Clpna Self-Assessment Tool

Kaitlin Young
January 21, 2016
Self-Assessment Tool CCP

College of LPNs of Alberta
Page 1
2nd Edition - Revised October 2008

Page 2
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 3
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
Competent
Requires
Improvement
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.
Developmental Not Applicable

Requires
Not applicable to
education and/or
current role and
orientation to meet responsibility.
the expectations
and /
or requirements of
the competency.
STEP 1: SELF-ASSESSMENT WITHIN STANDARDS OF PRACTICE

Competenc
y 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.

Page 4
Year
2015
Competenc
y Number
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.
A-8-2
Integrates knowledge and skills from the

sciences and humanities into the application of
the nursing process.
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)
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.
2
2
2
2
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

Year
20__
B: Nursing Process
C: Safety
Year
20__
Page 5
Year
2015
Competenc
y Number
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)
asepsis in the delivery of care.

C-12
Applies nursing knowledge and clinical judgment

to maintain physical safety of client.
Rating
(1-5)
D: Communication and Interpersonal Skills

2
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.
2
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.
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.

Page 6
Year
2015
Competenc
y Number
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.

Year
20__
Year
20__
Year
20__
Year
20__
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Rating
(1-5)
Page 7
Year
2015
Competenc
y 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
2015
Competency
Number
A
a-1
a-3
a-5-9
a-7
a-8-2
Describe the competency areas you want to improve or develop. List all items rated 2
(Competent), 3 (Requires Improvement), 4 (Developmental) in Step 1.
Nursing Knowledge
Nursing Process
2015
B
b-2-3
b-3
b-3-2
b-4
Safety
2015
C
C-1 to
C-4

Page 8
Communication and Interpersonal Skills

2015
D
d-1
d-2
d-3
d-3-7
d-4
d-7
2015
Professionalism
w-1-3
w-4-5
w-5-1
w-9-4
w-11
2015
Nursing Practice and Leadership
x-1-5
x-3-5
x-4
x-7-1
x-7-3
x-7-4

Page 9
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
Describe & Assess Specific Competencies
Rating
(1-5)
G-3-4
Demonstrate knowledge and ability to perform post-procedural

care including:
2015
observing for signs and symptoms of post-procedural

complications including:
o abdominal bloating
o abdominal pain
o chest pain
o crepitus
o decrease in client condition
o nausea and vomiting
o perforation
o rectal bleeding
o swelling of throat
o vital signs
pain/comfort management
discharge health teaching and coaching
referral to resources
K-2-2
2015

Demonstrate knowledge and ability to perform fetal monitoring

assess position of fetus (Leopolds Maneuvers)
perform interventions as appropriate (offer juice/ice water,
reposition, provide oxygen)
Page 10
20___
20___
20___

Page 11
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 2013
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 list off 1. I will study my

the signs and symptoms
medicine/surgery
of post procedural
fundamentals textbook
complications.
with the chapter about
post procedural
complications.
2. I will be able to
demonstrate Leopolds
maneuvers to find the
position of the fetus
within the mothers
abdomen
2. I will study my maternal

and child health nursing
textbook about Leopolds
maneuvers and practice on
my friend who is pregnant.
Name: ___________________________

1. Within one
week of
studying the
textbook, I will
know all the
signs and
symptoms of
post procedural
complications,
by January 28,
2015.
2. After a week
of practicing on
my friend and
studying the
textbook, I will
be able to
demonstrate
Leopolds
maneuvers by
January 28,
2015.
1. I will have a fellow

colleague ask me to
write down all the signs
and symptoms of post
procedural
complications, without
letting me look up
anything.
2. I will have a fellow

colleague ask me to
demonstrate Leopolds
maneuvers on my pregnant
friend, while they look at
the textbook to ensure my
technique is right.
CLPNA Registration #: ____________
Page 12

Page 13
RECORD OF PROFESSIONAL ACTIVITIES

Date
Professional Activity
(include course,
seminar, research,
hours, details)
Summary of Learning
June 1, 2015 - Continuing/Long Term

June 26, 2015 Care Clinical, 145 hours,
Allen Grey Continuing
Care Centre
Gained experience as a member of the interdisciplinary

health-care team by providing safe, holistic, and evidenceinformed nursing care in a continuing care setting. Minor
medication administration, mostly oral routes, GI tube
feeings, and assisting patients with their activities of daily
living.
October 26,
2015 November
20, 2015
Medicine (Family
Medicine) Clinical, 145
hours, Grey Nuns
Community Hospital
Continued to gain experience as a member of the

interdisciplinary health-care team in an acute hospital setting,
on a family medicine unit. Was able to practice nursing skills
learned in labs, focusing mainly on medication
administration (oral, transdermal and injection), fall
prevention, safety measures, and following contact
precautions.
November
23, 2015 December 18,
2015
Surgery (General
Surgery) Clinical, 122.5
hours, Grey Nuns
Community Hospital
Continued to gain experience as a member of the

interdisciplinary health-care team in an acute hospital setting,
on a general surgery unit. Was able to further practice and
refine the nursing skills I learnt in labs, such as:
simple/complex wound care, IV therapy/medications, IV
flushes, JP drain removal/JP dressing changes, ostomy care,
GI tube feedings, NG tube maintenance/suctioning and
removal, fall prevention, safety measures, and following
contact precautions.

Page 14
Name: Kaitlin Young

CLPNA Registration #:__________
Page 15

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Kaitlin Young

January 21, 2016

Self-Assessment Tool CCP

Self-Assessment Tool CCP

SELF-ASSESSMENT TOOL - RATING SCALE...........................................................................4

STEP 3: LEARNING PLAN......................................................................................................10

RECORD OF PROFESSIONAL ACTIVITIES.............................................................................11

Self-Assessment Tool CCP

Developmental Not Applicable

STEP 1: SELF-ASSESSMENT WITHIN STANDARDS OF PRACTICE

Applies knowledge of anatomy and physiology of

Applies knowledge of microbiology throughout

Applies knowledge of pathophysiology to the

Uses appropriate medical terminology to report

Self-Assessment Tool CCP

Adjusts nursing practice to the specific growth

Applies principles of nutrition to the assessment

Applies knowledge of pharmacology throughout

Integrates knowledge and skills from the

Performs health assessment of client using

Implements the planning process and

Identify and analyze nursing diagnosis.

Implements nursing interventions to carry out

Reassess, review, and modify plan of care to

Evaluates the clients response to care and

Applies critical thinking and clinical judgment

Effectively uses protective devices to protect

Demonstrates the consistent application of

Applies principles of medical and surgical

Self-Assessment Tool CCP

asepsis in the delivery of care.

Applies nursing knowledge and clinical judgment

D: Communication and Interpersonal Skills

Uses effective verbal and written communication

Appropriately establishes, maintains, and closes

Collaborates with health care team to function as

Adheres to the channels of communication

Provides client and family teaching.

Reports and documents following legal

Applies clinical judgment in identifying problems

Effectively manages time and organizes client

Demonstrates ability to rank the priority of client

Understands the key components of the Health

Understands the Restricted Activity

Understands the CLPNA Standards of Practice.

Self-Assessment Tool CCP

Adheres to the CLPNA Code of Ethics and

Acts as an advocate for client and empowers

Demonstrates accountability for own nursing

Maintains the confidentiality of client information.

Recognizes professional boundaries within the

Accepts responsibility for continuing competence

Participates in continuous quality improvement

Keeps informed of current research affecting

X: Nursing Practice and Leadership

Recognizes own strengths and limitations as a

Uses appropriate channels of communication to

Applies critical thinking and clinical judgment

Shares knowledge, skill, and expertise with

Self-Assessment Tool CCP

Seeks opportunities to teach and mentor others.

Participates in committees, task forces and