PERFORMANCE APPRAISAL OF INTENSIVE CARE UNIT NURSES

Appraisal Score: ___________ Overall Score: _________

Name: ___________________ Employee ID: _________
Job Title: _________________ Hire Date: ____________
Department: ______________
Appraisal Date: ____________
Review Period: From: _______ To: _______
Appraised by: _____________

Key Responsibilities:
Responsible to the Nursing Service Director for the efficient, economical and orderly
administration of the Intensive Care Unit in proper documentation, carrying out orders of the
Doctors pertaining to the treatment, maintaining the patient’s dignity during the entire intubations
process and during extubation, administration of medicines, comfort and safety of the patient,
assisting in the surgical procedures, monitoring of vital signs, exhibit knowledge on Advanced
and Basic Life Support and ECG reading, care of the equipments and the cleanliness sterility and
orderliness of the Intensive Care Unit. Reports to Nurse Supervisor and Accountable to the Chief
Nurse.

Rating Scale*:
Level 5 (E) Exceptional
Performance far exceeded expectations due to exceptionally high quality of work performed in all essential areas of
responsibility, resulting in an overall quality of work that was superior; and either 1) included the
completion of a major goal or project, or 2) made an exceptional or unique contribution in support of
unit, department, or University objectives. This rating is achievable by any employee though given
infrequently.

Level 4 (EE) Exceeds expectations

Performance consistently exceeded expectations in all essential areas of responsibility, and the quality of
work overall was excellent. Annual goals were met.

Level 3 (ME) Meets expectations

Performance consistently met expectations in all essential areas of responsibility, at times possibly
exceeding expectations, and the quality of work overall was very good. The most critical annual goals
were met.

Level 2 (I) Improvement needed

Performance did not consistently meet expectations – performance failed to meet expectations in one or
more essential areas of responsibility, and/or one or more of the most critical goals were not met. A
professional development plan to improve performance must be outlined including timelines, and
monitored to measure progress.

Level 1 (U) Unsatisfactory

Performance was consistently below expectations in most essential areas of responsibility, and/or
reasonable progress toward critical goals was not made. Significant improvement is needed in one or
more important areas. A plan to correct performance, including timelines, must be outlined and
monitored to measure progress.

*The inclusion of goals is typically a consideration in assessing the overall rating.

 RATING
KEY RESPONSIBILITIES COMMENT
LEVEL LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5
1

HOSPITAL BEHAVIORAL EXPECTATIONS

A. COURTESY
1. Acknowledges a patient’s presence by
making eye contact.
2. Addresses calls in a warm professional
manner.
3. Personalizes conversations by using
names.
4. Politely answers telephone calls.
5. Tackle concerns with co-workers
professionally and privately.

B. RESPECT/PRIVACY
1. Greets patient in a joyous and
respectful manner.
2. Announces arrival before entering
private patient areas.
3. Close curtains for patient’s privacy as
appropriate.
4. Discusses confidential or sensitive
information only with appropriate parties
and privately.
5. Builds and maintains morale in the
workplace.

C. COMMUNICATION
1. Listens carefully to orders of doctors
and call of patients.
2. Exhibit sensitivity to the needs of the
patients.
3. Keeps patients and families informed
about their progress through the system.
4. Acknowledge customer concerns
immediately.
5. Seeks constructive feedback regarding
his/ her own practice.

D. RESPONSIVENESS
1. Acknowledge call lights within one
minute.
2. Anticipate the needs of the patient.
3. Makes clear, consistent and transparent
decisions.
4. Distinguishes relevant from irrelevant
information.
5. Quickly conducts good analyses and
searches for best possible solutions.

E. TEAMWORK
1. Take ownership and responsibility for
addressing problems.
2. Cooperate well with others.
3. Take initiative.
4. Maintains a good relationship with
peers and superiors.
5. Actively demonstrates willingness to
help others.

F. OPERATIONAL
1. Arrives promptly at work.
2. Performs dispensing tasks according to
accepted standard operating procedures.
3. Competently solves operational
problems.
4. Pays attention to details and takes pride
in their work.
5. Complies with tasks ably,
demonstrating a spare capacity at
workload.
NURSING PROCESS

1. Nursing diagnosis and care needs are

based on thorough assessment.
2. Plans for care are formulated
immediately based on identified patient’s
needs.
3. Nursing care is based on the standards
of nursing practice.
4. Nursing care is prioritized based on
assessment of patient’s immediate
condition or needs.
5. Significant others are involved in the
plan of care.
6. Patient education or health teachings
are implemented in the care course
process.
7. Evaluation of the patient’s response to
nursing care rendered.
8. Patient’s response to care, treatment
and interventions are recorded promptly.
9. Documents medications, treatments,
and nursing intervention on appropriate
chart forms.
10. Completes Discharge Instruction
Sheet as appropriately indicated.
(Demonstrates expertise in the RATING
following areas) LEVEL LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5 COMMENT
1
1. ECG Interpretation
2. Basic Life Support
3. Advanced Cardiac Life Support
4. Pulmonary Machines/ Ventilator Use
Diseases:
1. Stroke
2. Myocardial Infarction & or Ischemia
3. Diabetes
4. COPD
5. Heart Failure
6. Hypo/ Hyperthyroidism
7. Renal Failure
8. Cancer
9. Mental Health
10. Palliative Care
What do you particularly value about this Nurse’s input to the successful operation and development of the Practice?
(In both clinical and personal terms)

Are there any areas which you would like to highlight as being in need of further development?

General Comments:

Signatures:
Employee:_____________________________________ Date: __________
Signature: ___________________________
My signature indicates that I have received a copy of this evaluation.
___ I would like to include comments from my self assessment.

Manager/supervisor: Name:______________________________
Signature: ____________________________ Date: __________

Department manager: Name: ____________________________

Signature: ____________________________ Date: _____________

The employee being evaluated is to receive a copy of the completed evaluation form
and one copy shall be placed in the personnel file.