Self-assessment Tool

Self-assessment Tool

Complete the self-assessment by answering the questions on this web page or by downloading and completing the Self-assessment Workbook, which includes additional prompts for you to consider.

The more you answer “yes” to the questions, the closer you are to being ready to apply for Stellar certification.

If you are completing the self-assessment on this web page, note that your answers are not recorded, saved, tallied, or submitted to the Stellar Certification Program. This web page is strictly for your records, so we suggest you print a copy after you have completed it.

Standard 1: Nursing Voice

Shared decision-making

Do direct care nurses have a leading role in decisions affecting clinical workflows and nursing practice as they relate to the delivery of care to individuals living in the LTC home?

Are all direct care nurses, particularly those that work nights and weekends, involved in decision-making?

Are nurses supported to express their views? Do LTC administrators and managers understand (and have strategies to overcome) the potential roadblocks that nurses can face when voicing their opinions?

Are the views of Indigenous nurses, as well as Indigenous people living in the LTC home and their families, engaged as part of the decision-making process?

Does the following organizational document provide evidence of support for shared decision-making? A list of all the LTC home council/committee meetings that occurred over the past year. This document may include (but is not limited to) meetings related to the following topics: nursing practice, nursing quality, patient safety, workplace safety, representation of individuals living in the home and their families, etc.

Diversity, equity and inclusion

Does the LTC home address diversity, equity and inclusion by amplifying the voice of racialized people in the workplace, and by providing the nursing team with opportunities to gain cultural knowledge and modify their behaviours?

Does the LTC home promote a culture of diversity, equity and inclusion?

Do all employees receive orientation and training to instil principles of collaboration, equity and mutual respect?

Are the following organizational documents available? Organizational policies and procedures related to diversity, equity and inclusion: This document should show how the LTC home addresses workplace diversity, equity and inclusion and should take the needs of employees and individuals living at the facility into account.

Standard 2: Leadership Excellence

Nursing leadership

Is the LTC home’s nursing leadership visible and active in the care environment?

Have administrators and nurse managers received exceptional education and training — or do they have access to it?

Do leaders seek out input from direct care nurses, understanding that they are excellent sources for new initiatives focused on the promotion of staff well-being (safety, physical health and mental health)?

Well-being of nurses

Does the LTC home have a solid understanding of what matters most to direct care nurses? Does it strive to ensure nurses’ well-being?

Is the health of nurses regularly assessed, and are health initiatives based on the results of those assessments implemented?

Is the LTC home creating work schedules that support nurses’ well-being? This could include flexible hours that promote a balance between work and personal life.

Is there a process in place for the LTC home to assess the health of the nursing team and nurses in leadership positions?

Is the well-being of nurses integrated into strategic planning?

Do direct care nurses use a shared decision-making approach to plan and evaluate well-being initiatives?

Are the following organizational documents available? Organizational policies and procedures related to the safety and physical and psychological well-being of the nursing workforce: This document should address the mitigation and management of alleged psychological harassment of the workforce and should describe the complaint process for the employee workforce, with a clear indication of the reporting structure, should an issue arise concerning a direct manager or the senior administration.

Are the following organizational documents available? Policies and/or procedures related to nurses’ well-being: This document should include the resources available (either on site or external) to the nursing team to promote their mental health and well-being.

Standard 3: Education and Career Progression

Professional growth

Does your organization value and recognize the importance of supporting nurses’ ongoing education, gerontological certification, and opportunities for professional growth?

Is the pursuit of higher education and opportunities encouraged and supported?

Are nurses’ professional needs carefully assessed?

Is a high percentage of the facility’s nursing staff CNA certified in gerontology? For an LTC home’s initial Stellar certification, 25% or more of the facility’s nurses (RNs, LPNs/RPNs, NPs) must be CNA-certified in gerontology. If unable to meet this requirement, a plan for increasing nurses’ gerontological certification must be in place.

Does the facility support its nursing workforce (RNs, LPNs/RPNs, NPs) to voluntarily achieve CNA certification in gerontological nursing?

Nursing orientation and mentorship

Does the LTC home have a strong nursing orientation and mentorship program that supports all levels of nurses and helps prevent burnout, increase job satisfaction and improve person-centred care?

Are mentors who orient new staff supported with resources and education, and are they evaluated constructively by managers?

Are direct care nurses encouraged and supported to take a leadership role in orienting new nurses?

Is the following organizational document available? A document or policy indicating staff appraisals: This document should show that individual members of the nursing team participated in a self-assessment and were able to identify their own need for opportunities for growth in education and certification. It should also provide a copy of policies and/or any documents related to performance appraisals/assessments of the nursing workforce. This may include (but is not limited to) annual assessment, individual learning plans, peer assessments, SMART goals, LEADS 360 assessment, etc.

Standard 4: Resourcing

Safe and effective resourcing

Is the LTC home committed to providing the best in evidence-based policy, practice, products and professional development to ensure a safe ratio of nurses to individuals living in the facility?

Do LTC administrators recognize the complexity of achieving the right mix of skills and staff?

Is there a robust contingency plan in place to guide the nurse manager when staff shortages occur?

Are there easily accessible guidelines for the charge nurse to follow when no one is available to replace staff?

Are the following organizational documents available? Policies, procedures and contingency plans related to staff shortages. These are key documents and should address the following items:

  • What are the guidelines the charge nurse must follow when no one is available to replace staff? What do the guidelines specify under different scenarios, such as when the LTC home has no RN available? What are the guidelines when one or more other staff members are not available?
  • Provide your plan /process to mitigate problems related to staff shortages and ensure the care needs of individuals living in the LTC home are met.
  • What are the guidelines for nurses when documenting practice circumstances they deem to be unsafe due to lack of staff?
  • What are the relevant reporting and documentation practices to fulfil the requirements of regulatory bodies and the LTC home’s policies?
  • If applicable, provide the processes and/or mechanisms being used to reduce dependence on private nursing agencies.

Standard 5: Practice Environment

Positive practice environment

Is the nursing perspective meaningfully recognized and valued as contributing to the foundation of a positive practice environment and a safe and enjoyable work culture?

Is an exceptional employee recognition program in place?

Does the team celebrate important milestones and personal achievements?

Are training and supports provided to enhance practice environments?

Are the following organizational documents available? Policies, procedures and other documents related to employee recognition: These documents should outline details of a program and/or process that ensures staff members are recognized and celebrated in the workplace. It should include a description of the robust reporting capabilities that are in place.

Safe practice environment

Is the physical safety and mental well-being of nurses and individuals living in the LTC home ensured through a culture of responsibility that is free of incivility, bullying and violence?

Are all reasonable efforts to protect the physical safety and mental health of nurses and those living in the LTC home (and their families) taken?

Are policy and processes in place to address adverse situations in a timely manner? Are all team members familiar with the process?

Is incident reporting viewed as a positive and constructive learning process, and is this viewpoint exemplified by the leadership team?

Are staff members, individuals living in the LTC home and their families, aware of the process to report an incident and feel safe doing so (i.e., the LTC home creates a culture where nurses feel safe to self-report a medical error)?

Are the following organizational documents available? Policies, procedures, schedule or planning documents related to debriefing processes: This document should include any debriefing education and/or coaching provided to the leadership of the LTC home.

Standard 6: Optimizing Care

Supporting nurses to optimize care delivery using a holistic approach

Does the LTC home support nurses to optimize care delivery using an evidence-based, person-centred holistic approach?

Does the LTC home’s staff have training, education and other supports available to them to implement programs for optimizing care?

Does the LTC home’s leadership support nurses in their efforts to promote healthy aging for the individuals living in the home?

Does the LTC home’s staff make regular use of established best practices and resources?

Are new and innovative ideas allowed to be brought forward by non-medical staff, individuals living in the LTC home, and their families?

Is there a process in place to review innovative suggestions and determine their appropriateness for incorporation into practice — potentially allowing the home to develop and/or participate in research opportunities?

Are the following organizational documents available? Policies, structures or other documents that outline how nursing care plans are developed. This document should indicate how nurses, individuals living in the LTC home, and their families, all contributed to the plan to ensure it aligns with the individual’s care needs. In addition to providing the frequency and structure of family meetings, this document should outline how people living in the LTC home are active participants in their care plans.