The mastery of physical assessment skills by nursing students lays the foundation for quality nursing practice and safe patient care. Two methods for promoting proficiency and subsequent mastery of physical assessment skills involve the use of standardized patient (SP) simulations followed by feedback from peers (George, Weaver, & Kershner, 2018). Unlike traditional pedagogical methods, such as lectures and skill demonstration by faculty, SP simulation promotes a safe learning environment for active participation in the mastery of skills (Sarmasoglu, Dinc, & Elcin, 2016; Tuzer, Dinc, & Elcin, 2016). Peer feedback after simulation encourages constructive critique among learners and promotes reflection for skill improvement (Rush, Firth, Burke, & Marks-Maran, 2012).
We describe an innovative approach to teaching for skill acquisition that integrates SP simulation and peer evaluation with deliberate practice to improve physical assessment skill proficiency among first-semester baccalaureate nursing students at a major southern university. We obtained institutional review board approval when implementing this approach. The use of deliberate practice has recently gained traction in nursing education due to its association with increased skill proficiency. Deliberate practice focuses on skill retention, rather than skill attainment, through intentional practice opportunities beyond initial instruction (Oermann, Molloy, & Vaughn, 2015). When used alone, these three teaching techniques are becoming common practice in nursing education. Integrating the three educational techniques is an inventive strategy for promoting student success.
DELIBERATE PRACTICE
One hundred eleven first-year students participated in this new approach to teaching physical assessment after completing reading assignments and completing a baseline evaluation of knowledge (Gonzalez & Kardong-Edgren, 2017). Nine instructors delivered the content weekly throughout the semester. Content included cardiovascular, pulmonary, head/eyes/ears/nose/throat, musculoskeletal/neurological, and gastrointestinal/genitourinary focused assessments in addition to shift assessments. Focused assessment is defined as a thorough assessment of a specific health concern performed when a patient presents with a specific problem; shift assessment is defined as an abbreviated reassessment of each body system, highlighting critical assessment points such as level of consciousness, pulses, and respirations (Weber & Kelly, 2014).
Initial discussion of content included rationales for when a particular assessment might be used and how it relates to patient care (Clapper & Kardong-Edgren, 2012). After initial discussion and skill demonstration by faculty, students practiced the new skill in groups of three to four. After receiving individual feedback from course faculty, they were given time to practice and implement the suggested improvements. Throughout the following weeks, students were encouraged to practice assessment skills in the nursing open lab with faculty and other students who analyzed their performance according to course standards (Chee, 2014). They were encouraged to practice skills for fluidity and correctness until they could perform them with consistent success.
SIMULATION AND PEER FEEDBACK
The simulation included structured scenarios with SPs who were trained to interact with nursing students. Each SP had an assigned chief complaint and associated physical assessment findings; six different scenarios prompted the performance of different focused assessments, including chest pain (focused cardiovascular assessment), dyspnea (focused pulmonary assessment), sinus pressure and sneezing (focused head/eyes/ears/nose/throat assessment), motor vehicle crash (focused musculoskeletal/neurological assessment), and constipation (focused gastrointestinal/genitourinary assessment). In the motor vehicle crash scenario, for example, the patient was dressed in a hospital gown with multiple bandages applied to simulate wounds on the patient's extremities; the SP used crutches for ambulation.
For each scenario, one student performed as the nurse while two other students evaluated how the nurse performed a physical assessment. Groups of three students rotated to three different patient scenarios to allow each student to perform once as the nurse and twice as evaluator. Students were given 15 minutes to perform a shift assessment and the most appropriate focused assessment (e.g., a focused musculoskeletal assessment in the case of the motor vehicle accident example). The student evaluators and faculty used the same physical assessment rubric as a guide for assessment and further deliberate practice following the simulation. The simulations were not graded.
Once each group rotated through three scenarios, all groups gathered in a classroom for a debriefing session. Using an investigator-developed structured debriefing guide, students had 30 minutes to participate in a self-guided debrief with their assigned groups and provide feedback to one another regarding their performance. After debriefing, students completed an anonymous evaluation of the experience. Six questions used a 5-point Likert scale (0 = not at all likely, 5 = extremely likely), and three open-ended questions asked about what they learned and what they would change about the experience.
The SP simulations were not graded, but later, the same rubric was used to evaluate performance for a graded physical assessment check-off. To be successful in the course, students were required to demonstrate proficiency with a check-off score of 80 percent or greater. Students were given 15 minutes to perform a shift assessment and one randomly assigned focused assessment with an SP.
RESULTS
All 111 students completed the survey, reporting that they felt the deliberate practice, SP simulation, and peer feedback experience would improve their performance of a shift assessment (4.92 +/- 0.27) and a focused assessment (4.83 +/- 0.42). They also felt the SP simulation and peer feedback experience would help them determine the most appropriate focused assessment to perform depending on a patient's chief complaint (4.72 +/- 0.56). They felt that the simulation following deliberate practice improved their confidence when performing an assessment on a patient (4.74 +/- 0.57) and better prepared them for the physical assessment check-off (4.81 +/- 0.5). Lastly, they thought that use of peer feedback was valuable to their learning experience (4.64 +/- 0.67). The overall mean score of the survey questions was 4.78.
Two primary themes emerged from student comments: benefits of receiving peer feedback and benefits related to the structure of the SP simulation. The only reoccurring suggestion for improvement was to allow more time for physical assessment performance during the simulation. Students expressed that peer feedback helped improve their assessment skills and the debriefing session provided an atmosphere conducive to open communication. They valued both positive and negative feedback. Students wrote: "I loved being evaluated by peers - less pressure to be perfect" and "Receiving peer feedback let me know what I need to work on and what I need to focus on, not just for check-offs but also for clinicals."
Students found the structure of the SP simulation advantageous and felt that being able to evaluate their peers during this experience helped with their own physical assessment performance: "I like being on the other side of validating; it's helpful to grade someone else so then when I practice I know what they are looking for and what not to miss."
CONCLUSION
Although students reported that their physical assessment skill performance improved after undergoing this educational trio, we were unable to determine the extent to which our approach enhanced physical assessment skills due to the observational nature of the activity and lack of a control group for comparison purposes. We were also unable to determine the influence of this activity on student performance in the subsequent physical assessment check-off, in the clinical setting, and throughout the remainder of the students' nursing education.
Despite these limitations, the combined use of deliberate practice, simulation, and peer evaluation activities has the potential to enrich subsequent deliberate practice and enhance physical assessment skill mastery in first-semester nursing students. This educational trio may also be applied to other basic or advanced nursing skills courses to promote the mastery of physical assessment skills.
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