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<p align="center">CLINICAL COMPETENCY SURVEY</p>
Date Today:
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Month
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Day
Year
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Part I: Demographic Data
1. Age
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Less than 23 years old
23-30 years old
31-40 years old
41-50 years old
More than 50 years old
2. Gender
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Male
Female
3. Nursing Education Program Completed
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Associate Degree in Nursing
Bachelors Degree in Nursing
Master's Degree in Nursing
Doctoral Degree
Other
4. Country Where Nursing Degree Completed
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Philippines
United States
Other
5. Length of Service (Worked as a Nurse)
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Less than 6 months
6 months to 1 year
2-5 years
6-10 years
11-15 years
More than 15 years
6. Work Experience
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Medical Surgical Nursing / Labor and Delivery, Orthopedic
Specialty Areas: ER Recovery Room, Operating Room, ICU, Pediatrics, Cath Lab, Telemetry, Stepdown Unit, Preholding Unit
Outpatient, Ambulatory Surgery
Community Health
Psychiatry / Mental Health
Other
7. Healthcare Facility Worked
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Rural: small town or village
Urban: City
8. Nursing Positions Held
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Staff Nurse
Nurse Manager
Director
Nursing Supervisor
Faculty
Other
9. How many beds in the healthcare facility where you work/ed?
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Less than 20
21-50
51-75
76-100
101-200
More than 200
10. How many patients did you care for every shift?
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1-3
4-8
9-12
More than 12
11. Do you think your education and clinical experience prepares you for clinical practice in the US?
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Yes
No
Unsure
12. What areas do you need assistance prior to practice in the US healthcare setting?
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a. Nursing Skills
b. Critical Thinking Skills
c. Technology
d. Medication Administration
e. Nursing Process to Manage Disease
f. Physical Assessment
1st Choice
2nd Choice
3rd Choice
13. What would be the best teaching method to suit your learning needs? Please select the top three areas that you feel you will require the most assistance.
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a. Face to Face Lectures
b. Online / Web CT Course
c. Blended (Face to Face and Online)
d. Lecture and Clinical Lab
1st Choice
2nd Choice
3rd Choice
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Next: Part II: Clinical Competencies
Part II: Clinical Competencies
14. Clinical Skills: PerformsPlease rate the competencies from 1 to 5.
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Rows
Not Proficient
Less Proficient
Proficient
Moderately Proficient
Highly Proficient
a. IV Insertion
b. Wound care such as wound dressing
and wound irrigation
c. Tracheal suctioning
d. Chest tube dressing and care
e. Urinary catheter insertion
f. Nasogastric tube insertion
g. Suctioning
h. Care of patient while receiving
hemodialysis or peritoneal dialysis
15. Medication Administration: Administers medication via:
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Rows
Not Proficient
Less Proficient
Proficient
Moderately Proficient
Highly Proficient
a. Central line
b. Peripheral line
c. Secondary line such as piggy back
d. Intraosseous
e. Portacath
f. Nasogastric Tube
g. Peg Tube
16. Nursing Process
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Rows
Not Proficient
Less Proficient
Proficient
Moderately Proficient
Highly Proficient
a. Develops nursing care plans on nursing
diagnosis and problems identified
b. Writes measurable patient outcomes
c. Evaluates interventions
17. Pain Management
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Rows
Not Proficient
Less Proficient
Proficient
Moderately Proficient
Highly Proficient
a. Assesses pain using pain scale
b. Provides other pain relief measures such
as heat, cold, massage, and repositioning.
c. Administers pain medication based on
patient’s level of pain.
18. Assessment
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Rows
Not Proficient
Less Proficient
Proficient
Moderately Proficient
Highly Proficient
a. Recognizes cardiac arrhythmias such as
Bradycardia, Tachycardia, and other life threatening
ventricular arrhythmias.
b. Performs head to toe assessment.
c. Identifies normal and abnormal assessment findings.
19. Technology
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Rows
Not Proficient
Less Proficient
Proficient
Moderately Proficient
Highly Proficient
a. Documents patient assessment and plan of care using
electronic medical record.
b. Operates the following equipments:
i. Feeding Pump
ii. Intravenous Pump
iii.Patient Controlled Analgesia Pump
iv. Doppler
v. Automatic Blood Pressure Machine
vi. CPM Machine
20. Critical Thinking Skills
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Rows
Not Proficient
Less Proficient
Proficient
Moderately Proficient
Highly Proficient
Uses clinical pathways and guidelines to manage
care of patient with specific health problem.
Care of patient with different diseases at the same
time.
Triages and prioritizes patient’s problems and
treatments.
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Next: Part III: Factors Affecting Acculturation Level
Part III. Factors Affecting Acculturation Level
Factors Affecting Acculturation Level
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Rows
Strongly Disagree
Disagree
Agree Proficient
Moderately Agree
Strongly Agree
21. The help of the strong and supportive preceptors and staff
in the clinical area encourage me to easily learn the clinical
operations in the unit.
22. I have difficulty understanding the language of the patients
and my co-workers in the clinical areas and this affects my
nursing practice in the US setting.
23. The use of computer and other technology in nursing care
affects my ability to perform clinical operations in the unit in
a timely fashion.
24. I feel bothered by the differences in clinical set up
(nurse station, patient rooms, medication room, etc.)
in the US and the Philippines.
25. People have difficulty understanding my cultural
background, thus, preventing me to perform my duties
and responsibilities in the clinical area.
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Next: Part IV: Factors that Affects Acculturation in the US Clinical Setting
Part IV. Rank the following factors that you think may affect your acculturation in the US clinical setting.
26. Arrange into order (from 1st choice to 5th choice) the factors that you think may affect your acculturation in the US clinical setting.
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Staff support in the unit
Language barrier
Use of technology in nursing care
Differences in clinical setting
Differences in cultural orientation
1st Choice
2nd Choice
3rd Choice
4th Choice
5th Choice
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