
questioning techniques for from the patient trusting
sensitive topics. the nurse because of the
formed relationship.
From this experience, I
completed my own Mental
Status Exam. I Integrated
the observed skills and
adopted some questioning
approaches from the
observed example. This
experience allowed me to
analyze and adapt learned
techniques. It enabled me to
apply them effectively in a
practical setting.
7. Use CNO’s Professional I respected clients' rights to I maintained public Your practices align seamlessly PASS
with the CNO’s Professional
Standards and Code of make choices in their care confidence in nursing by Standards. Respecting patient
Conduct to demonstrate by allowing my patients to completing reflections on choices, embracing cultural
behaviours that enhance time and reflecting on humility, and proactively
choose between hospital ensuring safety highlight your
professional identity and gowns when assisting them situations that were helpful patient-centered care.
accountability and assume a for my learning. I also Collaborating with team members
in changing into a new and displaying accountability in
leadership role to enrich reported when I made an
gown. I practised cultural your actions underline your
professional relationships error charting the incorrect
humility when listening to professionalism and leadership.
with members of the health chart to the patient's nurse
care team. my patient about their and my clinical instructor, Your commitment to upholding
history; they shared where who guided me through public confidence in nursing is
commendable. Timely reflections
they grew up, their religious correcting the error. I and reporting errors demonstrate
practices and personal worked respectfully with your accountability and
information about who they the healthcare team when dedication to learning. Working
respectfully with the healthcare
are. I provided safe and the patient's doctor spoke
 to me and another nurse team, whether with doctors or
competent care within my
experienced nurses, reflects your
scope of practice when my about their plans to professionalism and leadership
patient was cold by taking increase levels of role within the team. Keep up the
electrolytes and when a excellent work in adhering to
their vitals and bringing professional standards and
warm blankets and coffee. I staff nurse guided me fostering positive relationships.
work respectfully as a team through the nursing skill of Your actions set a positive
placing a catheter. example for your peers.
by asking for, listening, and
accepting feedback from the
Personal Support Workers
on shift. I act in my patient's
best interests by ensuring
that I do not share patient
identifiers in my
assignments to protect my
patients' identities. I take
accountability when I make
a mistake, like charting in
the wrong file, correct the
mistake and use this as a
learning opportunity in my
reflection.
I've applied the principle of
self-reflection from the
CNO's professional
standards, recognizing the
power dynamics between
nurses and patients. While
conducting an interview, I
noticed that I was in a
higher physical stance while
the patient remained seated,
 which could convey a sense
of power imbalance.
Upon recognizing this, I
engaged in a reflective
process. I consulted my
clinical instructor and
reviewed research to
explore best practices. This
allowed me to gain deeper
insights into the impact of
these dynamics on patient
care, especially from a
trauma-informed
perspective. This will allow
me to promote a more
supportive and empowered
environment for future
patients.
8. Use knowledge of the I identified social detriments Through conversation for Your adeptness in pinpointing PASS
social determinants of health
determinants of health and of health through patient my education plan on through patient interactions is
relationship to the conversation and patient October 10th , I identified commendable. By discerning the
environment (ecological, health detriments such as links between employment
research. I identified conditions, access challenges, and
economic, global, etc.), to employment and working Gender, Finances, health outcomes, you've
critically examine the conditions that may have Environment and Support showcased a profound
differences in health for a patient. With this understanding of broader health
contributed to a medical influences. Your holistic
outcomes for clients and information in mind, I was perspective is vital for well-
families. condition and a lack of able to consider my rounded care.
access to health services, teaching plan and
which led to hospitalization Impressive work in identifying
implement strategies that health determinants like gender,
due to a lack of resources. were in the best interest of finances, environment, and
support during your education
 my patients, meeting them plan discussion on October 10th.
I identified detriments of
Your approach of tailoring your
health during patient where they are based on teaching plan to the patient's
research, such as the information shared, specific circumstances reflects
your commitment to patient-
insufficient income, centered care and considering
compromised health and determinants of health.
well-being due to
addictions, and limited
access to health services.
These identified
determinants allowed me to
consider barriers to care and
to discuss these barriers
with my patients where
appropriate.
9. Demonstrates personal I completed the reflections, I completed the Your timely submissions, active PASS
engagement with feedback, and
responsibility for learning submitted them on time, and reflections, submitted initiative to seek and apply hands-
through self-assessment, peer reviewed the feedback on them on time, and on demonstration show a
feedback, instructor feedback, the day it became available. reviewed the feedback commendable commitment to
your learning journey. You
and the creation of learning I also completed a learning when available. I took the exemplify the essence of lifelong
goals, learning plans, and a time to complete my learning by integrating self-
plan, and updated this plan assessment, feedback, and
professional practice portfolio assignments thoroughly
based on instructor practical application.
as a beginning step in life- and thoughtfully to
long learning. feedback. I have also maximize learning. I Your commitment to personal
requested the instructor's requested feedback from responsibility for learning is
demonstration to complete a evident in your actions.
peers and shared feedback Completing reflections on time,
physical assessment and when providing care with reviewing feedback, and
completed my own peers about situations, approaching assignments
thoughtfully showcase your
assessment independently outcomes, and next steps. dedication to continuous
with that learning. improvement. Seeking and
sharing feedback with peers in
I completed all reflections care situations highlights your
and CASA assignments by collaborative and growth-oriented
mindset. Your proactive approach
the due date. I attended two
 aligns perfectly with the goal of
meetings with my clinical
demonstrating personal
instructor to review my responsibility for learning and
patient research. I received pursuing lifelong professional
development.
feedback at these meetings,
which enhanced my
knowledge base and
improved my research
priorities.

Final Grade: Pass Fail

Pass = Satisfactory. The student consistently meets all course outcomes.
Fail = Unsatisfactory. Course outcomes have not been met.

Faculty Signature: Alex Watson RN Date: 10-19-2023

Student Signature: Date:
* The student’s signature indicates that the student has read the CASA and has had the opportunity to discuss it with the faculty at the student
or faculty request.