Domain L: Professional Responsibilities

Employee Name______Performance Review* (*This document has been edited from the School District of Beloit School Nurse Performance Review) School Nurse Domain 1: Professional Responsibilities Component I: Maintaining Accurate Records Elements: Government/state/county compliancy reporting • School District student health reporting Levels of Performance Element Unsatisfactory Basic Proficient Distinguished A) Government/state/county Nurse fails to maintain and Nurse maintains and submits Nurse properly maintains and Nurse properly maintains and compliancy reporting submit required compliancy required compliancy reports. submits required compliancy submits required compliancy reports. reports. Reports are usually reports. Reports are submitted in a timely fashion. consistently submitted in a timely fashion.

B) School District student Nurse fails to document and Nurse maintains confidential Nurse accurately maintains Nurse accurately maintains health reporting maintain confidential student student health records and confidential student health confidential student health health records. documents student health records and documents records and documents concerns. student health concerns. student health concerns. Reporting and documenting is Reporting and documenting is usually done in a timely consistently done in a timely fashion. fashion.

Nurse is knowledgeable of Nurse is knowledgeable of School District health services School District health services policies. policies and is actively involved in the development and review of these policies/procedures.

Evaluator’s Comments ______

______Employee Name ______Domain 1: Professional Responsibilities Component II: Contributing to School, District, and Community Elements: Relationships with colleaguesRelationships with students and their familiesParticipation in school and district projects Demonstrates employee responsibilities Supports a safe and healthy school environment  Provides/contributes to Health Education Programming (HEP) in the school and community Levels of Performance Element Unsatisfactory Basic Proficient Distinguished A) Relationships with Nurse’s relationships with Nurse maintains cordial Nurse maintains supportive Nurse maintains supportive colleagues colleagues are negative. relationships with colleagues and cooperative relationships and cooperative relationships to fulfill the duties that the with colleagues. with colleagues. The nurse school requires. assumes a leadership role.

B) Relationships with Nurse makes no attempt to Nurse communicates with Nurse communicates with Nurse communicates with students and their families communicate with students students and families about students and families on a students and families on a and families about health health-related issues and regular basis about health regular basis about health related issues and concerns concerns, but responses to related issues and concerns related issues and concerns their concerns are minimal. and is available to respond as and is available as needed to needed to their concerns. respond to their concerns. The nurse handles concerns with great sensitivity and delivers care in a non- judgmental and non- discriminatory manner.

C) Participation in school and Nurse avoids becoming Nurse participates in school Nurse volunteers to Nurse volunteers to district projects involved in school and district and district projects only participate in school and participate in school and projects. when asked. district projects and makes a district projects and assumes a substantial contribution. leadership role.

______Employee Name ______Domain 1: Professional Responsibilities Component II: Contributing to School, District, and Community Elements: Relationships with colleaguesRelationships with students and their familiesParticipation in school and district projects Demonstrates employee responsibilities Supports a safe and healthy school environment  Provides/contributes to Health Education Programming (HEP) in the school and community

Levels of Performance Element Unsatisfactory Basic Proficient Distinguished D) Demonstrates employee Nurse fails to present self in a Nurse usually presents self in Nurse consistently presents Nurse consistently presents responsibilities. professional manner. a professional manner. self in a professional manner. self in a professional manner. Reliability, accountability and Reliability, accountability and Reliability, accountability and Reliability, accountability and punctuality are in question. punctuality are apparent. punctuality are excellent. punctuality are exemplary.

Nurse makes no attempt to Nurse is aware of the health Nurse recognizes the health Nurse recognizes the health E) Supports a safe and recognize the health and and safety needs of staff and and safety needs of staff and and safety needs of staff and healthy school environment safety needs of staff and students. students, and offers students and assumes a students. suggestions as to how these leadership role in planning needs may be met. programs and providing interventions to address those needs. F Provides/contributes to Fails to provide/contribute Provides minimal HEP within Provides effective HEP in the Provides effective HEP within Health Education HEP within the school and the school and community. school and community. the school and community. Programming (HEP) in the community. Takes a leadership role in the school and community delivery of HEP and is knowledgeable of health education curriculum.

Evaluator’s Comments:

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______Employee Name ______Domain 1: Professional Responsibilities Component III: Growing and Developing Professionally Elements: Enhancement of professional knowledge and skills  Service to the profession. Levels of Performance Element Unsatisfactory Basic Proficient Distinguished A) Enhancement of Nurse does not engage in Nurse engages in professional Nurse seeks out opportunities Nurse seeks out opportunities professional knowledge and professional development development activities to a for professional development for professional development skills activities to enhance limited extent when they are activities to enhance content activities to enhance content knowledge or skill. convenient. knowledge and nursing skills. knowledge and nursing skills. The nurse is able to apply this new knowledge/skill to his/her work with students and families.

B) Service to the profession Nurse makes no effort to Nurse contributes to the Nurse contributes to the Nurse contributes to the share knowledge/skills with profession by sharing profession by sharing profession by initiating others or to collect school knowledge/skills with others. knowledge/skills with others. activities that share his/her health data. knowledge/skills with others. Nurse assists in collecting Nurse collects school health The nurse participates in school health data. data and participates in the local, state, or national interpretation of this data. organizations. Nurse uses school health data to improve health programming for the school community.

______Employee Name ______Domain 2: Delivery of Service Component I: Advocating for and Maintaining Student Health Elements: Provide care for the sick and injured  Health assessments Levels of Performance Element Unsatisfactory Basic Proficient Distinguished A) Provide care for the sick Nurse’s ability to provide care Nurse’s ability to provide care Nurse’s ability to provide care Nurse’s ability to provide care and injured for the sick and injured for the sick and injured for the sick and injured for the sick and injured demonstrates an inadequate demonstrates minimal demonstrates effective and demonstrates effective and knowledge of basic first aid, knowledge of basic first aid, appropriate knowledge of appropriate knowledge of infectious disease control, and infectious disease control and basic first aid, infectious basic first aid, infectious parameters of basic standards parameters of basic standards disease control and disease control and of nursing care. of nursing care. parameters of basic standards parameters of basic standards of nursing care. of nursing care. Nurse demonstrates a keen sensitivity in providing care for the sick and injured.

B) Health assessments Nurse fails to perform state Nurse adequately performs, Nurse appropriately performs, Nurse appropriately performs, and district mandated health evaluates, and coordinates evaluates, and coordinates evaluates, and coordinates assessments and screenings. state and district mandated state and district mandated state and district mandated Nursing assessment skills are health assessments and health assessments and health assessments and inadequate with poor nursing screenings. screenings. screenings. interventions. Nurse demonstrates Nurse demonstrates excellent Nurse demonstrates acceptable nursing assessment nursing assessment skills with exceptional nursing skills with adequate nursing appropriate nursing assessment skills with interventions. interventions. appropriate nursing interventions, implemented in a safe and timely manner.

Evaluator’s Comments

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______Employee Name ______Domain 2: Delivery of Service Component II: Training and Supervision of Non-Nursing Personnel Elements: Medication administration  Health-related procedures Levels of Performance Element Unsatisfactory Basic Proficient Distinguished A) Medication administration Nurse fails to follow district Nurse follows district Nurse demonstrates accurate Nurse demonstrates accurate medication administration medication administration medication administration and medication administration and policies and procedures. policies and procedures, and provides effective staff provides effective staff is knowledgeable of related instruction and monitoring. instruction and monitoring. statutory requirements. Nurse Nurse consistently follows Nurse consistently follows instructs and monitors staff district medication district medication according to district policy. administration policies and administration policies and procedures and is procedures and is knowledgeable of related knowledgeable of related statutory requirements. statutory requirements. Nurse is actively involved in the review and revision of district medication administration policies and procedures.

B) Health-related procedures Nurse fails to demonstrate Nurse usually demonstrates Nurse consistently Nurse consistently appropriate skills in accurate nursing skills in demonstrates accurate nursing demonstrates accurate nursing performing, delegating, performing health-related skills in performing health- skill in performing health- instructing and monitoring of procedures. Delegation, related procedures. Nurse related procedures. Nurse health-related procedures. instruction and monitoring of appropriately delegates appropriately delegates health-related procedures is nursing acts and provides nursing acts and provides usually done in an appropriate effective staff instruction and effective staff instruction and manner. monitoring. monitoring. Nurse is actively involved in the review and development of district policies related to these procedures.

Evaluator’s Comments

______School Nurse Performance Review

Employee Name ______INSTRUCTIONS This performance review is divided into 2 domains. Domain 1: Reflects the professional responsibilities of the school nurse. Domain 2: Reflects direct nursing services for students.

 Each domain is then subdivided into components.  Each component is comprised of elements. Please evaluate the school nurse by selecting his/her level of performance for each element.  Check the appropriate box . The levels of performance are: unsatisfactory, basic, proficient, distinguished

Completed By ______Date ______

*This document has been edited from the School District of Beloit School Nurse Performance Review

Reference: Scope and Standards of Practice, School Nursing Enhancing Professional Practice: A Framework for Teaching, 2nd ed. National Association of School Nurses, Inc. 2011 Charlotte Danielson, 2007 Suggested Performance Review Procedures 1. A school nurse performance review should be completed individually by the following. a. Student Services Administrator b. Appropriate Site Administrator c. School Nurse 2. Evaluating parties should meet to discuss the individual performance reviews. 3. The final performance review will be a composite of the 3 individually prepared reviews.