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

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
20 16

Year
20

Year
20

Year
20

Year
20

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

Rating
(1-5)

2
2
2
2
2
2

Page 1
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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.

Self-Assessment Tool CCP

College of LPNs of Alberta

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)

2
2
2
2
Rating
(1-5)

C: Safety

Year
20

2
2
2
2
2
Rating
(1-5)

2
2
2
2

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Year
20

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.

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)

3
2
3
2
2
Rating
(1-5)

2
2
2
2
2
2
2
2
2
2

3
Rating
(1-5)

2
2

Page 3
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2 Edition - Revised October 2008

Year
20

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

2
2
2
2

SELF-ASSESSMENT SUMMARY
Year

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

Competency
Number

A 8-2

Integrates knowledge and skills from the sciences and humanities into the application of
the nursing process.

B -1

Performs health assessment of client using assessment techniques and a systematic

process.

2016

2016

C-1 to C-4 Applies critical thinking and clinical judgment when responding to emergency situations.
2016

D-4

Provides client and family teaching.

W-11

Keeps informed of current research affecting health care delivery.

2016

2016

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 4
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2 Edition - Revised October 2008

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

X-1-5

Recognizes own strengths and limitations as a leader- As an LPN in a

continuing care/long-term care setting, it is my responsibility to guide the
unregulated health professionals under my supervision. Therefore, I need
to recognize my strengths and limitations as a leader so I can assess
whether I am efficient as a team lead and where I can improve on.

W-11

Keeps informed of current research affecting health care delivery- As an

LPN, it is my responsibility to update myself on current information
affecting nursing and health care, so that I can provide my clients with the
most recent research and evidence-based findings to better support quality
care.

B-1

Performs health assessment of client using assessment techniques and a

systematic process- As an LPN in a long-term care setting, the frontline
staff are the eyes and ears of the physician who may not be available in
the facility when needed, therefore, it is essential that I must perform a
systematic and accurate assessment of the client to facilitate adequate
treatment even when the physician is not able to physically see the client.

B-3-2

Reassess, review, and modify plan of care to meet the needs of the clientIt is the LPNs role to review the clients plan of care especially after further
assessment, whether upon admission, ongoing care or following discharge.
This is to better suit the needs of the client, to involve them in their plan of
care and individualize

C-6-1

Demonstrates the consistent application of standard precautions- As an

LPN, I have to adhere to the facilitys policy regarding standard
precautions, in order to practice safety for myself, the client and the rest of
the health care team.

2016

2016

2016

2016

2016

Rating
(1-5)

Describe & Assess Specific Competencies

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 5
nd

2 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

(What I am going to learn?)

(What will I do to meet

objectives?)

(Realistic time
frame for
achievement)

1. I want to be able
to perform care
of a PICC line,
following proper
asepsis and
maintaining the
sterility of the
procedure.

1.1. Reviewing policy

and procedure manual of
care of a PICC line

3 months

2. I want to identify
the difference
between delirium
and dementia,
including its signs
and symptoms and
treatment

2.1. Reviewing at least 2

nursing journals on
current research about
delirium and dementia

1.2. Shadowing a
colleague

Evaluation
(How will I know I learned it?)

1.1.
Return
demonstration of
procedure
1.2.
Feedback
from senior
colleague/
supervisor

3 months

2.2. Attending a
workshop

Name: Leslie Kay Galope-Rivera

Self-Assessment Tool CCP

College of LPNs of Alberta

Target Date

2.1. Ability to assess a

clinical situation
involving a client and
formulate plan of care
with the appropriate
interventions

CLPNA Registration #:

Page 6
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RECORD OF PROFESSIONAL ACTIVITIES

Date

Professional Activity

Summary of Learning

(include course, seminar,

research, hours, details)

December Delegation for HCAs:

Review of unregulated health care professionals roles
7,2015
Facility In-service session and responsibilities

December Order Processing: Facility Review of order processing, identifying a complete and
21, 2015 in-service session
legal order and how to verify orders for processing

January
Care of Suprapubic Foley Review of care for suprapubic foley catheter, who can
18, 2016 Catheter: Facility ininsert one and what to do when it is removed
service session

October
2015

Appropriate Use of
Workshop on the appropriate use of antipsychotics,
Antipsychotics Workshop: when and when not to use them, leading to reduction
Alberta Health Services
of side effects

March
2016

The Basics of Wound Care Appropriate assessment and dressing use for various
by Molnlycke
wound types

Septembe CPI Non-Violent Crisis

r 2015
Intervention Training

The use of proper techniques in handling a crisis

situation

May 18- Mental Health First Aid:

19, 2016 Covenant Health

Resource person training for identifying the initial

signs of mental illness, especially in the workplace

Name: Leslie Kay Galope-Rivera

Self-Assessment Tool CCP

College of LPNs of Alberta

CLPNA Registration #:

Page 7
nd

2 Edition - Revised October 2008

RECORD OF PROFESSIONAL ACTIVITIES

Date

Professional Activity

Summary of Learning

(include course, seminar,

research, hours, details)

Name:

Self-Assessment Tool CCP

College of LPNs of Alberta

CLPNA Registration #:

Page 8
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2 Edition - Revised October 2008