Yamauchi-2001-Nursing & Health Sciences

INTRODUCTION
Assessment has been recognized as an essential
element of nursing practise. The more precise assess-
ments nurses can perform, the better outcomes
patients can achieve. Educators and the health-care
community in general often stress the use of physical
assessment skills once they are learned. Even when
nurses do not use comprehensive assessment skills in
daily practise, nurses must be confident in their ability
to perform physical assessment skills.
Many nurses feel and express ambivalence to and
awkwardness when using assessment skills. In addi-
tion, some nurses might not consider it necessary to
learn physical assessment skills. Some skills are used
based on the needs of patient populations and some
might not be used due to nurses’ lack of confidence in
using certain skills.
Knowing more about the reality of the use of physi-
cal assessment skills in a clinical setting is crucial for
the development of educational programs that would
enable nurses to function independently.
BACKGROUND
There is no doubt that assessment by nurses is within
the scope of nursing practise. The nurse who recog-
nizes normal findings can recognize health, with all its
normal variations, during client assessment in any
health-care setting. This enables the nurse to identify
abnormal assessment findings accurately, providing
the basis for developing nursing diagnosis and plans
for client care. Today, nursing assessment is not
merely allowed but is indeed required by the
standards of professional nursing practise. Better
knowledge of physical assessment provides a more
complete database for nurses and enhances nurses’
abilities to monitor and identify the changes in their
patients, to assess the functional ability of their
patients and to support adaptations in patients’
lifestyles (Taggart, 1977).
Furthermore, the nurse can ‘make independent and
interdependent judgments about the patients’ care
management’ (Taggart, 1977). It is also important to
remember that nursing assessment is not the same
as medical diagnosis, but is a unique nursing activity.
The ability to recognize normal findings enhances
the nurse’s self-confidence in promoting, maintaining
and restoring client health, the nurse’s primary
responsibility.
The benefits to patient care, as a result of nurses’
performance of physical assessment, are summarized
Nursing and Health Sciences (2001), 3, 213–224
Research Article
Correlation between work experiences and physical
assessment in Japan
Toyoaki Yamauchi, md,nd,phd
Oita University of Nursing and Health Sciences, Oita, Japan
Abstract The purpose of this study was to obtain baseline data of Japanese nurses’ knowledge, skills and
attitudes concerning physical assessment. The design of the study was survey research, using a
self-administered questionnaire. Nurses with more experience were more knowledgeable about
almost all physical assessment skills. Fourteen of the physical assessment skills were used more
often by respondents with more experience in nursing practise. Ten of the physical assessment
skills were cited as more difficult to carry out by respondents with less experience in nursing. The
group with more clinical practise experience had more knowledge of physical assessment skills,
used the skills more frequently and had less difficulty in using them. The results of this study
indicated that Japanese nurses learn physical assessment skills ‘on the job’.
Key words assessment, attitudes, Japan, Japanese nurses, knowledge, physical assessment, skills, survey.
Correspondence address: Toyoaki Yamauchi, Oita University of Nursing
and Health Sciences, 2944–1 Notsuharu, Oita 870-1201, Japan.
Email: [e-mail]
Received 14 June 2001; revised 21 June 2001; accepted 21 August 2001.

214 T. Yamauchi
as follows: (i) enhancement of effective communica-
tion (Yamauchi, 1997); (ii) recognition of changes in
the patient’s condition (Gender, 1983; Barrows, 1985;
Lont, 1992; Wilson & Lillibridge, 1995); (iii) enhance-
ment of triage skills (George, 1984); (iv) early estab-
lishment of a nurse–client relationship (Bates &
Lynaugh, 1973); (v) promotion of nursing decision-
making and management (Lynaugh & Bates, 1974;
Hagopian et al., 1982); (vi) assistance to patients in
overcoming problems (Turnbull, 1976; Gender, 1983);
and (vii) increased job satisfaction (Gender, 1983).
Physical assessment skills used to be learned on the
job. Nurses often learned practical skills, but without
any theoretical understanding. In fact, they might
have learned erroneous techniques. Education is an
effective way to provide people with precise knowl-
edge and skills and to promote nurses’ confidence in
using skills. Nursing education must prepare nurses to
meet the health-care needs of the patients. Now, in
many nursing educational programs, nursing assess-
ment courses, including history-taking and physical
assessment, are provided as standard courses. Surveys
of nurse educators revealed that they considered
physical assessment skills to be an essential part of
undergraduate curricula (Wallhead, 1983; James &
Reaby, 1987; Solomon, 1990).
A comprehensive nursing approach to the physical
assessment of patients was first introduced in North
America with the advent of nurse practitioner pro-
grams in the 1960s; subsequently, masters’ programs
in nursing incorporated comprehensive physical
assessment (Taller & Feldman, 1984). Ultimately, the
subject was taught at undergraduate level (Hagopian
& Kilpack, 1974; Wong, 1975; Quarto & Natapoff,
1979; Natapoff et al., 1982) and in continuing educa-
tion programs for practising nurses (Lincoln et al.,
1978; Shortridge et al., 1977).
The use of physical assessment skills by nurses and
the importance of using these skills as they are
learned are often stressed. However, many nurses
complain of ambivalence and lack of comfort in using
assessment skills. Nurses may think that learning
physical assessment skills is unnecessary. Even when
nurses do not use comprehensive assessment skills in
their daily nursing practise, nurses must be confident
in these skills. One reason that assessment skills are
not used comprehensively is that skills might be used
based on demand from the patient population.
Another is as a result of nurses’ lack of confidence in
using certain skills.
To learn more about the reality of the use of physi-
cal assessment skills in a clinical setting, several
studies have been conducted (Barrows, 1985; Colwell
& Smith, 1985; Brown et al., 1987; Schare et al., 1988;
Reaby, 1990; Vines & Simons, 1991; Lont, 1992).
Although comprehensive physical assessment skills
were not carried out on a daily basis, certain skills
were used by most nurses currently working in
various settings.
Studies commonly pointed out several obstacles,
such as physical assessment skills not being regarded
as a nursing responsibility. These obstacles include
lack of knowledge, confidence or time to perform
physical assessment skills and lack of support from
other nurses in performing physical assessment. In a
study conducted by Sony (1992), barriers to imple-
menting physical assessment skills were identified as:
(i) physician’s performance; (ii) inappropriateness to
clinical setting; (iii) no equivalent available; (iv) physi-
cal assessment not considered a nursing responsibil-
ity; (v) no opportunity to use physical assessment
skills; (vi) lack of time due to heavy workload; (vii)
use only if problem is suspected; and (viii) lack of
support from colleagues.
Barrows (1985) reported five factors required for
successful implementation of physical assessment by
nurses: (i) clear definition of the nurse’s role in per-
forming physical assessment with the benefits of per-
forming these skills being clearly recognized both by
nurses themselves and by other health professionals;
(ii) the course and objectives for an educational
program of physical assessment skills being planned
jointly by educators, clinical nurses and other key
persons; (iii) the structure and content of the assess-
ment classes; (iv) the development of confident,
assertive and knowledgeable nurses; and (v) continu-
ing education for nurses.
Continuing education in conducting physical assess-
ment can assist the nurses to feel more confident in
their nursing practise; interpret individual patient
findings better; understand physicians’ progress notes
and examinations better; improve their interaction
with patients; feel more comfortable in reporting their
findings and in initiating specific nursing actions;
and provide direct referrals to appropriate resource
persons. Furthermore, it has been noted that younger
nurses with fewer years of experience are more
willing to learn chest auscultation skills (Brown et al.,
1987).
SIGNIFICANCE OF STUDY
To achieve nursing goals, nurses must function inde-
pendently. To attain this goal, nurses have to acquire
and be confident in the use of health assessment
skills. Except for those in North America and
Australia, there are few studies on the development
of assessment educational programs. In addition, few

studies on the use of assessment skills are reported
outside the United States and Australia. A general
survey of relevant literature reveals that there are no
studies related to the use of assessment skills in
Japan.
This study is the first phase of a longitudinal project
identifying the outcomes of educational programs on
assessment skills that will be introduced in the near
future. The development of new educational pro-
grams requires the identification of nurses’ use of and
specific needs regarding assessment skills in clinical
settings. Thus, this study is significant in providing
baseline data for one aspect of Japanese nursing prac-
tise today. It will be a useful reference for Japanese
nursing education in the future.
CONCEPTUAL FRAMEWORK
The framework of this study was a systematic physical
assessment model based on a physiological model.
The systematic physical assessment approach was
intended to gather as much information as possible
on the function, size and appearance of organs and
body parts in order to make a comprehensive and
integrated evaluation of the presence or absence of
pathology and of the total body response to patholo-
gical processes.
The physiological model provides a guideline for
detecting signs of changes in the client’s health status,
assessing the client’s living activities and facilitating
preventive care and health promotion. The physiolo-
gical model also provides a common communication
tool among health-care professionals.
Guzzetta and Dossey (1983) pointed out that phy-
sicians have a standardized database, while nurses do
not. One reason for this may be related to the recom-
mendation by nurse theorists that a conceptual model
of nursing is needed to guide the development of
a nursing database (Guzzetta, 1987). Because of the
many conceptual models available to nursing, it is
impossible to standardize a nursing database across
the country, as the conceptual models and resultant
assessment tools are so different.
Gordon (1982) introduced functional health pat-
terns as a guide for organizing assessment data. She
suggested that, as they become more familiar with
nursing models and test them in clinical practise,
nurses would choose a model that was realistic, useful
and in concert with their values and their philosophy
of nursing. By using a physiological model as a com-
munication tool, nurses who use different nursing
models can translate and exchange findings on the
physical aspects of their clients.
RESEARCH QUESTIONS
The purpose of this study was to answer the following
questions: (i) what is the extent of the knowledge and
skills of Japanese nurses concerning physical assess-
ment in various clinical settings?; (ii) how frequently
are physical assessment skills performed by nurses in
Japanese clinical settings?; and (iii) to what extent is
each physical assessment skill recognized as necessary
by nurses in Japanese clinical settings?
RESEARCH DESIGN
Methods
The design of this study was survey research. Consent
was obtained from an Institutional Review Board for
Human Studies at a renowned middle American uni-
versity that contained a school of nursing.
Instrument
Because no instrument had been developed that was
appropriate for obtaining data for this study, the
investigator developed a self-administered question-
naire. Three Japanese nursing educators and three
nurses currently practising in Japan examined the
questionnaire for content validity, clarity and discrimi-
nation of items. The questionnaire was revised and
modified appropriately. Because each item of the
questionnaire was independent, establishing internal
consistency among items was not necessary. A pilot
survey with 20 Japanese nurses was conducted to
establish the reliability of the questionnaire. The
Wilcoxon matched-pairs signed ranks test was used to
determine the stability of test–retest reliability.
The questionnaire consisted of two major parts:
demographic data questions and behavioral data
questions. The demographic data consisted of the
respondent’s age, sex, educational background, clini-
cal experience and current working situation. The
behavioral data questions included Likert-like differ-
ential scales. Twenty-eight physical assessment items
were selected for the questionnaire (Table 1). Ques-
tions for each of the selected physical assessment
items addressed: (i) the extent of knowledge and skill
used in that assessment; (ii) the frequency of use of
that assessment skill and perceived factors necessary
for performing the skill; and (iii) the perceived need
for that assessment skill as well as the factors neces-
sary for the perceived needs (Table 2).
Using a 5-point Likert scale, the extent of knowl-
edge of and skill for each physical assessment item
Physical assessment in Japan 215

216 T. Yamauchi
was classified by each respondent as follows: (i) not
known; (ii) barely known; (iii) known but unable to
be performed by the respondent; (iv) able to be per-
formed by the respondent; and (v) able to be per-
formed and to be taught to others by the respondent.
The frequency of use of each physical assessment
item was classified, using a 5-point Likert scale, by
each respondent as follows: (i) never used or used less
than once per year; (ii) used more than once per year
but less than once per month; (iii) used more than
once per month but less than once per week; (iv) used
more than once per week but less than once per day;
and (v) used every day.
Using a 5-point Likert scale, the extent of respon-
dents’ need for each assessment item was classified
as follows: (i) strongly unnecessary; (ii) unneces-
sary; (iii) undecided; (iv) necessary; and (v) strongly
necessary.
Sample site and sampling
The site for this study was a 630-bed regional
hospital, which is also an educational hospital for a
baccalaureate nursing program in Japan. The ques-
tionnaires were distributed to all registered nurses
who worked at the study site. No exclusion criteria
were set for the data collection.
Data analysis
The levels of data from this questionnaire were
nominal and ordinal. Thus the data were analyzed by
means of frequency tabulations as percentiles, with
analysis by chi-squared test when possible, to deter-
mine the association between the variables.
Limitations
The findings of this study are able to be generalized
only to a limited extent, because the study was con-
ducted at only one clinical site, in a selected geo-
graphic location in Japan. Due to the restricted
number of assessment items, the questionnaire de-
vised for this study has limited validity for the evalua-
tion of nurses’ attitudes towards assessment skills.
Human subjects
Confidentiality was ensured by omitting names from
the questionnaire and providing envelopes for reply.
Table 1. Twenty-eight physical assessment items selected
for the questionnaire
1 Measuring vital signs (blood pressure, body
temperature, respiratory rate, pulse rate)
2 Assessing consciousness level
3 Testing for skin turgor
4 Examining for skin lesions
5 Testing for pitting edema
6 Examining the external eye
7 Evaluating extraocular movement
8 Testing pupil response
9 Examining the nose and the oral cavity
10 Palpating the lymph nodes of the neck
11 Assessing carotid pulses
12 Assessing for jugular venous distension
13 Palpating the thorax for vocal fremitus
14 Percussing the thorax
15 Auscultating the lungs for breathing sounds
16 Palpating the precordium for PMI
17 Auscultating the heart for murmurs
18 Determining pulse deficit
19 Palpating for breast lumps
20 Palpating for axillary nodes
21 Auscultating for bowel sounds
22 Percussing the abdomen
23 Palpating the abdomen
24 Testing the motor function and range of motion in any of
the extremities
25 Testing sensory status of any of the extremities
26 Observing gait
27 Assessing coordination
28 Testing deep tendon reflexes
PMI, point of maximal impulse.
Table 2. Answer keys for each question
The extent of knowledge of and skill for each physical
assessment item
1 Not known
2 Barely known
3 Known but unable to be performed by the respondent
4 Able to be performed by the respondent
5 Able to be performed and taught to others by the
respondent
The frequency of use of each physical assessment item
1 Never or less than once per year
2 More than once per year but less than once per month
3 More than once per month but less than once per week
4 More than once per week but less than once per day
5 Every day
The extent of respondents’ need for each assessment item
1 Strongly unnecessary
2 Unnecessary
3 Undecided
4 Necessary
5 Strongly necessary

After completion, each questionnaire was placed in
an envelope by the respondent. The respondent
sealed the envelope himself or herself and returned
the sealed envelope to a drop box that was placed on
each unit. These envelopes were kept closed until
they were given to the investigator. In order to main-
tain confidentiality, no one except the investigator
opened the envelopes.
SAMPLE DESCRIPTION
Three hundred and forty-nine of the 357 registered
nurses completed and returned the questionnaires, a
response rate of 97.8%. Three hundred and forty-two
(98.0%) of the respondents were female and seven
(2.0%) were male. The age of the respondents varied
from 21 to 62 years, with a mean age of 39.8 years
(SD =10.5), a median age of 43 years and a modal age
of 48 years.
Three hundred and twenty-nine (94.3%) of the
respondents were diploma graduates, 19 (5.4%) were
associated degree graduates and one registered nurse
(0.3%) graduated from a nursing baccalaureate pro-
gram. The total years in nursing of the respondents
varied from 0 to 38 years; the average total years in
nursing was 16.6 years (SD =10.3); the median was 20
years; and the mode was 6 years and 20 years.
Thirty-nine (11.2%) of the respondents were work-
ing in outpatient departments; 22 (6.3%) were work-
ing at general units; 63 (18.1%) were in medical units;
99 (28.4%) were in surgical units; 34 (9.7%) worked
at the pediatric unit; 22 (6.3%) were working on the
obstetrical and gynecologic unit; none of the respon-
dents worked in a psychiatric unit; and 24 (6.9%)
worked in the intensive care unit. Only one of the
respondents (0.3%) worked on the rehabilitation unit,
while 22 (6.3%) worked on the operation unit and
one (0.3%) worked in the supply unit. None of the
respondents worked for the home care unit, or for the
administrative department.
The participants were classified into two groups
based on their number of years in nursing. One group
was a less experienced group; it consisted of those
who had worked as nurses for fewer than 20 years.
The other group consisted of those nurses who had 20
years’ experience or more (Fig. 1).
RESULTS
Frequencies
Knowledge of physical assessment skills
Research question 1: what is the extent of the
knowledge and skills of Japanese nurses con-
cerning physical assessment in clinical settings
(Table 3)?
In regard to the degree of knowledge of the various
physical assessment skills included, 63.3% of the par-
ticipants responded that they could teach others how
to assess vital signs, including measurement of blood
pressure, body temperature and counting pulse rate
and respiratory rate. More than 30% of the respon-
dents specified seven further physical assessment
skills that they felt they could teach to others. More
than 75% of these respondents specified 10 physical
assessment skills they felt they could perform.
More than 40% of the participants specified nine
physical assessment skills they knew but could not
perform. Three physical assessment skills, including
assessing vocal fremitus, palpating the point of maxi-
mal impulse and examining deep tendon reflex,
were identified as ‘not known’ by over 20% of the
respondents.
Use of physical assessment skills
Research question 2: how frequently are physical
assessment skills performed by nurses in Japanese
clinical settings (Table 4)?
Over 80% of the participants reported that they
assessed vital signs every day. More than half of the
respondents assessed pulse deficit, consciousness level
and pitting edema on a daily basis. Vital signs were
assessed by over 90% of the respondents at least once
per week. In addition to the physical assessment skills
performed daily, skin turgor, bowel sounds, breath
sounds and skin lesion were examined at least weekly
by more than half of the participants.
In contrast, seven of the 28 physical assessment
skills, including examining deep tendon reflex, per-
cussing thorax, assessing vocal fremitus, examining
breast lumps, palpating axillary nodes, percussing
abdomen and palpating point of maximal impulse,
Physical assessment in Japan 217
0 2 4 6 8 10121416182022242628303234 36 38
0
5
10
15
20
25
30
Nursing experience (years)
No. nurses
Figure 1. Distribution of years in nursing.