Self and Senior Nurse Assessment, Summaries of Nursing

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Helpful Hints for Writing Self and Senior

Nurse Assessments

PLEASE NOTE: This guide is intended to be just that, a guide. The information

given is not exhaustive and there is likely to be other evidence suitable for each

competency. This guide does not replace robust discussions with colleagues or

personal reflection on practice.

When completing your self-assessment or the senior nurse assessment for a

colleague, you MUST still include examples from practice, suitable for the level at

which you/your colleague are applying, and that are less than 12 months old.

The lists below are points to consider or reflect on when writing the self or senior

nurse assessment.

Each competency should include an actual patient/practice example. You could consider starting with

an opening statement such as:

• “As a nurse working in….. “
• “Working with patients with… I”
• “Many of our patient have…”

Before writing about your practice example with:

• “I recently cared for a patient with… and I…”
• “For example I recently….”
• “One of my patients ….”
• “I was allocated a patient with… and I…”

Remember to maintain privacy.

Statements such as “A patient with”, “An elderly man with”, “A young woman with” or similar are more than adequate. Keep patient care details to a minimum and focus on your clinical care and clinical judgements.

Similarly maintain your colleagues privacy with statements such as “ A nursing colleague and I…”, and using job titles not names., such as CNM/ACNM/CNE/CNS etc.

NCNZ Competency and Competent Performance Indicator

DOMAIN 1: Professional Responsibility

1.3 Demonstrates

accountability for directing, monitoring and evaluating nursing care that is provided by Registered Nurses, Enrolled nurses and others.

Nurses and assessors must include a practice example of how you meet this competency This could refer to other RNs, new graduate nurses, ENs, Students nurses, HCAs, support workers, caregivers, other healthcare professionals, other students. This could also include family members if you are providing them with teaching or directing them to perform cares. Use a practice example to illustrate this.

• Seeking advice from a senior colleague
• Principles of direction and delegation
• Examples of good decision making when delegating

DOMAIN 1: Professional Responsibility

1.1 Accepts responsibility for ensuring that his/her nursing practice and conduct meet the standards of the professional, ethical and relevant legislated requirements.

Nurses and assessors must include a practice example of how you meet this competency Mental Health Act HPCA Act Code of Conduct Professional Boundaries Fraser Guidelines Ethical dilemmas Informed Consent Policies & procedures Medicines Act

Infectious diseases reporting (RPH) Code of Health and Disability Services Consumers' Rights Enduring Power of Attorney End of life Compulsory Treatment Orders Restraint Patient dignity

NCNZ Competency and Competent Performance Indicator

DOMAIN 1: Professional Responsibility

1.2 Demonstrates the ability to apply the principles of the Treaty of Waitangi/Te Tiriti o Waitangi to nursing practice

Nurses and assessors must include a practice example of how you meet this competency This must specifically refer to the care you give patients who identify as Māori.

• Addressing/assessing a Māori patients cultural needs
• Māori Health Unit
• Māori Models of Care
• Addressing disparities in health of our Māori populations
• Specific cultural needs of individual Māori patients e.g. return of body parts, Tapu and Noa, Taonga, family & Whanau needs.
• Assisting colleagues in addressing Māori patients/populations cultural needs
• Working with Māori health providers in the community
• Services you have started to address health needs of Māori client/patient/group of Māori patients

DOMAIN 1: Professional Responsibility

1.4 Promotes an

environment that enables patient/client safety, independence, quality of life, and health.

Nurses and assessors must include a practice example of how you meet this competency Reporting and addressing safety issues for patients and staff, including equipment, environment, infection control and patient acuity. Use a patient/client example to illustrate.

• Have you contributed to improving a client’s quality of life? o Consider issues of mobility, safety at home, goal planning with patients
• Have you helped increase a client’s independence? o Consider disability awareness for example.
• Have you helped improve a client’s health status?
• Have you helped a colleague improve a client’s safety, quality of life or independence?

NCNZ Competency and Competent Performance Indicator

DOMAIN 1: Professional Responsibility

1.5 Practices nursing in

a manner that the patient/client determines as being culturally safe.

Nurses and assessors must include a practice example of how you meet this competency Culture is many things to many different people and the list below is by no means complete. Use a patient/client example to illustrate culturally safe practice.

• Religion
• Ethnic group
• Cultural group
• Age (youth, aged care)
• Employment (NZ defence force, nursing, police)
• Accommodation (corrections)
• Circumstances (refugee, Immigrant)
• Gender and sexual orientation
• Health e.g. Mental health, disability, hearing impaired,

NCNZ Competency and Competent Performance Indicator

DOMAIN 2: Management of Nursing care

2.1 Provides planned nursing care to achieve identified outcome.

Nurses and assessors must include a practice example of how you meet this competency Use a patient/client example to illustrate this, you could consider:

• Discharge planning
• Care planning
• Holistic care – how processes can support recovery
• Using evidence based practice in delivery of care
• Informed decision making
• Administration of interventions, treatments and medications within legal, policy and scope of practice.

NCNZ Competency and Competent Performance Indicator

DOMAIN 2: Management of Nursing care

2.3 Ensures documentation is accurate and maintains confidentiality of information.

Nurses and assessors must include a practice example of how you meet this competency Using a patient/client example consider issues such as:

• Confidentiality
• Privacy and sharing of patient information to appropriate colleagues
• Patients rights in information sharing
• Keeping records safe e.g. logging off, locking away notes
• Timeliness of record keeping
• Legalities of documentation

NCNZ Competency and Competent Performance Indicator

DOMAIN 2: Management of Nursing care

2.4 Ensures the client has adequate explanation of the effects, consequences and alternatives of proposed treatment options.

Nurses and assessors must include a practice example of how you meet this competency Use a patient/client example to consider issues such as:

• A patient refused medication/treatment. What did you do and why?
• Legal - Informed consent, refusal of treatment, rights of clients
• How do you ensure your patient/client understands the information given?
• Health literacy
• Informed consent in difficult circumstances, e.g. impaired cognition, children & teens
• Is client ready to participate in education?
• Enables clients to choose appropriate interventions/therapies by explaining options
• Client centred care

DOMAIN 2: Management of Nursing care

2.2 Undertakes a comprehensive and accurate nursing assessment of clients in a variety of settings.

Nurses and assessors must include a practice example of how you meet this competency Common assessments in your clinical area, could include:

• Admission assessment
• Triage (ED, Primary care)
• Cardiac Risk assessment screening
• Diabetes assessment
• Respiratory assessment
• Mental Health Assessments
• Psychosocial assessments

Use a patient/client example to illustrate the assessments you use. Are your assessments evidence based?

NCNZ Competency and Competent Performance Indicator

DOMAIN 2: Management of Nursing care

2.6 Evaluates client’s progress towards expected outcomes in partnership with clients.

Nurses and assessors must include a practice example of how you meet this competency Use a patient/client example to illustrate evaluating patient/client care with the patient/client in:

• MDT meetings
• Family meetings
• Family conferences
• Care coordination
• Care planning and goal setting with patient/client/family

NCNZ Competency and Competent Performance Indicator

DOMAIN 2: Management of Nursing care

2.7 Provides health education appropriate to the needs of the client within a nursing framework.

Nurses and assessors must include a practice example of how you meet this competency Use a patient/client example to illustrate how you:

• Educate a patient/client on… e.g. medications, equipment, managing at home, dressing, diet, exercise etc.
• Educate family/carer on caring for their relative/friend
• Educate prior to a treatment/intervention to ensure informed consent
• How do you ensure your patient/client understands?
• Answer patient/client concerns, questions and requests for more information.
• Provide health promotion

DOMAIN 2: Management of Nursing care

2.5 Acts appropriately to protect oneself and others when faced with unexpected client responses, confrontations, personal threat or other crisis situations.

Nurses and assessors must include a practice example of how you meet this competency Use a patient/client example to illustrate your involvement in:

• Managing a MET call
• Cardiac arrest
• Combative/Distressed/aggressive client
• Refusal of treatment
• Family/partner violence
• Management of safety issues for staff/colleagues

DOMAIN 2: Management of Nursing care

2.8 Reflects upon, and evaluates with peers and experienced nurses, the effectiveness of nursing care.

Nurses and assessors must include a practice example of how you meet this competency Consider evidence like:

• Debriefs after critical events
• Regular team meeting to discuss patient/client care/progress
• One-on-one discussion with colleagues regarding issues with a patient/clients care
• Evaluations of care e.g. audits
• Situations where you reached your level of skill/knowledge and asked for assistance

NCNZ Competency and Competent Performance Indicator

DOMAIN 2: Management of Nursing care

2.9 Maintains professional development.

Nurses and assessors must include a practice example of how you meet this competency Note the professional development completed that is specific to the area of practice.

• Conferences
• Training courses
• Journal clubs (formal)
• E-learning
• Grand round/Forums
• Post-graduate education (recent or current)
• Webinars
• Updating on new best practice, treatments, interventions and guidelines. This competency should not include mandatory training or other training considered compulsory by your service/organisation.

NCNZ Competency and Competent Performance Indicator

DOMAIN 3: Interpersonal Communication

3.1 Establishes and

maintains & concludes effective interpersonal relationships with patients/clients

Nurses and assessors must include a practice example of how you meet this competency Consider client/patient episodes of care where you may have used:

• Interviewing skills
• Counselling
• Respect, empathy and rapport – particularly in difficult situations
• Gaining and maintain trust in patient/nurse relationships
• Concluding the nurse/patient relationship in difficult circumstances
• Professional boundaries

DOMAIN 3: Interpersonal Communication

3.2 Practices nursing in

a negotiated partnership with the client where possible.

Nurses and assessors must include a practice example of how you meet this competency Consider client/patient episodes of care where you have:

• Goal planning and setting with the client
• Discharge planning with patient/whanau/family
• Client/patient centred care
• Advocated for patient/client/family/whanau
• Worked with the client/patient to improve independent, safety and/or quality of life

NCNZ Competency and Competent Performance Indicator

DOMAIN 3: Interpersonal Communication

3.3 Communicates

effectively with the patient/client’s and members of the health care team.

Nurses and assessors must include a practice example of how you meet this competency Consider client/patient episodes of care where you have:

• Used a translator
• Had to use different ways of communicating to a client
• Addressed health literacy
• Given client/family/whanau more time to understand and process information
• Communicated differently with clients and families compared to health care professionals e.g. layman’s terms compared to professional terminology
• Explaining jargon and acronyms to patients

DOMAIN 4: Interprofessional Health care & Quality Improvement

4.1 Collaborates and participates with colleagues and members of the health care team to facilitate and coordinate care.

Nurses and assessors must include a practice example of how you meet this competency Consider occasions when you have actively participated in:

• MDT meetings
• Family meetings/conferences
• Complex discharge planning
• Complex patient transfers to other hospitals/facilities
• Helped a junior colleague with another member of the health care team e.g. nursing students, new staff, new graduates
• Referrals to other health care professionals
• Acute patient care e.g. resuscitation, MET calls, deteriorating patient

NCNZ Competency and Competent Performance Indicator

DOMAIN 4: Interprofessional Health care & Quality Improvement

4.2 Recognises and values the roles and skills of all members of the health care team in the delivery of care.

Nurses and assessors must include a practice example of how you meet this competency Consider clinical situations where you have:

• Contributed to care coordination for a patient
• Provided another health care professional with information about a client e.g. referrals, treatments plans, interventions, medications

Use a client/patient episode of care to illustrate your knowledge of the resources and services available to support their care and recovery

NCNZ Competency and Competent Performance Indicator

DOMAIN 4: Interprofessional Health care & Quality Improvement

4.3 Participates in quality improvement activities to monitor and improve standards of nursing.

Nurses and assessors must include a practice example of how you meet this competency This could include:

• Reviewing policies, processes or procedures
• Being involved in audits
• Recognising and acting on a practice issue that needs addressing
• Sharing best practice with colleagues
• Case presentations, teaching sessions, education of colleagues
• Quality initiatives