Nurse Education Today 31 (2011) 832–836

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Nurse Education Today

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / n e d t

A review of clinical competence assessment in nursing

Chen Yanhua a,⁎, Roger Watson b
a
Infectious Disease Department of the Affiliated Hospital of Luzhou Medical College, Luzhou, China
b
School of Nursing and Midwifery, University of Sheffield, UK

a r t i c l e i n f o s u m m a r y

Article history: Aims: To investigate trends in the evaluation of clinical competence in nursing students and newly qualified
Accepted 2 May 2011 nurses over the last 10 years.
Design: A literature review following PRISMA guidelines.
Keywords: Methods: The following databases were searched: Cochrane, Medline and CINAHL using the terms
Competence competenc*, nurs*and assess*, evaluat*, measure*, from January 2001–March 2010. Strict inclusion and
Assessment
exclusion criteria were applied.
Nursing
Results: Twenty three papers were included and these mainly considered the following topics: instrument
development and testing; approaches to testing competence; assessment and related factors. A holistic
concept of competence is gaining popularity, and consensus around definitions is emerging. Some methods
and instruments to measure competence are under systematic development and testing for reliability and
validity with large samples and rigorous statistical method. Wider national and international cooperation is
evident in competence-based assessment.
Conclusions: Competence-based education is evident, but this does not mean that issues related to
competence definition have been resolved. Larger and more international cooperation is required to reach
common agreement and validity in competence-based education and assessment.
© 2011 Elsevier Ltd. All rights reserved.

Introduction A holistic competence was accepted by other researchers and statutory

Watson et al. (2002) published a systematic review of clinical
competence assessment in nursing from 1980 to 2000 and argued that
the definition of competence was obscure, the measurement of
competence was unsystematic and the reliability and validity of
measurement tools or strategies was seldom reported. They found
that a significant amount of literatures came from outside nursing.
The present paper seeks to examine the situation 10 years on.
The Concept of Clinical Competence in Nursing
Nearly 10 years later, after Watson et al.'s (2002) review, the
definition of competence lacks consensus, remains obscure and
contradictory (Cowan et al., 2007; Axley, 2008; Scott Tilley, 2008;
Cassidy, 2009; Valloze, 2009) especially, the differentiation between
competence and competency (Cowan et al., 2007). However, there is
some evidence of progress.
Scott Tilley (2008), Axley (2008) and Valloze (2009) used the
process of Walker and Avant (1995, 2004) to study the concept of
competence and demonstrated different model cases, borderline
cases and contrary cases to help clarify the meaning of competence.
⁎ Corresponding author. Tel.: + 86 13882795016.
E-mail address: chen_yanhua25@163.com (C. Yanhua).
bodies (Percival, 2004; Meretoja et al., 2004; ANMC, 2005; Black et al.,
2008). In the UK, Cowan et al. (2007) advocated applying a holistic
conception of competence including knowledge, skills, performance,
attitudes and values and claimed that the use of a holistic concept
could enable people to accept this concept and to develop more precise
competence standards and assessment instruments.
Besides academic debate, the regulatory bodies have also tried
to unify the definition of the concept and the framework of nursing
clinical competence to reach national or international consensus. In the
UK, the Nursing & Midwifery Council (NMC) used the term competence
referring to “the overarching set of knowledge, skills and attitudes
required to practice safely and effectively without direct supervision”
(NMC, 2010, p. 145), In Australia, in the National Competency
Standards for the Registered Nurse (2005, p. 8), competence was
defined as “a combination of skills, knowledge, attitudes, values and
abilities that underpin effective and/or superior performance in a
professional/occupational area”. In Canada, competence was defined
as “the ability of the registered nurse to integrate and apply the
knowledge, skills, judgments and personal attributes required to
practice safely and ethically in a designated role and setting” by 10
nursing regulatory bodies cooperatively (Black et al., 2008, p. 173).
Although the concept of clinical competence in nursing is not
universally defined, as before 2000, progress towards consensus and
clarity of the concept is emerging. However, the above literature is
based on collaboration and consensus seeking in the design of systems

0260-6917/$ – see front matter © 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nedt.2011.05.003
 C. Yanhua, R. Watson / Nurse Education Today 31 (2011) 832–836
for the assessment of competence and tends not to be concerned with
providing evidence.
The Study
The review aims to explore trends in clinical competence
assessment in nursing students and newly qualified nurses in the
decade 2001–2010.
Method
This review reports only the articles on student nurses' clinical
competence and newly graduated nurses in their first year of work;
therefore, studies mainly concerning cultural competence and other
special competencies of general nurses, nursing practitioners and
public health nurses are excluded. The literature between January
2001 and March 2010 was retrieved using the following search
strategies and databases: competenc* and nurs* in TI and assess*/
measure*/evaluat* in AB for consulting CINAHL and competenc* and
nurs* in author's keywords and assess*/measure*/evaluat* in AB for
consulting Medline, and keywords competenc* and nurs* were also
used in search of Cochrane. The search term competenc* and nurs*
were determined to be too broad terms compared with 10 years ago,
yielding a large quantity of material but were still useful if combined
with assess*/measure*/evaluat*. Only research papers in English were
reviewed; non-research papers were excluded.
The literature review initially identified 211 papers in CINAHL and
169 in Medline; after removing duplications, 219 papers were
relevant to the study. Subsequently, the following inclusion/exclusion
criteria were used.
Inclusion criteria:
• The main focus of the research was general clinical competence
assessment.
• The research related to nursing students and/or newly qualified nurses.
• The study samples were general nursing students and newly
graduated students.
• Methodology included literature reviews, experiments, survey and,
qualitative studies.
Exclusion criteria:
• The general area of the paper was specific competence, such as
cultural competence, computer competence, and safety competence.
• The research was related to nurse management in hospitals.
• The sample was non-general nursing students, such as public health
nursing students, or advanced practitioner students.
Following this, as shown in Fig. 1, 25 studies were appropriate for
this study. Only 23 were available locally, through inter-library loan or
by contacting the corresponding author; two months were allowed
for retrieval of papers.
Results
Three categories of paper emerged:
• Instrument development and testing (n = 4)
• Approaches to testing competence (n = 7)
• Assessment and related factors (n = 12).
Papers on assessment and related factors were the majority (12),
and the smallest proportion was instrument development and testing
(4) (Table 1). In term of research methodology, the most popular was
survey (11) and only quasi-experimental studies were found (Lee-
Hsieh et al., 2003; Komaratat and Oumtanee, 2009). The papers are
categorized in Table 2. There are 11 papers from UK, four from USA,
three from Australia, two from Taiwan, China; the remaining three
833
PRISMA 2009 Flow Diagram
Identification
380 records identified through
database searching
219 records after duplicates removed
Screening
197 records excluded
25 records screened
Eligibility
23 full-text articles
2 articles unobtainable
assessed for eligibility
Included
23 of studies included in
qualitative synthesis
Fig. 1. PRISMA 2009 flow diagram.
came respectively from Ireland, South Africa and Thailand, which is
similar to Watson et al.'s (2002) findings.
Discussion
Instrument Development and Testing
Reliability and Validity Testing of Instruments
Since 2001 new measurement tools have been developed and
tested with larger sample sizes and rigorous statistical methods for
ensuring reliability and validity for use in assessment and old
instruments were tested further. Meretoja and Leino-Kilpi (2001)
reviewed 15 articles on instrument development and testing and
specifically scrutinized their reliability and validity. Meretoja et al.
found that many tools required further testing of their validity and
reliability, particularly the stability, equivalence, concurrent and
convergent validity, with larger sample sizes. Also, Meretoja et al.
found the Six-Dimension Scale of Nurse Performance (6-D Scale) was
the only instruments applied frequently and tested rigorously
(Meretoja and Leino-Kilpi, 2001). The 6-D Scale is used today by
many researchers (Meretoja et al., 2004; Klein and Fowles, 2009).
Meretoja et al. (2004) tested concurrent validity of the newly
developed Nurse Competency Scale (NCS) and Schwirian's (1978)
6-D Scale with approximately 500 subjects. The results strongly
supported the reliability and validity of the NCS; following which it
was tested against the Australian National Competency Standards for
Registered Nurses (ANCI) for convergent validity by Cowin et al.
(2008). The correlation (r = 0.75) indicated a strong convergent
validity of the two instruments and showed that the tools assessed
similar dimensions.
In Taiwan, Hsu and Hsieh (2009) developed an eight-item Self-
Evaluated Core Competencies (SECC) Scale and sampled 802 senior
834 C. Yanhua, R. Watson / Nurse Education Today 31 (2011) 832–836

Table 1
Classification of papers from systematized review.

Review (R) Quasi-experimental study (E) Qualitative study (Q) Survey (S) Total

Instrument development and testing (IDT) – – – 4 4

Approaches to testing competence (ATC) 3 – 3 1 7
Assessment and related factors (ARF) 2 2 2 6 12
Total 5 2 5 11 23

undergraduate student nurses to test the reliability and validity in 2007.
Findings from principal component analysis (PCA) suggested a two-
factor structure: (1) cognitive/performance and (2) humanity/respon-
sibility of SECC which was confirmed using confirmatory factor analysis.
In Macao, Liu et al. (2009) reported the testing of the internal
consistency reliability, stability validity and construct validity of their
nursing competence measurement tool with a stratified random
sampling method. In the test 533 nurses were recruited, Cronbach's
alpha, paired t-test, and confirmatory factor analysis were used.
The data indicated that the tool was acceptable in clinical nursing
competence evaluation both in PRC and in Macao, China.
Globalization and Cooperation Trends in Instrument Development and
Testing
Along with the reliability and validity there is also a globalization
trend in the instrument development and testing process over the
decade. Much national and international cooperation is evident.
In Ireland, O'Connor et al. (2009) reported cooperation between
three universities in Dublin, Ireland to apply and measure the
usability and suitability of a newly developed competence assessment
tool, the Shared Specialist Placement Document (SSPD) used by
student nurses and clinical nursing teachers. In this study, O'Connor
highlighted the benefits of inter-institutional collaboration to evalu-
ate nursing students' clinical competence and indicated that this
would be a good model for future work in this area. Other national
cooperation is also found in Switzerland and Canada (Lindpaintner
et al., 2009; Black et al., 2008). All these endeavors echo previous calls
for collaborative unified strategies (Calman et al., 2002; Norman et al.,
2002, Watson et al., 2002).
With the increasing mobility of international nurses, the ICN
(2003) published the pre-registered generalist nurses' competence
framework to ensure public health, safety. Later, the Western Pacific
and South-east Asian Region (WPSEAR) project developed common
competencies for the 27 Pacific and South-East Asian countries
(Percival, 2004). In the European Union (EU), a project was launched

Table 2
Classification of papers from systematized review.

Study Method Category

O'Connor et al., 2001. An evaluation of the clinical performance of newly qualified nurses: a competency based assessment. S ARF
Nurse Education Today 21, 559–568
Neary, 2001. Responsive assessment: assessing student nurses' clinical competence. Nurse Education Today 21, 3–17 Q ATC
Calman et al., 2002. Assessing practice of student nurses: methods, preparation of assessors and student views. Journal of S ARF
Advanced Nursing 38(5), 516–523
Watson et al., 2002. Clinical competence assessment in nursing: a systematic review of the literature. Journal of Advanced R ARF
Nursing 39(5), 421–431
Norman et al., 2002. The validity and reliability of methods to assess the competence to practice of pre-registration S IDT
nursing and midwifery students. International Journal of Nursing Studies 39, 133–14
Dolan, 2003. Assessing student nurse clinical competency: will we ever get it right? Journal of Clinical Nursing 12, 132–141 Q ARF
McMullan et al., 2003 Portfolios and assessment of competence: a review of the literature. Journal of Advanced R ATC
Nursing 41(3), 283–294
Lee-Hsieh et al., 2003. Clinical Nursing Competence of RN-to-BSN Students in a Nursing Concept-Based Curriculum in E ARF
Taiwan. Journal of Nursing Education 42(12), 536–545
Scholes et al., 2004. Making portfolios work in practice. Journal of Advanced Nursing 46(6), 595–603 Q ATC
Reising and Devich, 2004. Comprehensive practicum evaluation across a nursing program. Nursing Education Perspective Q ATC
25(3),114–118
Uys et al., 2004. The competence of nursing graduates from problem-based programs in South Africa. Journal of Nursing Q ARF
Education 43(8), 352–61
McCready, 2007. Portfolios and the assessment of competence in nursing: a literature review. International Journal of R ATC
Nursing Studies 44, 143–151
Cowin et al., 2008. Competency measurements: testing convergent validity for two measures. Journal of Advanced S IDT
Nursing 64(3), 272–277
Lauder et al., 2008a,b. An evaluation of fitness for practice curricula: self-efficacy, support and self-reported competence in S IDT
preregistration student nurses and midwives. Journal of Clinical Nursing, 7(14), 1858–67
Hengstberger et al., 2008. Relating new graduate nurse competence to frequency of use. Collegian 15(2): 69–76 S ARF
Komaratat and Oumtanee, 2009. Using a mentorship model to prepare newly graduated nurses for competency. Journal of S ARF
Continuing Education in Nursing. 40(10), 475–480
Hsu and Hsieh, 2009. Testing of a measurement model for baccalaureate nursing students' self-evaluation of core E ARF
competencies. Journal of Advanced Nursing 65(11), 2454–2463
Cassidy, 2009. Interpretation of competence in student assessment. Nursing Standard 23(18), 39–46. R ARF
Marshburn et al., 2009. Relationships of New Nurses' Perceptions and Measured Performance-Based Clinical Competence S ARF
Journal of Continuing Education in Nursing 40(9), 426–32
Klein and Fowles, 2009. An investigation of nursing competence and the competency outcomes performance assessment curricular S ARF
approach: senior students' self-reported perceptions. Journal of Professional Nursing 25(2), 109–121
Walsh et al., 2009. Objective structured clinical evaluation of clinical competence: an integrative review. Journal of R ATC
Advanced Nursing 65(8), 1584–1595.
O'Connor et al., 2009. An evaluation of a collaborative approach to the assessment of competence among nursing students S ARF
of three universities in Ireland. Nurse Education Today 29, 493–499
Christine et al., 2009. Nursing students' appraisal of their professional portfolios in demonstrating clinical competence. S ATC
Nurse Educator 34(5), 217–222
 C. Yanhua, R. Watson / Nurse Education Today 31 (2011) 832–836
to produce a measurement strategy through the establishment of a
skills competence framework for EU nurses. In the project, two
versions of a nursing competence self-assessment questionnaire
instrument were developed (Cowan et al., 2005a,b). Following this,
the two versions of the self-assessment tool were used to assess 588
migrant and non-migrant nurses across five European countries. The
results showed that nurses' self-assessment of competence varied
between their country of origin and the country where they were
currently employed, and varied between EU countries as reflected
in non-migrant nurses self-assessment of competence. Therefore, the
author claimed that the tools were able to detect differences in
competence (Cowan et al., 2007).
Assessment and Related Factors
In the seven assessment approach studies, four focus on the topic
of portfolios. This implies that portfolios are gaining more currency in
the evaluation of nursing students' clinical competences, particularly
in the UK. To develop a portfolio, students are asked to demonstrate
evidence related to their academic and clinical skills achievement and
progress through a purposeful collection of traditional and nontradi-
tional work. McMullan et al. (2003) found that portfolios, in addition
to promoting active learning and individual accountability, also
promote the development of critical-thinking skills.
Portfolios are widely accepted and used by schools of nursing, but
their evaluation continues to be a subjective process (McMullan et al.,
2003). Many researchers recommend that the aim, structure and
composition of portfolios should be clearly demonstrated in the
guidelines for the student and the assessor (Dolan et al., 2004;
McCready, 2007; McMullan, 2008; Christine et al., 2009) and students'
clinical practical skills and academic skills should be equally
emphasized in portfolios (McMullan, 2008). In Australia, Christine
et al. (2009) recommended some strategies to improve the use of
portfolio: trialing an electronic document; allocating marks to the
portfolio in selected courses, as opposed to binary grading; and
continuing evaluation and monitoring of students' perceptions of the
use of portfolios. The popularity of portfolios in nursing competence
assessment was discussed by McCready (2007) who also pointed out
that there remained considerable concern over their reliability and
validity of portfolios with formal studies showing, for example, only
low to moderate inter-rater agreement on portfolio assessment.
McCready was, nevertheless, optimistic that the careful application of
portfolios could reduce the difficulty of defining and measuring
competence. To test the effectiveness of portfolio, McCready also
suggested that qualitative methods would be more suitable, due to
the holistic nature of competence. Finally, McCready advocated that
nursing researchers should do more research in the use of portfolios
instead of theoretical debating.
Objective structured clinical examinations (OSCEs) are another
highly recommended assessment approach by many medical and
nursing educators in many countries; but this objective assessment
strategy was not popular in the past decade (Walsh et al., 2009).
Walsh et al. (2009) found many researches showing that OSCEs were
useful and positive assessment strategies, but small samples and lack
of psychometric property testing limited the generalization of their
studies. Walsh et al. also observed an increasing use of OSCE in
nursing competence evaluation internationally. Nevertheless, lack of
psychometric properties, suitability for nursing and associated high
costs of the OSCE was obvious in the literature. Walsh et al. suggested
that it was essential that OSCEs be applied in nursing education as a
valid and reliable method of assessment.
Assessment and Related Factors
Competence assessment is a systematic process and many factors
can detract from a valid and reliable measurement and the
competence level of student nurses can also be influenced by many
835
situational factors. The clinical competence of newly registered nurses
has become a crucial issue related to professional standards and
public safety. Therefore, the assessment of the newly graduated nurse
is a key issue for educators and administrators. O'Connor et al. (2001)
showed that different assessor's evaluated new nurses' competence
inconsistently and this was reflected in the following studies (Calman
et al., 2002; Cassidy, 2009) which both suggested that assessors
should develop an objective evaluation capacity to ensure a just
assessment of nurses' competence. Marshburn et al. (2009) found that
problem management skills and previous work experience would
influence new nurses' competence and concluded that, as new nurses
became more self-confident and comfortable with their skills, they
would probably perform more successfully and this is echoed in a
recent national survey in Scotland (Holland et al., 2009; Lauder et al.,
2008a,b). The competence of newly qualified nurses also has a relation
with the frequency of use (Hengstberger et al., 2008). Additionally,
some programs have been tested and adopted to enhance the newly
qualified nurses' competence, such as mentorship, which is claimed to
have a significant influence on the newly graduated nurse' knowledge,
skills, and development of self-confidence (Komaratat and Oumtanee,
2009).
In the wake of growing concern about nurse competence, some
nursing programs have moved toward competency-based curricula.
Uys et al. (2004) observed that problem-based learning (PBL)
programs improved nursing students' competence and made them
progress quicker and obtain higher competence in practice setting
than their colleagues taught by traditional methods. Klein and Fowles
(2009) explored the influence of a competence-based curricular
model (Lenburg, 1999), the Lenburg's Competency Outcomes Perfor-
mance Assessment (COPA) model on the students' competence. Klein
et al. showed that student-focused strategies, an important aspect of
COPA, had a significant impact on all six subscales of 6-D Scales for the
COPA students. Besides COPA and PBL, some other curricula and
teaching strategies are valuable in fostering competence. Cant and
Cooper (2010) found that simulation had some advantages over other
teaching methods in nursing teaching and the Fitness for Practice
curriculum model – which emphasized the development of clinical
skills – succeeded in strengthening the competence of nursing
students in Scotland (Lauder et al., 2008a).
Conclusion
In the last 10 years of work on nursing clinical competence
assessment and education, some improvement is evident. Larger
samples are being used to develop and test evaluation scales and more
powerful statistical methods are being used and a greater national and
international cooperation is seen. Some assessment strategies have
been developed and tested and accepted by nursing educators
globally. The consequences for nursing education are that more
valid and widely applied measures of nursing competence are now
available.
Most of the studies reported are cross-sectional studies and there
is a need for more longitudinal work to track the change in clinical
competence throughout nurse education and also across the transi-
tion from nursing student to newly qualified nurse. Now that better
and more widely applied measures of competence are available it is
important to investigate just how widely they are being used in nurse
education and what the facilitators and barriers are to their
implementation. Finally, the psychometrics of measures of compe-
tence in nursing require further investigation with the application of
more sophisticated methods of analysis and scaling that are becoming
available. The possibility must exist, with large databases being
available, of combining databases from different studies and different
instruments in the search for common dimensions to nursing
competence that can form the basis of better instruments in future.
836 C. Yanhua, R. Watson / Nurse Education Today 31 (2011) 832–836
Funding
This research received no funding.
Author Contributions
Study design: YC
Data collection and analysis: YC
Manuscript preparation: YC, RW
Conflict of Interest
None.
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