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School&of&Nursing&"

The"Clinical"Practicum:""Guidelines"for"Success"

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Adult9Gerontology"Clinical"Nurse"Specialist""&""

Primary"Care"Adult9Gerontology""Nurse"Practitioner""

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Table!of!Contents!"1.Introduction .................................................................................................................... 3"2.Selection of Clinical Preceptors and Sites ..................................................................... 3"3.The Student: Responsibilities and Accountability .......................................................... 3"

Scheduling of Clinical Hours .................................................................................. 4 Paperwork..............................................................................................................4 Preceptor Interview ...............................................................................................4 Scheduling of Clinical Hours..................................................................................4 Attendance.............................................................................................................5Attire and Behavior ...............................................................................................5 Clinical Objectives ................................ ................................................................5 Preparation for Clinical Practicum..........................................................................6 Guidelines for Clinical Preparation.........................................................................6

4.Clinical Faculty Responsibility ....................................................................................... 7"5.Documentation of the Clinical Encounter ...................................................................... 7"6.The Clinical Site Visit ..................................................................................................... 8

The studentis responsible for: ............................................................................... 8"The clinical faculty is responsible for: .................................................................... 9"The preceptor is responsible for: ........................................................................... 9"

7. Problem/Conflict Management ..................................................................................... 9"8. Pogram Requirements ............................................................................................... 11"9. Health Examination .................................................................................................... 12"10. Personal Health History ............................................................................................ 13 11. Mid-Clinical Evaluation ........................................................................................... 14 12. NP Student Clinical Evaluation ................................................................................. 15 13. NP Clinical Skills & Procedures Documentation ...................................................... 17"14. Student Evaluation of Site & Preceptor .................................................................... 19"""""

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1. Introduction!!

This"manual"serves"as"a"guide"to"establish"guidelines,"facilitate"student"role"development,"and"provide"materials"for"use"by"clinical"nurse"specialist"(CNS)"and"nurse"practitioner"(NP)"students"during"their"clinical"preceptorship"experiences."""2. Selection!of!Clinical!Preceptors!and!Sites!

"Developing"a"skilled"practitioner"depends"upon"both"academic"learning"in"the"classroom"and"appropriate"experiences"in"clinical"practice."Clinical"nurse"specialists"and"nurse"practitioner"will"be"required"to"identify"and"contact"preceptors."As"a"graduate"student,"developing"the"skills"to"promote"yourself"are"very"important"and"one"way"to"enhance"this"experience"is"to"have"students"work"to"develop"their"clinical"practice"relationships.""Ultimately"students"are"more"comfortable"with"sites,"preceptors,"and"locations"that"they"have"procured"than"sites"that"we"can"provide."""Once"you"have"identified"your"potential"site"and"preceptor"you"should"contact"the"faculty"lead"for"your"course.""Please"provide"them"detailed"information"about"the"site"so"that"they"may"determine"its"appropriateness."Once"approved"by"your"course"faculty"you"will"need"to"contact"Bobbi"Towne.""Bobbi"Towne"is"the"official"coordinator"for"the"graduate"program"and"will"work"with"the"site"to"obtain"an"affiliation"agreement"permitting"you"to"do"your"clinical"hours"in"that"facility"and"with"that"preceptor."Students"should"begin"their"search""at"least"3"months"prior"to"the"desired"clinical"date."This"will"ensure"adequate"time"to"evaluate"the"clinical"site,"ascertain"preceptor"credentials"and"gather"the"appropriate"information"needed"to"formalize"a"contractual"agreement"between"the"University"and"the"facility"if"one"does"not"already"exist."""3. The!Student:!Responsibilities!and!Accountability!!

Students"enter"the"clinical"arena"for"mentoring"and"clinical"preceptorship"when"they"have"progressed"to"a"specific"point"in"their"education"e.g."completed"sciences,"theoretical,"and"assessment"courses.""It"is"important"for"students"to"understand"their"roles"and"responsibilities"as"a"student."When"assigned"to"or"selecting"a"clinical"site"and"preceptor,"the"student"is"expected"to"fulfill"basic"requirements."Meeting"the"clinical"requirements"will"assist"the"student"in"optimizing"the"learning"experience."Within"the"partnerships"between"the"student"and"course"faculty"and"preceptor,"there"are"roles"that"each"partner"must"fulfill."""Clinical'Placement'Request"Complete"and"submit"clinical"placement"request"form"by"the"date"assigned."The"request"forms"are"available"on"the"program"website."It"is"very"important"for"the"student"to"consider"any"restrictions"they"need"to"place"on"their"clinical"time/placements."For"instance,"transportation"concerns,"family"responsibilities,"specific"days,"and"work"commitments"should"all"be"considered"when"selecting"clinical"placements."Minimally,"students"should"expect"to"spend"4"hours"per"day"at"a"clinical"site."An"8"hour"clinical"day"is"the"most"typical"scenario"and"may"encompass"a"variety"of"clinical"care,"client"rounds,"procedures,"home"visits,"chart"reviews"and"other"experiences.""

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"Necessary'Paperwork"All"students"are"responsible"for"submitting"updated"health"forms,"immunization"records,"CPR"certification,"nursing"licenses,"criminal"background"checks"and"other"items"as"required"by"the"EMU"School"of"Nursing."Individual"clinical"sites"may"also"have"specific"requirements"that"must"be"met."Students!will!not!be!allowed!to!participate!in!clinical!experiences!without!completion!of!the!appropriate!paperwork.!Students"will"be"required"to"verify"that"their"certification"is"good"for"the"entire"semester."If"any"of"the"necessary"paperwork"expires"midsemester,"the"student"is"expected"to"update"their"records"immediately."""Preceptor'Interview"Some"preceptors"require"an"interview"with"the"student"seeking"placement"with"them."The"purpose"of"the"interview"is"to:"""

1."Provide"the"preceptor"with"an"understanding"of"the"level,"ability,"and"personality"of"the"student"

" 2."Enable"the"preceptor"to"assess"if"the"students"would"be"a"good"fit"for"the"clinical"" site"and"the"population"it"serves."" "" Typical"questions"from"the"preceptor"may"include:"

1. Why"do"you"want"me"as"a"preceptor?"What"are"your"expectations?"What"are"your"primary"clinical"objectives"for"this"semester?"

2. Why"do"you"want"to"be"a"CNS"or"NP?"What"are"your"future"goals?"3. Tell"me"what"a"CNS"or"NP"is?"How"will"you"explain"this"role"to"a"client?"4. What"are"your"strengths/weakness?"5. How"do"you"handle"mistakes?"6. How"often"do"you"like"to"have"feedback?"Do"you"prefer"a"formal"evaluation"or"

informal"evaluation?"Do"you"prefer"a"“wrap9up”"at"the"end"of"every"day?"7. What"hours"do"you"expect"to"be"here?"When"do"you"wish"to"start?"Do"you"have"

certain"days"that"you"are"available?"8. Along"with"providing"primary"care,"I"also"can"provide"other"experiences"such"as"

grand"rounds,"home"visits,"etc."Do"you"want"to"participate?"9. How"long"have"you"been"a"nurse?"What"types"of"patients"do"you"prefer"to"care"

for?""

Scheduling'of'Clinical'Hours'Clinical'practicum'hours'are'to'be'scheduled'at'the'convenience'and'availability'of'the'preceptor.!Students"are&not&to&ask&preceptors"to"conform"to"a"schedule"that"meets"their"personal"and"employment"needs."The"student’s"personal"and"work"schedules"are"expected"to"accommodate"participation"in"the"required"number"of"clinical"hours"prescribed"by"the"clinical"course."Students"and"preceptors"need"to"agree"on"the"days"and"times"that"the"student"will"be"in"the"clinical"agency"prior!to!beginning"the"practicum"experience."When"determining"the"hours,"it"is"wise"to"schedule"several"“contingency”"days."These"are"days"that"can"be"used"as"“make9up”"time"in"the"event"that"the"preceptor"or"student"is"unavailable"i.e.,"ill,"the"clinic"is"closed,"or"weather"events"make"travel"hazardous."Clinical'hours'must'be'completed'within'the'semester'that'students'are'registered.'

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"Attendance"Performance"of"clinical"hours"at"the"negotiated"times"and"day"with"the"preceptor"is"required."Careful"attention"to"attend"clinical"on"the"days"which"the"preceptor"can"accommodate"the"student"is"important."Often,"specific"days"of"the"week"are"chosen"by"the"preceptor"due"to"client"availability,"client"mix,"or"the"availability"of"extra"examination"rooms."It"is"the"student’s"responsibility"to"monitor"the"number"of"hours"completed,"and"plan"on"completing"the"required"hours"within"the"semester."The"student"is"responsible"for"adjusting"his/her"personal"and"employment"commitments"so"that"the"required"number"of"clinical"hours"can"be"completed."If"the"student"does"not"complete"the"required"number"of"clinical"hours"for"the"semester,"he/she"cannot"expect"the"preceptor"to"continue"the"precepting"relationship."Extension"of"the"clinical"period"with"the"preceptor"cannot"be"assumed"but"is"granted"only"by"agreement"with"the"preceptor,"clinical"agency"and"school/college"of"nursing."Exceptions"related"to"unexpected"illness"of"the"student/family"and"or"preceptor"should"be"discussed"with"course"faculty"and"the"parties"involved."""When'the'student'cannot'attend'clinical'on'a'day'that'is'scheduled,'the'preceptor'and'clinical'faculty'must'be'notified'immediately."The"student"should"obtain"contact"information"(telephone"number"or"email"address)"from"the"preceptor"and"discuss"the"procedure"for"notifying"the"preceptor"and"faculty"for"unexpected"absences."Failure"to"notify"the"preceptor"as"negotiated,"prior"to"the"beginning"of"the"scheduled"clinical"day"is"unacceptable"and"may"place"the"student"and"clinical"placement"in"jeopardy."The"student"should"present"the"faculty"and"preceptor"with"a"plan"to"complete"the"lost"clinical"time."""Attire'and'Behavior'Students"are"representatives"of"the"Eastern"Michigan"University"School"of"Nursing"and"must"present"themselves"as"ambassadors"of"their"programs."Students"are"expected"to"be"respectful"to"preceptors,"faculty,"staff,"patients,"and"their"families."Reports"of"unprofessional"behavior"will"result"in"the"student"being"counseled"and"possibly"subject"to"review.""Interactions"with"clients,"staff,"other"health"providers"and"students"are"learning"opportunities"for"the"student"to"role"model"nurse"practitioner"expertise."The"clinical"preceptorships"are"designed"to"provide"advanced"practice"nursing"experiences"but"in"the"early"semesters"of"clinical"it"is"not"uncommon"for"students"to"fall"back"into"a"comfortable"“staff"nurse”"role."Students"are"highly"encouraged"to"observe"their"preceptor’s"interactions"with"support"staff"and"others"as"it"relates"to"APN"practice.

Students"should"dress"professionally"and"carry"their"Eastern"Michigan"University"School"of"Nursing"identification"badge"denoting"status"as"a"nurse"practitioner"student.""Work"identification"badges"should"not"be"worn"during"clinical"preceptorships."Some"clinical"sites"may"require"that"lab"coats"or"other"specialized"garb"are"worn"in"client"care"areas."Students"are"to"discuss"the"appropriate"dress"attire"with"their"preceptor"prior"to"the"first"clinical"day."""Clinical'Objectives"It"is"the"responsibility"of"the"student"to"construct"and"provide"the"preceptor"with"student9specific"clinical"objectives"for"the"clinical"practicum."The"preceptor"is"provided"with"a"copy"of"the"course"description"and"objectives"in"a"letter"that"Dr."Bumpus"distributes"when"the"preceptor"confirms"their"agreement"for"student"placement."The"

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student"should"reflect"and"develop"individual"learning"objectives"that"will"meet"and"facilitate"his/her"learning"needs"and"previous"clinical"nursing"experience"(e.g."assessment"of"abnormal"heart"sounds,"skills"acquisition9clinical"use"of"the"microscope"or"phlebotomy,"suturing,"etc.)"that"are"not"explicit"in"the"course"or"clinical"objectives."Guidelines"for"developing"clinical"objectives"include:"" 1."The"student"will"write"specific"clinical"objectives"according"to"individual"learning"needs."These"objectives"should"be"discussed"with"the"preceptor"EACH!WEEK."The"objectives"should"also"be"submitted"to"the"clinical"faculty"when"SOAP"notes"are"submitted."""2."Examples"of"clinical"objectives"include"APN"skills,"diagnostic"reasoning,"diagnostic"labeling,"interventions,"evaluation"methods,"and"record"audits."""3.""Clinical"objectives"must"be"measurable"and"evaluated"at"the"end"of"the"clinical"day."Written"objectives"do"not"provide"learning"feedback"unless"evaluation"occurs."If"the"objective"is"not"completed,"it"may"be"used"in"subsequent"clinical"days"until"it"is"met."""4."Clinical"objectives"should"reflect"the"level"of"competency"the"student"would"like"to"achieve"at"the"end"of"the"practicum,"e.g.,"minimal"competency,"proficient,"etc."""5."Clinical"objectives"should"be"congruent"with"and"complement"the"course"objectives."""6."A"method"for"evaluation"of"individual"objectives"should"be"planned"and"completed."""7."Specific"clinical"objectives"should"be"sufficiently"limited"in"number"so"that"appropriate"attention"can"be"directed"toward"each."Typically"293"objectives"per"clinical"day"is"adequate."""Preparation'for'Clinical'Practicum The"clinical"practicum"extends"the"learning"environment"of"the"classroom"to"integrate"theoretical"concepts"with"clinical"practice."Students"should"prepare"for"the"clinical"practicum"by"developing"individual"learning"objectives,"as"previously"discussed."Students"should"prepare"for"clinical"by"reading"course"texts"and"professional"journals,"and"using"other"audiovisual"and"electronic"learning"aids"as"necessary."The"preceptor"may"recommend"additional"materials"and"topics"for"review"prior"to"the"first"clinical"day."The"student"should"review"the"common"clinical"problems"relevant"to"the"clinic’s"population."Follow9up"reading"of"current"reference"material"following"the"clinical"day"provides"the"student"with"the"opportunity"to"increase"the"breadth"of"scientific"and"clinical"knowledge"from"that"gained"in"the"clinical"arena. Guidelines for clinical preparation 1."Students"are"expected"to"have"full"knowledge"of"entrance"requirements"for"clinical,"including"credentials,"dress,"location,"timing,"security"clearances,"etc.,"before"scheduling"the"first"clinical"day"at"the"agency."" 2."Students"are"responsible"for"their"own"health"records"and"other"requirements,"such"as"current"CPR"certification"and"immunizations,"in"order"to"fulfill"the"clinical"requirements"on"

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the"first"day."In"accordance"with"school"and"agency"policy,"students"without"appropriate"clearance"will"not"be"allowed"to"enter"the"clinical"setting."" 3."Whenever"possible,"discussion"with"other"students"who"have"the"same"or"similar"placements"may"be"beneficial."""4."On"the"first"clinical"day,"discuss"questions"about"computer"access,"the"procedure"for"preceptor"co9signing"documents,"eating"and"parking"arrangements,"and"the"communication"with"other"disciplines."""5."Learn"something"about"the"preceptor,"when"possible,"in"order"to"acknowledge"the"preceptor’s"background"and"broaden"the"student’s"educational"experience."""4. Clinical!Faculty!Responsibility!!

Each"student"will"have"a"clinical"faculty"member"assigned"to"them"for"the"duration"of"the"semester."The"role"of"the"clinical"faculty"is"to"facilitate"the"student’s"learning"via"personal"observation"of"the"student’s"clinical"skills"and"clinical"conferences."Pairing"of"clinical"faculty"with"a"student"also"provides"sensitivity"to"the"student’s"life"experiences,"expertise,"unique"perspectives,"learning"preferences,"and"career"goals."The"clinical"faculty"also"acts"as"a"role"model"for"the"numerous"dimensions"of"the"nurse"practitioner"role."""The"clinical"faculty"member"is"responsible"for"the"completion"of"student"site"visits,"assessing"the"student’s"SOAP"notes,"clinical"objectives"and"progression"in"the"clinical"sequence,"communications"with"the"preceptor"via"telephone,"emails"or"onsite"visits,"and"for"providing"timely"and"constructive"feedback"to"the"student."The"clinical"faculty"also"communicates"regularly"with"the"course"faculty"and"track"coordinators"regarding"student"progress"and"achievement."""Students"should"contact"the"clinical"faculty"immediately"if"concerns"arise"about"the"clinical"preceptorship"experience"or"their"ability"to"successfully"adhere"to"the"original"agreements"made"with"the"preceptor."Also,"the"student"should"seek"advice"from"the"clinical"faculty"should"challenges"occur"at"the"clinical"site"that"the"student"cannot"reasonably"resolved"on"their"own."""The"clinical"faculty"will"have"a"mid"term"and"final"conference"with"each"student"to"review"academic/clinical"progress,"set"objectives"for"the"remaining"or"upcoming"semester,"and"provide"constructive"feedback."""""5. Documentation!of!the!Clinical!Encounter!!

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Each"clinical"encounter"performed"by"the"student"must"be"documented"in"the"client’s"record."Documentation"should"be"consistent"with"current"billing"and"coding"guidelines"and"adhere"to"the"current"national"and"facility"standards"of"care.""Typically,"SOAP"notes"are"the"preferred"format"of"documentation"using"paper,"electronic,"digital"or"taped"methods."However,"many"agencies"now"have"templates,"check"sheets"and"other"formats"to"document"the"clinical"encounter."BEFORE"SUBMITTING"SOAP"notes"for"review"by"the"clinical"faculty,"the"student"is"highly"encouraged"to"discuss"the"format/method."""All!SOAP!notes!must!be!coLsigned!by!the!preceptor.!It"is"highly"encouraged"that"the"preceptors"do"more"than"simply"sign"the"note."Many"facilities"now"have"stipulations"regarding"the"meaning"i.e.,"legal"and"reimbursement"designations,"of"a"preceptor"signature"and"have"developed"their"own"policies"on"co9signing."Following"are"some"suggested"wording"that"may"be"used"if"the"agency"does"not"have"guidelines"in"place."""Agree"with"the"above."Signed___________________.""Agree"with"the"above."Also"include9999999."Signed___________________.""Agree"with"the"above"documentation."Present"during"visit."Signed_____.""I"have"reviewed"the"history"and"physical"findings"and"repeated"pertinent"physical"exam"elements"necessary"to"develop"the"diagnosis"and"plan"Signed______________."""All"client"visits"must"also"be"recorded"in"the"electronic"clinical"log"(ProjectConcert)."This"log"is"used"to"document"the"breadth"and"depth"of"the"student’s"clinical"experiences."The"clinical,"course"and"program"faculty"also"use"the"log"as"a"tool"to"assess"and"evaluate"the"appropriateness"of"clinical"placement"and"the"increasing"independence"of"the"student’s"clinical"skills."The"summative"data"from"the"log"will"be"used"in"the"student’s"career"portfolio"that"is"developed"in"the"final"semester"of"coursework."""6. The!Clinical!Site!Visit!!

Clinical"site"visits"are"completed"at"designated"intervals"throughout"the"student’s"program"of"study."The"site"visit"facilitates"the"clinical"faculty’s"understanding"of"student"progress"via"direct"observation"of"their"clinical"skills,"enables"the"student"to"demonstrate"their"expertise"and"to"conference"with"their"clinical"faculty"member,"and"allows"the"preceptor"to"share"their"experiences"regarding"the"student’s"accomplishment"and"their"precepting"with"the"clinical"faculty."The"member"of"the"team"plays"an"important"role"in"a"successful"site"visit"as"noted"below."""The'student'is'responsible'for:""1."Coordinating"the"date"of"the"site"visit"with"the"clinical"faculty"member,"providing"important"contact"numbers"that"can"be"used"while"the"faculty"member"is"enroute"to"the"site"should"something"occur,"and"confirming"the"site"visit"one"day"prior"to"the"event."""2."Ascertaining"with"the"preceptor"that"client’s"will"be"available"the"day"of"the"site"visit"and"selecting"several"that"can"be"seen"by"the"student."""

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3."Introducing"the"faculty"member"to"the"preceptor"and"support"staff,"providing"a"“tour”"of"the"facility"if"appropriate,"discussing"charting"procedures,"and"how"clients"are"selected"for"the"student."""4."Reminding"the"preceptor"that"the"clinical"faculty"will"be"arriving"for"a"site"visit"and"that"the"faculty"will"need"several"minutes"of"their"time"to"discuss"the"student’s"progress."""The'clinical'faculty'is'responsible'for:''1. Observing"the"student"during"2"clinical"encounters."This"will"include"observing"oral"summaries"given"to"the"preceptor"and"any"subsequent"client"management."""

2. Observing"the"student’s"interactions"with"the"environs"of"the"site:"preceptor,"clinical"staff,"support"staff,"clients"and"their"support"persons,"use"of"technology"at"the"site"and"others."""

3. Conferencing"with"the"preceptor"regarding"the"student’s"abilities"and"progress,"learning"goals"and"suggested"changes."""

4. Providing"constructive"feedback"regarding"the"encounters"and"the"whole"of"the"site"visit"as"well"as"making"recommendations"to"facilitate"clinical"expertise."""

5. Completing"the"site"visit"evaluation"and"sharing"the"results"with"the"student."""The'preceptor'is'responsible'for:''1. Providing"appropriate"site"visit"clients"for"the"students."""

2. Providing"feedback"to"the"student"and"the"clinical"faculty"regarding"the"student’s"experiences"and"abilities"at"the"site."""

3. Providing"feedback"on"the"student’s"documentation"of"client"visits,"attendance,"professionalism,"and"other"components"of"the"nurse"practitioner"role."""

4. Completion"of"the"appropriate"student"evaluations"for"clinical."""The"site"visit"day"should"be"conducted"as"a"normal"clinical"day"for"both"the"student"and"the"preceptor."Although"the"student"is"usually"nervous"at"the"prospect"of"being"observed,"the"faculty"and"preceptor"are"well"aware"of"this"and"try"to"place"the"student"at"ease."Also,"it"is"important"that"the"clinical"faculty"observe"the"flow"of"the"clinic"at"large,"the"interaction"of"the"staff"with"the"various"care"providers,"the"client"mix"and"the"student’s"interactions"within"all"of"these"arenas."This"assists"in"not"only"evaluating"the"student"but"ascertaining"the"appropriateness"of"the"clinical"site"for"the"current"and/or"future"students."""7.!!Problem/Conflict!Management!!

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The"potential"for"conflict"and"disagreement"in"interpersonal"relationships"is"common"and"should"be"anticipated."In"the"clinical"setting,"preceptors"are"under"pressure"to"be"productive"which"may"constrain"time"that"can"be"fully"devoted"to"teaching."Other"factors,"such"as"level,"ability,"communication"style"and"motivation"of"the"student"coupled"with"the"uniqueness"of"the"preceptor’s"client"load"can"provide"fertile"ground"for"conflict."It"is"the"student’s,"preceptor’s"and"faculty"responsibility"to"use"the"appropriate"resources"for"problem9solving"while"optimizing"learning"experiences."""Examples"of"potential"conflict"situations"include:"""1.""Placement"of"a"student"with"preceptor"with"a"conflict"of"interest"that"is"personal,"family"related"or"via"job"alliances."""2.""Cultural"differences"between"the"student"and"preceptor"in"communication"to"clients"and"other"providers."""3.""Inappropriate"matching"of"student"competence"level"with"preceptor"expectations."""4.""Inexperience"of"preceptor"in"coping"with"student’s"unacceptable"behaviors.""Preceptor"is"not"providing"expected"level"of"mentorship"or"clinical"care."""Intervention"strategies"for"conflict"resolution"are"dependent"upon"the"urgency"of"the"matter."In"instances"where"an"immediate"response"is"needed,"the"clinical"faculty"should"be"notified"first."If"there"is"no"response,"then"notification"of"either"the"course"faculty"and/or"program"coordinator"should"be"done"immediately.""

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Eastern!Michigan!University!School!of!Nursing!!

Program!Requirements!!All"students"must"provide"the"following"information"to"the"School"of"Nursing"Office,"311"Marshall.""Please"send"to"Bobbi"Towne,"Coordinator"at"734948796949"(fax)"or"email"to"rtowne1@emich.edu."!!!

1.""A"report"of"current"physical"examination"(form"enclosed)""2.""Completion"of"immunization"record"(form"enclosed)"that"provides"proof"of""""""""immunity"(evidenced"by"titer)"or""immunization"for"the"following:"""""""""""a.""Rubella"""""""""""b.""Rubeola"""""""""""c.""Mumps"""""""""""d.""Varicella"Zoster"(*"History"of"any"of"the"above"diseases"is"not"sufficient"proof"of"immunity)"3."""Proof"of"tetanus"vaccination"within"the"past"five"years.""4."""Proof"of"having"at"least"the"first"of"three"Hepatitis9B"injections"or""a"positive"titer"""""""titer"result"or"submission"of"a"signed"declination"form"(enclosed)."5.""Annual"documentation"that"the"student"is"free"from"Tuberculosis."""""""Freedom"from"TB"is"evidenced"by:"1)""negative"TB"skin"test,"2)"current"""""""negative"Chest"X9ray,"or"3)"negative"chest"x9ray"in"the"past"with"current"""""""documentation"by"health"care"provider"that"student"is"free"from"TB"**A"7"panel"drug"screen"will"be"required"by"some"affiliated"clinical"agencies."

""CPR! Documentation"of"current"Adult,"Child,"Infant,"Two"Person"CPR"certification"

for"the"professional"rescuer.""!Personal!Health!Insurance!

Proof"of"Personal"Health"Insurance"is"required."""!

Professional!Liability!Insurance!Optional!

Proof"of"Professional"Liability"Insurance"(1,000,"000"each"incident"3,"000,000"aggregate)"is"optional.""You"can"contact"the"Nursing"Service"Organization"(www.nso.com),"Marsh"Affinity"group"(www.proliability.com)"or"any"other"nursing"liability"insurance"provider."""

Criminal!Background!Check:"Form"attached.""You"must"order"and"pay"for"this.""Access"the"website:""www.myvci.com/emu"and"the"cost"is"$30.oo"Nursing!License:!Copy"of"unexpired,"non9restricted"nursing"license."!!!

NO!STUDENT!WILL!BE!ABLE!TO!BEGIN!CLINICAL!CONTACT!HOURS!WITHOUT!MEETING!THESE!REQUIREMENTS!

!I"have"read,"understand,"and"agree"to"the"above"EMU"program"requirements.""I"have"made"a"personal"copy"of"these"requirements"for"my"own"reference.""Failure"to"complete"these"program"requirements"will"result"in"my"not"being"able"to"attend"clinical"nursing"courses.""""""Student"Signature" " " " Printed"Student"Name" " " "" Date"

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12"

EASTERN!MICHIGAN!UNIVERSITY!HEALTH!EXAMINATION!

**TO"BE"COMPLETED"BY"MD,"NURSE"PRACITIONER,"OR"PHYSICIAN’S"ASSISTANT**""

Name"""__________________________________________________________" " ______""""""""""""""Last" " " " First" " " Middle" " " Date""1.""Explain"any"significant"family"or"personal"history:""__________________________________________""______________________________________________________________________________________""2.""Height"_______" " Blood"Pressure______" " Hb"_______""""""Weight"_______"" Pulse"_______" " " Urinalysis"___________________"" " " " " " " " " """Alb." " Sugar"3.""Please"complete"the"following"by"indicating"normal"with"a"check.""Explain"abnormal"findings:""""""A." Vision" " Visual"Acuity:""Right"20/_______" " " Left"20/________" """"""B."""""Hearing"__________________________________________________________________________________________________""""""""C."""""Eye,"Ear,"Nose,"Throat"__________________________________________________________________________________"""""""D."""""Neck,"Thyroid"___________________________________________________________________________________________"""""""E."""""Heart"_____________________________________________________________________________________________________"""""""F."""""Lungs" ____________________________________________________________________________________________________"""""""G.""""Breasts"___________________________________________________________________________________________________"""""""H.""""Abdomen,"Hernia" _______________________________________________________________________________________"""""""I."""""Nervous"System"_________________________________________________________________________________________"""""""J""""""Bone"and"Joint"___________________________________________________________________________________________"""""""K.""""Genito9Urinary"__________________________________________________________________________________________"""""""L.""""Skin"_______________________________________________________________________________________________________""4.""""Immunization"given:""(Dates!required!or!need!to!get!immunization/titer)!*!Note:!Students!will!be!unable!go!to!clinical!sites!without!dates!given!or!titers.!!!!!!Tetanus!Toxoid" " Date"1" " Date"2" Tdap! "Rubeola!Vac." " Date"1" " Date"2" Titer!Result! "Mumps!Vac.! " Date"1" " Date"2" Titer!Result! "Varicella!Zoster" " Date"1" " Date"2" Titer!Result! "Rubella!Vac." " Date"1" " Date"2" Titer!Result! "*Rubella"vaccine"must"be"after"1969"or"will"need"Rubella"titer"as"proof"of"immunity"Hepatitis!B!Vac.! Three"shot"

series:"" " " " "

" " " " " """""Date"1"" """""""""""""Date"2" " """""""Date"3"*If!student!declines!Hepatitis!B.!Vac.!please!document!declination,!and!have!student!sign!as!well.!"Tuberculin!Skin!Test:! Date" " Positive" " Negative" "*If"skin"test"is"“positive”,"then"chest"X9ray"is"required."Chest"X9ray:" """Date" " Positive" " Negative" "!!!!!!!____________________________________________________________________________!"5.""Is"student"capable"of"regular"physical"activity?"_________"If"not,"please"explain:"____________________________"_______________________________________________________________________________________________""6.""Summary"of"findings:"___________________________________________________________________________"________________________________________________________________________________________________""Health!Care!Provider!(M.D.,!Nurse!Practitioner,!Physician’s!Assistant),!please!sign!and!date:!"Name______________________________" " Signature__________________________"""""""""""""""""""Please"print""Address____________________________" " Date______________________________""""""""""""""____________________________"

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13"

!EASTERN!MICHIGAN!UNIVERSITY!

School!of!Nursing!This"side"to"be"completed"by"students:"

"I." Enrollment"for"" ______________" " Student"#"__________________"" " " """"" Semester"year""II." Name"_________________________________________________________________________________________""" " Last" " " " First" " " " Middle""" Address"____________________________________________________""" """""""""""""""Street"" """""""""""""""""""________________________________________________________________""" """"""""""""""""""City" " " State" " """""""""Zip""III." Age" ""________"Birthday"_________________""" PERSON"TO"BE"NOTIFIED"IN"CASE"OF"EMERGENCY:"" _________________________________" " Address"____________________________"" Name" " " " " " " ____________________________""" _________________________________" " Phone" ____________________________"" Relationship" " " " " " " "Personal!History:!Have"you"lived"with"or"been"in"contact"with"anyone"having"Tuberculosis"in"the"past"two"years?""_________"If"yes,"please"explain:"____________________________________________________________________"______________________________________________________________________________________""Do"you"have/have"you"ever"had:"Rheumatic"Fever" " " Tuberculosis" "Scarlet"Fever" " " Kidney"Infection" "Heart"Disease" " " Convulsions" "Diabetes" " " Persistent"or"Migraine"

Headaches""

Asthma" " " High"Blood"Pressure" "Hay"Fever" " " Anemia" "Pneumonia" " " Thyroid"Trouble" "Mental"Illness" " " Ulcers" "If"yes,"please"explain:"____________________________________________________________________"______________________________________________________________________________________""Past"Immunizations:" " " " "(Also!see!#!4! Polio" " Date" "on!other!side)! Smallpox" " Date" "" Diphtheria" " Date" ""Have"you"ever"been"hospitalized?"_________"For"what"and"when?"________________________________"______________________________________________________________________________________"Do"you"have"any"allergies?"________"If"so,"specify:"___________________________________________"Are"you"allergic"to"any"drugs?"______If"so,"specify:____________________________________________"Do"you"have"any"physical"impairment?"__________"If"yes,"please"specify:"__________________________"______________________________________________________________________________________"""**Student’s"Signature"_________________________________________________________________________________"

Please&Return&to:!Sherry!Bumpus,!Eastern!Michigan!University,!340!Marshall!Building,!Ypsilanti,!MI!48197;!sherry.bumpus@emich.edu;!office:!734I487I2279;!Fax!734I487I6946! ! ! ! !!

Eastern(Michigan(University(Mid2Clinical(&(Site(Evaluation(

!Primary!Care!Adult/Gerontology!!Nurse!Practitioner!Program!

!Student!!! ! ! ! ! ! !!!!Course!! ! !!!!!!!!!!!Term!!! ! ! !! ! ! ! ! ! !Preceptor!! ! ! ! ! ! !!!!!Site!!! ! ! ! ! ! !

!Please!circle!the!appropriate!response!to!each!of!the!statements.!!SA(=(Strongly(Agree((((((((((A(=(Agree((((((((((D(=(Disagree((((((((((SD(=(Strongly(Disagree( NO=Not(Observed(

!1. History!taking!skills!are!well!developed.! SA( A( D( SD( NO(

2. Physical!exam!skills!are!well!developed.! SA( A( D( SD( NO(

3. Collected!data!is!presented!in!a!complete!and!organized!manner.! SA( A( D( SD( NO(

4. Management!of!common!acute!problems!is!appropriate!for!patient!needs!and!student!level!of!preparation.!

SA( A( D( SD( NO(

5. Consistently!address!health!promotion!issues!to!age!and!gender.! SA( A( D( SD( NO(

6. Patient!teaching!is!well!done.! SA( A( D( SD( NO(

7. A!good!working!relationship!with!patients!is!developed.! SA( A( D( SD( NO(

!Student!Strengths:!!!!Student!Limitations:!!!!Other!Comments:!!!!Preceptor!/!Faculty!Signature!&!Date:!!! ! ! ! ! ! ! ! ! !!!!!!!!!!!!(circle!one)!!Student!Signature!&!Date:!!! ! ! ! ! ! ! ! ! ! ! !

NP Student Clinical Evaluation

Student’s Name:___________________________________________ # of Hours Completed: _________________________ Preceptor’s Name: _________________________________________ Course Title & #: ________________________________

COMPETENCY AREA: Scientific Foundation CONSIDERABLE guidance needed

MODERATE guidance needed

Fairly CONSISTENT in meeting

competency goals

CONSISTENT & Self directed in meeting competency goals

1. Critically analyzes data and evidence for improving advanced nursing practice. 2. Integrates knowledge from the humanities and sciences within the context of nursing science. 3. Translates research and other forms of knowledge to improve practice processes and outcomes. 4. Develops new practice approaches based on the integration of research, theory, and practice knowledge.

COMPETENCY AREA: Leadership CONSIDERABLE guidance needed

MODERATE guidance needed

Fairly CONSISTENT in meeting competency goals

CONSISTENT & Self directed in meeting competency goals

1. Assumes complex and advanced leadership roles to initiate and guide change. 2. Provides leadership to foster collaboration with multiple stakeholders (e.g., patients, community, integrated health care teams,and policy makers) to improve health care.

3. Demonstrates leadership that uses critical and reflective thinking. 4. Advocates for improved access, quality, and cost effective health care. 5. Advances practice through the development and implementation of innovations incorporating principles of change. 6. Communicates practice knowledge effectively both orally and in writing. 7. Participates in professional organizations and activities that influence advanced practice nursing and/or health outcomes of a

population focus.

COMPETENCY AREA: Quality CONSIDERABLE guidance needed

MODERATE guidance needed

Fairly CONSISTENT in meeting competency goals

CONSISTENT & Self directed in meeting competency goals

1. Uses best available evidence to continuously improve quality of clinical practice. 2. Evaluates the relationships among access, cost, quality, and safety and their influence on health care. 3. Evaluates how organizational structure, care processes, financing, marketing and policy decisions impact quality of health care. 4. Applies skills in peer review to promote a culture of excellence. 5. Anticipates variations in practice and is proactive in implementing interventions to ensure quality.

COMPETENCY AREA: Practice Inquiry CONSIDERABLE guidance needed

MODERATE guidance needed

Fairly CONSISTENT in meeting competency goals

CONSISTENT & Self directed in meeting competency goals

1. Provides leadership in the translation of new knowledge into practice. 2. Generates knowledge from clinical practice to improve practice and patient outcomes. 3. Applies clinical investigative skills to improve health outcomes. 4. Leads practice inquiry, individually or in partnership with others. 5. Disseminates evidence from inquiry to diverse audiences using multiple modalities. 6. Analyzes clinical guidelines for individualized application into practice.

COMPETENCY AREA: Technology and Information Literacy CONSIDERABLE guidance needed

MODERATE guidance needed

Fairly CONSISTENT in meeting competency goals

CONSISTENT & Self directed in meeting competency goals

1. Integrates appropriate technologies for knowledge management to improve health care. 2. Translates technical and scientific health information appropriate for various users’ needs. 2a. Assesses the patient’s and caregiver’s educational needs to provide effective, personalized health care. 2b. Coaches the patient and caregiver for positive behavioral change. 3. Demonstrates information literacy skills in complex decision making. 4. Contributes to the design of clinical information systems that promote safe, quality, and cost effective care. 5. Uses technology systems that capture data on variables for the evaluation of nursing care.

Please Return to: Sherry Bumpus, Eastern Michigan University, 340 Marshall Building, Ypsilanti, MI 48197; sherry.bumpus@emich.edu; office: 734-487-2279; Fax 734-487-6946

COMPETENCY AREA: Policy CONSIDERABLE guidance needed

MODERATE guidance needed

Fairly CONSISTENT in meeting competency goals

CONSISTENT & Self directed in meeting competency goals

1. Demonstrates an understanding of the interdependence of policy and practice. 2. Advocates for ethical policies that promote access, equity, quality, and cost. 3. Analyzes ethical, legal, and social factors influencing policy development. 4. Contributes in the development of health policy. 5. Analyzes the implications of health policy across disciplines. 6. Evaluates the impact of globalization on health care policy development.

COMPETENCY AREA: Health Delivery Systems CONSIDERABLE guidance needed

MODERATE guidance needed

Fairly CONSISTENT in meeting competency goals

CONSISTENT & Self directed in meeting competency goals

1. Applies knowledge of organizational practices and complex systems to improve health care delivery. 2. Effects health care change using broad based skills including negotiating, consensus-building, and partnering. 3. Minimizes risk to patient and providers at the individual and systems level. 4. Facilitates the development of health care systems that address the needs of culturally diverse populations, providers, and other

stakeholders.

5. Evaluates the impact of health care delivery on patients, providers, other stakeholders, and the environment. 6. Analyzes organizational structure, functions, and resources to improve the delivery of care. 7. Collaborates in planning for transitions across the continuum of care.

COMPETENCY AREA: Ethics CONSIDERABLE guidance needed

MODERATE guidance needed

Fairly CONSISTENT in meeting

competency goals

CONSISTENT & Self directed in meeting competency goals

1. Integrates ethical principles in decision making. 2. Evaluates the ethical consequences of decisions. 3. Applies ethically sound solutions to complex issues related to individuals, populations, and systems of care.

COMPETENCY AREA: Independent Practice CONSIDERABLE guidance needed

MODERATE guidance needed

Fairly CONSISTENT in meeting

competency goals

CONSISTENT & Self directed in meeting competency goals

1. Functions as a licensed independent practitioner. 2. Demonstrates the highest level of accountability for professional practice/ 3. Practices independently managing previously diagnosed and undiagnosed patients. 3a. Provides the full spectrum of health care services to include health promotion, disease prevention, health protection,

anticipatory guidance, counseling, disease management, palliative and end of life care.

3b. Uses advanced health assessment skills to differentiate between normal, variations of normal and abnormal findings. 3c. Employs screening and diagnostic strategies in the development of diagnoses. 3d. Prescribes medications within the scope of practice. 3e. Manages the health/illness status of patients and families over time. 4. Provides patient-centered care recognizing cultural diversity and the patient or designee as a full partner in decision making. 4a. Works to establish a relationship with the patient characterized by mutual respect, empathy, and collaboration. 4b. Creates a climate of patient-centered care to include confidentiality, privacy, comfort, emotional support, mutual trust, and

respect.

4c. Incorporates the patient’s cultural and spiritual preferences, values, and beliefs into health care. 4d. Preserves the patient’s control over decision making by negotiating a mutually acceptable plan of care.

Student Strengths: Areas for development/improvement:

Preceptor’s Signature/Date :_________________________________________________ Student Signature/Date:_____________________________________________________

NP CLINICAL SKILLS & PROCEDURES CHECKLIST*

NAME:

#

PROCEDURE (e.g. suturing)

SKILL LEVEL PRECEPTOR’ SIGNATURE & DATE (PROCEDURE AND SKILL LEVEL TO BE SIGNED OFF BY PRECEPTOR WHEN COMPLETED)

CONFIDENT & INDEPENDENT

FAIRLY

CONFIDENT MINIMAL

SUPERVISION NEEDED

MODERATE

SUPERVISION NEEDED

PERFORMED ONCE

& WITH SUPERVISION

NEVER

PERFORMED OR NOT APPLICABLE

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

*Checklist should be customized by each NP program and can be continued after the student enters advanced practice to document newly acquired expertise.

Please Return to: Sherry Bumpus, Eastern Michigan University, 340 Marshall Building, Ypsilanti, MI 48197; sherry.bumpus@emich.edu; office: 734-487-2279; Fax 734-487-6946

NAME:

#

PROCEDURE

SKILL LEVEL PRECEPTOR’ SIGNATURE & DATE (PROCEDURE AND SKILL LEVEL TO BE SIGNED OFF BY PRECEPTOR WHEN COMPLETED)

CONFIDENT & INDEPENDENT

FAIRLY

CONFIDENT MINIMAL

SUPERVISION NEEDED

MODERATE

SUPERVISION NEEDED

PERFORMED ONCE

& WITH SUPERVISION

NEVER

PERFORMED OR NOT APPLICABLE

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

*Checklist should be customized by each NP program and can be continued after the student enters advanced practice to document newly acquired expertise.

Please Return to: Sherry Bumpus, Eastern Michigan University, 340 Marshall Building, Ypsilanti, MI 48197; sherry.bumpus@emich.edu; office: 734-487-2279; Fax 734-487-6946

STUDENT EVALUATION OF CLINICAL PRACTICUM and SITE

INSTRUCTIONS: Please evaluate your clinical practicum site for this semester. Answer each statement by circling the number that most accurately reflects your evaluation of the clinical practicum. Please use the scale defined below:

1 = Strongly Disagree 3 = Neither disagree or agree, or not applicable 5 = Strongly Agree 2 = Disagree 4 = Agree 1. The clinical site provided adequate practice opportunities for growth as an

advanced practice nurse. 5 4 3 2 1

2. This clinical site has resources to support a student practicum.

5

4

3

2

1

3. This clinical site has procedure and protocol manuals, educational

materials, and personnel to adequately support a student in advanced practice nursing.

5

4

3

2

1

4. I was able to use a theoretical model to guide my practice in the clinical site

with little or no difficulty.

5

4

3

2

1

5. The clinical preceptor was sensitive to my need for guidance.

5

4

3

2

1 6. The clinical preceptor was able to allow for latitude for my developing

autonomy.

5

4

3

2

1

7. I was stimulated by the clinical preceptor to confront new problems and

situations to prepare me for advanced practice.

5

4

3

2

1

8. The clinical site director, preceptor (circle one) assisted me to fulfill the

objectives of the course of study for which this clinical practicum was organized.

5

4

3

2

1

9. The clinical site personnel did not utilize my services as a worker except as

contracted in my clinical contract.

5

4

3

2

1

10. I was evaluated fairly and objectively by my clinical preceptor.

5

4

3

2

1 11. I would recommend this preceptor to my peers for practicum experience.

5

4

3

2

1

12. I would recommend this clinical site to my peers for practicum experience.

5

4

3

2

1

13. Patients are variable in age, diagnoses, and numbers.

5

4

3

2

1

14. Diagnostic test results are readily accessible.

5

4

3

2

1

15. The philosophy of the personnel was directed toward quality care, health

promotion, and disease prevention.

5

4

3

2

1

16. Opportunities were readily available for my participation in management of care for patients.

5

4

3

2

1

17. My overall evaluation of this clinical practicum site is: (Indicate as below)

Excellent (5) Good (4) Fair (3) Poor (2) Would not recommend (1)

5

4

3

2

1

Name of Clinical Preceptor : Name of Clinical Site:

Name of Student: Dates Faculty: Date:

FOR COMMENTS, PLEASE USE ADDITIONAL PAGE