As the number of well elderly assessment clinics in the U.S.A. increases, these clinics are being recognized as an effective means of providing needed health care services to an increasing number of older adults. Nursing education programs are using well elderly clinics for practice experience in assessment of students and to provide health services for older adults.1 3 Clients and nurses alike feel that the clinics provide valuable services and educational experiences. However, few systematic studies have been conducted to evaluate the effectiveness or the accuracy with which nurses and nursing students perform assessment skills. It is imperative that such studies be undertaken before well elderly clinics become one method of health care services to the elderly rather than a trend.
It was suggested in the 1971 report of the Committee to Study Extended Roles for Nurses4 that routine physical and psychosocial assessments of individuals and families could be provided best by the nurse. Comprehensive assessment requires more than the psychomotor skills of history taking, physical examination, and laboratory tests. Clinical judgment or critical thinking is necessary for the accurate interpretation of assessment data. The judgment involved in processing this information is requisite to accurate health appraisal, referral and quality of care.
Review of the literature reveals few studies that document whether nurses who have been prepared to utilize psychomotor assessment skills possess the clinical judgment needed to identify client health problems accurately. Kaku et al.5 compared the health appraisal skills of graduate nurses, who had three months inservice training in physical assessment, with evaluations made by physicians. The concurrence of physical findings was significantly high. Both the physicians and nurses concurred that there were no significant findings in 70.3% of the 16,000 independent variables. In 5% of the variables, the physician found a sign or symptom that the nurse did not find. In 14.4% of the variables, the nurse found signs not found by the physician.
The abilities of nurse practitioners to perform patient assessments was studied by Bailit and associates.6 A physican reexamined a patient who already had been seen by a nurse practitioner who performed the examination, defined a problem list, and made recommendations for referral or followup. Results of the study indicated that nurse practitioners were able to detect signs and symptoms deviating from normal and provide for followup of the problems. A similar study compared findings of nurse practitioners and physicians on physical examinations alone. In only two cases (0.7%) were differences between the nurses' and physicians' assessments considered significant. Total agreement was achieved in 240 of 278 conditions noted in the 182 children of the sample.7 Henriques et al.8 also support the premise that nurse practitioners are able to use accurate clinical judgment in the identification of patient problems. In this two-year study, more than 30,000 patients were seen by four nurse practitioners whose findings were referred to one physician for validation. As of the date of the report, "no significant errors of omission were noted."
These studies indicate that nurses, especially nurse practitioners, do possess the psychomotor and clinical judgment skils needed to identify health care problems accurately and to provide for needed referral or followup. However, we found only two articles that addressed student nurses' abilities to utilize assessment skills. Reese, Swanson and Cunning9 addressed how to measure the students' ability to use correctly and sequence the motor skills of physical examination in a testing situation. Crowell et al.10 described the problems (abnormalities) that student nurses and faculty were able to detect at well elderly clinics, but did not address the validity of these findings.
It is necessary that the quality of services that nurses and/or nursing students provide to clients be evaluated continuously and systematically. Only then will nursing educators be able to provide meaningful learning experiences for students and valuable services to clientele. Therefore, the specific problem addressed in our study was: Are client health problems, identified by student nurses and faculty at well elderly clinics, validated by physicians to whom the clients are referred subsequently? Intrinsic to this question are the following: What kinds of health care problems are student nurses and faculty at well elderly clinics able to identify accurately?; and, Did the problems identified accurately by student nurses and faculty require treatment or medical followup?
Each semester the University of low» College of Nursing plans and operates health screening clinics in which Nursing I students have opportunities to assess well elderly clients. The purposes are to provide learning opportunities for Nursing I students to become proficient and confident in utilizing their assessment skills and to provide a free screening service for the elderly.
The Council on Aging and the public health nurses in the communities assist in finding a site for the clinic, and in advertising the clinic and scheduling clients who volunteer to participate in the program. The clinic is mainly for those 60 years of age or older. The clinic site usually is a church or a public hall. Provisions for the students include booths for physical examinations, a laboratory testing table, and an area for interviewing clients. Working in pairs, the students interview the client about past and present health history, complete a urinalysis and hemoglobin test, and perform a physical examination. Because of limited space and equipment, abdominal and genital examinations usually are not included in the complete physical. However, if the health history indicates an abdominal problem this portion of the examination will be done. The students record their findings on the assessment record, marking any special concern or abnormal finding with an asterisk. At the completion of the physical examination, a faculty member reviews the clinic form with the students, validates the area(s) of student concern and reexamines the client's heart, lungs, thyroid gland and breasts. At the conclusion, a post-conference is held to inform the client about the findings. Any necessary teaching and/or referral is done at this time. The total procedure takes approximately three hours.
If client assessment indicates a problem, a physician's referral form is completed, identifying the abnormal findings or problems. This form, with a stamped return envelope to the College of Nursing, is given to the client. The client is instructed to take the form to a physician, have the physician complete the form at the time of the visit, and mail the form to the College of Nursing as soon as possible. The completed form provides the following informational) validation or non-validation of the problem(s); (2) a brief description of the physician's findings; and (3) a description of health care action, including whether it is old or new treatment for the client.
Results of the Study
A total of 469 clients was seen at nine well elderly clinics in Southeastern and Southcentral Iowa counties. The clinics were conducted between May 1979 and July 1980. Health problems were identified by Nursing I students and/or their faculty members in 158 clients (34%). All of these clients were referred to physicians for validation of the problem(s) and potential health care treatment.
Ages of the 158 clients ranged from 45 to 93 years. Although initially the lower age limit of the population for screening was set at 60 years, exceptions were made for three clients under age 60 who specifically requested to be seen at the clinic. The mean age for the population was 72 years. Most of the subjects were female (66.45%) and widowed (44.3%). These findings are consistent with the fact that there are more widowed females in the elderly population, hence more attending the clinic.
The study sample consisted of 124 clients (78.8%) who returned the referral forms. The characteristics of the sample are consistent with the target population. We identified the following questions that we hoped to answer:
Question 1: Are client health problems, identified by the student nurses and faculty at well elderly clinics, validated by physicians to whom the clients are referred subsequently?
From one to six health problems were identified for each subject; the mean was two problems. A total of 375 health problems was identified in the sample, with physicians' giving feedback on only 234 problems. Eighty percent of these 234 problems were validated by the physicians. This suggests that student nurses are able to identify health care problems and that their physical assessment skills are reliable. A major limitation in drawing this conclusion, however, is that the skills of the physicians were not validated or tested for reliability. Using one physician rather than each client's personal physician would make these figures more reliable. Because physicians traditionally have been considered experts in diagnosis, and because many agencies consider physician's findings valid, we conclude that these findings indicate that student nurses and faculty accurately identify clients' health care problems. No conclusions can be drawn regarding the 47 (20%) problems that were not validated because of their possibly transient nature (e.g. glucosuria, elevated blood pressure, cprdiac arrhythmia, etc.).
FIGURE 1 Comparison Between Numbers of Problems Identified and Validated According to Systems
Question 2: What kinds of health care problems are student nurses and faculty at well elderly clinics able to identify accurately?
All problems identified by the students and faculty were categorized according to system and/or diagnostic test. This was done to determine whether there was any variation in the types of problems that could be identified accurately. Figure 1 compares by system-diagnostic test the total number of problems identified and the total number validated. It is evident that more cardiopulmonary problems were identified; 81.9% were validated. Of the cardiopulmonary problems, only cardiac murmurs adventitious lung sounds, hypertension, and peripheral edema were not validated consistently. These were validated in seven of eight cases, 10 of 17 cases, 35 of 45 cases, and eight of nine cases, respectively. Two thirds of the cardiopulmonary problems were validated 100% of the time (dyspnea, chest pain, bruits, arrhythmias, alterations in vocal fremitus are some examples).
The students and faculty were ible to identify accurately EENT problems in 18 of 19 cases (89%). Specifically, the nurses were able to identify problems with acuity, inflammation, obstruction, bleeding, lens opacity and dentition. The only problem not validated was a nodule of the larynx.
Three of five problems in the endocrine system were identified correctly. All of the problems in this system related to the thyroid gland's being enlarged, tender or nodular. Two of three cases of thyroid enlargement were validated. The one case of thyroid tenderness (subjective data) was not validated.
Lesions of the breast, lymph system and integument were categorized together. The students and faculty were able to identify and describe these lesions in 17 out of 20 cases. The three cases that were not validated involved enlargement and/or tenderness of the breast or lymph nodes
Although there were limited numbers of cases, all of the problems identified by the student nurses and faculty in the neuromuscular, gastrointestinal and genitourinary systems were validated by the physicians. Urine and blood tests seemed to have the greatest source of error on the part of the examiners. Fifteen of 38 urine tests were inaccurate. It is assumed that transporting the equipment in variable temperature extremes (from below freezing to 90 F or higher) altered or affected the readings on the multi-stix used for urine testing. The only blood test done was a hemoglobin reading. Four of 15 cases were in error. Presumably the batteries used in hemoglobinometers deteriorate with use, thereby affecting accuracy of some readings.
The final category (Other) of problems includes: lack of health role behaviors, weight gain/loss, and frequent colds. Physicians did not agree with one of four noncompliance diagnoses and one of seven health maintenance problems. The one reported case for each of the other problems was validated.
In summary, student nurses and faculty were able to identify health problems in all systems examined and with all diagnostic tests performed with at least 64% reliability. However, no conclusive statements can be made, because of the limited number of cases in each problem category.
Question 3: Did the problems that were identified accurately by student nurses and faculty require treatment or medical followup?
This last question is significant because it has been implied that nurses are overly zealous in referring "insignificant" problems to physicians. The authors believe that all deviations from health norms should be communicated to the entire health team, whether or not treatment in required. Knowledge of these findings may prove significant in future health regimes for the client. Nonetheless, the researchers do feel Question 3 is significant to elderly clientele on fixed incomes.
The findings in this area of the study are inconclusive. Of 187 problems that were validated by the physicians, approximately 50% required treatment and/or followup. Thirty-five of these required continuation of past medical regimes and 58 required implementation of new treatment plans for the clients. In addition, two problems required treatment but there was no indication whether it was an old or a new treatment. Thirty percent of the problems required no treatment or medical followup. There was no indication of whether treatment was needed or not needed in 18% of the validated problems. Although it is difficult to say whether a problem is more significant if it requires treatment, the authors feel it is significant that at least one third of the problems required new treatment. This suggests that nurses are playing a vital role in the health care of older adults in these Iowa communities.
There are several limitations to this study. First, not all of the physical examinations were validated. Only those clients whose problems were identified by students/faculty and referred to their physicians had those problems validated. Some problems in the clients not referred may have been overlooked. Secondly, using a number of physicians without controlling for consistency in physical assessment skills decreases the reliability of the findings. It is suggested that a future replication be done using one physician for whom reliability has been established, and that entire examinations be validated by this physician (although this might be highly impractical due to time and financial constraints). A third limitation is that some referral forms were not returned or were incomplete, perhaps due to time constraints of the physicians. Using one physician, with known reliability of skills, could reduce all of these problems. In summary, the findings of this study cannot be generalized to a large audience. A larger study, with other geographic locations, other schools of nursing, other physicians, and other clients, could be more conclusive.
Our study indicates that student nurses and faculty at well elderly clinics in Southeastern and South Central Iowa identified a significant number of health care problems. Of those problems referred to a physician and for which a referral form was returned to the researchers, approximately 80% were validated. There was no one type of problem identified with a more significant degree of validity, yet the majority of all problems in each system and diagnostic test category were validated. Approximately one third of all validated problems required new medical regimes. Undoubtedly, student nurses and faculty are able to use assessment skills accurately in well elderly clinics, therefore contributing valuable services to the community.
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