Carly Legault

September 12, 2013

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 1
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 2
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

2
2

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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 5
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

20_15__

A-1
A-2
A-3
A-5-9
A-6
A-7
A-8-2
B-A
B-2-2
B-3
B-3-2
B-4
C-7-1

Nursing Knowledge

D-4
D-7
D-8-1
D-8-2

Communication and Interpersonal Skills

W-1-3

Professionalism

2015___

Nursing Process

Safety

2015___

2015___

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 6
2nd Edition - Revised October 2008

2015___

2015

W-2-3
W-3
W-4
W-9
W-9-4
W-11
X-1-5
X-3-5
X-4
X-7-1
X-7-3
X-7-4

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

Competency
Number

Rating
(1-5)

Describe & Assess Specific Competencies

Understands the Restricted Activity authorizations in the LPN
Regulation.

20_16_

W-2-3

As an LPN it is required to have an understanding of activities

which are restricted to you in your role. I would like to feel
confident knowing that I can work within my scope of practice in
a safe and professional manner.

Understands the key components of the Health Professions Act-LPN

Regulation.
2016__
_

W-1-3

Self-Assessment Tool CCP

College of LPNs of Alberta

As a student LPN continuing on to my final preceptorships, it is

important to refine my knowledge related to the Health
Professions Act- LPN Regulation. This awareness will aide in my
ability to be a profession and competent LPN in the future.

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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 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?)

W-2-3
Understands the Restricted
Activity authorizations in
the LPN Regulation.

To meet this objective I will

complete my NFDN 2008
theory course, which will
further my understanding of
activities which are
restricted to my role as an
LPN.
I will also review the
organizations policy
manual at my clinical site to
ensure I am aware of the
site-specific regulations and
restrictions.

June 30th 2016

I will evaluate my
learning by successfully
completing the NFDN
2008 course and final
exam, which will
encompass the LPN
restrictions and
regulations.
After reading the
organizations policy
manual, I will be able to
verbalize to my preceptor
where my scope lies in
that specific organization.

By June 30th 2016, I will

rate myself a 1 on this
competency. I will have a
full understanding of an
LPNs restricted activity
authorizations in order to
practice as a safe and
competent LPN in the
future.

W-1-3
Understands the key
components of the Health
Professions Act-LPN
Regulation.
By June 30th 2016, I will be
able to give myself a 1
rating on this competency. I
will be confident in my
understanding of the Health
Professions Act- LPN
Regulations.

To receive this competency

rating, I will complete my
NFDN 2008 class. This
class incorporates lecture,
seminar, and guest speakers
in order to advance our
understanding and
proficiency in the LPN
competencies such as this.
I will also review the
organizations policy
manual at my clinical site to
ensure I am aware of the
site-specific regulations and
restrictions.

Name: ___________________________

Self-Assessment Tool CCP

College of LPNs of Alberta

June 30th 2016

I will evaluate my
learning by successfully
completing the NFDN
2008 course and final
exam, which will
encompass the LPN
restrictions and
regulations.
After reading the
organizations policy
manual, I will be able to
verbalize to my preceptor
where my scope lies in
that specific organization.

CLPNA Registration #: ____________

Page 8
2nd Edition - Revised October 2008

RECORD OF PROFESSIONAL ACTIVITIES

Date

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

Summary of Learning

May 4th-29th
2015

NRPT 1001
Continuing Care
St. Michaels LTC

I applied my knowledge of patient care and assessment in

order to successfully care for five patients. I completed daily
head to toe assessments and administered medications using
the 10 rights and 3 checks taught in NFDN 1001, 1002, and
2003.

October 26th
December
18th 2015

NRPT 2101-2102
Acute Care
Medicine and Surgery
Fort Saskatchewan
Community Hospital

December 8th
2015

Palliative Pain
Management In-Service
Fort Saskatchewan
Community Hospital

November
16th 2015

BLS-HCP CPR
Recertification
Saving Grace Medical

During this clinical, I was able to administer oral and

injectable medications, perform IVs, personal care, sterile
dressing changes, removal of a drainage tube, pre- and postop assessments and even follow one patient through the OR
to watch their surgery. I also had the opportunity watch a
doctor from the emergency department insert a chest tube
into a patient on the floor.
During this in-service, the palliative care manager spoke to
us about pain management and related pharmacology in
palliative patients. We covered baseline versus breakthrough
pain management as well as holistic care options. We also
spoke about therapeutic communication specific to a
palliative patient and their loved ones.
We refreshed our skills including chest compressions,
ventilation ratios, adult and child 1-2 person CPR, bag
masks, and J-thrust maneuvers.

Name: _____________________

Self-Assessment Tool CCP

College of LPNs of Alberta

CLPNA Registration #:__________

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2nd Edition - Revised October 2008