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Self-Assessment Tool CCP

College of LPNs of Alberta

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2nd Edition - Revised October 2008

TABLE OF CONTENTS

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

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

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

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Self-Assessment Tool CCP

College of LPNs of Alberta

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2nd Edition - Revised October 2008

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SELF-ASSESSMENT TOOL

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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

Competent

Requires
Improvement

Developmental

Not Applicable

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

Not applicable to
current role and
responsibility.

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

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Meets the
expectations
and / or
requirements of
the competency.

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

STEP 1: SELF-ASSESSMENT WITHIN STANDARDS OF

PRACTICE

Competenc
y Number

Year
2016

A: Nursing Knowledge

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A-1

A-2

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A-3

A-4-4

Applies knowledge of anatomy and physiology

of the human body to the assessment of client
and delivery of nursing care.
Applies knowledge of microbiology throughout
care, disease prevention, and health
promotion.
Applies knowledge of pathophysiology to the
nursing care of the client.
Uses appropriate medical terminology to report
and document client care.

Self-Assessment Tool CCP

College of LPNs of Alberta

Rating
(1-5)

Year
20__

Rating
(1-5)

Year
20__

Rating
(1-5)

Year
20__

Rating
(1-5)

Year
20__

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Rating
(1-5)

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2nd Edition - Revised October 2008

Competenc
y Number

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A-5-9

A-6

A-7

A-8-2

Adjusts nursing practice to the specific growth

and development of the client.
Applies principles of nutrition to the
assessment and care of the client.

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Integrates knowledge and skills from the

sciences and humanities into the application of
the nursing process.

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B-2-2

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B-2-3
B-3
B-3-2

B-4

Performs health assessment of client using

assessment techniques and a systematic
process.
Implements the planning process and
establishes client priorities involving client in
planning.
Identify and analyze nursing diagnosis.
Implements nursing interventions to carry out
nursing care plan.
Reassess, review, and modify plan of care to
meet the needs of the client.

Evaluates the clients response to care and

treatment.

C: Safety

C-1 to
C-4

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C-5-1

C-6-1

C-7-1

C-12

Applies critical thinking and clinical judgment

when responding to emergency situations.

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Effectively uses protective devices to protect

client, self, and others.
Demonstrates the consistent application of
standard precautions.
Applies principles of medical and surgical
asepsis in the delivery of care.
Applies nursing knowledge and clinical
judgment to maintain physical safety of client.

D: Communication and Interpersonal Skills

Self-Assessment Tool CCP
College of LPNs of Alberta

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B-1

Year
20__

Applies knowledge of pharmacology

throughout client care and teaching.

B: Nursing Process

Year
2016

Rating
(1-5)

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Rating
(1-5)

Year
20__

Rating
(1-5)

Year
20__

Rating
(1-5)

Year
20__

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Rating
(1-5)

1
Rating
(1-5)

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(1-5)

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(1-5)

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2nd Edition - Revised October 2008

Competenc
y Number

Year
2016

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D-1

D-2

D-3

D-3-7

Uses effective verbal and written

communication in the practice setting.
Appropriately establishes, maintains, and
closes the nurse-client relationship.
Collaborates with health care team to function
as an effective team member.
Adheres to the channels of communication
within the employing agency.

D-4

Provides client and family teaching.

D-5

Reports and documents following legal

protocols, agency policy and procedure.

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D-7

D-8-1

D-8-2

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Applies clinical judgment in identifying

problems and resolving issues in client care.
Effectively manages time and organizes client
care to meet priority needs.

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2
4

W-4-5

Acts as an advocate for client and empowers

clients and families.

W-5-1

Demonstrates accountability for own nursing

practice.

W-2-3

W-3

W-4

W-6
W-7

Understands the Restricted Activity

authorizations in the LPN Regulation.
Understands the CLPNA Standards of
Practice.
Adheres to the CLPNA Code of Ethics and
Standards of Practice.

Maintains the confidentiality of client

information.
Recognizes professional boundaries within the
nurse-client therapeutic relationship.

Self-Assessment Tool CCP

College of LPNs of Alberta

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Rating
(1-5)

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Understands the key components of the Health

Professions Act-LPN Regulation.

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Year
20__

Year
20__

Year
20__

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W-1-3

Year
20__

Demonstrates ability to rank the priority of

client needs.

W: Professionalism

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Rating
(1-5)

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(1-5)

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Rating
(1-5)

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2nd Edition - Revised October 2008

Competenc
y Number

Year
2016

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

X-3-5
X-4

X-7-1
X-7-3

X-7-4

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Uses appropriate channels of communication

to report risks within setting.

Applies critical thinking and clinical judgment

when assessing or managing risk.

Shares knowledge, skill, and expertise with

colleagues and students.

Seeks opportunities to teach and mentor

others.

Participates in committees, task forces and

professional activities to offer the LPN
perspective.

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Year
20__

Rating
(1-5)

Recognizes own strengths and limitations as a

leader.

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Year
20__

Rating
(1-5)

Year
20__

Rating
(1-5)

Year
20__

Rating
(1-5)

Rating
(1-5)

SELF-ASSESSMENT SUMMARY

2016

A-2
A-3
A-6
A-7

Nursing Knowledge

C-1
to C-4
C-5
C-7

Safety

Year

2016

Competency
Number

Self-Assessment Tool CCP

College of LPNs of Alberta

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

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2nd Edition - Revised October 2008

D-1
D-3
D-3-7
D-4
D-5
D-8-1

Communication and Interpersonal Skills

W-1-3
W-2-3
W-9-4
W-11

Professionalism

X-3-5
X-7-1
X-7-3
X-7-4

Nursing Practice and Leadership

2016

2016

2016

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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.

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Year

2016

Competency
Number

W-2-3

D-3-7

2016

Describe & Assess Specific Competencies

In the hospital, I was confused as to what the restrictions were on the

LPN scope of practice. Some LPNs said some skills were completely
restricted while others said the same skills were allowed. I realize it is
my responsibility to find out for my own scope of practice what the
restrictions are.

I find it difficult to know the proper channels of communication in the

hospital. I found I only asked/informed my instructor and fellow student,
even though this is not correct. As each agency is different, I realize the
importance of finding out the proper channels of communication
wherever I am placed.

Rating
(1-5)

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Self-Assessment Tool CCP
College of LPNs of Alberta

Page 7
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2nd Edition - Revised October 2008

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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.

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Learning Objectives

(What I am going to learn?)

1. I am going to learn
specifically which skills
and activities are
restricted in the LPN
scope of practice.

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2. I am going to learn
what the proper channels
of communication are in
each health care setting I
am placed, and adhere to
them.

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YEAR 2016

Resources & Strategies

(What will I do to meet
objectives?)

(Realistic time frame

for achievement)

1. I will read through the

LPN scope of practice
and make note of which
activities are restricted
and put them on a
separate list so I can
reference it in the future.

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Target Date

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1. I will
complete this
by July 20th,
2016.

Evaluation
(How will I know I learned it?)

2. I will ask my employer

2. I will achieve
and my preceptor what
this by July
are the proper channels of
20th, 2016.
communication and also
review them in the
agency policy books.

Name: ___________________________

1. I will know I have

learned this by being able
to delegate skills and
activities that I know are
restricted. Also I will be
able to correctly answer
an employer or charge
nurse as to what I am
allowed to do.
2. I will have learned this
by going through the
proper channels of
communication in any
employing agency. Also I
will be able to inform any
other employees of the
correct ways of
communication.

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CLPNA Registration #: ____________

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Self-Assessment Tool CCP
College of LPNs of Alberta

Page 8
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2nd Edition - Revised October 2008

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RECORD OF PROFESSIONAL ACTIVITIES

Date

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

Summary of Learning

April 14,
2016
(3 Hours)

Research and
Presentation in Nursing
Foundations: Maternity

Project on Da Vinci Robot for women's surgery. Learned

how it is similar to laproscopic surgery. The Robot reduces
risk of infection, recovery time in hospital, and size of
scar.

April 16,
2016
(3 Hours)

CPR Renewal
(BLS for HCP: C)

A refresher of how to assess before performing CPR,

demonstrating CPR for both adults and children, the use of
AEDs, and what to do for choking victims.

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Jan 4 - Jan Acute Care Medicine

9, 2016
Royal Alexandra
(115 Hours) Hospital

On a Pulmonary Medicine Unit. Learned many different

lung sounds and how to identify them, the care of chest
tubes, use of oxygen therapy, and the use of full PPE.

Feb 1 - Feb Acute Care Surgery

26, 2016
Royal Alexandra
(115 Hours) Hospital

At the Orthopaedic Surgery Centre. Learned how to care

for post-surgery Clients, the dos and donts of hip and
knee replacements, and practiced many dressing changes.

Oct 19 Long Term Care

Nov 13,
Clinical
2015
Citadel
(115 Hours)

Learned the importance of time management, how to

maintain the dignity of elderly clients, and reducing
pressure wounds.

Name: _____________________

Self-Assessment Tool CCP

College of LPNs of Alberta

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CLPNA Registration #:__________

Page 9
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2nd Edition - Revised October 2008