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									                                         BSc (Hons) Nursing
                                                Stage Two
                        Continuous Assessment of Practice Portfolio
                                                   Part A


Student

Student Email                                                                                        @york.ac.uk

Personal Supervisor

Personal Supervisor Email                                                                            @york.ac.uk



As a student you are required to ensure that this Continuous Assessment of Practice (CAP) Portfolio:

     1. is kept secure at all times so that access is limited to those with a legitimate reason to read or
        contribute to it.

     2. is available to your mentors and personal supervisor at all times when you are in practice.




CAP Portfolio Stage 2                                                                                   Page 1 of 85
CAP Portfolio Stage 2   Page 2 of 85
        Quick Reference

        Student Name



        Practice Experience 3

Spoke 1                                                                                 Spoke 4



Start               End                                             Start    End
Date:               Date:                                           Date:    Date:

                                              Practice Base Area
Spoke 2                                                                                  Spoke 5



Start               End                                             Start    End
Date:               Date:                                           Date:    Date:


                                Start Date:           End Date:
Spoke 3                                                                                  Spoke 6



Start               End                                             Start    End
Date:               Date:                                           Date:    Date:




        Practice Experience 4

Spoke 1                                                                                Spoke 4



Start               End                                            Start    End
Date:               Date:                                          Date:    Date:

                                              Practice Base Area
Spoke 2                                                                                 Spoke 5



Start               End                                            Start    End
Date:               Date:                                          Date:    Date:


                                Start Date:          End Date:
Spoke 3                                                                                 Spoke 6



Start               End                                            Start    End
Date:               Date:                                          Date:    Date:




        CAP Portfolio Stage 2                                                   Page 3 of 85
CAP Portfolio Stage 2   Page 4 of 85
Table of Contents
Quick Reference ...................................................................................................................................................3
Table of Contents .................................................................................................................................................5
Introduction ..........................................................................................................................................................7
Important Notice ..................................................................................................................................................7
General Information .............................................................................................................................................8
Continuous Assessment of Practice Process ..................................................................................................... 10
How to fill in this portfolio................................................................................................................................. 11
Mandatory Training Record – Stage Two Form i2.1 ....................................................................................... 13
SECTION 1: PRACTICE EXPERIENCE 3
Overview of Section 2: Practice Experience 3 ................................................................................................... 17
1000-Word Reflection ....................................................................................................................................... 19
Initial Assessment Form p3.1 ......................................................................................................................... 21
Orientation to Practice Base                   Form p3.2 ......................................................................................................... 23
Initial Practice Experience Interview Form p3.3............................................................................................. 25
Progress Interview Form p3.4 ........................................................................................................................ 27
Action Plan           Form p3.5................................................................................................................................... 29
Record of Meetings Form p3.6 ....................................................................................................................... 31
Testimonies           Form p3.7................................................................................................................................... 33
Medicines Management Summative Assessment Form p3.8 ........................................................................ 35
Record of Spoke Visit Form p3.9 .................................................................................................................... 37
Orientation to Practice Spoke                    Form p3.10 ..................................................................................................... 39
Learning outcomes and performance criteria not achieved Form p3.11 ...................................................... 41
Final interview           Form p3.12............................................................................................................................. 43
Statement of Practice Achievement Form p3.13 ........................................................................................... 45
Practice Attendance Record                    Form p3.14 ....................................................................................................... 47
SECTION 2: PRACTICE EXPERIENCE 4
Overview of Section 3: Practice Experience 4 ................................................................................................... 51
1000-Word Reflection ....................................................................................................................................... 53
Initial Assessment Form p4.1 ......................................................................................................................... 57
Orientation to Practice Base                   Form p4.2 ......................................................................................................... 59
Initial Practice Experience Interview Form p4.3............................................................................................. 61
Progress Interview Form p4.4 ........................................................................................................................ 63
Action Plan           Form p4.5................................................................................................................................... 65
Record of Meetings Form p4.6 ....................................................................................................................... 67
Testimonies           Form p4.7................................................................................................................................... 69
Medicines Management Summative Assessment Form p4.8 ........................................................................ 71
Record of Spoke Visit Form p4.9 .................................................................................................................... 73
Orientation to Practice Spoke                    Form p4.10 ..................................................................................................... 75

CAP Portfolio Stage 2                                                                                                                                     Page 5 of 85
Learning outcomes and performance criteria not achieved Form p4.11 ...................................................... 77
Final interview         Form p4.12............................................................................................................................. 79
Statement of Practice Achievement Form p4.13 ........................................................................................... 81
Practice Attendance Record                 Form p4.14 ....................................................................................................... 83




CAP Portfolio Stage 2                                                                                                                                Page 6 of 85
Introduction
This CAP Portfolio is used by you (the student), your personal supervisor, mentors and spoke supervisors.
The portfolio will assist in the continuing development of your nursing knowledge and skills and will be a
useful guide to learning throughout Stage Two.

Continuous assessment of practice is an integral part of all pre-registration nursing programmes. Successful
completion of the practice element is essential for your progression.

A summative assessment will be carried out by your primary mentor at the end of each practice experience
using the criteria in this portfolio. Other staff will contribute to this process – your assessment is not based
on observation by your primary mentor alone.

This assessment process is cumulative. In each practice experience your will accrue evidence of the
development of your skills in nursing care. For each stage of the programme, you will complete a separate
CAP portfolio.

In Stage Two you are encouraged to see your professional role in relation to others. This stage in practice
takes the student from some of the more general principles of nursing practice (Stage One) and begins to
assist you to relate this to the different fields of practice. There are strong links to knowledge and skills
development and working in partnership (team working) with patients/clients and other health
professionals.

Important Notice
You will have access to privileged and confidential information in the course of your practice education.
Such information must be protected and must not be shared with any unauthorised person.

You also need to maintain service user and/or carer confidentiality. Please do not include any stationery
from the practice area. No confidential information, care plans or case notes can be removed from the
practice area or photocopied, photographed or otherwise reproduced for inclusion as evidence.




CAP Portfolio Stage 2                                                                                   Page 7 of 85
General Information
Intended Learning Outcomes and Performance Criteria
The skills that you need to develop and demonstrate by the end of Stage Two are described in a particular
format: an intended learning outcome is followed by a number of performance criteria. Section 3 of this
portfolio lists all learning outcomes and performance criteria that are relevant to Stage Two.

Intended learning outcomes can be defined as “what you should be able to do as a result of engaging in the
learning process”. An important part of doing something is understanding the underpinning knowledge. This
may be gained in university, on practice experience, by personal reading as well as prior learning. The
learning outcomes are set out in the latter half of this portfolio.

Performance Criteria provide more detailed descriptions of the competencies required. Performance
criteria are again described in terms of the skills required to perform a task, to demonstrate an approach or
to provide an intervention. However, mentors can and should ensure that underpinning knowledge is
present in addition to psychomotor competence. Performance criteria are numbered under the appropriate
intended learning outcome.

The intended learning outcomes and performance criteria are informed by the requirement to adhere to the
standards and essential skills clusters set by the Nursing and Midwifery Council (NMC) for progression to
Stage Three.

Tripartite Meetings
A tripartite meeting should normally occur within the first four weeks of a practice experience. The aim of
this meeting is for the student, primary mentor and link lecturer to develop agreed learning contracts for the
practice experience. Tripartite meetings should have the following objectives:

     1. To facilitate identification of the practice learning needs of students relevant to the stage of the
        curriculum.

     2. To discuss and select learning opportunities most relevant to identified needs and required learning
        outcomes and explore how those can be best met using base and spoke experiences.

     3. To discuss the criteria against which achievement of outcomes can be measured and types of
        evidence students can use to demonstrate competence.

     4. To provide a supportive and open climate for practice-based learning in which all contributions are
        valued and respected.

Progression
You should attempt all the outcomes on each practice experience, though it is recognised some practice
experiences may offer different learning opportunities. If you have not achieved a performance criterion this
should be recorded in the appropriate section of the ‘Learning outcomes and performance criteria not
achieved’ sheet. Mentors should distinguish between outcomes not achieved due to student performance
and those not achieved due to lack of opportunity, by recording in the appropriate sections. You should not
be penalised for lack of opportunity.

You must achieve all performance criteria for Outcome A on every Practice Experience and demonstrate a
breadth of experience, usually across all fields. All other outcomes (and all performance criteria) must be
achieved at least once before progression to Stage Three.




CAP Portfolio Stage 2                                                                                   Page 8 of 85
Progress Reviews
Progress will be reviewed at approximately the mid-point of each practice experience, but may be reviewed
more frequently at the discretion of your mentor. These are opportunities for student and mentor to get
together and establish progress. In most instances this will be satisfactory and there is no need to involve
anyone else.

Concerns about progress
If mentors have concerns about your progress at any stage on a Practice Experience, they must raise them
with you as soon as possible and ensure they are formally documented in this portfolio. At this point the
personal supervisor/link lecturer and practice learning facilitator (PLF) (if appropriate) must also be notified.

Your personal supervisor/link lecturer and mentor will meet with you to agree a statement of ‘Areas
Requiring Significant Improvement’ and the support plan that will help you achieve the outcomes before
the end of the Practice Experience (or in some instances, a shorter period).

Pass/Fail decisions
As noted above, you should attempt all the outcomes on each Practice Experience. In order to pass each of
the STAGE TWO Practice Experiences you must have met all the criteria for Outcome A.

If the above criteria are not met to the satisfaction of the named mentor, the decision should be that you fail
that Practice Experience. If the mentor’s decision is that you have failed then he/she must notify the
personal supervisor/link lecturer.

You and your mentor should note that in order to achieve the requirements for progression to Stage Three
identified above, you will need to have achieved all remaining performance criteria at least once by the
end of Practice Experience Two.

Mentors wishing to identify how the Outcomes and Criteria in this document relate to the NMC Outcomes
for Entry to Stage Three can find a summary table on the NMC web site at http://www.nmc-uk.org/

In the event of a fail
You must meet with your personal supervisor, within a week, and agree an ACTION PLAN. This action plan
will normally be reviewed by the end of the fourth week of your next Practice Experience.

You are only allowed to redeem one practice failure in Stage Two in order to progress to Stage Three.

Therefore a failure to achieve the requirement of the ACTION PLAN will result in a recommendation of
discontinuation from the course.




CAP Portfolio Stage 2                                                                                    Page 9 of 85
Continuous Assessment of Practice Process
                   Prior to commencing practice experience
     Student contacts practice supervisor in advance. Practice experience
      staff identify primary mentor and student collects off-duty and times
                primary mentor is available for tripartite meeting.


                    1st day of the practice experience
     Student and primary mentor discuss learning outcomes and conduct
                                 induction.


                                                                                     At any point – Concerns requiring
                   End of first week – initial interview                                  significant improvement
   Student and primary mentor conduct initial interview and identify specific
                            learning outcomes.
                                                                                These must be raised with the student as early
                                                                                   as possible. The personal supervisor/link
                                                                                 lecturer must be notified, and an action plan
                       Week 1 to 4 - Tripartite meeting                                            agreed.
                 Student, primary mentor and link lecturer meet.
                                                                                   Opportunities need to be put in place to
                                                                                facilitate achievement of the required learning
                                                                                                  outcomes.
                        Midpoint - Progress review
       Student and primary mentor review progress towards meeting the
        agreed learning outcomes and identify strengths and areas for
                               development.




                End of practice experience – final interview
        Student and primary mentor complete the final interview. Using
    authenticated evidence gathered from base and spokes. Achievements
   and unmet outcomes are identified. Primary mentor is responsible for the
   summative assessment and indicates pass or fail in the CAP document




              PASS                                         FAIL



       Student submits the                          Student and personal
   ‘Statement of Achievement’                    supervisor agree an action
    with the attendance record                     plan, within one week of
     and practice experience                      completion of the practice
   evaluation forms by the due                     experience. This will be
        date, shown on the                       reviewed in the 4th week of
      assessment schedule.                      the next practice experience.
     Student meets with the                          This is in addition to
   personal supervisor prior to                      achieving all the next
          the next practice                           summative practice
            experience.                                   outcomes.




          Following the
    final/elective placement
                                                           PASS                            FAIL
    Student returns to the Sign
        off mentor (in last
       summative practice
    experience) for completion
         of ‘Statement of
    Achievement of Practice:
                                                                                Student is recommended
        Requirements for
                                                                                for discontinuation from
       Progression to the
             Register’.                                                              the programme




CAP Portfolio Stage 2                                                                                                Page 10 of 85
How to fill in this portfolio
This portfolio comprises four sections:

          Section 2: Practice Experience 3

          Section 2: Practice Experience 4

          Section 3: Second Progression Point

          Section 4: Skills Inventory

Within each section you will find a number of forms. These forms all have a similar structure:




  Each form has a form                                                                      Each form has a form
  title in the top left                                                                     number in the top
  corner.                                                                                   right corner.



  The guidance notes
  tell you how to
  complete the form.
                                                                                            The central part of the
                                                                                            form is where all the
                                                                                            information goes.
                                                                                            Only write in the
                                                                                            boxes with a white
                                                                                            background.




  Most forms require
  one or more
  signatures. Do not
  forget to obtain these.
                                                                                            At the bottom of each
                                                                                            form you will find a
                                                                                            next steps box.


When completing this portfolio, please:

     1. Only use black or blue ink
     2. Write clearly
     3. Do not use correction fluid




CAP Portfolio Stage 2                                                                              Page 11 of 85
CAP Portfolio Stage 2   Page 12 of 85
Mandatory Training Record – Stage Two                                                              Form i2.1
Guidance Notes
Aim             During Stage Two, you must attend the following mandatory training sessions. Failure to attend
                these sessions will result in a referral to the departmental Fitness to Practise Committee at the
                University of York.
When            Complete this form during Stage Two
Who             Completed by             Student
                Signed by                Personal Supervisor


Student to complete and initial
Session                                                                        Date           Student Initials
Moving and Handling Techniques
           Theory supporting Moving and Handling Techniques                /     /20
Infection Control
                          Theory supporting Infection Control              /     /20
Basic Life Support
                                                                           /     /20
Breakaway Techniques (Mental Health Nursing students only)
                                                                           /     /20
Fire Safety and Procedures
                                                                     / /20
Blood transfusion and safe handling of blood products (Adult and Child Field of Practice only)
                                                                     / /20

Personal supervisor
I have verified that the above student has attended the required mandatory training sessions.
Personal Supervisor Signature
Date

Next Steps
      1. Keep this form in your CAP document
      2. You have now completed the introduction and are ready to move on to the Section 1: Practice
         Experience 3.




CAP Portfolio Stage 2                                                                                   Page 13 of 85
CAP Portfolio Stage 2   Page 14 of 85
                                       BSc (Hons) Nursing
                                           CAP Portfolio
                                               Section 1
                                     Practice Experience 3


Practice Base

Mentor

Start Date

End Date



This Practice Experience links directly with the theoretical module Nursing Practice Experience 3.

To achieve the outcomes for Nursing Practice Experience 3, you must demonstrate a range of essential skills
and competencies as identified by the NMC (2010) and Essence of Care, Department of Health (2010) for
Stage Two.




CAP Portfolio Stage 2                                                                                Page 15 of 85
CAP Portfolio Stage 2   Page 16 of 85
Overview of Section 2: Practice Experience 3
This section comprises 13 different forms. The diagram below shows when and in which order to complete
these:

                                                               Before your practice experience
                  Form P3.1
             Initial Assessment




                Form P3.2                           Upon arrival at your practice experience
               Orientation to
               Practice Base



                 Form P3.3
               Initial Practice
            Experience Interview




                                                            Whilst at your practice experience

                 Form P3.4                Form P3.5                         Form P3.6
             Progress Interview           Action Plan                   Record of Meetings
                                                                               Form P3.6
                                                                           Record of Meetings


                                                                           Form P3.8
                Form P3.14                 Form P3.7                       Medicines
            Practice Attendance           Testimonies
                                              Form P3.5                   Management
                   Record                    Testimonies                   Summative
                                                                          Assessment




                                                                    Whilst visiting spoke areas
                                          Form P3.14
                   Form P3.9
                                      Practice Attendance
              Record of Spoke Visit
                                             Record



                  Form P3.10
                 Orientation to
                 Practice Spoke




                                                        At the end of your practice experience
                  Form P3.11
              Learning Outcomes            Form P3.12
               and Performance           Final Interview
             Criteria Not Achieved

                                           Form P3.13
                                      Statement of Practice
                                          Achievement




CAP Portfolio Stage 2                                                                             Page 17 of 85
CAP Portfolio Stage 2   Page 18 of 85
1000-Word Reflection

During Nursing Practice Experience 3 you will be expected to submit a 1000-word reflection on your practice.
To begin this process, you must take notes about two situations associated with the essential competencies
for this practice experience. These are:
      Ability to work within a multi-disciplinary, multi-agency team
      Ability to give and receive constructive feedback
      Knowledge of the principles of delegation of tasks to and from others
      Knowledge and understanding of the roles and responsibilities of the nurse within the care
         environment

The notes taken for one of these situations will form the basis for the 1000-word reflection required for the
reflection element of the summative assignment for Practice Experience 3. It is suggested that you use the
Driscoll (2007) model of reflection. This is a simple model which starts with basic description and answering
the questions below. This form can be used for helping you map out your 1000-word reflection and should
be completed in conjunction with the assessment guidelines for Nursing Practice 3

Situation one
What occurred?




What did you see or do?




What was your reaction?




What did other people do (colleagues, patient, relatives,…)?




CAP Portfolio Stage 2                                                                               Page 19 of 85
What are the key aspects of the situation?




Situation two
What occurred?




What did you see or do?




What was your reaction?




What did other people do (colleagues, patient, relatives,…)?




What are the key aspects of the situation?




Reference
Driscoll, J. (2007) Practising Clinical Supervision: A Reflective Approach for Healthcare Professionals. 2nd ed.
Edinburgh: Bailliere Tindall Elsevier




CAP Portfolio Stage 2                                                                                  Page 20 of 85
Initial Assessment                                                                                Form p3.1
Guidance Notes
Aim             This form enables the student to assist their practice area to meet your individual learning
                needs. The student will reflect on their areas of strength and on areas needing development.
                The student’s personal supervisor provides additional information to assist the practice area.
When            Complete this form before the start of the practice experience
Who             Completed by            Student
                                        Personal Supervisor
                Signed by               Student
                                        Personal Supervisor

Student to complete
Areas of strength




Areas needing development




Signature
Date

Personal Supervisor to complete
Additional information for the practice area, including areas of concern, support needed (including support
required for any health issue or disability that may affect performance)




Signature
Date

Next Steps
     1. Keep this form in your CAP document
     2. Proceed to complete Form p3.2 Orientation to Practice Base




CAP Portfolio Stage 2                                                                                  Page 21 of 85
CAP Portfolio Stage 2   Page 22 of 85
Orientation to Practice Base                                                                         Form p3.2
Guidance Notes
Aim             This form is a check-list to verify that the student has received all relevant induction information
                when arriving at the new practice base.
When            Complete this form within 24 hours of arriving at your practice base
Who             Completed by              Mentor
                Signed by                 Student
                                          Mentor

Mentor to discuss with student and complete
                          Information/Orientation                                     Date and Mentor Initial
1     Responsibilities in emergency situations:
          - Cardiac arrest
          - Alerting team
2     Fire safety and procedures:
          - Alarm points and assembly points
          - Standing orders, procedures and policies
3     Location of resuscitation equipment
4     Special equipment and procedures
5     Moving, handling and mobility techniques
6     Immediate personal safety and risk issues
7     Other relevant policies (please list):

8     Accident and incident procedures:
          - Staff and Identified First Aiders
          - Visitors
9     Infection control and disposal of used equipment, sharps and linen
10    Vulnerable adults and safeguarding children
11    Communication processes:
          - Observation and duty hours
          - Reporting sickness and absence
          - Person to whom the student must report
          - Understanding how to receive and refer messages
12    Complaints procedure
13    Confidentiality and mobile phone procedure
14    Policy and regulations relating to dress and attire
15    Tour of the placement area, briefing on staff and staffing structure
16    Management and storage of patients’ valuables
17    Management and storage of student’s personal belongings
18    Specific support or needs the student may have with regard to
      health or learning requirements

Student and Mentor to sign
Student Signature
Date
Mentor Signature
Date

Next Steps
      3. Keep this form in your CAP document
      4. Proceed to complete Form p3.3 Initial Practice Experience Interview

CAP Portfolio Stage 2                                                                                     Page 23 of 85
CAP Portfolio Stage 2   Page 24 of 85
Initial Practice Experience Interview                                                            Form p3.3
Guidance Notes
Aim             Before commencing this placement experience, the student needs to reflect on their own
                hopes, expectations and possible concerns. This will involve their personal supervisor.

                At the start of your placement experience, the student needs to discuss and negotiate with their
                mentor their personal strategy for learning during the placement experience.

                The student and their mentor will use this form for documenting the process and outcomes of
                this initial interview.
When            Complete this form within 24 hours of arriving at your practice base
Who             Completed by            Student
                                        Mentor
                Signed by               Student
                                        Mentor

Student to complete
Process and outcomes of initial interview with your mentor




Negotiated and planned activities and visits away from or within the practice base that will enhance your
learning.




CAP Portfolio Stage 2                                                                                 Page 25 of 85
Mentor to complete
Notes from the initial interview, including any arrangements for student supervision and support, name(s) of
associate mentor(s) and planned dates for review of progress.




Student and Mentor to sign
Student Signature
Date
Mentor Signature
Date

Next Steps
     1. Keep this form in your CAP document
     2. At the midpoint of your practice experience, proceed to complete Form p3.4 Progress Review




CAP Portfolio Stage 2                                                                              Page 26 of 85
Progress Interview                                                                               Form p3.4
Guidance Notes
Aim             The student’s progress will normally be reviewed at the midpoint of a practice experience.

                At the start of your placement experience, the student needs to discuss and negotiate with their
                mentor their personal strategy for learning during the placement experience.

                The student and their mentor will use this form for documenting the process and outcomes of
                this initial interview.
When            Complete this form at the midway point of your practice experience
Who             Completed by            Student
                                        Mentor
                Signed by               Student
                                        Mentor

Student to complete
Areas of strength




Areas needing development




CAP Portfolio Stage 2                                                                                  Page 27 of 85
Mentor to complete
Areas of strength




Areas needing development (but not causing concern)




Student and Mentor to sign
Student Signature
Date
Mentor Signature
Date

Next Steps
     1. Keep this form in your CAP document




CAP Portfolio Stage 2                                 Page 28 of 85
Action Plan                                                                                     Form p3.5
Guidance Notes
Aim             If significant concerns arise about the student’s progress regarding safety, professional
                behaviour or competence at any point within the practice experience, a formal review should
                take place as soon as these concerns are identified by the mentor.

                The personal supervisor, mentor and student should attend this review.

                The mentor will complete this form to list the outcomes and performance criteria that cause
                concern and, unless addressed, will lead to the student being awarded a Fail.
When            Complete this form at each formal review during the practice experience
Who             Completed by           Mentor
                Signed by              Student
                                       Mentor
                                       Personal Supervisor

Mentor to complete
Outcome or              Concerns identified          Actions planned to support the student          Review
Performance                                          achieving the required competence               date
Criteria




Student, Mentor and Personal Supervisor to sign
Date for next review
Student Signature
Mentor Signature
Personal Supervisor Signature
Date

Next Steps
      1. Keep this form in your CAP document
      2. Review this form at the agreed review date
CAP Portfolio Stage 2                                                                                Page 29 of 85
CAP Portfolio Stage 2   Page 30 of 85
Record of Meetings                                                                                Form p3.6
Guidance Notes
Aim             The student will use this form to keep a record of all relevant meetings taking place during this
                practice experience. These include meetings with the link lecturer, personal supervisor, practice
                learning facilitator and other professionals
When            Complete this form during the practice experience
Who             Completed by             Student
                Signed by                Professional present at the meeting

Student to complete
Meeting description and notes                                                          Date and signature




Next Steps
      1. Keep this form in your CAP document




CAP Portfolio Stage 2                                                                                  Page 31 of 85
CAP Portfolio Stage 2   Page 32 of 85
Testimonies                                                                                         Form p3.7
Guidance Notes
Aim             NMC standards require any progression decision to include service user and/or carer
                involvement.

                The student will use this form to collect relevant testimonials from service users and/or carers .
                The student must seek permission from their mentor or a qualified member of staff before
                approaching any service user and/or carer for a testimonial. Service users and/or carers must
                not sign their testimonials to maintain confidentiality. The mentor should countersign each
                testimonial.
When            Complete this form during the practice experience
Who             Completed by             Service user and/or carer
                Signed by                Mentor

Service User and/or Carer to complete
Please comment on the student’s progress                                                 Date         Mentor
                                                                                                      Signature




Next Steps
      1. Keep this form in your CAP document



CAP Portfolio Stage 2                                                                                    Page 33 of 85
CAP Portfolio Stage 2   Page 34 of 85
Medicines Management Summative Assessment                                                       Form p3.8
Guidance Notes
Aim             NMC standards state: “People can trust the newly registered graduate nurse to correctly and
                safely undertake medicines calculations.” To meet the second progression point at the end of
                Stage Two the student should be competent in basic medicines calculations relating to:

                         Tablets and capsules
                         Liquid medicines
                         Injections, including
                              o Unit dose
                              o Sub and multiple unit dose
                              o SI unit conversion

                The mentor and the student will use this form as a summative assessment of the students’
                medicines management skills. The student must successfully complete a minimum of six
                calculations to specific examples provided by the mentor per practice experience.
When            Complete this form during the practice experience
Who             Completed by               Student
                                           Mentor
                Signed by                  Mentor

Mentor and Student to complete
Example                                                  Calculation 1
Calculate the volume to be injected if a patient
requires 1mg of bumetanide and each stock ampule
is 2mg per 4ml.

The strength required is 1mg
The stock strength is 2mg in 4 ml

The units match, so the formula becomes:

Volume to be injected:


Calculation 2                                            Calculation 3




CAP Portfolio Stage 2                                                                                Page 35 of 85
Calculation 4                                         Calculation 5




Calculation 6                                         Calculation 7




Calculation 8                                         Calculation 9




Mentor to complete and sign
Summative Assessment (delete as appropriate)          PASS

                                                      FAIL

                                                      REFER TO ACTION PLAN
Mentor Signature
Date


Next Steps
     1. Keep this form in your CAP document
     2. Complete Form p3.5 Action plan if outcome is “Refer to Action Plan”




CAP Portfolio Stage 2                                                         Page 36 of 85
Record of Spoke Visit                                                                              Form p3.9
Guidance Notes
Aim             This form is a record of a visit to a Spoke Practice Experience. The student uses this form to
                document, for each spoke visit, the purpose and the outcomes of this visit. Photocopy extra
                sheets as required or download from our departmental web site.
When            Complete this form before arriving at your spoke area and when leaving your spoke area.
Who             Completed by             Student
                Signed by                Student
                                         Mentor
                                         Spoke Supervisor

Student to complete
Spoke Area
Spoke Area Address




Spoke Supervisor Name
Spoke Supervisor Email
Spoke Supervisor Telephone No
Purpose of visit and learning outcomes to be achieved




Date of visit
Number of hours worked
Record of visit(s)




Spoke Supervisor to complete and sign
Spoke Supervisor Signature
Date


Next Steps
      1. Keep this form in your CAP document
      2. Complete Form p3.10 Orientation to Practice Spoke when arriving at the spoke area



CAP Portfolio Stage 2                                                                                   Page 37 of 85
CAP Portfolio Stage 2   Page 38 of 85
Orientation to Practice Spoke                                                                      Form p3.10
Guidance Notes
Aim             This form is a check-list to verify that the student has received all relevant induction information
                when arriving at the new practice spoke.
When            Complete this form within 24 hours of arriving at your practice spoke
Who             Completed by              Spoke Supervisor
                Signed by                 Student
                                          Spoke Supervisor

Spoke supervisor to discuss with student and complete
                          Information/Orientation                                     Date and Mentor Initial
1     Responsibilities in emergency situations:
          - Cardiac arrest
          - Alerting team
2     Fire safety and procedures:
          - Alarm points and assembly points
          - Standing orders, procedures and policies
3     Location of resuscitation equipment
4     Special equipment and procedures
5     Moving, handling and mobility techniques
6     Immediate personal safety and risk issues
7     Other relevant policies (please list):

8     Accident and incident procedures:
          - Staff and Identified First Aiders
          - Visitors
9     Infection control and disposal of used equipment, sharps and linen
10    Vulnerable adults and safeguarding children
11    Communication processes:
          - Observation and duty hours
          - Reporting sickness and absence
          - Person to whom the student must report
          - Understanding how to receive and refer messages
12    Complaints procedure
13    Confidentiality and mobile phone procedure
14    Policy and regulations relating to dress and attire
15    Tour of the placement area, briefing on staff and staffing structure
16    Management and storage of patients’ valuables
17    Management and storage of student’s personal belongings
18    Specific support or needs the student may have with regard to
      health or learning requirements

Student and Spoke Supervisor to sign
Student Signature
Date
Spoke Supervisor Signature
Date

Next Steps
      1. Keep this form in your CAP document


CAP Portfolio Stage 2                                                                                     Page 39 of 85
CAP Portfolio Stage 2   Page 40 of 85
Learning outcomes and performance criteria not achieved                                      Form p3.11
Guidance Notes
Aim             The mentor will use this form to record any learning outcomes and/or performance criteria not
                achieved by the student due to inadequate performance or lack of opportunity. The mentor and
                the student will also provide any additional comments on this list.
When            Complete this form at the end of the practice experience
Who             Completed by             Student
                                         Mentor
                Signed by                Student
                                         Mentor

Mentor to complete
Learning outcomes and/or performance criteria not        Learning outcomes and/or performance criteria not
achieved due to inadequate performance                   achieved due to lack of opportunity




Mentor and student to complete
Additional comments by mentor




Additional comments by student




Student and Mentor to sign
Student Signature
Date
Mentor Signature
Date

Next Steps
      1. Keep this form in your CAP document
      2. Arrange a final interview and complete Form p3.12 Final Interview



CAP Portfolio Stage 2                                                                              Page 41 of 85
CAP Portfolio Stage 2   Page 42 of 85
Final interview                                                                                 Form p3.12
Guidance Notes
Aim             This form acts as record of the student’s achievement during this practice experience.
When            Complete this form at the end of the practice experience
Who             Completed by            Student
                                        Mentor
                                        Personal Supervisor
                Signed by               Student
                                        Mentor
                                        Personal Supervisor

Student to sign
I confirm that the evidence of achievement presented within this section of CAP document:
    1. Is all my own work
    2. Has achieved outcomes in different fields
    3. Maintains client and staff confidentiality to NMC 2008 requirements
Student Signature
Date

Student to complete
Evaluate your learning and performance, specifying particular aspects that you believe have enhanced your
learning. Also reflect on factors that may have impeded your progression and to what extent strategies used
to manage this were successful.




CAP Portfolio Stage 2                                                                                    Page 43 of 85
Mentor to complete
Please comment on the student’s progress on this Practice Experience since the progress review. These
comments will complement comments made earlier in relation to specific learning outcomes and should
provide examples to illustrate points. Your judgement should be based on overall performance and the
achievement of practice experience and NMC outcomes. The mentor should indicate whether the student
has achieved a PASS or FAIL both below and on Form p3.13 Statement of Practice Achievement.




         PASS                                             FAIL

Supervisor to complete
Please comment on the student’s achievement during this practice experience




Student, Mentor and Personal Supervisor to sign
Student Signature
Mentor Signature
Personal Supervisor Signature
Date
Next Steps
     1. Keep this form in your CAP document
     2. The Mentor and Student complete Form p3.13 Statement of Practice Achievement


CAP Portfolio Stage 2                                                                         Page 44 of 85
Statement of Practice Achievement                                                              Form p3.13
Guidance Notes
Aim             This Form provides a formal record of the student’s achievement and will be kept by the
                University
When            Complete this form at the end of the practice experience
Who             Completed by            Mentor
                Signed by               Student
                                        Mentor

Mentor to complete
Name of student
Student number
Practice base
Organisation (e.g. name of NHS Trust)
Primary Mentor Declaration
I declare that I am identified as a mentor/sign off mentor on the local mentor register, and that I have
engaged in appropriate updating of my knowledge and skills (including a Mentor Update) within the last 12
months.
Name of Primary Mentor
Primary Mentor Signature

Mentor to complete
         PASS                                                   FAIL
Based on the evidence documented to date on this          Based on the evidence documented to date on this
student’s performance during this Practice                student’s performance during this Practice
Experience and summarised on the final interview          Experience and summarised on the final interview
sheet, I confirm that the student has PASSED the          sheet, I confirm that the student has FAILED the
Practice Experience including the competencies for        Practice Experience.
Nursing Practice Experience 3.
                                                          The student’s progress has been discussed and an
                                                          ACTION PLAN will be developed with the appropriate
                                                          lecturer and used in the next Practice Experience.


Student and Mentor to sign
Student Signature
Date
Mentor Signature
Date


Next Steps
      1. The student must hand in this form to the Student Information Service, Department of Health
         Sciences




CAP Portfolio Stage 2                                                                                 Page 45 of 85
CAP Portfolio Stage 2   Page 46 of 85
                                                                                                 SIS         ALLOC


Practice Attendance Record                                                                     Form p3.14
Guidance Notes
Aim             The student uses this form to record their attendance and absence at their base area and their
                spoke area(s) during the practice experience. The form is submitted to the University as
                evidence of the time spent on this practice experience.
When            Complete this form during the practice experience
Who             Completed by            Student
                Signed by               Mentor
                                        Spoke Supervisor

Student to complete
Student Name
Base Area
Mentor Name
Practice Experience Start Date
Practice Experience End Date
CAP Document Submission Date


How to record attendance/non-attendance
Attendance                             Exclude meal breaks
                                       Exclude study days
                                       Exclude study time
                                       Record in hours, to the nearest quarter hour (e.g. 6, 6.25, 6.5. 6.75)
                                       Add the letter ‘N’ for night shifts (e.g. 6.25N)
                                       Do not use any other shift codes
Non-attendance                         Fill in one absence code per day of non-attendance:
                                       SK         Sickness, not covered by a medical certificate
                                       SC         Sickness, covered by a medical certificate
                                       SL         Special Leave (must be approved by your personal supervisor)
                                       CL         Carer’s Leave (must be approved by your personal supervisor)
                                       AB         Absence for any other reason

Student to complete
Total number of hours required for this Practice Experience                                                 hours
(you will find this on your allocation sheet)
Total number of hours achieved for this Practice Experience                                                 hours

Mentor to sign
Mentor Signature
Date

Next Steps
      1. The student must hand in this form to the Student Information Service, Department of Health
         Sciences



CAP Portfolio Stage 2                                                                                  Page 47 of 85
Base Area(s)
Week                    Mon   Tue   Wed    Thu      Fri       Sat     Sun   Weekly     Base Area                             Mentor Signature
Commencing                                                                  Total
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
Spoke Area(s)
Spoke Area                                                   Start Date     End Date           Hours Worked   Spoke Supervisor Signature
                                                                / /20         / /20
                                                                / /20         / /20
                                                                / /20         / /20
                                                                / /20         / /20
                                                                / /20         / /20
                                                                / /20         / /20
                                                                / /20         / /20
Total
Total Hours Achieved (add together all base and spoke area hours)                                                                                   hours




Stage 2 CAP Portfolio                                                                                                                           Page 48 of 85
                                       BSc (Hons) Nursing
                                           CAP Portfolio
                                               Section 3
                                     Practice Experience 4


Practice Base

Mentor

Start Date

End Date



This Practice Experience links directly with the theoretical module Nursing Practice Experience 4.

To achieve the outcomes for Nursing Practice Experience 4, the student will demonstrate a range of essential
skills and competencies as identified by the NMC (2010) and Essence of Care, Department of Health (2010)
for Stage Two.




Stage 2 CAP Portfolio                                                                                Page 49 of 85
Stage 2 CAP Portfolio   Page 50 of 85
Overview of Section 3: Practice Experience 4
This section comprises 13 different forms. The diagram below shows when and in which order to complete
these:

                                                               Before your practice experience
                  Form p4.1
             Initial Assessment




                Form p4.2                           Upon arrival at your practice experience
               Orientation to
               Practice Base



                 Form p4.3
               Initial Practice
            Experience Interview




                                                            Whilst at your practice experience

                 Form p4.4                Form p4.5                         Form p4.6
             Progress Interview           Action Plan                   Record of Meetings
                                                                               Form P3.6
                                                                           Record of Meetings


                                                                           Form p4.8
                Form p4.14                 Form p4.7                       Medicines
            Practice Attendance           Testimonies
                                              Form P3.5                   Management
                   Record                    Testimonies                   Summative
                                                                          Assessment




                                                                    Whilst visiting spoke areas
                                          Form p4.14
                   Form p4.9
                                      Practice Attendance
              Record of Spoke Visit
                                             Record



                  Form p4.10
                 Orientation to
                 Practice Spoke




                                                        At the end of your practice experience
                  Form p4.11
              Learning Outcomes            Form p4.12
               and Performance           Final Interview
             Criteria Not Achieved

                                           Form p4.13
                                      Statement of Practice
                                          Achievement




Stage 2 CAP Portfolio                                                                             Page 51 of 85
Stage 2 CAP Portfolio   Page 52 of 85
1000-Word Reflection

As part of the assessment of Nursing Practice 4, the student will write a 1000 word reflection on
collaborative working with colleagues in practice, particularly focusing on ONE of the following essential
competencies:
     In partnership with clients, carers and other professionals, identify priorities for care
     Manage time effectively
     Ability to provide relevant client/patient information to promote health and wellbeing
     To maintain contemporaneous records

The notes taken in your CAP document using Element 1-Wha t? of Driscoll’s (2007) model of reflection will
form the basis for your essay. To reflect upon the experience you have noted you need to follow the next
two elements of Driscoll and use the following questions to assist you to understand the context of that
element of practice and how you might modify future practice in relation to the specific aims of the module.

Element 2-So What?
          What were you feeling at the time?
          What are you feeling now?
          What were the effects of what you did?
          What good emerged from the situation?
          What troubles you, if anything?
          What have I noticed about my behaviour in practice by taking a more measured look at it?

Element 3-Now What?
          What are the implications for me in practice?
          What difference does it make if I do nothing?
          Where can I get more information to help me face a similar situation again?
          How can I modify my practice if a similar situation was to happen again?
          Who can help me ‘modify’ my practice?
          How will I notice that I am different in practice?
          What is the main learning I can take from reflecting on my practice this way?

Reference: Driscoll, J. (2007) Practising Clinical Supervision: A Reflective Approach for Healthcare
Professionals. 2nd ed. Edinburgh: Bailliere Tindall Elsevier




Stage 2 CAP Portfolio                                                                                  Page 53 of 85
Element 2 - So What?
What were you feeling at the time?




What are you feeling now?




What were the effects of what you did?




What good emerged from the situation?




What troubles you, if anything?




What have I noticed about my behaviour in practice by taking a more measured look at it?




Stage 2 CAP Portfolio                                                                      Page 54 of 85
Element 3 - Now What?
What are the implications for me in practice?




What difference does it make if I do nothing?




Where can I get more information to help me face a similar situation again?




How can I modify my practice if a similar situation was to happen again?




Who can help me ‘modify’ my practice?




How will I notice that I am different in practice?




What is the main learning I can take from reflecting on my practice this way?




Stage 2 CAP Portfolio                                                           Page 55 of 85
Stage 2 CAP Portfolio   Page 56 of 85
Initial Assessment                                                                               Form p4.1
Guidance Notes
Aim             This form allows the student to assist their practice area in meeting their own learning needs.
                The student needs to reflect on their areas of strength and on areas needing development. The
                student’s personal supervisor provides additional information to assist the practice area.
When            Complete this form before the start of the practice experience
Who             Completed by            Student
                                        Personal Supervisor
                Signed by               Student
                                        Personal Supervisor

Student to complete
Areas of strength




Areas needing development




Signature
Date

Personal Supervisor to complete
Additional information for the practice area, including areas of concern, support needed (including support
required for any health issue or disability that may affect performance)




Signature
Date

Next Steps
       Keep this form in your CAP document
       Proceed to complete Form p4.2 Orientation to Practice Base




Stage 2 CAP Portfolio                                                                                 Page 57 of 85
Stage 2 CAP Portfolio   Page 58 of 85
Orientation to Practice Base                                                                         Form p4.2
Guidance Notes
Aim             This form is a check-list to verify that the student has received all relevant induction information
                when arriving at the new practice base.
When            Complete this form within 24 hours of arriving at your practice base
Who             Completed by              Mentor
                Signed by                 Student
                                          Mentor

Mentor to discuss with student and complete
                          Information/Orientation                                     Date and Mentor Initial
1     Responsibilities in emergency situations:
          - Cardiac arrest
          - Alerting team
2     Fire safety and procedures:
          - Alarm points and assembly points
          - Standing orders, procedures and policies
3     Location of resuscitation equipment
4     Special equipment and procedures
5     Moving, handling and mobility techniques
6     Immediate personal safety and risk issues
7     Other relevant policies (please list):

8     Accident and incident procedures:
          - Staff and Identified First Aiders
          - Visitors
9     Infection control and disposal of used equipment, sharps and linen
10    Vulnerable adults and safeguarding children
11    Communication processes:
          - Observation and duty hours
          - Reporting sickness and absence
          - Person to whom the student must report
          - Understanding how to receive and refer messages
12    Complaints procedure
13    Confidentiality and mobile phone procedure
14    Policy and regulations relating to dress and attire
15    Tour of the placement area, briefing on staff and staffing structure
16    Management and storage of patients’ valuables
17    Management and storage of student’s personal belongings
18    Specific support or needs the student may have with regard to
      health or learning requirements

Student and Mentor to sign
Student Signature
Date
Mentor Signature
Date

Next Steps
      1. Keep this form in your CAP document
      2. Proceed to complete Form p4.3 Initial Practice Experience Interview

Stage 2 CAP Portfolio                                                                                     Page 59 of 85
Stage 2 CAP Portfolio   Page 60 of 85
Initial Practice Experience Interview                                                            Form p4.3
Guidance Notes
Aim             Before commencing this placement experience, the student needs to reflect on their own
                hopes, expectations and possible concerns. This will involve their personal supervisor.

                At the start of your placement experience, the student needs to discuss and negotiate with their
                mentor their personal strategy for learning during the placement experience.

                The student and their mentor will use this form for documenting the process and outcomes of
                this initial interview.
When            Complete this form within 24 hours of arriving at your practice base
Who             Completed by            Student
                                        Mentor
                Signed by               Student
                                        Mentor

Student to complete
Process and outcomes of initial interview with your mentor




Negotiated and planned activities and visits away from or within the practice base that will enhance your
learning.




Stage 2 CAP Portfolio                                                                                  Page 61 of 85
Mentor to complete
Notes from the initial interview, including any arrangements for student supervision and support, name(s) of
associate mentor(s) and planned dates for review of progress.




Student and Mentor to sign
Student Signature
Date
Mentor Signature
Date

Next Steps
     1. Keep this form in your CAP document
     2. At the midpoint of your practice experience, proceed to complete Form p4.4 Progress Review




Stage 2 CAP Portfolio                                                                              Page 62 of 85
Progress Interview                                                                               Form p4.4
Guidance Notes
Aim             The student’s progress will normally be reviewed at the midpoint of a practice experience.

                At the start of your placement experience, the student needs to discuss and negotiate with their
                mentor their personal strategy for learning during the placement experience.

                The student and their mentor will use this form for documenting the process and outcomes of
                this initial interview.
When            Complete this form at the midway point of your practice experience
Who             Completed by            Student
                                        Mentor
                Signed by               Student
                                        Mentor

Student to complete
Areas of strength




Areas needing development




Stage 2 CAP Portfolio                                                                                  Page 63 of 85
Mentor to complete
Areas of strength




Areas needing development (but not causing concern)




Student and Mentor to sign
Student Signature
Date
Mentor Signature
Date

Next Steps
      Keep this form in your CAP document




Stage 2 CAP Portfolio                                 Page 64 of 85
Action Plan                                                                                     Form p4.5
Guidance Notes
Aim             If significant concerns arise about the student’s progress regarding safety, professional
                behaviour or competence at any point within the practice experience, a formal review should
                take place as soon as these concerns are identified by the mentor.

                The personal supervisor, mentor and student should attend this review.

                The mentor will complete this form to list the outcomes and performance criteria that cause
                concern and, unless addressed, will lead to the student being awarded a Fail.
When            Complete this form at each formal review during the practice experience
Who             Completed by           Mentor
                Signed by              Student
                                       Mentor
                                       Personal Supervisor

Mentor to complete
Outcome or              Concerns identified          Actions planned to support the student          Review
Performance                                          achieving the required competence               date
Criteria




Student, Mentor and Personal Supervisor to sign
Date for next review
Student Signature
Mentor Signature
Personal Supervisor Signature
Date

Next Steps
      1. Keep this form in your CAP document
      2. Review this form at the agreed review date
Stage 2 CAP Portfolio                                                                                 Page 65 of 85
Stage 2 CAP Portfolio   Page 66 of 85
Record of Meetings                                                                                Form p4.6
Guidance Notes
Aim             The student will use this form to keep a record of all relevant meetings taking place during this
                practice experience. These include meetings with the link lecturer, personal supervisor, practice
                learning facilitator and other professionals
When            Complete this form during the practice experience
Who             Completed by             Student
                Signed by                Professional present at the meeting

Student to complete
Meeting description and notes                                                          Date and signature




Next Steps
      1. Keep this form in your CAP document




Stage 2 CAP Portfolio                                                                                  Page 67 of 85
Stage 2 CAP Portfolio   Page 68 of 85
Testimonies                                                                                         Form p4.7
Guidance Notes
Aim             NMC standards require any progression decision to include service user and/or carer
                involvement.

                The student will use this form to collect relevant testimonials from service users and/or carers .
                The student must seek permission from their mentor or a qualified member of staff before
                approaching any service user and/or carer for a testimonial. Service users and/or carers must
                not sign their testimonials to maintain confidentiality. The mentor should countersign each
                testimonial.
When            Complete this form during the practice experience
Who             Completed by             Service user and/or carer
                Signed by                Mentor

Service User and/or Carer to complete
Please comment on the student’s progress                                                 Date         Mentor
                                                                                                      Signature




Next Steps
      1. Keep this form in your CAP document



Stage 2 CAP Portfolio                                                                                    Page 69 of 85
Stage 2 CAP Portfolio   Page 70 of 85
Medicines Management Summative Assessment                                                       Form p4.8
Guidance Notes
Aim             NMC standards state: “People can trust the newly registered graduate nurse to correctly and
                safely undertake medicines calculations.” To meet the first progression point at the end of
                Stage Two the student should be competent in basic medicines calculations relating to:

                         Tablets and capsules
                         Liquid medicines
                         Injections, including
                              o Unit dose
                              o Sub and multiple unit dose
                              o SI unit conversion

                The mentor and the student will use this form as a summative assessment of the students’
                medicines management skills. The student must successfully complete a minimum of six
                calculations to specific examples provided by the mentor per practice experience.
When            Complete this form during the practice experience
Who             Completed by               Student
                                           Mentor
                Signed by                  Mentor

Mentor and Student to complete
Example                                                   Calculation 1
Calculate the volume to be injected if a patient
requires 1mg of bumetanide and each stock ampule
is 2mg per 4ml.

The strength required is 1mg
The stock strength is 2mg in 4 ml

The units match, so the formula becomes:

Volume to be injected:


Calculation 2                                             Calculation 3




Stage 2 CAP Portfolio                                                                                Page 71 of 85
Calculation 4                                         Calculation 5




Calculation 6                                         Calculation 7




Calculation 8                                         Calculation 9




Mentor to complete and sign
Summative Assessment (delete as appropriate)          PASS

                                                      FAIL

                                                      REFER TO ACTION PLAN
Mentor Signature
Date


Next Steps
     1. Keep this form in your CAP document
     2. Complete Form p4.5 Action plan if outcome is “Refer to Action Plan”




Stage 2 CAP Portfolio                                                         Page 72 of 85
Record of Spoke Visit                                                                              Form p4.9
Guidance Notes
Aim             This form is a record of a visit to a Spoke Practice Experience. The student uses this form to
                document, for each spoke visit, the purpose and the outcomes of this visit. Photocopy extra
                sheets as required or download from our departmental web site.
When            Complete this form before arriving at your spoke area and when leaving your spoke area.
Who             Completed by             Student
                Signed by                Student
                                         Mentor
                                         Spoke Supervisor

Student to complete
Spoke Area
Spoke Area Address




Spoke Supervisor Name
Spoke Supervisor Email
Spoke Supervisor Telephone No
Purpose of visit and learning outcomes to be achieved




Date of visit
Number of hours worked
Record of visit(s)




Spoke Supervisor to complete and sign
Spoke Supervisor Signature
Date


Next Steps
       Keep this form in your CAP document
       Complete Form p4.10 Orientation to Practice Spoke when arriving at the spoke area



Stage 2 CAP Portfolio                                                                                   Page 73 of 85
Stage 2 CAP Portfolio   Page 74 of 85
Orientation to Practice Spoke                                                                      Form p4.10
Guidance Notes
Aim             This form is a check-list to verify that the student has received all relevant induction information
                when arriving at the new practice spoke.
When            Complete this form within 24 hours of arriving at your practice spoke
Who             Completed by              Spoke Supervisor
                Signed by                 Student
                                          Spoke Supervisor

Spoke supervisor to discuss with student and complete
                          Information/Orientation                                     Date and Mentor Initial
1     Responsibilities in emergency situations:
          - Cardiac arrest
          - Alerting team
2     Fire safety and procedures:
          - Alarm points and assembly points
          - Standing orders, procedures and policies
3     Location of resuscitation equipment
4     Special equipment and procedures
5     Moving, handling and mobility techniques
6     Immediate personal safety and risk issues
7     Other relevant policies (please list):

8     Accident and incident procedures:
          - Staff and Identified First Aiders
          - Visitors
9     Infection control and disposal of used equipment, sharps and linen
10    Vulnerable adults and safeguarding children
11    Communication processes:
          - Observation and duty hours
          - Reporting sickness and absence
          - Person to whom the student must report
          - Understanding how to receive and refer messages
12    Complaints procedure
13    Confidentiality and mobile phone procedure
14    Policy and regulations relating to dress and attire
15    Tour of the placement area, briefing on staff and staffing structure
16    Management and storage of patients’ valuables
17    Management and storage of student’s personal belongings
18    Specific support or needs the student may have with regard to
      health or learning requirements

Student and Spoke Supervisor to sign
Student Signature
Date
Spoke Supervisor Signature
Date

Next Steps
      A. Keep this form in your CAP document


Stage 2 CAP Portfolio                                                                                     Page 75 of 85
Stage 2 CAP Portfolio   Page 76 of 85
Learning outcomes and performance criteria not achieved                                      Form p4.11
Guidance Notes
Aim             The mentor will use this form to record any learning outcomes and/or performance criteria not
                achieved by the student due to inadequate performance or lack of opportunity. The mentor and
                the student will also provide any additional comments on this list.
When            Complete this form at the end of the practice experience
Who             Completed by             Student
                                         Mentor
                Signed by                Student
                                         Mentor

Mentor to complete
Learning outcomes and/or performance criteria not        Learning outcomes and/or performance criteria not
achieved due to inadequate performance                   achieved due to lack of opportunity




Mentor and student to complete
Additional comments by mentor




Additional comments by student




Student and Mentor to sign
Student Signature
Date
Mentor Signature
Date

Next Steps
      A. Keep this form in your CAP document
      B. Arrange a final interview and complete Form p4.12 Final Interview



Stage 2 CAP Portfolio                                                                              Page 77 of 85
Stage 2 CAP Portfolio   Page 78 of 85
Final interview                                                                                 Form p4.12
Guidance Notes
Aim             This form acts as record of the student’s achievement during this practice experience.
When            Complete this form at the end of the practice experience
Who             Completed by            Student
                                        Mentor
                                        Personal Supervisor
                Signed by               Student
                                        Mentor
                                        Personal Supervisor

Student to sign
I confirm that the evidence of achievement presented within this section of CAP document:
    4. Is all my own work
    5. Has achieved outcomes in different fields
    6. Maintains client and staff confidentiality to NMC 2008 requirements
Student Signature
Date

Student to complete
Evaluate your learning and performance, specifying particular aspects that you believe have enhanced your
learning. Also reflect on factors that may have impeded your progression and to what extent strategies used
to manage this were successful.




Stage 2 CAP Portfolio                                                                                    Page 79 of 85
Mentor to complete
Please comment on the student’s progress on this Practice Experience since the progress review. These
comments will complement comments made earlier in relation to specific learning outcomes and should
provide examples to illustrate points. Your judgement should be based on overall performance and the
achievement of practice experience and NMC outcomes. The mentor should indicate whether the student
has achieved a PASS or FAIL both below and on Form p4.13 Statement of Practice Achievement.




         PASS                                             FAIL

Supervisor to complete
Please comment on the student’s achievement during this practice experience




Student, Mentor and Personal Supervisor to sign
Student Signature
Mentor Signature
Personal Supervisor Signature
Date
Next Steps
      Keep this form in your CAP document
      The Mentor and Student complete Form p4.13 Statement of Practice Achievement


Stage 2 CAP Portfolio                                                                         Page 80 of 85
Statement of Practice Achievement                                                              Form p4.13
Guidance Notes
Aim             This Form provides a formal record of the student’s achievement and will be kept by the
                University
When            Complete this form at the end of the practice experience
Who             Completed by            Mentor
                Signed by               Student
                                        Mentor

Mentor to complete
Name of student
Student number
Practice base
Organisation (e.g. name of NHS Trust)
Primary Mentor Declaration
I declare that I am identified as a mentor/sign off mentor on the local mentor register, and that I have
engaged in appropriate updating of my knowledge and skills (including a Mentor Update) within the last 12
months.
Name of Primary Mentor
Primary Mentor Signature

Mentor to complete
         PASS                                                   FAIL
Based on the evidence documented to date on this          Based on the evidence documented to date on this
student’s performance during this Practice                student’s performance during this Practice
Experience and summarised on the final interview          Experience and summarised on the final interview
sheet, I confirm that the student has PASSED the          sheet, I confirm that the student has FAILED the
Practice Experience including the competencies for        Practice Experience.
Nursing Practice Experience 4.
                                                          The student’s progress has been discussed and an
                                                          ACTION PLAN will be developed with the appropriate
                                                          lecturer and used in the next Practice Experience.


Student and Mentor to sign
Student Signature
Date
Mentor Signature
Date


Next Steps
      1. The student must hand in this form to the Student Information Service, Department of Health
         Sciences




Stage 2 CAP Portfolio                                                                                 Page 81 of 85
Stage 2 CAP Portfolio   Page 82 of 85
                                                                                               SIS       ALLOC


Practice Attendance Record                                                                     Form p4.14
Guidance Notes
Aim             The student uses this form to record their attendance and absence at their base area and their
                spoke area(s) during the practice experience. The form is submitted to the University as
                evidence of the time spent on this practice experience.
When            Complete this form during the practice experience
Who             Completed by            Student
                Signed by               Mentor
                                        Spoke Supervisor

Student to complete
Student Name
Base Area
Mentor Name
Practice Experience Start Date
Practice Experience End Date
CAP Document Submission Date


How to record attendance/non-attendance
Attendance                             Exclude meal breaks
                                       Exclude study days
                                       Exclude study time
                                       Record in hours, to the nearest quarter hour (e.g. 6, 6.25, 6.5. 6.75)
                                       Add the letter ‘N’ for night shifts (e.g. 6.25N)
                                       Do not use any other shift codes
Non-attendance                         Fill in one absence code per day of non-attendance:
                                       SK         Sickness, not covered by a medical certificate
                                       SC         Sickness, covered by a medical certificate
                                       SL         Special Leave (must be approved by your personal supervisor)
                                       CL         Carer’s Leave (must be approved by your personal supervisor)
                                       AB         Absence for any other reason

Student to complete
Total number of hours required for this Practice Experience                                                hours
(you will find this on your allocation sheet)
Total number of hours achieved for this Practice Experience                                                hours

Mentor to sign
Mentor Signature
Date

Next Steps
      1. The student must hand in this form to the Student Information Service, Department of Health
         Sciences



Stage 2 CAP Portfolio                                                                                 Page 83 of 85
Use black ink only  Do not use correction fluid  Ask your mentor to countersign any amendments  Only use the absence codes listed overleaf
Base Area(s)
Week                    Mon   Tue   Wed    Thu      Fri       Sat     Sun    Weekly      Base Area                                     Mentor Signature
Commencing                                                                   Total
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
  / /20
Spoke Area(s)
Spoke Area                                                   Start Date      End Date            Hours Worked           Spoke Supervisor Signature
                                                                / /20          / /20
                                                                / /20          / /20
                                                                / /20          / /20
                                                                / /20          / /20
                                                                / /20          / /20
                                                                / /20          / /20
                                                                / /20          / /20
Total
Total Hours Achieved (add together all base and spoke area hours)                                                                                           hours




Stage 2 CAP Portfolio                                                                                                                                 Page 84 of 85
Stage 2 CAP Portfolio   Page 85 of 85

								
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