SELF-ASSESSMENT TOOL

Continuing Competency Program

TABLE OF CONTENTS

SELF-ASSESSMENT TOOL - RATING SCALE ........................................................................ 1

STEP 1: SELF-ASSESSMENT WITHIN STANDARDS OF PRACTICE .................................... 1
A: Nursing Knowledge .............................................................................................................. 1
B: Nursing Process .................................................................................................................... 2
C: Safety................................................................................................................................... . 2
D: Communication and Interpersonal Skills ............................................................................... 2
W: Professionalism ................................................................................................................... . 3
X: Nursing Practice and Leadership........................................................................................... 3
Self-Assessment Summary......................................................................................................... 4
STEP 2: SELF-ASSESSMENT OF SPECIFIC COMPETENCIES ............................................. 5

STEP 3: LEARNING PLAN ....................................................................................................... 6

RECORD OF PROFESSIONAL ACTIVITIES............................................................................. 7

Self-Assessment Tool CCP

College of LPNs of Alberta

nd

2 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

5
Not Applicable

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.

Not applicable to
current role and
responsibility.

STEP 1: SELF-ASSESSMENT WITHIN STANDARDS OF PRACTICE

Competency
Number

A: Nursing Knowledge
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

Year
20 16

Year
20

Year
20

Year
20

Year
20

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

1
1
1
1
1
1

Page 1
nd

2 Edition - Revised October 2008

Year
20 16

Competency
Number

A-8-2

Integrates knowledge and skills from the

sciences and humanities into the application of
the nursing process.

B: Nursing Process
B-1

B-2-2

Performs health assessment of client using

assessment techniques and a systematic
process.
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.

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.

D: Communication and Interpersonal Skills

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.

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)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

1
Rating
(1-5)

1
1
1
1
1
Rating
(1-5)

C: Safety

Year
20

1
1
1
1
1
Rating
(1-5)

1
1
1
1

Year
20 16

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
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

X-1-5

Recognizes own strengths and limitations as a

leader.

X-3-5

Uses appropriate channels of communication to

report risks within setting.

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)

1
2
1
1
1
Rating
(1-5)

1
2
2
1
1
1
1
1
1
1

1
Rating
(1-5)

1
1

Year
2016

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

1
1
1
1

SELF-ASSESSMENT SUMMARY
Competency
Number

Year

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

Reports and documents following legal protocols, agency policy and procedure.
20 16 _

D-5

-I am still learning the requirements in this area. I will have to refer back to literature on
these topics to refresh my memory. As I come to different dilemmas, then I will have to go
to these documents to follow up to make the right informed decisions.
Understands the Restricted Activity authorizations in the LPN Regulation.

20 16 _

W-2-3

I am cautious to make the correct decision in my practice, so I will have to refresh my

restricted activities so they do not conflict and make errors.

Understands the CLPNA Standards of Practice.

20 16 _

20

20

W-3

because I am in the novice learning stage of my nursing career I will have to refer
back to the CLPNA to be sure that I am practicing safe ethical care.

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.
Competency
Number

Year

20 16 _

E-3-3

Describe & Assess Specific Competencies

-Demonstrate knowledge and ability to seek guidance and assistance

from

Rating
(1-5)

inter- professional team as necessary .

Demonstrate knowledge and ability to perform drug counts on controlled medications

according to agency policy including:

20 16 _

Demons
trate
knowle
dge and
20 16 _

2016

Demonstrate knowledge and ability to align the Code of Ethics to guide

practice and behavior with:

W-4-2
-professional standards
- competencies
- employer policies
- legal requirements

G-2-2

Demonstrate knowledge and ability to perform preoperative care

according to
agency policy including.
-

2016

- maintain accurate record

- accurately record addition and/or removal
- participate in shift count and accurately record inventory
- co-sign waste of controlled medication

ensure client/witness consent

family contact information
preoperative history and assessment
pre-surgical preparation
- transfer client to operating room

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 20 16
Learning Objectives

Resources & Strategies

(What I am going to learn?)

(What will I do to meet

objectives?)

Target Date

(Realistic time
frame for
achievement)

Evaluation
(How will I know I learned it?)

K-2-4
Demonstrate knowledge and ability to
provide pre-operative care to client prior
to emergency or elective caesarean
section including:

Research various course and lectures

available

continual monitoring and care

I would like to feel comfortable and
knowledgeable while providing
assessments and routine care for a patient
that is about to receive an elective
caesarean section.

By the end of my
clinical July 2016.

I will know this after I have

completed my research and I am
able to feel comfortable and
discuss my knowledge of elective
caesarean surgery

U-2-4
Demonstrate knowledge and ability to
appropriately prepare medications for
administration according to agency
policy.

As I transition from a student to the

clinical setting and complete routine
medication administration, I will be
proactive and review agency policies
regarding medication administration.

Name:

Review Shuswap Lake General

Hospitals policies and procedures so I
will be proficient

May 10-23 2016 I will

review policies and when I
My understanding where to
begin my clinical on May locate policies and fell
24, 2016 and as I need to comfortable attaining information
discuss with my nursing preceptor
review them.
from these polices and applying it
where to find information while on the
to my safe practice.
job.

CLPNA Registration #:

RECORD OF PROFESSIONAL ACTIVITIES

Date

Professional Activity

Summary of Learning

(include course, seminar,

research, hours, details)

March
2016

Respectful work place

fostering culture of
respect

Working in a professional atmosphere and how to treat

other and how to be treated.

Online course 2 hours

March
2015

January
2016

March
2016

WHMIS
Online 2 hours

Hand Hygiene

Working with dangerous goods and how to store them

and identify them.

Proper asepsis and hand washing.

Online 1 hour

Emerging infectious
diseases- donning and
doffing PPE

Learning about infectious diseases and how to

prevent by proper precautions.

3 hours online
March
2016

Using the LBS Bariatric

board

Transporting heavy patients safely

March
2016

Online hour course

Clinical trainingWhen and where to ambulate patients using critical
guidelines for ambulating thinking and safe practice guidelines
patients.
2 hour course online

March
2016

Violence prevention

Learning to read violent situations and to stay safe.

Online 2 hours

Name:

CLPNA Registration #:

RECORD OF PROFESSIONAL ACTIVITIES

Date

Professional Activity

Summary of Learning

(include course, seminar,

research, hours, details)

Name:

CLPNA Registration #: