Respiratory Care
Program
Clinical Affective
Evaluation
Student Name ______________________________________________ Date___________________
Faculty Name ______________________________________________ Course ________________
Clinical Affiliate
___________________________________________________________________
1 - CONFIDENCE
Points /
Description
5 Functions independently with no apparent
anxiety in new, high-stress or emergency situation; displays assurance in
abilities without overdependence on others.
4 Usually
functions independently with infrequent dependence on others in normal or new
activities; displays minimal anxiety in new, high-stress or emergency
situations; displays assurance in abilities.
3 Functions
with minimal supervision when conducting normal activities; displays an
infrequent need for counseling in new, high-stress or emergency situations;
displays general assurance in abilities.
2 Requires
frequent supervision by other when conducting normal or new activities;
frequently depends on others as demonstrated by inability to perform routine
activities without constant feedback and/or apprehension; usually appears
nervous and apprehensive.
1 Requires
constant supervision; unable to carry out routine activities because of
apprehension; allows new, emergency or high stress situations to control
responses; consistently appears nervous, apprehensive and anxious.
NA Insufficient
information to provide valid rating or not applicable.
Comments:
_________________________________________________________________________
2 - LEARNING ADAPTABILITY
5 Learns
and applies new experiences exceptionally quickly; adjusts rapidly to new
conditions or altered situations. Has
exceptional knowledge and comprehension of subject matter beyond the student
level.
4 Very
quick to learn from new experiences; readily accommodates changed conditions or
situations. Applies knowledge and
comprehension of subject matter to appropriate situation.
3 Grasps
new experiences and adjusts to changes when given a satisfactory time interval.
Has ability to grasp new ideas
through learned experience.
2 Rather
slow in learning new tasks and has some difficulty accommodating to changing
conditions. Has difficulty verbally communicating
his/her thoughts and ideas to preceptor.
1 Seems
unable to learn from or apply new experiences and can’t adjust to changes.
NA Insufficient
information to provide valid rating or not applicable.
Comments:
_________________________________________________________________________
3 - INITIATIVE
5 Is
a self-starter and self-directed learner; doesn’t permit non-learning time to
occur; seeks and participates in individual learning experiences when nothing
structured is available; frequently volunteers information or initiates
discussion.
4 Usually
a self-starter and self-directed learner; usually doesn’t permit non-learning
time to occur; frequently seeks and participates in individual learning
experiences when nothing is structured is available; occasionally volunteers
information or initiates discussion.
3 Usually
a self-starter and self-directed learner; recognizes potential learning
experiences outside normal activities and participates in them.
2 Must
be shown information/experiences/opportunities for learning; reluctantly
participates in learning experiences; often uninterested in reviewing or
learning new material.
1 Performs
only required activities and shows no interest in learning outside of these
activities; avoids new or challenging material or experiences which would
enhance growth and learning.
NA Insufficient
information to provide valid rating or not applicable.
Comments:
_________________________________________________________________________
4 - ORGANIZATION AND EFFICIENCY
5 Always
sets goals, plans, and organizes activities to achieve optimum and efficient
patient care; arranges time in order to assist others.
4 Organizes
and plans assignments well; fails to achieve goals only when unexpected
circumstances intervene; frequently arranges time to assist others.
3 Usually
establishes priorities and plans activities efficiently; most goals achieved as
intended.
2 Makes
some attempt to set goals and organize activities but many priorities are not
achieved; frequently finds self without time for completion of assigned tasks.
1 Exhibits
no planning or goal setting; is unaware of priorities and is constantly
disorganized.
NA Insufficient
information to provide valid rating or not applicable.
Comments:
_________________________________________________________________________
5 - GROOMING AND ATTIRE
5 Always
dressed appropriately; personal hygiene impeccable; well groomed, always
prepared.
4 Almost
always dressed appropriately; good personal hygiene; fairly well groomed,
usually prepared.
3 Usually
dressed appropriately; occasional lapse of hygiene; acceptably groomed,
somewhat prepared.
2 Occasional
inappropriate attire; occasional lapse of hygiene; occasionally poor grooming,
inadequately prepared.
1 Had
to be sent home for inappropriate attire, poor hygiene or poor grooming and not
having the necessary equipment for clinical.
NA Insufficient
information to provide valid rating or not applicable.
Comments:
_________________________________________________________________________
6 - MATURITY AND COLLABORATIVENESS
5 Consistently
solicits constructive criticism and collaborates with instructor to maximize
learning; enhance self-improvement and optimize patient care; is self-directed.
4 Usually
initiates feedback and constructive criticism from faculty; reacts positively
to guidance applies faculty’s recommendations to improve knowledge, skills, or
attitudes; usually a self-starter and self-directed.
3 Willingly
accepts supervision and guidance; generally applies recommendations and is
receptive to constructive criticism; self-directed in assuming most
responsibilities.
2 Reacts
negatively toward supervision and guidance; often rejects guidance or fails to
apply recommendations; has difficulty accepting constructive criticism.
1 Resents
supervision and rejects guidance; is defensive or abusive when approached with
recommendation; fails to alter behavior when appropriateness criticized; fails
to recognize need for continued learning as evidenced by inability to accept or
relate new ideas or information.
NA Insufficient
information to provide valid rating or not applicable.
Comments:
_________________________________________________________________________
7 - INTEGRITY AND PROFESSIONAL
ETHICS
5 Consistently
exhibits concern for the dignity and welfare of patients and insures confidence
of privileged information; maintains forthright, honest and professional
behavior at all times; seeks to improve the practice of respiratory care,
relations with others, and health care delivery to the patient.
4 Generally
displays concern for the dignity and welfare of patients and insures confidence
of privileged information; consistently interacts others in a forthright,
honest and professional manner; seeks to improve the practice of respiratory
care, relations with others, and health care delivery to patient.
3 Seldom
fails to recognize the importance of the patient’s dignity and welfare and
responsibility of privileged communication; usually displays forthright, honest
and professional behavior
2 Often
disregards patients’ dignity or welfare and right to privileged communication;
is sometimes negligent in displaying forthright, honest and professional
behavior.
1 Is
negligent or abusive of patients’ dignity and consistently fails to maintain
confidentiality of privileged communications; is often dishonest and
unprofessional; frequently criticizes and acts antagonistically toward others.
NA Insufficient
information to provide valid rating or not applicable.
Comments:
_________________________________________________________________________
___________________________________________________________________________________
8 - APPROPRIATE REPORTING OF
PATIENTS’ STATUS AND NEEDS
5 Consistently
astute and conscientious in reporting patients’ status or needs to appropriate
personnel.
4 Usually
alert to most changes, never overlooks or fails to report patient’s condition
or needs to appropriate personnel.
3 Provides
satisfactory reporting of patient’s status and needs; generally assures that
appropriate personnel are notified.
2 Often
careless in reporting patient’s condition or needs; often fails to communicate
changes to appropriate personnel.
1 Habitually
displays negligence in reporting patients’ status and needs to appropriate
personnel
NA Insufficient information to provide valid
rating or not applicable.
Comments:
_________________________________________________________________________
___________________________________________________________________________________
9 - COOPERATION
5 Consistently
makes obvious efforts to complete activities in order to provide assistance to
others; displays a constant willingness to help others but not at the expense
of his/her own quantity or quality of work.
General attitude and interaction with staff, physicians, preceptor and
peers is outstanding.
4 Usually
completes activities in order to provide assistance to others after completing
own workload completely and without errors.
3 Generally
recognizes opportunities to assist others and demonstrates willingness to
assist as time permits; infrequently leaves own work unfinished in these
attempts.
2 Rarely
completes tasks in order to provide assistance to others; frequently avoids
situations in which his/her aid may be requested by prolonging activities or
avoiding contact with those who may request assistance; leaves own work
uncompleted to assist others.
1 Exhibits
no interest in assisting others or reluctantly offers help when requested to do
so; consistently avoids situations in which hi/her aid may be requested by
prolonging activities or avoiding contact with those who may request
assistance.
NA Insufficient
information to provide valid rating or not applicable.
Comments:
_________________________________________________________________________
___________________________________________________________________________________
10 - EMPATHY
5 Actively
solicits communication with patients about their feelings and deals with those
feelings with minimal anxiety; communicates these feelings to faculty and
significant others. Has general
consideration for patient comfort/needs and has good patient rapport.
4 Frequently
solicits communication with patients about their feelings and usually deals
with those feelings with minimal anxiety; usually communicates these feelings
to faculty and significant others.
3 Generally
recognizes patients’ feelings, expresses understanding and concern; modifies
actions or therapy in order to deal with those feelings.
2 Occasionally
recognizes patients’ feelings; fails to act upon them in a constructive manner;
fails to modify behavior or approach in order to deal with expressed feelings.
1 Fails
to recognize expression of others’ feelings; or recognizes others’ feelings but
ignores them and fails to communicate them to faculty and significant others;
fails to modify behavior or approach in order to deal with expressed feelings.
NA Insufficient
information to provide valid rating or not applicable.
Comments:
_________________________________________________________________________
___________________________________________________________________________________
11 - PUNCTUALITY AND ATTENDANCE
5 Always
on time and present for clinical; calls instructor prior to start of clinical
if will be absent.
4 Late
once; always present; calls instructor prior to start of clinical if will be
absent.
3 Late
more than once or absent without appropriate reason; calls prior to start of
clinical if will be absent.
2 Frequently
late or absent more than once without appropriate reason; calls if will be
absent.
1 Frequently
late or frequently absent without appropriate reason; fails to call or calls
after start of clinical.
NA Insufficient
information to provide valid rating or not applicable.
Comments:
_________________________________________________________________________
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12 - THOROUGHNESS AND SAFETY
5 Consistently
demonstrates thoroughness, accuracy, attention to detail; performance exceeds
safety expectations and is essentially error free.
4 Usually
exhibits thoroughness; work seldom needs to be rechecked; demonstrates due
consideration for safety and errors are few.
3 Demonstrates
an acceptable level of performance with occasional (though not critical)
errors; safety considerations are rarely overlooked.
2 Is
frequently careless or negligent, lacking attention to many details; errors
occur frequently and safety considerations are often overlooked; requires close
supervision.
1 Exhibits
overt carelessness and consistent poor quality of performance; makes critical
errors of potential danger to patient’s well-being; is unsafe and hazardous.
NA Insufficient
information to provide valid rating or not applicable.
Comments:
_________________________________________________________________________
___________________________________________________________________________________
13 - VERBAL COMMUNICATION
5 Exhibits
consistent goal-directed communication; always definite, unambiguous and clear
in meaning and intent.
4 Usually
initiates goal-directed communication that is informed, deliberate, and
generally unambiguous.
3 Generally
initiates adequate communication with infrequent errors of indefiniteness or
ambiguity; seldom displays misleading word or phrase choices.
2 Has
frequent difficulty in communicating meaning or intent; frequently ambiguous or
indefinite; often chooses misleading words and phrases.
1 Consistently
ambiguous and indefinite; exhibits poor voice tone, modulation and clarity;
misleading words or lack of clarity in intent and meaning preclude effective
communication.
NA Insufficient
information to provide valid rating or not applicable.
Comments:
_________________________________________________________________________
___________________________________________________________________________________
14 - CLINICAL JUDGEMENT
5 Displays
outstanding judgment; seeks answers/strategies to clinical problems
independently; makes correct therapeutic and patient care decisions, recognizes
inappropriate therapeutic decisions then responds to these decisions in an
appropriate manner.
4 Displays
above average judgment; usually seeks answers/strategies to clinical problems
independently; makes correct therapeutic and patient care decisions; usually
recognizes inappropriate therapeutic decisions then responds to these decisions
in an appropriate manner.
3 Demonstrates
good judgment in most situations; recognizes inappropriate therapeutic
decisions then responds to those decisions in an appropriate manner.
2 Occasionally
recognizes inappropriate therapeutic decisions but fails to respond in an
acceptable manner.
1 Can’t
be depended upon to make sound judgments; makes inappropriate judgments even
when correct data are collected.
NA Insufficient
information to provide valid rating or not applicable.
Comments:
_________________________________________________________________________
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GRADING
NOTE: To pass,
the student must achieve a minimum score of 42 overall.
Final
Score ___________ would you recommend this student to apply to your facility yes ____ no _____
Categories,
by number, where cut score not met: ___________________________________________
FACULTY
SIGNATURE_____________________________________________________________
DATE
_______________
Comments: ___________________________________________________________________________________
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STUDENT
SIGNATURE _____________________________________________________________
DATE
_______________
STUDENT
COMMENTS ______________________________________________________________
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RETURN THIS EVALUATION TO Jean Arlauckas MS, RRT-NPS
Respiratory
Care Program