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__

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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

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

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

Year

Competency
Number

2015_

A
A-2
A-6

Nursing Knowledge

W
W-13
W-23
W-11
X
X-7-1
X-7-3

Professionalism

2015__

2015___

Nursing Practice and Leadership

20___

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 7
2nd Edition - Revised October 2008

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

Competenc
y Number

G-1-4

Rating
(1-5)

Describe & Assess Specific Competencies

Demonstrate knowledge and ability to provide health teaching

and coaching associated with surgical nursing.

2015__

I-1-2
2015__
_

Self-Assessment Tool CCP

College of LPNs of Alberta

Demonstrate knowledge and understanding of anatomy,

physiology and pathophysiology related to illness/trauma of the
neurological system including: determinants of normal
neurological function, neurological impairment, shock,
neurological illness, trauma and surgery including:

brain and spinal tumors

carotid endarterectomy

Guillian-Barre syndrome

intracranial haemorrhage

increased intracranial pressure

meningitis

neurosurgery

seizures and epilepsy

stroke

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2nd Edition - Revised October 2008

transient ischemic attack

traumatic head injury

traumatic spinal cord injury

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?)

Be able to demonstrate
in-depth patient health
teaching post operatively

I will use the Med Surg

textbook to understand
how to teach each patient
individually

March 30 2016

Take an online examine to

assess my personal level
and receive higher than
90%

Look at previous teaching

for surgical discharge
patients to get a better
understanding and more
resources for patients

Better my personal
knowledge on all
medical aspects of
nursing of a neurological
condition

Use previous textbooks

for information, videos of
the neurological issue at
hand and possible nursing
interventions
Talk to other nurses on the
unit to increase my
knowledge of what the
unit experiences and how
to prepare for each patient

Name: _Madison Kinshella____________

Self-Assessment Tool CCP

College of LPNs of Alberta

Get a co-worker to rate

my teaching for each
surgery

April 10 2016

Make a knowledge
checklist to see how much
I have achieved weekly
After 1-2 weeks I will be
able to repeat learned
aspects to the nurses who
gave me more information
on neuro conditions

CLPNA Registration #: ____________

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2nd Edition - Revised October 2008

RECORD OF PROFESSIONAL ACTIVITIES

Date

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

Summary of Learning

Long-term Care Clinical

Learned how to do full morning care on patients, feed

clients and administer PO/ IM/ SC medications to 2 patients.

Seminar on safe oxygen

therapy

Learned safety precautions when filling O2 tanks.

Taught how to trouble shoot when O2 tanks are not properly
working for patient therapy

CPR

Recertified in basic pediatric and adult life support

Medicine Clinical

This clinical I was able to complete many skills such as

catheterizing males and females, completing an IV, hooking
up patients to IV meds, wound care, all routes of medication
administration and proper moving of patients.

October
2015

Surgery Clinical

During this clinical I learned proper pre/ post op care for

patients, wound care, IV starts, catheterization and all routes
of medication administration.

October
2015

Preventing post
operative infections
seminar

Learned about common post op infections, and their signs

and symptoms. From there we were taught important points
to watch for when working with post op patients and how to
prevent serious infections

May 2015

May 2015

August 2015

September
2015

Name: _____________________

Self-Assessment Tool CCP

College of LPNs of Alberta

CLPNA Registration #:__________

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2nd Edition - Revised October 2008