Journal of Nursing Education

Determining the Use of Physical Assessment Skills in the Clinical Setting

Carolyn B Colwell, RN, MA; Joyce Smith, RN, MSN, SNP

Abstract

ABSTRACT

This study examined the clinical application of physical assessment skills by baccalaureate nurses. Fifty-nine pediatric staff nurses practicing in two different hospitals in Southern California completed a questionnaire which surveyed how frequently assessment skills were utilized and what deterrents, if any, inhibit their use. Approximately one-third of the 36 skills listed were utilized daily by at least 74% of the participants, and respondents selected a variety of deterrents to the utilization of other skills. There was no significant difference in the utilization of skills between nurses who had taken a separate course in physical assessment and those from an integrated curriculum.

Abstract

ABSTRACT

This study examined the clinical application of physical assessment skills by baccalaureate nurses. Fifty-nine pediatric staff nurses practicing in two different hospitals in Southern California completed a questionnaire which surveyed how frequently assessment skills were utilized and what deterrents, if any, inhibit their use. Approximately one-third of the 36 skills listed were utilized daily by at least 74% of the participants, and respondents selected a variety of deterrents to the utilization of other skills. There was no significant difference in the utilization of skills between nurses who had taken a separate course in physical assessment and those from an integrated curriculum.

Problem Statement

The baccalaureate nursing curriculum is increasingly incorporating the content of physical assessment. The concerns addressed here are to what degree these skills are finding practical application in the clinical setting, if the manner of teaching them affects their use, and how their use affects optimal patient outcomes. Little research has been done in this area. Therefore, a pilot study was devised to learn the frequency of use of 36 specific skills by pediatric staff nurses. The investigators also looked at deterrents to the use of each skill and compared nurses with a separate course in physical assessment to those from an integrated curriculum. A separate course is defined as a one semester course within the baccalaureate nursing curriculum which concentrates on physical assessment. An integrated curriculum includes this subject matter throughout the nursing major as it is applicable to the specific content of each course.

Literature Review

Since the first nurse practitioner program began in Colorado 20 years ago, physical assessment courses have appeared with increasing frequency not only in the graduate nursing curriculum but in undergraduate baccalaureate nursing programs as well (Natapoff, Moetzinger & Quarto, 1982). A survey sent to deans and directors of 143 NLN accredited baccalaureate programs across the country indicated that all respondents considered physical assessment a part of the contemporary professional nursing role, and 95% felt that baccalaureate nursing students should learn these skills (Natapoff, et al., 1982).

There is sound theoretical basis for inclusion of assessment skills in the baccalaureate curriculum. Physical assessment constitutes an essential part of the first step of the nursing process, provides a foundation for health promotion, and affords a common ground for communication with other health professionals.

It is apparent that graduate nurses are seeking more expertise in assessment skills, evidenced by the increasing popularity of continuing education courses addressing this subject matter. If expanded knowledge in this area is desirable and taking a more prominent place in the undergraduate curriculum, then what are the observable results of this trend?

A review of the literature indicates there are few answers to this question. Instead, additional questions exist as to how assessment skills should be taught in the undergraduate curriculum, whether they are being utilized in the clinical setting, and what impact their utilization has on patient outcomes and the quality of nursing care (Natapoff, et al., 1982).

There were no studies dealing specifically with the utilization of assessment skills following graduation, and only one report addressed the use of these skills by students (Voight, 1980). Voight reported that 36% (eight students) stated they did not feel comfortable with assessment skills following a course in their sophomore year. Lack of time and opportunity to use these skills were the primary reasons for the students' concerns.

Purpose

The purpose of this study was to answer the following questions: 1) What type of physical assessment skills are being utilized in the clinical setting? 2) How frequently are these skills being utilized? 3) What deterrents exist to greater utilization? and 4) Do nurses who have had a separate course in physical assessment use these skills more frequently than nurses who have not had such a course?

Design and Method

The setting for this study was two hospitals in a large metropolitan area. One was a 400-bed teaching facility with a 30-bed pediatric unit, the other was a 68-bed private children's hospital. These facilities were chosen because of the high ratio of registered nurses on their staffs and their large pediatric patient population. The two investigators both specialize in the area of child health.

The sample consisted of 59 registered baccalaureate nurses. Subjects used were those available on the units and willing to participate at the time the questionnaire was distributed. Head nurses and/or charge nurses were excluded from the study.

The instrument for data collection was a questionnaire consisting of two parts. The first part was demographic data including the respondent's date of graduation, highest degree earned, and the nature of physical assessment courses taken. The second part was behavioral data, where respondents indicated on checklists which skills were utilized and with what frequency. Deterrents to the use of each skill were chosen from a list of eight and ranked according to priority (Appendix, Survey Questionnaire). Since there were no previously utilized questionnaires of this kind, the investigators devised their own; thus its validity and reliability had not been established.

A letter describing the study accompanied each questionnaire, and was given to every baccalaureate staff nurse who was available and willing to participate. Anonymity was insured by omitting names from the questionnaire. All results were analyzed in aggregate form, thus avoiding the possibility of individual identification. After completion, the questionnaires were returned in a sealed envelope to the administrative nurse's office.

Results

In considering frequency of use of the various skills included, greater than 50% of the participants specified 13 skills which they used daily (Table 1). Eleven of these skills were used daily by at least 74% of the participants. Auscultating the lungs for breath sounds and adventitious sounds, auscultating the apical pulse, and auscultating for bowel sounds were all checked for daily use by at least 90% of the respondents. The 10 skills least frequently utilized are listed in Table 2; more than 50% of the participants stated they never used these particular skills. More than 80% of the respondents indicated they never performed ophthalmoscopy and otoscopy.

Twenty-nine of the 36 skills were designated as used "On Admission Only," but each of the 29 skills was chosen by only a few of the participants. A mean of 3.6 respondents per skill stated they utilized that skill on admission only.

Of the possible deterrents to use of these assessment skills (Table 3), "Not identified as a problem area" was selected most frequently followed by "Not a nursing responsibility" and "Lack of familiarity with the skill." "Insufficient time" was chosen 41 times in 12 skills, but if the one skill of palpating the point of maximum impulse is discounted, this deterrent was chosen only one to three times for each of the remaining 11 skills. The least frequently chosen deterrents were "Lack of equipment" and "Presence of medical students."

Table

TABLE 1SKILLS MOST FREQUENTLY USED-DAILY

TABLE 1

SKILLS MOST FREQUENTLY USED-DAILY

Table

TABLE 2SKILLS NEVER USED

TABLE 2

SKILLS NEVER USED

Table

TABLE 3DETERRENTS

TABLE 3

DETERRENTS

Table

TABLE 4SKILLS NOT UTILIZED DUE TO LACK OF FAMILIARITY

TABLE 4

SKILLS NOT UTILIZED DUE TO LACK OF FAMILIARITY

Table

TABLE 5SKILLS NOT CONSIDERED A NURSING RESPONSIBILITY

TABLE 5

SKILLS NOT CONSIDERED A NURSING RESPONSIBILITY

The 10 skills for which "Lack of familiarity with the skill" was chosen most frequently are listed in Tanle 4, aspire the eight skills for which "Not a nursing responsibility" was most often selected (Table 5). These two deterrents were thought to be of special interest to educators and so were listed separately.

The participants were asked to specify any additional deterrents not listed in the questionnaire, and several stated the young age of their patients precluded the necessity of utilizing such skills as palpation for breast lumps, testing extraocular muscles, observing coordination, and palpating for axillary nodes.

Although additional comments were not specifically requested, several respondents used space at the end of the questionnaire to volunteer information. Three participants stated that although many of the skills listed were not utilized or deemed appropriate in their setting, they felt that knowledge of these skills was extremely important.

To compare nurses who had taken a separate course in physical assessment with those from an integrated curriculum, we looked at the 13 skills most frequently utilized and the 10 skills used least. To avoid confusion, we compared only those participants who had checked "separate course" or "integrated course" alone, omitting those who selected any combination of the two. As can be seen in Table 6, a consistently higher percentage of respondents with a separate course indicated daily use of the 13 skills. The only exception was auscultation of the lungs for adventitious sounds. The difference, however, between the two sets of respondents is small. When comparing separate versus integrated in the 10 least frequently utilized skills (Table 7), there is a consistently lower percentage of respondents with a separate course having checked "never" for each of these skills. The only exception here was for the skill of testing deep tendon reflexes, but the differences between the two groups are, again, too small to be significant.

An additional comparison was made of the groups of separate and integrated respondents by examining the frequency with which the deterrents, "Lack of familiarity with the skill" and "Not a nursing responsibility," were selected (Table 8). Of the 22 skills for which these deterrents were chosen, 16 showed a higher percentage selection of "Lack of familiarity with the skill" by the integrated group; whereas 16 of the 22 in the separate group showed a higher percentage selection of "Not a nursing responsibility."

Discussion

The frequency of utilization of the specified skills raises interesting questions for educators, clinical nurse specialists, and nursing administrators. Is it necessary for 100% and 98% of clinical nurses to auscultate patients' lungs for breath sounds and adventitious sounds on a daily basis? If 86% of the respondents are auscultating daily for heart murmurs and 78% are palpating for peripheral pulses, is this the most valuable use of their time? Why are 90% auscultating for bowel sounds daily when only 76% are palpating the abdomen? Does this imply that nurses believe more knowledge is gained about patients from auscultation of the abdomen than from palpation? Does a significant percentage of their patient clientele have obvious or even potential problems involving the abdomen to require daily abdominal assessment?

Of the least utilized skills, 55% stated they never test extraocular muscles despite the fact that the respondents all practice in a pediatric setting. Isn't this a sufficiently important aspect of child assessment that nurses should at least be performing it on each new admission? The findings suggest a need to evaluate how nurses in the clinical setting can most effectively and efficiently utilize each assessment skill being taught.

Table

TABLE 6COMPARISON BETWEEN THE SEPARATE COURSE GROUP AND INTEGRATED COURSE GROUP

TABLE 6

COMPARISON BETWEEN THE SEPARATE COURSE GROUP AND INTEGRATED COURSE GROUP

Table

TABLE 7COMPARISON BETWEEN THE SEPARATE COURSE GROUP AND INTEGRATED COURSE GROUP

TABLE 7

COMPARISON BETWEEN THE SEPARATE COURSE GROUP AND INTEGRATED COURSE GROUP

Although 29 skills were stated to be used on admission only, the fact that only a mean of 3.6 respondents per skill chose this category suggests that only a few nurses are considering the admission procedure an optimal time for utilizing all or at least many of these assessment skills in attempting to identify problem areas upon initial contact with the client.

The infrequency of use of such skills as ophthalmoscopy and otoscopy leads one to question whether, in fact, these skills should be utilized in the clinical setting; and if so, whether or not we should be teaching them with more diligent attention to their clinical application. If clinical application is not expected, why emphasize them to the same degree as those skills which are more readily adaptable to the clinical setting?

Another interesting finding from this study was that of the 22 skills for which deterrents were specified, 16 (73%) showed a higher percentage of nurses with a separate course in physical assessment choosing the deterrent, "Not a nursing responsibility." This further implies not only the need for including more clinical applications when teaching physical assessment, but also the need to clarify those skills which do fall within the nurses responsibility.

The fact that "Insufficient time" was chosen as a deterrent as infrequently as it was indicates that the respondents consider the use of physical assessment skills a high priority. This was also supported by comments voluntarily submitted from a few participants at the end of the questionnaire.

Table

TABLE 8COMPARISON BETWEEN THE INTEGRATED COURSE GROUP AND SEPARATE COURSE GROUP IN FREQUENCY OF USE OF DETERRENTS D AND E

TABLE 8

COMPARISON BETWEEN THE INTEGRATED COURSE GROUP AND SEPARATE COURSE GROUP IN FREQUENCY OF USE OF DETERRENTS D AND E

Summary

This preliminary study has provided data indicating that many physical assessment skills are being utilized in the clinical setting by the group of nurses studied. Educators must evaluate whether all of the skills should be used on a regular basis; and if not, which ones result in the most effective use of the nurse's time and warrant increased emphasis on application to the clinical setting. The frequently chosen deterrents of "Not a nursing responsibility" and "Lack of familiarity with the skill" are also of concern to educators. Why were these chosen so frequently, and does this indicate a need to increase the staff nurse's awareness of the value and practical use of assessment skills? No significant differences were found in utilization of skills between nurses with a separate course and those from an integrated curriculum.

Further Research

The results of this pilot study need to be verified by surveying a larger and more diverse sample of nurses. In order to expedite data collection, the investigators plan to refine the instrument by: 1) more clearly isolating those nurses having had a separate course in physical assessment from those with an integrated course so that the entire sample would fall into one group or the other; 2) reevaluating the list of specific skills with an attempt towards limiting their number and ensuring congruency with other baccalaureate schools of nursing; and 3) seeking information on the rationale for utilizing specific skills at particular times in the hospital setting.

Much research in this area is necessary as the nursing profession continues to consider how the use of physical assessment skills by baccalaureate nurses actually enhances patient care.

References

  • Jackson, B., & Mantle, D. (1977). leaching patient assessment: The pros and cons of clinical rounds. Journal of Nursing Education, 16(2), 24-29.
  • Leondard, A. (1979). Client assessment. Journal of Nursing Education, 18(5), 41-48.
  • Natapoff, J.N., Moetzinger, CA., & Quatro, J.M. (1982). Health assessment skills in the baccalaureate program. Nursing Outlook, 30, 44-47.
  • Reese, J.L., Swanson, E., & Cunning, B. (1979). Evaluating physical assessment skills. Nursing Outlook, 27 662-665.
  • Voight, J.W. (1980). Physical assessment skills in the curriculum. Journal of Nursing Education, 29(2), 26-30.

TABLE 1

SKILLS MOST FREQUENTLY USED-DAILY

TABLE 2

SKILLS NEVER USED

TABLE 3

DETERRENTS

TABLE 4

SKILLS NOT UTILIZED DUE TO LACK OF FAMILIARITY

TABLE 5

SKILLS NOT CONSIDERED A NURSING RESPONSIBILITY

TABLE 6

COMPARISON BETWEEN THE SEPARATE COURSE GROUP AND INTEGRATED COURSE GROUP

TABLE 7

COMPARISON BETWEEN THE SEPARATE COURSE GROUP AND INTEGRATED COURSE GROUP

TABLE 8

COMPARISON BETWEEN THE INTEGRATED COURSE GROUP AND SEPARATE COURSE GROUP IN FREQUENCY OF USE OF DETERRENTS D AND E

10.3928/0148-4834-19851001-07

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