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.

Definition of competence
UK 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). Australia 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. Canada 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).

Portfolio
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 nontraditional 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] and [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 interrater 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.