DOH NCP-CAC Self-Assessment Tool (Form 1) Revision 0
April 2013
Self-Assessment Tool for Level 3 Certification in Pediatric Nursing
Name of Candidate: __________________________________________________________
Hospital of current employment: _______________________________________________
Introduction: A nurse Candidate who seeks to be certified as a specialist in Pediatric Nursing, Level 3, will have to accomplish this self-assessment form and prepare the needed evidence to show proof of competence. Upon accomplishment of the form, the candidate will discuss the data and the evidence with his/her immediate supervisor for validation. It may be necessary to revise responses based on this discussion. The Candidate then submits to the Committee on Assessment and Certification the validated self-assessment tool and supporting evidence for review and assessment by the independent Assessors, who will determine competency or recommend development opportunities.
This Self-Assessment Tool is both formative and summative. As such it provides information as to the areas and levels of competency of the Candidate with respect to the standard performance criteria. It also informs on competency gaps and therefore provides the Candidate with leads on which learning and development interventions he/she should undertake.
Instructions: The second column in the table lists behavioural indicators that determine successful/outstanding performance in the workplace. In order to provide a calibrated picture of the Candidate’s proficiency at demonstrating these behaviors, the tool uses a three-point rating scale that indicates frequency (consistency) of demonstrating a behaviour in a given situation at the workplace.
After accomplishing the Self-Assessment Tool, take it for discussion and validation to your Immediate Supervisor, with the accompanying evidence to prove statements of competence. Refer to the Assessment Guide for the list of evidences. Submit the validated tool and evidence to the Committee on Assessment and Certification.
Indicate with a tick mark in the corresponding box areas in the hospital where you are currently assigned (most of the time) to provide nursing services:
Validated by:
_____________________________________________ ___________
Signature over Printed Name of Immediate Supervisor Date Signed
Ward OPD DR OR ER
NICU PICU MICU SICU RR
CCU CVLab Nursery PDU CAPD Clinic
HDU Others
DOH NCP-CAC Self-Assessment Tool (Form 1) Revision 0
April 2013
Place a tick mark in the corresponding frequency column if you demonstrate the behaviour indicated in the second column as the situation arises at the workplace. Consistency in demonstrating the specified behaviour while meeting the standard required for performance is gauged using the frequency terms:
Rarely, Sometimes, Always.
No. Performance Criteria Rarely Sometimes Always Comments
1
NCPEDL3A01
Formulate accurate nursing diagnosis based on salient characteristics of critical paediatric condition with corresponding urgency.
2
NCPEDL3A02
Recognize clinical manifestation that warrants emergency management such as respiratory shock, bleeding, or life threatening congenital abnormalities.
3
NCPEDL3A03
Provide a comprehensive correlation of
patient’s history and physical assessment based on the clinical manifestation with actual diagnosis by physician
4
NCPEDL3A04
Follow through full implementation of relevant diagnostic procedures /correctional intensive care interventions to facilitate prompt interpretation by the physician.
5
NCPEDL3A05
Interpret diagnostic results and initiate emergency management as needed.
6
NCPEDL3A06
Correlate present clinical manifestations and latest diagnostic results in order to modify plan of care.
7
NCPEDL3A07
Integrate innovative nursing intervention in the plan of care.
8
NCPEDL3A08
Prepare a plan of care in collaboration with other health care team members.
9
NCPEDL3A09
Initiate supplementary treatment based on present condition of the patient
10
NCPEDL3A10
Provide feedback on encountered hindrances and implemented solutions in carrying out doctor’s orders.
11
NCPEDL3A11
Administer high alert medications (e.g.
morphine, chemotherapeutic drugs, antidotes etc.) base on the standards.
DOH NCP-CAC Self-Assessment Tool (Form 1) Revision 0
April 2013
No. Performance Criteria Rarely Sometimes Always Comments
12
NCPEDL3A12
Analyze adverse drug event with the health care tem
13
NCPEDL3A13
Re-assess the effectiveness of nursing care interventions base on the present clinical manifestation and diagnostic results.
14
NCPEDL3B01
Develop materials and interactive learning activities that will reinforce teaching on health, nutrition, diseases prevention and
management relevant to patients condition
15
NCPEDL3C01
Present options to the patient or significant others that will help decision making relative to the treatment or procedure provided to the patient
16
NCPEDL3C02
Sustain support with timely and accurate information about patient’s condition 17
NCPEDL3D01
Provide observation, inputs concerning the patient during multi disciplinary rounds or as needed
18 NCPEDL3D02
Provide holistic perspective to health care 19
NCPEDL3D03
Act as liaison / advocate of the patient during decision-making by the health team
20
NCPEDL3E01
Investigates lapses in judgement that resulted to critical incidents
21
NCPEDL3E02
Act on patients bio-ethical issues according to ethico-legal standards, protocols, and polices 22
NCPEDL3E03
Reinforce awareness of patients responsibility for own health through education and communication activities
23
NCPEDL3E04
Guide the patient and significant others in making ethico-legal decisions
24
NCPEDL3F01
Supervise the replenishment of medical supplies and medication
25
NCPEDL3F02
Assist the patients’ in resolving concern regarding availment of diagnostic and therapeutic procedures
DOH NCP-CAC Self-Assessment Tool (Form 1) Revision 0
April 2013
No. Performance Criteria Rarely Sometimes Always Comments
26
NCPEDL3F03
Implement patient safety guidelines to eliminate environmental risk and hazard 27
NCPEDL3F04
Implement Infection Control and Patient Safety Principles and policies.
28
NCPEDL3G01
Consider carefully the ethical and legal
implication in the documentation of a patient’s condition
29
NCPEDL3G02
Adapt to varying documentation processes and formats in different sub-specialty areas 30
NCPEDL3H01
Participate in creation of quality circle/quality improvement team.
31
NCPEDL3H02
Develops a comprehensive quality improvement plan
32
NCPEDL3I01
Perform chest compression and rescue breathing on a neonates utilizing bag valve mask device
33 NCPEDL3J01
Conducts pre test to validate the tools 34 NCPEDL3J03
Oral defence and/or poster presentation 35
NCPEDL3J04
Motivate health members in conceptualizing nursing research.
36
NCPEDL3K01
Maintain an enabling work environment that promote trust, cooperation, and mutual concern
37
NCPEDL3K02
Maintain adequate supply of resources (medical supply, medicine, equipment) to effectively implement policies and SOP’s 38
NCPEDL3L01
Actively engages in the pursuit of continuous professional development.
39
NCPEDL3MO1
Behaves such that an image of professionalism is observed and professional values becoming of a role model are demonstrated
DOH NCP-CAC Self-Assessment Tool (Form 1) Revision 0
April 2013
Self-Assessment Tool for Level 4 Certification in Pediatric Nursing
Name of Candidate: __________________________________________________________
Hospital of current employment: _______________________________________________
Introduction: A nurse Candidate who seeks to be certified as a specialist in Pediatric Nursing, Level 4, will have to accomplish this self-assessment form and prepare the needed evidence to show proof of competence. Upon accomplishment of the form, the candidate will discuss the data and the evidence with his/her immediate supervisor for validation. It may be necessary to revise responses based on this discussion. The Candidate then submits to the Committee on Assessment and Certification the validated self-assessment tool and supporting evidence for review and assessment by the independent Assessors, who will determine competency or recommend development opportunities.
This Self-Assessment Tool is both formative and summative. As such it provides information as to the areas and levels of competency of the Candidate with respect to the standard performance criteria. It also informs on competency gaps and therefore provides the Candidate with leads on which learning and development interventions he/she should undertake.
Instructions: The second column in the table lists behavioural indicators that determine successful/outstanding performance in the workplace. In order to provide a calibrated picture of the Candidate’s proficiency at demonstrating these behaviors, the tool uses a three-point rating scale that indicates frequency (consistency) of demonstrating a behaviour in a given situation at the workplace.
After accomplishing the Self-Assessment Tool, take it for discussion and validation to your Immediate Supervisor, with the accompanying evidence to prove statements of competence. Refer to the Assessment Guide for the list of evidences. Submit the validated tool and evidence to the Committee on Assessment and Certification.
Indicate with a tick mark in the corresponding box areas in the hospital where you are currently assigned (most of the time) to provide nursing services:
Validated by:
_____________________________________________ ___________
Signature over Printed Name of Immediate Supervisor Date Signed
Ward OPD DR OR ER
NICU PICU MICU SICU RR
CCU CVLab Nursery PDU CAPD Clinic
HDU Others
DOH NCP-CAC Self-Assessment Tool (Form 1) Revision 0
April 2013
Place a tick mark in the corresponding frequency column if you demonstrate the behaviour indicated in the second column as the situation arises at the workplace. Consistency in demonstrating the specified behaviour while meeting the standard required for performance is gauged using the frequency terms:
Rarely, Sometimes, Always.
Note that where distinct behaviors (criteria) are indicated for each of the three sub-specialties, you may fill out only the criteria corresponding to the sub-specialty of choice.
No. Performance Criteria Rarely Sometimes Always Comments
1
NCPEDICUL4A01
Coordinate with the members of the health care team regarding the care needed according to recognize clinical manifestation of crititcally – ill patient.
2
NCPEDORL4A01
Oversees nursing interventions or activities that provides a standard of excellence in the care of the patient before, during, and after surgery.
3
NCPEDERL4A01
Coordinate with the members of the health care team regarding the care needed according to the recognized clinical manifestation of critically - ill patients.
4
NCPEDICUL4A02
Collaborate with other allied medical teams in the provision of holistic care of critically-ill patient.
5
NCPEDICUL4A03
Performs newborn-screening, Glasgow Coma Scale, APGAR and Ballard scoring as well as assessment of neonates variations of normal, congenital
deformities, and malformations accurately.
6
NCPEDERL4A02
Correlate deviated results and initiate appropriate actions promptly.
7
NCPEDORL4A02
Correlate deviated results and initiate appropriate actions promptly during and after surgery.
8
NCPEDERL4A03
Initiates needed emergency procedures such as:
Defibrillation
Endotracheal Intubation
Neonatal/Pediatric Resuscitation
Central Venous Access
9
NCPEDORL4AO3
Manage deviated diagnostic result such as:
Electrocardiogram
Pulse Oximetry Device
Arterial Blood Gas
Hemoglucose Test
DOH NCP-CAC Self-Assessment Tool (Form 1) Revision 0
April 2013
No. Performance Criteria Rarely Sometimes Always Comments
10
NCPEDICUL4A04
Manage deviated diagnostic results and initiate appropriate actions promptly.
11
NCPEDICUL4A05
Evaluates the need to modify mechanical ventilator set up based on disease progression and clinical findings.
12
NCPEDERL4A04
Formulate innovative strategies to zero out barriers in implementing emergency plan of care.
13
NCPEDORL4A04
Formulate innovative strategies to zero out barriers in implementing peri-operative plan of care.
14
NCPEDICUL4A06
Formulate innovative strategies to zero out barriers in implementing plan of care to critically-ill patient.
15
NCPEDERL4A05
Manage resources needed in the implementation of emergency diagnostic and therapeutic
procedure.
16
NCPEDORL4A05
Manage resources needed in the implementation of the surgical procedure.
17
NCPEDERL4A06
Explains to the parent/significant others the extent of patient’s clinical condition.
18
NCPEDORL4A06
Collaborate implementation of surgical plan with other health team members.
19
NCPEDICUL4A07
Manage resources needed in the implementation of modified plan of care of critically-ill patient.
20
NCPEDICUL4A08
Initiate appropriate interventions during life- threatening situation.
21
NCPEDICUL4A09
Demonstrates proficiency in supervision of nursing activities in situation that directly affects the patient’s health and safety.
22
NCPEDERL4A07
Integrate innovative emergency treatment in the plan of care.
23
NCPEDORL4A07
Integrate identified supplementary treatment in the plan of care.
24
NCPEDERL4A08
Initiate recommendations on quality improvement system based on gather adverse or sentinel events.
DOH NCP-CAC Self-Assessment Tool (Form 1) Revision 0
April 2013
No. Performance Criteria Rarely Sometimes Always Comments
25
NCPEDORL4A08
Initiate recommendation on quality improvement system based on gathered on adverse and sentinel events during peri-operative care.
26
NCPEDERL4A09
Execute expertise in carrying out emergency nursing care.
27
NCPEDORL4A09
Execute expertise in delivering pre-operative, intra- operative and post-operative nursing care.
28
NCPEDERL4A10
Initiates administration of emergency drugs and IV fluids to reverse patients condition.
29
NCPEDICUL4A10
Integrate identified supplementary treatment in the plan of care
30
NCPEDICUL4A11
Initiate recommendation on quality improvement system based on gathered on adverse and sentinel events.
31
NCPEDERL4A11
Anticipate and eliminate/manage risk during emergency management such as:
Medication error
Fall
IV burn
32
NCPEDORL4A10
Anticipate and eliminate/manage risk associated with surgical procedure such as:
Nosocomial infection
Medication error
Fall
Burn
Wrong site surgery
33
NCPEDICUL4A13
Anticipate and eliminate/manage risk during critical management such as:
Medication error
Fall
IV burn
Nosocomial infection 34
NCPEDL4B01
Revisit and review current policies and procedures in carrying out individualize patient care and make recommendation for improvement
35
NCPEDL4C01
Share with other nursing staff effective strategies and techniques in eliciting patient and significant other cooperation
DOH NCP-CAC Self-Assessment Tool (Form 1) Revision 0
April 2013
No. Performance Criteria Rarely Sometimes Always Comments
36
NCPEDL4C02
Organize learning sessions for nursing staff on current trends and issues on the specialty area 37
NCPEDL4D01
Rationalize observation, patient reactions to diagnostic, treatment
38
NCPEDL4D02
Engage in committee discussion and activities that contribute to the improvement of patient care 39
NCPEDL4E01
Intervene to mitigate effects of negative response of patients or significant others to hospital policies and procedures
40
NCPEDL4E02
Monitor continues cascading to patients and significant others of “Patient’s Bill of Rights and Obligations”
41
NCPEDL4F01
Refer to appropriate department or office equipment that is scheduled for preventive maintenance
42
NCPEDL4F02
Train nurses on the proper use of equipment and gadgets, troubleshooting of minor malfunctions and preventive maintenance
43
NCPEDL4G01
Implement a monitoring system for quality documentation
44 NCPEDL4G02
Recommend improvements to forms, charts, etc.
45
NCPEDL4G03
Identify data that can be used for the improvement of care and/or the system documentation.
46 NCPEDL4H01
Spearhead conduct of quality improvement studies 47
NCPEDERL4I01
Perform chest compression and rescue breathing on pediatric patients and neonates utilizing bag valve mask device.
48
NCPEDORL4I01
Assist surgeon in performing chest compression on pediatric patients and neonates during intra-and post-operative care.
49
NCPEDL4I02
Craft advance training program for clinical enhancement.
50
NCPEDL4I03
Develop and create standard list of equipment for use as checklist to check the instruments as it is set
DOH NCP-CAC Self-Assessment Tool (Form 1) Revision 0
April 2013
No. Performance Criteria Rarely Sometimes Always Comments
up for the case.
51
NCPEDL4I04
Monitor procedure of decontaminations and sterilization in accordance to the ORNAP guidelines.
52 NCPEDL4J01
Critique research studies/reports.
53
NCPEDL4J02
Conceptualize protocol/SOP in reviewing ethical researches comprehensively.
54
NCPEDL4K01
Mobilizes resources for effective program implementation and service delivery 55
NCPEDL4K02
Influence all nursing personnel to adhere to standards of safely, bioethical principles and evidence-based nursing practice
56 NCPEDL4K03
Perform nursing audit on system and operation 57 NCPEDL4K04
Monitor staff performance 58
NCPEDL4K05
Lead multidisciplinary team as appropriate in the care of pediatric client with different types of diagnosis
59
NCPEDL4K06
Recommend areas for improvement in nursing practice
60
NCPEDERL4L01
Demonstrates enhanced skills in emergency nursing care of pediatric patient.
61
NCPEDORL4L01
Demonstrates enhanced skills in peri-operative nursing care of pediatric patient.
62
NCPEDICUL4L01
Demonstrates enhanced skills in critical nursing care of pediatric patient
63 NCPEDL4L02
Act as mentor to level 1-3 nurses effectively 64
NCPEDL4L03
Identify staff development needs and make necessary recommendation
65
NCPEDL4M01
Seamlessly work with colleagues in tertiary care and other members of the multidisciplinary team 66
NCPEDL4M02
Mindful of emotional impact of interventions and be aware to work with them and other professional confidently
DOH NCP-CAC Self-Assessment Tool (Form 1) Revision 0
April 2013
Self-Assessment Tool for Level 5 Certification in Pediatric Nursing
Name of Candidate: __________________________________________________________
Hospital of current employment: _______________________________________________
Introduction: A nurse Candidate who seeks to be certified as a specialist in Pediatric Nursing, Level 5, will have to accomplish this self-assessment form and prepare the needed evidence to show proof of competence. Upon accomplishment of the form, the candidate will discuss the data and the evidence with his/her immediate supervisor for validation. It may be necessary to revise responses based on this discussion. The Candidate then submits to the Committee on Assessment and Certification the validated self-assessment tool and supporting evidence for review and assessment by the independent Assessors, who will determine competency or recommend development opportunities.
This Self-Assessment Tool is both formative and summative. As such it provides information as to the areas and levels of competency of the Candidate with respect to the standard performance criteria. It also informs on competency gaps and therefore provides the Candidate with leads on which learning and development interventions he/she should undertake.
Instructions: The second column in the table lists behavioural indicators that determine successful/outstanding performance in the workplace. In order to provide a calibrated picture of the Candidate’s proficiency at demonstrating these behaviors, the tool uses a three-point rating scale that indicates frequency (consistency) of demonstrating a behaviour in a given situation at the workplace.
After accomplishing the Self-Assessment Tool, take it for discussion and validation to your Immediate Supervisor, with the accompanying evidence to prove statements of competence. Refer to the Assessment Guide for the list of evidences. Submit the validated tool and evidence to the Committee on Assessment and Certification.
Indicate with a tick mark in the corresponding box areas in the hospital where you are currently assigned (most of the time) to provide nursing services:
Validated by:
___________________________________________ _________
Signature over Printed Name of Immediate Supervisor Date Signed
Ward OPD DR OR ER
NICU PICU MICU SICU RR
CCU CVLab Nursery PDU CAPD Clinic
HDU Others
DOH NCP-CAC Self-Assessment Tool (Form 1) Revision 0
April 2013
Place a tick mark in the corresponding frequency column if you demonstrate the behaviour indicated in the second column as the situation arises at the workplace. Consistency in demonstrating the specified behaviour while meeting the standard required for performance is gauged using the frequency terms:
Rarely, Sometimes, Always.
No. Performance Criteria Rarely Sometimes Always Comments
1 NCPEDL5A01
Acts as trainors on specialized pediatric procedures.
2 NCPEDL5A02
Suggest alternative/ comprehensive diagnostic procedure
3 NCPEDL5A03
Validate effectiveness of Innovative strategies 4 NCPEDL5AO4
Review nursing care plan and provide enhancements 5 NCPEDL5A05
Design alternative protocols in identifying needed supportive treatment
6 NCPEDL5A06
Develop strategies towards culture of safety.
7 NCPEDL5A07
Encourage reporting of adverse drug/sentinel events through analysis of data in a non-punitive manner 8 NCPEDL5A08
Review and enhance/ system relevant to patient care 9 NCPEDAL5A09
Suggest enhancement and innovations on patient care standards in compliance with accrediting bodies.
10 NCPEDL5A010
Provide appropriate guidance and supervision in nursing care.
11 NCPEDL5A11
Review and enhance as appropriate the monitoring system and tools
12 NCPEDL5A12
Cascade monitoring system and tools concerning patient safety standards, quality improvement strategies, etc.
13 NCPEDL5A13
Provide learning/ counselling sessions to nursing staff who’s are the subject of negative customer feedback 14 NCPEDL5B01
Supervise the implementation of area-wide health education activities
15 NCPEDL5B02
Develop and implements enhanced policies and procedures on individualized patient care and health education.
DOH NCP-CAC Self-Assessment Tool (Form 1) Revision 0
April 2013
No. Performance Criteria Rarely Sometimes Always Comments
16 NCPEDL5B03
Create new policies and procedure in carrying out individualizes patient care.
17 NCPEDL5C01
Act as a resource speaker during learning sessions 18 NCPEDL5C02
Establish policies system and guidelines on therapeutic communication
19 NCPEDDL5D01Monitor the performance of the health care team to ensure proper delivery of patient care.
20 NCPEDDL5D02
Resolve relational and system/process
(communication, information dissemination, etc.) concerns within the health care team for enhanced performance
21 NCPEDDL5D03
Utilize results of committee discussion to enhance system and produce relevant to patient care 22 NCPEDL5E01
Review and enhance policies/protocols that will guide nurses on how to assist patients and significant others in proper judgement and decision making when faced with crisis
23 NCPEDL5E02
Analyzes cause of differences in opinions and strategies
24 NCPEDL5E03
Present nursing care options for a patient crisis based on ethico-legal, moral and spiritual reasons and in accordance with hospital policies
25 NCPEDL5F01
Review and enhance policies on calibration of medical equipment
26 NCPEDL5F02
Monitor inventory of medical supply and medicines 27 NCPEDL5F03
Review and enhance policies and guidelines on patient safety, risk management and infection control 28 NCPEDL5G01
Review and enhance the forms, policies, guidelines and monitoring tools tailored fit to the institution’s mandate.
29 NCPEDL5H01
Review and enhance policies and procedures on the implementation of quality improvement activities.
30 NCPEDL5H02
Apply the result of successful/approved quality improvement studies in other areas as standard
DOH NCP-CAC Self-Assessment Tool (Form 1) Revision 0
April 2013
No. Performance Criteria Rarely Sometimes Always Comments
31 NCPEDL5H03
Act as a effective resource speaker on quality endeavours effectively and the hospital’s best practices
32 NCPEDL5I01
Develop activities that will provide enhancement in the delivery of health education to patients.
33 NCPEDL5J01
Integrate research findings in paediatric practice.
34 NCPEDL5J02
Act as adviser in the development of evidence-based research studies
35 NCPEDL5K01
Identify together with staff concerned, performance goals for a given period
36 NCPEDL5K02
Evaluates performances of nursing support staff using standard evaluation tool
37 NCPEDL5K03
Review and enhance management policies and guidelines
38 NCPEDL5K04
Comply with legal and regulatory standards 39 NCPEDL5K05
Disseminates policies, regulations, circulars and programs among nurses and nursing support staff.
40 NCPEDL5K06
Leads improvements efforts and manage resistant to change
41 NCPEDL5K07
Manage resistance to change 42 NCPEDL5L01
Prepare and implement a staff development plan 43 NCPEDL5M01
Monitors personality and professional decorum of the nursing staff while acting as their role model
