RESPIRATORY ASSESSMENT
Exploring nursing roles: using physical
assessment in the respiratory unit
Anthony Wheeldon
H
istorically, the role of the nurse has continued to
evolve progressively, with nurses embracing more
and more duties customarily part of the doctor’s
remit. Tasks such as temperature recording, blood
pressure monitoring and urinalysis, once considered beyond the
scope of the nurse, are now deemed fundamental nursing skills
(James and Reaby, 1987; Lont, 1992). However, recent
government policies have arguably accelerated the rate of role
change (Department of Health (DoH), 2000a), with the point
where nursing stops and medicine begins becoming somewhat
blurred. Physical assessment provides just one example of a
traditional medical skill, which is now moving stealthily into
advanced nursing practice. In the light of recent modernization
agendas (DoH, 1999, 2000a, 2002; DoH and Royal College of
Nursing, 2003) this article critically examines the application of
physical assessment within a respiratory unit and assesses its
potential impact on both patient care and the nursing profession.
Drivers for change
There appears a growing consensus, particularly in critical care
settings, that role re-evaluation is both welcome and necessary
(Royal College of Nursing, 1997). Nevertheless, it seems that the
main drivers for role change are external, with the recent
alterations in junior doctor working hours being the most
controversial. The New Deal initiative for junior doctors’ hours
(NHS Management Executive, 1994) and the European Working
Time Directive (Scallan, 2003) coupled with the Calman report
recommendations for junior doctor education (DoH, 1993) have
all resulted in a resource shortfall. Underpinning these changes is
an expectation that nurses will fill in the gaps. Indeed, some NHS
trusts already utilize nurse practitioners specifically to cover
deficiencies in the junior doctor workforce (Cass et al, 2003).
Furthermore, the utilization of a ready-made nursing workforce
avoids the financial burden incurred by training and developing
a larger medical workforce (Calpin-Davies and Akehurst, 1999).
However, the shortfall in junior doctors arguably legitimizes
nurse role re-evaluation by creating a tremendous opportunity
for practice development (Woods, 2000). Nevertheless, cover for
the reduction in junior doctors’ working time does rely on the
assumption that an ample supply of nursing staff are available to
undertake these new roles.
Unfortunately, evidence suggests that the current nursing
workforce is insufficient. Calpin-Davies and Akehurst (1999)
argued that the use of 1994/1995 NHS English hospital workforce
data to calculate a doctor–nurse ratio of 1:4.7 is inadequate.Taking
into account the disparate working hours of both professions the
actual ratio needed would be one doctor to 1.9 nurses, indicating
a radical need for an increased nursing workforce.However,despite
British Journal of Nursing, 2005,Vol 14, No 10
Abstract
The role of the nurse continues to change, with the point where nursing
stops and medicine begins becoming increasingly blurred. Arguably,
the main driver for this change could be the recent reduction in junior
doctors’ working hours. However, modern nursing is ripe for innovation
and nurses are taking on more and more tasks and skills that were
traditionally part of the doctor’s remit. One example is physical
assessment, which has very little evidence to support its use in any setting.
Analysis of the utilization of physical assessment in the respiratory unit
indicates that although it could facilitate earlier recognition of peri-arrest
symptoms, its usage highlights training and legal issues. Furthermore, this
article will explore whether the continual adoption of tasks, such as
physical assessment, constitute mere role extension, with nurses becoming
physicians’ assistants rather than advanced autonomous practitioners.
Key words:  Nursing: role  Patient assessment  Respiratory system
and disorders
the current Government’s commitment to an increase in nurse
numbers (DoH, 2000a), the workforce is rising at a derisory rate.
Although an additional 19 754 registrations occurred in 2002, the
overall number of registered nurses and midwives rose by just 1660
(0.26%) (Nursing and Midwifery Council, 2003). Furthermore,
the number of nurses leaving the profession per year (including
retirements) is set to rise from 15 000 to 25 000 over the next
10 years (Royal College of Nursing, 2005).
These retention and recruitment problems may also
contribute to redefining the nurse’s role. The thought that
20 000 nursing vacancies are being covered by agency nurses
every day, costing the NHS £810 million a year (Audit
Commission, 2001), provides a persuasive incentive. The
creation of nurse consultant posts (DoH, 1999) was perhaps in
part an attempt to curb the falling number of registrations by
providing dynamic career prospects free from the shackles of
the 24-hour responsibility enshrined in traditional ward
sister/charge nurse posts (Woods, 2000).
Undoubtedly the general public’s concerns over waiting
times and the apparent inability of casualty departments and
GPs to deliver care within an acceptable time frame
(Kmietowicz, 1999, 2001) will result in a potent political driver
for change. Currently, a third of patients wait more than
2 hours for a consultation in accident and emergency and 23%
of patients wait more than 2 days to see their GP
Anthony Wheeldon is Lecturer in Adult Nursing,Thames Valley
University, Ealing, London
Accepted for publication: April 2005
571
 Table 1. The Chief Nursing Officer’s (Smith, 2003). Such 1987; Reaby, 1990; Reaby and James, 1990; Sony, 1992). The
10 key roles for nurses facts have indubitably promotion of physical assessment has an extensive history with
influenced recent govern- almost all the arguments for its use centred on the concept of
 To order diagnostic investigations such as pathology ment and professional holistic care and the forum for the extensive nurse–patient
tests and X-rays policies. Indeed, the communication it provides (Yamauchi, 2001).The inclusion of a
 To make and receive referrals direct, ethos behind recent strat- physical assessment to complement a psychological and social
e.g. to a therapist or pain consultant egies is that of the assessment in order to ensure true holistic care makes for a
 To admit and discharge patients for specified attainment of acceler- powerful argument for its utilization (James and Reaby, 1987;
conditions and within agreed protocols ated treatment initiation. Lont, 1992). Furthermore, nurse-initiated physical assessment
 To manage patient caseloads, e.g. for diabetes Documents such as could promote psychological wellbeing as the patient is being
or rheumatology
Freedom to Practise (DoH assessed by a practitioner with whom they have already built a
 To run clinics, e.g. for ophthalmology and dermatology
and Royal College of therapeutic relationship (Rushforth et al, 1998).
 To prescribe medicines and treatments
 To carry out a wide range of resuscitation procedures
Nursing, 2003) espouse In addition, nurses already utilize many primary physical
including defibrillation great enthusiasm for the assessment methods, i.e. heart rate, respiration rate, and blood
 To perform minor surgery and outpatient procedures utilization of advanced pressure, providing a platform of knowledge on which to
 To triage patients using the latest information nurses within a modern, build. Indeed, by virtue of their continuous practice nursing
technology to the most appropriate health professional fast and efficient NHS staff could maintain optimum physical assessment skills.This is
 To take a lead in the way local health services are with the recently pub- in contrast to junior doctors who, as a result of frequent
organized and in the way that they are run lished 10 key roles (Table rotation, are often presented with steep learning curves with
Source: DoH (2002) 1) for nurses providing each new post, possibly resulting in inferior treatment
the license to perform (Castledine, 1998). However, a gradual lack of exposure to
tasks traditionally the skills such as physical assessment could arguably result in the
Table 2. Comprehensive respiratory
responsibility of doctors doctors themselves becoming deskilled and demotivated
assessment (DoH, 2002; DoH and (Calpin-Davies and Akehurst, 1999).
Royal College of
Observation
Nursing, 2003). Physical assessment in the respiratory unit
Cyanosis Is it central or peripheral? Success has been Respiratory examination as part of physical assessment involves
Finger clubbing Present or not present? noted in nurse-led rapid a comprehensive assessment (Table 2). Therefore, given the
Nicotine stains Present or not present? chest pain clinics with increasing intricate nature of inpatients and the modernization
Thoracic deformity Any of the following present: waiting times for ang- agenda as outlined in Comprehensive Critical Care (DoH, 2000b)
barrel chest; kyphosis;
ioplasty appointments the utilization of such skills appears validated, albeit with a
scoliosis; thoracoplasty; pectus
reduced to within 2 distinct lack of evidence. The 12% increase in intensive care
carinatum; pectus excavatum;
scars
weeks, thus fulfilling the beds and 43% rise in high-dependency beds between July 2000
Respiration rate In respirations per minute requirements of the and January 2001 provide ample proof that patients currently
Respiratory pattern Assess the following: National Service Frame- accessing care are proving increasingly complex (DoH, 2001).
work of breathing; use of work for Coronary Heart The underlying principle of Comprehensive Critical Care (DoH,
accessory muscles; pursed lip Disease (DoH, 2000c) 2000b) is that potential or actual critical care should be
breathing; intercostal (Shuldham et al, 2004). determined by severity rather than location. Arguably,
recession; paradoxical movement therefore, ward nurses should be competent in the early
Physical recognition of potential or actual deterioration (DoH, 2000b).
Palpation assessment However, those patients transferred to intensive care from the
Trachea Check position and mobility The case for ward area constitute the patient group with the highest
Thorax Assess thoracic expansion. physical assessment mortality. Goldhill and Sumner (1998) found that from a sample
Check for: bony crepitus; Physical assessment in- of 12 762 intensive care admissions, the mortality of ward
secretions; tenderness volves the performance patients was 52.9%, significantly higher than those transferred
of inspection, palpation, from theatres (22.3%) and casualty departments (30.2%).
Percussion auscultation and percus- Data generated by McQuillan et al (1998) indicate that
Anterior chest wall Note any: resonance; dullness; sion by nurses in general suboptimal care, defined as the lack of significance placed upon
Lateral chest wall flatness; hyper-resonance wards (Munro and dysfunction of airway, breathing and circulation, contributed to
Posterior chest wall Campbell, 2000) and the the mortality of this group of patients. Independent assessment
literature suggests that its of 100 intensive care admissions concluded that suboptimal
Auscultation use is commonplace care occurred in 47% of patients transferred from medical
(Doherty 2002a,b). How- wards. However, the assessors were not blinded to the
Trachea Establish tracheal breathing
Both bronchi Listen for added, reduced
ever, there is a dearth of outcomes of the patients.
Anterior chest wall or absent breath sounds evidence on its effect- The establishment of clinical outreach services (Goldhill et
Lateral chest wall iveness in terms of al, 1999a) aimed to counteract these problems. However, the
Posterior chest wall enhancing the patient use of nurse-initiated physical assessment in the environment
Source : Munro and Campbell (2000) experience (Colwell and of the respiratory ward could promote early recognition of
Smith, 1985; Brown et al, adverse occurrences and accelerate the instigation of interventions

572 British Journal of Nursing, 2005,Vol 14, No 10


and referrals. Furthermore, as ward-based nurses provide 24-hour
care, they remain the most ideal allied health professional to assess
patients regularly.The use of rigorous inspection will allow the nurse
to assess respiration rate and associated work of breathing.This is of
particular importance as respiration rate has been identified as one of
the most frequently omitted or misinterpreted physiological
observations (McArthur-Rouse, 2001).
An audit of 100 cardiopulmonary arrests found that
increased respiration rate was widespread, with 15%
experiencing dyspnoea, compared to 3% with chest pain
(Rich, 1999). Goldhill et al (1999b) audited the physiological
values in the 24 hours before admission to intensive care from
a general ward. From a total of 76 patients, 54 (71%) were
categorized as having a breathing problem. In 37 (49%) of
cases the cause was chest infection or respiratory failure;
therefore, one could argue that, for a sizable proportion, earlier
auscultation may have resulted in earlier emergency referral.
The reality of physical assessment for nurses
Role expansion or role extension
There is a distinct difference between what constitutes role
expansion as opposed to role extension. In role expansion nurses
develop their role in order to function more effectively in
whatever situation they find themselves. Role extension, however,
is solely the adoption of tasks previously the responsibility of other
allied health professionals (Castledine, 1998).
It is questionable whether the utilization of physical
assessment by nurses in the respiratory unit would constitute
role expansion or role extension. This is more than mere
semantics: the advancement of nursing practice has produced a
challenging dichotomy.The continual adoption of tasks at the
behest of other allied health professions could result in mere
role extension, rendering nurses as nothing more than
physicians’ assistants or doctors’ handmaidens (Castledine,
1998). Such a move is arguably inimical to the quest for
nursing to be recognized as a profession in its own right.
However, expansion or advancement of nursing suggests the
refinement of the paramount core therapeutic philosophies of
nurture and care, thus continuing to promote holistic patient-
centred nursing (MacAlister and Chiam, 1995).
The case for the enhancement of holistic care (James and
Reaby, 1987; Lont, 1992; Yamauchi, 2001) suggests that the
adoption of physical assessment by respiratory nurses would
represent role expansion. However, physical assessment is a
traditional medical skill and, as such, its utilization by nurses
could be construed as role extension and may ultimately dilute
nursing care rather than augment it (Kitson, 1996). Essentially
there is a finite amount of nursing time and, therefore, any
additional duties, such as physical assessment, will eat into the
nurse’s valuable time at the expense of fundamental nursing care.
There is growing evidence that nurses taking on extra
responsibilities are conceding some of their nursing activities to
healthcare assistants (Spilsbury and Meyer, 2004). Arguably, this
shift away from traditional nursing duties could result in senior
nurses becoming deskilled. Qualitative interviews demonstrate the
belief by senior nurses that advanced nurses are losing vital skills as
a result of performing history taking and physical assessment
instead of fundamental nursing care. However, the number of
senior nurses interviewed is unknown (Dowling et al, 1995).
British Journal of Nursing, 2005,Vol 14, No 10
RESPIRATORY ASSESSMENT
Training issues
The efficacy of physical-assessment training, both in the UK
and abroad, is arguably inconclusive. On initial inspection
physical-assessment training has been positively evaluated but
the scant research into this area is on the whole archaic and does
not bear close examination. For example, some studies utilize
only small sample sizes, e.g. 22 (Reaby, 1990; Reaby and James,
1990). In terms of auscultation, there are some apparently
positive findings with 100% of 59 nurses questioned by Colwell
and Smith (1985) and 73% of 150 nurses questioned by Lont
(1992) habitually auscultating the thorax. In addition, 83.9% of
148 nurses questioned by Sony (1992) auscultate the mitral area
as part of regular practice. However, each of these studies used
incidence of usage as a measure of efficacy, and an examination
of individual nurse performance was omitted. The fact that
95.56% of nurses felt more confident post-physical assessment
training (Brown et al, 1987) appears persuasive; however, such
projects rely on self-reported data from a nursing perspective;
data relating to how nurse-initiated physical assessment
enhances care from a patient perspective is lacking.
All the aforementioned studies have evaluated physical
assessment training in the US, Canada and Australia where it
forms part of undergraduate nurse education. Here in the UK,
physical-assessment training remains sporadic (Price et al, 2000)
and, therefore, the transferability of any evidence from these other
health cultures to the NHS is dubious. Also questionable is the
length of training and whether current courses in the UK are
adequate. A typical physical-assessment module in the UK
comprising 30 hours taught content (Coombs and Moorse, 2002)
appears scant in comparison to the integrated approach in the US
in which physical assessment is taught throughout a 3-year
undergraduate programme (Solomon, 1990).
Interestingly, from the study by Lont (1992), despite having
extensive training, 18% of those questioned stated that they
lacked confidence and professed ignorance when auscultating
patients.This highlights the need for continuous evaluation of
those undertaking physical assessment in practice. Indications
are that physical-assessment modules in the UK are specifically
aimed at specialist practitioners (Rushforth et al, 1998), and yet
there is no indication of how these nurses are themselves
regulated. Modular study will ensure that specialist
practitioners are examined academically but not while in
practice. Often specialist practitioners are among the first in
their clinical area to practice physical assessment and, therefore,
will be forced to practice in the absence of a suitable
competent peer. Medical colleagues appear to be the logical
choice for specialist nurses seeking assessment and evaluation;
however, whether doctors appreciate the values and nature of
the caring aspect of nursing is debatable (Dowling et al, 1995).
Therefore, nurses on the respiratory unit run the risk of being
assessed in a medical rather than a nursing context, suggesting
role extension rather than role expansion (Lillyman, 1998).
Legal issues
Given the inadequacies of physical-assessment training in the UK,
the legal standing of the nurses on the respiratory unit using physical
assessment is of particular importance. Price et al (2000) and
Coombs and Moorse (2002) contend that nurse-initiated physical
assessment is not concerned with diagnosis; rather, it should
573
 distinguish between normal and abnormal.This implies there is a
significant difference between nurse and doctor physical assessment.
However, this difference is not acknowledged legally and therefore
highlights the importance of adequate supervised practice for those
nurses new to physical assessment. In terms of nursing care, the
nurse is expected to provide care that meets the expected standard
of a competent nurse,i.e.the Bolam test (Dimond,2000).However,
physical assessment is a task traditionally performed by a doctor;
therefore, in the event of injury occurring during physical
assessment on the respiratory unit, the nurse concerned would be
judged against the standards of medicine rather than nursing.
Furthermore, despite the fact that the respiratory nurses would be
conducting physical assessment in what may constitute a new
innovative role, their inexperience unfortunately provides no
legitimate mitigation (Dowling et al, 1996).
Conclusion
Cynics may highlight the change in junior doctors’ working
practices as the main driver for role change but arguably modern
nursing is ready to take on the challenge.The adoption of tasks
such as physical assessment highlights legal issues of which
advanced practitioners need to be aware. Furthermore, physical
assessment training may be deficient in comparison to that
offered to colleagues in the US, Australia and Canada. For some
the continual adoption of traditional medical skills constitutes
mere role extension, and as such could retard nursing’s pursuit for
autonomy by diluting the core values of nurture and care.
However, the inclusion of physical assessment within the
framework of a nursing assessment clearly leans towards holistic
rather than fragmented care. Furthermore, analysis of suboptimal
care data suggests a need for the earlier recognition of peri-arrest
symptoms. Respiratory nurses, competent in physical assessment,
are in an ideal position to facilitate prompt action and prevent
deterioration, ultimately augmenting patient care.The utilization
of physical assessment in this context is arguably role expansion
rather than role extension. However, in the absence of adequate
research into nurse-initiated physical assessment the validity of
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KEY POINTS
■ Despite the main driver for change being the recent reductions in junior doctors’
working hours, modern nursing is ripe for change.
■ Physical assessment is a traditional medical skill that is being increasingly
utilized by advanced nurses.
■ Physical assessment in the respiratory unit could facilitate the earlier recognition
of peri-arrest symptoms.
■ The use of physical assessment by nurses presents both training and legal implications.
■ The utilization of physical assessment could constitute role extension rather
than role expansion.
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