A survey of Physical examination skills taught in undergraduate Nursing Programs: Are we teaching too Much?

Jean Foret Giddens, PhD, rN; and Linda eddy, PhD, rN, cPNP

Because content saturation is a growing concern, as reflected in the nursing literature, the content taught in undergraduate nursing curricula should be critically examined. The purpose of this descriptive cross-sectional research was to determine and analyze the physical assessment content currently taught in undergraduate nursing programs. A total of 198 individuals teaching in undergraduate nursing programs completed a Web-based survey. Of the 122 skills included on the survey, 81% were reportedly being taught in most of the nursing programs. Total scores for 18 systems-based assessment categories were significantly different among associate and baccalaureate nursing programs in all but three categories: assessment of integument, breast, and female genitals. Previous research has shown that nurses use less than 25% of these same skills regularly in clinical practice, regardless of their educational preparation. Findings from this research raise questions about the breadth to which physical examination content should be taught in undergraduate nursing education.

AbstrAct

ssessment is unquestionably a fundamental skill performed by all nurses in clinical practice. Assessment data provide the foundation on which nurses base their decisions, interventions, and evaluations. Previous research has shown that nurses in clinical practice use a limited number of skills when conducting a physical assessment (Giddens, 2007), and no differences in the physical examinations performed were found on the basis of nurses educational preparation (Giddens, 2006). Findings from those studies raised questions about what physical assessment content is taught in undergraduate nursing programs, as well as the differences in physical assessment taught in associate degree (ADN) and baccalaureate degree (BSN) nursing programs. The purpose of this study was to build on previous research by determining which physical assessment skills are taught and comparing how that content is taught among undergraduate nursing programs. LiterAture review There is no question that assessment is foundational to nursing practice. It has been identified as a practice standard (American Nurses Association, 2004) and has been taught in most BSN programs for at least the past 18 years (Solomon, 1990). Assessment is specifically identified as a competency of BSN education by the American Association of Colleges of Nursing (1998) and is considered a necessary component of nursing education by the accrediting organizations. However, the specific content, depth of content, and skills that should be taught are left for faculty within schools of nursing to determine. There is little in the nursing literature that specifically addresses physical assessment in undergraduate nursing. One study documenting the practice activities of newly licensed RNs reported that new graduates performed a focused assessment or reassessment an average of 4.07
Journal of Nursing Education

Received: February 18, 2007 Accepted: August 9, 2007 Dr. Giddens is Associate Professor, College of Nursing, University of New Mexico, Albuquerque, New Mexico; and Dr. Eddy is Assistant Professor, Washington State University Intercollegiate College of Nursing, Vancouver, Washington. This research was funded by a grant from Sigma Theta Tau, Gamma Sigma Chapter. Address correspondence to Jean Foret Giddens, PhD, RN, Associate Professor, College of Nursing, University of New Mexico, MSC09 5350, Albuquerque, NM 87131-0001; e-mail: jgiddens@ salud.unm.edu.

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times during the last shift worked and assessed a clients techniques performed. A small negative correlation was vital signs an average of 4.61 times (Wendt & ONeill, found between frequency and years of experience with the 2006). In the same study, graduates assigned a mean prinutrition assessment category (rho = 0.298, p = 0.003). ority rating of 3.52 and 3.53 on a scale of 1 (lowest priority) Although research devoted to physical assessment in to 4 (highest priority) for performing a focused physical nursing education and practice has been limited, comassessment or reassessment and for assessing a clients mon themes in the literature exist. There is no quesvital signs, respectively. These two interventions ranked tion that physical assessment is central to education 16th and 14th, respectively, in priority among 150 activiand practice; yet, studies have shown that a relatively ties within the survey (Wendt & ONeill, 2006). Although limited number of physical assessment techniques are these findings validate the importance of assessment, speactually applied in clinical practice. It is not clear the cific techniques performed as part of the assessment were extent to which physical assessment skills are taught not reported. among nursing programs and whether differences exist In another study, Barbarito, Carney, and Lynch (1997) among kinds of programs. The current study helps to reported that fewer than half of the skills taught in a answer these questions. physical examination course were actually used in clinical practice among BSN nursing students from one program. MethoD The authors questioned whether some of the physical examination content taught in that program was unnecesDesign and sample sary. Similarly, Secrest, Norwood, and duMont (2005) conThe study design used nonexperimental survey methducted an exploratory descriptive study and recommended ods, with a descriptive and comparative approach for data a reevaluation of physical assessment analysis. Approval for the study was skills taught in nursing courses. The given by the universitys institutional authors reported that nurse educators review board. Participants were faculty taught all of the 120 physical assesswho teach physical assessment courses Of 124 assessment skills, ment skills listed on their survey, yet from ADN and BSN programs. The nurses in practice performed only 30% sample was obtained from the approxionly 30 were reported to of those same skills on a daily to weekly mately 1,500 BSN and ADN programs basis. However, a major limitation to in the United States. A list of programs be routinely performed this study was the small sample size accredited by the National League for from which data were obtained. Nursing Accrediting Commission and by nurses across practice More recently, Giddens (2007) reportthe Commission on Collegiate Nursing ed findings from a study evaluating the education was generated. From these settings; the remaining physical assessment skills performed by lists, 500 undergraduate (250 BSN and nurses in clinical practice. A sample of 250 ADN) programs were randomly skills were performed 193 nurses completed a survey, indicatselected; faculty from the selected proing how often they performed various grams were invited to participate. The occasionally or not at all. physical assessment techniques. Of 124 rationale for the intended sample size assessment skills, only 30 were reporttook into account that survey response ed to be routinely performed by nurses rates tend to be low and that a large across practice settings; the remainnumber in the final sample size is deing skills were performed occasionally sirable for statistical power. or not at all. Most of these 30 core techniques involved inspection and general observation, with a majority asinstrument sociated with cardiovascular and respiratory assessment. Data were collected using a survey developed by the Various techniques routinely performed were unique to researcher (J.F.G.). The first part of the survey involved one or more subgroups, but not reflective of a core assessdemographic data. The demographic data analyzed for ment technique practiced by nurses across practice areas. this study included the state where the nursing program Only 30 assessment skills were regularly performed by was located, number of undergraduates, graduation and the sample, thus raising questions about which examinaNational Council Licensure examination for Registered tion skills should be included in a physical examination in Nurses (NCLeX-RN) pass rates, accreditation status, the clinical setting and which should be taught in nursing determination of the kind of course or courses in which programs. physical assessment is taught, credit hours allotted for In a secondary data analysis, Giddens (2006) matched physical assessment content, educational preparation 48 BSN-prepared participants with 48 ADN-prepared parof the faculty member teaching the course, and teachticipants by clinical area and years of experience to coning experience of the faculty. The second part of the surtrol for differences between the two groups on the basis of vey comprised a list of 122 physical assessment skills. those variables. A Mann-Whitney test revealed no differBecause of the specific information being assessed, the ences between the two groups in frequency of examination instrument used in this study was developed by the reJanuary 2009, Vol. 48, No. 1 25

TeACHING PHySICAL eXAMINATION SkILLS

searcher. In attempts to attain content validity, the 122 resuLts physical examination skills (in 18 system categories) included in the survey were based on two physical examiDemographics nation textbooks (Jarvis, 2004; Wilson & Giddens, 2005) A total of 198 individuals teaching in undergraduate commonly used for undergraduate and graduate nursing nursing programs completed the survey, accounting for education. a 42% return rate; this response rate is higher than the Prior to conducting the survey, 10 nursing faculty who average response rate of 36.83% reported by Sheehan currently or recently had taught physical examination (2001) in an evaluation of 31 Internet-based surveys. Just content (5 at the undergraduate level, 5 at the gradumore than half (n = 101) of the responses from faculty ate level) were asked to complete the survey twice (testcame from ADN programs and the rest (n = 97) from a retest), 2 weeks apart, to establish reliability. eight of variety of BSN programs (including generic baccalaurethese individuals completed and returned both surveys. ate, second-degree, and RN-to-BSN completion). Several A correlation coefficient was calculated between each of programs (n = 5) offering both ADN and BSN degrees were the 16 system categories. eight of the categories were not included in data analyses comparing the differences highly correlated and statistically significant (p < 0.05). between ADN and BSN programs. Of the remaining 10 categories, 6 were moderately corResponses from undergraduate programs were disrelated (r = 0.52 to r = 0.66), 4 categories had low correpersed fairly evenly among the New england (10.4%; n = lation (r = 0.48 to r = 0.39). A paired t test did not reveal 20), Mid-Atlantic (12.4%; n = 24), South Atlantic (13.4%; statistical differences for any of the assessment categon = 26), Northeast Central (9.8%; n = 19), Northwest Cenries. Although it is impossible to estral (11.9%; n = 23), and Southwest tablish instrument reliability with Central (16.6%; n = 32) geographic rethis small set, these data suggest that gions of the United States, with fewer the surveys were completed similarly respondents from the Southeast CenAll respondents at the two points in time. tral (5.2%; n = 10), Mountain (2.6%; n = 5), and Pacific (7.8%; n = 15) regions. reported that students Procedure The educational preparation of The survey was conducted in an onfaculty teaching physical assessment assessed each other in line format. Dillion (2000) advocated content included a masters degree in Web-based surveys because of the nursing (93.8%; n = 181), certification the laboratory setting, ease of distribution and data collecas an advanced practice nurse (35.8%; tion, low cost, and rapid responses. An n = 69), and doctoral preparation making this by far the initial prenotification e-mail was sent (8.8%; n = 17). Only 3.1% (n = 6) of the to the director or dean of each nursing sample were both doctorally prepared most common approach program 1 week prior to beginning the and had advanced practice certificasurvey. This e-mail informed the reciption, and 4.1% (n = 8) selected other used. ients that an important survey would to describe their educational preparabe conducted and that participation tion. Cross tabulations and chi-square from their program would be apprecistatistics revealed no differences in facated. This initial e-mail also allowed ulty with advanced practice experience the researchers to identify nondeliverable e-mail ador doctoral preparation teaching physical assessment in dresses, providing the opportunity to rectify as many as ADN and BSN programs (x2[1] = 0.267, p = 0.606; x2[1] = possible. After this process, a total of 468 undergraduate 0.111, p = 0.739, respectively). In addition, no differences (235 BSN and 233 ADN) programs were invited to parexisted in the years of teaching experience of faculty beticipate. A second e-mail was sent the following week, tween ADN and BSN programs (t[183] = 0.835, p = 0.405). which provided information about the survey with asThe years of experience specifically teaching physical assurances that information provided by respondents was sessment was not queried. confidential and anonymous. The director or dean was asked to forward the e-mail to the faculty member recurriculum Factors sponsible for teaching the physical assessment course Physical assessment was taught as an independent and content to complete the survey. A direct link to the course in 48.2% (n = 93) of the undergraduate programs. survey Web site was embedded within the e-mail. Two The content was taught in an integrated approach across weeks after the second e-mail, a follow-up e-mail was multiple courses in 26.4% (n = 51) of the programs and sent to express appreciation for responding or to serve was paired with other course content within one course as a reminder to complete the survey. Although there in 19.2% (n = 37). Other arrangements were described in is conflicting evidence about the benefits in response 6.2% (n = 12) of the programs. Striking differences exrates using prenotification and follow-up contact, this ist when comparing these approaches between ADN and process is advocated (Dillion, 2000; Sheehan & McMilBSN programs; 80.6% (n = 75) of BSN programs reported lan, 1999). teaching physical assessment content as an independent
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course, in contrast with only 19.4% (n = 18) of ADN programs. The mean number of total academic credits targeted toward physical assessment content was 3.38 (SD = 1.02). A t test demonstrated that BSN programs have significantly more academic credits than do ADN programs (t[76] = 3.167, p = 0.002). Further analysis revealed that the differences are attributed to didactic credits (t[116] = 4.12, p = 0.000), as opposed to laboratory credits (t[91] = 0.043, p = 0.966). A Pearson correlation was used to determine whether an association existed between the total number of academic credits for physical assessment and the reported pass rate on the NCLeX-RN; no statistically significant correlation was found (r = 0.69, p = 0.566). teaching Methods Respondents were asked to identify the methods by which physical assessment skills were taught in their programs. All respondents reported that students assessed each other in the laboratory setting, making this by far the most common approach used. Other applications included the use of computer simulation (18.1%; n = 35), manikins (18.1%; n = 35), and other (8.3%; n = 16); none of the undergraduate programs reported using live models for instructional purposes. No significant differences in laboratory teaching approaches existed between ADN and BSN programs; likewise, no differences based on the size of the nursing program were noted. content taught Of 122 skills within the survey, 81.1% (n = 99) were reportedly taught by more than 50% of nursing programs; 63.9% (n = 78) were reportedly taught by over 75% of nursing programs. The majority of skills not taught were nutrition skills and skills involving reproductive, genital, and anal or rectal assessment. The survey items were grouped into 18 assessment categories (integument, nutrition, head, ears, eyes, neck, thorax, breast, back or spine, cardiovascular, musculoskeletal, abdomen, female genitals, male genitals, anus or rectum, and neurologiccentral, neurologic-cerebellar, and neurologic-sensory); a total score was calculated for further analysis. A t test was used to determine whether differences existed in the techniques by category taught between BSN and ADN programs. Of note, significant differences were found in all but three categories (integument, breast, and female genitals; table). In all cases, more BSN programs than ADN programs reported teaching the skills. Findings The findings from this study suggest that faculty teaching physical assessment in undergraduate ADN and BSN programs are similar regarding their educational preparation and years of teaching experience. In addition, the methods used to teach physical assessment skills were similar between the two kinds of programs. Significant differences existed in the curricular approach (kind of course context in which physical assessment was taught), as well
January 2009, Vol. 48, No. 1

TABLE Differences in Physical Assessment Skill Categories Taught in ADN and BSN Programs
Assessment Category Integument Nutrition Head Ears Eyes Neck Thorax Breast Back or spine Cardiovascular Musculoskeletal Abdomen Genitals Female Male Anus or rectum Neurologic Central Cerebellar Sensory 2.67 4.18 5.66 177 175 175 0.008* 0.000** 0.000** 1.01 2.40 2.77 176 177 176 0.314 0.017* 0.006** t 0.85 3.45 4.01 4.74 4.82 3.78 3.99 1.66 2.62 2.30 5.61 6.24 df 187 187 187 187 187 187 187 187 187 187 180 179 p 0.397 0.001** 0.000** 0.000** 0.000** 0.000** 0.000** 0.100 0.009** 0.023* 0.000** 0.000**

Note. ADN = associate degree in nursing; BSN = baccalaureate nursing degree. * p < 0.05, two-tailed. ** p < 0.01, two-tailed.

as in total academic credits and didactic credits devoted to this content; however, no differences were found in the number of laboratory credits. The majority of undergraduate nursing programs taught the bulk of the physical assessment skills listed on the survey. Differences in 15 of the 18 assessment categories were found when the skills taught were compared between the ADN and BSN programs. Given the similarities in faculty, it is safe to assume that differences in the content taught were primarily influenced by differences in the curriculum, as opposed to faculty characteristics. LiMitAtioNs Findings from this study represent the teaching practice of a relatively small sample of faculty and may not be representative of the teaching practices of all nursing programs. Although an attempt was made for equal participation across regions of the country, participation was
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TeACHING PHySICAL eXAMINATION SkILLS

limited in the Southeast Central, Mountain, and Pacific areas. In addition, there is the possibility that survey respondents taught physical assessment in more than one kind of program, such as ADN and BSN programs or undergraduate and graduate programs, which might confound some findings. It is also unknown whether differences exist in how physical assessment is taught among BSN programs with more than one program of study (such as accelerated or RN-to-BSN programs). It is possible that this variable accounts for some of the differences reported. The survey may have failed to accurately capture what is taught in courses. Because the survey did not separate content taught in didactic and laboratory courses, it was not possible to tease out what skills students were expected to performor the depth of assessmentas opposed to what skills students were expected to know. Finally, reliability and validity of the instrument used for data collection have not been established; for this reason, the results may not accurately reflect the teaching practices of undergraduate faculty.

linked to patient-to-nurse staff ratios, one could argue that lack of time affects the ability of nurses to adequately apply assessment skills in their clinical practice (Agency for Healthcare Research and Quality, 2006; Clarke & Aiken, 2003). On the other hand, the ability of a nurse to notice, interpret, and act on subtle and overt cues before a patients condition deteriorates may be more related to the process of clinical judgment (Tanner, 2006) than the actual process of conducting an assessment. To what extent nursing programs emphasize these critical components (as opposed to teaching students how to perform a set of skills) is not known but may bring greater clarity to this point. It is also possible that nursing programs are teaching a greater breadth of skills and expecting students to learn how to conduct physical examinations in greater depth than is needed in clinical practice, particularly for entrylevel nursing practice. The link between the breadth of skills taught in a nursing program and the depth of physical examination performed (either in a school setting or in practice) is not DiscussioN AND iMPLicAtioNs clear; it is not addressed in the literature, nor was this relationship clariFindings from this study This study provides an opportunity fied by this study. Obviously, one needs to reflect on education in light of findto know how to perform a wide array suggest a disconnect ings from practice. In the majority of of skills to conduct a comprehensive undergraduate nursing (ADN and BSN) physical examination, yet the depth of between education and programs, students are taught 81% of examination is not necessarily defined the 122 physical assessment skills; yet, by the specific skills performed. For expractice, but interpreting three studies found in the literature sugample, examination of the internal eye gest that a fairly small set of skills are with an ophthalmoscope may or may the meaning of these routinely performed in clinical practice not be included in a comprehensive (Barbarito et al., 1997; Giddens, 2007; examination, and it may or may not findings presents many Secrest et al., 2005). Findings also rebe included in a focused examination; vealed that significant differences exist these are variables that are context challenges. in the number of credit hours (particudependent. However, if many of these larly didactic credits) and the physical physical assessment skills are rarely assessment skills taught between ADN performed by nurses outside a speand BSN degree programs. This is incialty setting, one should ask whether teresting, given that in a previous study, Giddens (2006) it is appropriate to include them in the nursing curricufound no differences in the physical assessment skills lum. The fact that BSN programs teach a greater breadth performed in clinical practice on the basis of educational of content than do ADN programs but no differences in preparation. practice exist based on educational preparation further Findings from this study suggest a disconnect between emphasizes this point. education and practice, but interpreting the meaning of The points raised above are reflective of concerns cited these findings presents many challenges. It is possible in health sciences and nursing literature related to exthat the level of content taught in ADN and BSN processive curricular content. According to the Institute of grams is appropriate, but that nurses are not conductMedicine (2003), one of the many challenges in health ing thorough enough assessments on their patients, professions education is overly crowded curricula and because of either lack of time or lack of perceived need. competing demands (p. 38). Similar concerns are echoed The failure-to-rescue rate (a concept referring to patient in the nursing literature. An important challenge facing deaths associated with the development of complications) nurse educators is management of the enormous content is affected by many variables, but one important such expected in nursing curricula (Tanner, 1998). This dilemvariable is nursing surveillance. Surveillance involves ma was aptly described by Ironside (2004), who suggested frequent patient assessment and recognizing subtle and the difficulty is not what to include in a course, but what overt cues. It would seem logical that the application of to leave out (p. 5). physical assessment skills would influence failure-toPhysical assessment textbooks targeted for undergradrescue rates. Because failure-to-rescue rates have been uate nursing education may also be a factor. The volume of
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information included in physical assessment textbooks has continually expanded to meet a perceived market need. How students and nursing faculty use textbooks should be considered. Many faculty, particularly novice faculty, may feel obligated to cover all of the physical assessment techniques described in the textbooks. Because of their inexperience, students often have difficulty differentiating the techniques that are important to learn from those that have little relevance for entry-level practice. This leaves many students overwhelmed with the large volume of information to learn. coNcLusioN Although findings from this study are interesting, additional research is needed to better understand the findings in the context of educational practice and learning. Because of the differences found between ADN and BSN programs, a comparison of skills taught between baccalaureate and graduate nursing programs should be investigated. The multiple educational tracks in BSN programs also raises questions related to potential differences. Replication of this study targeting these variables would be beneficial, as would a study with a focus on the link between teaching assessment skills and clinical judgment. Finally, a longitudinal study following individuals from their educational program to professional practice, focusing on the use of physical assessment skills, would be particularly interesting. Given the concerns about content saturation in nursing education and the disconnect between physical assessment skills taught in nursing education and those regularly used in practice, it seems clear that nurse educators should evaluate physical assessment content taught within nursing programs and consider revising curriculum and course expectations. It is not realistic to expect that nursing graduates will possess every skill necessary for all areas of nursing practice. Perhaps in this case, less is more. Faculty should consider teaching fewer skills, but with a stronger emphasis on interpreting physical assessment findings and the development of clinical judgment in undergraduate nursing programs. Graduates with a strong foundation in basic physical examination skills coupled with an understanding of interpretation should be capable of learning and applying additional assessment skills reflective of specialty practice. It is possible that such an ap-

proach might translate to improved surveillance in health care settings. reFereNces

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