Physical assessment competencies for nurses: A quality improvement initiative

Abstract As the only healthcare providers caring for hospitalized patients every hour of every day, nurses have a responsibility to keep patients safe. Physical assessment is a basic but essential nursing skill that fosters patient safety. Assessing a patient's current status enables nurses to recognize early patient deterioration. Contemporary nursing practice relies on vital signs and technology to aid in the detection of patient deterioration. The aim is to describe the Methodist Proficient Assessment Competency (MPAC©) quality improvement initiative. Surveys and directly observed patient assessment data were used to evaluate attitudes and practices. One hundred and seventy‐nine pre‐MPAC audits were conducted, followed by 1391 post‐MPAC audits. Pre‐ compared with post‐MPAC audits showed significant improvements in complete physical assessments (78% vs. 94%; p < .001), timeliness (within 4 h; 64% vs. 91%; p < .001) and accuracy (67% vs. 95%; p < .001) of documentation. In conclusion, nurses have a responsibility to quickly identify changes in a patient's condition and intervene to prevent serious adverse events. Taking the needed time to perform a full physical assessment at the beginning of the shift along with timely and accurate documentation, allows nurses to acquire the knowledge they need to establish a patient's current clinical status and usual behaviors, thereby facilitating early recognition of subtle changes that could indicate deterioration.


| INTRODUCTION
Physical assessment is a crucial nursing skill. However, as nurses are tasked with other skills this aspect of nursing may be less practiced.
As turnover in an inpatient setting increased with more newly licensed registered nurses as well as nursing management turnover, thought leaders at a large academic medical center identified a worrying trend in the nursing workforce around the performance of a full (head-to-toe) physical assessment. From 2014 to 2017, the number of Rapid Response Team (RRT) activation calls increased with greater time delays in calling the RRT, which led to worse patient deterioration and outcomes. Members of the RRT, all of whom are nurse practitioners, noticed that nurses knew less about their patients with a wide range of variation in nursing practices from unit to unit.
In 2015, the nurse education department leadership and the nurse practitioner leadership began to investigate and develop mitigation strategies for improving nurse's clinical knowledge of their patients to detect early patient deterioration. During an education fair that year, the nurse practitioners performed simulated rapid response scenarios with nurses from departments with the highest number of RRT calls; many nurses skipped any type of physical assessment with few nursing interventions before the RRT arrived.
From this exercise, the leaders in the nursing education department decided that refocusing nurses on the basic practice of physical assessment may improve early detection of patient deterioration and improve patient outcomes.
Methodist Proficient Assessment Competency (MPAC © ) was created in 2017. The goal for MPAC was to conduct a quality improvement project to assess the current practice of physical assessments, create a standardized, full physical assessment incorporating all body systems, provide education to all inpatient nurses, and complete follow-up audits to determine whether nursing practice not only changed immediately after the education but was sustained. The aim of this study is to describe the MPAC quality improvement initiative along with outcomes and implications for nursing practice.

| BACKGROUND
Physical assessment is a basic but essential nursing skill. Being able to assess the patient's current condition can help identify early changes.
Knowledge of a patient's clinical status and usual behaviors gained through a full (head-to-toe) physical assessment is a key influence on a nurse's ability to recognize subtle changes in a patient's condition. [1][2][3][4] The importance of early recognition of deterioration before overt physiologic signs, such as vital sign changes, cannot be overstated given the link between unrecognized patient deterioration and serious adverse events. [5][6][7][8][9] However, physical assessment as practiced daily in contemporary nursing focuses more on vital signs than physical assessment; this is likely due to time restraints and a reliance on technology to determine patient's clinical status. 10 Often nurses face barriers to completing a physical assessment, including lack of time and unit culture, 11 ambiguity around who is responsible for physical assessments, reliance on technology, and lack of confidence in assessment skills. 12,13 Electronic warning systems (EWSs) and RRTs, which often depend on patient vital signs, have widespread acceptance as the only safety interventions for detecting patient deterioration. However, the detection of abnormal vital signs is an end-stage deterioration, which may be detected earlier using a thorough patient assessment. 10 Schnock et al. 13 found that nursing documentation of their physical assessment often can predict patterns of patient deterioration events in both the critical care and acute care environments. 14 Indeed, the EWS used at the hospital in which the aforementioned project was conducted, relies upon timely, accurate nursing physical assessment data and documentation to optimally function in detecting patient deterioration.
Before MPAC, no formal instruction on physical assessment was provided to nurses at the project site. Preceptors were expected to validate a newly hired nurse's skill and knowledge during orientation, but it was dependent on each individual preceptor to determine what was considered a full physical assessment. Additionally, most preceptors and even nurse managers expect nurses to be proficient in performing a physical assessment, so often unit-based orientation is focused more on other tasks and skills. MPAC was implemented to help nurses recognize clinical deterioration through a standardized and systematic approach to physical assessment.  Practice Act, and the hospital's policy on assessment, a standardized physical assessment was established. Evidence shows the timeliness, accuracy, and relevancy of documented assessment findings increase with the use a structured patient assessment framework. 15 Table 1 shows components of the MPAC-standardized physical assessment.
A booklet with the new standardized physical assessment was produced as a learning aid for MPAC participants. In addition, a 10 min video was created, which demonstrated the new standardized physical assessment.
During this same time, we conducted a gap analysis to identify the current state of practice in physical assessments. First, an anonymous informal, nonvalidated survey was sent to all inpatient nurses asking them to list the barriers to completing a physical assessment. The survey showed that many of the nurses who responded (9% response rate) perceived other priorities such as administering medications, drawing labs, patient hygiene, and FONTENOT ET AL. | 711 mobility were more urgent than completing a patient physical assessment or documenting it fully and accurately in the EHR.
A second anonymous informal, nonvalidated survey was sent to the nursing unit leadership, asking their attitudes regarding nurses conducting a full physical assessment and how important is it for nurses to recognize a change in a patient's condition. With a 32% response rate, 25% of nursing leaders reported it was "extremely unimportant" for nurses to conduct a full physical assessment and/or recognize a change in a patient's condition with some leaders commenting it was predominantly the physician's responsibility.
The second phase of the gap analysis was to evaluate whether nurses were currently conducting full physical assessments. During randomly selected one to two nurses, to observe the nurse's initial physical assessment. Nurse evaluators were in the patient room with the nurse, while they were conducting a physical assessment. The nurse evaluators did not provide feedback to the nurse during their assessment, but would review with the nurses after they had left the patient room. Evaluators collected data on a standardized tool that mirrored the evidence-based, standardized full physical assessment.
These audits showed a large gap between best practice, hospital policy, and actual nursing practice.  Additionally, ongoing surveillance audits continued for each cohort for up to 12 months, to ensure the practice change was sustained.

| MPAC initiative
During the ongoing surveillance audits, the nurse educators modified the process to provide coaching when needed.
After the initial training was completed, MPAC was added to the nursing on-boarding curriculum so all newly hired nurses receive training before their first day on their unit. Additionally, physical assessment competency checkoffs have been added to annual nursing competencies.

| Measures and analysis
The key measures for this quality improvement project included: • Completeness of the physical assessment We found that 92% of staff had stethoscopes pre-MPAC and 99% had them post-MPAC (p < .001).
As the hospital's EWS relies on nursing documentation, timeliness and accuracy of documentation was also measured. Documentation was faster after MPAC. In the pre-MPAC audits, the percentage of documentation completed within 4 h of the assessment was 64% and after MPAC this increased to 91% (p < .001). In   physically present with the nurses as they performed assessments, the nurses may have changed their usual assessment routine because they knew they were being watched. Particularly for the post-MPAC audits, the nurse educators were the same who had witnessed return demonstrations during the MPAC classes. As such, it was not possible to determine how nurses performed the standardized physical assessment when they were not being audited. Lastly, the audit process evolved during the last 6 months of the project. Initially, the auditors just observed the nurses and did not provide any feedback.
However, the nursing leadership requested that the nurse educators utilize the opportunity to provide just-in-time teaching should they observe something that needed coaching; so, although the same data were collected, the process evolved as time went on.

| CONCLUSION
As healthcare providers who provide patient care around the clock, nurses are responsible for identifying changes in a patient's condition and taking action to prevent clinical deterioration. Performing a standardized physical assessment at the beginning of their shift allows nurses to know their patient's current status. Timely and accurate assessment documentation in the patient's EHR then facilitates EWS effectiveness. This quality improvement initiative focused on retraining nurses on how to perform an evidence-based, standardized full physical assessment, which resulted in significant improvement in completeness of assessments with more timely and accurate documentation.

CONFLICTS OF INTEREST
The authors declare no conflicts of interest.
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DATA AVAILABILITY STATEMENT
The data that support the findings of this quality improvement initiative are available on request from the corresponding author.
The data are not publicly available due to privacy restrictions.