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The effectiveness of an education program to teach Australian nurses comprehensive physical assessment skills
NursrEdurofron Today (1990) 10,206? 0 Longman Group UK Ltd 1990
02606917/9010010-0206/$10.00
14
The effectiveness of an education program to teach Australian nurses comprehensive physical assessment skills Linda L Reaby
This study investigates the effectiveness of an educational program to teach 22 registered nurses comprehensive physical assessment skills. Administration of questionnaires and tests provided measures of the nurses: a) h) c) d)
use of physical assessment skills; knowledge of physical assessment; changes in nursing practice since learning the skills; barriers to the use of these learned skills.
The major post program findings regarding increases in the nurses’ knowledge and use of physical assessment skills, positive changes in their nursing practice and lack of barriers to their use of these skills indicates that the participants did benefit from this educational experience.
INTRODUCTION Few nurses have been taught comprehensive physical assessment skills or are qualified to use them. Consequently, they undervalue the importance of such essential skills in daily assessment of patients (Potter 1985). This attitude has been perpetuated in Australia by the past and current preparation for nurse registration which has placed little or no emphasis on the teaching or role of the nurse in the physical assessment of
Linda Reaby MEd RN BSc Nursing Grad Dip Ed, Senior Lecturer, School of Applied Science, University of Canberra, PO Box 1, Belconnen ACT, Australia 2616. (Requests for offprints to LR) Manuscript accepted 20 January 1990
206
patients. In many instances, these assessment skills have been learned on the job without an adequate theoretical base games 8~Reaby 1987). James and Reaby (1988) surveyed 25 tertiary institutions throughout Australia who offered established undergraduate nursing programs. The results showed that only four of these institutions included the teaching of comprehensive physical assessment skills in the curriculum. James (1988) conducted a study which examined the clinical application of physical assessment skills by 827 nurses in the Australian Capital Territory (ACT). James concluded that none of the nurses who participated in her study used a comprehensive approach to the physical assessment of patients in their nursing practice. Two reasons were frequently provided by the respondents for not using a skili. One reason was
NURSE EDUCATION
that the skill ‘was not required
in current
practice
area’ and the other reason was that it had ‘never been taught’ to them (p 199). However, mately 93% of the respondents
approxi-
were interested
in attending an educational program to learn a comprehensive approach to the physical assessment of patients. Thus, it has been demonstrated a need
and
a demand
development
in the
of educational
nurses comprehensive
that there was ACT
for
programs
to teach
physical assessment
In 1987 such a program
the
207
TODAY
The program The
physical
developed
assessment
skills
program
was
from
Malcolm Knowles’ ( 1980) theory of androgogy. The term ‘androgogy’ was coined by Knowles to distinguish between what he called the ‘art and science of helping adults to learn’
and the traditional
children
method
of teaching
(p 19). This theory contains
two major
principles:
skills.
was offered.
1) adult students build new skills on their past knowledge and already developed skills; 2) adult students must see the relevance of learning the skills and be able to apply them in their work situation.
THE STUDY Definition of terms Registered nurse or nurse: Any references registered nurse or nurse should read qualified
nurse who has successfully
to a as a
undertaken
an accredited course of nurse education to registration in a State or a Territory.
leading
Comprehensive physical assessment: This approach is simply a way for a nurse to look at, feel and listen to the parts of the body that make up the whole patient.
Four specific techniques
are used
during the physical assessment: inspection, patation, percussion, and auscultation. information
gathered
is then compared
pattern or characteristics in a healthy height,
person
palThe
with the
The
program
held
over
taught
by eight
registered leaders
consisted
of five S-hour
a 5-day-period. program
nurse
worked
The leaders
academics.
classes
nurses
These
were
who
were
program
in pairs and were required
to
teach one of four specific areas: 1) head and neck; 2) the nervous
system;
3) heart and lungs; 4) breast, abdomen The
program’s
and genitalia
educational
based on the following
objectives
were
principles:
that would be expected
of the patient’s
same age,
weight and so on.
physical assessment tised frequently;
skills need to be prac-
all body systems need to be assessed; physical assessment should be based on the paramaters
The sample Nurses selected for the program
were employed
found in healthy
individuals.
The students were initially given the pertinent anatomy and physiology related to the various
in those health agencies which participated in the survey by James (1988). Directors of Nursing
physical assessment then demonstrated
from the various agencies were asked to nominate a specific number of nurses who were
skills. Finally, the students were given opportunities to practise the skills. These types of
employed
mainly in adult care areas. A total of
activities
22 nurses
were selected:
determine
14 from
three
acute
care hospitals, two from a nursing home, and six from the community health service.
allowed
skills. The program leaders the correct ways to use the
the
if students
program
leaders
had the necessary
ledge base, and whether skills correctly.
to
know-
they were using
the
208
NURSE EDUCATION
TODAY
cipants
Major questions and assumptions of the study The
study
addressed
the
following
major
questions.
in improving
participants 2. Do the
the
knowledge
participants,
after
completing
the
skills in their
practice?
b) perceive any change tice
of the
in physical assessment?
program: a) use more physical assessment nursing
program
as
a
direct
comprehensive
in their nursing result
of
prac-
learning
physical assessment
skills?
c) encounter certain barriers that inhibit or prevent them from using the learned skills? A number
of assumptions
initiating this study. A formal educational the knowledge
were made prior to program
can influence
of the participants
use of physical assessment
and their
skills.
The increased knowledge of physical assessment skills will lead to increased use of the
36 physical assessment five main areas:
on the first morning of them completed
post-program
measured
by pre- and post-learning
tests.
envelopes.
tionnaire
was eliminated
One
of the program.
the preceding
month.
respondent’s
pre- and post-program
A comparison
results.
the
areas
five assessment
skills. Percentages
The and
figure the
of use are given for each skill
since the pre- and post-program varied.
sample
20 question
test was designed.
to the
nurses undertaking
program
leaders
a degree conversion
to ascertain
its validity.
tionnaires
types of responses,
were distributed
these ques-
to the program
lead-
ers and 22 nurses in a degree conversion nursing program. They were requested to comment on the questionnaires. As a result, only slight modifications were made to these instruments. The questionnaires concentrated on the parti-
20
nursing
No changes
The
same test was used for collecting
the pre-
data. The pre-test
was given
of the program
and all the
completed it (n = 22). The post-test to the participants 3 months after
Use of physical assessment skills questionnaires: Two
elicit the desired
It was and
were made in the test as a result of this exercise.
and returned by 77% of the participants via self-addressed pre-paid envelopes.
skills by the participants. In order to verify that the questions were easily understood and would
sizes
Knowledge of physical assessment test: A multiple
they completed
devel-
shows
associated
The study’s instruments were
in
between
use of skills indicated
in the post-program
participants was mailed
questionnaires
ques-
because she wrote on it
that 33 of the 36 skills were used more frequently
on the first morning
self-administered
the
by self-addressed
that she had not given direct care to patients
and post-program
oped to collect pre- and post-program data regarding current uses of physical assessment
into
and returned
questionnaire
pre-paid
program can be
on
head and neck, chest,
Seventeen
choice
of physical assessment
skills were organised
general,
tionnaire
administered
questionnaires.
to indicate
abdomen, and nervous system. All of the 22 participants completed the pre-program ques-
The use of physical assessment skills can be measured by self-administered pre- and postprogram
skills before
those skills used in the last month. The
skills.
The knowledge
assessment
were asked in the questionnaires checklists
1. To what extent does an educational assist
use of physical
commencing the program and 3 months after they completed the program. The respondents
the program.
It was completed (n = 17)
The instrument tested knowledge in four main areas of physical assessment: head and neck, chest, abdomen and genitalia, system. It was used to determine pants’ knowledge
and nervous the partici-
of:
terms used in physical assessment; physical assessment techniques (inspection, palpatation, auscultation, percussion); anatomical structures assessed when using the skills; physiological capacities and functions.
nURSE
GENERAL 1. Assess
2. Assess
3. Assess
4. valuate
blood
body
6. Examine
7.
Test
SKILLS
pressure
of respiration
pulses
5. Tes!
of extremiliw
for skin
torgw
for skin lesions
for pitting
oedema 40
6.0 Percantage
HEAD 8. Assess
AND
NECK
fundus
10. Examine
13. Examine
internal
internal
lymph
16. Assess
17. Assess
for jugular
carotid
of neck
pulses
distension 40
20
60
Percentage
A sign test significance responses results
n
Pre-program
was undertaken to measure the of the difference in correct
between
indicated
the pre- and post-tests. that
a marked
change
The had
occurred. Out of the 20 test questions analysed, 19 recorded positive signs and one recorded a negative
sign. The
frequency
of occurrence
of
use
Post-program
Chunges
in
nursing
practice:
Changes
in
the
sample’s attitudes since completing the program were measured. This was accomplished by the respondents ticking yes or no to six statements which identified those attitudes concerning increased
confidence,
relationships, nursing
and
improved initiation
of
nurse-patient independent
actions,
these signs was determined by using Sharp’s (1979 p 355) binominal distribution table which indicated that p = 0.00 1. The results of this test
nurses reported
are shown in Table
nursing
1.
100
nose
0
n
60
ear
pharynx
nodes
venous
SKILLS
of mouth
14. Examine
15. Palpate
100
eye
inner
structures
EXAMINATION
6.0 us*
of eye
external
11. Examine
12. Examine
209
TODAY
temperature
rate and depth
peripheral
EXAMINATION
EDUCATION
As summarised practice.
in Table feeling
2, over 76% ot the
more confident
All of the respondents
in their indi-
2 10
NURSE EDUCATION
TODAY
CHEST EXAMINATION SKILLS 18.
Palpate
thorax
for tactile
lremitus
19. Percuss 20. Auscultate
lungs
21. Palpate 22. Palpate
for breath
chest sounds
for breast
lumps
for axillary
i
node
“---“:“I
25.
.
Auscultate
heart
for
,
.
,
,
,
.
,
.
,
murmurs 0
60
40
20
Percentage
80
100
80
100
“*)b
ABDOMINAL EXAMINATION SKILLS 26. Auscultate
for bowel
sounds
w-
0
20
40
60
Parcentegs
NERVOUS SYSTEM 29. Examine
range
of motion
32
Assess
one or more muscle
cranial
strength
sensory
status
pupil
response
of any of the extremities 35. Assess
36. Assess
gait
nerve(s)
of extremities
33. Test 34. Test
SKILLS
of extremities
30. Observe 31. Test
EXAMINATION
“8b
deep tendon
coordination
reflexes
in
limbs
-0
. 2b
4b
,
Perc*ntago
n Figure Comparison participants.
cated
that
Preprogram
between pre-program
they were
better
able
n
and post-program
to interpret
I
60
80
100
use
Post-program use of physical assessment skills by program
Barriers lo the Use ofskills:
The participants
patient findings and 88% were more confident in reporting their findings to other health pro-
asked to give their reactions
fessionals. A large number (88%) felt they better understood the physicians’ progress notes and
which might comprehensive
physical examination data. The with interactions reported
were
by ticking either yes
or no to questions
about six suggested barriers them from using prevent physical assessment skills in their
majority patients
(7 1%) had
nursing practice. Table 3 outlines The barrier most frequently
improved since acquiring comprehensive cal assessment skills and 94% reported confidence in initiating nursing actions.
physimore
group
(23%)
these results. cited by the
was a lack of confidence
in using
the skills. Lack of support from nursing colleagues constituted a barrier for approximately
NURSE EDUCATION
Table 1 Sign test result for sample’s pre- and post-learning
correct responses in physical assessment
Pre-Test tn = 22) F
Question Nature of vocal fremitus Nature of vesicular breath sounds Venous pressure of the heart Percussion sound heard in 7th intercostal space Location of pulmonic area of the heart Location of optic disc Structures of the retinal arterioles Qualities of cerumen in the ear Correct use of tuning fork Purpose of the Rhinne test Function of the reflex arc Correct grading for a normal deep tendon reflex Location of the trigeminal nerve Means used to elicit the abdominal reflex Function of the hypoglossal nerve Best location of bowel sounds Sound of distended bladder Location of kidneys Timing of selfbreast examination Nodes palpable during a routine self-breast exam
5. 6. 7. 8. 9. IO. 11. 12.
13. 14. 15. 16. 17. 18. 19. 20.
TODAY
knowledge
2 11
tests
Post-Test in = 17) %
F
%
Sign
18.2
12
70.6
+
0
11
64.7
+
31.9
12
70.6
+
5
22.9
13
76.5
8
36.4
16
94.1
10
45.4
15
88.2
1
4.5
2
11.8
12
54.5
16
94.1
2
9.1
12
70.6
0
0
11
54.7
0
0
3
17.6
0
0
13
76.5
+
6
27.3
16
94.1
+
4
18.2
2
11.8
-
1
4.6
13
76.5
+
3
13.6
15
88.2
I
11 0
50.0 0
13 10
76.5 58.8
+ +
10
45.5
15
88.2
+
4
18.2
15
88.2
+
P = 0.001 PLUS = 19 MINUS = 1
18% of the sample. Lack of support from employers and immediate supervisors was indi-
DISCUSSION
cated as a barrier by less than 6% of the nurses. None
of
the
respondents
reported
lack
of
support from doctors nor lack of patients acceptante when using the physical assessment skills.
Adult learning professional
theory principles: experiences
The participants’
had educational
eftts for them which were evident
during
benthe
2 12
NURSE EDUCATION
TODAY
Table 2 Changes in nursing practice since completing
physical assessment skills program (n = 17) Yes F
Attitudes 1.
I am more confident in my
2.
I feel I can interpret patient
nursing practice. findings better. I understand the physician’s progress notes and examination data better My interactions with patients have improved I am more confident reporting my findings to other health professionals. I am more confident initiating nursino actions.
3.
4. 5.
6.
program.
This finding
is congruent
Knowles’ (1980) major principles: build new skills on their already familiar
with one of
adult students
past knowledge
and
developed skills. These nurses were with the medical and nursing termino-
logy used during the program.
They could relate
physical
back
assessment
findings
they had previously
nursed
share this information and their peers. ledge
learning
process.
helped
This group,
able to move through and physiology
and were able to
with the program
Additionally,
and experience
more
to patients
this prior
4
23.5
17
100.0
0
0
15
88.0
0
0
12
70.6
5
29.4
15
88.0
2
12.0
16
94.1
1
5.9
response
they were also checking
cerning
these
skills,
improved.
Moreover,
they were practice.
using
When analysed
know-
between
the
more
tests
there
and
and
indicated
their
knowledge
for example,
was
related to that knowledge.
nursing
questionnaires
was an apparent using
the
were
relationship of physical skills
which
This was particularly
true of the skills associated chest and abdomen.
markedly
skills in their
the participants’ and
others,
the participants
assessment
anatomy
the adequacy
of the third cranial nerve. After the nurses completed the program, their knowledge con-
leaders
undergra-
%
76.5
the
than
No F
13
to expedite
the preparatory quickly
%
with assessing
The respondents
the
gave more
duate nursing students who have little or no past nursing experiences.
correct responses in the post-test and indicated that they were using more of the skills associated
Knowledge and use of physical assessment skills: All
the
with these assessment the participants background
entered
knowledge
the program
with some
and experience
related
to physical assessment of patients. They, like the majority of nurses since the Nightingale era, had been assessing patients on a limited, and some-
nurses
practice,
did
not
knowledge
areas. use
Conversely,
the
relating
skills
when
in clinical
to the skills was not
evident. This was shown by the nurses’ poor post-learning results associated with inspecting the fundus of the eye and testing for deep tendon reflexes. The responses to the skills
times erroneous basis. This lack of knowledge when using a physical assessment skill was evi-
questionnaires
denced
or post-program. Only one nurse tested for deep tendon reflexes pre-program and two nurses tested these reflexes post-program.
in the pre-program
skills questionnaire.
For instance, 18 nurses indicated in the questionnaire that they tested pupil responses, and two nurses indicated they tested one or more cranial nerve(s). At least 16 of them did not realise
that
when
checking
a patient’s
pupil
indicated
that
the
participants
did not inspect the fundus of the eye either pre-
Such findings are not unexpected. These skills take time and considerable practice to master, especially
examining
the
fundus
of the
eye.
NURSE EDUCATlON
Table 3 Barriers to the use of physical assessment
skills (n = 17)
Yes 1.
2. 3. 4. 5. 6.
No
Barriers
F
Lack of support from employers. Lack of support from nursing colleagues. Lack of support from nursing supervisors. Lack of support from doctors. Lack of patient acceptance. Lack of personal confidence in performing the physical assessment skills
1
5.9
16
94.1
3
17.6
14
82.4
1 0 0
5.9 0 0
16 17 17
94.1 100.0 100.0
4
23.5
13
76.5
However,
community
working
primarily
competent
health nurses, and nurses with the elderly
at assessing
Many patients nursing homes hypertension conditions
the fundus
should
be
of the eye.
within the community and in have histories of long-standing
and diabetes can
cause
mellitus.
retinal
Since both
changes
in the
fundus of the eye these nurses should be assessing for such changes. The information gained from this assessment patients
would allow nurses to refer
when
changes
are
detection
can
prevent
complications
blindness
and allow patients
medical attention.
noted.
This
to receive
Not all patients
early
such
as
prompt
however who
enter an acute care setting need to have the fundi of their eyes inspected
by the nurse.
gained by such inspections patient care. Important certain
2 13
TODAY
questions
Do all nurses
need
data
would not augment
arise regarding
physical assessment
The
the use of
skills. to be competent
in
assessing the fundus of the eye and testing deep tendon Can sufficient
reflexes? competency
be acquired
by
F
%
Lynaugh
1975).
%
Nevertheless,
the nursing
and
medical profession need to work out answers to these questions and determine limits to their own programs. Post-program changes to nursing practice and barriers to the use of skills: The
majority
more
their
certain
about
of nurses
ability
patients’ findings after completing Additionally, standing
to
the program.
they felt they had a better
of the physician’s
were report
progress
under-
notes and
physical examination
data, and were more con-
fident
nursing
in
findings
initiating
were reported
actions.
in America
Brown and Bayer (1987). Suggested barriers to
the
use
Similar
by Brown, of
physical
assessment
skills, such as lack of support
employers,
doctors
cant problems pleted
the
or patients
for the nurses
program.
The
from
were not signifiafter
barrier
they comcited
most
often was lack of self-confidence in using the learned skills. Moreover, the group did indicate that it was mainly nursing
peers who most often
blocked
the use of physical
nursing
practice.
assessment
skills in
This finding is not unexpected
all nurses in using these skills?
since the majority
Should the time it takes to learn these skills be applied to other skills that are used more frequently?
assessment skills and therefore may not perceive these skills as being relevant to nursing practice.
Unfortunately, answers
these questions
and the practice
been
of nurses
taught
in the ACT
comprehensive
have
physical
have no simple
of medicine
is faced
with similar dilemmas. Physicians as well as nurses must accept limits to their depth of knowledge
never
and how much they can do (Bates &
CONCLUSION The participants who completed the physical assessment skills program showed dramatic
2 14
NURSE EDUCATION
improvement
in
TODAY
knowledge
and
use
of
the
learned skills, indicated that positive changes had occurred in their nursing practice as a result of learning barriers light
these
skills, and encountered
when implementing
of
this
evidence
few
the skills. In the
educational
challenge cational
nurses
must not only be given edu-
opportunities
to learn
comprehensive
physical assessment skills but must also receive encouragement from their peers in the clinical setting to use these vital skills.
programs
should be made available to all nurses who do not know how to incorporate comprehensive physical assessment The
major
skills into their nursing
emphasis
need to be on the relevance these
skills
Educators operate
to providing teaching
with nurse
practice.
of these programs
would
and relationship better
patient
such programs practitioners
of
care.
need to co-
in determining
which skills should be used on a regular basis. Future research should be undertaken to determine physical Additional how
the
why nurses use or do not use certain assessment
skills in the clinical
research use
of
is also necessary physical
nurses actually improves Comprehensive patients
presents
this challenge
assessment
skills
by
patient care.
physical Australian
their most significant meet
setting.
to consider
assessment nurses
new challenges. will largely
of
with one of
How they their
determine
future as independent, accountable members of the health care team. In order to meet this
References Bates B, Lynaugh J L 1975 Teaching physical assessment. Nursing Outlook 23, 3: 297-302 Brown M, Brown J, Biyer M 1987 Changing nursing practice through continuing education in physical assessment: Perceived barriers to implementation. The Journal of Continuing Education in Nursing 18, 4: 111-115 James J 1988 The Extent to which registered nurses in the ACT use physical assessment skills as a basis for nursing practice. Unpublished master’s thesis, Canberra College of Advanced Education, Australian Capital Territory. James J, Reaby L 1987 Physical assessment skills for RNs? The Australian Nurses lournal 17. 1: 39-4 1 James J, Reaby L 1988 Teaching physical assessment skills: The current state of the art. The Australian Nurses Journal 17, 6: 51-52, 62 Knowles M 1980 The modern practice of adult education. Follett, Chicago, IL Potter D (Ed) 1985 Assessment (Nursing 85 Books). Springhouse, Springhouse, PA Sh arp V F 1979 Statistics for the social sciences. Little, Brown & Company, Boston MA.
02606917/9010010-0206/$10.00
14
The effectiveness of an education program to teach Australian nurses comprehensive physical assessment skills Linda L Reaby
This study investigates the effectiveness of an educational program to teach 22 registered nurses comprehensive physical assessment skills. Administration of questionnaires and tests provided measures of the nurses: a) h) c) d)
use of physical assessment skills; knowledge of physical assessment; changes in nursing practice since learning the skills; barriers to the use of these learned skills.
The major post program findings regarding increases in the nurses’ knowledge and use of physical assessment skills, positive changes in their nursing practice and lack of barriers to their use of these skills indicates that the participants did benefit from this educational experience.
INTRODUCTION Few nurses have been taught comprehensive physical assessment skills or are qualified to use them. Consequently, they undervalue the importance of such essential skills in daily assessment of patients (Potter 1985). This attitude has been perpetuated in Australia by the past and current preparation for nurse registration which has placed little or no emphasis on the teaching or role of the nurse in the physical assessment of
Linda Reaby MEd RN BSc Nursing Grad Dip Ed, Senior Lecturer, School of Applied Science, University of Canberra, PO Box 1, Belconnen ACT, Australia 2616. (Requests for offprints to LR) Manuscript accepted 20 January 1990
206
patients. In many instances, these assessment skills have been learned on the job without an adequate theoretical base games 8~Reaby 1987). James and Reaby (1988) surveyed 25 tertiary institutions throughout Australia who offered established undergraduate nursing programs. The results showed that only four of these institutions included the teaching of comprehensive physical assessment skills in the curriculum. James (1988) conducted a study which examined the clinical application of physical assessment skills by 827 nurses in the Australian Capital Territory (ACT). James concluded that none of the nurses who participated in her study used a comprehensive approach to the physical assessment of patients in their nursing practice. Two reasons were frequently provided by the respondents for not using a skili. One reason was
NURSE EDUCATION
that the skill ‘was not required
in current
practice
area’ and the other reason was that it had ‘never been taught’ to them (p 199). However, mately 93% of the respondents
approxi-
were interested
in attending an educational program to learn a comprehensive approach to the physical assessment of patients. Thus, it has been demonstrated a need
and
a demand
development
in the
of educational
nurses comprehensive
that there was ACT
for
programs
to teach
physical assessment
In 1987 such a program
the
207
TODAY
The program The
physical
developed
assessment
skills
program
was
from
Malcolm Knowles’ ( 1980) theory of androgogy. The term ‘androgogy’ was coined by Knowles to distinguish between what he called the ‘art and science of helping adults to learn’
and the traditional
children
method
of teaching
(p 19). This theory contains
two major
principles:
skills.
was offered.
1) adult students build new skills on their past knowledge and already developed skills; 2) adult students must see the relevance of learning the skills and be able to apply them in their work situation.
THE STUDY Definition of terms Registered nurse or nurse: Any references registered nurse or nurse should read qualified
nurse who has successfully
to a as a
undertaken
an accredited course of nurse education to registration in a State or a Territory.
leading
Comprehensive physical assessment: This approach is simply a way for a nurse to look at, feel and listen to the parts of the body that make up the whole patient.
Four specific techniques
are used
during the physical assessment: inspection, patation, percussion, and auscultation. information
gathered
is then compared
pattern or characteristics in a healthy height,
person
palThe
with the
The
program
held
over
taught
by eight
registered leaders
consisted
of five S-hour
a 5-day-period. program
nurse
worked
The leaders
academics.
classes
nurses
These
were
who
were
program
in pairs and were required
to
teach one of four specific areas: 1) head and neck; 2) the nervous
system;
3) heart and lungs; 4) breast, abdomen The
program’s
and genitalia
educational
based on the following
objectives
were
principles:
that would be expected
of the patient’s
same age,
weight and so on.
physical assessment tised frequently;
skills need to be prac-
all body systems need to be assessed; physical assessment should be based on the paramaters
The sample Nurses selected for the program
were employed
found in healthy
individuals.
The students were initially given the pertinent anatomy and physiology related to the various
in those health agencies which participated in the survey by James (1988). Directors of Nursing
physical assessment then demonstrated
from the various agencies were asked to nominate a specific number of nurses who were
skills. Finally, the students were given opportunities to practise the skills. These types of
employed
mainly in adult care areas. A total of
activities
22 nurses
were selected:
determine
14 from
three
acute
care hospitals, two from a nursing home, and six from the community health service.
allowed
skills. The program leaders the correct ways to use the
the
if students
program
leaders
had the necessary
ledge base, and whether skills correctly.
to
know-
they were using
the
208
NURSE EDUCATION
TODAY
cipants
Major questions and assumptions of the study The
study
addressed
the
following
major
questions.
in improving
participants 2. Do the
the
knowledge
participants,
after
completing
the
skills in their
practice?
b) perceive any change tice
of the
in physical assessment?
program: a) use more physical assessment nursing
program
as
a
direct
comprehensive
in their nursing result
of
prac-
learning
physical assessment
skills?
c) encounter certain barriers that inhibit or prevent them from using the learned skills? A number
of assumptions
initiating this study. A formal educational the knowledge
were made prior to program
can influence
of the participants
use of physical assessment
and their
skills.
The increased knowledge of physical assessment skills will lead to increased use of the
36 physical assessment five main areas:
on the first morning of them completed
post-program
measured
by pre- and post-learning
tests.
envelopes.
tionnaire
was eliminated
One
of the program.
the preceding
month.
respondent’s
pre- and post-program
A comparison
results.
the
areas
five assessment
skills. Percentages
The and
figure the
of use are given for each skill
since the pre- and post-program varied.
sample
20 question
test was designed.
to the
nurses undertaking
program
leaders
a degree conversion
to ascertain
its validity.
tionnaires
types of responses,
were distributed
these ques-
to the program
lead-
ers and 22 nurses in a degree conversion nursing program. They were requested to comment on the questionnaires. As a result, only slight modifications were made to these instruments. The questionnaires concentrated on the parti-
20
nursing
No changes
The
same test was used for collecting
the pre-
data. The pre-test
was given
of the program
and all the
completed it (n = 22). The post-test to the participants 3 months after
Use of physical assessment skills questionnaires: Two
elicit the desired
It was and
were made in the test as a result of this exercise.
and returned by 77% of the participants via self-addressed pre-paid envelopes.
skills by the participants. In order to verify that the questions were easily understood and would
sizes
Knowledge of physical assessment test: A multiple
they completed
devel-
shows
associated
The study’s instruments were
in
between
use of skills indicated
in the post-program
participants was mailed
questionnaires
ques-
because she wrote on it
that 33 of the 36 skills were used more frequently
on the first morning
self-administered
the
by self-addressed
that she had not given direct care to patients
and post-program
oped to collect pre- and post-program data regarding current uses of physical assessment
into
and returned
questionnaire
pre-paid
program can be
on
head and neck, chest,
Seventeen
choice
of physical assessment
skills were organised
general,
tionnaire
administered
questionnaires.
to indicate
abdomen, and nervous system. All of the 22 participants completed the pre-program ques-
The use of physical assessment skills can be measured by self-administered pre- and postprogram
skills before
those skills used in the last month. The
skills.
The knowledge
assessment
were asked in the questionnaires checklists
1. To what extent does an educational assist
use of physical
commencing the program and 3 months after they completed the program. The respondents
the program.
It was completed (n = 17)
The instrument tested knowledge in four main areas of physical assessment: head and neck, chest, abdomen and genitalia, system. It was used to determine pants’ knowledge
and nervous the partici-
of:
terms used in physical assessment; physical assessment techniques (inspection, palpatation, auscultation, percussion); anatomical structures assessed when using the skills; physiological capacities and functions.
nURSE
GENERAL 1. Assess
2. Assess
3. Assess
4. valuate
blood
body
6. Examine
7.
Test
SKILLS
pressure
of respiration
pulses
5. Tes!
of extremiliw
for skin
torgw
for skin lesions
for pitting
oedema 40
6.0 Percantage
HEAD 8. Assess
AND
NECK
fundus
10. Examine
13. Examine
internal
internal
lymph
16. Assess
17. Assess
for jugular
carotid
of neck
pulses
distension 40
20
60
Percentage
A sign test significance responses results
n
Pre-program
was undertaken to measure the of the difference in correct
between
indicated
the pre- and post-tests. that
a marked
change
The had
occurred. Out of the 20 test questions analysed, 19 recorded positive signs and one recorded a negative
sign. The
frequency
of occurrence
of
use
Post-program
Chunges
in
nursing
practice:
Changes
in
the
sample’s attitudes since completing the program were measured. This was accomplished by the respondents ticking yes or no to six statements which identified those attitudes concerning increased
confidence,
relationships, nursing
and
improved initiation
of
nurse-patient independent
actions,
these signs was determined by using Sharp’s (1979 p 355) binominal distribution table which indicated that p = 0.00 1. The results of this test
nurses reported
are shown in Table
nursing
1.
100
nose
0
n
60
ear
pharynx
nodes
venous
SKILLS
of mouth
14. Examine
15. Palpate
100
eye
inner
structures
EXAMINATION
6.0 us*
of eye
external
11. Examine
12. Examine
209
TODAY
temperature
rate and depth
peripheral
EXAMINATION
EDUCATION
As summarised practice.
in Table feeling
2, over 76% ot the
more confident
All of the respondents
in their indi-
2 10
NURSE EDUCATION
TODAY
CHEST EXAMINATION SKILLS 18.
Palpate
thorax
for tactile
lremitus
19. Percuss 20. Auscultate
lungs
21. Palpate 22. Palpate
for breath
chest sounds
for breast
lumps
for axillary
i
node
“---“:“I
25.
.
Auscultate
heart
for
,
.
,
,
,
.
,
.
,
murmurs 0
60
40
20
Percentage
80
100
80
100
“*)b
ABDOMINAL EXAMINATION SKILLS 26. Auscultate
for bowel
sounds
w-
0
20
40
60
Parcentegs
NERVOUS SYSTEM 29. Examine
range
of motion
32
Assess
one or more muscle
cranial
strength
sensory
status
pupil
response
of any of the extremities 35. Assess
36. Assess
gait
nerve(s)
of extremities
33. Test 34. Test
SKILLS
of extremities
30. Observe 31. Test
EXAMINATION
“8b
deep tendon
coordination
reflexes
in
limbs
-0
. 2b
4b
,
Perc*ntago
n Figure Comparison participants.
cated
that
Preprogram
between pre-program
they were
better
able
n
and post-program
to interpret
I
60
80
100
use
Post-program use of physical assessment skills by program
Barriers lo the Use ofskills:
The participants
patient findings and 88% were more confident in reporting their findings to other health pro-
asked to give their reactions
fessionals. A large number (88%) felt they better understood the physicians’ progress notes and
which might comprehensive
physical examination data. The with interactions reported
were
by ticking either yes
or no to questions
about six suggested barriers them from using prevent physical assessment skills in their
majority patients
(7 1%) had
nursing practice. Table 3 outlines The barrier most frequently
improved since acquiring comprehensive cal assessment skills and 94% reported confidence in initiating nursing actions.
physimore
group
(23%)
these results. cited by the
was a lack of confidence
in using
the skills. Lack of support from nursing colleagues constituted a barrier for approximately
NURSE EDUCATION
Table 1 Sign test result for sample’s pre- and post-learning
correct responses in physical assessment
Pre-Test tn = 22) F
Question Nature of vocal fremitus Nature of vesicular breath sounds Venous pressure of the heart Percussion sound heard in 7th intercostal space Location of pulmonic area of the heart Location of optic disc Structures of the retinal arterioles Qualities of cerumen in the ear Correct use of tuning fork Purpose of the Rhinne test Function of the reflex arc Correct grading for a normal deep tendon reflex Location of the trigeminal nerve Means used to elicit the abdominal reflex Function of the hypoglossal nerve Best location of bowel sounds Sound of distended bladder Location of kidneys Timing of selfbreast examination Nodes palpable during a routine self-breast exam
5. 6. 7. 8. 9. IO. 11. 12.
13. 14. 15. 16. 17. 18. 19. 20.
TODAY
knowledge
2 11
tests
Post-Test in = 17) %
F
%
Sign
18.2
12
70.6
+
0
11
64.7
+
31.9
12
70.6
+
5
22.9
13
76.5
8
36.4
16
94.1
10
45.4
15
88.2
1
4.5
2
11.8
12
54.5
16
94.1
2
9.1
12
70.6
0
0
11
54.7
0
0
3
17.6
0
0
13
76.5
+
6
27.3
16
94.1
+
4
18.2
2
11.8
-
1
4.6
13
76.5
+
3
13.6
15
88.2
I
11 0
50.0 0
13 10
76.5 58.8
+ +
10
45.5
15
88.2
+
4
18.2
15
88.2
+
P = 0.001 PLUS = 19 MINUS = 1
18% of the sample. Lack of support from employers and immediate supervisors was indi-
DISCUSSION
cated as a barrier by less than 6% of the nurses. None
of
the
respondents
reported
lack
of
support from doctors nor lack of patients acceptante when using the physical assessment skills.
Adult learning professional
theory principles: experiences
The participants’
had educational
eftts for them which were evident
during
benthe
2 12
NURSE EDUCATION
TODAY
Table 2 Changes in nursing practice since completing
physical assessment skills program (n = 17) Yes F
Attitudes 1.
I am more confident in my
2.
I feel I can interpret patient
nursing practice. findings better. I understand the physician’s progress notes and examination data better My interactions with patients have improved I am more confident reporting my findings to other health professionals. I am more confident initiating nursino actions.
3.
4. 5.
6.
program.
This finding
is congruent
Knowles’ (1980) major principles: build new skills on their already familiar
with one of
adult students
past knowledge
and
developed skills. These nurses were with the medical and nursing termino-
logy used during the program.
They could relate
physical
back
assessment
findings
they had previously
nursed
share this information and their peers. ledge
learning
process.
helped
This group,
able to move through and physiology
and were able to
with the program
Additionally,
and experience
more
to patients
this prior
4
23.5
17
100.0
0
0
15
88.0
0
0
12
70.6
5
29.4
15
88.0
2
12.0
16
94.1
1
5.9
response
they were also checking
cerning
these
skills,
improved.
Moreover,
they were practice.
using
When analysed
know-
between
the
more
tests
there
and
and
indicated
their
knowledge
for example,
was
related to that knowledge.
nursing
questionnaires
was an apparent using
the
were
relationship of physical skills
which
This was particularly
true of the skills associated chest and abdomen.
markedly
skills in their
the participants’ and
others,
the participants
assessment
anatomy
the adequacy
of the third cranial nerve. After the nurses completed the program, their knowledge con-
leaders
undergra-
%
76.5
the
than
No F
13
to expedite
the preparatory quickly
%
with assessing
The respondents
the
gave more
duate nursing students who have little or no past nursing experiences.
correct responses in the post-test and indicated that they were using more of the skills associated
Knowledge and use of physical assessment skills: All
the
with these assessment the participants background
entered
knowledge
the program
with some
and experience
related
to physical assessment of patients. They, like the majority of nurses since the Nightingale era, had been assessing patients on a limited, and some-
nurses
practice,
did
not
knowledge
areas. use
Conversely,
the
relating
skills
when
in clinical
to the skills was not
evident. This was shown by the nurses’ poor post-learning results associated with inspecting the fundus of the eye and testing for deep tendon reflexes. The responses to the skills
times erroneous basis. This lack of knowledge when using a physical assessment skill was evi-
questionnaires
denced
or post-program. Only one nurse tested for deep tendon reflexes pre-program and two nurses tested these reflexes post-program.
in the pre-program
skills questionnaire.
For instance, 18 nurses indicated in the questionnaire that they tested pupil responses, and two nurses indicated they tested one or more cranial nerve(s). At least 16 of them did not realise
that
when
checking
a patient’s
pupil
indicated
that
the
participants
did not inspect the fundus of the eye either pre-
Such findings are not unexpected. These skills take time and considerable practice to master, especially
examining
the
fundus
of the
eye.
NURSE EDUCATlON
Table 3 Barriers to the use of physical assessment
skills (n = 17)
Yes 1.
2. 3. 4. 5. 6.
No
Barriers
F
Lack of support from employers. Lack of support from nursing colleagues. Lack of support from nursing supervisors. Lack of support from doctors. Lack of patient acceptance. Lack of personal confidence in performing the physical assessment skills
1
5.9
16
94.1
3
17.6
14
82.4
1 0 0
5.9 0 0
16 17 17
94.1 100.0 100.0
4
23.5
13
76.5
However,
community
working
primarily
competent
health nurses, and nurses with the elderly
at assessing
Many patients nursing homes hypertension conditions
the fundus
should
be
of the eye.
within the community and in have histories of long-standing
and diabetes can
cause
mellitus.
retinal
Since both
changes
in the
fundus of the eye these nurses should be assessing for such changes. The information gained from this assessment patients
would allow nurses to refer
when
changes
are
detection
can
prevent
complications
blindness
and allow patients
medical attention.
noted.
This
to receive
Not all patients
early
such
as
prompt
however who
enter an acute care setting need to have the fundi of their eyes inspected
by the nurse.
gained by such inspections patient care. Important certain
2 13
TODAY
questions
Do all nurses
need
data
would not augment
arise regarding
physical assessment
The
the use of
skills. to be competent
in
assessing the fundus of the eye and testing deep tendon Can sufficient
reflexes? competency
be acquired
by
F
%
Lynaugh
1975).
%
Nevertheless,
the nursing
and
medical profession need to work out answers to these questions and determine limits to their own programs. Post-program changes to nursing practice and barriers to the use of skills: The
majority
more
their
certain
about
of nurses
ability
patients’ findings after completing Additionally, standing
to
the program.
they felt they had a better
of the physician’s
were report
progress
under-
notes and
physical examination
data, and were more con-
fident
nursing
in
findings
initiating
were reported
actions.
in America
Brown and Bayer (1987). Suggested barriers to
the
use
Similar
by Brown, of
physical
assessment
skills, such as lack of support
employers,
doctors
cant problems pleted
the
or patients
for the nurses
program.
The
from
were not signifiafter
barrier
they comcited
most
often was lack of self-confidence in using the learned skills. Moreover, the group did indicate that it was mainly nursing
peers who most often
blocked
the use of physical
nursing
practice.
assessment
skills in
This finding is not unexpected
all nurses in using these skills?
since the majority
Should the time it takes to learn these skills be applied to other skills that are used more frequently?
assessment skills and therefore may not perceive these skills as being relevant to nursing practice.
Unfortunately, answers
these questions
and the practice
been
of nurses
taught
in the ACT
comprehensive
have
physical
have no simple
of medicine
is faced
with similar dilemmas. Physicians as well as nurses must accept limits to their depth of knowledge
never
and how much they can do (Bates &
CONCLUSION The participants who completed the physical assessment skills program showed dramatic
2 14
NURSE EDUCATION
improvement
in
TODAY
knowledge
and
use
of
the
learned skills, indicated that positive changes had occurred in their nursing practice as a result of learning barriers light
these
skills, and encountered
when implementing
of
this
evidence
few
the skills. In the
educational
challenge cational
nurses
must not only be given edu-
opportunities
to learn
comprehensive
physical assessment skills but must also receive encouragement from their peers in the clinical setting to use these vital skills.
programs
should be made available to all nurses who do not know how to incorporate comprehensive physical assessment The
major
skills into their nursing
emphasis
need to be on the relevance these
skills
Educators operate
to providing teaching
with nurse
practice.
of these programs
would
and relationship better
patient
such programs practitioners
of
care.
need to co-
in determining
which skills should be used on a regular basis. Future research should be undertaken to determine physical Additional how
the
why nurses use or do not use certain assessment
skills in the clinical
research use
of
is also necessary physical
nurses actually improves Comprehensive patients
presents
this challenge
assessment
skills
by
patient care.
physical Australian
their most significant meet
setting.
to consider
assessment nurses
new challenges. will largely
of
with one of
How they their
determine
future as independent, accountable members of the health care team. In order to meet this
References Bates B, Lynaugh J L 1975 Teaching physical assessment. Nursing Outlook 23, 3: 297-302 Brown M, Brown J, Biyer M 1987 Changing nursing practice through continuing education in physical assessment: Perceived barriers to implementation. The Journal of Continuing Education in Nursing 18, 4: 111-115 James J 1988 The Extent to which registered nurses in the ACT use physical assessment skills as a basis for nursing practice. Unpublished master’s thesis, Canberra College of Advanced Education, Australian Capital Territory. James J, Reaby L 1987 Physical assessment skills for RNs? The Australian Nurses lournal 17. 1: 39-4 1 James J, Reaby L 1988 Teaching physical assessment skills: The current state of the art. The Australian Nurses Journal 17, 6: 51-52, 62 Knowles M 1980 The modern practice of adult education. Follett, Chicago, IL Potter D (Ed) 1985 Assessment (Nursing 85 Books). Springhouse, Springhouse, PA Sh arp V F 1979 Statistics for the social sciences. Little, Brown & Company, Boston MA.