12/10/2010 Revision No 4
CLINICAL PLACEMENT EVALUATION FORM
BSc in General/Psychiatry Nursing Programmes
Dublin-Mid Leinster
in partnership with
Athlone Institute of Technology
This questionnaire is part of a continuous evaluation of clinical placements for student nurses.
The aim is to develop and maintain practice placements where students can receive a high
quality experience. Please complete the following questionnaire reflecting your placement
experience and use the space provided for additional comments if so desired. Thank you for
taking time out to complete this questionnaire.
Clinical Placement site:
________________________________________________
Ward/Dept:
________________________________________________
Date:
________________________________________________
Duration of Allocation:
__________________________________________
Year of training:
_______
General
Psychiatry
Please tick each statement with the response closest to your experience of the placement.
Please reply to all statements.
Agree
Disagree
N/A
Comments
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
I received a comprehensive orientation to the
hospital/care facility (If applicable)
Staff in the clinical area were aware I was
commencing placement
I received a comprehensive orientation to the
clinical placement area by the CNM/Staff nurse
A preceptor/co-preceptor was identified for me
on this placement.
I was allocated a registered nurse to work with
during each shift.
I was welcomed as part of the multidisciplinary
team.
Learning outcomes for this placement were
available to me on site
Learning outcomes for this placement were
discussed with me at my preliminary interview.
My preceptor/co-preceptor was familiar with the
expected learning outcomes in relation to this
clinical placement.
I was able to achieve the learning outcomes
during the placement.
There were learning resources including
journals, books, articles and research material
available to me.
Information provided through evaluation feedback is used to continuously monitor and improve clinical placements
12/10/2010 Revision No 4
Agree
12.
IT resources were available.
13.
I had access to HSE policies, guidelines,
protocols and procedures.
I was facilitated to avail of my Protected
Learning Time.
My assessment was carried out by my
preceptor/co-preceptor.
The clinical placement was appropriate to my
level of experience.
During my clinical placement I was supervised
to an appropriate level
I was not allocated duties that were beyond my
scope of practice.
Staff facilitated my learning needs and
encouraged a questioning approach.
I received feedback (verbal & written) on my
performance throughout my clinical placement
which was constructive, helpful and given at an
appropriate time.
I was able to participate in the ward report/care
planning.
My duty roster was available far enough in
advance.
The Clinical Placement Co-ordinator (CPC)/
Clinical Placement Facilitator was available for
support and guidance.
I am familiar with and know how to contact the
Student Allocation Liaison Officer for the HSE
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
Disagree
N/A
Comments
What were the positive aspects of this placement?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What areas are in need of improvement?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Signed By____________________________________
(If you wish you can sign this form)
Information provided through evaluation feedback is used to continuously monitor and improve clinical placements