Perceived Factors Influencing Clinical Instructors' Ability to Perform Physical Assessment

Perceived Factors Influencing Clinical Instructors' Ability to Perform Physical Assessment Skills at Two Nursing Faculties

By

*Dr. NahlaShaaban Ali: Lecturer, Critical Care Nursing, Faculty of Nursing ,CairoUniversity

**Dr. Safaa Salah Ismail:Lecturer, Pediatric Nursing, Faculty of Nursing ,HelwanUniversity

Abstract

Background: Nurse educators are increasingly challenged to prepare new graduates to enter nursing practice particularly given the rapid changes in the health care system. Graduates of nursing programs need a diverse skill base and must be able to work within many clinical settings. Aim of the study: The aim of this study had three folded purposes; first, to assess clinical instructors' knowledge taught in undergraduate baccalaureate nursing programs; second to assess the frequency of physical assessment skills use in clinical settings as reported by clinical instructors; and third to assess the perceived barriers to the use ofphysical assessment skills. Design and Methods: A descriptive survey study design was utilized. Asample of convenience of 70 clinical instructors were recruited from two nursing faculties at Cairo (n=47) and Helwan (n=23) universities. The sample represented the following practice categories; adult medical surgical, maternity, pediatric, community, psychiatric and nursing administration. The participants, initially, were instructed to complete a demographic sheet; 20 items related to physical assessment skills'questionnaire, anda physical assessment frequency scale to assess the frequency of use of 70 listed skills on a Likert scale ranging from frequent to never. The listed skills represented general appearance; head and neck, respiratory and chest; cardiovascular; gastrointestinal; neurological and musculoskeletal systems. In case the clinical instructors rarely or never use any of the listed skills, they should mention the barriers of the non-performance. Results:Results of the 20 item questionnaire revealed poor knowledge scores for the Cairo (Mean=5.28 + 2.91) and Helwan (Mean=7.52 + 2.42) groups. The results of the physical assessment frequency scale revealed that, out of 70 listed physical assessment skills, 11 techniques were identified as performed frequently representing 15.7% of the techniques included in the survey. The majority of these techniques involved obtaining vital signs, general appearance(hygiene, grooming), inspection of skin color, palpation of edema, carotid artery, auscultation of bowel sounds, and assessment of conscious level.Frequent barriers for not performing physical assessment skills reported by clinical instructors are lack of knowledge and performance. Conclusion/recommendation: Low mean knowledge scores and low frequency of use of physical assessment skills were perceived by clinical instructors. More educational opportunities should be provided including educational programs based on the clinical instructor's skill levels and needs.

Key Words: Perceived factors,Physical assessment skills, Clinical instructors.

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Introduction and Review of Literature

Physical assessment requires an organized and systematic approach using the techniques of inspection, palpation, percussion, and auscultation. It also requires a trusting relationship and rapport between the nurse and the patient to decrease the stress the patient may have from being physically exposed and vulnerable(Hughey, 2007).

The professional nurse plays a vital role in the assessment of patient problems. Educational preparation and the clinical setting in part determine the extent to which the nurse participates in the assessment process. For example, a nurse in primary care may perform a comprehensive physical assessment of patients, while a critical care nurse may conduct selected patient assessments to monitor and evaluate current health problems. In either case, nurses are expected to be familiar with and comfortable while using physical assessment skills. Today’s nurses are sophisticated professionals who require information in order to make clinical decisions. The physical assessment findings provide this information ( 2006).

Barros et al. (1997) emphasized that teaching contents concerning the physical examination requires knowledge associated with prerequisite subjects, including principles of anatomy, physiology, pathology, biology, microbiology, and control over the basic methods needed to perform this examination.

West (2006) mentioned that increasing acuteness of care and developing technologies present new opportunities and challenges for the nursing profession. Previous studies emphasized the need for change to meet these demands, especially in the area of patient assessment. Nurses are extending their repertoire of skills to include those that were once the domain of junior doctors. These new skills tend to be used mostly by experienced nurses such as the specialist or advanced nurse practitioner. One such skill is physical assessment. Traditionally viewed as part of the doctor's role, physical assessment has not routinely been taught in nurse training.

With the advancement of nursing roles, it has been argued that physical assessment has become a key nursing skill. The use of physical assessment as part of the growing role of the nurse in critical care, nurses delivers holistic care, based on assessment. This assessment is incomplete, if a detailed physical assessment is omitted and, as a consequence, care is delivered in the absence of an appreciation of the impact of pathophysiological adaptations (West,2006).

The ability to physically assess the patient in a principled and systematic fashion, in conjunction with routine health assessment, is a necessary skill for the modern nursing professional working in critical care. It is further argued that, within the current climate of advancing nursing practice, the acquisition of this skill is important for all nurses, to improve patient care, not to supplant the skills of the junior doctor (West,2006).

As nurses progress toward more autonomy and advanced practice, there will be an increasing overlap between role expectations of nurses and of primary physicians. The availability of accessible education for nurses in physical assessment skills could decrease their fear about legal accountability, and result in a greater willingness to accept new responsibilities. Graduates of nursing programsneed a diverse skill base and must be able to work within many clinical settings. However, an ongoing concernwithin the nursing profession is thatnursing graduates are not adequately prepared to enter practice (Price et al, 2001).

Although many researches emphasized the importance of performance of physical assessment skills (PAS) in clinical practice, nevertheless, lack of knowledge and clinical application of these skills has prompted a number of researchers to study the barriers to performance. Although rarely measured, lack of confidence in skill performance has been identified as a main barrier to performing PAS (Reaby, 1991).In this respect,Reid (2003) added the importance of education in teaching the skill of taking patient history is imperative and the development of core skills of inspection, auscultation, palpation, and percussion are necessary components and can’t be taught on their own.

Very little is known about the" real" versus perceived barriers to the performance of physical assessment skills (PAS) in the clinical setting. Brown et al. (1987) found a significant relationship between the feeling of incompetence in using physical assessment skills and the basic educational preparation of the nurse. However,Reaby (1991) cited that the most common reasons for infrequent use of physical assessment skills were "inappropriate to clinical setting" and used only if problem suspected.

The current study revealed other reasons that inhibit the clinical instructors to perform the physical assessment skills including; lack of time due to workload experienced by majority of them,while Vines and Simon (1991) added other barriers for not performing PAS, is insufficient time devoted for teaching and learning physical assessment skills, as many skills require more time for training than other skills like auscultation of heart and lung sounds.

Finally, in the articles reviewed, manyauthors agreed that competent physical assessment was a foundation requirement of nursing practice, wherebyappropriately educated nurses have the ability to perform regular systematic examinations facilitating awareness ofchanges in patient condition (Longson Copley, 1989; and Goodfellow 1997).

Aim of the study

The aim of this study had three folded purposes; first, to assess clinical instructors' current knowledge taught in undergraduate baccalaureate nursing programs; second, to assess the frequency of physical assessment skills use in clinical settings as reported by clinical instructors; and third to assess the perceived barriers to the use of physical assessment skills.

Significance of the study

Although the physical assessment skills are mentioned in the planning of patient's care, job description, performance appraisals, standard of practice and care, it is incorporated in undergraduate courses; it is not valued within the variety of clinical settings. Incorporation of physical assessment training program into the existing preparation for newly appointed nurses in different clinical and academic settings could provide a format that ensures consistency in data collection and individualize nursing care. In addition, it could establish a mutual trust between nurses and physicians and the quality of nurse-physician interaction could exert a positive influence on the outcome of patient's care.

Today the current use of physical assessment skills within different clinical settings is a part of on-going nursing role development process. In fact, it has been suggested that enhanced assessment skills enables these nurses to safely and competently assess patients. Moreover, nurses in critical care units are required to perform detailed physical assessment skills. These skills help the nurse to identify the problems that the patient may have, to prescribe care, to evaluate the urgency of patient's problem and to make precise decision in critical situation.

Material and Methods

Research questions:

To fulfill the aim of the current study, the following questions were formulated:

1-What is the current knowledge of clinical instructors concerning physical assessment in clinical settings?

2-How frequently are physical assessment skills performed as perceived by clinical instructors in clinical settings?

3-What are the barriers clinical instructors perceive as deterrents in using physical assessment skills?

Design:

A descriptive survey design was utilized in the current study to answer the research questions. Data were collected through the academic year 2010-2011.

Setting:

The study was conducted in two academic nursing faculties at Cairo and Helwan universitiesin different nursing work areas; medical-surgical, maternity heath nursing, pediatric nursing, psychiatric & mental health, community, and nursing administration.The number of recruited subjects varied from one setting to another based on the size of faculty and number of clinical instructors working there.

Subjects:

A sample of convenience of 110 clinical instructors was recruited from two nursing faculties at two academic universities Cairo and Helwan. The final sample consisted of 70 clinical instructors aged 23–38 years. The response rate was 63.6%, as 36.4 percent of the participants did not respond because they either felt uncomfortable or did not have time to complete the questionnaire.

Tools

The following tools were used to collect relevant data to this study:

1-Socio- Demographic Data: it dealt with demographic and background data as age, educational level, marital status, and years of experience.

2-Physical Assessment Questionnaire: This test was developed by the researchers through literature review and it was reviewed by medical and nursing experts. The knowledge test covered all assessment techniques as it relates to different body systems and related clinical signs. This test consisted of 20 multiple choices questions designed to evaluate the ability of the instructors to interpret and conduct physical exam findings. One score was designated for each question, general observation and major body systems as cardiovascular, neurologic, pulmonary, gastrointestinal, and musculoskeletal, were represented. Each body system devoted somewhere two questions, totaling20 scores for the entire test. The scoring system was as follows: poor (< 10), pass (12- < 13), good (13- < 15), very good (15-< 17), and excellent(17-20) (Table 2)

3-Physical Assessment Frequency Scale (70 items, 4-point Likert scale):It was utilized in this study to assess the frequency of use of 70 listed skills on a Likert rating scale. The clinical instructors were asked to check the frequency with which they perform and document each listed physical assessment skill using the following scale : 1= frequent (>90%), 2=often (75- 90%) ,3=sometimes ( 50- 74% ),4= rarely ( 30- 49% ) ,and 5=never (< 30%).The skills were organized to be consistent with 12 sections: General appearance; skin, hair, and nails; head and neck; eye and vision; ear and hearing ; nose and smell; mouth and oropharynx,chest and respiratory, cardiovascular, gastrointestinal, and urinary,neurological and musculoskeletal systems . The number of skills listed within each section ranged from 5 sub-items (general appearance) to11sub-items (gastrointestinal). Frequency and percentage distribution were utilized to describe and compare simply the more frequent and never used physical assessment skills in each section among clinical instructors (table 5).In case, the clinical instructors responded with rarely or never uses any of the listed skills elsewhere, she/he should mention the barriers and /or reasons of the non-performance. pertaining to or emanating from the nervous system or from neurology.

neurological, neurologic
pertaining to or emanating from the nervous system or from neurology.

Procedure

An official permission to conduct this study was obtained from responsible authoritative nursing faculties personnel. Then, the investigators initiated data collection and explained the purpose and nature of the study. The investigators emphasized to the subjects that participation in the study is entirely voluntary and that anonymity and confidentiality of their responses were assured.

All clinical instructors who were chosen to participate in the study were asked to sign a consent form, while the investigatorswere available for any clarification needed.Distributed the survey sheets as well as collected them. A brief explanation was given regarding the study, noting that there were no risks or benefits to participants from taking part in the study, clinical instructors were also given the opportunity to ask any pertinent questions they had regarding the study. In addition, clinical instructors were asked to carefully read the instructions given and work individually on their questionnaires without the aid of textbooks or colleagues. Then, they were asked to complete the questionnaire related to demographic data and written test. The time allowed for eligible clinical instructors to complete the questionnaire was 90 minutes. After completion of the test, it was returned back immediately to the investigators. Then, a physical assessment frequency scale was distributed by the investigator. Next, they were asked to fill it at their own pace and return it to the investigators within one week.
pertaining to or emanating from the nervous system or from neurology.

Results:

The presentation and analysis of data are presented in the following order: The first section is devoted to the description of socio-demographic characteristics of the sample,following this, a simple descriptive statistical analysis was conducted to answer the research questions.

Description of the socio-demographic characteristics

Table (1) shows that the participants’ age ranged from 23–38 years, with a mean of 26.2+ 3.91; the majority of clinical instructors in Cairo and Helwan groups (85.7%) were less than 30 years. As regards gender , the entire studied sample of Helwan group was female, while the clinical instructors at CairoUniversity are almost equally distributed between males andfemales (46.810 vs 53.19 %). Regarding clinical experience, 75.7 % of the respondents their years of experience ranged from 3-5 years with a mean of 2.87 + 0.94 for both groups.

In reference to the educational category, all Cairo participants (100%) having a baccalaureate degree in nursing while less than half of the participants (47.8%) at Helwan having a master degree in nursing.

In reference to the work area, the highest percentages of clinical instructors in both Cairo and Helwan groups (76.5% 56.5 % respectively) worked in a medical-surgical nursing;while clinical instructors working in psychiatric/mental health settings represented (6.5% and 4.35 % respectively), pediatric nursing (4.25% & 13.05%respectively), maternity health nursing (4.25% &8.7% respectively), community health nursing (4.25% &4.35 respectively), and nursing administration (4.25% &13.05% respectively). Cairo and Helwan universities had a very low return rate which was reflected in the small representation within subgroups as their number is too small.

Results of overall knowledge questions

In order to answer the first research question, to assess the knowledge of clinical instructors regarding physical assessment skills, the knowledge scores were tabulated , analyzed and revealed that the mean knowledge score for Cairo University groupwas 5.28 + 2.91 and 7.52+ 2.42 for Helwan Universitygroup. Responses to individual knowledge questions revealed that most of clinical instructors had poor scores; Therefore,table (2) presents detailed analysis of knowledge scores obtained by subgroups of clinical instructors at Cairo and Helwan universities.

The study findings revealed that medical-surgical nursing groups at Cairo(94.4%) and Helwan (61.5%) universities had poor level of knowledge scores, while only5.6 % and 38.5%respectively demonstrated a pass level . In addition, all the clinical instructors (100%) in pediatric nursing, maternity health nursing, and psychiatric nursing demonstrated poor knowledge at both universities. On the other hand only participants in nursing administration (33.4 %) at HelwanUniversity demonstrated pass level and also one participant in community health nursing (50%) at CairoUniversity demonstrated pass level.

Results of knowledge questions sub-items

Table (3) shows frequencies and percentages of correct answers among clinical instructors in both Cairo and Helwan groups. Regarding questions related to knowledge about physical assessment techniques utilized from head to toe and its related signs; Q1; parts of hands which are sensitive to vibration, Q8; hand parts used in assessing lymph nodes, and Q16; the recommended body sites for light and heavy percussion; the study findings revealed that out of 70 participants only 18(25.7%), 15(21.4%) and 11(15.7%) respectively selected the right answers to those questions.

As regards questions related to integument assessment: Q2; a flat, small one centimeter or less skin lesion which is macule ;Q3, reddish purple spots of hemorrhage in the skin is petechial;Q9, sites for palpating lower limb edema are dorsum of foot and shaft of tibia; the findings revealed that out of 70 clinical instructors only 8(11.42%), 28(40%), 26( 37.1%) respectively selected the right answers for those questions. it is apparent that Q2 devoted the lowest frequencies of correct answers, this means that the majority of the clinical instructors have inadequate knowledge about skin lesions.