The following questionnaire is designed to provide us with an assessment of your orientation needs. It consists of a series of nursing tasks or interventions with which you may or may not currently be familiar.
What we would like to know is the following: What is your level of familiarity or experience with each tasks?
Past unit assignment(s) :
Date of Last Employment :
Date Nursing Experience :
Less than 6 months
1-5 years
6 months to 1-year
6 to more years
What was your usual patient assignment (number) :
The following pages contain list of tasks/interventions, which are common in nursing. It is important for us to know if you are, or are not, familiar with a task/intervention so that we can provide the most relevant orientation possible. There are no right or wrong answer, or right or wrong levels.
A scale is provided that describes the various levels of familiarity/experience. For each of the items in the following pages, please circle the one level that best describes your current level of experience for the task provided. Please use the rating scale as noted on the pages and make any comments as necessary.
CERTIFIED NURSE AIDE PROFILE :
Please refer to the rating scale as you answer the questions :
0
No familiarity at all with the task/intervention.
1
Practice in clinical setting with supervision only.
2
Performed competently in the past
3
Completely comfortable with task/intervention. Need no help.
ASSISTING WITH NUTRITIONAL NEEDS OF PATIENDS TO OBTAIN NUTRITION :
a.
Accurate intake and output
0
1
2
3
b.
Checking special diet trays (e.g., low sodium, diabetic)
0
1
2
3
c.
Fluid restricted diets
0
1
2
3
d.
PM/HS snacks
0
1
2
3
ASSITING RN/LPN WITH PATIENT’S OUTPUT AND INTERVENTION TO MAINTAIN SATISFACTORY ELIMINATION AND TOTAL BODY BALANCE :
a.
Enema :
1.
Tap water
0
1
2
3
2.
Soap suds
0
1
2
3
3.
Fleet
0
1
2
3
4.
Oil retention
0
1
2
3
b.
Care of Patient with Colostomy :
Colostomy care
0
1
2
3
c.
Rectal Tube
0
1
2
3
d.
Care of Patient with Foley :
1.
Taping
0
1
2
3
2.
Catheter care
0
1
2
3
3.
Measuring out from foley bag
0
1
2
3
e.
Application of Condom Catheter/Skin Care
0
1
2
3
f.
Blood Loss Measurement
:
Hemovac
0
1
2
3
g.
Use of Adult Incontinent Briefs
0
1
2
3
h.
Use of disposable Bed Liners (blue pads/chux)
0
1
2
3
SPECIMEN COLLECTION AND DIAGNOSTIC PROCEDURES :
a.
Special Collection:
1.
Urine (clean catch/mid-stream voided)
0
1
2
3
2.
Urine (catheter) with needle
0
1
2
3
3.
Sputum (routine)
0
1
2
3
4.
Stool
0
1
2
3
5.
24 hours urine collection
0
1
2
3
6.
Other (please specify)
b.
Special Testing :
1.
3-glass cycle
0
1
2
3
2.
Other (please specify)
MONITORING :
a.
TPR:
1.
Radial pulse
0
1
2
3
2.
Apical pulse
0
1
2
3
b.
Blood Pressure:
1.
Lying
0
1
2
3
2.
Sitting
0
1
2
3
3.
Standing (orthostatic blood pressure)
0
1
2
3
ASSISTING PATIENTS TO MAINTAIN OPTIMUM MOBILITY:
a.
Range of Motion Exercises
0
1
2
3
b.
Turning/Positioning
0
1
2
3
c.
Transfer from Bed to Clair and Back
0
1
2
3
d.
Use of Gait Belt
0
1
2
3
e.
Ambulation
0
1
2
3
f.
Use of Walker
0
1
2
3
g.
Patient Transport :
1.
By wheelchair
0
1
2
3
2.
By stretcher
0
1
2
3
h.
Other (please specify)
ASSISTING PATIENTS WITH THE FOLLOWING DAILY HYGIENIC :
a.
Nail Care
0
1
2
3
b.
Skin
1.
Bed bath
0
1
2
3
2.
Tub bath
0
1
2
3
3.
Use of shower chair
0
1
2
3
4.
Shower patients who are supine (e.g., bird bath)
0
1
2
3
c.
Hair (shampoo)
0
1
2
3
d.
Mouth :
1.
Brushing patient’s teeth
0
1
2
3
2.
Care of dentures
0
1
2
3
e.
Perineal Care
0
1
2
3
f.
Douche
0
1
2
3
g.
Sitz Bath
0
1
2
3
h.
Other (please specify)
SAFETY :
a.
Aspiration precautions
0
1
2
3
b.
Skin Precautions
0
1
2
3
c.
Seizure Precautions
0
1
2
3
d.
Fall Precautions
0
1
2
3
e.
Suicide precautions
0
1
2
3
f.
Patient Use of Restraints :
1.
Wrist/vest/belt/mitten
0
1
2
3
2.
Wheelchair/pelvic
0
1
2
3
3.
Crib nets
0
1
2
3
4.
Bed alarm
0
1
2
3
5.
Use of positioning devices (i.e., wedges)
0
1
2
3
6.
Side rails
0
1
2
3
g.
Staff Performance Safety :
1.
Turning and repositioning patient
0
1
2
3
2.
Transfer patient from bed to chair and back
0
1
2
3
3.
Proper body mechanics
0
1
2
3
4.
Evacuation of patients
0
1
2
3
h.
Other (please specify)
CARE OF PATIENT WITH :
a.
IV / Saline Lock
0
1
2
3
b.
Fracture/Cast
0
1
2
3
c.
NG / G Tubes
0
1
2
3
d.
Telemetry Monitoring
0
1
2
3
e.
Tracheostomy
0
1
2
3
CARE OF PEDIATRIC PATIENT :
a.
Taking Weight
0
1
2
3
b.
Emotional care such as play, offering comfort measures for family
What has been the average number of patients to who you
were assigned
to give care in an eight hour shift?
COMMUNICATION WITH :
a.
Patients :
1.
Hearing Impaired
0
1
2
3
2.
Visually Impaired
0
1
2
3
3.
Cognitively Impaired
0
1
2
3
b.
Healthcare Team :
1.
Shift Report
0
1
2
3
2.
Reporting Abnormal Signs and Symptoms
0
1
2
3
3.
Chain of Command
0
1
2
3
4.
Abuse of Patients
0
1
2
3
5.
Telephone Etiquette
0
1
2
3
c.
Documentation :
1.
TPR Graphics
0
1
2
3
2.
ADL (as applicable)
0
1
2
3
3.
Kardex (weights in kgms/lbs)
0
1
2
3
4.
Incident Reports
0
1
2
3
APPLICANT’S STATEMENT :
I attest to the validity of my level of competency in the above skills are rated by me. I also acknowledge my responsibility for obtaining appropriate instructions prior to performing any activity with which I am not familiar or have not actually performed.
CURRENT CERTIFICATIONS :
Please list any current certification, which you have earned (e.g., ANA specialty specification, AACN certification, AHA-CPR certification, etc.)
Certification
Organization
Date of Last Certification or Recertification
1.
2.
3.
4.
5.
Basic Life Support
6.
Advanced Life Support
7.
Instructor – BLS
8.
Instructor/Trainer
Please list any additional behavior/skill which you bring to your role which has not been listed above but which you feel is important to nursing practice :
ISLAND TEMPORARY NURSING
WORK PREFERENCE :
It is understood that :
1.
All regular part-time, part-time and call-in employees shall be required to be available for at least two (2) different shifts. However, consideration will be given to requests for permanent night shift assignments.
2.
Whenever possible, consistent with patient needs, the work preference expressed on this form will be given every consideration, but cannot be guaranteed.
3.
Preferences expressed on this form shall not be construed as a guarantee of work hours per day or per week or number of workdays per week.
4.
Regular part-time and part-time employees will be pre-scheduled as needed, based upon full-time employees’ work schedules. They may also be called on a PRN basis.
5.
Call-in employees are generally not pre-scheduled. However, during the preparation of work schedules, if it is known that part-time staff will not be available and availabilities of call-in staff known, the call-in staff may be pre-scheduled.
6.
Call-in employees are expected to be available at least one work shift per week including one weekend out of four. If a call-in is not available for work for four consecutive weeks, he/she will be considered to have terminated employment unless prior notification for non-availability is submitted to the nursing office in writing. Non-availability will not exceed (30) thirty days at any given time or frequency of more than every four months. EXCEPTION: Long term disability, including pregnancy.
My work preference is as follows :
STATUS:
Regular Part-Time
Part-Time
Call-in
SHIFT:
7:00 – 3:30
3:00 – 11:30
11:00 – 7:30
NO. OF DAYS PER WEEK :
COMMENTS :
NOTE :
1.
Changes in availability may be requested thru Island Temporary Nursing.
2.
Providing operational needs can be met, employee preference will be given consideration bargaining unit seniority but cannot be guaranteed
3.
Questions and/or concerns about work schedules are to be directed to Island Temporary Nursing.
