rrRRe

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 2
nd

2 Edition - Revised October 2008

Self-Assessment Tool CCP
College of LPNs of Alberta

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.

Page 3
nd

2 Edition - Revised October 2008

Self-Assessment Tool CCP
College of LPNs of Alberta

Year
2015
__

Competency
Number

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.

1
2

A-7

Applies knowledge of pharmacology

throughout client care and teaching.

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)

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: Safety
C-1 to
C-4

Applies critical thinking and clinical

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)

3
1
Rating
(1-5)

3
Page 4
nd

2 Edition - Revised October 2008

Self-Assessment Tool CCP
College of LPNs of Alberta

Year
2015
__

Competency
Number

Year
20__

Year
20__

Year
20__

Year
20__

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

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

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

2
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.

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.

1
Page 5
nd

2 Edition - Revised October 2008

Self-Assessment Tool CCP
College of LPNs of Alberta

Year
2015
__

Competency
Number

D-8-2

Demonstrates ability to rank the priority

of client needs.

W: Professionalism
W-1-3
Understands the key components of the

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
Rating
(1-5)

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.
Acts as an advocate for client and
empowers clients and families.
Demonstrates accountability for own
nursing practice.

W-4-5
W-5-1
W-6
W-7

W-9

W-9-4

W-11

Maintains the confidentiality of client

information.
Recognizes professional boundaries
within the nurse-client therapeutic
relationship.
Accepts responsibility for continuing
competence and professional
development.
Participates in continuous quality
improvement and evidence based
changes to nursing practice.
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.
Uses appropriate channels of

2
1
1
1

3
Rating
(1-5)

Page 6
nd

2 Edition - Revised October 2008

Self-Assessment Tool CCP
College of LPNs of Alberta

Competency
Number

X-3-5
X-4

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

communication to report risks within

setting.
Applies critical thinking and clinical
judgment when assessing or managing
risk.

Year
2015
__
1

Year
20__

Year
20__

Year
20__

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.

SELF-ASSESSMENT SUMMARY
Year

Competenc
y 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.

Page 7
nd

2 Edition - Revised October 2008

Self-Assessment Tool CCP
College of LPNs of Alberta

Year
20__

2015

A-1
A-2

I have theoretical knowledge about anatomy and physiology, but I have

not practice enough. I will read and watch videos to improve this
knowledge.
Microorganisms are always been in health setting. I will keep my
knowledge up to date about microbiology.

A-3
A-59
A-7

2015

2015

2015

Pathophysiology is the most important knowledge in every aspect of

nursing career, so I will keep myself educating about dieseases.
I want to expand knowledge on specific growth and development of
different age and groups of patients.
Pharmacology is a significant part of LPN career. I want to practice on
medication administration and client teaching to minimize drug errors.

A-8-2

I want to review Jean Watson's nursing theory again and again.

B-22

I will read nursing care plan book to improve nursing skills to recognize
client care planning according to priority of patient care.

B-32
C-1
to C4

I need more practice and reading textbook related patient care plans.

So far I remember, I do not have experience of handling emergency

situation. I will make sure I will be educated what to do during
emergency according to employer policy and other materials such as,
website or textbooks that explains common nursing emergency and
critical thinking.

D-37

I do not have adequate communication practice using SBAR. I think I

will do fine once I get education and proper orientation from employing
agency.

D-7

I need more practice and guidance to master this skill. I also need to work
independently to gain confidence.

Page 8
nd

2 Edition - Revised October 2008

Self-Assessment Tool CCP
College of LPNs of Alberta

2015

W-13

I must read more and understand Health Act-LPN regulation.

I need to review the restricted Activity authorizations in the LPN Regulation

W-23

via CLPNA.

I should practice more and need to understand when to advocate and

what are the processes.

W-45
W-94

I want to read related evidence based nursing books and most recent
articles. CLPNA and other nursing website provide such materials.
Nursing practice always changes. For this reason, I will subscribes
nursing newsletters for updated news and practice.

W-11
X-1-5 Even though I know my strength and limitations, I have not practiced
leadership, yet. I think I will gain the leadership quality as I will start
working as an LPN.

X-4

I need more experience to improve my critical thinking and clinical

judgment when assessing or managing risk. I am hoping I will develop it
once I pursue LPN responsibility.

X-7-3 I require more opportunities to teach and mentor others for the

development of my mentorship ability which is possible at LPN position.

X-7-4

I want to participate in nursing seminars, workshops, in-service and

meetings to acquire further knowledge.

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
Page 9
nd

2 Edition - Revised October 2008

Self-Assessment Tool CCP
College of LPNs of Alberta

guide your assessment of the Specific Competencies. Seek feedback from another health
professional.

Year

Competency
Number

A-1
2015

2015

"G-5-6"
CLPNA

Describe & Assess Specific Competencies

Anatomy and physiology are significant knowledge for
nurses to understand disease process in patients . By
following the anatomy and physiology, nurses are able to
assessment and provide competent care to all the
patients.
I have the basic knowledge of anatomy and physiology. I
equally like to learn more, but I want to know more about
respiratory system and cardiovascular systems
assessment of adult patients. The two systems are very
critical in nursing practice and always the priority of
nursing care.
I have demonstrated knowledge and ability to perform
wound irrigation, packing of wounds, and removal of
packing as per agency policy during my long-term care
and acute care clinical. It already has been about a year
that I had performed it, so I am not confident that if I can
do it by following all the clean and sterile principles or
not.

Rating
(1-5)

Page 10
nd

2 Edition - Revised October 2008

Self-Assessment Tool CCP
College of LPNs of Alberta

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?)

By May 01, 2016, I will

be able to perform adult
cardiovascular and
respiratory assessment in
15 minutes.

I will review nursing

fundamental of nursing
textbook that provide
step by step guidelines. At
the same time, I will
watch Mosby's video
and practice these
assessment with my
husband.

June 01, 2016

I video tape the practice

and review with coworker register nurse.

October 01,
2016

I will request register

nurse at my work place to
facilitate me wound
dressing tasks and watch
with feedbacks while I
will provide wound care.

By September 01, 2016

I will be able to perform
wound irrigation,
wounds packing , and
removal of packing n in
30 minutes by following
agency's policy.

I will read wound care

chapter in nursing
fundamental of nursing
textbook and review the
guidelines. I will watch
videos that shows proper
wound irrigation, packing,
removal of packing
techniques.

Page 11
nd

2 Edition - Revised October 2008

Self-Assessment Tool CCP
College of LPNs of Alberta

Name: Reeta Thapa

CLPNA Registration #: ____________

RECORD OF PROFESSIONAL ACTIVITIES

Date

August 2014

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

Summary of Learning

Attended "It's Your

Move" course in
Norquest College.
4 hours
CPR course
4 hours

I learned safe body mechanism while lifting ,

moving, and carrying heavy stuffs.

The course taught me how important is it to take
care of yourself beside patients.

Leant to perform choking thrust: abdominal

thrust for adult and breast bone thrust to
infant

February and

-Research on different

March 2015

kinds of diseases,
pharmacology use, and

CPR and AED

Had opportunity to learn more diseases

Had learned about common medications and

medication administration
Did dressing change, butter fly needle insertion,

Shared knowledge and learned from

nursing care
- Pre and post

classmates and instructors how to provide

conference for NPRT

safe and competent care to patients with

2101 and 2102

different health issues.

2 months

I learned how to teach to patient and family

Page 12
nd

2 Edition - Revised October 2008

Self-Assessment Tool CCP
College of LPNs of Alberta

March 2015

Presentation on

the proper use of incentive spirometer. I

Incentive Spirometry

demonstrated technique of using spirometry

during NPRT 2102

with use of real spirometry.

I associated spirometry to Hookah ( a type of smoke

device), so patient could remember it.

I learned that pain can alter a patient's all systems.

Pain management is crucial.
After post- operation pain can be manage with

30 minutes

March 2015

Research in Acute PostOperative Pain

Management in 2102

medication, frequent uses of spirometry, distraction

course

etc.
How nurses should monitor on Patient control
Analgesia machine. Sometime patient forget to push
analgesia button and remain until unbearable pain. I
learned that nurses need to remind patients to use it.

Name: Reeta Thapa

CLPNA Registration #:__________

Page 13
nd

2 Edition - Revised October 2008

Self-Assessment Tool CCP
College of LPNs of Alberta