Shaelyn Kormos

January 14, 2016

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 1
2nd Edition - Revised October 2008

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

Self-Assessment Tool CCP

College of LPNs of Alberta

Page 2
2nd 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

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
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.

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

Page 3
2nd Edition - Revised October 2008

Year
2015

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.

1
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.

Self-Assessment Tool CCP

College of LPNs of Alberta

Year
20__

Rating
(1-5)

D: Communication and Interpersonal Skills

Year
20__

B-1

C: Safety

Year
20__

Page 4
2nd Edition - Revised October 2008

Year
2015

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.

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)

Page 5
2nd Edition - Revised October 2008

Year
2015

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

Competency
Number

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

2015

Nursing Knowledge

A-2
A-3
A-4-4
A-6
A-7
A-8-2

B
2015

B-2-2
B-2-3
B-3
B-3-2
B-4

C
2015

Safety

C-1 to
C-4
C-7-1

D
2015

Nursing Process

Communication and Interpersonal Skills

D-1
D-2
D-3
D-3-7
D-5
D-7

W
Self-Assessment Tool CCP
College of LPNs of Alberta

Professionalism
Page 6
2nd Edition - Revised October 2008

2015

W-1-3
W-2-3
W-3
W-9
W-9-4
W-11

2015

Nursing Practice and Leadership

X-1-5
X-3-5

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

L-3-2
2015

G-2-4
20___

Rating
(1-5)

Describe & Assess Specific Competencies

Demonstrate knowledge and ability to adapt pain management

and comfort measures for pediatric client:
physical
psychological
pharmacological
Demonstrate knowledge and ability to assess and manage
surgical incision and wound care to facilitate healing:
dressings
empty, remove and shorten drains
irrigation
packing
removal of packing
removal of staples and sutures
wound VAC (vacuum assisted closure)

20___

STEP 3: LEARNING PLAN

This page is intended to document your Learning Plan for one year. Photocopy this BLANK page for each additional year.
Self-Assessment Tool CCP
College of LPNs of Alberta

Page 7
2nd Edition - Revised October 2008

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 2015
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?)

Demonstrate the ability

to adapt pain
management measures
for at least 2 pediatric
patients by March 25,
2015

Read my Potter & Perry

textbook about pain
management strategies
and techniques

Demonstrate the ability

to care for wounds and
surgical incisions by
April 22, 2015

Read my Potter & Perry

textbook about different
types of wounds/surgical
incisions and how to care
for them

Create a list of different

pain management
techniques within
physical, psychological,
and pharmacological
areas

Talk to wound care nurse

on the unit about the best
way to care for wounds
and to facilitate healing
Name: Shaelyn Kormos

Self-Assessment Tool CCP

College of LPNs of Alberta

March 25,
2015

Teach another co-worker

about different pain
management measures for
pediatric patients
Do an online exam about
pain management
strategies and pass with at
least 90%

April 22, 2015

Teach another co-worker

and patients about the best
way to care for the wound
to ensure quick healing
with no infections
After 1 week, recite back
to wound care nurse what
he/she taught me

CLPNA Registration #: ____________

Page 8
2nd Edition - Revised October 2008

RECORD OF PROFESSIONAL ACTIVITIES

Date

Professional Activity
(include course,
seminar, research,
hours, details)

Summary of Learning

May 4-28,
2015

Long Term Care

Clinical 145hrs

Learned how to successfully care for 2 patients at a time,

including helping each patient with their ADLs and giving
them their medication

October 26
November
20, 2015

Medicine Clinical
145hrs

Learned how to care for patients on a medicine unit of a

hospital. Helped patients with AM/PM care, as well as
giving medication. Also learned how to tick chart, and how
to condense my long hand charting.

November
23December
18, 2015

Surgery Clinical
145hrs

Learned how to care for patients on a surgery unit at a

hospital. Learned how to do discharge teaching, care and
removal of catheters, wound care for simple and complex
wounds, IV removal, and how to give medications through
various routes.

February 12,
2015

CPR course

Learned the proper technique to provide CPR to adults and

babies in emergency situations. Also learned how to help
someone if they are choking or have a sudden airway
obstruction.

October
2014

Its Your Move Course

Learned how to transfer patients in multiple different ways,

including with a transfer belt, or a mechanical lift. Also
learned proper way to use body mechanics while caring for
patients

Name: Shaelyn Kormos

Self-Assessment Tool CCP

College of LPNs of Alberta

CLPNA Registration #:__________

Page 9
2nd Edition - Revised October 2008