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

2
Competent
Meets the
expectations and / or
requirements of the
competency.

3
Requires
Improvement
Has identified
weakness in areas
of knowledge,
skills, attitudes, or
clinical judgment.

4
Developmental

5
Not Applicable

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
2016

Year
20

Year
20

Year
20

Year
20

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

1
3
3
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

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.

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)

Rating
(1-5)

1
1
1
1
Rating
(1-5)

C: Safety

Year
20

3
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
3
3
1
1
Rating
(1-5)

3
1
1
1
1
1
1
1
1
1

3
Rating
(1-5)

2
1

Year
20 16

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

3
1
1
1

SELF-ASSESSMENT SUMMARY
Year

Competency
Number

A-2
A-3
20 16 _

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

Applies knowledge of microbiology throughout care, disease prevention, and health promotion.
Applies knowledge of pathophysiology to the nursing care of the client.
Applying knowledge of pharmacology throughout client care and teaching.

A-7

C1- C4
20 16 _

-I rated myself 3 on these competencies. I want to improve and review on microbiology and
pathophysiology, pharmacology as I am not confident with my knowledge on these.
Applies critical thinking and clinical judgment when responding to emergency situations.
- I rated myself 3 on this competency. My weakness for this is if I can think clearly when responding
to emergency situations in the actual workplace setting.

D- 5
20 16 _

D-7
W-1-3
20 1 6

W-11
X-1-5
20 1 6 _

X-4

Reports and documents following legal protocols, agency policy and procedure. -I rated myself 3
on this competency. I am competent with my knowledge regarding these but I need to master them.
Applies clinical judgment in identifying problems and resolving issues in client care. I rated 3 on
this as I need to master these in the workplace setting.
Understands the key components of the Health Professions Act-LPN Regulation.
I rated myself 3 on this competency. I rated 3 on this as I need to master these in the workplace
setting and review on it.
Keeps informed of current research affecting health care delivery.
I rated myself 3 on this competency because I need to be updated with the current research and
look it up.
Recognizes own strengths and limitations as a leader. I rated myself 2 on this competency. I am
competent on this but needs to be excellent in the workplace setting. I need practice on how to be a
leader in the workplace.
Applies critical thinking and clinical judgment when assessing or managing risk. I rated myself 3
on this as I need to have practice on critical thinking in the workplace setting.

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

Rating
(1-5)

Describe & Assess Specific Competencies

Demonstrate knowledge of routes for medication administration.

20 16 _

20 1 6 _

U-1-4

A-1-6

I am able to demonstrate knowledge on routes from medication

administration. I have to master on these though once I am working in a
healthcare facility. I already know the different types of routes, I just need
to master them and also on administering them, keeping in mind the
process and what to prepare before the medication administration.
Identify the structure and explain the function of body systems.
-

20 1 6 _

J-2-7

2016

_ C-5-4

20
16_

B-1-7

I have proficient knowledge regarding anatomy and physiology.

But I sometimes have a hard time explaining them in my own
words.

Demonstrate knowledge and ability to recognize signs and symptoms of a

life threatening cardiac event and implement or assist with cardio
pulmonary resuscitation according to agency policy. As an LPN student, I
have knowledge on recognizing the sign and symptoms when a patient is
3
about to have a cardiac arrest. I have training in CPR recently so I can say I
have proficient skills on this. However, I need to be able to apply my
knowledge and my weakness is not to overthink when that situation arises.
Demonstrate knowledge and ability to utilize controls to identify and
2
reduce risk of physical injury to self and others including : hazard and
exposure (chemical, biological) ; safe handling and use of tools and
equipment; safe lifting and transferring of loads; use of personal protective
equipment. I am proficient on these as I have already taken the Its your
move program and know the use of PPE but I need more exposure and
application on these in the actual workplace setting.
Demonstrate knowledge and ability to perform vital signs and other
2
assessments including blood glucose level, elimination, hydration,LOC,
nausea, pain, pulse oximetry. I believe that I am proficient in performing
these skills but I just need more exposure on the healthcare setting and do
these skills on actual patients in the workplace.

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

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?)

To be able to identify risks of Review the online course on

physical injury, to be able to Its your move program and
properly use mechanical lifts, attend the training with my
know the principles of safe instructors to review on safe
lifting and transferring of
lifting and use of proper lifting
loads (patient, equipment) , equipment, transferring
proper body mechanics after patients, proper body
the online course on Its your mechanics.
move and the actual Its your
move training at Norquest this
coming September 14, 2016
in preparation for my
practicum this September 19.

Complete the
training on
September 14,
2016.

Be able to pass Its your move

program, be able to master the
lifting equipment and the
procedures related with it and
get a certificate after the
training. Be able to do these
techniques on proper lifting,
proper body mechanics without
hurting my back during the
practicum on September 19November 19, 2016.

Be able to complete Be able to commit no mistakes

To be able to demonstrate
Review on medications and
and prepare on
in medication administration
knowledge of routes for
different types of meds
these two weeks
and its routes and being able to
medication administration and administration by reviewing on
before my clinical consult Drug guide all the time
to be able to commit no
Davis drug guide and always duty on Medicine
when in doubt during my
mistakes in medication
bringing it during my
unit on September practicum this September 19administration during my
practicum. Check the
21, 2016.
November 19, 2016.
practicum on September 19, procedure manual and policies
2016.
on med administration of the
hospital when in doubt. Always
do med checks. Review
Safemedicate module online.

Name: Klaus Rivales

CLPNA Registration #:

RECORD OF PROFESSIONAL ACTIVITIES

Date

Professional Activity

Summary of Learning

(include course, seminar,

research, hours, details)

February
2016

Its Your Move Program training

for 3 hours at Norquest college
and Its Your Move Program
online module training

1. Learned about proper body mechanics.

2. Learned to identify risks of physical injury in the hospital.
3. Learned how to properly use mechanical lifts.
Learned about the principles of safe lifting and transferring
of loads (patient, equipment).
1.

August 2016 Human Blood-borne Pathogen

online learning module at
Norquest College

2.

August 2016 Basic Life Support for Health

Care Providers training for 8
hours.

1.

Workplace Hazardous Materials

Information System online
August 2016 learning module at Norquest
college.

1.

September
2016

AHS Information and Privacy

Training online learning module.

Name: Klaus Rivales

2.

2.

Learned about safety measures due to exposure of blood

borne pathogens in the health care setting.
Learned about identification of risks and recommended
work practices related to exposure of blood borne pathogens
in the workplace.

Learned about, how to handle emergency situations and how to do

CPR on an infant, adult and child and how to use an AED.
Learned how to handle rescue breathing.

Learned the proper safety procedures when handling hazardous

materials in the workplace.
Learned how to identify hazards, classify, correctly label, and
the warning signs of hazardous materials in the workplace.
1. Learned about Information Privacy and It security and
compliance in AHS hospitals.
2. Learned about the importance of Patient confidentiality and
privacy related to his personal and health information.

CLPNA Registration #:

RECORD OF PROFESSIONAL ACTIVITIES

Date

Professional Activity

Summary of Learning

(include course, seminar,

research, hours, details)

Name:

CLPNA Registration #: