Clpna Self-Assessment Tool

Carly Legault
September 12, 2013
Self-Assessment Tool CCP

College of LPNs of Alberta
Page 1
2nd Edition - Revised October 2008

Page 2
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

Page 3
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
2016_
_
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.

Page 4
Year
2016_
_
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.

Year
20__
Rating
(1-5)
D: Communication and Interpersonal Skills
Year
20__
B-1
C: Safety
Year
20__
Page 5
Year
2016_
_
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

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
Year
2016_
_
Competency
Number
Year
20__
Year
20__
Year
20__
Year
20__
report risks within setting.

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.
SELF-ASSESSMENT SUMMARY
Year
2016
2016
Competency
Number
Describe the competency areas you want to improve or develop. List all items rated 2
(Competent), 3 (Requires Improvement), 4 (Developmental) in Step 1.
A-1
A-2
A-3
A-4-4
A-5-9
A-6
A-7
A-8-2
A: Nursing Knowledge
B-1
B-2-2
B-2-3
B-3
B-3-2
B-4
B: Nursing Process
C: Safety
2016
2016
C-7-1
D-1
D-3
D-4
D-5
D-7
D-8-1

D: Communication and Interpersonal Skills
Page 7
D-8-2
2016
2016
W-1-3
W-2-3
W-3
W-4
W-4-5
W-9-4
W-11
X-1-5
X-3-5
X-4
X-7-1
X-7-3
W: Professionalism
X: Nursing Practice and Leadership
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
2016
2016
Competency
Number
D-8-1
A-7

Rating
(1-5)
Describe & Assess Specific Competencies
This competency is time management and organization to meet a

client(s) needs. I believe that I can assess and differentiate what
are top priorities and needs that have to be completed first
versus a task that is lower priority but I need to work on my time
management. Time management is a key component to nursing
effectively and allows for tasks to be completed in a timely
manner. Time management makes one able to complete tasks
efficiently and even allows the nurse to help out others that may
be behind. Over the past clinical experiences I find my time
management has improved a lot but I still find myself behind
sometimes and requiring the assistance of others to address all
priorities and tasks.
This competency is about the use of pharmacology knowledge
when teaching the client and in their care. I can apply this
knowledge and am able to teach client(s) about the medications
they are getting but this is one of my weaker links and I still have
to brush up on and familiarize myself with drugs and the
classifications that they fall under. Once I have the information I
can relay it to the client but sometimes I have to double check my
notes to make sure I addressed all the key information and side
effects.
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Page 9
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 2016
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) I will talk to my
preceptor and/or
employer about ways that
they would recommend to
improve my time
management. I will also
update and improve my
organizational plan.
1) I will
complete this
by the end of
the preceptor
rotation, August
19, 2016.
1) I am going to learn
strategies of good time
management.
2) I am going to learn
and become more
familiar with common
drugs and classifications.
Name: Shae-Lynn Seib

2) I will make more notes

and/or med cards about
drugs Im not familiar with
and review them
regularly.
2) I will
complete this
by the end of
the preceptor
rotation, August
19, 2016.
1) I will know this by

receiving feedback from
my preceptor and I will be
on time with my tasks and
will complete them in a
timely manner.
2) I will know this by

being able to identify the
drugs I am using without
always reviewing my med
cards and will be able to
state the correct answer
about a drug if asked to
do so.
CLPNA Registration #: ____________
Page 10
RECORD OF PROFESSIONAL ACTIVITIES

Date
Sept. 13,
2015
Oct. 19,
2015 Nov.
13, 2015
February 29,
2016
March 24,
2016
Professional Activity
(include course,
seminar, research,
hours, details)
Heart and Stroke CPR
course
BSL for HCP (C)
3 hours
Long term care Clinical

115 hours
Medicine Clinical
115 hours
March 28,
2016 April
22, 2016
Surgery Clinical
115 hours
Name: Shae-Lynn Seib

Summary of Learning
In this course I learned how to preform proper resuscitation,

AED use, two person CPR and how to help someone that is
choking. We worked in pairs and with a mannequin to
perform the correct techniques as our instructor watched
and assessed us. At the end of the course we wrote an
exam to make sure we knew all the information we had
learned throughout the day.
This was my first clinical and it allowed me to work on and
use all the skills I had learned throughout the previous
semesters. I learned how to build on my time management
skills and how to assist an elderly client with their activities
of daily living.
This was my second clinical and it allowed me to continue
building my time management and assessment skills. We
had many opportunities to do wound care, tube feeds and
how to use/wear proper PPE. The unit I was on was a
stroke unit so we had to assist many clients with their
activities of daily living and reorient them as to limit
confusion.
This was my third clinical where I continued to develop my
time management and assessment skills. I was on a hip
and knee replacement unit so I had the opportunity to do
many dressing changes and learned the importance of and
times to do post op assessments. I also learned about
narcotics and prns and how to administer them affectively
thus helping the clients manage their pain.
CLPNA Registration #:__________
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Carly Legault

September 12, 2013

Self-Assessment Tool CCP

Self-Assessment Tool CCP

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

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

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

Self-Assessment Tool CCP

STEP 1: SELF-ASSESSMENT WITHIN STANDARDS OF

Applies knowledge of anatomy and physiology

Applies knowledge of microbiology throughout

Applies knowledge of pathophysiology to the

Uses appropriate medical terminology to report

Adjusts nursing practice to the specific growth

Applies principles of nutrition to the assessment

Applies knowledge of pharmacology throughout

Self-Assessment Tool CCP

Integrates knowledge and skills from the

Performs health assessment of client using

Implements the planning process and

Identify and analyze nursing diagnosis.

Implements nursing interventions to carry out

Reassess, review, and modify plan of care to

Evaluates the clients response to care and

Applies critical thinking and clinical judgment

Effectively uses protective devices to protect

Demonstrates the consistent application of

Applies principles of medical and surgical

Applies nursing knowledge and clinical

Uses effective verbal and written

Appropriately establishes, maintains, and

Collaborates with health care team to function

Adheres to the channels of communication

Self-Assessment Tool CCP

D: Communication and Interpersonal Skills

Provides client and family teaching.

Reports and documents following legal

Applies clinical judgment in identifying problems

Effectively manages time and organizes client

Demonstrates ability to rank the priority of client

Understands the key components of the Health

Understands the Restricted Activity

Understands the CLPNA Standards of Practice.

Adheres to the CLPNA Code of Ethics and

Acts as an advocate for client and empowers

Demonstrates accountability for own nursing

Maintains the confidentiality of client

Recognizes professional boundaries within the

Accepts responsibility for continuing

Participates in continuous quality improvement

Keeps informed of current research affecting

X: Nursing Practice and Leadership

Recognizes own strengths and limitations as a

Uses appropriate channels of communication to

Self-Assessment Tool CCP

report risks within setting.

Applies critical thinking and clinical judgment

Shares knowledge, skill, and expertise with

Seeks opportunities to teach and mentor others.

Participates in committees, task forces and

Self-Assessment Tool CCP

D: Communication and Interpersonal Skills