Clinical Skills and Knowledge (peer must be an RN)

Assessment

Nursing Diagnosis

Planning/Implementation/Evaluation

Technology

Patient/Family Education

Policy/Procedure/Protocols

Promoting Culture of Safety

Documentation

Therapeutic Relationships

Therapeutic Communication

Empowerment - Nurse, Patient, Family

Compassion

Advocacy and Ethics

Valuing of Diversity with Patients and Family

Professional Relationships

Collaboration with the Health Care Team

Valuing Teams/Teamwork

Valuing of Diversity in Team

Delegation

Professional Development

Self

Contribution to Others

Advancing Evidence Based Practice Through Innovation and Research

Evidence Based Practice and Research

Scale (NOTE: Level F is for Master's prepared RNs) A = Level A behaviors best describe the nurse C = Level C behaviors best describe the nurse D = Level D behaviors best describe the nurse E = Level E behaviors best describe the nurse F = Level F behaviors best describe the nurse

RN Name:

Uniqname:

Unit/Area:

Framework Level:

Evaluation Period:

Peer Feedback Form - FrameworkNOTE: DO NOT attempt to fill form in the website. Download (save) it to your computer, flash drive or H drive first. Close the website. Fill saved form only in Adobe Acrobat. Include nurse’s uniqname in file name - Example Peer: Type nurse information at right. Referring to Framework Nursing Behaviors, select ratings for the domain(s) you were requested to evaluate. You are encouraged to provide concrete examples in the text areas. Please complete form within 7 days.

Tip Sheet | Video Save your work - form does not auto-save. Using a Mac?

Please describe a time when you saw me at my very best. What qualities did I display in these domains?

Please provide your input regarding opportunities for my personal and/ or professional growth.

Peer submit instructions: Enter your name/uniqname/role at right. Digitally sign below. Save for your records.

Email the signed form to BOTH: 1) the nurse 2) nurse’s Clinical Nursing Director/Supervisor

Peer Signature: Tip Sheet | Video

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Peer Name:

Uniqname:

Role:

For description of levels/behaviors,

refer to:

Framework Nursing Behaviors

STAFF MEMBER INFORMATION

RN Name:

Uniqname:

Unit/Area:

Framework Level:

Evaluation Period:

http://www.med.umich.edu/NURSING/performance_evaluation/docs/example-peerfeedback-filename.pdfhttp://www.med.umich.edu/nursing-PDE/framework/docs/behaviors.pdfhttp://www.med.umich.edu/NURSING/performance_evaluation/docs/tipSheet-Esign.pdfhttps://nursing.mivideo.it.umich.edu/media/t/1_8c06h04nhttp://www.med.umich.edu/nursing-PDE/framework/docs/behaviors.pdfhttp://www.med.umich.edu/NURSING/performance_evaluation/docs/tipSheet-hDrive.pdf#page=2https://nursing.mivideo.it.umich.edu/media/t/1_dy1p5c6hhttp://www.med.umich.edu/NURSING/performance_evaluation/docs/tipsheet-MacUsers.pdf

Assessment: [Select...]Diagnosis: [Select...]Planning: [Select...]Technology: [Select...]PatientFamily Eduation: [Select...]Policy: [Select...]Culture: [Select...]Documentation: [Select...]Diversity: [Select...]Therapeutic: [Select...]Empowerment: [Select...]Compassion: [Select...]Advocacy: [Select...]Collaboration: [Select...]Teamwork: [Select...]Diversity in Team: [Select...]Delegation: [Select...]Self: [Select...]Others: [Select...]EBP: [Select...]Describe a time: Peer, type your response here (replace this text, up to 1000 characters). Font size in text boxes will adjust smaller as you type.Input re growth: RN Name: Uniqname: Unit/Area: Framework Level: [Select...]Evaluation Period: Peer Name: Peer Uniqname: Peer Role: [Select...]