FINAL EVALUATION – SUPERVISOR’S REPORT

CLINICAL PASTORAL EDUCATION

Accredited by: The Commission on Accreditation for Pastoral Education (CAPE) Student:

Supervisor:

Student Unit:

Dates of Unit:

Completion Status:

Type of Unit (Intensive or Extended):

This evaluation is a confidential document containing observations and reflections of the student named above and their educational experience during this unit of Clinical Pastoral Education. It will only be released with the student’s written permission. This evaluation should be read in conjunction with the student’s final self-evaluation in order to receive a full picture of the educational process which was engaged. Certification I certify that has successfully met the requirements for one unit of Clinical Pastoral Education as certified by Clinical Pastoral Education International (CPEI). Introduction of Student Program Structure A CPE unit/group consists of student interns who have been selected from an application and interview process. A unit requires 400 hours of supervised education to complete. Up to 300 hours of the student intern’s time is in the clinical setting where they respond to pastoral and spiritual care needs of patients, family members, staff and others. The remaining 100 hours include the following: • A gathering time for spiritual leadership, feedback and re-connecting purposes • Didactic presentations in pastoral theology and pastoral practice • Verbatim reports (case studies) • Hospital and community resource presentations • Reading seminars • Group time for interpersonal relationship issues • Individual supervision time with the CPE supervisor.

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Individual Supervisory Sessions Supervisor Evaluation Legend The following evaluation is based on the CPEI Outcomes for Pastoral Formation (2001.1-200.1.3), Pastoral Reflection (300.1.1-300.1.2), and Pastoral Competence (400.1.1-400.1.4), which can be found in the CPEI Standards Manual. Please evaluate the student’s performance by placing an (X) by the phrase that best describes the student’s abilities related to the following competencies and expectations.

Fully Meets Outcomes: 4

Mostly Meets Outcomes: 3 Partially Meets Outcomes: 2

Beginning to Meet Outcomes: 1 Not Started on Outcome or NA: 0

PASTORAL FUNCTIONING CPEI Outcomes 4 3 2 1 0

Ability to center self and engage a patient/client with confidence.

PF 200.1.1 PF 200.3.1

Ability to make a pastoral/spiritual assessment based on the patient/client’s perceived ability at the time of the visit.

PC 400.1.1

Ability to use appropriate pastoral intervention, services, and to provide a pastoral presence.

PC 200.3.1

Ability to chart spiritual assessment effectively fulfilling Joint Commission standards.

PF, 200.4.1 PC 400.1.1 PC 400.2.1

Ability to set aside personal and religious agenda(s).

PC 200.3.1

Ability to follow organizational policies and procedures.

PF 200.4.1 PC 400.4.1

Ability to navigate the clinical setting and handle multiple requests for pastoral care and presence.

PC 200.2.1 PC 200.4.1

Ability to incorporate new clinical processes into pastoral functioning.

PC 200.4.1 PF 400.3.1

INTERDISCIPLINARY FUNCTIONING

CPEI Outcomes 4 3 2 1 0

Ability to participate in collaborative decision making and problem solving with other caregiving professionals.

PC 400.2.1

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Ability to consult, collaborate and communicate with other caregiving professionals

PC 400.2.1

Demonstrates the ability to debrief with staff/leaders/others after crisis events.

PF 200.2.1 PR 300.1.1 PC 400.2.1

Ability to be relational with staff/leaders/others while keeping appropriate boundaries.

PF 200.4.1 PC 400.3.1

Ability to share pastoral/spiritual assessments with interdisciplinary/organizational staff while maintaining appropriate confidentiality.

PC 400.1.1 PC 400.2.1

GROUP DYNAMICS CPEI Outcomes 4 3 2 1 0

Ability to enter into personal processing and to be able to identify and as appropriate acknowledge personal issues during group and individual supervision.

PR 300.1.1

Ability to be pastoral with peers. PR 300.1.1

Ability to be direct with peers. PF 200.4.1 PR 300.1.1

Ability to give and receive feedback during group time.

PR 300.1.1

Ability to seek clarification and navigate confrontation within group.

PF 200.4.1 PR 300.1.1

Ability to be present for others without having personal issues interrupt or usurp their processing.

PF 200.4.1 PR 300.1.1

EDUCATIONAL FUNCTIONING CPEI Outcomes 4 3 2 1 0

Ability to complete the unit educational requirements.

PF 200.1.1 PF 200.2.1 PF 200.4.1

Ability to engage the didactic material for learning purposes.

PF 200.1.1 PF 200.2.1 PF 200.4.1

As appropriate, ability to chart effectively in the electronic medical records.

PF 200.4.1 PC 400.1.1 PC 400.2.1

Ability to establish appropriate personal and professional learning objectives for the unit.

PF 200.4.1

Ability to provide devotional material relevant to the CPE process.

PF 200.2.1 PF 200.4.1

Ability to engage process education and utilize the Action/Reflection/Action model of learning.

PF 200.2.1 PF 200.4.1

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SELF-REFLECTION/AWARENESS CPEI Outcomes 4 3 2 1 0

Ability to exercise non-anxious presence in emotionally charged circumstances.

PF 200.2.1 PF 200.4.1 PR 300.2.1 PC 400.4.1

Demonstrates the ability to be conversant with past hurts and disappointments on a personal/professional level.

PF 200.2.1 PF 200.4.1 PR 300.2.1 PC 400.4.1

Ability to engage shadow self. PF 200.1.1 PF 200.4.1 PR 300.1.1

Ability to understand and engage one’s own personality traits.

PF 200.1.1 PF 200.4.1 PR 300.1.1

Ability to understand and process family of origin issues.

PF 200.1.1 PF 200.4.1 PR 300.1.1

Ability to possess a clear sense of ministry or spiritual direction.

PF 200.1.1 PF 200.4.1 PR 300.1.1

ENGAGING PATIENTS/CLIENTS CPEI Outcomes 4 3 2 1 0

Ability to track with patient/clients by using, open-ended questions and listening for conversational themes.

PF200.1.1 PF 200.3.1 PF 200.4.1 PR 300.1.1

Ability to become a patient/client advocate when/if needed.

PF 200.1.1 PF 200.3.1 PF 200.4.1 PR 300.1.1 PC 400.3.1

Ability to stay focused on the patient/client when family members/friends seek to interject into the pastoral conversation.

PF 200.3.1 PF 200.4.1

Ability to facilitate patient/client processing. PF 200.3.1 PF 200.4.1

Ability to allow the patient to tell their story without interjecting personal events that may parallel a life event.

PF 200.1. PF 200.2.1 PF 200.3.1 PF 200.4.1

THEOLOGICAL/SPIRITUAL REFLECTION

CPEI Outcomes 4 3 2 1 0

Ability to self-reflect theologically and spiritually patient/client visits or crisis events.

PF 200.2.1

Ability to assess and evaluate embedded and deliberate theology in self and others.

PF 200.2., 200.3.1, 200.4.1

Ability to provide sacramental and religious rites as requested.

PF 200.2.1 PF 200.3.1 PF 200.4.1

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Ability to inquire about theological and spiritual symbols to better understand their meaning.

PF 200.2.1 PF 200.3.1 PF 200.4.1 PR 300.1.1 PR 300.1.2

Ability to remain present for patients/clients with various faith perspectives.

PF 200.2.1 PF 200.3.1 PF 200.4.1

SYSTEMS DYNAMICS & AWARENESS CPEI Outcomes 4 3 2 1 0

Ability to assess systems and navigate family dynamics.

PF 200.2.1 PF 200.3.1 PF 200.4.1

Ability to remain calm and focused during family struggles.

PF 200.2.1 PF 200.3.1 PF 200.4.1

Ability to communicate family dynamics to healthcare staff effectively.

PF 200.2.1 PF 200.3.1 PF 200.4.1

Ability to establish a pastoral bond with families in crisis situations.

PF 200.2.1 PF 200.3.1 PF 200.4.1

Ability to assess behavioral dynamics within a family system.

PF 200.2.1 PF 200.3.1 PF 200.4.1

Ability to assess the impact stage of grief upon family functioning.

PF 200.2.1 PF 200.3.1 PF 200.4.1

CRISIS FUNCTIONING CPEI Outcomes 4 3 2 1 0

Ability to provide non-anxious presence. PF 200.2.1 PF 200.3.1 PF 200.4.1

Ability to defuse/debrief with staff after a major crisis or trauma event.

PF 300.1.1 PR 300.2.1 PC 400.2.1

Ability to function effectively with local authorities during a crisis or traumatic event.

PF 200.2.1 PF 200.3.1 PF 200.4.1

Ability to be present during a mass casualty event and function as a team member event.

PF 300.1.1 PR 300.2.2 PC 400.2.1

GRIEF AND LOSS CPEI Outcomes 4 3 2 1 0

Ability to be a compassionate presence to family and staff during a patient’s dying process.

PF 200.2., PF 200.3.1 PF 200.4.1

Ability to process the impact stage of grief with family members and staff.

PF 200.2., PF 200.3.1 PF 200.4.1

BEHAVIORAL ASSESSMENT CPEI Outcomes 4 3 2 1 0

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Ability to assess psycho-social dynamics in patients and family members.

PF 200.2., PF 200.3.1 PF 200.4., PR 3001.1 PR 300.2.1 PC 400.2.1

Awareness of personality issues that may affect patient/client’s functioning.

PC 200.1.1 PR 300.1.1

Peer Group and Supervision 4 3 2 1 0

How has the person used the peer group for support, dialogue and feedback in a way which will assist her/him in integrating personal characteristics into the pastoral role?

Identify each peer by initials or first names, the peer’s faith//religious affiliation, location of the peer’s clinical settings.

Briefly describe how the CPE student interacted with his/her peer group.

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Individual Supervision 4 3 2 1 0

How has the person used the individual supervision for support, dialogue and feedback in a way which will assist her/him in integrating personal characteristics into the pastoral role?

Comments:

Summary: As a CPE Supervisor what recommendations would you give this person in terms of his/her expressed learning and goals (present and future)?

Comments:

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Summary This evaluation reflects the student’s ability to engage the standards, objectives and expected outcomes for Clinical Pastoral Education as set forth by the Standards for Clinical Pastoral Education International (CPEI). The student has had the opportunity to review this final evaluation and is free to add an addendum to this document. This document will be on file with the center for three years in accordance with CPEI Standards and will not be released to anyone without permission. Site members for CAPE accreditation may have access to confirm compliance with policies.

Student’s Signature: Date:

Supervisor’s Signature: Date:

Supervisory Student’s Signature (as applicable): Date: