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: [email protected] 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. 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