Continuing Competency Program Instruction Guide

Transcription

1 Contents Continuing Competency Program Instruction Guide Introduction... 1 Basis for the CCP and the CCP audit in legislation... 2 The parts of the CCP... 3 Practice hours... 4 Self-assessment... 5 Learning plan... 7 Professional portfolio The CCP audit...14 CCP audit materials The audit process Verification of hours Frequently asked questions...20 What is the Continuing Competency Program (CCP)? Is the CCP mandatory? How is the CCP related to the Standards of Practice? When do I start participating in the CCP? Do I have to do CCP every year or just when I m chosen to be audited? Why was I audited two years ago and then again this year? If I have been off work for a year, do I have to complete a learning plan for that year? Can I fax in my CCP materials to the College? Do I have to send in my self-assessment forms? How will I know if I have successfully met the audit requirements? What if I don t successfully meet the audit requirements? How will I know about my audit results if I am away on vacation? Will my employer be made aware if I have not met the CCP requirements? I completed my online registration renewal application; can I submit my audit materials later? Where do I find further information on the CCP and the CCP audit?... 24

2 Introduction As part of its mandate to protect public safety, the College of Licensed Practical Nurses of Manitoba (CLPNM) determines standards of education and practice and ensures these standards are met. Each nurse is expected to assume personal responsibility for maintaining competence, along with personal, physical, social and emotional fitness to practice. To meet these requirements, LPNs in Manitoba participate in the CCP, creating, maintaining, and following a personal professional learning plan. All active practising LPNs participate in the CCP, building professional portfolios to serve as guidance for future learning and a record of past learning for future review. As the regulator for LPNs in Manitoba, the CLPNM is available to assist LPNs with learning sessions on how to fulfill the requirements of the CCP. In order to monitor compliance with the CCP, the CLPNM conducts an annual audit of CCP practice in the LPN population of Manitoba. Every year, the CCP audit guides the CLPNM in its mandate to ensure LPNs provide safe, competent and ethical nursing care, and assist LPNs in their general professional obligation to attain and maintain competence relevant to their specific area(s) of practice. A number of LPNs in Manitoba are randomly chosen each year to participate in an audit of CCP practice in the province. Registrants chosen to participate in this CCP audit which goes from January to May must send in their CLPNM-specified CCP materials as directed during the registration renewal period. An audit party consisting of active practising LPNs (who have been educated in audit guidelines and signed confidentiality agreements) will assess the CCP materials to see if they comply with the expected standards. The auditors, the CLPNM, and the registrants all work together to ensure that registrants whose CCP submission does not meet the expected standards receive guidance on how to complete their CCP in a manner to best support their practice. Any registrant who completes the entire audit process and whose CCP submission does not meet audit requirements will no longer meet the requirements for registration as an active practising LPN in Manitoba. CCP Instruction Guide 16/07/2013 Page 1

3 Basis for the CCP and the CCP audit in legislation The College is accountable through legislation, by The Licensed Practical Nurses Act (2001), to ensure nurses provide safe, competent and ethical nursing care. The establishment of the CCP and the expectations regarding its completion every year work directly to support this mandate: The Board [of the CLPNM] shall establish a continuing competence program which shall provide for supervision of the practice of licensed practical nursing by members. The program may provide for, but is not limited to, a) Reviewing the professional competence of members; b) Conducting practice audits in accordance with this Act; and c) Requiring members to participate in programs for ensuring competence. Concerning the practice of the CCP, the Standards of Practice, Standard VI Continuing Competence states: The Licensed Practical Nurse assumes responsibility for attaining and maintaining competence relevant to own practice. Further, Standard VI specifies the following indicators of successful practice: The Licensed Practical Nurse: 1. Demonstrates appropriate knowledge, skills and judgment related to own practice. 2. Demonstrates awareness of the changing trends in nursing, health and society that impact practice. 3. Continually assesses own competence to identify learning needs and opportunities for growth and development. 4. Uses reflective thought and feedback from others when assessing own practice. 5. Provides feedback to others to support their professional development. 6. Participates in the College of Licensed Practical Nurses of Manitoba Continuing Competency Program. 7. Incorporates knowledge gained into practice. 8. Maintains a record of professional activities. All of the above serve to create the framework for the expectations of the CLPNM concerning the CCP: the CCP is a mandatory part of practice, therefore to not participate in the CCP to the criteria specified in the Standards is to not meet the requirements for registration as an active practising LPN. Therefore, any registrant who completes the entire audit process and whose CCP submission still does not meet audit requirements no longer meets the requirements for registration as an active practising LPN in Manitoba. CCP Instruction Guide 16/07/2013 Page 2

4 The parts of the CCP The Continuing Competency Program has five (5) main components: 1. Practice hours: LPNs must meet a minimum requirement of hours practised in a four-year period 2. Self-assessment: LPNs must formally assess their knowledge, judgment, skills, and learning to identify gaps and possible areas for further learning 3. Learning plan: LPNs must create a formal learning plan every year, outlining their learning goals, the relevance of those goals to their current or expected area(s) of practice, the means they have undertaken (or will take, for the current year) to meet those goals, and the impact of that learning on their practice 4. Profession portfolio: LPNs must possess, maintain, and update a portfolio with professional education materials gathered in the course of educational goals; this portfolio is to serve as an easy place to refer back to as a refresher, or as a compilation of materials for current study, and serves as evidence of education acquired 5. Audit: LPNs must work with the CLPNM from time to time to ensure compliance with the practice of the CCP in an effective, relevant, and useful way that directly contributes to public protection Each of these items is described in detail below including item number five, the CCP audit, which is described in detail in the following chapter. These explanations are intended to assist you with your obligation to participate in all components of the CCP, and to explore what is required to complete this part of practice satisfactorily. If at any time you have any questions or wish to have more information, contact the CLPNM at (204) ; toll free at , or by at ccp@clpnm.ca CCP materials are available online on the CLPNM s website at CCP Instruction Guide 16/07/2013 Page 3

5 Practice hours Practice hours are work experience that requires the competencies, knowledge, skills and judgment of a licensed practical nurse (LPN). In order to be considered as LPN practice hours, the individual seeking to claim the practice hours must have been an active practising LPN at the time the hours were accrued. There is a minimum number of practice hours required, as specified in Regulation 26 (1): Subject to subsection (2), to satisfy the requirement of continuing competence for renewal of registration on the register of practicing licensed practical nurses, a member must have practiced for a minimum of 1,000 hours in the four years immediately preceding the year for which renewal is sought. Every year, 15% of the LPNs selected for the CCP audit will be asked to verify their practice hours by submitting forms to previous and current employer(s) to fill out and submit directly to the CLPNM on the LPN s behalf. The 15% selected each year are notified they have been chosen for verification of hours when they sign in to the registration renewal system. To learn more regarding practice hour criteria, refer to the CLPNM s Registration Policies and/or contact the CLPNM directly at (204) or toll free at Further information may also be found on the CLPNM website at CCP Instruction Guide 16/07/2013 Page 4

6 Self-assessment The self-assessment component of the CCP is an assessment and reflection of your nursing practice and knowledge. The self-assessment tool is based on the CLPNM s Standards of Practice, and guides the LPN through each of the eight (8) Standards. For each indicator, you must reflect on your LPN practice and select one of the five (5) descriptors that best describes your level of competence. The five (5) competence descriptors: 1. COMPETENT I consistently meet the expectation of this indicator in my practice. 2. SATISFACTORY I meet the expectation of this indicator in my practice. 3. DEVELOPING I have identified areas requiring improvement within this indicator. 4. INTERVENTION REQUIRED Identifies a priority area of learning in my practice. 5. NOT APPLICABLE This indicator is currently not part of my practice. To complete the self-assessment: 1. Review the CLPNM s Standards of Practice and the Code of Ethics available online at The Competency Profile for LPNs (v. May 2007) may also be referenced when conducting the self-assessment. This can be found on the CLPNM website at 2. Read each standard of practice and the indicators associated with each. 3. For each indicator, assess and select your level of competence based on the above descriptors. 4. Comment on strengths in your practice as identified by COMPETENT or SATISFACTORY. 5. Comment on areas for professional development in your practice as identified by DEVELOPING or INTERVENTION REQUIRED. CCP Instruction Guide 16/07/2013 Page 5

7 Sample self-assessment Standard II: Application of Knowledge, Skills & Judgement The Licensed Practical Nurse assesses the client s actual or potential strengths and limitations and plans interventions and evaluates outcomes. (1- Competent; 2- Satisfactory; 3- Developing; 4- Intervention Required; 5- Not Applicable) Indicators Year Year Year Year Year As a licensed practical nurse, I: 2.1 Practice within my own level of competence Obtain information from a variety of sources Apply critical thinking and problem solving processes in decision-making. 2.4 Determine client status and responds to actual or potential health problems, by planning nursing interventions, performing planned interventions, evaluating outcomes and revising care as necessary. 2.5 Exercise judgment to distinguish between relevant and irrelevant information when assessing, evaluating and reporting. 2.6 Initiate, maintain and conclude the therapeutic nurse client relationship. 2.7 Maintain documentation of client care and observations that are chronological, legible, clear, timely, accurate and concise Strengths that I have demonstrated in this Standard: Year /2.2/2.3/2.5/2.6 Year /2.3/2.4/2.5/2.6 Year Year Year Areas for professional development in this Standard: Year /2.7 Year /2.7 Year Year Year CCP Instruction Guide 16/07/2013 Page 6

8 Learning plan A learning plan is a personalized action plan designed to help you set, meet, and evaluate your professional development goals. A completed learning plan demonstrates not only learning but the direct impact of that learning on your practice. The learning plan has four (4) components. 1. Goal (based on the self-assessment) 2. Planning 3. Interventions 4. Impact on Practice (knowledge gained) Every year, as outlined above, each LPN completes a self assessment. During this reflective exercise, the LPN focuses on their practice area(s), competencies, Standards of Practice, and Code of Ethics. The LPN reviews their strengths and areas for self development, and then prioritizes the area(s) identified as needing further development. At the time of annual registration renewal, the LPN is expected to identify a minimum of two (2) learning goals for the coming year. These projected learning goals are based on the indicators identified within their annual self-assessment. The planning phase of the CCP allows you to explore ideas, opportunities, and best practises related to the achievement of your stated goal(s). In this phase, you must consider the following three questions: Where am I right now? What are my future goals? How can I achieve these goals? The planning process allows you to investigate methods of acquiring the skills, knowledge and/or experience required for your LPN role(s). A good plan allows you to increase existing competencies and to add new competencies to your repertoire. Throughout the year, you are expected to update your learning plan by listing the specific learning interventions and activities you have completed in order to meet your goals. It is during this phase that you record in your portfolio any education sessions, workshops, or conferences attended including information such as the name of the session, the date and place the session took place, and copies of materials presented. You may also add any reading materials referenced for learning, such as peer-reviewed journal articles. Once again, it is important to record specific details in the learning plan (i.e. name of journal, title of article, dates, authors, specific internet sites and addresses, textbook titles and chapters, dates of publications, and so on). CCP Instruction Guide 16/07/2013 Page 7

9 As the year goes on and goals are met, you are expected to detail the impact the interventions, learning activities and the newly gained knowledge has had on your practice. The impact on practice phase requires you to once again reflect on not only your practice but on your learning, and to then summarize what additional knowledge has been acquired and how it has influenced your practice. This last step has specific expectations: describe the impact of the learning on your area(s) of practice, include a synopsis of what you learned in pursuing this goal. Ultimately, the goal is for your learning plan to be able to serve on its own as a reasonable refresher of the learning achieved. Step 1: Goal (based on self-assessment) Once the self assessment has been completed, you are to review your strengths and areas for self development, and then prioritize the area(s) identified during the self assessment as areas requiring further development. Reflecting on your nursing career by assessing where you are currently and where you want to be can assist you to focus on the area(s) of practice that you can enhance. Helpful to remember is that this exercise is meant not to just review knowledge, but to add to and expand your body of knowledge. It is important to note that employer-mandated renewals and review of knowledge (i.e. CPR, WHMIS, lifts & transfers, etc.) are not considered acceptable learning goals for the purpose of the CCP. For example, annual CPR re-certification is not considered an acceptable learning goal as this is often mandated by the employer and doesn t have additional impact on your knowledge base and practice. CPR recertification is merely reviewing information that you are expected to know every day you report to work. However, if you have identified that CPR certification is a new requirement in your current area of practice or you are expanding your knowledge base related to code blue interventions by taking ACLS or PALS, then these goals would be considered acceptable. Ongoing recertification courses would not be acceptable learning goals. When developing the learning goal, remember to make it specific. For example, the following would not be an acceptable learning goal: To improve upon my knowledge, skills and professional judgment relevant to my practice at the Comfort Living Nursing Home. This goal is too broad and could encompass many objectives. An acceptable learning goal would state, for example: To increase my knowledge, skills and professional judgment in caring for aggressive clients with dementia. This learning goal is much more specific and clearly identifies the learning objective. When developing a learning goal, a useful tool is to be SMART: CCP Instruction Guide 16/07/2013 Page 8

10 S M A R T Specific to your needs and applicable to your practice. Measurable, real objectives that can be achieved through planned learning. Attainable, accessible learning that can be accessed by you where you are. Realistic for you to fit your learning needs, your life, and work environment. Timely, achievable within the next few months or within the year. Step 2: Planning The planning phase of the CCP allows you to explore ideas regarding the achievement of your goal. This planning process allows you to investigate methods of acquiring the skills, knowledge, and experience that is required for your LPN role(s). Further, this planning provides a means to start the thought process on how you are going to meet your learning objectives by listing possible activities and learning interventions as real steps to immediate action. The planning portion is not only a requirement of the CCP, but is an important way to show that thought and appropriate focus has been put into learning. This phase requires you to ask yourself: What can I do to meet my goal? Possible actions might include: Attend specific education sessions, in-services or conferences Online or library research Consult with or observe other health care professionals at the work place Develop an education session to share with colleagues, then share that session Certificate training courses related to the learning goal Courses leading to a degree or diploma Involvement in research Preceptoring/mentoring students or new staff Teaching or lecturing in formal courses Read current/relevant journals or newsletters Staff training While in the planning phase, it is important to remember that all activities must be related to learning goals. CCP Instruction Guide 16/07/2013 Page 9

11 Step 3: Interventions It is during this phase that you are to record what activities and learning interventions you have completed to achieve your goal of learning. This phase requires your to ask yourself: What did I do to meet my goals? Key points to remember to include during this phase are: Specific dates of activities: dates of workshops, seminars, conferences, etc. Specific details of the learning activities. When referencing articles, internet sites, textbooks, and so on, include dates, website addresses, article titles, authors and dates of publication, etc. Recording this information with as much specific detail as possible enables you to refer to the learning plan in the future to seek out and easily retrieve this information again. Step 4: Impact on Practice As the year goes on and you meet your learning goals, you are expected to detail the impact the interventions, learning activities, and the newly-gained knowledge has had on your practice. The impact on practice phase requires you to once again reflect on not only your practice but on your learning and to then summarize what additional knowledge has been acquired and how it has influenced your nursing practice. This phase requires you to ask yourself: What has this learning added to my practice; what do I know now that I didn t know before? If a goal is not completed within the current year, it can be carried over to the next year; however, any achievements made should be documented. It is important to remember that the requirement is to achieve a minimum of two (2) learning goals every year, so if there has only been one (1) goal completed this year, you will need to complete another goal to replace it for that year. For this reason alone, it is crucial that you assess, evaluate, and revise your learning plan as required several times throughout the year to ensure goals are met as required. Finally, as the last step of the Impact on Practice, you evaluate your overall sense of this specific learning experience, using the provided Evaluation of Learning tool with the following statements to select from: This learning enhanced my professional knowledge, skills and/or judgments. I have shared the new information with colleagues and clients. A positive impact of learning has been confirmed by feedback from clients or others. Very little has changed in my knowledge or practice. CCP Instruction Guide 16/07/2013 Page 10

12 Sample learning plan Continuing Competency Program Learning Plan Year: 2008 Goal #: 1 of 2 Reg #: XXXXXXXX Goal: Based on self-assessment, state your learning goal. To increase my knowledge, skills, and abilities regarding chest auscultation of pediatric clients. Planning: What activities can you do to meet your goal? Consult with co-workers (RTs & nurses) to review auscultation of lung sounds. Review land marking the anterior & posterior lung fields. Review the various breath sounds and related nursing interventions. Interventions: What activities did you do to meet your goals? Include detailed information such as dates of activities, reference articles; their authors, internet sites, textbooks, journals, etc. January Read an internet article at titled, Pulmonary Auscultation by J. Hudson RT. January Reviewed Airway Assessment Implications from the PICU/PSCU Orientation Manual. January Performed chest assessments on patients then had co-workers assess the same patient; and then compared findings. CCP Instruction Guide 16/07/2013 Page 11

13 Impact on practice: What have you learned, and what is the effect of this learning on your daily practice? With continuing practice, I have an increased understanding of the various adventitious breath sounds that may occur and the varying degrees they may occur in the pediatric patients I care for. I also have an increased understanding of what these adventitious sounds could mean to the patient and what treatment path they may require; in addition as to how these symptoms can affect their overall health status. For ex. crackles can either mean that the small airways are open during inspiration but collapse during expiration or may possibly be from air bubbles through secretions or from incompletely closed airways during expiration (i.e. asthma, early CHF, chronic bronchitis). Also that respiratory wheezes are produced when air flows through airways narrowed by secretions, foreign bodies or obstructive lesions. (i.e. COPD, asthma, pulmonary edema). Rhonchi are lower pitched wheezes, usually implying obstruction of a larger airway. Pleural rubs are heard when the pleural surfaces are inflamed or roughened, causing them to rub against each other. (i.e. pleural effusion or pneumothorax). When a patient is in distress, aside from administering O2 and medications as ordered/required, it s important to assist them to assume a comfortable position, i.e. elevating the head of the bed, have patient lean on an overbed table or sit on the edge of bed if able. Elevating of the head of the bed may facilitate respiratory function by use of gravity, however a patient in distress may seek a position that most eases their breathing so it s important to take cues from the patient. Encouraging and assisting abdominal and pursed lip breathing exercises provides some means to cope with or control dyspnea and reduces air trapping. Evaluation of Learning: Check all that apply. This learning enhanced my professional knowledge, skills and/or judgments. I have shared the new information with colleagues and clients. A positive impact of learning has been confirmed by feedback from clients or others. Very little has changed in my knowledge or practice. Other: CCP Instruction Guide 16/07/2013 Page 12

14 Professional portfolio The professional portfolio is an organized collection of documents that chronicle your nursing career and demonstrates the activities undertaken to assess, maintain and build professional competence. It is important to note that the development and maintenance of a professional portfolio is a required component of the CCP and may be requested for auditor viewing during an audit. A professional portfolio is unique to each individual, so choosing a method to contain and track professional development activities must suit the needs of each individual. A binder, a drawer in a filing cabinet, or a large plastic container may work well for some, while a digital file may suit the needs of others. No matter which method is utilized, ensure that it is user-friendly and easily accessible for ongoing updates throughout the year. Some examples or suggested documents to keep in a professional portfolio may include, but are not be limited to: Self-assessments and learning plans A record of practice hours A current resume and references Copies of diplomas or certificates Records of attendance to workshops, seminars, etc. with learning materials obtained Performance appraisals Reports you wrote and presentations you have made Awards, letters of appreciation, and letters of recommendation Copies of articles read in journals, professional magazines, online material, textbooks, etc. CCP Instruction Guide 16/07/2013 Page 13

15 The CCP audit Every year as part of registration renewal, a number of LPNs in Manitoba are randomly chosen to participate in an audit of CCP practice in the province. Registrants chosen to participate in this CCP audit which goes from January to May must send in their CCP materials as directed by the CLPNM during the registration renewal period. Registrants selected for the audit will have a condition on their license that indicates to employers that they are participating in the CCP audit. This condition does not affect the LPN s ability to work to full scope and may persist until the registrant has successfully met the requirements of the audit. As outlined in Part 3, section 10 of The Licensed Practical Nurses Act of Manitoba, any registrant subject to a condition of registration may appeal. For more information on the appeal process, see An audit party consisting of active practising LPNs (who have been educated in audit guidelines and signed confidentiality agreements) will assess the submitted CCP materials to see if they comply with the expected standards. The auditors, the CLPNM, and the registrants all work together to ensure that registrants whose CCP submission does not meet the expected standards receive guidance on how to complete their CCP in a manner to best support their practice. Any registrant who completes the entire audit process and whose CCP submission does not meet audit requirements will no longer meet the requirements for registration as an active practising LPN in Manitoba. The CCP is not meant to be a punitive process, and neither is the audit. Rather, the audit is a requirement outlined in Part 5, section 15 of The Licensed Practical Nurses Act of Manitoba. Every year, a computer-generated, random selection of active practising registrants are chosen to be audited. Registrants selected for audit are advised in the annual registration renewal notice sent by regular mail to registrants at the address on record at the CLPNM, and are also notified they have been selected for the audit when accessing the CLPNM s online registration renewal system through the CLPNM website. The CLPNM will not process registration renewal applications for registrants who are chosen for the CCP audit until all of the required CCP documents are received by the CLPNM. All registration penalties apply for applicants who do not meet renewal deadlines. The CLPNM recommends that all registrants renew early during the renewal period in order to prevent late fees in the event of missing or delayed requirements of registration, including receipt of the CCP materials at the CLPNM, if required. CCP Instruction Guide 16/07/2013 Page 14

16 CCP audit materials Registrants selected to participate in the audit are required to submit the following: The previous year s learning plans (a minimum of two (2) learning plans, identifying one (1) goal per learning plan), The current year s learning plans (a minimum of two (2) learning plans, identifying one (1) goal per learning plan), which each may be partially completed (with only step one (1) and two (2) complete; steps three (3) and four (4) may be completed during the remainder of the current registration year), The CCP Audit Questionnaire (Form A), which may be obtained directly from the CLPNM website at Independent practice is the application of nursing theory and principles in a self- employment setting. The parameters are determined within legislation (the Licensed Practical Nurse Act (2001)), regulations, by-laws, the Code of Ethics, and the Standards of Practice and competencies identified in the Competency Profile for Licensed Practical Nurses in Manitoba (v. May 2007). Independent nursing practice may include but is not limited to: Foot care Nursing agency Consultation services Registrants in independent practice who are selected to participate in the audit are required to submit the above items, and also to submit the following: The CCP Independent Practice Audit Questionnaire (Form B), which may be obtained directly from the College website at a copy of the table of contents of the independent practitioner s policy manual(s), a copy of at least one (1) of the independent practitioner s policies that pertains to specific nursing care provided by the LPN in independent practice, a copy of at least one (1) of the independent practitioner s billing policies, a copy of at least one (1) of the independent practitioner s, documentation/record keeping policies regarding the storage, retention, and destruction of health records, a copy of at least one (1) of the independent practitioner s policies outlining infection control practices, and CCP Instruction Guide 16/07/2013 Page 15

17 a copy or template of documents and/or tools used to assist the independent practitioner in the provision of nursing care, including but not limited to: a nursing care plan assessment/care flow record and, nurse s notes When submitting the required material(s) to the CLPNM, all audited LPNs must comply with privacy legislation including the Personal Health Information Act (PHIA). LPNs must not send any identifiable personal health information, numbers, materials and/or statements that would constitute a breach of confidentiality. Failure to do so may constitute professional misconduct. Please visit for further information. The CCP audit is anonymous. If you have been selected to participate in the CCP audit, please do not put any identifying information other than your CLPNM registration number. Your registration number must be on every document submitted. Your learning plans must have your registration number and the corresponding year for which it was developed. Any materials submitted without a registration number will be destroyed without consultation on December 31. Each audit submitted is independently reviewed by a minimum of two (2) LPN auditors. During the audit, the auditors look for all of the required components and review the learning plans for completeness, evidence of interventions, and for evidence of knowledge gained. After the CCP audit, all materials received are destroyed for confidentiality. Please only submit copies of your CCP materials, not your originals, as they will not be returned to you after the successful completion of the audit. CCP Instruction Guide 16/07/2013 Page 16

18 The audit process Auditors assess the received material to determine if the learning plan contains adequate information to validate that appropriate learning has taken place. Auditors may be required to verify websites, journals, textbooks used, attendance of in-services, workshops, etc. If detailed and specific information is not provided within a learning plan, the auditors may request that the registrant submit their professional portfolio, either in part or in its entirety (copies preferred; the registrant is advised to keep their original copies). This may also include the registrant s self-assessments. The portfolio will be returned to the registrant after completion of the audit. It is the responsibility of the LPN to notify their employer(s) they are being audited, and to ensure the employer(s) realize that if the LPN does not respond to requests for information within any deadlines imposed, it may result in cancellation of the LPN s active practising registration. In order to provide LPNs with multiple opportunities to succeed in the audit, the annual CCP audit takes place over three (3) phases: 1. Audit Phase 1 The first phase begins in January. Registrants should expect to receive and written notice regarding the results of the CCP audit phase one (1) between the last part of January to the early part of February. Registrants who meet the requirements at this stage according to the auditors have completed their CCP audit. 2. Audit Phase 2 The next phase of the CCP audit, phase two (2), takes place at the end of February. Registrants should expect to receive and written notice regarding the results of the CCP audit phase two (2) by the early part of March. Registrants who meet the requirements at this stage according to the auditors have completed their CCP audit. 3. Audit Phase 3 The third and final part of the CCP audit, phase three (3), takes place at the end of April. Registrants should expect to receive and written notice regarding the results of the CCP audit phase three (3) between the last part of April to the early part of May. Once the audit is complete, the auditors determine if the registrant s learning plans have either met the requirements of the CCP or if further follow up is required. The CLPNM will contact all of the audited registrants who successfully meet the requirements of the CCP by at their address on record at the CLPNM. CCP Instruction Guide 16/07/2013 Page 17

19 If further follow up is needed to successfully meet the requirements of the CCP, the Executive Director of the CLPNM will notify the registrant by registered mail to the addresses on record at the CLPNM, communicating what information and/or materials the auditors require and the timeframe for submission. An is also sent to the address on file, indicating there is timesensitive registered mail inbound to the registrant. Important to note, registrants are responsible for ensuring the CLPNM records contain current contact information, including mailing and addresses, phone number(s) and current employer(s). Ensure the CLPNM has appropriate contact information for you at all times. It is the responsibility of each registrant to ensure their registration is active and in good standing in order to practice as a LPN. Therefore, if a registrant has not received notification from the CLPNM with regard to the results of their CCP audit, and/or if they are expected to be away from their place of residence for an extended period at any time during the audit phases, they are responsible to contact the CLPNM for verification of their audit results. Any registrant who completes the entire audit process and whose CCP still does not meet audit requirements will no longer meet the requirements for registration as an active practising LPN in Manitoba, and will have to contact the CLPNM for further options. CCP Instruction Guide 16/07/2013 Page 18

20 Verification of hours As stated in Regulation 26 (1), to satisfy the requirement of continuing competence and for ongoing registration, the registrant must have practised a minimum of one thousand (1000) hours in the four (4) years immediately preceding the year for which renewal is sought. Every year, out of the randomly selected registrants chosen for the audit, 15% of those registrants will also randomly be required to submit a verification of hours. The registrant must forward a CLPNM Verification of Hours form to all of their previous and current nursing employers from the past four (4) years to verify that they have practised a minimum of 1000 hours over that period of time. The registrant is responsible to print the form off the CLPNM website ( and make the required number of copies. The registrant is then to submit the form(s) to their employers and request that the employers send the completed form(s) directly to the CLPNM. Forms submitted by registrants will not be accepted. It is the responsibility of the LPN to ensure their employer(s) submit the required information to the CLPNM in a timely fashion. For further information regarding CLPNM policies surrounding the CCP and the CCP audit, please refer to CLPNM policies R-30 Continuing Competence and R-31 CCP Audit, found on the CLPNM website at CCP Instruction Guide 16/07/2013 Page 19

21 Frequently asked questions What is the Continuing Competency Program (CCP)? The Continuing Competency Program (CCP) is a formal system of assessing the ongoing knowledge, skills and judgments of a professional practitioner. It is unacceptable for a professional to take a basic program and work continuously without maintaining competence. Competence is continually maintained and acquired through reflective practice, lifelong learning, and integration of learning into nursing practice. Per part 5 of the LPN Act, LPNs have a professional obligation and responsibility to attain and maintain competence relevant to their specific area(s) of practice. Ultimately, continuing competence contributes to the CLPNM s mandate to protect the public and allows LPNs the opportunity to reflect on their practice. Is the CCP mandatory? Yes. Participation in the CCP is mandatory for registration with the CLPNM. During registration renewal, registrants are required to self-declare their participation in the CCP. How is the CCP related to the Standards of Practice? The Standards of Practice serve as objective guidelines to provide and evaluate LPN practice. The Standards articulate the expectations the public can have of an LPN and they are the achievable minimum standards against which actual practise can be measured. The Standards of Practice serve as a legal reference to describe reasonable and prudent nursing practice. The Standards of Practice are used to provide the framework of the CCP. The self-assessment component of the CCP is a tool that guides the LPN through each Standard, requiring the LPN to assess their individual practice against each indicator listed. When do I start participating in the CCP? Participation is mandatory as soon as the LPN is registered on the active practising register. It is then a continuous process that the professional nurse is expected to participate in annually throughout their nursing career, as long as they remain on the active practising register with the CLPNM. CCP Instruction Guide 16/07/2013 Page 20

22 Do I have to do CCP every year or just when I m chosen to be audited? Participation in the CCP is mandatory for registration with the CLPNM, as well as for maintenance of registration. Each year, during registration renewal, registrants are required to self-declare their participation in the CCP. The CCP audit is an individual component of the entire CCP intended to verify compliance with CCP practice. Participation in the audit is mandatory for registrants who are selected. Each year, a random selection of active practising registrants is generated to participate in the CCP audit. Why was I audited two years ago and then again this year? The CCP audit runs in four (4) year cycles that are tracked through a computerized system. The computer generates a random list of ten percent (10%) of the active practising registrants every year. After a registrant is chosen for an audit, their name is removed from the system to ensure they are not selected again within that four (4) year cycle. Depending on the selection year, it is conceivable that a registrant may be audited two years in a row. For example, if a registrant was selected in the 2011 registration year, which was the fourth year of an audit cycle, they may be chosen again for an audit the following year, as the 2012 registration year marked the first year of another four (4) year cycle. At the end of each four (4) year cycle, all registrants names are put back onto the list of registrants that are eligible to be selected for audit. If I have been off work for a year, do I have to complete a learning plan for that year? Yes. It is the expectation that all individuals who hold active practising registration participate in the CCP, regardless of their employment status. Applicants who are not on the active practising register who are applying for reinstatement of active registration have thirty (30) days to provide documentation related to the assessment of their practice and the development of a minimum of two (2) learning plans. Can I fax in my CCP materials to the College? Yes. Registrants may submit their CCP documents in several ways. Materials may be sent via to ccp@clpnm.ca; by fax to (204) ; or by regular mail to the CLPNM office at 463 St. Anne s Road, Winnipeg, MB, R2M 3C9. All documents received by the CLPNM must be legible to be accepted as a legitimate submission. CCP Instruction Guide 16/07/2013 Page 21

23 Do I have to send in my self-assessment forms? Maybe. If the CCP auditors have determined they require further information from the registrant, they may request the registrant submit their professional portfolio in part or in its entirety. Registrant s CCP documents are considered to be a part of the professional portfolio; therefore, if a registrant has been asked to submit their portfolio that may include their selfassessments. Registrants must keep their original copies and submit photocopies only, as materials submitted for the audit are destroyed once the audit is complete, for reasons of confidentiality. How will I know if I have successfully met the audit requirements? You will be notified via if you have successfully met the audit requirements. What if I don t successfully meet the audit requirements? You will have to submit follow up information as directed by the auditors. This information will be sent to you via registered mail. If a registrant is required to submit follow up for having not met the CCP requirements, the auditors will conduct a second audit phase at the end of February in order to review the additional information and materials. If the auditors conclude that the registrant has not met the CCP requirements for a second time, the registrant will be notified by registered mail to the address on record at the CLPNM in early March. The registrant will be given details regarding the need for mandatory CCP education. The mandatory CCP education is provided by the CLPNM Practice Department and is available in various mediums. After participating in the mandatory CCP education, the registrant is advised as to what further follow up is required in order for them to meet the CCP requirements. The registrant will be given a timeframe in which to comply with these directions. If a registrant continues to not meet the CCP requirements after the completion of the second audit phase, the auditors will return to conduct a third and final audit phase at the end of April. If the auditors conclude that the registrant has not met the CCP requirements for a third time, the registrant will be notified by and by registered mail to the addresses on record at the CLPNM in early May. Once again, the registrant will be provided details as to what further action is required of them within a provided timeframe. Any registrant who completes the entire audit process and whose CCP still does not meet audit requirements will no longer meet the requirements for registration as an active practising LPN in Manitoba. CCP Instruction Guide 16/07/2013 Page 22

24 How will I know about my audit results if I am away on vacation? Audit results are sent out via at the end of each audit phase. This will indicate one of two things: The requirements of the CCP have been met successfully. Or There is a registered letter en route containing the next steps required by registrants who did not meet the requirements. If you can t check your or mailbox, it is up to the registrant to contact the CLPNM to verify their audit status. It is the responsibility of each registrant to ensure their registration is active and in good standing in order to practice as a LPN. Therefore, if a registrant has not received notification from the CLPNM with regard to the results of their CCP audit, and/or if they are expected to be away from their place of residence for an extended period at any time during the audit phases, they are responsible to contact the CLPNM for further direction. If a registrant has not met the CCP requirements during any phases of the audit and fails to comply with directions provided by the CCP auditors and/or the Executive Director within the deadline imposed, the registrants active practising registration may be cancelled. This means their registration will no longer be valid, and they will not be authorized to practice as a licensed practical nurse (LPN) in Manitoba. Will my employer be made aware if I have not met the CCP requirements? Yes. Per 7(3) of the LPN Act, information regarding conditions, suspensions, and cancellations of registration is accessible to any person. Per 4(2) of the LPN Act, the CLPNM must carry out its duties in a manner that serves and protects the public. With that in mind, any registrant who has not met the requirements for CCP is in jeopardy of having their registration cancelled and it is therefore the obligation of the CLPNM to inform the registrant s employer(s), as this may put the public they care for at risk if the nurse is not available for work. LPNs who have been selected to participate in the CCP audit and who continue to comply with the requirements of the CCP and any deadlines provided for the audit process will continue under a conditional registration status that has no effect on their ability to work. Once the auditors have determined that the registrant has successfully met the requirements of the CCP and the audit, the conditional registration status may be removed. After which the CLPNM notifies the registrant and the employer(s) that the LPN s registration status is no longer conditional. CCP Instruction Guide 16/07/2013 Page 23

25 I completed my online registration renewal application; can I submit my audit materials later? Provided your audit materials are received by the CLPNM before the registration renewal deadline, then the answer is yes. If your audit materials are not received in time, your application is not complete, and your renewal will not be processed. Late CCP submissions may result in late fees and cancellation of registration. Where do I find further information on the CCP and the CCP audit? For further information regarding the CCP, you can: Visit the CLPNM website at Telephone the CLPNM directly at (204) , or toll free at Contact the CLPNM via at ccp@clpnm.ca CCP Instruction Guide 16/07/2013 Page 24