As mentioned previously, from 2005 onwards nurse educators were concerned about specific factors that were influencing the increasing number of medical PAS taught in undergraduate nursing programmes. There appeared to be a clear dichotomy between nurse educators views as to the amount of skills needed by practicing nurses, and those actually used.
A number of earlier studies examined physical assessment education (Cowell and Smith 1985; Sony 1992; Solomon 1990; Anderson et al. 1995 & Skillen et al. 2001). All the studies agreed on the need to examine RNs’ education in assessment practices with emphasis on the application to nursing practice. This debate was ignited by two US survey studies on nurse educators’ views on which medical PAS should be taught in undergraduate nursing programmes (Solomon 1990 and Bowman & Duldt 1993). Nurse educators’ expressed concerns regarding the identity of medical PAS, and how it fits within the framework of the nursing process.
These findings were also evident in the study by Secrest, Norwood and du Mont (2005) study, which compared medical PAS taught in undergraduate programmes, as reported by (n=12) nurse educators and (n=21) practicing nurses. The findings identified a clear ‘dichotomy between medical physical assessment skills valued by educators and what nurses actually used in practice’ (Secrest, Norwood and du Mont 2005:p117).
Concomitantly, various other studies have described a mismatch between what is taught in undergraduate nursing programmes, and the ability of graduate nurses to function in clinical practice (Lee et al. 2002; & Maben and Clark 2006). International studies over the past decade suggest that nursing graduates in hospitals are not meeting competency expectations from their employers’ point of view, and are not ‘practice ready’ (Bekow, Virkstis, & Stewart & Conway 2009). This has resulted in nurse educators’ saturating the curricula with additional medical PAS, to develop competency-based curricula to prepare nurses for independent practice (Giddens 2007).
Giddens (2007) emphasised the negative effects of over saturation of assessment skills in nurse education. Nursing students are unable to prioritise the development of the main medical PAS skills required for ward work, and are not sufficiently supported to develop medical PAS competence to the fullest capacity, because of the competing demands on hospital wards. Giddens (2007) concluded that more time, qualified staff support, and opportunities for continued presence with ward patients would enable newly qualified nurses develop medical PAS confidence and competence over time. Although Tanner (2006) presents a different view, by proposing that graduate nurses are able to use assessment skills, but lack the ability to formulate clinical judgements from their assessment findings. Both authors concede to teaching fewer medical PAS at undergraduate levels, with emphasis instead on interpretation of assessment findings and developing nurses’ clinical judgement. Giddens (2007) argues that teaching core medical PAS for nursing assessment practices on hospital wards would have better outcomes for patients. Graduate nurses should spend more time understanding and interpreting clinical findings to effectively identify patients who are at risk of deteriorating on hospital wards.
Reilly (2003) reported similar concerns on the inadequacy of professional preparation programmes in preparing medical students for clinical practice. He attributes these findings to medical educators seeking to promote the efficacy of diagnostic testing as a replacement to traditional medical PAS use for making diagnoses. He argues that unless medical students are encouraged by their supervisors to develop medical PAS competence, they will experience deficits in their clinical judgement skills in the long-term. Reilly (2003) proposes that physical examination should remain 'standard care until proven ineffective or superfluous' (Reilly 2003:1104) for medical practice.
Kelly and Kopac (2007) in the US were the only researchers who investigated the use of medical PAS in specialist and graduate nurse practitioner programmes. These findings formed the basis of a five year follow up survey of (n=390) graduate nursing schools, to track changes to health assessment education for advanced nursing practice since 2001. Their findings concluded that an array of medical PAS is core to the advanced nursing practice curricula. These findings were justified on the grounds that advanced nursing practice specialities require medical PAS to be in-depth and comprehensive, because the focus is on forming differential diagnoses. This study reported on the ease of integrating PAS into the holistic assessment framework of the nursing process for specialist roles (Kelley & Kopac 2007).
2.13.1 Summary of Theme two
Nurse educators need to teach medical PAS that are necessary for the practice of nursing related to the philosophical framework of nursing, particularly within undergraduate preparation programmes. A reported problem is that the breadth of medical PAS taught in undergraduate nursing programmes is too exhaustive. Ward-based nursing students are unable to prioritise medical PAS competence to the context of ward work, which is compounded by competing agendas and
reduced access to the patients over sustained periods, because of increased patient-nurse ratios on hospital wards. These factors not only restrict medical PAS competence, but compromise the development of graduate nurses clinical judgement skills. Additionally, opportunities for junior doctors to develop competence for diagnostic purposes are restricted by the focus on clinical diagnostics.
A dichotomy remains; evidence to support the inclusion of a breath of medical PAS in undergraduate nursing programmes is not supported. However, as RNs' progress to specialist and advanced roles, a greater range and depth of PAS education is required. To achieve this RNs require a broader understanding of an array of medical PAS to begin with, because core medical PAS competence underpins diagnostic work in CPE programmes of nursing.
2.14 Theme three: Physical assessment – role of education- UK perspective