For the past two years, we have worked to develop a course which draws heavily on two skills: psychosocial and physical assessment. Our goal is to provide learning situations which will offer students the greatest opportunity to work with clients as whole, complete individuals. The value and need for this type of approach is increasingly being recognized under the general rubric of "holistic medicine."
Unfortunately, the integration of these two approaches is seldom realized. Kramer has written extensively regarding the problems of new graduates.1 The reality shock from which they suffer, stems from spending years preparing for their profession only to discover the preparation did not enable them to meet demands placed upon them, in this case, care of the total patient.
Students frequently experience high levels of anxiety when requested to assess psychosocial as well as physical components of their clients' health. Students find themselves most eager to add technical skills to their inventory of accomplishments. "I can start an IV, draw ABG's, read an EKG, and identify adventitious breath sounds." But we do not often hear, "I can finally do a really good mental status exam, complete a family assessment, or take a psychiatric history."
Even less frequently, do we hear of accomplishments involving the use of both technical and psychosocial skills in reference to the same client.
As educators, we need to plan and present courses that direct student behavior. Many courses actually promote separation of skills, rather than integration. We often see advertisements for courses in physical assessment, behavioral assessment, etc. Moreover, in courses and/or textbooks with titles that imply an integra ted content, for example "client assessment," the actual content is heavily oriented in either direction.
Assignments, designed to teach and reinforce new skills, often separate rather than integrate these concepts. For example, when a complete history and physical exam are assigned, most often basic formats are utilized. These cover a minimum of cursory questions which focus primarily on a strict medical orientation. Interviewing skills and psychosocial assessment skills fall out of the limelight. Perhaps they have been covered in another course in another semester. This is a common acceptable teaching strategy: moving from the simple to the complex. But where and how do we combine all of these skills to apply to a single client in a single situation?
Our course. Nursing Assessment II, is presented in the second semester to registered nurses returning to school to earn baccalaureate degrees. These students come from a wide variance of background, age, skill level, and work experience. Many are skeptical and resistive about returning to school, and question the value of a baccalaureate education.
The courses in the bridge, or junior, year afford them an opportunity to update knowledge and skills while taking a look at self, role, and values. It also allows time for adjustment to new roles and expectations before being integrated with the generic students for the senior year.
Our specific course involves psychosocial and physical assessment as well as psychosocial interventions. Two faculty members are assigned to the course for 30 to 35 students. One faculty member is a psychiatric clinical specialist and the other an adult nurse practitioner. Both have background skills in the other's specialization.
The unit load for Nursing Assessment II is two units for lecture and four units for laboratory. There are two hours of teamtaught lecture time per week. Each instructor holds two-hour small group seminars during the week. Each student attends one two-hour psychosocial seminar and one two-hour physical assessment seminar. In addition, the students utilize self-paced multi-media, preceptorships, and community groups.
The course has a single syllabus. Students earn grades which are equally weighted between the physical assessment and psychosocial portions of the coruse. The majority of the assignments have points credited to both portions, with both instructors giving feedback on each assignment. Some examples of joint assignments which we have developed include: complete written histories and physicals, preceptorships with physicians or nurse practitioners, case presentations, and a clinical mastery performing a complete physical and psychosocial exam. A major focus of every assignment is an assessment of the client's lifestyle, stress levels, and the relation of these factors to illness and health maintenance.
One of our jointly approached assignments is a video-taped history. Students are required to demonstrate beginning skills in gathering information in both physical and psychosocial areas of the client's life.
Since the use of videotaping equipment is an integral part of our nursing program, students came to this course familiar with the equipment and the process of taping. While many are still anxious about seeing themselves perform on videotape, they are somewhat desensitized and thus generally open to the experience. The majority of the students have learned from previous semesters to value taping as a very special learning experience. This year, we also began to assign a video cassette to each student for their exclusive use over the two semesters of their bridge year. This provides each student with a personal, simple record of their progress in taping communication assignments throughout the year, as well as saving management time for our Learning Center staff.
Students are given the following directions regarding the videotaped history:
I. The objectives for this assignment are:
A. To demonstrate basic interviewing skills specific to the history-taking process.
B. To initiate a physical and psychosocial history.
C. To demonstrate a disciplined intellectual approach to analysis of the interaction.
II. The method for meeting these requirements is:
A. Select a partner for this assignment.
B. Sign up fora time tobe videotaped. Bring your cassette to that appointment.
C. Come fifteen minutes early to the Learning Center. Select a card which will contain a brief description of your simulation. This is a random selection process. The client's chief complaint will be included on the card. Your partner will role play the situation as real as possible by simulating factors from actual clinical contacts with situations similar to the one presented on the card.
D. Presenting problems or chief complaints may be of the following nature: headache, sore throat, back pain, dysuria, edema, palpitations.
E. Videotape for 15 to 20 minutes, budgeting half of your time for physical assessment of the chief complaint and half for psychosocial components of the chief complaint. Remember to focus on health maintenance and stress management.
F. Sign up for an evaluation appointment. Your partner must attend the feedback session with you. Both instructors will also be present. Bring your cassette with the footage noted. The evaluation session will require approximately one hour.
G. Bring a problem list with you. Again, remember to focus on health maintenance and prevention, as well as stress management.
A. You may earn a total of 100 points from this assignment. 50 points will be credited to the psychosocial portion of your grade and 50 to the physical assessement portion.
B. The evaluation tool (appendices A and B) is designed with a total of 50 points. Each instructor will evaluate you on this instrument. You will then add the two scores together for your final grade.
C. Your partner will attend the evaluation session to provide feedback, but will not participate in giving you a grade.
D. Students achieving a total score of less than 75 points have the opportunity of repeating this assignment once.
This videotaped history is one of several assignments in the course. Videotaping is utilized to assist in the evaluation of the process, as well as content of history taking. Written histories and physicals, assigned later in the semester, enable us to evaluate the student's recording skills and problem-solving abilities.
We strongly oppose teaching designs and approaches which require students to perform skills not first modeled for them by faculty members. Teaching through simulations involving faculty and students is an integral part of the curriculum. Seminars given before the required taping are devoted to reviewing and modeling basic interviewing skills as they relate to the history-taking process. Before each student does the assigned taping, he/she has practiced on videotape at least once. Feedback has been provided by the seminar group. Each student is assigned a videotape for the entire semester. This provides a record of progress throughout the course and the evaluation process is thus further enhanced.
To date, student response to this assignment has been outstanding. In an anonymous survey at the completion of the course, 96% of the students made very specific and positive comments. Two areas of positive feedback frequently mentioned were: opportunity to receive constructive feedback from two instructors simultaneously and the value of peer support.
While instructor comments were often very similar, divergent responses also occurred. Through the modeling of interventions, the students were able to recognize that the interviewing/history-taking process is somewhat abstract and that most situations have more than a single correct approach. The opportunity to observe faculty disagree with each other was repeatedly viewed as very valuable.
Frequent positive remarks also included peer feedback and support. Having a peer say, "Perhaps you could have tried to ask that question this way. . ." or "Right there would have been a good place to introduce the subject of. . ." is another valuable method of student learning. Since they have chosen their partners, they are generally less sensitive about having their peers participate in the evaluation process in this way.
Student feedback has been mixed regarding the fact that case simulations are randomly assigned immediately prior to the taping. While we feel that this system provides for a more accurate assessment of interviewing skills, some students felt that having the assigned simulation beforehand provided a better learning experience, as they preferred to research and prepare.
An ongoing criticism of any simulation method is that actual interviewing skills are much improved outside of this artificial setting. An open discussion of this with students significantly decreases their anxiety.
As faculty, we too have found this assignment and particular approach to evaluating students' history-taking skills extremely valuable. Since we have reviewed all of the videotaped histories by the fourth week of the course we have quickly gathered a wealth of data regarding students entering interview skills. The taped history thus serves as a pre-test of student skills.
This enables us to then guide and structure the remaining seminar Aime to meet specific needs identified in the evaluation of the tapes. For example, we quickly discovered that students had an unusual amount of difficulty asking questions pertaining to psychosexual content. Further seminar time was then devoted to discussion and practice of this area through additional simulations.
We have found that assessement of interviewing strengths and problem areas is more effectively completed through this taping process than through utilization of exclusively written histories. It provides a rapid and dramatic method for instructors to evaluate current interviewing skills. These are obviously very different skills from the ability to complete and submit a written history.
This assignment has also had a significant impact on overall curriculum planning for RN education. Utilizing the project as an evaluation tool, deficits in the first semester content have been recognized and revised. We have specifically added content related to assessment of angry, depressed, and extremely anxious clients. A new focus on psychosexual assessment skills has also been integrated into our curriculum following feedback gained from this assignment.
Another very valuable outcome of this project has been the stimulating opportunity for faculty members to learn from and evaluate one another. Reviewing and evaluating each tape together has been an exceptional learning experience for us. Since together we provide expertise in both physical and psychosexual assessment, not only are students given an integrated evaluation of their work; but we also learn from each other's specialized perceptions.
We are currently conducting a study of the inter-rater reliability of our evaluation tool (Appendices A and B). During the last semester, in evaluating more than thirty tapes, the maximum divergence from both instructors on all final scores was never more than four points. As we continue to study reliability measure, students are reassured that their scores are not totally subjective.
While observation of history taking with actual clients is the ideal, this assignment is certainly an adequate and effective substitute. Students are able to quickly identify areas of communication and gathering information which call for improvement. We highly recommend this procedure to faculty members interested in the integration of physical and psychosocial components of history taking.
- 1. Kramer: Reality Shock. CV Mosby, 1976.