this cross - sectional study was carried out in a university hospital in shiraz , iran .
this hospital was selected because of the availability and the subsequent enthusiasm of its nursing managers .
this hospital admits patients from southern iran , and nurses who work in this hospital play a vital role in providing health care for people living in this area .
a census sampling was used . the sample comprised of all nurses ( n=330 ) and head nurses ( n=19 ) working in this hospital , and all inpatient wards including medical , surgical , pediatrics , emergency ,
criteria for selecting the samples included1 graduation in the bsc nursing program2 and working full - time in university hospital as a nurse . in the beginning of the study ,
an explanatory session was held for the head nurses and nurses to introduce the whole plan , its objectives and its method .
then , prepared envelops each containing two similar competence questionnaires , one for the nurses and the other for the head nurses , along with an informed consent form and a manual of the instructions of filling the questionnaire were distributed among the head nurses .
they had the responsibility of handing the envelops to the nurses of their respective wards . in the manual ,
the nurses were asked if they agreed to participate in the study , they filled the questionnaire independently and handed the head nurse the second questionnaire to be filled in .
the two questionnaires were completely identical in their content and structure . after completing the questionnaires ,
data collection process lasted for one month . to maintain the privacy of the participants , all closed envelops were delivered to the main investigator .
the instrument used in this research was nurse competence scale ( ncs ) which assesses 73 skills in 7 different categories .
these categories were as follows : helping role ( 7 skills ) , teaching  coaching ( 16 skills ) , diagnostic functions ( 7 skills ) , managing situations ( 8 skills ) , therapeutic interventions ( 10 skills ) , ensuring quality ( 6 skills ) and work role ( 19 skills ) .
( 2004 ) based on benner 's framework and its validity and reliability have been confirmed.418 in this study , each nurse was asked to identify the level of competence on a visual analogue scale ( vas ) ( 0 - 100 ) with values 0 - 25 , 26 - 50 , 51 - 75 , and 76 - 100 that were respectively weak , moderate , good and excellent levels of competence .
the mean individual scores in each item was the indicator of clinical competence in that item .
the total mean of items in each category was the indicator of competence of nurses in that category and the total mean of categories was indicator of the total clinical competence of nurses .
therefore , in addition to identifying the level of nurse 's clinical competence in each skill , the competence level in each seven category and finally , the overall nurse competence were identified .
moreover , every evaluator was asked to determine the level of performance of skills in the ward where the nurse was working at that time period .
this was done by using likert 's four point scale in which 0 means not applicable ; 1 , rarely used ; 2 , occasionally used ; and 3 , frequently used .
the logic behind this was based on the disparity of possessing the competence and its actual use in clinical practice .
demographic data such as age , gender , work experience in the current ward and total work experience were also collected through this questionnaire . in order to yield a correct translation based on the recommended way of world health organization , the instrument used for assessing clinical competence of nurses
was first translated into persian language by a researcher and then , translated back into english . finally , two english language specialists approved the accuracy of the translation .
then , validity of the instrument was approved by consulting specialists and experts of clinical nursing education and experienced nurses from different universities of the country .
the reliability of the instrument was assessed by doing a pilot study and cronbach 's  coefficients in 7 categories ranged between 0.75 - 0.89 , indicating the favorable internal consistency and high reliability of the instrument.18 completed questionnaires were received from 205 staff nurses ( response rate of 62% ) and from all 19 head nurses ( response rate of 100% ) .
all participants were given a letter containing information about the study 's aims and procedures .
the voluntary nature of participation and anonymity had been emphasized in the informed consent form .
data analysis was done by the statistical package for social sciences version 11.5 ( spss , chicago , il , usa ) .
anova was used for comparing the means and chi - square for comparing the frequency of using skills .
this cross - sectional study was carried out in a university hospital in shiraz , iran .
this hospital was selected because of the availability and the subsequent enthusiasm of its nursing managers .
this hospital admits patients from southern iran , and nurses who work in this hospital play a vital role in providing health care for people living in this area .
a census sampling was used . the sample comprised of all nurses ( n=330 ) and head nurses ( n=19 ) working in this hospital , and all inpatient wards including medical , surgical , pediatrics , emergency ,
criteria for selecting the samples included1 graduation in the bsc nursing program2 and working full - time in university hospital as a nurse . in the beginning of the study ,
an explanatory session was held for the head nurses and nurses to introduce the whole plan , its objectives and its method .
then , prepared envelops each containing two similar competence questionnaires , one for the nurses and the other for the head nurses , along with an informed consent form and a manual of the instructions of filling the questionnaire were distributed among the head nurses .
they had the responsibility of handing the envelops to the nurses of their respective wards . in the manual ,
the nurses were asked if they agreed to participate in the study , they filled the questionnaire independently and handed the head nurse the second questionnaire to be filled in .
the two questionnaires were completely identical in their content and structure . after completing the questionnaires ,
data collection process lasted for one month . to maintain the privacy of the participants , all closed envelops were delivered to the main investigator .
the instrument used in this research was nurse competence scale ( ncs ) which assesses 73 skills in 7 different categories .
these categories were as follows : helping role ( 7 skills ) , teaching  coaching ( 16 skills ) , diagnostic functions ( 7 skills ) , managing situations ( 8 skills ) , therapeutic interventions ( 10 skills ) , ensuring quality ( 6 skills ) and work role ( 19 skills ) .
( 2004 ) based on benner 's framework and its validity and reliability have been confirmed.418 in this study , each nurse was asked to identify the level of competence on a visual analogue scale ( vas ) ( 0 - 100 ) with values 0 - 25 , 26 - 50 , 51 - 75 , and 76 - 100 that were respectively weak , moderate , good and excellent levels of competence .
the mean individual scores in each item was the indicator of clinical competence in that item .
the total mean of items in each category was the indicator of competence of nurses in that category and the total mean of categories was indicator of the total clinical competence of nurses .
therefore , in addition to identifying the level of nurse 's clinical competence in each skill , the competence level in each seven category and finally , the overall nurse competence were identified .
moreover , every evaluator was asked to determine the level of performance of skills in the ward where the nurse was working at that time period .
this was done by using likert 's four point scale in which 0 means not applicable ; 1 , rarely used ; 2 , occasionally used ; and 3 , frequently used .
the logic behind this was based on the disparity of possessing the competence and its actual use in clinical practice .
demographic data such as age , gender , work experience in the current ward and total work experience were also collected through this questionnaire . in order to yield a correct translation based on the recommended way of world health organization , the instrument used for assessing clinical competence of nurses
was first translated into persian language by a researcher and then , translated back into english .
then , validity of the instrument was approved by consulting specialists and experts of clinical nursing education and experienced nurses from different universities of the country .
the reliability of the instrument was assessed by doing a pilot study and cronbach 's  coefficients in 7 categories ranged between 0.75 - 0.89 , indicating the favorable internal consistency and high reliability of the instrument.18 completed questionnaires were received from 205 staff nurses ( response rate of 62% ) and from all 19 head nurses ( response rate of 100% ) .
the study was approved by the ethics committee of the university . approval for data collection
all participants were given a letter containing information about the study 's aims and procedures .
the voluntary nature of participation and anonymity had been emphasized in the informed consent form .
data analysis was done by the statistical package for social sciences version 11.5 ( spss , chicago , il , usa ) .
anova was used for comparing the means and chi - square for comparing the frequency of using skills .
almost 24% ( n=46 ) of nurses had less than 2 years work experience and all the nurses had a bachelor 's degree .
the other demographic data of 19 head nurses and 190 practicing nurses are presented in table 1 .
demographic characteristics of head nurses ( n=19 ) and practicing nurses ( n=190 ) the overall mean competence ( 87.03  10.03 ) obtained in self - assessment was significantly greater than that calculated by head nurse assessment ( 80.15  15.54 ) ( p < 0.05 ) .
the difference between the results of these two types of assessment was also perfectly significant in seven categories of competence scale ( anova ) ( table 2 ) .
comparison of self - assessment and assessment made by head nurses of level of clinical competence ( anova ) the nurses considered themselves more competent in the categories of  managing situations  and  teaching coaching  while the head nurses considered them to be more competent in the categories of  diagnostic functions  and  managing situations  .
the least level of competence in both types of assessment was identified in the category of  ensuring quality 
the greatest level of difference between nurses and head nurses results was reflected in the categories of  managing situations  and  teaching  coaching  and the least level of difference was observed in the categories of  helping roles  and  diagnostic functions  ( table 2 ) .
the level of using the skills in clinical practice in the current ward ( occasionally or frequently ) determined the minimum of 76 percent and maximum of 88 percent in self - assessment and 82 percent and 88 percent in the head nurse assessment , respectively , and there was no significant difference between the results in this regard ( chi -square ) ( figure 1 ) .
the difference of self - assessment and head nurse assessment of using skills in different categories of clinical competence
this study aimed to compare the results of nurse competence assessment by two methods of self - assessment and head nurse assessment .
although the overall competence level was recognized as favorable by both methods , the head nurses recognized the nurses as less competent than in self - assessment .
in fact , the competence assessment showed that , regardless of the type of assessment , nurses competence was judged as favorable .
( 2010 ) concerning competence assessment of nursing graduates of jordanian universities.22 on the other hand , demographic data showed that practicing nurses were younger than the head nurses .
the results of some studies declared that new and young nurses generally overestimate their clinical competence level that can explain the reason of difference between self - assessment of practicing nurses and that done by their head nurses .
( 2001 ) found that younger assessors have the tendency to assess nurse competence as higher than older assessors.1923 this significant difference reflects a rather severe disagreement between the nurses and the head nurses in assessing the clinical competence .
this has been previously reported in certain researches . in a research carried out in hospitals in isfahan / iran about the performance of freshly graduated nurses by themselves and their head nurses
, the results indicated that there was a significant difference between the two assessment types.21 considering the results of that study , the nurses understood themselves as more competent than did their head nurses , so the results were congruent with the present research .
a possible explanation for these differences could be related to higher expectations of the nurses from the managers .
in contrast , some researches have had different results ; i.e. , the head nurses have rated the nurses as more competent than the nurses themselves.19 these dissimilarities make further investigations necessary to explore influential factors on assessment results . however , the present research indicated a significant difference between the two methods of assessment .
it should be noticed that by point to point comparing of the results in categories of nurse competence , there was a relatively similar pattern of assessment , so the higher and the lower competence levels of nurses belonged to categories of  managing situations  and  ensuring quality  , respectively . in studies carried out previously ,
some similarities can be seen such as studies of bahraini et al . in bushehr ( 2008 ) , meretoja et al . in finland ( 2003 ) and salonen et al . in finland
( 2007).181924 a similar pattern of assessment results obtained in comparing a university hospital in a developed country like finland , a university hospital of shiraz and a university hospital of bushehr demonstrated that nurses have common weak and strong points regardless of the work environment .
it is essential to pay adequate attention to these points to improve the strengths and eliminate weaknesses .
these common points reflect the high capability of nurses in managing complicated clinical situations as a strong point and their low competence in ensuring quality skills like care giving based on evidence and utilizing research findings in clinical practice as a weak point .
it seems that the weak points should be noticed more than ever not only in iran also in other parts of the world . despite significant differences between self - assessment of nurses competence and head nurses assessment
, they had common viewpoints in terms of assessment of actual use of skills in clinical practice .
this agreement was seen in the comparison of the frequency of using the skills in seven categories and in overall frequency of using the skills .
perhaps , the high level of agreement of assessment results in terms of performance is because of the visible nature of performance that can lead to a decrease on the subjectivity .
in fact , the lack of a clear definition of competence has been implied in many studies.25 there have been some limitations in performing this research .
anyway , the entity of evaluation is such that it can be affected by individual evaluator characteristics .
furthermore , the behavior of nurses can be changed because of knowing that they will be assessed by their managers .
it must be remembered that no direct observation has been done to assess the nurse performance in order to remove any direct effect on the nurses behavior . despite reasonable number of samples , since the sample had been chosen from a university hospital in shiraz , the cultural and environmental factors of research area can be influential , so this is noteworthy in generalizing the results .
the results of this study indicated that although head nurses agreed with nurses about the frequency of using the skills , there was profound disagreement between these two groups in assessing the level of nurses competence .
in fact , comparison of the results in different categories indicated that the nurses considered themselves more competent than what head nurses reported .
this study also indicated that for assessment of competence more than one method should be used .
assessment made by head nurses led nurses to recognize categories that need to be improved and by self 
assessment , the nurses could achieve self - awareness in terms of their weak and strong points .
therefore , a multi - method approach to the assessment of nurse competence is advisable .
since this study has focused on the importance of nurse clinical competence assessment and enhancement of its precision by utilizing different resources , more research is needed to assess competencies in different environments and to compare the perceptions of nurse managers , nurses and peers . moreover , the nurses and head nurses points of view about clinical competence assessment and methods of assessment are to be investigated by qualitative and mixed studies .
 background : nurses play a crucial role in patient - care . 
 therefore , assessing nurses clinical competence is essential to achieve qualified and safe care . 
 the aim of this study was to determine and compare the competence assessments made by head nurses and practicing nurses in a university hospital in iran in 2009.methods:a cross - sectional survey was conducted to make comparisons of both self - assessment of nurse competence as well as assessment made by their respective head nurses working in a university hospital setting in iran . 
 the instrument employed for data collection was nurse competence scale ( ncs ) , whose reliability and validity have been previously confirmed . 
 the clinical competence of the nurses in 73 skills under 7 categories was determined based on a visual analogue scale ( vas ) ( 0 to 100 ) . 
 they were also asked to indicate the extent to which their competence was actually used in clinical practice on a four - point scale of likert . 
 the data was analyzed through descriptive and inferential statistics.results:comparison of self - assessment ( 87.03  10.03 ) and the assessment done by head nurses ( 80.15  15.54 ) showed a significant difference but no precise differences were found between the assessment methods for the frequency of using these competencies.conclusions:the results of this study indicated no consensus between the nurses owns assessment and their head nurse assessment . 
 therefore , it is necessary to use a combination of nurses competence assessment methods in order to reach a more valid and precise conclusion . 
Methods
Design, sampling and data collection
Measurement
Ethical consideration
Data analysis
Results
Discussion
Conclusion