Student Nurse Preceptorship Survey
Full Name of Primary Preceptor
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First Name
Last Name
School Name
Hospital Location
*
Please Select
Ronald Reagan UCLA Medical Center
Santa Monica UCLA Medical Center and Orthopedic Hospital
Resnick UCLA Medical Center
RR Unit
*
Please Select
4ICU (MICU)
5 East (OB)
5ICU (PICU-PEDS)
5 North (NICU)
5 West (PEDS)
6 East (Oncology)
6ICU (Neurotrauma ICU)
6 North (Neuro)
6 West (MED/SURG)
7E/5E (MS Geriatrics)
7ICU (Cardiothorasic)
7 North (CCU)
7 North (COU)
7 West (MED/SURG)
8 East (MED/SURG)
8ICU (Liver Transplant)
8 North (MED/SURG)
8 West (MED/SURG)
SM Unit
*
Please Select
2MNP (Nursery)
2MNP (Post Partum)
2SWW (L&D)
2SWW (NICU)
3CW (PTU)
3NW (ORTHO)
3SWW (Overflow)
3SWW (PACU)
3SWW (PTU)
4CW (ICU)
4MNP (Medicine)
4NW (Med/Surg)
4SWW (Oncology)
5MNP (Intermediate Care)
5MNP (Monitor Tech)
5NW (Geriatrics)
6NW (Pediatrics)
ER (Nurses Station)
NPH Unit
*
Please Select
4 West Child/Adolescent
4 West Adolescent Eating Disorder
4 West Swing
4 East Adult Psych ICU
4 East Adult Substance Abuse
4 East Adult Acute
4 North Adult/Geriatric Psych
4 North Adult Eating Disorder
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Student Nurse Preceptorship Survey
DIRECTIONS:
Please rate your preceptor on the following items:
EXCELLENT
- Exceeded Expectations
SATISFACTORY
- Good/Met Expectations
FAIR
- Usually Met Expectations
POOR
- Did Not Meet Expectations
N/A
- Not Applicable
ASSESSMENT
*
Excellent
Satisfactory
Fair
Poor
N/A
Assessed and incorporated your learning style and preferences
Please provide an explanation for any areas marked "poor" and/or provide any other comments regarding your experience:
*
COMPETENCY
*
Excellent
Satisfactory
Fair
Poor
N/A
Conveyed relevant policies and standards of practice on the unit/clinic
Please provide an explanation for any areas marked "poor" and/or provide any other comments regarding your experience:
*
COMMUNICATION
*
Excellent
Satisfactory
Fair
Poor
N/A
Verbally expressed ideas in a way that you could understand
Communicated effectively with patients, families, staff, and physicians (BRN)
Demonstrated effective communication practices to minimize risks to self, patient (Q)
Served as a resource to document nursing care in the electronic medical record (Q)
Please provide an explanation for any areas marked "poor" and/or provide any other comments regarding your experience:
*
CRITICAL THINKING
*
Excellent
Satisfactory
Fair
Poor
N/A
Guided you to set priorities and make appropriate decisions
Please provide an explanation for any areas marked "poor" and/or provide any other comments regarding your experience:
*
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Student Nurse Preceptorship Survey
INTERPERSONAL
*
Excellent
Satisfactory
Fair
Poor
N/A
Acknowledged your strengths and weakness in an honest and respectful way (Q)
Was personable and approachable
Reflected a positive attitude/desire to work with you (BRN)
Provided patient centered care with sensitivity and respect for diversity of others (Q)
Please provide an explanation for any areas marked "poor" and/or provide any other comments regarding your experience:
*
LEADERSHIP ACCOUNTABILITY
*
Excellent
Satisfactory
Fair
Poor
N/A
Demonstrated nursing expertise in the delivery of care through planning, delegating, and supervising others (BRN)
Served as a role model for ethical and legal behaviors
Used resources appropriately and efficiently (material and human)
Modeled professional development behaviors (i.e., life-long learner, specialty certified, member of a professional nursing organization)
Please provide an explanation for any areas marked "poor" and/or provide any other comments regarding your experience:
*
FACILITATION OF LEARNING
*
Excellent
Satisfactory
Fair
Poor
N/A
Advocated to meet your needs in the learning environment
Evaluated your knowledge/skills and provided constructive feedback
Helped you meet your educational objectives of the preceptorship/practicum
Please provide an explanation for any areas marked "poor" and/or provide any other comments regarding your experience:
*
KNOWLEDGE INTEGRATION SKILLS
*
Excellent
Satisfactory
Fair
Poor
N/A
Reviewed outcomes of nursing care (ie: nursing sensitive indicators, HCAHPS) (Q)
Used clinical evidence to make decisions and guide practice (Q)
Please provide an explanation for any areas marked "poor" and/or provide any other comments regarding your experience:
*
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Student Nurse Preceptorship Survey
OVERALL EXPERIENCE
*
Excellent
Satisfactory
Fair
Poor
N/A
Placement helped me meet my educational/career goals
Clinical placement compared to other clinical placement sites
Computer access for this rotation
Unit orientation by your preceptor or other member of the staff on the unit
Please provide an explanation for any areas marked "poor" and/or provide any other comments regarding your experience:
*
Would you recommend this unit to other students?
*
Please Select
Yes
No
If no, please provide comments below:
*
What type of program are you currently enrolled in?
*
Please Select
AD
BSN
MECN
MSN
CNS
NP
DNP
PHD
Are you interested in employment at UCLA Health?
*
Please Select
Yes
No
Please provide any other comments about your experience below:
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