Teaching and Learning in Nursing 12 (2017) 3234
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Teaching and Learning in Nursing
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Options for Teaching Physical Assessment Skills On-Line for Nurse
Education Students
Stephanie Pickett, PhD, RN
School of Nursing, University of North Carolina at Greensboro, Greensboro, NC
Physical assessment is an important component of nursing educa-
tion and practice. In fact, the American Association of Colleges of
Nursing has mandated that all master's-level nursing programs in-
clude an advanced physical assessment course as outlined in its Es-
sentials of Master's Level Education in Nursing (2011). This course
builds upon and expands on the content taught in the undergraduate
or entry-level nursing practice course (Essentials of Master's Level
Education in Nursing, 2011).
Faculty in our on-line master of science in nursing nurse educa-
tion program developed an on-line teaching strategy to meet this
mandate. We required all students to enroll in a one-credit, on-line
physical assessment skills laboratory in order to learn advanced
physical examination skills/techniques. We also required them to en-
roll in a concurrent three-credit on-line advanced physical assess-
ment theory course. Prerequisites for the two courses were a
bachelor of science in nursing with at least 1 year of clinical experi-
ence as a bachelor of science in nursing-prepared nurse.
The on-line advanced physical assessment skills laboratory course
combined physical examination videos with other teaching strategies
tailored for on-line learning. The strategies that we used included an
on-line Web-based program, the use of a local tutor, and an option-
al on-campus skills laboratory, which are briey described below.
On-Line Web-Based Program
We selected a commercially available Web-based program to
simulate the physical assessment laboratory experience. This Web-
based program was initially used in 12 nursing programs at varying
program levels that included graduate and undergraduate nursing
programs (Kleinheksel, 2014). Students were required to register
on-line in order to gain access to the program. After registration, stu-
dents engaged in a required program orientation before accessing
their weekly case-based assignments, which covered the assessment
of one body system per week, for example, respiratory system, car-
diovascular system, and musculoskeletal system.
Corresponding author. Tel.: +1 919 619 0310 (Mobile).
E-mail address: s_picke2@uncg.edu.
http://dx.doi.org/10.1016/j.teln.2016.09.001
1557-3087/ 2017 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.
This program included case-based exercises that created a dy-
namic, immersive experience designed to teach physical assessment
history taking and physical examination skills using a digital stan-
dardized patient (https://shadowhealth.com/advanced-health-
assessment.html). The digitalized patient was an avatar that
breathed, spoke, and had a complex medical and psychosocial histo-
ry. The students communicated with the digitalized patient by typing
their health history questions into a dialog box. The digitalized pa-
tient responded verbally to typed questions. The students performed
their physical examinations by selecting the desired body system and
then selecting a test or examination action (e.g., Romberg test, aus-
cultating lung sounds). Then, they documented both normal and ab-
normal ndings within the program (https://shadowhealth.com/
health-assessment.html/). The virtual Web-based program recorded
each student's health history questions and physical examination
and actions for the student and faculty to review.
Each case-based exercise corresponded to the history and physical
examination that were relevant to the digitalized patient's chief com-
plaint. As students progressed through a case by entering history ques-
tions and performing focused physical examinations, they received
program feedback based on their entries. Some of the cases included
laboratories with visual and audio components, such as a funduscopic
examination, medical grade heart sounds, and breath sounds (https://
shadowhealth.com/health-assessment.html). After completing four
out of six case-based assignments, students completed a midsemester
survey evaluating their condence level with history taking and physi-
cal assessment. All of the students reported that they felt condent in
their ability to document both subjective and objective ndings in a pro-
fessional manner. A majority of the students reported feeling condent
in their history taking and physical assessment skills. More than 90% of
the students said that virtual patients were easy to use, simulated a real
patient, and allowed them to reect on their skills in a meaningful way.
Local Tutor
As a component of the on-line physical assessment skills laborato-
ry, students were required to select an advanced practice health care
provider to serve as a local tutor for them. The responsibility of
that professional was to observe the student practicing physical
 S. Pickett / Teaching and Learning in Nursing 12 (2017) 3234
assessment skills and to provide verbal feedback on a regular basis
throughout the semester. The local tutor had the option of evaluating
a comprehensive physical examination performed by the student at
the end of the semester using a checkoff form. If that person declined,
then a faculty member evaluated the student's performance of the
comprehensive physical examination.
Local tutors were required to be an advanced practice nurse
(Nurse Practitioner [NP], Doctor of Nurse Practitioner [DNP], Clinical
Nurse Specialist [CNS]), physician's assistant (PA), or a physician
(Medical Doctor [MD] or Doctor of Osteopathy [DO]). In addition,
they were expected to have advanced physical assessment training
and to utilize those skills on a regular basis in their areas of practice.
When a health care provider agreed to serve as a local tutor, the per-
son signed an agreement form and returned it, along with the re-
quired proof of credentials (i.e., curriculum vita, professional license
number, and copy of work identication badge) to course faculty.
Students met with their local tutor on a regular basis during the se-
mester and kept a written record of the dates and times of those meet-
ings along with the physical assessment systems/skills practiced. The
student and local tutor each signed the record, and the student submit-
ted it to the course faculty for review three times during the semester.
Supplemental Voluntary Skills Laboratory on Campus
Two optional on-campus skills laboratories were offered to pro-
vide the students with other opportunities to practice physical as-
sessment skills in a laboratory setting and receive face-to-face
feedback from course faculty. The laboratory was unstructured with
faculty available for 3 hours. The rst optional skills laboratory was
offered midsemester. Less than 10% of the students from the course
attended. The second skills laboratory was offered near the end of
the course to practice the complete physical examination and receive
faculty feedback. Again, only a few students (14%) attended.
Final Evaluation
As the nal course outcome, students in the on-line physical as-
sessment course were required to perform a comprehensive physical
examination checkoff on an adult person in front of their local tutor
or a course faculty member. A student had to complete the physical
examination in 30 minutes with 90% competency in order to pass
the course. All of the students in the course achieved the 90% compe-
tency within the required timeframe.
Strengths and Limitations
We developed the on-line physical assessment teaching strategies
because they offered two main advantages to the students while
maintaining the integrity of the course. First, students were not re-
quired to attend an on-campus course. This meant that the course
could better meet the needs of students who found it difcult to at-
tend on-campus classes such as nontraditional students or those
who did not live locally. Second, the on-line strategies, when
employed together, maintained rigor and accountability similar to a
face-to-face course. Students had to complete a weekly assessment
of a body system using the digitalized patient. This involved taking
a history and performing a physical examination. The Web-based
program and course faculty both provided individual feedback to
the students after they completed their weekly assessments. In addi-
tion to this, students were required to perform a face-to-face physical
assessment check off in front of a practicing health care provider
(local tutor) or course faculty member, which was similar to a face-
to-face course.
A potential limitation of this on-line teaching strategy was that
the course required that each student locate a local tutor. To support
33
students with this activity, we e-mailed an information letter about
the local tutor requirement to students registered for the course up
to 6 weeks before it began. The majority of students in the on-line
course were able to meet this requirement. Students who were un-
able to locate a practitioner to serve in this capacity were required
to meet with a course faculty member on campus on a regular basis
for skills practice and comprehensive physical assessment checkoff.
This might have been a hardship for those students and increased
the workload for course faculty because they had to schedule practice
times and reserve the on-campus physical assessment laboratory.
Implications for Undergraduate Nursing Education
Web-based virtual patients and environments have a viable role
in undergraduate nursing education (Kardong-Edgren, Willhaus,
Bennett, & Hayden, 2012). Undergraduate nursing students have lim-
ited exposure to patients in clinical settings for a number of reasons
including a shortage of clinical practice sites, shortage of nurse educa-
tors, higher patient acuity, shorter length of patient stay in hospitals,
and increase in patient-to-staff ratios (Niederhauser, Schoessler,
Gubrud-Howe, Magnussen, & Codier, 2012). These issues limit oppor-
tunities for undergraduate nursing students to practice clinical skills
and develop decision-making and problem-solving skills in tradition-
al clinical settings (Guise, Chambers, & Vlimki, 2012; Hayden,
Jeffries, & Kardong-Edgren, 2012; Kardong-Edgren et al., 2012).
Web-based virtual programs provide undergraduate nursing stu-
dents with opportunities to practice skills and procedures multiple
times at their own pace, provide immediate feedback on student per-
formance, and provide opportunities for self-reection, which is im-
portant for developing clinical reasoning skills (Guise et al., 2012;
Society for Simulation in Healthcare, 2015).
A national survey that examined simulation use in nursing pro-
grams showed that various simulation methods were being used in
associate degree programs (Kardong-Edgren et al., 2012). Of the
523 associate degree nursing programs that completed the survey,
38% reported using standardized patients, 53% reported using CD-
ROM, and 29% reported using Internet-based virtual hospital envi-
ronments (Kardong-Edgren et al., 2012). Associate degree nursing
programs were the least likely to require students to participate in
specic simulation scenarios such as cardiac arrest, labor and deliv-
ery, and/or newborn care compared with other undergraduate nurs-
ing programs. Most of the associate degree nursing programs
reported that they should be using more simulation in their programs
(Kardong-Edgren et al., 2012). A national longitudinal simulation sur-
vey indicated that supplementing traditional clinical experiences
with up to 50% simulation showed no signicant difference in
National Council Licensure Examination (NCLEX) pass rates, clinical
competency, or nursing knowledge (Hayden, Smiley, Alexander,
Kardong-Edgren, & Jeffries, 2014).
Conclusion
An important component of nursing education and practice is
learning physical assessment skills. In light of the growing emphasis
on on-line teaching and learning, strategies to teach physical assess-
ment skills on-line are important. This article provides details about
the process and outcomes of on-line teaching strategies that included
a Web-based virtual patient and environment, local tutors, and op-
tional on-campus skills laboratories using one cohort of students. Stu-
dents were able to achieve physical health assessment competency
by using these strategies. The process and outcomes of these on-
line teaching strategies are not examined from a research perspec-
tive. However, this article provides support for using a Web-based
virtual patient in an on-line physical assessment course.
34 S. Pickett / Teaching and Learning in Nursing 12 (2017) 3234
Acknowledgments
The author gratefully acknowledges the editorial assistance of the
late Elizabeth Tornquist and Peggy Markham.
References
American Association of Colleges of Nursing (2011). Essentials of master's education in
nursing. Washington, DC: American Association of Colleges of Nursing.
Guise, V, Chambers, M, & Vlimki, M (2012). What can virtual patient simulation
offer mental health nursing education? Journal of Psychiatric and Mental Health
Nursing, 19(5), 410418.
Hayden, J, Jeffries, P, & Kardong-Edgren, S (2012). The NCSBN national simulation
study. Clinical Simulation in Nursing, 8(8), e407.
Hayden, JK, Smiley, RA, Alexander, M, Kardong-Edgren, S, & Jeffries, PR (2014). The
NCSBN national simulation study: A longitudinal, randomized controlled study re-
placing clinical hours with simulation in prelicensure nursing education. Journal of
Nursing Regulation, 5(2) (July Supplement), C1-64.
Shadow health digital clinical experience. https://shadowhealth.com/health-
assessment.html
Kardong-Edgren, S, Willhaus, J, Bennett, D, & Hayden, J (2012). Results of the National
Council of State Boards of Nursing national simulation survey: Part II. Clinical
Simulation in Nursing, 8(4), e117e123.
Kleinheksel, AJ (2014). Transformative learning through virtual patient simulations:
Predicting critical student reections. Clinical Simulation in Nursing, 10(6),
e301e308.
Niederhauser, V, Schoessler, M, Gubrud-Howe, PM, Magnussen, L, & Codier, E (2012).
Creating innovative models of clinical nursing education. Journal of Nursing
Education, 51(11), 603608.
Society for Simulation in Healthcare (2015). About simulation. Retrieved from http://
www.ssih.org/About-Simulation