Encouraging nurses physical assessment skills: a small pilot study in Tai Tokerau/Northland has revealed why nurses don't use the full range of physical assessment skills in their practice.

Registered nurses (RNs) have a challenging role in the delivery of health care in New Zealand. Nurses have opportunities to take up strategic positions within public health organisations (PHO) and to lead nursing into the future. Advanced nursing practice skills and an expanding scope of practice are required for such positions, as the nurse may be working in complex acute care, alone in rural areas or in collaboration with medical practitioners. One area of knowledge and skill vital to nurses working in all these environments is physical assessment.

But how confident are nurses about undertaking physical assessments and how frequently do they undertake them? To idenitfy Tai Tokerau/ Northland RNs' current knowledge and skills in physical assessment, we decided to adapt an existing questionnaire (1) and to conduct a small pilot study in the region. The questionnaire asked: What is your current level of knowledge and skills in physical assessment? What is your current frequency of use of specific physical assessment skills? What are your reasons for not using physical assessment skills?

This report discusses the background to the pilot study, its findings and contains some recommendations for nursing education and practice in our region. The need for further research is indicated by the findings of the pilot study and a longer study is planned to further investigate issues raised.

For the purposes of the pilot study, physical assessment was defined as the application of the "classic" skills of inspection, palpation, percussion and auscultation. The authors acknowledge this is a narrow definition, identifying only one part of a complete health assessment. Physical assessment has been part of undergraduate nursing education in New Zealand since the early 1980s. However, the application of this knowledge in clinical practice has been slow. For example, graduates of New Zealand polytechnic nursing degree programmes reported that three months after graduation, they still required direction and support in assessment and planning skills. Although their abilities improved over the first year of practice, it was suggested holistic assessment skills should be highlighted during their education. (2) A recent unpublished study by nursing Lecturers in one polytechnic found that nursing graduates did not feel confident performing assessment skills and did not observe more experienced RNs role modelling these skills. (3)

A survey of RNs in rural New Zealand found that nurses were providing more complex health care in these settings, due, in part, to the lack of GPs. (4) It is dear nurses have taken the opportunity to develop advanced roles, partly because the service is not being provided by other health professionals.

Community expectations of RNs' role in service delivery have also increased. (5) Rural nurses have a "generalist" role caring for people of all ages in isolated areas and in diverse situations. The nurse provides continuity of care for family members of all ages, with nursing care extending from the community to hospital and back to the home. The nurse is perceived to be the coordinator and facilitator of health care within these community settings. Hospital care is also becoming more complex.

Senior nurse clinicians from medical/surgical areas in two New Zealand hospitals listed what they perceived to be the ten most important skills of a new graduate. Nursing assessment was mentioned frequently as an important skill; however, these clinicians did not believe new graduates would frequently undertake this. It appears that clinicians do not identify the assessment skills of inspection, palpation, percussion and auscultation as part of the nursing assessment. But nursing education should prepare students with good assessment skills for the changing health environment. (6)

While it appears from the literature, that nurses will undertake physical assessment, studies have shown many health care providers believe physical assessment is a medical function. A survey of GPs in one of New Zealand's district health boards (DHB) asked what they saw as the advanced practice role of nurse practitioners. Findings identified that while GPs in the area were very much in favour of nurses expanding their role in areas such as health teaching and history taking, their view was less favourable about expanding the nurses' role to include physical assessment. There appeared to be a lack of physician confidence in nurses' competence, skills and knowledge. Another concern was that nurses would intrude on the domain of the GP, particularly in the areas of prescribing medications, ordering and interpreting laboratory tests and performing physical assessments. (7)

Many RNs also perceive physical assessment as a medical function and this is an obstacle to their use of expanded assessment skills. In a Canadian study, graduate nurses were asked to identify specific barriers to their use of patient assessment skills. While 50 percent of the participants reported using all the listed elements of patient assessment, many considered them to be the responsibility of the patient's physician. (8) Participants in the Christchurch Polytechnic Institute of Technology's School of Nursing assessment course also reported an initial concern that this new skill would be viewed unfavourably by physicians. These concerns were dispelled, however, as physicians realised that a nursing assessment leads logically to nursing interventions, not to medical diagnosis and treatment. (9)

A nursing physical assessment is an organised process of gathering information for the patient care plan. Therefore it is vital nurses are skilled in effectively and reliably obtaining not only a useful patient health history, but also accurate, objective data from a physical examination. The benefit of assessment information accurately obtained, dearly communicated and effectively applied to nursing care should be obvious to the entire health care team. In addition, increasing RNs' skill and confidence in physical assessment could increase physician acceptance. (10) 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.

Results of the pilot study

An adapted, self administered questionnaire was used for the pilot study. From a purposive sample of 60 RNs, 33 responded. Demographic data included the qualification of the RN, the area of work, age, years of experience, education and gender. Ethnicity was not included. Perceptions of personal competence in physical assessment and the importance of improvement were collected, using a Likert scale. Registered nurses selected the method they would use to improve their competency in physical assessment from a list including for-real education leading to a qualification, individual interaction with skilled professional colleagues, journals, textbooks, videos, workshops, conferences or other.

Reasons for not using physical assessment skills were identified from a list of ten options. Respondents also identified the frequency of use of 36 listed skills on a likert scale of daily, weekly, monthly or never. The skills were organised into four areas: general; head and neck, chest; and neurological.

Thirty-two females and one male responded. When sorted by age, the respondents fell into three groups: 30-39 (30 percent), 40-49 (36 percent) and over 50 (26 percent).

All had current New Zealand registration and 75 percent had a bachelor's degree in nursing. A limited number had postgraduate qualifications. All were employed as RNs in Te Tai Tokerau/Northland.

Years of experience was evenly distributed between one and more than 25 years. Almost 50 percent of respondents reported having ten or fewer years' nursing experience. Seventy percent were nurses from a variety of hospital specialty areas and departments. The remaining areas of practice were within community health settings, including Maori health providers, public health and district nursing.

The majority of respondents reported they had taken a physical assessment course of some description following their initial registration and felt this had increased the frequency of skill use. All participants identified that it was important or very important to improve physical assessment skills. Assistance from a skilled work colleague was the preferred method of improving skills.

Respondents ranked the frequency of use of skills under the categories "general", "head and neck", "chest", and "neurologic" All respondents stated they used the skills under the "general" heading regularly and with the most frequency. These were blood pressure, temperature, respiration, peripheral pulses, skin turgor, skin lesions and pitting oedema. The next most frequent skills used were those listed under neurological function. Highest in this category was gait, followed by coordination. Strength and sensation of extremities and pupil response were the next most frequently used. Testing for cranial nerves, range of motion and reflexes were the least used.

Responses highlighted differences in frequency of use of physical assessment skills between hospital-based and community-based RNs. Community-based RNs indicated a higher frequency of use, particularly nurses working for Maori health providers. These nurses were working in isolated rural areas with limited GP coverage.

The correlation between frequency of use of skills and the registrations of RGON and RCpN showed a fairly even distribution. There was no correlation between attainment of a degree and frequency of skill use.

Approximately half the respondents stated they would only use assessment skills when problems were suspected. Reasons for not using physical assessment skills were: it was not a nursing responsibility; lack of time; not appropriate to the clinical setting, no equipment available; no support from colleagues; and no opportunity to use these skills.

Preliminary results from this pilot study suggest that the skills used most frequently were in the "general" category and involved primarily the use of inspection. Vital sign recording has been a traditional part of nursing practice and these findings confirm the regular use of these skills. However, areas of assessment that required palpation, percussion and auscultation skills were used less frequently.

There were no clear relationships found between age, nursing education, experience, and the frequency of use of physical assessment skills. There was a difference in frequency of use of physical assessment skills between RNs working in a hospital and in the community.

Promoting assessment skills

The findings from this pilot study suggest more undergraduate education in physical assessment skills and the role modelling of these skills by senior nurses would promote greater confidence in and use of these skills by less experienced nurses.

Most DHBs in New Zealand currently offer a one-year, new graduate programme that includes support from a nominated preceptor. (11) Ideally, these preceptors complete a course on teaching and learning techniques for the clinical environment to better prepare themselves for their support role. From the findings in this study it is recommended that courses for preceptors include discussion on the importance of physical assessment skills and that preceptors role model these skills in clinical settings.

This article was reviewed by Kai Tiaki Nursing New Zealand's editorial committee in August this year.

References

(1) Milligan, K. and Neville, S. (2003) Conceptualisation of health assessment Nursing Proxis in New Zealand; 19: 1. 23-31.

(2) Walker, J. & Bailey, S. (1999) The clinical performance of new degree graduates. Nursing Praxis in New Zealand; 14: 2, 31-41.

(3) Schroyen, B., Hylton, J., Wilkinson, K., Maklad, I., Scobie, N. & Saunders-Pannett, M. (2001) Examination of the physical assessment component of the undergraduate nursing curriculum at Northland Polytechnic: An action research study. Unpublished manuscript: Northland Polytechnic, Whangarei, New Zealand.

(4) Ross, J., Jones, S. & Litchfield, M. (2000) The national role of Rural Nursing Project. Centre for Rural Health: Christchurch.

(5) Burton, J. (1997) Difficulties encountered in rural general practice in New Zealand. New Zealand Family Physician; 24: 6, 41-44.

(6) Holloway K. (1999) Developing an evidence base for teaching nursing practice skills in an undergraduate nursing programme. Nursing Praxis in New Zealand; 14 :1, 22-32.

(7) MacKay, B. (2003) General practitioners' perceptions of the Nurse Practitioner role: An exploratory study. The New Zealand Medical Journal; 2003: 116, 1170.

(8) Sony, S.D. (1988) Baccalaureate nurse graduates' perception of barriers to the use of physical assessment skills in the clinical setting. The Journal of Continuing Education in Nursing; 23: 2, 83-87.

(9) Bullock, L. Peterson, P., Fox, B., Bennett, C. (1996) New skills advance practice. Koi Tiuki Nursing New Zealand; 2: 8, 13-15.

(10) Price, C., Han. S. & Rutherford, I. (2001) Advanced nursing practice: An introduction to physical assessment. British Journal of Nursing; 9: 22, 2292.

(11) New Zealand Ministry of Health (2004) New graduate first year of clinical practice nursing programme: evaluation report, http://www.moh.govt.nz. Retrieved on 17/11/04.

Bonnie Schroyen, RCpN, MA, is a senior nursing lecturer; Nancy George, RCpN, PhD, is a nursing lecturer; Judy Hylton, RGON, MA, is a principal nursing lecturer; and Norma Scobie, RGON, MN, is a principal nursing lecturer at Northland Polytechnic's School of Nursing.