Nurse Performance Evaluation (Form 1A)
Employee:
School Year:
EIN:
School:
Fall Summative Evaluation
Evaluator:
Status:
Probationary
Date:
Spring Summative Evaluation
Continuing
Evaluation
Self-Review
DOMAIN 1 FOR NURSES: PLANNING AND PREPARATION
COMPONENT
1a.
Demonstrating knowledge of
school nurse practice by
maintaining student health and
safety on campus/Understanding
the professional, ethical and legal
standards that guide the nurse in
the school setting
INEFFECTIVE
DEVELOPING
EFFECTIVE
HIGHLY EFFECTIVE
Nurse demonstrates little
understanding of school nurse
practice. Nurse has little
understanding of professional
expectations and legal regulations
related to the practice of school
nursing.
Nurse demonstrates basic
understanding of School Nurse
Practice, through the utilization of
data, documentation and treatment
planning. Nurse has basic
understanding of professional
expectations and legal regulations
related to the practice of school
nursing.
Nurse demonstrates adequate
understanding of school nurse
practice, through the utilization of
data, documentation and
treatment planning. Nurse has
understanding of professional
expectations and legal regulations
related to the practice of school
nursing.
Nurse demonstrates deep and
thorough understanding of school
nurse practice. School nurse actively
maintains student health through
assessment, planning, treatment,
documentation and evaluation. The
school nurse has a thorough
understanding of the ethical
expectations and legal regulations
and provides leadership in sharing
such knowledge with colleagues.
Nurse displays little knowledge of
child and adolescent development
and has little ability to assess student
developmental milestones.
Nurse displays basic knowledge of
child and adolescent development.
Supports are needed to further skills
in developmental assessment.
Nurse displays accurate
understanding of child and
adolescent development and is
able to apply this knowledge in
health teachings, health promotion
and special education meetings.
Nurse displays thorough knowledge
of child and adolescent development.
Nurse displays knowledge of
development delays and their impact
on student performance. Nurse
provides leadership in sharing such
knowledge with colleagues.
EVIDENCE:
1b:
Demonstrating knowledge of child
and adolescent development
EVIDENCE:
1c:
Establishing goals for the school
health program appropriate to the
setting and the students served
Nurse has no clear goals for the
school health program, or they are
inappropriate to either the situation or
the age of the students.
Nurse’s goals for the school health
program are rudimentary and are
partially suitable to the situation and
the age of the students.
Nurse’s goals for the school
health program are clear and
appropriate to the situation and
age of the students. Nurse is able
to coordinate work and establish
goals independently by
communicating with the school
community.
Nurse's goals for the school health
program are highly appropriate to the
situation and to the age of the
students. Goals have been
developed through consultations with
students, parents, and/or colleagues.
Nurse demonstrates little or no
knowledge of nursing scope of
practice, governmental regulations or
district procedures/resources.
Nurse demonstrates basic
knowledge of nursing scope of
practice. Nurse displays awareness
of governmental regulations and of
most district procedures/resources.
Nurse demonstrates limited
knowledge of resources available
within the community.
Nurse demonstrates adequate
knowledge of nursing scope of
practice. Nurse displays
awareness of governmental
regulations, district procedures
and resources for students
available through the school,
district and the community.
Nurse demonstrates substantial
knowledge of nursing scope of
practice. Nurse’s knowledge of
governmental regulations, district
procedures and resources is
extensive. Nurse takes a leadership
role in sharing knowledge and
participates in department review and
ongoing evaluation of health manual
guidelines.
Nurse does not appear to have an
overall plan but instead provides
services in a seemingly random way.
Nurse does not use a problemsolving framework to work with
teachers, colleagues, and parents in
writing and implementing care plans
for the students.
Nurse writes an Individual healthcare
plan but does not individualize the
plan. Does not consistently use a
problem-solving framework.
Nurse writes student Individual
healthcare plans that are
individualized and utilizes problem
solving approach to respond to
concerns by consulting with
parent and medical provider.
Nurse is able to collaborate with
school staff in implementing the
plan.
Nurse writes, individualizes and
implements student Individual
healthcare plans that are detailed,
relevant and appropriate to the
school setting. Nurse consistently
utilizes problem solving framework in
responding to concerns and assumes
a leadership role in training.
EVIDENCE:
1d:
Demonstrating knowledge of
nursing scope of practice/Utilizes
district resources and health
manual procedures/Follows state
and federal regulations, by
maintaining appropriate license
and certifications
EVIDENCE:
1e:
Writing Individual healthcare plans
for students
EVIDENCE:
1f:
Demonstrating knowledge of
school and community resources
EVIDENCE:
Nurse has little knowledge of school
and community resources. Does not
know how to access district
resources webpage.
Nurse has some knowledge of school
and community resources and may
occasionally research resources.
Nurse utilizes resources for the
benefit of students or the school
community.
Nurse utilizes and develops
resources for the school and
community. Nurse regularly provides
feedback regarding the use of
resources.
DOMAIN 2 FOR NURSES: THE ENVIRONMENT
COMPONENTS
2a:
Creating an environment of
respect and rapport in
professional relationships and
with students, staff and parents
INEFFECTIVE
DEVELOPING
EFFECTIVE
HIGHLY EFFECTIVE
Nurse’s interactions with some staff,
students or parents may be negative
or inappropriate. School nurse rarely
engages in collaborative, effective,
and/or ethical professional
relationships. The school nurse does
not promote teamwork.
Nurse’s interactions with staff,
students or parents are a mix of
positive and negative. School nurse
engages in some collaborative
relationships but these are not
always effective.
Nurse’s interactions with students,
parents or staff are positive and
respectful. The school nurse
engages in collaborative, effective,
and ethical professional
relationships that promote a
positive team environment.
In addition to the standard, students,
staff and parents often seek out the
nurse, reflecting a high degree of
comfort and trust in the relationship
and collaborative outcomes.
Nurse makes no attempt to establish
a culturally sensitive environment in
the health office.
Nurse attempts to establish a
culturally sensitive environment in the
health office, but additional support
and training are necessary.
Nurse promotes a culturally
sensitive environment in the
health office by understanding the
cultural diversity of the school
population.
A culturally sensitive environment is
promoted and fostered by the school
nurse. The school nurse actively
seeks knowledge and works with
others to promote acceptance.
Nurse does not consistently follow
procedures as outlined in the health
manual and state/county
immunization reporting guidelines.
Nurse partially follows procedures.
Nurse is able to locate district policy,
Health Services guidelines and is
aware of immunization regulations.
Nurse follows procedures in a
consistent and predictable
manner, utilizing the health
services manual and other
state/county reporting documents.
Identifies and refer students who
are not in compliance with state
immunization law.
In addition to the standards, nurse
consistently follows procedures in a
seamless fashion, anticipating
unexpected situations. Suggestions
for changes are appropriate and data
driven.
EVIDENCE:
2b:
Establishing an environment that
is culturally sensitive
EVIDENCE:
2c:
Utilizing health protocols and
procedures in providing care to
students
EVIDENCE:
2d:
Supervising health assistants
No guidelines for delegated duties
have been established or the
guidelines are unclear. Nurse does
not monitor health assistant activities
or documentation.
Nurse’s efforts to establish guidelines
for delegated duties are partially
successful. Nurse monitors health
assistant activities sporadically.
Nurse has established guidelines
for delegated duties and monitors
health assistant activities on a
regular basis including review of
documentation and ongoing
mentoring.
Nurse provides clear guidance and
ongoing supervision of the health
assistant. Nurse facilitates
independent and safe functioning of
health office duties by the Health
Assistants and provides ongoing
mentoring.
Health office is disorganized and
unkept. Substitute folder is not
properly maintained.
Health office is adequately
organized, and clean. Substitute
folder is often out of date.
Health office is well organized and
clean. Resource information and
student care plans are accessible
and substitute folder is up to date.
Health office is efficiently organized.
Resource information, care plans and
student information is accessible.
Nurse is able to prioritize
organizational tasks.
EVIDENCE:
2e:
Organizing health office
EVIDENCE:
DOMAIN 3 FOR NURSES: DELIVERY OF SERVICE
COMPONENTS
3a:
Assessing student needs
INEFFECTIVE
DEVELOPING
EFFECTIVE
HIGH EFFECTIVE
Nurse does not assess student
needs or the assessment results are
inaccurate. Cannot apply triage
principles to identify critical incident.
Nurse provides basic assessment of
student's needs and can apply some
triage principles.
Nurse provides adequate
assessment of student needs and
applies appropriate interventions
during incidents of a critical
nature.
Nurse conducts detailed and
individualized assessment of student
needs and applies intervention
strategies to determine the best use
of resources.
Medications are administered with no
regard to state or district policies.
Medications are not properly stored.
Medications are administered by
designated individuals. Nurse
assures basic training of delegated
persons and effective record
keeping. Medications are difficult to
find.
Medications are appropriately
administered by designated
individuals. Nurse evaluates and
re-adjusts delegation duties as
needed. Medications are properly
stored and well organized.
Medications are administered by
designated individuals in a highly
effective manner. Students take an
active role in medication compliance.
Parent and medical provider are
informed of potential problems in a
timely and professional manner.
Nurse does not provide wellness
education programs or provide public
health information to school
community.
Nurse promotes wellness through
classroom presentations or individual
education. Public health information
is not clear and concise.
Nurse promotes wellness through
classroom presentations and
individual education. Public health
information and monitoring are
performed on a regular basis and
are effective.
Nurse promotes wellness through
classroom presentations and
individual education. Public health
information and monitoring are highly
effective. Positive life choices are
encouraged.
EVIDENCE:
3b:
Administering medications to
students
EVIDENCE:
3c:
Promoting wellness through
individual, classroom or school
wide education and acts as a
public health resource
EVIDENCE:
3d:
Managing emergency situations
Nurse has no contingency plans for
emergency situations.
Nurse’s plans for emergency
situations have been developed for
the most frequently occurring
situations.
Nurse’s plans for emergency
situations have been developed
for many situations and are clear
and concise.
Nurse's plans for emergency
situations have been developed for
many situations. Students and
teachers have learned their
responsibilities in case of
emergencies. Nurse provides input
into preparedness planning and
follow-up.
Nurse declines to collaborate with
parents and teachers to develop
individualized health care plans. Few
staff are trained to provide service.
Nurse collaborates with parents and
teachers in developing individualized
healthcare plans when asked. Some
staff are trained to provide service.
Nurse initiates collaboration with
parents and teachers in
developing individualized
healthcare plan (IHP) for students.
IHP is clear, concise and is
reviewed annually or as needed.
Training and delegation follows
guidelines with at least three
school staff trained.
In addition to standards, the nurse
initiates collaboration with parents,
medical providers and teachers in
developing individualized healthcare
plans. Nurse actively locates
resources for parents, students and
teachers, as appropriate.
EVIDENCE:
3e:
Collaborating with parent and
teachers to develop individualized
healthcare plans (IHP) and
services for students with special
medical needs
EVIDENCE:
DOMAIN 4 FOR NURSES: PROFESSIONAL RESPONSIBILITIES
COMPONENT
4a:
Reflecting on nursing practice
which is based on current
scientific evidence
INEFFECTIVE
DEVELOPING
EFFECTIVE
HIGHLY EFFECTIVE
Nurse does not show evidence of
school nurse practice, or the
reflections are inaccurate or selfserving.
Nurse's reflection of evidence based
practice is moderately accurate and
objective. Nurse needs development
in analysis of planning and
implementation of school nurse
techniques and practice.
Nurse's reflection provides an
accurate and objective description
of evidence based practice, citing
specific positive and negative
characteristics. Nurse actively
seeks ideas for program
improvement through selfdirection and feedback from
colleagues.
Nurse's reflection is highly accurate
and perceptive. Nurse draws on an
extensive repertoire to suggest
alternative strategies to improve
health office activity. Health office
activities support the educational
goals of the school. Nurse serves as
a mentor and engages in professional
activities.
Nurse’s health log, medication
records and immunization records,
are frequently missing, late or
inaccurate.
Nurse’s health log, medication
records and immunization records
are generally accurate, but are
occasionally late.
Nurse’s health log, medication
records and immunization records
are accurate and are submitted in a
timely manner.
In addition to meeting the criteria on
this standard, the nurse’s approach to
record keeping is highly systematic
and efficient. Nurse's documentation
serves as a model for colleagues
across the school. Reports are
accurate and timely.
Nurse does not communicate clearly
or effectively and in a timely manner
with students, parents and school
personnel.
Nurse makes an effort to
communicate with students, parents,
and school personnel, but these
communications may not always be
made in a timely manner or may
occasionally lack clarity and/or
sensitivity.
Nurse regularly communicates
with students, parents, and school
personnel and these
communications are made in a
timely manner and are delivered
with clarity and sensitivity. The
nurse frequently acts as a
resource person to staff and
families.
In addition to meeting the criteria on
this standard, the nurse proactively
consults with families, medical
providers and colleagues.
EVIDENCE:
4b:
Maintaining health records in
accordance with policy and
submitting reports in a timely
fashion
EVIDENCE:
4c:
Professional communication
EVIDENCE:
4d:
Maintaining confidentiality
Nurse violates confidentiality of
sensitive issues when dealing with
colleagues or student issues.
Nurse appropriately maintains
confidentiality of sensitive issues
when dealing with colleagues or
student issues in most interactions.
Nurse appropriately maintains
confidentiality in all interactions.
Nurse is sensitive to issues when
dealing with health related
concerns and provides information
when appropriate.
Nurse maintains confidentiality in all
interactions. Nurse is seen as a
resource and instructs colleagues in
confidentiality rules. Nurse has a
clear understanding of HIPPA and
FERPA laws pertaining to interactions
in the school setting.
Nurse does not participate in
professional development activities,
even when such activities are clearly
needed for the development of school
nursing skills.
Nurse’s participation in professional
development activities is limited to
those that are convenient or are
required.
Nurse seeks out opportunities for
professional development based
on an individual assessment of
need. Nurse networks with
colleagues to share strategies.
Nurse actively pursues professional
development opportunities and
makes a substantial contribution to
the profession through such activities
as offering workshops to colleagues.
Nurse belongs to professional
organizations for increased
continuing education. Nurse stays up
to date with school nursing journals,
articles, websites.
Nurse is not seen as a role model in
the school. Nurse displays dishonesty
in interactions with colleagues,
students, and/or the public, does not
exercise good judgment in
professional settings and does not
have dependable attendance.
Nurse is seen as a role model in
some situations. Nurse is honest in
interactions with colleagues,
students, and/or the public, plays a
moderate advocacy role for students,
and exercises good judgment in
professional settings.
Nurse is seen as a role model in
the school in most interactions.
Nurse displays high standards of
honesty, integrity with interactions
with colleagues, students, and/or
the public. Nurse exercises good
judgment in professional settings
and advocates for students when
needed.
Nurse is consistently seen as a
professional role model by students
and colleagues in the school. Nurse
can be counted on to hold the highest
standards of honesty, integrity,
professional judgment and advocates
for students, taking a leadership role
with colleagues.
EVIDENCE:
4e:
Engaging in professional
development
EVIDENCE:
4f:
Shows professionalism by being a
good role model including
dependable attendance,
punctuality in performance of
duties and professional
appearance.
EVIDENCE: