Nurse practitioners assess and manage clients with both acute episodic and chronic common health care problems. Competence in physical assessment, a skill basic to their role, requires practice in recognizing a wide variety of physical findings. Clinical rounds, as a means to expose students to this variety, were recently introduced into our physical assessment course in the Primary Care graduate curriculum at the University of North Carolina at Chapel Hill.
To pass the course students must demonstrate a final systematic, orderly, thorough, sequential, and technically proficient physical exam on a well "patient." Rapport with the patient and sensitivity to client modesty must also be demonstrated. Clinical rounds are integrated into the second half of the course after students have mastered the skills of the complete physical examination and medical history. The rounds serve to increase student appreciation of normal variations and abnormal findings; provide immediate, repetitive, individualized student feedback; transfer and enhance assessment skills from well student partners to ill patients; decrease student anxiety by providing faculty support and offering role modeling in data acquisition; and review differential diagnoses of common pathologies.
Rounds are taught by Nurse Practitioner faculty utilizing two medical floors in a university teaching hospital and a nursing home/convalescent center.
On the medical floors in the university teaching hospital setting, three-hour rounds are conducted with one instructor and four student nurses. The smallness of the group encourages active participation from every member. The patient's complete history and diagnosis are discussed and the systems containing positive physical findings are identified. One student then volunteers to examine those systems. Before seeing the patient, this student verbally reviews the organization, sequence and technique of the exam to be performed. For example, the student will summarize the components of inspection, auscultation, percussion and palpation of the abdominal exam before examining a patient with an abdominal mass. During the preparatory conference, the other three student nurses listen and supplement the student's verbal review.
At the bedside, the first student performs the exam for the group, who later critique her technique. Then the faculty member critiques that student's performance, reinforcing the strengths of her exam and offering suggestions for further improvement. Finally, all students repeat the same exam and are critiqued on their performance. Thus, all four students view three classmates' approaches to a regional exam and have the opportunity to integrate the strengths of each approach into their own style. This sequential observing builds repetition into the learning process which helps cement skills.
Immediately following each examination, the student is expected to verbally describe the physical findings succinctly and correctly. These initial impressions are validated by the instructor at the bedside. This process of learning to correctly interpret physical findings often necessitates faculty guiding several reexaminations so all students can concur in their interpretations, since novice learners frequently need faculty assistance with interpretation of abnormal findings.
The nursing home site is used for two sets of clinical rounds: cardiovascular rounds and mental status change rounds. All nurse practitioner students come to the nursing home on two evenings for two or two and a half hours each time. In both instances a faculty-student ratio of 1:3 is maintained to maximize student learning. A format of preconference, rounds and postconference is used.
During the preconference for cardiovascular rounds, the students verbally review the components of the cardiovascular exam, normal physical changes in the aged heart and common abnormal findings in the older adult client. Students are encouraged to review and synthesize course material to guide them in recognizing and interpreting the signs they are likely to find in the nursing home residents.
During rounds each student independently assesses the same resident's cardiovascular system and then records the findings. After all three students have completed these two steps, a brief postconference is held away from the resident's room to compare the students' and faculty member's findings. Any student whose findings are incompatible with the group's is allowed to reasses that resident. Thus students can learn without being expected to have consistent findings after the first assessment. During the postconference each student is given feedback on his/her examination technique, noting strengths, needs for refinement or correction, and maneuvers omitted, and students discuss the correct format and vocabulary for description of findings. Finally, the postconference deals with the differential diagnosis and probable pathology of the resident's composite signs.
The process is then repeated on three or four more residents, so students can experience several successive practices of the cardiovascular exam with real patients, and can do a comparative analysis of different heart sounds and cardiovascular findings and relate these to common pathological conditions.
Students often require opportunities to recall the normal physical changes of aging and help in differentiating these changes from cardiac diseases common to older adulthood and in synthesizing theory relevant to a particular resident. Improvement in the students' examination techniques, self-confidence and interpretation of positive findings can be seen as rounds progress.
Mental status rounds are conducted using a similar format. During the preconference students verbally review class content on the mental status exam used (JAMCO), normal physical changes in the aged nervous system and the pathology, signs, symptoms and causes of depression, delirium and dementia. Next each student performs a mental status exam and records the results for one resident, then repeats the process on a second resident. The faculty member selects the residents to be tested in order to provide variety in both type and degree of mental status impairment.
During the postconference faculty and students discuss the problems encountered in conducting a mental status exam with various residents, and ways to deal with these problems. They critique the accuracy of the write-up, the validity of questions asked during each mental status exam, and the analysis of the resident's responses and the student's conclusions drawn from these responses. Next, the mental status exams are compared to assist students in recognizing and appreciating the functional ability of patients with mild to severe depression and dementia. Finally, discussion focuses on the use of mental status exam findings in determining the resident's cognitive functional capacity so that expectations are realistic and appropriate interventions are planned.
Students find these rounds very helpful since many have never been exposed to demented patients and none have ever learned to collect data on a client's cognitive ability. The experience also gives them greater sensitivity to patients with depression, delirium and dementia.
Rounds offer an opportunity to integrate key clinical content from the curriculum into the patient discussion. For example, while examining patients with cancer of the breast, lung, colon, or prostate, the epidemiology, clinical presentation, risk factors, screening methods, essential laboratory tests, and indications for referral are summarized. While examining a patient with positive finding, the signs, symptoms and diagnoses which have the highest incidence in primary care are stressed. Each group of students is exposed to a significant collection of positive physical findings.
During skills laboratory practice and initial clinical rounds, students typically have most difficulty with measurement of jugular venous pressure, palpation of fiver and spleen, cardiac auscultation, and funduscopic exam. Errors of omission are few since the course utilizes the behavioral checklist for all systems and the complete exam is memorized. During rounds, students are given several opportunities to measure jugular venous pressure on a patient with prominent jugular veins, palpate an enlarged liver and spleen, auscultate hearts with abnormal gallops and murmurs, and view fundi.
All students feel they can better differentiate normal from abnormal findings after these extra opportunities. Aloia and Jones (1976) have noted that house officers' proficiency in physical examination in internal medicine residency program improves with increasing experience. Our experience is similar. After being corrected once on an incorrect measurement of jugular venous pressure, students are able to correctly measure jugular venous pressure on a second patient. Increased experience and close, continuous supervision refines physical assessment skills and produces an examiner adroit in their use and interpretation of findings. Obviously, the more supervised experience the student has, the more refined her exam will be.
All students are asked to evaluate clinical rounds by a questionaire. To date 90% of the student respondents have indicated that clinical rounds are an excellent learning experience. Students perceive the content and process of the rounds to be comprehensive and clear, and find that they encourace discussion and stimulate interest. Immediate instructor feedback, small group size, high faculty-student ratio and a teaching method which utilizes student recall, application and synthesis are all perceived as course assets by students. They are especially delighted to see real patients with real findings and feel this helps to solidify their skills. A supportive nonthreatening faculty environment has also been identified as helpful to learning new skills. Students would like greater time for clinical rounds so that more class content could be applied to patients, exposure to a greater variety of positive physical findings, and advance notice on positive physical findings likely to be seen so they could review before rounds.
Faculty have also found the experience a success. Students gain an increased ability to distinguish normal and abnormal physical findings. Individualized immediate feedback serves to break bad habits and reinforce good ones. All students readily transfer their skills from well people to ill patients. Faculty focus on differential diagnosis for common symptoms, and a warm supportive atmosphere makes students feel comfortable. Faculty also noted students' increasing self-confidence.
Faculty recommendations for course revision include the following:
1. Age specific clinical rounds, with opportunities to see pertinent findings on newborns, children and adolescents;
2.. More time for rounds to increase exposure to positive findings;
3. Histories elicited by students prior to exams;
4. Inclusion of all systems;
5. Extension of clinical rounds over the course to include weekly rounds with review and application of each system studied in class.
For example, while learning the exam of the eye, common abnormalities of the lid, lashes, sclera, conjunctiva, pupil, cornea and fundus could be seen concurrently. This would eliminate the hit and miss approach to acquainting students with essential signs.
In summary, we feel that clinical rounds provide an excellent learning experience and are a useful teaching tool for nurse practitioner students. Students progress more rapidly in mastering their analytical and manual skills of physical assessment. Once they gain confidence in the newer physical assessment skills, they are able to shift their focus and begin integrating their existing nursing knowledge and skills with the newer physical assessment skills. This integration is basic to the provision of holistic health care.
- Aloia, J.F., & Jones, E. (1976). Skills in history taking and physical examination. Journal of Medical Education, 51(5), 410-415.