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Yamauchi-2001-Nursing & Health Sciences

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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.
INTRODUCTION
BACKGROUND
Assessment has been recognized as an essential
element of nursing practise. The more precise assessments 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 addition, 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 physical assessment skills in a clinical setting is crucial for
the development of educational programs that would
enable nurses to function independently.
There is no doubt that assessment by nurses is within
the scope of nursing practise. The nurse who recognizes 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
Correspondence address: Toyoaki Yamauchi, Oita University of Nursing
and Health Sciences, 2944–1 Notsuharu, Oita 870-1201, Japan.
Email: yamauchi@oita-nhs.ac.jp
Received 14 June 2001; revised 21 June 2001; accepted 21 August 2001.
214
as follows: (i) enhancement of effective communication (Yamauchi, 1997); (ii) recognition of changes in
the patient’s condition (Gender, 1983; Barrows, 1985;
Lont, 1992; Wilson & Lillibridge, 1995); (iii) enhancement of triage skills (George, 1984); (iv) early establishment of a nurse–client relationship (Bates &
Lynaugh, 1973); (v) promotion of nursing decisionmaking 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 knowledge 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 assessment 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 programs 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 education 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 physical assessment skills in a clinical setting, several
studies have been conducted (Barrows, 1985; Colwell
& Smith, 1985; Brown et al., 1987; Schare et al., 1988;
T. Yamauchi
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 implementing physical assessment skills were identified as:
(i) physician’s performance; (ii) inappropriateness to
clinical setting; (iii) no equivalent available; (iv) physical assessment not considered a nursing responsibility; (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 performing physical assessment with the benefits of performing 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 assessment classes; (iv) the development of confident,
assertive and knowledgeable nurses; and (v) continuing education for nurses.
Continuing education in conducting physical assessment 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 independently. 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
Physical assessment in Japan
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 programs 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 practise 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 pathological 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 physiological model also provides a common communication
tool among health-care professionals.
Guzzetta and Dossey (1983) pointed out that physicians have a standardized database, while nurses do
not. One reason for this may be related to the recommendation 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 patterns 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 communication tool, nurses who use different nursing
models can translate and exchange findings on the
physical aspects of their clients.
215
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 assessment 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 university 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 questionnaire. Three Japanese nursing educators and three
nurses currently practising in Japan examined the
questionnaire for content validity, clarity and discrimination 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, clinical experience and current working situation. The
behavioral data questions included Likert-like differential scales. Twenty-eight physical assessment items
were selected for the questionnaire (Table 1). Questions 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 necessary for the perceived needs (Table 2).
Using a 5-point Likert scale, the extent of knowledge of and skill for each physical assessment item
216
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
T. Yamauchi
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
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 questionnaires were distributed to all registered nurses
who worked at the study site. No exclusion criteria
were set for the data collection.
PMI, point of maximal impulse.
Data analysis
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 performed by the respondent; and (v) able to be performed 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 respondents’ need for each assessment item was classified
as follows: (i) strongly unnecessary; (ii) unnecessary; (iii) undecided; (iv) necessary; and (v) strongly
necessary.
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 determine 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 conducted at only one clinical site, in a selected geographic location in Japan. Due to the restricted
number of assessment items, the questionnaire devised for this study has limited validity for the evaluation of nurses’ attitudes towards assessment skills.
Human subjects
Confidentiality was ensured by omitting names from
the questionnaire and providing envelopes for reply.
Physical assessment in Japan
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 program. 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 working in outpatient departments; 22 (6.3%) were working 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 respondents 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-
30
25
No. nurses
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 maintain confidentiality, no one except the investigator
opened the envelopes.
217
20
15
10
5
0
0
2
4
6
8
10 12 14 16 18 20 22 24 26 28 30 32 34 36 38
Nursing experience (years)
Figure 1. Distribution of years in nursing.
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 participants 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 respondents 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 maximal 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, percussing thorax, assessing vocal fremitus, examining
breast lumps, palpating axillary nodes, percussing
abdomen and palpating point of maximal impulse,
218
Table 3.
T. Yamauchi
Knowledge of physical assessment skills
Physical assessment item
Vital signs
Consciousness level
Skin turgor
Skin lesion
Pitting edema
External eye
Extraocular movement
Pupil response
Nose and oral cavity
Palpate neck lymph nodes
Carotid pulse
Jugular venous distension
Vocal fremitus
Percuss thorax
Breath sounds
Palpate PMI
Heart murmur
Pulse deficit
Breast lumps
Palpate axillary nodes
Bowel sounds
Percuss abdomen
Palpate abdomen
Motor function and range of motion
Sensory status
Gait
Coordination
Deep tendon reflex
Skills (%) can be
taught to others
Skills (%) can be
performed by oneself
Skills (%) known but
cannot be performed
Skills (%) not
known
62.3
37.7
30.7
19.8
37.2
24.3
16.4
39.4
20.1
17.2
34.5
22.9
3.6
2.1
17.9
6.6
8.2
30.7
14.2
14.2
43.6
6.5
11.7
11.1
13.2
15.0
9.1
3.0
97.1
89.0
80.9
75.5
90.7
76.0
57.6
90.7
69.5
62.9
84.8
69.4
24.3
19.9
84.2
35.7
48.2
87.3
54.1
52.7
95.6
37.4
57.5
51.9
63.0
62.1
45.6
24.0
2.0
9.3
17.4
17.8
8.4
18.0
23.9
7.3
26.0
30.9
10.8
22.9
30.3
68.5
14.7
40.2
44.4
10.9
40.8
40.8
4.1
55.3
38.4
42.5
33.1
31.2
46.2
55.2
0.9
1.7
1.7
6.7
0.9
5.9
18.5
2.0
4.4
6.2
4.4
7.6
45.4
11.6
1.2
24.0
7.4
1.8
5.0
6.5
0.3
7.4
4.1
5.6
3.8
6.8
8.2
20.8
PMI, point of maximal impulse.
were never carried out or were performed less than
once per year by over half of the respondents.
fremitus and examining deep tendon reflex were not
necessary for them.
Need for physical assessment skills
Comparison between the groups of various
years in nursing
Research question 3: to what extent is each physical
assessment skill recognized as necessary by nurses in
Japanese clinical settings (Table 5)?
In considering the degree of need for physical
assessment skills, over half of the respondents cited
nine skills, including assessing vital signs, consciousness level, skin turgor, pitting edema, bowel sounds,
pupil response, pulse deficit, breath sounds and skin
lesion, as ‘strongly necessary’. Except for percussing
thorax and assessing vocal fremitus, over 50% of participants reported that the listed physical assessment
skills were necessary skills for them.
In comparison, over 10% of respondents reported
that the skills of percussing thorax, assessing vocal
The participants were able to be classified into two
groups based on their years in nursing. One was the
less experienced group, consisting of those who had
worked as nurses for fewer than 20 years. The other,
more experienced, group consisted of nurses with 20
years or more of experience. The less experienced
group consisted of 174 respondents, while the more
experienced group consisted of 175 respondents.
Knowledge of physical assessment skills
Chi-squared test analysis revealed that there were significant differences in the extent of knowledge about
Physical assessment in Japan
Table 4.
219
Use of physical assessment skills
Physical assessment item
Vital signs
Consciousness level
Skin turgor
Skin lesion
Pitting edema
External eye
Extraocular movement
Pupil response
Nose and oral cavity
Palpate neck lymph nodes
Carotid pulse
Jugular venous distension
Vocal fremitus
Percuss thorax
Breath sounds
Palpate PMI
Heart murmur
Pulse deficit
Breast lumps
Palpate axillary nodes
Bowel sounds
Percuss abdomen
Palpate abdomen
Motor function and range of motion
Sensory status
Gait
Coordination
Deep tendon reflex
Skills (%) performed
every day
Skills (%) performed
at least once per week
Skills (%)
not used
80.3
52.5
47.2
36.8
50.6
18.3
12.1
19.5
17.7
3.7
6.1
6.4
4.0
1.8
41.2
9.8
20.2
57.6
3.6
2.1
34.8
5.8
27.7
13.8
14.6
16.5
7.8
0.9
92.4
71.9
73.1
62.0
76.8
46.3
30.5
39.0
41.9
18.7
17.8
17.1
9.9
5.2
64.3
19.3
32.7
70.6
11.6
7.9
65.5
14.6
49.7
34.6
33.7
35.4
18.8
6.8
1.2
5.1
6.6
12.3
3.3
16.5
36.1
14.6
18.3
38.3
39.6
45.0
73.8
75.3
11.0
60.1
35.5
11.2
70.8
61.0
12.6
60.5
20.8
28.4
24.8
30.4
49.7
78.3
PMI, point of maximal impulse.
physical assessment skills between the two groups
based on the nurses’ experience (Table 6). The more
experienced group was much more knowledgeable
about all physical assessment skills except for auscultating breath sound, palpating point of maximal
impulse and auscultating heart murmur. There were
no significant differences between the groups’ knowledge about auscultating breath sound, palpating point
of maximal impulse and auscultating heart murmur.
lar movement, examining pupil response, examining
the nose and the oral cavity, palpating neck lymph
nodes, examining jugular venous distension, percussing thorax, auscultating breath sounds, examining
pulse deficit, examining breast lumps, palpating axillary nodes, auscultating bowel sounds, percussing
abdomen and examining coordination.
Need for physical assessment skills
Use of physical assessment skills
Some statistically significant differences regarding the
nurses’ use of their physical assessment skills were
found (Table 7). Fourteen physical assessment skills
were used more often by the group of respondents
who had more experience in nursing. These skills
were examining the external eye, examining extraocu-
Except for auscultating heart murmur and examining
sensory status, there were no significant differences
between the two groups’ perceived need for physical
assessment skills (Table 8). Compared with the less
experienced group, only a few more respondents from
the more experienced group selected auscultating
heart murmur and examining sensory status as ‘not
necessary’.
220
Table 5.
T. Yamauchi
Need for physical assessment skills
Physical assessment item
Vital signs
Consciousness level
Skin turgor
Skin lesion
Pitting edema
External eye
Extraocular movement
Pupil response
Nose and oral cavity
Palpate neck lymph nodes
Carotid pulse
Jugular venous distension
Vocal fremitus
Percuss thorax
Breath sounds
Palpate PMI
Heart murmur
Pulse deficit
Breast lumps
Palpate axillary nodes
Bowel sounds
Percuss abdomen
Palpate abdomen
Motor function and range of motion
Sensory status
Gait
Coordination
Deep tendon reflex
Skills (%) needed strongly
Skills (%) needed
Skills (%) not needed
92.7
90.1
80.4
60.4
78.1
43.1
34.1
67.6
42.9
29.1
31.4
28.5
10.8
9.8
64.9
23.6
40.3
67.5
23.9
22.4
74.3
20.8
40.7
39.0
43.0
42.2
31.2
13.6
98.5
98.3
95.6
89.0
98.0
84.4
74.9
93.8
83.6
71.2
73.4
69.4
46.8
47.4
95.5
60.6
83.9
94.9
69.1
69.1
95.9
58.4
80.4
81.7
84.2
84.3
73.0
50.0
0.3
0.0
0.3
1.2
0.3
0.6
3.0
0.6
1.2
5.0
5.0
5.0
13.8
16.2
0.3
9.4
2.1
0.6
5.5
4.8
0.6
7.8
3.0
3.0
2.1
1.8
3.3
11.7
PMI, point of maximal impulse.
DISCUSSION
Sample
Among all registered nurses in Japan, 97.45% are
female and 2.55% are male (Nursing Division, Health
Policy Bureau, Ministry of Health and Welfare, 1996).
In the present study, 98% of the respondents were
female, which was similar to the percentage of female
nurses in general Japanese nursing practise.
The total number of new nursing students in Japan
was 52 703 in 1996. The total number of new nursing
students was 3009 (5.7%) for baccalaureate programs,
6139 (11.6%) for associate degree programs and
43 555 (82.7%) for diploma programs (Nursing
Division, Health Policy Bureau, Ministry of Health
and Welfare, 1996). In 1986, there was a total of 38 781
new nursing students in Japan, with 481 (1.2%) new
nursing students for baccalaureate programs, 3794
(9.7%) for associate degree programs and 34 943
(89.1%) for diploma programs (Nursing Division,
Health Policy Bureau, Ministry of Health and
Welfare, 1996). A total of 1048 basic nursing educational programs (46 baccalaureate programs, 84 associate degree programs and 918 diploma programs)
existed in Japan in 1996. In contrast, there were only
11 baccalaureate programs, 58 associate degree programs and 855 diploma programs available in Japan
in 1986. These statistics demonstrate that the number
of students, as well as the number of nursing baccalaureate and associate degree programs increased
in Japan between 1986 and 1996.
There was only one baccalaureate nurse among the
respondents in this study. This might be a reflection
of Japan’s limited number of baccalaureate nursing
programs and of the newness of the baccalaureate
nursing programs. Furthermore, because of the recent
rapid growth of the number of nursing baccalaureate
programs in Japan, the majority of baccalaureate
nurses have changed workplaces from clinical practise
sites to educational settings, mainly four-year nursing
colleges. Nineteen of the respondents were associate
Physical assessment in Japan
221
Table 6. Comparison between the groups’ knowledge of
physical assessment skills
c2
Vital signs
Consciousness level
Skin turgor
Skin lesion
Pitting edema
External eye
Extraocular movement
Pupil response
Nose and oral cavity
Palpate neck lymph nodes
Carotid pulse
Jugular venous distension
Vocal fremitus
Percuss thorax
Breath sounds
Palpate PMI
Heart murmur
Pulse deficit
Breast lumps
Palpate axillary nodes
Bowel sounds
Percuss abdomen
Palpate abdomen
Motor function and range of motion
Sensory status
Gait
Coordination
Deep tendon reflex
35.75
12.09
33.81
37.00
34.26
27.28
41.75
19.73
32.10
55.43
25.46
31.62
13.34
38.91
3.31
8.39
3.38
19.31
65.05
83.54
28.88
42.45
15.63
15.60
19.16
32.72
31.06
16.30
Table 7. Comparison between the groups’ use of physical
assessment skills
Knowledge
d.f.
P
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
3
4
4
4
4
4
4
4
0.000*
0.017*
0.000*
0.000*
0.000*
0.000*
0.000*
0.001*
0.000*
0.000*
0.000*
0.000*
0.010*
0.000*
0.507
0.078
0.496
0.001*
0.000*
0.000*
0.000*
0.000*
0.004*
0.004*
0.001*
0.000*
0.000*
0.003*
*P < 0.05.
d.f., degrees of freedom; PMI, point of maximal impulse.
degree graduates, which also is reflective of the
number and short history of Japanese nursing associate degree programs.
The respondents’ distribution of years in nursing
revealed that a gap exists around the 15th year in
nursing. This gap reflects that there were fewer
respondents aged in their thirties than aged in their
twenties or aged 40 and over. Because social support
systems for working mothers in Japan are not well
developed, many women in their thirties may have
difficulty continuing to work. In addition, Japanese
cultural norms may force mothers with young children to be away from regular work settings. The
pattern of age distribution in the present study may
be characteristic of the particular study sample and
may not be similar to that of Japanese nurses in
general.
c2
Vital signs
Consciousness level
Skin turgor
Skin lesion
Pitting edema
External eye
Extraocular movement
Pupil response
Nose and oral cavity
Palpate neck lymph nodes
Carotid pulse
Jugular venous distension
Vocal fremitus
Percuss thorax
Breath sounds
Palpate PMI
Heart murmur
Pulse deficit
Breast lumps
Palpate axillary nodes
Bowel sounds
Percuss abdomen
Palpate abdomen
Motor function and range of motion
Sensory status
Gait
Coordination
Deep tendon reflex
0.50
2.60
2.33
3.24
3.56
11.74
15.05
11.86
12.69
13.04
7.43
11.26
7.12
24.74
7.86
0.20
2.43
7.96
9.21
17.76
8.83
8.45
4.19
1.53
1.38
3.06
7.84
3.15
Use
d.f.
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
P
0.919
0.457
0.506
0.356
0.313
0.008*
0.002*
0.008*
0.005*
0.005*
0.059
0.010*
0.068
0.000*
0.049*
0.977
0.488
0.047*
0.027*
0.000*
0.032*
0.038*
0.241
0.676
0.710
0.382
0.049*
0.369
*P < 0.05.
d.f., degrees of freedom; PMI, point of maximal impulse.
Frequencies
Over 90% of the respondents reported that they
knew 23 of the 28 listed physical assessment skills,
although there were only four skills listed that could
be performed by over 90% of the respondents. There
appears to be a gap between the level of what is
‘known’ and what ‘can be performed’. It was surprising that three respondents reported that they did not
know how to assess vital signs.
Because this study used a self-administered questionnaire, there was some limitation in the scale in
measuring the respondents’ actual extent of knowledge of physical assessment skills.
Less than half of the respondents did not use seven
assessment skills, while five skills were used every day
by over half of the respondents. The study conducted
222
T. Yamauchi
Table 8. Comparison between the groups’ need for physical assessment skills
c2
Vital signs
Consciousness level
Skin turgor
Skin lesion
Pitting edema
External eye
Extraocular movement
Pupil response
Nose and oral cavity
Palpate neck lymph nodes
Carotid pulse
Jugular venous distension
Vocal fremitus
Percuss thorax
Breath sounds
Palpate PMI
Heart murmur
Pulse deficit
Breast lumps
Palpate axillary nodes
Bowel sounds
Percuss abdomen
Palpate abdomen
Motor function and range of motion
Sensory status
Gait
Coordination
Deep tendon reflex
1.00
—
1.03
1.03
1.02
1.89
0.01
1.91
3.77
0.01
1.41
2.62
2.32
1.35
1.00
3.45
3.85
2.01
0.83
0.87
0.00
0.27
0.00
3.44
5.28
1.06
1.35
0.55
Need
d.f.
1
—
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
P
0.318
—
0.310
0.311
0.314
0.170
0.928
0.167
0.052
0.936
0.235
0.106
0.128
0.245
0.318
0.063
0.050*
0.156
0.363
0.351
0.989
0.603
0.972
0.064
0.022*
0.303
0.246
0.459
*P < 0.05.
d.f., degrees of freedom; PMI, point of maximal impulse.
by Sony (1992) in Canada revealed that 90.4% of the
participants in that study palpated abdomens very
frequently, while less than half of the respondents in
the present study palpated abdomens at least once a
week, and over 20% of the respondents did not
palpate abdomens at all. Thirty percent of the participants in Sony’s (1992) study did not examine deep
tendon reflexes, while 78.3% of the respondents in the
present study indicated that they did not examine
deep tendon reflexes.
Colwell and Smith (1985) reported that over half of
the participants in their study used the following 13
skills on a daily basis: auscultating lungs, palpating
apical pulse, auscultating adventitious sounds, auscultating bowel sounds, auscultating heart murmurs,
assessing skin lesions, assessing skin turgor, assessing
capillary refill, assessing peripheral pulses, palpating
abdomens, examining range of motion, examining
external eye, and assessing pupil response. Only four
skills, including assessing vital signs, assessing pulse
deficit, assessing consciousness level and examining
pitting edema, were reported to be used every day by
over half of the respondents in this study. The order
of ‘the skills used daily’ reported by Colwell & Smith
(1985) was similar to the order of ‘the skills used at
least once a week’ in the present study. There was no
significant difference between the list of ‘skills never
used’ in the study by Colwell & Smith (1985) and in
the present study.
Overall, the order of utilization frequency of physical assessment skills was similar to previous studies,
but the actual frequencies of skills were lower than
those of previous studies.
In this study, ‘lack of knowledge’ was selected most
frequently as a possible deterrent. Colwell & Smith
(1985) revealed that ‘not a problem area’ was a
leading deterrent, while the participants in Sony’s
(1992) study identified ‘physicians doing physical
assessment’ as the top inhibiting factor to use of
physical assessment skills by nurses.
Comparison between the groups of various
years in nursing
The data revealed that the group of respondents with
more years of clinical experience had better knowledge of physical assessment skills, except for the
following three skills: auscultating breath sounds, palpating the point of maximal impulse and auscultating
heart murmurs. There was no difference in basic
nursing education among the two groups, so the difference in the extent of knowledge might be based on
the difference in the length of time the nurses had
been practising nursing. In the present study, the
longer the nurses worked in practise, the more they
knew about physical assessment skills. This finding
may indicate that physical assessment skills are being
learned ‘on the job’. Statistical analysis revealed that
the more experience the nurses had in nursing, the
more likely they were to use physical assessment
skills more frequently. The experienced nurses faced
less difficulty in carrying out physical assessment
skills. The degree of perceived need for physical
assessment skills by the respondents in both groups
were not found to be different.
Even though the degree of perceived need for
physical assessment skills was high in both groups, the
more experienced group had more knowledge of
physical assessment skills, used the skills more fre-
Physical assessment in Japan
quently and had less difficulty in using physical assessment skills. The three elements of knowledge, use and
difficulty might be linked to each other.
Nurses seemed to learn physical assessment skills
‘on the job’, as acquiring physical assessment skills
required more experience. Experiencing and learning
‘on the job’ used to be the most common way for
nurses to acquire physical assessment skills.
Education is an effective means for providing
people with more knowledge about physical assessment skills and promoting confidence to use the skills.
Brown et al. (1987) investigated changes in nursing
practise by measuring confidence levels of nurses.
Their study revealed that nurses reported more confidence in their nursing practise after learning physical
assessment skills. A better educational program about
physical assessment skills might make nurses more
knowledgeable about those skills, enabling them to
use the skills more frequently and with less difficulty.
Effective educational programs for physical assessment skills may fulfil the nurses’ perceived need for
physical assessment skills.
LIMITATION
Due to the fact that all the data were gathered from
one clinical site, general implications from the findings of this study are limited. A convenience sample
was used and might have affected the results, as only
a limited number of physical assessment skills were
included in the questionnaire. This study did not
attempt to ascertain nurses’ knowledge of, use of or
attitude towards all physical assessment skills.
FURTHER RESEARCH
The results of this study need to be verified by surveying a larger and more diverse, randomly selected
sample of nurses. In order to expedite data collection,
the instrument must be refined by re-evaluating the
list of physical assessment skills and by seeking information on the rationale for using specific physical
assessment skills at particular times in various clinical
settings.
Improved medical technology and shorter term
hospitalization for patients requires nurses to possess
high levels of assessment skills to ensure optimum
care for their patients. More research in this area is
necessary as the nursing profession continues to consider how the use of physical assessment skills by
nurses actually enhances patient care.
223
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