In this age of seemingly endless amounts of new health information, educators and students alike are overwhelmed with information. In nursing alone, knowledge doubles every 6 years.1 As a result, nursing faculty continue to add to their already full curricula. Overwhelmed by information, new nurses struggle to discern the important skills and apply them to practice. Shockingly, only 23% of novice nurses demonstrate entry-level practice competency.2
Physical assessment is a foundational component of any prelicensure nursing program. Sound physical assessment skills are pivotal to ensuring safe, high-quality nursing care. However, assessment courses are loaded with physical assessment skills, with many outdated or unnecessary for entry to nursing practice. In the “Essentials of Baccalaureate Nursing Practice,”3 the American Association of Colleges of Nursing indicates that nurse educators should provide students with the core principles underlying skills, preparing them for basic levels of competency and patient safety. As such, assessment course content should translate to current practice and entry-level practice competency of nurses in their first year of nursing practice. With the large number of skills in most assessment courses, which physical assessment skills should be taught in a prelicensure program needs further exploration.
For the purpose of this project, physical assessment skills are defined as techniques to inspect, palpate, percuss, or auscultate a patient to gain data about his or her physiological status. Skill categories are defined as groupings of skills by their associated body system.
Despite the number of studies in the literature about physical assessment, there is limited research identifying which physical assessment skills faculty view as important to teach to prelicensure nursing students in an assessment course. Therefore, the purpose of this study was to rank the importance of physical assessment skills and skill categories as perceived by nursing faculty.
Design and Sample
A cross-sectional descriptive study was used to explore the perceived importance by faculty of physical assessment skills and skill categories taught in prelicensure nursing education programs in the United States. The sample was identified using a nonprobability convenience sample from faculty listed in a Commission on Collegiate Nurse Education (CCNE) or Accreditation Commission for Education in Nursing (ACEN) accredited nursing program. Nursing faculty teaching in BSN (traditional and accelerated), associate degree in nursing, and diploma programs in the United States were included in this survey. Exclusion criteria include faculty teaching exclusively in licensed practical nursing, graduate, or postlicensure programs and faculty who have taught nursing for less than 1 year.
The 136-item questionnaire called Faculty Demographics and Importance of Physical Assessment Skills for Prelicensure Nursing Students was adapted from the Giddens and Eddy4 2009 survey. Eight experts in nursing education reviewed the questionnaire for face validity (content of the questions). The first section of our questionnaire contained 10 demographic questions including teaching experience of faculty and how the physical assessment course was taught in their nursing program. The second section addressed the 126 physical assessment skills commonly included in physical assessment textbooks. The physical assessment skills were divided into 18 skill categories. Educators were asked to rate each physical assessment skill using the following Likert scale: 1, this skill does not need to be taught in a standard prelicensure assessment course; 2, this skill is of minimal importance; 3, this skill should be taught but is not necessary for students to have hands-on practice experience; 4, this skill is important and should be taught to all students—hands-on practice would be beneficial; and 5, this skill is crucial and must be taught with time allotted for hands-on practice of the skill.
Institutional Review Board approval was obtained from a midwestern university. During the fall semester of 2018, questionnaires were sent via email to the dean listed in the CCNE and ACEN listservs, with a request to forward the email containing the secure link to an electronic questionnaire to faculty to complete. The questionnaire took approximately 20 to 30 minutes to complete. The data were stored in a password-protected database.
Data were exported from the electronic questionnaire into SAS 9.4 (SAS Institute Inc, Cary, North Carolina) for analysis. Descriptive statistics were used to describe the distribution of background characteristics including age, gender, years of practice, practice area (acute vs community setting), education level of practicing nurses, and skill ratings. Criteria were used to identify which physical assessment skills were perceived to be the most critical for teaching in an assessment course. Scores of 4 to 5 were considered critical skills, scores of 2 to 3 were defined as minimally important skills, and a score of 1 was defined as not an important skill.
The physical assessment skills on the survey were divided into 18 categories. For each of the categories, a category score was computed for each respondent by taking the mean of their responses to the physical assessment skills within the category. A category score, a number between 1 and 5, was interpreted relative to the Likert scale used at the skill level, with 1 indicating a generally low endorsement of the skill category and 5 indicating a generally high endorsement. The respondents were divided into 3 groups based on their teaching experience: those with 5 years or less, 6 to 10 years, and more than 10 years. Examination of whether there were group differences in the means of category scores also occurred.
Of the respondents, 402 rated all of the physical assessment skills. This was the sample used for analyses. The sample was predominantly female (96.5%) and white (n = 356, 88.6%), and they had an MS degree (63.5%). More than half (55.4%) reported that they were currently practicing as RNs; only 11.1% were practicing as advanced practice RNs (APRNs). The sample had a mean age of 51.4 ± 11.4 years, and the average years of teaching in nursing was 11.9 ± 9.4. Most participants were employed full-time in an academic setting (81.3%) located in the southern region of the United States (33.3%). The largest portion of the participants who responded to the survey indicated they taught in both the classroom and clinical environments (56.2%) and that the assessment course was integrated into other courses (51.9%) throughout the curriculum (Supplemental Digital Content, Table 1, available at http://links.lww.com/NE/A725).
Years of Teaching Experience
Summaries of the category scores, based on years of teaching experience of the respondents, are presented in Supplemental Digital Content, Table 2, http://links.lww.com/NE/A726, and illustrated in Supplemental Digital Content, Figure, http://links.lww.com/NE/A724. There was little difference in the relative ranking of the skill categories based on the years of teaching experience of faculty. In Supplemental Digital Content, Table 2, http://links.lww.com/NE/A726, the categories appear in alphabetical order. However, in Supplemental Digital Content, Figure, http://links.lww.com/NE/A724, the categories were ranked by the mean scores based on years of teaching experience.
Distribution of Skill Categories
Among the skill categories, integumentary system (4.57 ± 0.51), central nervous system (4.29 ± 0.62), and cardiovascular system (4.20 ± 0.51) had the highest mean scores (Table). The categories with the lowest scores were nutrition (2.31 ± 0.96), female reproductive system (2.67 ± 0.97), anus/rectum/prostate (2.74 ± 0.88), and male reproductive system (2.89 ± 1.03).
Among these categories, 37 physical assessment skills were identified as critical and should be taught by nurse educators in an assessment course (Supplemental Digital Content, Table 3, available at http://links.lww.com/NE/A727). The top-scoring physical assessment skills involved for each category were inspection, auscultation, and palpation. Eighty-four physical assessment skills were identified as minimally important skills that should be taught by nurse educators pertaining to an assessment course (Supplemental Digital Content, Table 3, available at http://links.lww.com/NE/A727). These skills also involved inspection, auscultation, palpation, and percussion. In addition, these skills were associated with the neurological and reproductive systems. Five skills (palpate anal canal, palpate prostate, transillumination of the scrotum, vaginal examination with speculum, and palpation of the cervix) were identified as the least important skills to be taught in an assessment course (Supplemental Digital Content, Table 3, available at http://links.lww.com/NE/A727). These physical assessment skills are more appropriate for advanced practice nurses or specialty areas in nursing.
Physical assessment is an essential component in prelicensure nursing programs. However, questions about the number of physical assessment skills taught in these programs versus those used by practicing nurses have been raised for more than 20 years.4 In a 1997 study, students reported using less than 50% of the physical assessment skills they learned in their assessment course.5 In 2005, in another important study, Secrest et al6 found that practicing nurses used only 29% of 120 commonly taught physical assessment skills. Four years later, Giddens and Eddy4 found that 81% of 122 physical assessment skills were routinely taught in prelicensure programs across the country, whereas in another study, only 25% of these skills were used regularly by practicing nurses.7 In 2017, 1 midwestern BSN program explored the assessment skills taught and used by students in their program.8 Interestingly, the findings were remarkably similar to those from the Giddens study 10 years prior, with students reporting that only 30 of 126 skills (23.8%) were used on a regular basis in clinical practice.8
The ultimate goal of prelicensure nursing programs is to prepare students to function as entry-level nurses, delivering safe, high-quality patient care that meets the needs of a diverse population.9 Flexibility is given to academic institutions to achieve outcomes that promote innovation in curriculum development. However, such large variation between the physical assessment skills that faculty find important to teach and the skills practicing nurses are actually using suggests the need for some degree of consistency.
The results from this study are important because, to date, no studies have considered the faculty perceptions and years of teaching experience for which physical assessment skills and skills categories are critical to be taught to prelicensure nursing students. The findings of this study reinforce those of earlier work suggesting the need for physical assessment curriculum revision to reduce unnecessary content.6
One can hypothesize that the complexity of the nursing role imposes the reason for inclusion of abundant skills in physical assessment courses. While knowledge for the profession continues to expand, evolving technologies have substituted the need for many antiquated physical assessment skills. Evidence supports teaching skills that are current and used in entry-level practice, rather than advanced skills specific to settings or populations.6 Secrest et al6 determined that teaching numerous physical assessment skills results in increased confusion and the inability to master more critical nursing skills. In addition, Cowen et al10 found that students were overwhelmed after a comprehensive physical assessment course and lacked confidence with performing physical assessment skills in the clinical environment.
Previous studies suggest physical assessment frameworks are built to encompass a medical model as opposed to a nursing model.4,11 A nursing framework for assessment is essential to gather pertinent patient data, allowing for accurate nursing diagnoses and appropriate interventions.12 Textbooks that focus on a nursing perspective could help faculty and students differentiate between critical versus less important physical assessment skills for entry-level practice.
A limitation to this study was the inability to determine how many faculty members actually received the survey from the listserv. This study did not group the categories according to age; instead, the study grouped the categories in 1 group across the lifespan. Another limitation was that we did not ask participants about their area of expertise in nursing practice, although we asked whether they were currently practicing as an RN or APRN. Despite these limitations, the study obtained a large sample size from each region of the United States. Future studies might consider the importance of skills for specialty nursing courses as well as faculty perception based on practice specialties.
Prelicensure physical assessment courses need to focus on teaching critical skills that are essential for entry-level nursing practice. The results of this study build on previous evidence suggesting the need for revising the physical assessment skills taught in prelicensure programs to reduce unnecessary skills. Teaching physical assessment skills that are “not likely” to be used in practice is occurring at the expense of mastering more important skills.
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