The current methods used for training in medical procedural (or technical) skills are inefficient and may jeopardise patient safety as medical trainees are required to practice procedures on patients. The resultant worldwide move towards competence-based training programmes has necessitated the search for valid and reliable competence assessment procedures (CAPs). The challenges in developing such CAPs lie in defining each competence and taking account of the many factors which influence learning and performance of medical procedures. Such determinants include cognitive, motor, communication, and human (e.g. fatigue, anxiety, fear) factors. In other domains, competence based knowledge space theory (CbKST) has been successfully applied to enhance learning, assess competence and facilitate personalised learning.