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The use of physical assessment skills by registered
nurses in Australia: Issues for nursing education
Melanie Birks, PhD, MEd, BN, DipAppSci(Nsg), RN, FRCNA a ,∗ ,
Robyn Cant, PhD, MHlthSc, GradDipHEd b, Ainsley James, MN, GradCert.HEd,
GradCert.Paeds, BN, RN c, Catherine Chung, MAdvNsgPrac (Emerg), Grad.Dip
AdvNsgPrac (Emerg), Grad.Cert HPE, BN, RN c, Jenny Davis, Grad Dip Crit
Care, Grad Dip Periop, GradCert.HEd, BHIM (Hons), BAppSci (Nsg), Cert IV
T&A, RN, RM, MRCNA d
a (^) School of Nursing and Midwifery, Learning and Teaching Education Research Centre, Central Queensland University, Noosa
Campus, Queensland 4566, Australia b (^) School of Nursing and Midwifery, Monash University, Berwick, Victoria 3806, Australia c (^) School of Nursing and Midwifery, Monash University, Churchill, Victoria 3842, Australia d (^) Central Queensland University, Noosa Campus, Queensland 4566, Australia
Received 14 December 2011; received in revised form 20 February 2012; accepted 21 February 2012
KEYWORDS
Health assessment; Nursing assessment; Physical assessment skills; Undergraduate nursing education
Summary The purpose of pre-service nursing education programs is to prepare competent graduates who are able to function as safe, professional registered nurses. An extensive element of these programs is the teaching of physical assessment skills, with most programs educating students to perform over 120 such skills. Previous research from North America suggests that the majority of skills taught to nurses in their pre-service programs are not used in practice. As part of a larger study, an online survey was used to explore use of 121 physical assessment skills by Australian nurses. Recruitment occurred via mailed invitation to members of the Aus- tralian Nursing Federation. Data were extracted from 1220 completed questionnaires returned by nurses who were mostly employed in New South Wales, were female and experienced nurses. Respondents indicated that they used only 34% of skills routinely. Results reinforce evidence found in the literature that many of the skills taught to nurses are either not used at all (35.5%) or are used rarely (31%). These findings have implications for the teaching of physical assess- ment skills in pre-service nursing programs, and raise questions about the value of extensive skills teaching in the context of contemporary health care. Further research into barriers to the use of physical assessment skills in nursing and the need for comprehensive skills preparation for the generalist nurse is likely to offer some solutions to these questions. © 2012 Australian College of Nursing Ltd. Published by Elsevier Ltd.
∗ (^) Corresponding author. Tel.: +61 7 54407034. E-mail address: m.birks@cqu.edu.au (M. Birks).
1322-7696/$ — see front matter © 2012 Australian College of Nursing Ltd. Published by Elsevier Ltd. doi:10.1016/j.colegn.2012.02.
28 M. Birks et al.
Introduction
University programs aim to educate pre-registration nursing students to achieve competence in the skills required for the physical assessment of patients. Debate exists, however, about whether nurses are adequately prepared for practice (Berkow, Virkstis, Stewart, & Conway, 2009). This is in spite of the fact that the average nursing curriculum requires pre-registration nursing students to master over 120 obser- vational and assessment skills (Giddens, 2007). A recent survey of nurses in clinical practice in USA reported use of only half this number (Giddens & Eddy, 2009). A degree of conflict therefore exists between what is taught and what is required for physical assessment of patients. This paper reports on a study that aimed to examine registered nurses’ utilization of physical assessment skills in practice.
Background
The demands placed on newly qualified nurses by increas- ingly complex health systems, together with the explosion of knowledge and use of increasing technology, reinforce the need for skilled new graduates (Halfer & Graf, 2006). Studies over the past decade suggest that graduates are not meeting competency expectations from the employer point of view, or are not ‘practice ready’ (Berkow, Virkstis, Stewart, & Conway, 2009; Burns & Poster, 2008). Concomitantly, various studies have described a mismatch between what is taught in pre-registration programs and the ability of new nurses to function in clinical situations (Lee et al., 2002; Maben, Latter, & Clark, 2006). While universities constantly strive to develop competency-based curricula that will prepare new nurses for independent practice, few studies have evaluated the application of physical assessment skills learned during nursing education in the real-world environment of clinical practice. In order to meet the requirements for registration, nurses are required to reach the level of proficiency prescribed by national competency standards for a registered nurse (Australian Nursing and Midwifery Council, 2006). Physical assessment in this context is a part of health assessment; it includes a sequence of data collection using inspection, palpation, percussion and auscultation (employing nurses’ core senses of sight, hearing, smell and touch) (Baid, 2006). Nurses then interpret clinical findings in the context of the patient’s history. Secrest, Norwood, and DuMont (2005) sug- gest that all nurses must be able to detect alterations in the status of their patients to provide the appropriate nurs- ing care. In most Australian universities, nursing education during undergraduate years involves teaching students an extensive number of different skills for assessing the physi- cal status of a patient. Based on standard nursing texts, 120 skills have been identified as being demanded of students (Giddens, 2007; Wilson & Giddens, 2000). In contexts where this number is in fact taught, actual mastery of all these skills may not be possible. In a small study that surveyed fac- ulty members and 51 clinical nurses in the USA, respondents reported that nearly all of 120 physical assessment skills were taught in the baccalaureate nursing program, although only 29% of skills were regularly performed (daily/weekly) in clinical practice (Secrest, Norwood, & Dumont, 2005). A
subsequent study of 193 nurses reported that nurses rou- tinely used only 30 skills, prompting the author to question whether the teaching of assessment skills to such an extent was in fact necessary (Giddens, 2007). No recent published data on Australian general nurses’ physical assessment prac- tices has been identified. The research reported in this paper was undertaken as part of a larger study that aimed to examine the relevance of physical assessment skills taught in pre-registration nurs- ing programs. As the second part of a two-phase study, the survey reported on here aims to identify the use of physi- cal assessment skills by registered nurses working in clinical environments. The survey tool was based on one developed by Giddens (2007) in her work with nurses in the USA.
Methods
Quantitative survey by questionnaire was chosen as the most efficient and effective method for obtaining data from a broad sample of nurses practicing in Australia. Following approval from the university’s ethics committee, a con- venience sample of registered nurses was recruited with assistance from the Australian Nursing Federation (ANF). The ANF advertized an invitation to participate with a survey access link in their professional journal. Owing to the limited response, recruitment was subsequently extended and indi- vidualized invitations were generated. The ANF (NSW) sent an individual e-mailed survey invitation and access link to a random sample of their members who were registered nurses. The surveys were conducted between October 2010 and July 2011. The survey instrument developed by Giddens (2007) was modified to ensure relevance to the Australian environ- ment. This modification included changing some terminology in respect of items that sought demographic data: postal code, practice status, age, sex, qualifications, work role and length of nursing experience. The questionnaire is divided into skills sections based on human anatomical and physiological functional or regional group: integument, nutrition, head, ears/eyes, neck/thorax, breasts/spine, car- diovascular, musculoskeletal, abdomen/anus, reproductive, neurological and sensory. In total there are 121 items. Respondents were asked to indicate their use of skills in accordance with frequency of practice based on a six-point Likert scale (Table 1). The survey was pre-tested electroni- cally on-line by a panel of six university nursing lecturers. No changes were deemed necessary following this process and the survey was subsequently posted on-line for participants to complete. Data were downloaded and analyzed using SPSS statis- tics software (SPSS Inc., 2007). Summary statistics (means, percentages) were used to describe demographic variables. Spearman’s rank order correlation was used to determine association between demographic variables. For each of the scale items the median response was computed from the response range (0—5) and this was used as the main indi- cator of overall skills use. Section ratings were summed by category of survey item (e.g. ‘Head’, ‘Neck, Thorax’) to obtain a sectional response score. Differences by pro- fessional role were explored using these grouped data with Wilcoxon signed ranks test (as an alternative to t -tests owing
30 M. Birks et al.
Table 2 Ranking of physical assessment techniques used in clinical nursing practice based on the median response ( N = 1220).
Used every time I work (median response = 5)
Used frequently or occasionally (median response = 3 or 4)
Used rarely (median response = 2)
Inspect overall skin colour/tone Inspect skin lesions Inspect wounds Evaluate breathing effort (rate, patterns, chest expansion) Assess mental status/level of consciousness Glasgow Coma Scale Evaluate speech Palpate distal pulses for circulation Palpate and inspect capillary refill Inspect/palpate extremities for oedema Palpate extremities for temperature Inspect extremities for skin colour/hair growth Inspect abdomen
Assess BMI through measurement of height and weight Inspect oral cavity Inspect/palpate external ear Assess hearing based on conversation Assess hearing using whisper and/or finger rubbing test Inspect external eyes Assess visual acuity Inspect/palpate external ear Inspect chest shape Palpate chest wall for thoracic expansion Percuss the lungs Auscultate lung sounds Inspection of female genitalia (hair distribution, vulva) Inspection of male genitalia (pubic hair, penis, scrotum) Inspection of groin area Assess facial movement and symmetry (raise eyebrows, wrinkle forehead, show teeth, puff out cheeks) Test for gag reflex Assess gait Sensation to light touch Sharp/dull sensation Inspect the breasts Inspect for jugular pulsation Inspect muscles and extremities for size/symmetry Palpate extremities for tenderness Palpate joints for tenderness Observe range of motion of joints Measure range of motion of joints with goniometer Assess for carpel tunnel using Phalen’s sign or Tinel’s sign Auscultate abdomen for bowel sounds Palpate abdomen for generalized tenderness, distension
Inspect hair for colour, texture Inspect internal nasal cavity with light source Palpate lips, tongue, mucous membranes of mouth Inspect the internal ear with an otoscope Assess hearing using whisper and/or finger rubbing test Assess peripheral vision Inspect corneal light reflex Check PERRLA Palpate thyroid gland Palpate the trachea Palpate lymph nodes in the neck Palpate chest wall for vocal fremitus Percuss for diaphragmatic excursion Auscultate the chest for vocal reso Palpation of female genitalia Palpation of male genitalia (penis, scrotum) Palpation for hernia Evaluate olfactory nerve (smell test) Test tongue for taste Test shoulders for muscle strength Assess patient ability to hop on one foot Assess patient ability to walk on heels/then toes Assess fine motor coordination (finger/thumb; nose/index finger) Vibratory sensation Position sense Perform a clinical breast examination Inspect the spine Palpate the spine Assess range of motion to back/spine Auscultate thorax for heart sounds Auscultate carotid artery Estimate (measure) jugular venous pressure Auscultate abdomen for vascular sounds Percuss abdomen for abdominal tones Percuss abdomen to determine liver span Palpate abdomen to assess for a mass Palpate the liver
nurses’ work. Median scores of 1 or 2 (performed never or rarely) suggest these skills are not performed by the entire sample group, while median scores of 3 or 4 sug- gest wider use. It is apparent that the use of skills was influenced by the nursing role. For example, of five car- diovascular assessment skills with an overall median score of 5 that were commonly performed ‘every time I work’, the mental health nurse subgroup assessed these less frequently as their median score was 3 or 4 (performed fre- quently/occasionally). As expected, the midwife subgroup
had significantly higher scores on frequency of reproduc- tive health assessment skills ( n = 61; mean: 51.7 ± 10.06) compared with all nurses (mean: 28.69 ± 12.61, p ≤ 0.001). Almost all midwives (94%) palpate the uterus in preg- nancy to measure fundal height and 93% palpate the foetal position. Alternatively, only 6% of midwives fre- quently palpate for a hernia or 3% for a prostate. While these results confirm the currency of practice variations, a more detailed analysis is beyond the scope of this paper.
The use of physical assessment skills by registered nurses in Australia: Issues for nursing education 31
Assessment practices
On completion of the survey, respondents were given an opportunity to make further comments. Two of every three respondents provided general comments, while even more listed specific skills they used that could have been included in the survey. A commonly occurring theme was that nurses offered suggestions as to why specific skills were not used in the practice setting. These factors are explored below, with illustrative quotations from the nurses. The results of the survey indicate that 43 skills (36%) com- monly taught in pre-registration nursing programs are not actually performed. Some nurses reported that in their cur- rent field of practice a number of skills were taught but not performed because they were not required in that particular clinical environment.
‘‘Like many nurses, I have learnt majority of these assess- ments, but due to the areas I have worked in over the years and currently, majority of these assessments are not required as they are very specific assessments.’’
Some nurses even reported that they believe they have lost the ability to perform certain physical assessment skills due to lack of opportunity and increased administrative requirements such as paper work.
‘‘You are taught many skills at university but you never get to use them in nursing practice. It is all paper work and minimal patient care’’.
Even though some of these skills are not practiced in the clinical environment, one nurse suggested that knowing the theoretical knowledge behind the skill has been useful in her practice.
‘‘I know very well but have never used at the bed side! However, this knowledge has been useful when interpre- ting doctor’s notes, observations and recommendations regarding patient care.’’
Responses showed that 37 skills were used ‘rarely’ and 28 skills used ‘frequently or occasionally’. Variations in fre- quency of use may relate to individual work schedules and also to nurses’ area of clinical allocation.
‘‘I work on night shift so the assessments would be rare and... the area you are working frequently determines what assessment you will perform.’’ ‘‘The assessment skills I do use regularly I learned in the clinical setting in the specialized area of haemodial- ysis’’.
The results show that few skills (13; 11%) have a median score of 5; that is, few skills were routinely used on every shift. Commonly, the clinical speciality in which nurses were practicing was identified as a reason why certain physical assessment skills were or were not practiced.
‘‘I work in an intensive care unit so we do thorough phys- ical assessments at least once a shift. There are some skills I have no idea on how to do but would like to.’’
Overall, the main reasons why certain skills were not practiced were based on a lack of time or else specialty nursing roles that had a bearing on required skill sets.
Furthermore, there were numerous comments question- ing whether certain physical assessment skills fell within a nurse’ role or scope of practice, as nurses felt that those skills were in the domain of other health professionals such as doctors or allied health professionals.
‘‘So many of the skills taught at uni are things that doc- tors do, not nurses. Maybe they are used by nurses in ICU settings?’’ ‘‘Many of the skills learnt during university training are redundant in a hospital setting, there is simply no time to use them. They also become primarily ‘doctors domain’ in hospital.’’ It is clear from the comments above that the use of assessment skills in practice is heavily dependent on the clinical context.
Discussion
The results of this study indicate that a small number of physical assessment skills are regularly practiced in the clinical environment. The majority of the skills practiced ‘frequently or occasionally’ (18 out of 28), and ‘every time I work’ (9 out of 13) by registered nurses involved inspec- tion and general observation of a patient. These results are consistent with research conducted by Giddens (2007) who identified a set of 30 physical assessment skills that were practiced by RNs in the USA, the majority of which employed inspection. There were, however, another 43 skills that nurses indicated had been taught-yet the current results show these were not practiced universally. This raises ques- tions that should be debated, such as whether or not there is value in teaching skills that are not used in practice. In her work that was the impetus for this study, Giddens (2007) suggested that the teaching of this number of skills was, in fact, redundant given that they were not being performed. The authors of the present study question this asser- tion, particularly when factors that impact on whether or not certain skills are performed are considered. The find- ings presented here suggest that the necessity or value of the skill appears to have little bearing on the incidence or frequency of use. Rather, issues such as time available to conduct physical assessments, area of clinical practice or specialty and the presence or absence of other health care professionals such as doctors and allied health professionals appear to be more influential.
Barriers to conducting physical assessments
The qualitative data gathered in this study indicates that time is a key factor that determines not only the type of physical assessment skills practiced by nurses, but also the depth of assessment they complete. For example, in a busy ward or department, a nurse may not have the time to perform a thorough respiratory assessment and may only complete inspection of factors such as a patient’s respira- tory rate, depth, effort, accessory muscle use. The nurse may omit palpation, percussion and auscultation knowing that the medical team will also be conducting a respira- tory assessment as part of their role. This fits with the idea that there are two possible outcomes of nurses’ physical
The use of physical assessment skills by registered nurses in Australia: Issues for nursing education 33
Conclusion
For the registered nurses who responded to this study, time pressures and role boundaries were barriers to con- ducting detailed physical assessments, while specialty roles appear to facilitate use of particular assessment skills. The results suggest that registered nurses are not utilizing a considerable proportion of the physical assessment skills that are currently being taught to undergraduate nursing students within their curriculum. Pre-registration nursing programs aim to teach skills, knowledge and attributes that reflect the contemporary Australian health care context. Should these programs be modified in acknowledgement of the subsequent disuse of these skills? Or should the health care environment embrace the broad scope of practice for which registered nurses are prepared? These questions highlight the need for the conduct of further research to explore barriers to the use of physical assess- ment skills by nurses and to identify strategies that might promote their use in practice. As assessment is the founda- tion of effective nursing care, improved patient outcomes may result from any strategy that enhances such activ- ity.
Acknowledgement
The authors wish to acknowledge the support of the Aus- tralian Nursing Federation in providing a small grant to assist with the conduct of this research.
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