Clpna Self-Assessment

Carly Legault
September 12, 2013
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
2
Competent
3
Requires
Improvement
4
Developmental
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.
5
Not Applicable
Not applicable to
current role and
responsibility.
STEP 1: SELF-ASSESSMENT WITHIN STANDARDS OF

PRACTICE
Competency
Number
A: Nursing Knowledge
Year
2016
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.

Page 4
Year
2016
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.
4
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.

Year
20__
Rating
(1-5)
D: Communication and Interpersonal Skills
Year
20__
B-1
C: Safety
Year
20__
Page 5
Year
2016
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
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.

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)
Page 6
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.
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
2016
Competency
Number
A
A-3, A4-4, A6, A-82
B
B-2-2,
B-2-3
C
C-5-1,
C-6-1,
C-12,
D
D-1, D3-7, D5, D-81, W
W-1-3,
W-2-3,
W-3,
W-4,
W-11,
X
X-7-1,

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
Applies knowledge of pathophysiology to the nursing care of the client.
Uses appropriate medical terminology to report and document client care.
Applies principles of nutrition to the assessment and care of the client.
Integrates knowledge and skills from the sciences and humanities into the
application of the nursing process.
Nursing Process
Implements the planning process and establishes client priorities involving
client in planning.
Identify and analyze nursing diagnosis.
Safety
Effectively uses protective devices to protect client, self, and others.
Demonstrates the consistent application of standard precautions.
Applies nursing knowledge and clinical judgment to maintain physical

safety of client.
Communication and Interpersonal Skills
Reports and documents following legal protocols, agency policy and
procedure.
Effectively manages time and organizes client care to meet priority needs.
Professionalism
Understands the key components of the Health Professions Act-LPN
Regulation.
Understands the Restricted Activity authorizations in the LPN Regulation.
Understands the CLPNA Standards of Practice.

Page 7
& X-7- Adheres to the CLPNA Code of Ethics and Standards of Practice.
3
Keeps informed of current research affecting health care delivery.
Nursing Practice and Leadership
Shares knowledge, skill, and expertise with colleagues and students.
Seeks opportunities to teach and mentor others.
20___
20___
20___
20___
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
D, D-8-1
2016
C, C-6-1

Rating
(1-5)
Describe & Assess Specific Competencies
Communication and Interpersonal Skills

Effectively manages time and organizes client care to meet
priority needs.
Safety
Demonstrates the consistent application of standard precautions.
Page 8
20___
20___
20___
20___

Page 9
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
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?)
D, D-8-1
I am going to improve
my time management
and organizational skills.
D, D-8-1
I am going to do this by
preparing organizational
plans everyday before I
begin my shift, and by
asking questions to nurses
who have been working in
the field for more than
two years about
techniques and strategies
they like to use to save
time and increase
organization while still
maintaining the best
standards of practice.
D, D-8-1
I will
achieve this
objective by
August 19th,
2016.
C, C-6-1
I am going to increase
my knowledge on safety
standards and
precautions and apply
what I learn to my
practice.
C, C-6-1
I will read the safety
standards that are specific
to each unit that I work on
and ask another nurse that
has worked at least two
years to show me how to
use safety equipment that
is specific to the unit
properly.
D, D-8-1
I will know I achieved my
objective if I have compiled
at least 10 organizational
plans from 10 different days
as well as if I can teach
someone how to use a
strategy that I have learned
from another nurse that
increases organization and
saves time by the target date I
have indicated and the learner
can repeat at least three
things back to me that they
have learned.
C, C-6-1
I will know I have achieved
my objective if I can show
the nurse teaching me how to
use the equipment properly
what I have learned and she
agrees that I am using it
correctly as well as the
technique taught to me will
match the safety standards
protocol of the unit. At this
time I will be able to
complete a three-question
exam about how to use the
devices properly and I will be
able to achieve 100%.
Name: Kyra Scheuerman Date: 05/20/2016

C, C-6-1
I will
achieve the
objective by
August 19th,
2016.
CLPNA Registration #: ____________

Page 10
RECORD OF PROFESSIONAL ACTIVITIES

Date
Professional Activity
(include course,
seminar, research,
hours, details)
D, D-8-1
Summary of Learning
10/19/15
11/13/15
Continuing Care
NPRT 1001 (145 hours)
D, D-8-1
This was a placement at a continuing care facility where I
was able to learn how to manage my time effectively
through experience. I also learned how to adjust my
organizational plan as special circumstances arose
throughout the day.
01/04/16
01/29/16
Medicine Clinical
This placement I was placed on a pulmonary medicine unit

and learned the specific assessments that were appropriate
for the unit and how to manage my time around my
assessments.
02/01/16
02/26/16
Surgery Clinical
This was an orthopedic surgical placement where I learned

how to take care of patients who have just come out of
orthopedic surgeries. I learned the appropriate assessments
for these patients, how to administer medications correctly
to the patients and how to manage my time around these
skills efficiently.
05/16/16
C, C-6-1
Its your Move
XHLT 1070 (2 hours)
C, C-6-1
This was a course where I learned proper body mechanics so
I dont injure myself on the job. I learned how to transport,
lift, move, and assist patients while putting as little strain on
my body as possible as well as how to use assistive
equipment correctly.
10/19/15
11/13/15
Continuing Care
This was a placement at a continuing care facility where I

was able to work with a variety of different lifts, wheel
chairs and other safety equipment and really get a feel for
how to use the equipment correctly.

Page 11
Name: Kyra Scheuerman Date: 05/20/2016
Signature:

CLPNA Registration #:__________
Date: May 20, 2016
Page 12

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Carly Legault

September 12, 2013

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

STEP 1: SELF-ASSESSMENT WITHIN STANDARDS OF

Applies knowledge of anatomy and physiology

Applies knowledge of microbiology throughout

Applies knowledge of pathophysiology to the

Uses appropriate medical terminology to report

Adjusts nursing practice to the specific growth

Applies principles of nutrition to the assessment

Applies knowledge of pharmacology throughout

Self-Assessment Tool CCP

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

Applies nursing knowledge and clinical

Uses effective verbal and written

Appropriately establishes, maintains, and

Collaborates with health care team to function

Adheres to the channels of communication

Self-Assessment Tool CCP

D: Communication and Interpersonal Skills

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.

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

Recognizes professional boundaries within the

Accepts responsibility for continuing

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

Self-Assessment Tool CCP

Applies critical thinking and clinical judgment

Shares knowledge, skill, and expertise with

Seeks opportunities to teach and mentor others.

Participates in committees, task forces and

Self-Assessment Tool CCP

Uses appropriate medical terminology to report and document client care.

Applies principles of nutrition to the assessment and care of the client.