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 3

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

Uses appropriate medical terminology to report 2

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
2016

3
2

Applies knowledge of pharmacology throughout 3

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)

3
3
2
2

3
3
3
3
3

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 16

3
3
3
3

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

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)

Rating
(1-5)

Rating
(1-5)

3
3

Applies clinical judgment in identifying problems 3

and resolving issues in client care.
Effectively manages time and organizes client
care to meet priority needs.

Demonstrates ability to rank the priority of client 3

needs.

W: Professionalism
W-1-3

Year
20

Understands the key components of the Health 3

Professions Act-LPN Regulation.
Understands the Restricted Activity
authorizations in the LPN Regulation.

Understands the CLPNA Standards of Practice. 3

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.

3
4
3
2
2
2
3

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.

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
X-7-4

Year
20

Year
20

Year
20

Year
20

3
3

Seeks opportunities to teach and mentor others. 2

Participates in committees, task forces and
professional activities to offer the LPN
perspective.

SELF-ASSESSMENT SUMMARY
Competency
Number

Year

20 16 _

2016_

20

20

20

W-4-5

D-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.

I would like to develop the competency where I have to act as an advocate for my
clients as well as empower them. I feel I need the confidence to transmit this
empowerment to them, and to be for them as this is one of the core areas in
nursing. That will bring me closer to my clients and will have them develop
confidence in me.
I need to improve the skill of rating my clients priority needs. This is crucial in
client care to have other needs attended to before attending to others, both for the
comfort of the client in reducing any harm that may arise by not attending to some
needs first.

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.
Competency
Number

Year

O-1-4

Improve knowledge to plan and implement activities that 3

would promote wellbeing of elderly clients.

O-1-6

Effectively assess cognitive changes to provide the best

possible care.

0-2-3

Improve knowledge and ability to assess pain level of

patient with dementia.

O-3-1

Improve my understanding of the cognitive changes

related to dementia and the normal cognitive changes of
aging.

O-4-2

Improve my ability to recognize and manage distress

related behavior to protect patient and staff from getting
hurt.

2016 _

2016 _

2016

2016

2016

Rating
(1-5)

Describe & Assess Specific Competencies

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?)

B-1 To demonstrate the

*Review latest health
ability to perform physical assessment books and
assessment systematically videos.
and accurately.

Target Date

(Realistic time
frame for
achievement)

*Within the next *Improved knowledge,

3-6 months.
skills and confidence in
physical assessment.

Perform physical assessment

to assigned patient in the
unit as required.

D-5 To demonstrate ability

to document the care
provided following the
legal protocol, agency,
policy and procedure.

*Review the important

medical terminologies,
1-3 months
approved abbreviation,
metric system and subjective
and objective data.

*Attend the regularly

scheduled in service on
documentation in the unit.

Evaluation
(How will I know I learned it?)

*Demonstrate ability to take

and record vital signs
accurately during physical
assessment.

*Demonstrate ability on
quality documentation on
clients chart.
*Improved understanding on
the importance of quality
documentation in relation to
patient care and legal issues.

*Demonstrate ability to
apply knowledge and skills
on quality documentation
towards daily care of
patients in the unit.

Name: Matelyn Tolentino

CLPNA Registration #:

RECORD OF PROFESSIONAL ACTIVITIES

Date

Professional Activity

Summary of Learning

(include course, seminar,

research, hours, details)

Name: Matelyn Tolentino

CLPNA Registration #:

RECORD OF PROFESSIONAL ACTIVITIES

Date

Professional Activity

Summary of Learning

(include course, seminar,

research, hours, details)

August 1-7, HBPE Course Certification

2016
(Human Blood-borne
Pathogen Exposure)

July 6,
2016

Basic Life Support (CPR)

In this course, I learned that blood-borne pathogen is hazard in

workplace and that health care workers, emergency personnel,
mortuary workers, clinical lab workers, etc. are considered to
be most at risk. I learned that there are different types of
exposure incidents to pathogen such as cuts, contacts with
eyes, nose and mouth. That the hands are the most common
site for exposure. I learned that Hepatitis B and C and
Acquired Immunodeficiency Syndrome (AIDS) are the highrisk diseases. The principle of Standard precautions is to
consider that all blood and body fluids are potentially
infectious and therefore treated the same by all who may come
into their contact. I learned that in health care setting, control
measures involve using gloves, gowns, face shields and eye
protection when dealing with blood, blood products and body
fluids. Additionally, wash hands often especially after contact
with each client and also after removing gloves. Also, health
care workers are taught not to recap needles to reduce their
risk of infection by accidental needle sticks. Furthermore, I
learned that there are protocols and exposure guidelines to
follow whenever a health care worker is exposed to a bloodborne pathogen such as making an incident report about the
exposure so that appropriate management is done. This for
sure has a great impact on me as future practical nurse because
my profession is to care for the people, on the other hand I am
also at great risk for human blood-borne pathogen exposure.
However, because I had training and education about it, I
know how to protect myself and my clients of blood-borne
exposure and transmission. I will perform hand washing at any
times, I will use protective equipment such as gown, mask and
gloves whenever I will be in contact with blood and body
In this course, I learned how to perform Cardiopulmonary
resuscitation or CPR. I learned that high-quality CPR
improves a victims chances of survival. That there are critical
characteristics of high-quality CPR: 1) chest compression
should be started within 10 seconds of recognition of cardiac

which means compress at a rate of at least 100/min with a

depth of at least 5cm for adults, approximately 5 cm for
children and approximately 4 cm for infants, 3) allow
complete chest recoil after each compression, 4) minimize
interruptions to less than 10 seconds, 5) give effective breaths
that make the chest rise and 6) avoid excessive ventilation. I
also learned how to use the Automated External Defibrillator
(AED) for adults and children. I also learned adult, children,
and infant CPR with one and two rescuer. This learning
experience has a great impact on me as a future practical nurse
because I will be working in the community and hospitals
providing care. At any time, things happen such as cardiac
arrest and if I have the training and knowledge about CPR, I
can perform the skill helping the client survive. In this way, I
am upholding the standards of practice which is service to the
March 2016WHMIS Course Certification In this course, I learned that it is very important to know about
the hazardous chemicals in the workplace so that we are able
to protect ourselves from harm. I learned how to identify
hazardous chemicals with just the signs. That there are
corrosive, flammable, and combustible chemicals that they
should be handled with extra care to prevent exposure. I
learned that being knowledgeable of the labels, Material
Safety data sheets and other identifiers provides the workers
idea on how to handle the hazardous chemicals. I learned that
employees most especially RNs, LPNs, HCAs and
Housekeepers should know where the MSDS is located in
their unit so that in case of exposure, they know where to
locate it. As practical nurse, WHMIS course is very important
because we encounter hazardous chemicals at work. I know
that in hospitals and all other health care facility, compressed
air and chemicals for cleaning are always present in the
building. Therefore being knowledgeable on proper handling
is of great importance to prevent accidents in the workplace.
March 2016
Belite Training (4 hours)

I have learned the proper body mechanics in transferring a

client to keep myself from injury and for the safety of the
client.
I have learned the proper way of using transferring device such
as mechanical lift, sit stand lift, transfer board etc.
I have learned the importance of using a slider sheet when
repositioning patient especially when they are heavy.

October 2, Non-violent crisis intervention I have learned how to manage or handle psychiatric patients in
2015
the hospital after my training. I knew the different strategies
or techniques in dealing with those violent or aggressive
patients.

Name: Matelyn Tolentino

CLPNA Registration #: