DSN Direct Client Care - Performance Appraisal template
PERFORMANCE APPRAISAL
DESIGNATED SENIOR NURSE
Direct Client Care
Name:
NCNZ Registration number:
APC Expires:
Position:
Department & Service:
FTE:
PDRP Level
Peer Reviewer/s (if applicable)
Nurse/Midwife MANAGER Name:
Date of annual appraisal:
Previous annual appraisal date:
The purpose of the Appraisal
 Annual
 PDRP
 Other
 Designated Senior Nurse
 Level 4
Name:
Designation:
Name:
Designation:
Job description Current:
 Yes
 No
NDHB Values:
Nurse consistently displays the values and behaviours of NDHB (please read through descriptors’ with nurse
and discuss how they reflect these):





People first – Taangata i te tuatahi
Respect – Whakaute (tuku mana)
Caring - Manaaki
Communication – Whakawhitiwhiti korero
Excellence – Taumata teitei (hiranga)
The Performance Appraisal is written in conjunction with the relevant job description by the Charge Nurse/Team Leader
and may include peer review.
The Performance Appraisal is photocopied:
 one copy given to the Nurse
 original copy is placed on personal file in Human Resources
 Nurse managers may also choose to keep a copy on their personnel records
 the documents must be signed by a senior and their title and contact details need to be recorded as well as the
RN being reviewed
If the nurse is submitting for PDRP or being audited by Nursing Council an example of their practise is required
under each competency.
NORTHLAND DISTRICT HEALTH BOARD
TITLE: DSN (direct client care) Performance appraisal
Page 1 of 9
Date of first Issue: 2013
Current Issue: May 2013
Revision Date: March 2016
Authored by: Nurse coordinator PDRP
Reviewed by: PDRP assessors / PDRP council
AUTHORISED BY: Director of Nursing and Midwifery
Initials of nurse completing form: _____________
DSN Direct Client Care - Performance Appraisal template
VALUES AND BEHAVIOURS
Our
VALUES
and Our BEHAVIOURS
Supporting Statements
People First
Taangata i te tuatahi
He whakapapa, he mokopuna, he tamariki, he maatua, he tupuna
He aha te mea nui. He tangata, he tangata, he tangata.
We are inclusive
We acknowledge individuality, teamwork and partnership
People are central to all that
we do
Respect
We bring humour in to our work
Kia ngohengohe, whakaaro nui ki etahi atu
Whakaute (tuku mana)
We show courtesy, care and respect for people’s needs, values and beliefs
We treat others as we
would like to be treated
We enquire
We take personal responsibility for our actions
We honour commitments
Caring
Manaaki
Ko te manaaki – he whangai – he kakahu he ropiropi. Akona e te whanau whaanui
We understand the impact of our actions on others
We are sensitive and empathetic
We nurture those
around us, and treat all
with dignity and
compassion
Communication
Whakawhitiwhiti korero
We are available and accessible
We are kind to each other
We display integrity
Tika, pono, aroha
We listen
We use language the recipient understands
We communicate
safely, openly and with
respect to promote
clear understanding
We openly share information and knowledge
We are timely in our responses
We smile
Excellence
Taumata teitei (hiranga)
Kia mataara te wairua – kia ngakau whakaiti
We display leadership, efficiency and commitment in all our activities
We are open to new ideas and doing it differently
Our attitude of
excellence inspires
success, competence,
confidence and
We are accountable
We value personal and professional development
NORTHLAND DISTRICT HEALTH BOARD
TITLE: DSN (direct client care) Performance appraisal
Page 2 of 9
Date of first Issue: 2013
Current Issue: May 2013
Revision Date: March 2016
Authored by: Nurse coordinator PDRP
Reviewed by: PDRP assessors / PDRP council
AUTHORISED BY: Director of Nursing and Midwifery
Initials of nurse completing form: _____________
DSN Direct Client Care - Performance Appraisal template
innovation
We make decisions based on fact and best evidence
DOMAIN ONE: PROFESSIONAL RESPONSIBILITY
This domain contains competencies that relate to professional, legal and ethical responsibilities and cultural safety.
These include being able to demonstrate knowledge and judgement and being accountable for own actions and
decisions, while promoting an environment that maximises patients’ safety, independence, quality of life and
health.
Competency
1.1 Accepts responsibility for ensuring that his/her nursing practice and conduct meet the standards of the
professional ethical and relevant legislated requirements.
1.2 Demonstrates the ability to apply the principles of the Treaty of Waitangi/Te Tiriti o Waitangi to nursing
practice
NORTHLAND DISTRICT HEALTH BOARD
TITLE: DSN (direct client care) Performance appraisal
Page 3 of 9
Date of first Issue: 2013
Current Issue: May 2013
Revision Date: March 2016
Authored by: Nurse coordinator PDRP
Reviewed by: PDRP assessors / PDRP council
AUTHORISED BY: Director of Nursing and Midwifery
Initials of nurse completing form: _____________
DSN Direct Client Care - Performance Appraisal template
1.3 Demonstrates accountability for directing, monitoring and evaluating nursing care that is provided by
nurse assistants, enrolled nurses and others.
1.4 Promotes an environment that enables client safety, independence, quality of life, and health.
1.5 Practices nursing in a manner that the client determines as being culturally safe
NORTHLAND DISTRICT HEALTH BOARD
TITLE: DSN (direct client care) Performance appraisal
Page 4 of 9
Date of first Issue: 2013
Current Issue: May 2013
Revision Date: March 2016
Authored by: Nurse coordinator PDRP
Reviewed by: PDRP assessors / PDRP council
AUTHORISED BY: Director of Nursing and Midwifery
Initials of nurse completing form: _____________
DSN Direct Client Care - Performance Appraisal template
DOMAIN TWO: MANAGEMENT OF NURSING CARE
This domain contains competencies related to client assessment and managing client care, which is
responsive to clients’ needs, and which nursing knowledge and evidence supports based research.
2.1 Provides planned nursing care to achieve identified outcome.
2.2 Undertakes a comprehensive and accurate nursing assessment of clients in a variety of settings.
2.3 Ensures documentation is accurate and maintains confidentially of information.
2.4 Ensures the client has adequate explanation of the effects, consequences and alternative of proposed
treatment options.
2.5 Acts appropriately to protect oneself and others when faced with unexpected client responses,
confrontation, personal threat or other crisis situations.
2.6 Evaluates client’s progress toward expected outcomes in partnership with clients.
NORTHLAND DISTRICT HEALTH BOARD
TITLE: DSN (direct client care) Performance appraisal
Page 5 of 9
Date of first Issue: 2013
Current Issue: May 2013
Revision Date: March 2016
Authored by: Nurse coordinator PDRP
Reviewed by: PDRP assessors / PDRP council
AUTHORISED BY: Director of Nursing and Midwifery
Initials of nurse completing form: _____________
DSN Direct Client Care - Performance Appraisal template
2.7 Provides health education appropriate to the needs of the client within a nursing framework.
2.8 Reflects upon, and evaluates with peers and experienced nurses the effectiveness of nursing care.
2.9 Maintains professional development
DOMAIN THREE: INTERPERSONAL RELATIONSHIPS
This domain contains competencies related to interpersonal and therapeutic
communication with clients, other nursing staff and inter-professional communication and documentation.
3.1 Establishes, maintains and concludes therapeutic relationships with client
3.2 Practices nursing in a negotiated partnership with client where and when possible
3.3 Communicates effectively with clients and members of health team
NORTHLAND DISTRICT HEALTH BOARD
TITLE: DSN (direct client care) Performance appraisal
Page 6 of 9
Date of first Issue: 2013
Current Issue: May 2013
Revision Date: March 2016
Authored by: Nurse coordinator PDRP
Reviewed by: PDRP assessors / PDRP council
AUTHORISED BY: Director of Nursing and Midwifery
Initials of nurse completing form: _____________
DSN Direct Client Care - Performance Appraisal template
DOMAIN FOUR: INTERPROFESSIONAL HEALTH CARE & QUALITY IMPROVEMENT
This domain contains competencies to demonstrate that, as a member of the health care team; the nurse evaluates the
effectiveness of care and promotes a nursing perspective within the inter-professional activities of the team.
4.1 Collaborates and participates with colleagues and members of the health care team to facilitate and
coordinate care.
4.2 Recognises and values the roles and skills of all member of the health care team in the delivery of care.
4.3 Participates in quality improvement activities to monitor and improves standards of nursing.
Key performance outcomes from Job description:
Please make comment on the out come requirements from the nurses Job descriptions key responsibilities:
Key Responsibility
area:
Comments on expected outcomes:
NORTHLAND DISTRICT HEALTH BOARD
TITLE: DSN (direct client care) Performance appraisal
Page 7 of 9
Date of first Issue: 2013
Current Issue: May 2013
Revision Date: March 2016
Authored by: Nurse coordinator PDRP
Reviewed by: PDRP assessors / PDRP council
AUTHORISED BY: Director of Nursing and Midwifery
Initials of nurse completing form: _____________
DSN Direct Client Care - Performance Appraisal template
Performance Development Objectives 6 – 12 months time frame
E.g. PDRP development, Post graduate study (CTA), Short courses, Skill acquisition, Quality
initiatives, Leadership roles/responsibilities, conferences .
Refer to current job description in order to make comment.
Objective
(Skill/Experience/Knowl
edge to be gained)
How will this be
gained?
(e.g. on the job
experiences; seminars;
conferences; PG study)
Provider
(e.g.
Nurse/Midwife
Educator on the
Ward; SM0;
University)
Professional Development
Start Date
Completion
Date
Key Performance Indicators/ roles and responsibilities
NORTHLAND DISTRICT HEALTH BOARD
TITLE: DSN (direct client care) Performance appraisal
Page 8 of 9
Date of first Issue: 2013
Current Issue: May 2013
Revision Date: March 2016
Authored by: Nurse coordinator PDRP
Reviewed by: PDRP assessors / PDRP council
AUTHORISED BY: Director of Nursing and Midwifery
Initials of nurse completing form: _____________
DSN Direct Client Care - Performance Appraisal template
Manager’s Comments:
Nurse/Midwife Manager
Signature:
Date:
Print name:
Role:
Contact Details :
1. Appraiser (if applicable) Comment:
Appraiser Signature:
Role:
Print name:
Contact Details:
Date:
Nurse being Appraised Comment:
Nurse Signature:
Role:
Print name:
Date:
Contact Details:
After Document signed by Nurse Being appraised no further information to be added
NORTHLAND DISTRICT HEALTH BOARD
TITLE: DSN (direct client care) Performance appraisal
Page 9 of 9
Date of first Issue: 2013
Current Issue: May 2013
Revision Date: March 2016
Authored by: Nurse coordinator PDRP
Reviewed by: PDRP assessors / PDRP council
AUTHORISED BY: Director of Nursing and Midwifery
Initials of nurse completing form: _____________