Carly Legault

September 12, 2013

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 1
2nd Edition - Revised October 2008

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 2
2nd Edition - Revised October 2008

TABLE OF CONTENTS

SELF-ASSESSMENT TOOL - RATING SCALE..........................................................................4

STEP 1: SELF-ASSESSMENT WITHIN STANDARDS OF PRACTICE.....................................4
A: Nursing Knowledge ...............................................................................................................4
B: Nursing Process..................................................................................................................... 5
C: Safety..................................................................................................................................... 5
D: Communication and Interpersonal Skills................................................................................5
W: Professionalism..................................................................................................................... 6
X: Nursing Practice and Leadership............................................................................................6
Self-Assessment Summary.......................................................................................................... 7
STEP 2: SELF-ASSESSMENT OF SPECIFIC COMPETENCIES..............................................8

STEP 3: LEARNING PLAN......................................................................................................10

RECORD OF PROFESSIONAL ACTIVITIES............................................................................11

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 3
2nd Edition - Revised October 2008

SELF-ASSESSMENT TOOL
The Self-Assessment Tool is used to assess your professional practice using the LPN Standards of
Practice and Competency Profile as a guide. Focus your assessment on your practice as a whole and
then those Specific Competencies which are directly related to your role and responsibilities.

RATING SCALE Use the following rating scale to complete your Self-Assessment.
1
Excellent

2
Competent

3
Requires
Improvement

4
Developmental

Demonstrates
excellence in the
expectations and /
or requirements of
the competency.

Meets the
expectations and /
or requirements of
the competency.

Has identified
weakness in
areas of
knowledge, skills,
attitudes, or
clinical judgment.

Requires
education and/or
orientation to
meet the
expectations and /
or requirements of
the competency.

5
Not Applicable
Not applicable to
current role and
responsibility.

STEP 1: SELF-ASSESSMENT WITHIN STANDARDS OF

PRACTICE
Competency
Number

A: Nursing Knowledge

Year
2015

Year
20__

Year
20__

Year
20__

Year
20__

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

A-1

Applies knowledge of anatomy and physiology

of the human body to the assessment of client
and delivery of nursing care.

A-2

Applies knowledge of microbiology throughout

care, disease prevention, and health promotion.

A-3

Applies knowledge of pathophysiology to the

nursing care of the client.

A-4-4

Uses appropriate medical terminology to report

and document client care.

A-5-9

Adjusts nursing practice to the specific growth

and development of the client.

A-6

Applies principles of nutrition to the assessment

and care of the client.

A-7

Applies knowledge of pharmacology throughout

client care and teaching.

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 4
2nd Edition - Revised October 2008

Year
2015

Competency
Number

A-8-2

Integrates knowledge and skills from the

sciences and humanities into the application of
the nursing process.

B: Nursing Process

Rating
(1-5)

Performs health assessment of client using

assessment techniques and a systematic
process.

B-2-2

Implements the planning process and

establishes client priorities involving client in
planning.

B-2-3

Identify and analyze nursing diagnosis.

B-3

Implements nursing interventions to carry out

nursing care plan.

B-3-2

Reassess, review, and modify plan of care to

meet the needs of the client.

B-4

Evaluates the clients response to care and

treatment.

Year
20__

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

C-1 to
C-4

Applies critical thinking and clinical judgment

when responding to emergency situations.

C-5-1

Effectively uses protective devices to protect

client, self, and others.

C-6-1

Demonstrates the consistent application of

standard precautions.

C-7-1

Applies principles of medical and surgical

asepsis in the delivery of care.

C-12

Applies nursing knowledge and clinical

judgment to maintain physical safety of client.

1
Rating
(1-5)

D-1

Uses effective verbal and written

communication in the practice setting.

D-2

Appropriately establishes, maintains, and

closes the nurse-client relationship.

D-3

Collaborates with health care team to function

as an effective team member.

D-3-7

Adheres to the channels of communication

within the employing agency.

Self-Assessment Tool CCP

College of LPNs of Alberta

Year
20__

Rating
(1-5)

D: Communication and Interpersonal Skills

Year
20__

B-1

C: Safety

Year
20__

Page 5
2nd Edition - Revised October 2008

Year
2015

Competency
Number

D-4

Provides client and family teaching.

D-5

Reports and documents following legal

protocols, agency policy and procedure.

D-7

Applies clinical judgment in identifying problems

and resolving issues in client care.

D-8-1

Effectively manages time and organizes client

care to meet priority needs.

D-8-2

Demonstrates ability to rank the priority of client

needs.

W: Professionalism

Rating
(1-5)

W-1-3

Understands the key components of the Health

Professions Act-LPN Regulation.

W-2-3

Understands the Restricted Activity

authorizations in the LPN Regulation.

W-3

Understands the CLPNA Standards of Practice.

W-4

Adheres to the CLPNA Code of Ethics and

Standards of Practice.

W-4-5

Acts as an advocate for client and empowers

clients and families.

W-5-1

Demonstrates accountability for own nursing

practice.

W-6

Maintains the confidentiality of client

information.

W-7

Recognizes professional boundaries within the

nurse-client therapeutic relationship.

W-9

Accepts responsibility for continuing

competence and professional development.

W-9-4

Participates in continuous quality improvement

and evidence based changes to nursing
practice.

W-11

Keeps informed of current research affecting

health care delivery.

X: Nursing Practice and Leadership

Rating
(1-5)

X-1-5

Recognizes own strengths and limitations as a

leader.

X-3-5

Uses appropriate channels of communication to

report risks within setting.

Self-Assessment Tool CCP

College of LPNs of Alberta

Year
20__

Year
20__

Year
20__

Year
20__

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Page 6
2nd Edition - Revised October 2008

Year
2015

Competency
Number

X-4

Applies critical thinking and clinical judgment

when assessing or managing risk.

X-7-1

Shares knowledge, skill, and expertise with

colleagues and students.

X-7-3

Seeks opportunities to teach and mentor others.

X-7-4

Participates in committees, task forces and

professional activities to offer the LPN
perspective.

Year
20__

Year
20__

Year
20__

Year
20__

SELF-ASSESSMENT SUMMARY
Year
2015

Competency
Number

A-1
A-2
A-3
A-4-4
A-5-9
A-6
A-7
A-8-2
B-1
B-2-2
B-2-3
B-3
B-3-2
B-4
C-1
C-2
C-3
C-4
D-1
D-2
D-3
D-7
D-8-1
D-8-2
W-11

Describe the competency areas you want to improve or develop. List all items rated 2
(Competent), 3 (Requires Improvement), 4 (Developmental) in Step 1.

Nursing Knowledge, Nursing Process, Safety, Communication and Interpersonal Skills,

Professionalism, Nursing Practice and Leadership.

20___

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 7
2nd Edition - Revised October 2008

20___

20___

20___

STEP 2: SELF-ASSESSMENT OF SPECIFIC COMPETENCIES

In this section, describe, assess, and rate the competencies specific to your area of work, specialty,
role and responsibility. Review the competency sections in the Competency Profile to guide your
assessment of the Specific Competencies. Seek feedback from another health professional.
Year

Competency
Number

G-2-2
2015

Rating
(1-5)

Describe & Assess Specific Competencies

Demonstrate knowledge and ability to perform preoperative care

according to agency policy including:
Confirm oral intake restrictions

Ensure client/witness consent

Family contact information

Preoperative history and assessment

Pre-surgical preparation

Transfer client to operating room

The reason I chose this competency is because I struggled with
pre-operative care in my medical-surgical clinical rotation and I
would love to have more practice and seek guidance to strengthen
this competency.
U-1-8

Demonstrate knowledge and ability to perform drug counts on

controlled medications according to agency policy including:
maintain accurate record
Self-Assessment Tool CCP
College of LPNs of Alberta

Page 8
2nd Edition - Revised October 2008

accurately record addition and/or removal

participate in shift count and accurately record inventory

co-sign waste of controlled medication

The reason I chose this competency is because I have never
participated in performing a controlled drug count with the
exception of lab experience. I would like to have this knowledge
so I can pass the knowledge to others, and be a useful part of the
nursing team.

20___

20___

20___

20___

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 9
2nd Edition - Revised October 2008

STEP 3: LEARNING PLAN

This page is intended to document your Learning Plan for one year. Photocopy this BLANK page for each additional year.

Your Learning Plan must consist of at least TWO objectives for each year. You are required to fill out
all FOUR columns for each objective. Transfer your Learning Plan onto your Annual CLPNA
Registration Renewal Form. Please refer to the Guidelines at www.clpna.com for more information.

YEAR 2015
Learning Objectives

Resources & Strategies

Target Date

Evaluation

(What I am going to learn?)

(What will I do to meet

objectives?)

(Realistic time
frame for
achievement)

(How will I know I learned it?)

1. How to improve
my pre-operative
care organization
skills.

Practice pre-operative
care in a hospital setting
with a preceptor or senior
nurse guiding me.

September 2016

Constructive feedback
from preceptor or senior
nurse, repeat procedure
without cues.

2. How to perform
drug counts of
controlled drugs
on the unit
according to
agency policy.

Review how-tos in
previous lab manual, as
well as read up on
specific agency policy
and follow the guidance
of the preceptor or
LPN/RN on staff.

April 2016

Constructive feedback
from preceptor, able to
perform procedure
without cues.

Name: Rebecca Friesen____________

Self-Assessment Tool CCP

College of LPNs of Alberta

CLPNA Registration #: N/A_________

Page 10
2nd Edition - Revised October 2008

RECORD OF PROFESSIONAL ACTIVITIES

Date

Professional Activity
(include course,
seminar, research,
hours, details)

Summary of Learning

May 2015

Diet and Nutrition

Discussed diet levels for residents, thickened fluids, special
St. Michaels Long Term diets, specific dietary supplements, meal portions, and how
Care Centre (0.5hrs)
to avoid aspiration.

August
2015

Skin Care Presentation

Rivercrest Continuing
Care Centre
(0.5hrs)

Learned about facility-specific body wash, shampoo,

moisturizing skin creams, protective skin creams, and other
skin care products.

November
2015

Telehealth In-service
Fort Saskatchewan
Community Hospital
(1.5hrs)

All about telehealth: what its used for, how to use it, who
can use it, and the security features involved.

Name: Rebecca Friesen______

Self-Assessment Tool CCP

College of LPNs of Alberta

CLPNA Registration #:N/A_______

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2nd Edition - Revised October 2008