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 1

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

Uses appropriate medical terminology to report 1

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
20 16

1
1

Applies knowledge of pharmacology throughout 1

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)

2
1
1
1

1
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
20

2
2
2
2

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 2

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
1
1

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
20 16

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

1
1

Seeks opportunities to teach and mentor others. 1

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

2016

B-1

I feel as if I already do a systematic approach to client assessments, but it can be

improved. I tend to do a full assessment and go back and do a focused, I feel I can
prove by integrating those together and making my assessments more efficient.

B-2-2

I believe I can integrate my clients more in their own care, and within
the planning process more then I currently do.

B-2-3

As I advance in my nursing profession, I will gain more experience in

being able to identify and analyze nursing diagnosis more efficiently.

D-1

I would like to enhance my written skills, often when documenting I

forget to include items that happened in the morning and end up
having to add a late entry. I would like to rectify this.

D-2

I can effectively establish, and maintain the nursing-client relationship

but I have difficulty closing that relationship.

20 16 _

20 16 _

20 16 _

20 16 _

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

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

20 16 _

20

20

20

20

Competency
Number

Describe & Assess Specific Competencies

Rating
(1-5)

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 20 16
Learning Objectives

Resources & Strategies

(What I am going to learn?)

(What will I do to meet

objectives?)

Improvement in overall
pharmacology skills, in
regards to medication
preparation and
recognition.

Target Date

(Realistic time
frame for
achievement)

Evaluation
(How will I know I learned it?)

December 2017 I will evaluate my

I will make medication
learning by being able to
cards, as cue cards in order
recognize drugs on
to gain memorization skills
patients MARs without
in regards to recognition. As
having to look them up,
I constantly prepare
able to recite common
medications, I will gain
side effects and drugmore confidence and
drug interactions.
familiarity with the proper
medication administration
procedures for specific
drugs.

Dec 2020

I will do weekly patient

research, making cue cards
Understand and recognize of diagnosis that I come
across. The cue cards will
more diagnosis and
have definition, morbidity
diseases.
and mortality rates,
treatment, diagnosis as well
as common drugs associated
with the disease.
Name: Catherine Fedoruk

I will successfully
evaluate it by being
familiar with most
common diagnoses for
my unit. For example if I
work on a urology
surgical unit, I will be
able to correctly identify
all diagnosis that are
assigned to that unit.

CLPNA Registration #:

RECORD OF PROFESSIONAL ACTIVITIES

Date

Professional Activity

Summary of Learning

(include course, seminar,

research, hours, details)

Feb 2016 Long term care clinical

Proper administration of AM care, safe patient moves

and transfers, medication administration in the long
term care facility.

May 2016 Medicine Clinical

Proper administration of AM care, safe patient moves

and transfers, medication administration, and
evaluation clients. Successful administration or
completion of catheters, wound care, incentive
spirometry and other general nursing duties.

June 2016 IV course

Effective initiation of a IV, strategies to reduce

infection, transmission of infectious diseases and
proper care of an IV site

July 2016 Surgical Clinical

Proper administration of AM care, safe patient moves

and transfers, medication administration, and
evaluation clients. Successful administration or
completion of catheters, wound care, incentive
spirometry and other general nursing duties with a
focus on the post-operative patient.

Name: Catherine Fedourk

CLPNA Registration #:

RECORD OF PROFESSIONAL ACTIVITIES

Date

Professional Activity

Summary of Learning

(include course, seminar,

research, hours, details)

Name:

CLPNA Registration #: