Physical Assessments are Essential to Patient Outcomes: Are RNs Really Performing Them?

Friday, 22 February 2019: 12:45 PM

Anita Grace Fennessey, DrNP
College of Nursing, Jefferson (Philadelphia University + Thomas Jefferson University), Willow Grove, PA, USA

Between 210,000 and 440,000 patients die each year as a result of some type of preventable harm that occurred during their hospitalization. The Joint Commission has identified inadequate or lack of patient assessment as one of the primary causes of sentinel events. Research has demonstrated that astute assessment is essential to safe patient care. A through physical assessment is the foundation for all planned nursing intervention and provides the framework against which subsequent findings during hospitalization can be compared and evaluated.

There are several positive outcomes attributed to RNs consistently performing thorough physical assessment exams that have been validated in the literature including: improved nurse-physician collaboration, decreased adverse medical events, and better patient outcomes. However, research has shown that nurses do not routinely perform even one-half of the assessment skills they learned in school.

There may be many variables related to assessment skills not being used consistently and thoroughly. Burnout may contribute to this phenomenon. High burnout levels have been linked with lower levels of job satisfaction, increased errors of judgment, and decreased work efficiency. The literature also substantiates the relationship between burnout and RNs’ work environment. The net effect of the work environment on job performance affects overall quality of patient care. However, there have been few studies that define job performance effectively, and no studies that specifically address RNs’ physical assessment skill performance as a function of job performance that may be affected by factors such as burnout and work environment attributes.

This study evaluated the performance of physical assessment exams. Even though no specific significance between physical assessment performance and burnout, work environment, and/or knowledge was identified, its relevance and importance to patient outcomes was verified, especially as cited in the literature. The demographic data established a difference between frequencies of use of physical assessment exams based on the clinical unit where the nurse worked. This is significant when reviewing the units in which physical assessment exams appear to be done less often. For example, nurses who work on Pediatric, Neurology, Oncology, and Geriatric units were identified as performing physical assessment exams at a lower rate than the nurses on the critical care and telemetry units. This is significant in that some of these units have more vulnerable and at-risk patients who need closer observation and more frequent assessments in order to prevent serious complications. As expected, the nurses in the critical care and telemetry units perform physical assessment exams most often. This could be due to acuity or even protocol. No matter what the reason is for the differences among the frequency of assessments nurses performed, it has become evident that a change in care is needed, and this finding may even provide a starting point.

Furthermore, it was also concerning to find that out of 28 physical assessment skills listed on the PAPQ, only seven were reported at greater than 80% for being done on a daily basis. This is an important finding given the higher acuity of the typical Medical-Surgical patient, along with the finding that in some of the other clinical areas, excluding Critical Care and Telemetry, nurses were not performing physical assessment exams as frequently as may be needed given the severity of their patient’s disease processes or vulnerability of the patient. This is an essential finding given that nurses are viewed as the frontline warriors in healthcare. The role of frontline warrior increases the expectations of the nurse in that patients, as well as administration, believe that the nurse who is with the patient at longer intervals than any other healthcare provider, will provide care that will enable the patient to regain his/her previous state of health without any serious consequences.

Clinical assessment skills are important to all levels of nursing practice. Since the goal of the professional nurse is to promote, reestablish, and preserve the optimal health of patients by assessing, diagnosing, and treating actual and potential health problems that can affect one’s functional abilities, it is imperative that the nurse consistently and accurately assesses each and every patient. Performing a physical assessment is an essential skill that falls within the scope of nursing practice. As a consequence, failure to perform physical assessment exams may result in the nurse not practicing within the expected standards of practice for the professional nurse.

Another implication to consider is the documentation of the physical assessment exam. With the advancement of the Electronic Medical Record (EMR), it is easy for the nurse to just check off within defined limits. The assumption is that the nurse has assessed everything in that definition before he/she documents in that area. The reality is that each major assessment may include multiple layers of additional assessments. The question is whether all of these assessments are being performed or is the nurse just assuming that since some of the assessments are normal then all of the assessments in that area are normal. Therefore, more research investigating the accuracy of assessment documentation in the EMR is needed.

Establishing a baseline within a framework of the patient’s medical diagnosis and presenting symptoms, will provide the nurse with the information he/she needs to not only care for the patient, but to also keep the patient safe. Evidence has shown that incorrect assessment of patient conditions was found to be the second leading cause of sentinel events. Consequently, this investigator believes that if nurses consistently perform complete physical assessment exams, they will increase their ability to pick up the subtle cues of changes occurring in the patient’s condition. As a result, a sentinel event, failure to rescue, and even a patient fall or infection may be prevented.

Unfortunately, global statistics indicates that one in every 300 errors results in death. Nurses as part of the healthcare team need to be advocates in error prevention. Of course, there are multiple errors that do not involve nursing, but as vigilant frontline warriors they need to be proactive in helping to improve patient outcomes. Even though performance of physical assessments is only a piece of the puzzle, it is an essential piece. It is also a basic skill that has been shown to help protect the patient. Therefore, it is imperative that investigators continue to research this concept in order to validate the truth of what is actually occurring in practice. For example, plans for future research include developing a "Quick Nursing Assessment Guide" which is taught to undergraduate baccalaureate nursing students and then to follow-up on how these graduate nurses are completing assessments at 1, 2 and 3 years post graduation and to correlate the number and level of associate adverse events. This same idea could also be researched in nurses enrolled in a nurse-residency program.

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