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
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

4
Developmental

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.

2
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.

D-4

Provides client and family teaching.

D-5

Reports and documents following legal protocols,

agency policy and procedure.

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__

Page 5
2nd Edition - Revised October 2008

Year
2015

Competency
Number

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

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.

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)

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2nd Edition - Revised October 2008

Year
2015

Competency
Number

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__

SELF-ASSESSMENT SUMMARY
Year

Competency
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.

2015

Nursing Knowledge

A
A-2
A-4-4
A-5-9
A-6
A-7
A-8-2

B
2015

Nursing Process

B-1
B-2-2
B-2-3
B-3
B-3-2
B-4

Safety
2015

C
C-1 to
C-4
C-7-1
C-12

D
2015

Communication and Interpersonal Skills

D-1
D-2
D-3
D-3-7
D-4
D-5
D-7
D-8-1
D-8-2

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 7
2nd Edition - Revised October 2008

W
2015

W-1-3
W-6
W-7
W-11

X
2015

Professionalism

Nursing Practice and Leadership

X-3-5
X-4

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

2015

Competency
Number

U
U-2
U-2-9

Medication administration
Medication Preparation and administration
Demonstrate knowledge and ability to recognize and manage
adverse medication reaction and anaphylaxis including:
identify signs and symptoms

2015

G
G-2
G-2-4

Self-Assessment Tool CCP

College of LPNs of Alberta

Rating
(1-5)

Describe & Assess Specific Competencies

implement protocol according to agency policy

Surgery
Surgery Nursing Interventions
Demonstrate knowledge and ability to assess and manage surgical
incision and wound care to facilitate healing:
dressings

empty, remove and shorten drains

irrigation

packing

removal of packing

removal of staples and sutures

wound VAC (vacuum assisted closure)

Page 8
2nd Edition - Revised October 2008

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?)

1) I will be able to
demonstrate my
knowledge and ability
to recognize and
manage adverse
medication reaction
and anaphylaxis
including: identifying
the signs and
symptoms, and
implement protocol
according to agency
policy by March 11,
2016.

1) I will check my patient

chart to identify any
medication allergies; also
I will educate myself by
researching the
medications for my
patient (use and action,
onset, sign and symptoms,
nursing implications)
prior to medication
administration. I will
inform my client about
the adverse reactions and
the importance of
reporting it right away
following and
implementing the
agencies protocol.

March 11, 2016

1) I will ask my client to

repeat back the
anaphylactic reaction or
adverse reactions that
needed to be reported
right away before I give
the medications, on this
way I will be able to
evaluate my health
teachings and promote
safety.

2) To be able to perform, I
will review my skills by
reading Brunner and
Saddharts Medical
Surgical Book; also I will
read Potter and Perry. I
will watch the videos
available in youtube and
NorQuest Library. I will
practice my skills in my
house using available
tools prior to the target
day of performance.

April 16, 2016

2) I will ask my instructor

or my buddy nurse to
witness my skills in
performing surgery
nursing interventions and
ask them to rate my skills
from 1-5, 1 as the lowest
and 5 as the highest.

2) I will be able to
perform skills in any of
the surgery nursing
interventions:

dressings empty,
remove and shorten
drains,

irrigation,

packing,

removal of packing,

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 10
2nd Edition - Revised October 2008

removal of staples
and sutures

wound VAC (vacuum

assisted closure)
available in my unit
by April 16, 2016

Name: Beverly Ann Billones

Self-Assessment Tool CCP

College of LPNs of Alberta

CLPNA Registration #: ____________

Page 11
2nd Edition - Revised October 2008

RECORD OF PROFESSIONAL ACTIVITIES

Date

February 7,
2015

February 8,
2015

March 21,
2015

June 1, 2015
to June 26,
2015

October 26,
2015 to
November
20, 2015
November
23, 2015 to
December
18, 2015

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

Summary of Learning

(WHIMIS) Workplace
Hazardous Material
Information System
Length: 4 hours
Online course

I learned about proper handling of hazardous products in the

workplace. I also learned the different types of hazardous
material in the hospital and the correct way of storing it.

Human Blood-Borne
Pathogen
Length: 5 hours
Online course

I learned about Hepatitis, especially Hepatitis B, which can

be transmitted through, contaminated needle prick. I learned
about proper handling of hospital equipment and disposal to
prevent injury.

Basic Life Support

(BLS) for Health-Care
Providers
Length: 4.5 hours
In class course

I learned about cardio-pulmonary resuscitation following the

new protocol to check CAB (circulatory or pulse, airway
and breathing). I learned about Heimlich maneuver, and the
steps to help a choking person. I also learned to use the
automated external defibrillator in both adult and infant.

Continuing Care
Placement at St. Joseph
Auxiliary Hospital
Length: 4 weeks
145hours
Clinical Experience

My first clinical experience where I learned about a lot of

things. I learned how to give medications to elderly. I also
learned about the basic morning care, helping dependent
patient with meals. I also learned how to use different lifting
devices and the importance of proper body mechanics.

Acute Care/ Medicine

Placement at Grey Nuns
Hospital UNIT 54
Length: 4 weeks 137
hours
Clinical Experience
Acute Care/ Surgery at
Grey Nuns Hospital
UNIT 42 (Surgery Unit)
Length: 4 weeks 137
hours
Clinical Experience

During medicine rotation, I leaned how to give multiple

medications to more than 1 person following 10 patients
rights and 3 medication checks. I also learned the
differences between long-term care documentations and
acute care documentations. I learned the importance of
communication especially in reporting important findings.
In surgery unit, I learned how to do simple dressing change;
also I learned how to do ostomy change. I also get to do in
and out catheter. I manage to give piggyback medications. I
learned about emptying JP drains, adjusting oxygen,
maintaining integrity of scope sites; I observed wound
dressing change and application of renasys wound vacuum.

Name: Beverly Ann Billones

Self-Assessment Tool CCP

College of LPNs of Alberta

CLPNA Registration #:__________

Page 12
2nd Edition - Revised October 2008

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 13
2nd Edition - Revised October 2008