RN Case Manager RN Peer Input Tool for Annual Evaluation:
Therapeutic Relationships-Engagement
Peer feedback for (RN name):
Directions:
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Evaluatee to send domain portions to peers who evaluatee would like feedback from
Clinical Thinking and Judgment domain is to be completed by another RN
Peers should indicate within the last column the level they feel is appropriate for the Evaluatee on each row
Peers are encouraged to support their views with concrete examples
Peers should complete the peer review within 7 Days and return electronically to the Manager/Designee and Evaluatee
Role Entry / Competent
Expert
Mastery
Peer Should Designate
Appropriate Level Below
DOMAIN: Therapeutic Relationships-Engagement: A constellation of nursing activities that are responsive to the uniqueness
of the patient and family and that create a compassionate and therapeutic environment with the aim of promoting comfort and
preventing suffering
Therapeutic Communication
Individualizes communication
based on assessment of
patients and families.
Possesses clarity on one’s own
values and how they affect
interactions, relationships and
boundary setting, incorporating
that understanding into
patient/family interactions
Consistently role models
individualized therapeutic
communication based on patient
and family needs.
Identifies when peers and team
members’ values and beliefs
affect their clinical judgment and
patient/family care.
Intuitively uses therapeutic
communication with
patient/family.
Challenges and moves to
resolves team biases utilizing
appropriate resources (I.e.
Ethics Committee) as
needed.***
Caring Practice and Engagement
Demonstrates empathy in
interactions with patients and
families.
Plans and provides care
management actions that
promote intentional caring.
Proactively anticipates
patient/family response and
provides creative approaches to
optimize comfort and support
Empowerment
Invites patients and families to
actively participate in plan of
care to foster growth,
competence, and selfefficacy.***
Maximizes patient/family
participation in decision-making
and goal setting along the
continuum to ensure and
advance the plan of care to
support successful transition to
the next level of care (I.e. care
conferences and other
practices).***
Identifies and actively engages
patient/family strengths and
expertise and motivates them to
implement the plan towards a
successful transition.***
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Please describe a time when you saw me at my very best. What qualities did I display in this domain?
Please provide your input regarding opportunities for my personal and/or professional growth
I have completed the Peer Feedback Class as required by the UMPNC contract, paragraph 28E, for participation in the
peer review process.
Name:
Date:
Revised 7/2015 Professional Development Framework RSAM Steering Committee/JIT Approved.
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