The overwhelming impression gained from textbooks and the literature is that physical assessment is good for nursing (Coombs & Morse, 2002; Jarvis, 2004; Milligan & Neville, 2003; Weber & Kelley, 2007). Indeed, physical assessment is considered an essential skill for all nurses. In New Zealand, as in other countries, a complete systematic physical assessment using the skills of inspection, palpation, auscultation, and percussion is being taught to both undergraduate and postgraduate nurses. As nurses learn the skills of physical assessment, many ask, “Is this nursing?” Some nurses question the emphasis on systematic physical assessment in a profession that values holism and caring. Other nurses, particularly undergraduate students, seem more accepting of the role of physical assessment in practice but comment on the lack of visible role models in most areas of nursing, with the exception of specialist practice areas where nurses practice more autonomously such as emergency departments, intensive care units, and community settings. If physical assessment is so essential to nursing, why is it not more visible in all areas of nursing practice?
The invisibility of physical assessment in everyday nursing practice suggests a mismatch between the theory of physical assessment in nursing and its actual practice. Theory suggests that it is essential to patient care, as evidenced by the emphasis on systematic physical assessment within nursing health assessment textbooks and curricula. However, a significant number of the skills taught as part of a systematic physical assessment are never or rarely used in practice.
Research into physical assessment in nursing has focused on the identification of the skills most frequently used (Giddens, 2007; Secrest, Norwood, & duMont, 2005), factors influencing skill use (O’Farrell, Ford-Gilboe, & Wong, 2000; Skillen, Anderson, & Knight, 2001; Sony, 1992), and the effects of educational programs on skill use (Giddens, 2006; Neville, Gillon, & Milligan, 2006). There has been little research into or critique on the purpose of these skills for nursing practice and the benefits to patient outcomes.
The discrepancy between the physical assessment skills taught and those practiced presents a challenge for nurse educators. It is not clear whether the discrepancy exists because nurses are not confident to perform the skills once taught or whether the skills taught are irrelevant to nursing practice and thus not used. Reactions from academic colleagues to the author’s questioning of the value of systematic physical assessment to nursing and patient outcomes suggest this may be a “sacred cow.” The purpose of the systematic physical assessment in everyday nursing practice is not questioned. Has the systematic physical assessment become the status quo in the physical assessment of patients by nurses?
Thompson (1987) urged nurses to question the assumptions that underpin practice and the acceptance of the status quo. The aim of this article is to explore the systematic physical assessment through the lens of the philosophical paradigms of positivism and interpretivism. The author challenges nurse educators to reflect on the purpose of the systematic physical assessment within nursing by analyzing some of the underlying assumptions of this apparent sacred cow.
The Positivist Perspective
Positivism forms the basis of the scientific method in identifying cause and effect and considers objectivity, reductionism, and systematic and detailed observations important in establishing the true characteristics of illness and disease (Petersen, 1994). It drives the belief that certain observations of signs and symptoms should lead to the same diagnosis of a condition by all who are observing them. Systematic physical assessment stems from this perspective of the world and how we come to know things and the Cartesian view of the body as an object or machine (Capra, 1982). Rather than taking an individual approach, it matches patient symptoms with known physiological responses to illness and disease.
The questions asked and the specific areas assessed are directed by the clinician’s attempt to explain signs and symptoms through the diagnosis of disease. The main purpose of the systematic physical assessment is the identification of patterns and their comparison to established criteria to diagnose disease and prescribe treatment. The majority of nursing textbooks about physical assessment follow the positivist perspective, linking abnormal findings to pathophysiology and the diagnosis of disease.
However, the effectiveness of the diagnostic process depends on the scientific method to accurately describe the relationship between signs and symptoms and physiological change. Unfortunately, many of these relationships are still an inexact science. There is variability in how people respond to illness and disease. Relying on knowledge of generalized signs and symptoms based on symptomatic cases often results in diseases being undiagnosed or untreated. The identification of undiagnosed deep vein thrombosis and pulmonary embolus on autopsy highlights this fact, as many patients with these conditions have no observable signs (Ryu, Olson, & Pellikka, 1998).
The assessment of chest pain is another example because it is based on what are considered classic male symptoms of myocardial infarction (Arslanian-Engoren, 2002; Frich, Malterud, & Fugelli, 2006). Many patients diagnosed with myocardial infarction never experience the classic symptoms. In fact, a physical assessment may not be conducted when the history does not match the classic symptoms.
Physical assessment has a second distinct purpose—the recognition of deterioration based on close monitoring of the patient’s physiological status. Monitoring involves assessing patients frequently, following cues, and recognizing changes (Benner, 2001; Coombs & Morse, 2002). The skills needed for monitoring deterioration include inspection, palpation, and monitoring vital signs. However, even our basic monitoring parameters have uncertainty over their value as markers of serious physiological change.
There is general consensus that the assessment of an individual’s respiratory rate is important in identifying changes in condition (Considine, 2005; Hogan, 2006), yet a systematic review by the Joanna Briggs Institute (Lockwood, Conroy-Hiller, & Page, 2004) found little research supporting the monitoring and recording of respiratory rates to identify serious illness. The same review found that the use of pulse rate to detect serious physiological change has not been rigorously evaluated (Lockwood et al., 2004). In a Cochrane review exploring the indications for the use of oxygen therapy for children ages 3 months to 15 years, the authors found no clinical signs that accurately identify a child with hypoxemia (Rojas, Granados Rugeles, & Charry-Anzola, 2009). The wide variation in respiratory and pulse rates between individuals, the ability of the body to compensate, and other factors that can affect change make these difficult parameters in which to detect early change.
Physical assessment does play a significant role in monitoring deterioration (Minick & Harvey, 2003; Peden-McAlpine, 2000; Peden-McAlpine & Clark, 2002); however, it is not clear what specific skills are needed. Getting to know the patient, noticing changes over time, and knowing what to expect through previous experience all contribute to monitoring and may be more significant than specific physical assessment skills, which are focused on disease diagnosis.
In addition, the emphasis on physical assessment to monitor signs and symptoms devalues the patient’s perspective, particularly when the signs and symptoms do not conform to positivist defined generalizable signs and symptoms. Foucault (1994) described how the medical gaze of the professional has consistently taken precedence over the voice of the patient. Although there is a perception that physical assessment or additional tests is key to diagnosis, the patient’s story is the most significant source of diagnostic knowledge in the majority of cases (Larivaara, Kiuttu, & Taanila, 2001; Peterson, Holbrook, von Hales, Smith, & Staker, 1992). The reliance on systematic physical assessment to diagnose disease and monitor patient change may be at the expense of listening to patients and their families and valuing their voices.
The Interpretive Perspective
The interpretive paradigm emphasizes holism and caring within nursing and seeks to value the patient voice and experience. It attempts to understand rather than to explain (as in positivism) and to individualize rather than to generalize (Crotty, 1998). It incorporates Merleau-Ponty’s (1962) embodied view of human beings and challenges the Cartesian dualistic view of the body. Embodiment is defined as how “we live in and experience the world through our bodies, especially through perception, emotion, language, movement in space, time and sexuality” (Wilde, 1999, p. 27). Embodiment encompasses the patient’s description and interpretation of their condition.
Physical assessment within the interpretive paradigm focuses on the whole person. It goes beyond assessment of the physical to identify the illness experience for the patient. Physical assessment can help nurses explore patients’ illness experiences. Rather than simply a diagnostic tool, it can be used to assess the effects of a condition on emotional well-being, functioning, and coping. Completing a physical assessment in this way provides an opportunity to talk about what the symptoms mean to the individual (Benner & Wrubel, 1989) and enables the nurse to understand the lived experience of the illness. It enables the nurse to enter the world of the patient in a way that simply asking questions will not. The focus is on understanding and getting to know the patient and his or her illness experience rather than simply identifying signs and symptoms.
Physical assessment within an interpretive paradigm also provides an opportunity for the nurse to recognize subtle changes that are so vague that they may not be labeled as a recognizable sign or symptom (Minick & Harvey, 2003). The early recognition of these subtle changes in the patient is based on a philosophy that values each person’s unique psychological, social, and physiological response to illness or disease and his or her coping mechanisms. Slight changes in color, temperature, mood, or behavior are often difficult to detect and would be insignificant when considering normal variation in measurements or reporting from one nurse to another.
Although still a part of monitoring, identifying subtle changes in an individual over a period of time requires an assessment by the same person repeatedly to notice them. They rely on nurses getting to know the patient; to do this, nurses need to continually observe and assess over time so they are able to recognize individual changes in status rather than compare changes to generalized patterns of signs and symptoms (Benner, Tanner, & Chelsea, 1996; Peden-McAlpine & Clark, 2002). This recognition of change often begins with an awareness that something is not quite right (Minick & Harvey, 2003; Peden-McAlpine, 2000).
The type of assessment needed to recognize subtle individual change is different from the routine systematic physical assessment described earlier and is attributed to the positivist perspective. The nurse uses each encounter to continually assess the patient’s physiological status, function, and coping. This assessment is done each time the nurse administers medication, checks on an intravenous infusion, assists with a shower or toileting, or any of the other times the nurse observes the patient during the course of a shift. This type of physical assessment is often unsystematic but is at the heart of individualized holistic caring. It is also an accumulative assessment rather than a one-off assessment and is often invisible because it is incorporated within other nursing activities.
Physical assessment based on the identification of subtle individual changes (those that are only noticeable once the nurse has gotten to know the patient) may be much more important in identifying deterioration or improvement than the routine systematic physical assessment currently being taught and promoted within nursing. Indeed, this is the type of assessment more likely to be a part of the expert nurse’s practice (Benner, 2001; Peden-McAlpine, 2000) and the type of assessment needed to decrease the incidence of adverse events (Considine & Botti, 2004; Minick & Harvey, 2003). It is also the type of assessment needed to direct individualized care for patients.
Range of Physical Assessment Skills
The inclusion of advanced physical assessment skills in the undergraduate nursing curriculum suggests that the margins between everyday nursing practice and advanced nursing practice have blurred. Specialist nursing roles and the demands of contemporary health care systems have increased the amount and type of physical assessment skills thought necessary for nursing practice.
The current push for increased physical assessment by nurses is coming from governments (KPMG Consulting, 2001; Wilson et al., 1995), health care providers, and patients as advanced technology and inadequate staffing levels and systems within hospitals put more patients at risk of adverse events (Considine & Botti, 2004; Health and Disability Commissioner, 2007). However, by increased assessment, do we mean an increase in the variety of skills used, or more frequent use of relevant skills? An increase in the ability to diagnose requires an increase in the range of skills needed, whereas an increase in the ability to monitor deterioration requires an increase in the use of specific and relevant skills. The systematic physical assessment suggests that physical assessment is an “all or nothing” activity aimed at diagnosing rather than an activity focused on monitoring actual or potential problems.
Nurse researchers have explored the choice and range of assessment skills taught to nurses. Secrest et al. (2005) compared the skills taught in undergraduate programs with those nurses said they actually used. Although nurse educators confirmed that they taught 92% of a potential 120 assessment skills, only 29% were used daily or weekly and 37% were never used. Similarly, Giddens (2007) identified 30 core nursing skills routinely performed by nurses from a list of 126 identified from nursing assessment textbooks. All of the core skills routinely used involved inspection and palpation with the exception of auscultation of the lungs, heart, and abdomen. The emphasis of the core skills was on assessment of cardiovascular and respiratory status, suggesting that these are the skills considered by nurses to be most beneficial to patient outcomes.
This research confirms that many of the skills routinely taught to undergraduate and postgraduate nurses are never used in practice. The skills taught mimic those taught to medical students despite the belief that many of them do not contribute to nursing care. Giddens (2007) suggested that nurses need more skill in the observation and recognition of cues indicative of changes in patient status rather than the current wide range of physical assessment skills taught. Kitson (1996) suggested that an image of contemporary nurses as advanced practitioners is being presented. She does not believe that all nurses need or want these advanced skills.
The discrepancy between what is taught and what is practiced reflects an ambiguity in the purpose of physical assessment for nursing practice. To identify which skills are relevant to practice, a clear understanding of the purpose of physical assessment within nursing is needed. Rather than focusing on which skills nurses need or want, the focus should be on identifying which skills contribute to nursing’s purpose—that of improving patient outcomes.
Identifying a Purpose
Much of the literature on the inclusion of systematic physical assessment into nursing is based on the belief that a more detailed physical assessment will improve patient outcomes (Crighton & Winter, 1997; Lesa & Dixon, 2007; West, 2006), yet there is little research linking physical assessment with patient outcomes. One of the ways in which physical assessment is thought to improve patient outcomes is by detecting deterioration early enough to prevent serious complications or death (Considine, 2005; Wheeldon, 2005). Although monitoring patient safety is considered an accepted use for physical assessment findings, diagnosis is more controversial, with nursing opting for a nursing diagnosis as the outcome of its physical assessment (Baid, 2006; Jarvis, 2004). However, the advent of specialist nurse roles, such as the nurse practitioner, has made the diagnosis of disease a legitimate nursing function.
Current nursing assessment textbooks focus on the identification of physical signs and link them to the diagnosis of disease (Cook & Smith, 2004; Jarvis, 2004; Weber & Kelley, 2007). This emphasis within nursing assessment textbooks supports the positivist paradigm, particularly in relation to diagnosis. There is minimal or no content related to monitoring for recognizing deterioration (Cook & Smith, 2004) or using assessment to understand or individualize the patient’s experience. It is no wonder nurses are uncertain as to the purpose of their physical assessment, with many performing a medically focused assessment (Lillibridge & Wilson, 1999). The overall impression is that nurses use physical assessment to support medical practice but have a limited view of the role of physical assessment in supporting nursing practice.
This uncertainly over the purpose of the physical assessment in nursing is not helped by the knowledge that the medical diagnosis of diseases such as pneumonia is often more useful in determining the next actions and patient outcomes than the nursing diagnosis of decreased oxygenation. Although nurses contend that medical diagnosis is not their role, like physicians they need to work through a process of ruling out differential diagnoses to know which areas to focus on in their assessment of the patient and how to respond in emergency situations. Nurses are expected to know and act on critical diagnoses such as myocardial infarction independent of and prior to calling the physician (Group & Roberts, 2001). This creates tension for the nurse, who uses differential diagnosis to identify areas to assess but then is limited to developing nursing diagnoses as an outcome.
A less obvious purpose of physical assessment but one that is no less important is that of enhancing communication and caring opportunities with the patient. The incorporation of physical assessment into the nurse’s everyday practice brings the nurse to the bedside—touching, observing, and communicating with the patient. Physical assessment can provide an opportunity to take time to be with the patient, an important component in developing a therapeutic relationship. It is not only a fact-finding activity, but also serves to place the patient at the center of the nurse’s attention. Patients get a sense that the nurse is “really looking” at them and is concerned about them and that they really matter. This is the essence of caring (Benner & Wrubel, 1989; Leininger, 1984), and patients are often left feeling dissatisfied with the care they have received when it does not occur (Benner, 2004; Lumby, 2001).
A physical assessment that follows a strictly positivist perspective has the potential to deflect attention away from the patient experience and history. The physical assessment can distance the patient by depersonalizing the interaction and placing the patient in a subordinate position to the nurse (Bishop & Scudder, 2003). When nurses act in this way, they disembody and disempower the patient. However, this criticism can be overcome by the way in which nurses complete their assessments.
Doane (2002) stated that nurses have the ability to make a difference to patient outcomes by engaging in respectful, compassionate, and authentically interested inquiry into their experiences. She referred to this engagement as relational practice. The ability to engage in relational practice is often overshadowed by the emphasis on mechanistic models of practice, such as the systematic physical assessment following a positivistic perspective. Incorporating an interpretive perspective into the teaching and application of physical assessment skills would enhance the nurse’s ability to engage in relational practice.
Given the reduction in the length of hospital stay and the increase in patient age and acuity, it is clear that nurses must cope with sicker patients, more complex technology, more difficulties in coordination with more specialized caregivers, and physicians who are “not present in the hospital or easily accessible for direct consultation” (Group & Roberts, 2001, p. 287). As a result of these changes, the monitoring purpose of physical assessment will take on even more importance in the acute care setting. Thus, the need for nurses to improve the quality of their assessments of patients is real. Increasing nurses’ understanding and use of physical assessment skills is needed to recognize deterioration early and to improve patient outcomes. However, it is not clear that the systematic physical assessment is the best way to achieve this.
The opportunity for nurses to assess subtle individual change is decreasing as they spend more of their time away from the bedside and in patient management systems (Allen, 2007; Nelson & Purkis, 2004). The current emphasis on systematic physical assessment directs attention away from getting to know the patient and the assessment of individual patient change, which may be more significant in recognizing deterioration and preventing adverse events. In addition, the wide range of skills taught with little thought to their purpose leaves many nurses questioning the benefits to patient care and outcomes. Emphasis on systematic assessment and the acquisition of advanced assessment skills used simultaneously by physicians creates overlap at the expense of assessment of other important patient needs and decreases the amount of time available for nurses to learn and gain the required skill level needed for safe and competent practice.
Changes in technology, patient acuity, systems of practice, and political and economic constraints have the potential to influence and shape the way nurses perform their assessment and monitoring role, as do the underlying beliefs about the purpose and goals of physical assessment. Nurse educators play an important role in establishing the type of physical assessment and its purpose and the skills most beneficial to patient outcomes. They also have a responsibility for translating theory into practice by teaching physical assessment in a responsible and context-specific manner (Haigh, 2008).
Nurses have a limited amount of time with each patient. They also have a limited amount of time to learn and master the skills needed for safe, competent practice. Doane and Varcoe (2005) maintained that all theory is already practice and thus an:
...opportunity for theory development—for rethinking the ideas, assumptions, beliefs, and theories that govern our practice by examining the consequences of them.
It is time nurse educators recognize and value the practice that is already occurring. Rather than seeing the lack of skill use as a flaw within nursing practice, it should be used to guide our understanding and education of the skills that are most useful to improving patient outcomes.
The systematic physical assessment currently taught is an apparent sacred cow within nursing. It follows the positivist paradigm of monitoring generalized signs and symptoms and has the diagnosis of disease as its main outcome. Recent research has identified the skills registered nurses use most frequently in practice. Nurses are demonstrating the physical assessment skills they feel are most relevant for everyday nursing practice and improving patient outcomes by their actions.
Further research into the consequences of using these skills on patient outcomes would confirm that this is the case. In the meantime, it is recommended that nurse educators limit the teaching of physical assessment skills to those considered most relevant to everyday nursing practice. Additional skills can be learned within the specific context in which practice occurs. Teaching nurses how to use these specific skills from a balanced perspective, which includes both positivist and interpretive perspectives, will ultimately serve nursing’s purpose—to improve patient outcomes.
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