regarding increased rates of premature and low birth weight newborns as well as associated 
 factors with high risk pregnancies , the number of infants who require admission to neonatal 
 intensive - care units ( nicu ) is growing . along with the increasing complexity of technology and the development of the nicu wards , 
 the survival of these newborns have improved . currently , the number of neonatal intensive 
 care units in hospitals has met a rise ; however , more complex diseases and preterm infants 
 requiring critical care are also increasing . a major share of the responsibility for such 
 care practices is related to the nurses working in the nicus.these changes have raised the need for skilled nurses with 
 specialty regarding the infants more than ever . nursing in intensive care units is dynamic , and nurses have to meet complex and changing 
 needs of critically ill patients . since competence is considered as a substantial part of 
 mitigating the risks and damages to the patient , it is of great importance in the intensive 
 care units .   the complexity of competence dimensions have made it difficult to provide a single 
 definition of competence . in most studies , 
 the benner definition ( 1982 ) is referred to explain the concept of competence , which defines 
 competence as  the ability to perform a task to obtain optimum and favorable results in 
 changing conditions in the real world  . the definition of competence can also be very 
 simple , consisting of professional standards that the nurses use as an activation 
 directory . professional competence in general activities of nurses includes a set 
 of knowledge , abilities and skills . in some definitions , in addition to knowledge , abilities 
 and skills , the concepts such as performance , memarian et al . , showed that the most important noviceal factor affecting the process of 
 obtaining competence include work experience , effective communication , interest to the 
 profession , responsibility , accountability and personal factors such as knowledge and 
 skills , respecting ethical and professional principles and respect to self and others . among 
 external factors , environmental factors including efficient education system and providing 
 technology , and professional factors including effective management , control , monitoring and 
 having work permission can be mentioned . community and government support , marital status and participation at in - service training 
 programs are also the factors that affect the competence .   during the competence acquisition process , with the development of practical skills and 
 gaining insight based on work experience and effective ethical practices by the nurses , the 
 problem solving skills and interacting with patients among the nurses will be 
 improved . one of the major challenges in assessing clinical competence of nurses is using tools with 
 appropriate validity and reliability . challenges in assessing and measuring nursing competence are due to a variety of nursing 
 roles , which are resulting from the complexity of nursing activities and human interactions 
 that measurement of each , even alone , is a difficult task . problems regarding reliability 
 and validity of assessment tools are seen when  the tools used in assessing the clinical 
 experience have a good validity , while the reliability of these devices is not considered ; 
 as a result , the presence of several variables in clinical environments may affect the 
 results .   in the recent years , nursing education in iran has focused on theoretical education that 
 could lead to the gap between knowledge and practice in nursing . while in the developed countries since 1994 , competence - based 
 education and evaluation is a main priority . currently our information about clinical competence of nurses in the neonatal intensive 
 care units and applying the nursing skills by them is scarce . because of this lack of information ; we decided to investigate 
 the clinical competence of nurses working in the neonatal intensive care units affiliated to 
 tehran university of medical sciences . this was a cross - sectional study , in which  a total of 132 nurses working in neonatal 
 intensive care units in the hospitals affiliated to tehran university of medical sciences 
 were selected by census method during july 2012 to march 2013 . among them , 117 nurses were 
 completed and returned the questionnaire . the inclusion criteria were having at least six months of experience in nicu and nurses 
 interest for participating in research . as our methodology was descriptive there were no 
 exclusion criteria , unless the participant asked to withdraw from the research . the first part of the questionnaire 
 was the researcher - made part that assessed the nurse s demographic characteristics included 
 age , marital status , job experience , educational status , specialized training programs , 
 employment status , hours per month work and interest in the nursing profession . the second 
 part was the " competency inventory for registered nurses questionnaire ( cirn ) . this 
 questionnaire was used for the first time by ming liu et al . , in 2007 in china . the questionnaire has 59 items in 7 aspects 
 which assess the clinical competence of nurses . the dimensions and items include critical 
 thinking and tendency to do research ( 10 items ) , clinical care ( 10 items ) , leadership ( 10 
 items ) , moral and legal activities ( 8 items ) , professional development ( 8 items ) , 
 interpersonal relationships ( 6 items ) and training and mentoring ( 7 items ) . to measure the 
 competence level , a five - point likert scale ( 1 : never , 2 : rarely ,  3 : sometimes , 4 : most of 
 the times and 5 : always ) was used for scoring each items . according to the total score of 
 the questionnaire , the nurses competency was measured as poor : < 225 , moderate : 225 - 273 , 
 and good : > 273 , respectively .   to ensure the translation accuracy , an expert in english language familiar with the nursing literature was asked to 
 review the tool by back - translation method. the face and content validity of the research 
 tools evaluated by ten expert faculty members of tehran university of medical sciences . the 
 questionnaire made available to 10 nurses working in the neonatal intensive care units of 
 the hospitals affiliated to tehran university of medical sciences after undergoing validity 
 processes . one month later , the questionnaires refilled by the same subjects and the 
 reliability of the tool evaluated using test - retest method ( correlation coefficient : 0.78 ) . 
 also , the cronbach 's alpha method was used in order to determine the correlations between 
 competence aspects ( correlation coefficient : 0.89 ) . the questionnaires were completed by nurses as a self - assessment method and by head nurses 
 as a supervisor.the spss software version 13 was used for data analysis . descriptive 
 statistics methods including the frequency , mean ( sd ) and inferential statistics methods 
 including pearson correlation coefficients were used for analysis . the relationships between 
 the categories of clinical competence and other factors such as demographic factors were 
 assessed by the pearson correlation coefficient , t - test and chi - square test .   in this study a written permission was obtained from ming liu for using the tool cirn . 
 after obtaining the license from the medical ethics committee of tehran university of 
 medical sciences ( the ethical code number : 92/d/130/839 ) , by referring to the research 
 environments and  assuring the subject and authorities regarding anonymousness and 
 confidentiality of information and explaining the objectives of the study , the required data 
 were collected . also we have observed all different aspects of ethical codes including 
 voluntary participation , confidentiality , informed consent and autonomy . of the 132 questionnaires , 117 ( 89% ) questionnaires were completed and returned to the 
 researcher . the mean job experience of 
 subjects was 8.39 ( 5.7 ) years work that 4.79 ( 3.67 ) years work were in the neonatal 
 intensive care unit . the educational level of the nurses was as follows : bachelor of 
 nursing : 92.4% , and master of sciences ( msc ) in nursing : 7.6% . the nurses who had undergone 
 no specialized training programs regarding infants nursing accounted for 35% , while 42.7% 
 had participated in workshops related to nursing care of the infants , such as breastfeeding 
 and newborn resuscitation , and 22.3% had passed the infants nursing courses .   the employment status of the participants was as following : novice nurses ( 12% ) ; 
 short - time contracts ( 1 year ) ( 6.8% ) ;  long - term contracts ( 2 - 5 year ) ( 54.7% ) and formally 
 employed ( 26.5% ) . the mean hours work per month among the nurses was as 72.88 ( 34.28 ) hours 
 ( table 1 ) . among demographic variables , three 
 variables of marital status , employment status and interest in the nursing profession had 
 a  direct statistically significant correlation with the degree of clinical competence of 
 individuals , so that the mean competency score of married and single participants was 239.01 
 and 228.17 respectively ( p - value = 0.007 ) . the mean competency score of nurses with 
 short - time contracts was 219.62 while nurses with long - term contracts had the mean 
 competency score equal to 240.52 ( p - value = 0.03 ) .   also based on our findings , the mean competency score for the nurses who had low level of 
 interest in the nursing profession was 238.52 , however , the mean competency score for nurses 
 who had high level of interest in the nursing profession was 246.91 ( p - value = 0.03 ) ( table 1 ) . t - test and fisher 's exact test , direct statistically 
 significant relationship   the pearson correlation coefficient was used to evaluate the relationship among the 
 dimensions of clinical competence of the nurses . hence , all of the seven dimensions of 
 clinical competence were tested in a two - by - two pattern after categorization into 3 levels : 
 weak / poor : < 225 , moderate : 225 - 273 and good : > 273 using t - test and chi - square test . the test results showed that there was a direct statistically significant relationship among 
 all aspects of clinical competence , which means with increased competence in one aspect , the 
 rates of competence in other dimensions will also increase ( p - value < 0.001 ) . in our 
 research most of the participants ( 92.3% ) had good critical thinking and research attitude , 
 moderate clinical care ( 65.8% ) , moderate leadership ( 73.5 ) , good interpersonal 
 relationships ( 85.5% ) , moderate legal and ethical practice ( 75.2% ) , moderate professional 
 development ( 69.2 ) , and moderate teaching in this study , more than half of the nurses ( 65.8% ) had a moderate competence . in 
 mertojaet al . , , studies , most of the nurses reported their competence as good , 
 which is not consistent with the results of the present study .   in a study by ying et al . , to investigate the relationship between clinical competencies 
 and organizational atmosphere , most of the nurses assessed their competence as highly 
 competent , which is not consistent with the results of the present study . the reason for 
 high levels of care provided in the studied hospital may be due to its educational nature 
 and position , since in such environments , the nurses are constantly learning and used to 
 teach the nursing students .   in another study , bahraini et al . , evaluated the nurses ' clinical competence working in 
 hospitals affiliated to shiraz and bushehr universities of medical sciences . the nurses in their self - assessment had reported their competence at good level , which is 
 not consistent with the results of the present study . in this comparison , the nurses in 
 hospitals affiliated to shiraz university of medical sciences had a better competence level , 
 which bahraini et al . , considered due to factors such as better educational facilities , more 
 in - service training programs , and organizing of educational processes . given that the 
 study conducted in the neonatal intensive care units and teaching hospitals affiliated with 
 the university , the nurses in these wards have many opportunities for experiential learning 
 in the real environments . however , perhaps one of the issues may affect the nurses ' competence would be not 
 conforming the nursing standards such as the number of shifts required and further working 
 hours per month that could cause fatigue and exhaustion in nurses and leaving them no 
 opportunity to study and doing research . one of the standards in the nicu , which is not 
 followed , is the nurse to patient ratio . this ratio in some level of nicu is 1 to 1 , and in 
 some other is two nurses per one baby based on the patient 's condition . in our research environment , the ratio is most 
 of the 3 patients per one nurse . at such times , the nurse probably would not have enough 
 time to perform the care tasks appropriately , and obviously not enough time to study and 
 update information , and thus , he / she will estimate his / her competence lower than the real 
 rates . one of the most important issues in nursing is to employ nurses based on standards 
 developed by the ministry of health . the curriculum and terms document of subspecialty 
 pediatrics and perinatal medicine approved by the iran ministry of health and medical 
 education states that " the care of patients in the nicu must be provided under the 
 supervision of and by specially trained and experienced nurses in neonatal intensive care . the nurses working in nicu must have at least five years of experience of working in one of 
 the child or infants wards such as infants ' medical and surgical wards or operating room . it 
 is referred that employing the graduates in master 's degree of nursing in the nicus and the 
 nurses with bachelor 's degrees that have at least five years of experience in the mentioned 
 units is permitted . however , we found 
 that all nurses working in the neonatal intensive care units do not meet the ministry of 
 health standards . due to the shortage of skilled human resources , the hospitals have 
 employed the nurses with little working experience . as reported , in some cases , the nurses 
 had not passed the courses required to work in the nicus . a study conducted in scotland refers to the same challenge that the nurses working in 
 infants units are graduated nurses in nursing courses for adults or children . although such nurses receive some training courses before working formally in nicus , but 
 they  have not yet achieved the full competence in this regard . they also need supervising in 
 performing nursing activities , and it refers that there is a need to pass the nicu - required 
 complementary nursing courses to provide nursing care with good quality in such units . in 
 addition , standardized training courses according to the required competencies are 
 needed .   also , according to specialty in the neonatal intensive care units and given the standards 
 for hiring nurses in nicus , the need for specialist nurses is issued . however , only 7.6% of nurses in the study population have passed the master of nursing , 
 despite the existing standard that defines the nurses working in the neonatal intensive 
 units should have at least 5 years ' experience of working with infants or children s 
 associated wards . among the nurses working in neonatal icus as noted above , one reason to employing the novice students in nicus is the 
 workforce shortage .   in the present study , there was statistically significant relationship between marital 
 status , employment status , number of hours per month work , interested in a neonatal 
 intensive care units and the level of clinical competence . as shown , interest in the 
 profession is also considered as factors affecting the competence ; hence it is better to provide the conditions in such a way that 
 people can choose their academic field based on their interest , and thus , select the nursing 
 profession and serve in hospital wards . given the extension and complexity 
 of competence , the number of evaluation items is very high and this can affect the given 
 responses . however , to reduce the restrictions of the self - assessment method , supervisor 
 assessment method was also used simultaneously . to improve and enhance the clinical competence of nurses in performing their professional 
 tasks and roles in a safe way and with good quality , some effective variables on the 
 competence of individuals , including : interest in the nursing profession , employment status , 
 passing neonatal intensive theoretical and practical training courses and the amount of 
 overtime working hours should be considered . employing interested and competent nurses and 
 considering the standards required in the nicu can increase the quality of care in these 
 wards . this project was sponsored by the school of nursing and midwifery , tehran university of 
 medical sciences . also , all the nursing managers , supervisors , and nurses in the studied 
 hospitals were cooperated in the implementation of project that we would mind to appreciate 
 them one by one .