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

2
Competent

3
Requires
Improvement

4
Developmental

5
Not Applicable

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.

Not applicable to
current role and
responsibility.

STEP 1: SELF-ASSESSMENT WITHIN STANDARDS OF PRACTICE

Competency
Number

A: Nursing Knowledge
A-1

A-2
A-3
A-4-4

Applies knowledge of anatomy and physiology

of the human body to the assessment of client
and delivery of nursing care.

Year
20

Year
20

Year
20

Year
20

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Applies knowledge of microbiology throughout 2

care, disease prevention, and health promotion.
Applies knowledge of pathophysiology to the
nursing care of the client.

Uses appropriate medical terminology to report 3

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

Year
2016

1
3

Applies knowledge of pharmacology throughout 3

client care and teaching.

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 1
nd

2 Edition - Revised October 2008

Competency
Number

A-8-2

Integrates knowledge and skills from the

sciences and humanities into the application of
the nursing process.

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.

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.

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

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)

Rating
(1-5)

Rating
(1-5)

3
1
1
1

2
1
1
1
1

D: Communication and Interpersonal Skills

D-1

Year
20

C: Safety
C-1 to
C-4

Year
20

B: Nursing Process
B-1

Year
2016

2
1
1
1

Competency
Number

D-4

Provides client and family teaching.

D-5

Reports and documents following legal

protocols, agency policy and procedure.

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

W-2-3
W-3

Effectively manages time and organizes client

care to meet priority needs.

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)

Demonstrates ability to rank the priority of client 1

needs.

Understands the key components of the Health 3

Professions Act-LPN Regulation.
Understands the Restricted Activity
authorizations in the LPN Regulation.

Understands the CLPNA Standards of Practice. 1

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.

1
1
1
1
1
2
3

X: Nursing Practice and Leadership

X-3-5

Year
20

Applies clinical judgment in identifying problems 1

and resolving issues in client care.

W-4

X-1-5

Year
20

W: Professionalism
W-1-3

Year
2016

Recognizes own strengths and limitations as a

leader.

Uses appropriate channels of communication to 1

report risks within setting.

Year
2016

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.

Year
20

Year
20

Year
20

Year
20

3
1

Seeks opportunities to teach and mentor others. 2

X-7-3
X-7-4

Participates in committees, task forces and

professional activities to offer the LPN
perspective.

SELF-ASSESSMENT SUMMARY
Competency
Number

Year

A-1
2016

A-2
A-3
A-4-4

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

I will be able to explain with confident the structure and function of the
lymphatic system during clients nursing care.
Be able to explain the different types of microorganisms and explain
the selection of masks to client and how to properly put it on.
I will be able to discuss and describe disease process related to
diabetes mellitus.
I will be able to learn new terminology every week and able to apply it
to the clients report and documentation.

A-6
A-7

I will be able to identify clients adequate nutrition intake and able to

identify clients nutritional condition within one week of nursing care.
Learning how to interpret Lab values related to medication, how the
drugs affect the human body (organs, cell, tissue)

B-2-3
2016

C-1-4
2016

To Be able to determine the nursing diagnosis. Verbalize actual and

potential diagnosis after finishing clients assessment.

To be able to help in process of emergency situations, demonstrate fire

and safety procedures.

2016

D-1

To be able to communicate verbal and written effectively and clearly by

properly using appropriate words, speaking clearly and normal tone of
voice. Working on my self-confidence.

D-4

Be able to confidently provide teaching to client or family without

feeling of anxiety.
Be able to understand and be able to verbalize continuing competency.

W-1-3
2016

W-2-3

Be able to identify key components of the Restricted Activity

authorizations in the LPN Regulations.

W-9

To be able to assess my competency and identify strength and

weakness and learning needs.

W-9-4

To be able to describe updated evidence based practice.

W-11

Will keep informed of the current research affecting health care delivery
by doing research and discuss with other team members.

X-1-5

Will be able to recognize my own strengths and limitations as a leader

and apply it.

X-4

X-7-3

I will be able to apply and manage risk appropriately through critical

thinking development/ learning how to critically think on risk situations.
To be able to confidently teach others.

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

2016

2016

20

20

20

Rating
(1-5)

Describe & Assess Specific Competencies

D-1

To be able to communicate effectively.

U-7-3

Demonstrate IV initiation and administration process.

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

(What I am going to learn?)

(What will I do to meet

objectives?)

D-1

Communication Skills

Target Date

(Realistic time
frame for
achievement)

From April 1,
Review
2016 June 30,
communication
2016
skills textbook
Register for a
communication
skills program
Be confident and
have the courage
to speak up during
conversations with
other colleague.
Be an active
listener
Make eye contact

Evaluation
(How will I know I learned it?)

Ask for feedback

from other
colleagues.
I will specify all
the
communication
techniques used.

U-7-3
Initiation of IV.

Watch the video

From July 1,
for IV initiation
2016 August
skills
1, 2016
Review NFDN
textbooks
Practice the skills
in Lab

Verbalizing the
whole procedure
without any help
from instructor.
landmark the
injection site and
inserting the
catheter
successfully.

Name: Bona vida Capistrano

CLPNA Registration #:

RECORD OF PROFESSIONAL ACTIVITIES

Date

Professional Activity

Summary of Learning

(include course, seminar,

research, hours, details)

04/2015

Clinical Practicum

How to administer heparin

How to properly ambulate a client post
operatively
How to monitor post-op patients
Learning the importance of Lab values

Medicine Unit

Learned how to administer Insulin

Importance of Lab values
Proper medication administration
How to assess patients confidently

Clinical Practicum

Continuing Care

Learned the value of time management when

caring for 3 patients.
How to prioritize nursing care.
Learned how to established rapport with senior
residents.
Helping seniors with daily living activities such
as bathing, feeding etc.

Orthopedic Surgery unit

10/2014

02/2014

Clinical Practicum

Name: Bona vida Capistrano

CLPNA Registration #:

RECORD OF PROFESSIONAL ACTIVITIES

Date

Professional Activity

Summary of Learning

(include course, seminar,

research, hours, details)

Name:

CLPNA Registration #: