Physical Assessment Techniques Performed by Jordanian Registered Nurses (RNs): Survey Study

Within the nursing curriculum, there is a growing concern about unnecessary content. Since content overload is a growing issue, the content taught in undergraduate nursing curricula should be critically evaluated as reflected in the nursing literature. In the creation of quality client care in nursing practice, recognizing challenges to performing physical examination techniques among nurses produces a more thorough assessment. This research aimed to investigate the physical assessment techniques performed by Jordanian registered nurses practicing in both selected public and privet health sectors to gain better understanding of the skills required by graduates of nursing programs in Jordan. A descriptive research design of 138 Jordanian registered nurses working in different practice units using questionnaire was used. The Jordanian registered nurses reported the frequency in which they performed 30 physical assessment techniques. Different statistical methods used to analyse the data collected. The results indicated that the Jordanian registered nurses’ performance frequency of the selected physical assessment techniques was high. However, there were statistical differences evident regarding the type of healthcare sector, Gender & work experience variables. The results were in favor in registered nurses working in the public sector, females & registered nurses with less than ten years of experience. However, there were no statistical differences evident regarding the practice unite variable. Registered nurse requires to know how to perform a broad range of techniques to carry out a thorough physical assessment, however the complexity of assessment is not inevitably characterized by the specific techniques applied. And if several of these physical assessment techniques are seldom performed by registered nurses beyond their specific practice unit, the question arises whether it is suitable to incorporate them in the nursing curriculum.


Introduction
The adequacy of educational preparation of nursing graduate; and the tremendous content within nursing curricula continue to represent a dilemma [1]. Graduates of nursing programs necessities' various skill base and they should have the ability to work within various clinical settings. Nevertheless, within the nursing profession there is a continuing concern regarding the insufficient preparedness of nursing graduates to enter practice [2][3][4].
Nursing programs in universities offer a variety of structures, irrespective of length of program or facility location, all offer training in physical assessment techniques [5]. Thus, developing a curriculum that is compatible with the physical assessment techniques tutored in the Global Nursing Program considered essential for preparing nurses of the future [5]. The problem facing nursing schools is to decide which physical assessment techniques entry-level nurses need and which skills should be learned "on the job" [6].
Traditionally, performing physical assessments and obtaining health histories from clients in many regions is usually regarded as a medical role instead of a nursing role [7]. However, health assessment creates a point of reference for nurses from which to base their nursing care plan. It gives them the chance to develop a professional therapeutic rapport with their clients to deliver a holistic nursing care [8,9]. Thus, the ability of a nurse to identify both normal and abnormal physical findings augment the nurse's self-confidence and enhances client health outcomes [10,11].
Changes in health care field pressure nurses to become dynamic and more competent than any time in recent memory, bridging the gap between nursing service prospects and the real aptitude base of standard nursing graduates. Worry about satisfactory readiness of graduates is not exceptional to nursing though.
This research provides an opportunity to reflect on education based on findings in practice. It aims to explore the physical assessment techniques most frequently used by Jordanian registered nurses and reflect the findings on the Jordanian nursing curricula.

Literature Review
Physical assessment is a crucial skill for nurses [12], since it is an essential part of the first step of the nursing process, provides a framework for promoting wellness, and provides a shared ground for communication with other health professionals [13].
It is frequently a prerequisite for graduate study and is a foundational skill for students moving into advanced practice areas [12].
Hence, there is sound theoretical bases for inclusion of physical assessment techniques in the undergraduate nursing program [13].
However, several research studies on physical assessment techniques stated that only one third of the physical assessment techniques educated in basic nursing education courses are regularly implemented into practice [2,[14][15][16].
Physical assessment techniques related to the respiratory system found to be one of the core techniques [15]. It was established that the core techniques of nurses' physical assessment mainly included vital signs [17].
One would expect that well-defined and specific subject such as physical health assessment rarely raises questions about what to teach. Yet, there is a debate about the scope of physical assessment techniques should be taught in the undergraduate nursing curriculum, this debate is largely unified by the evidence of what nursing students have learned and practiced [1]. Ever Since Giddens [15] published her research findings, this situation has been debatable. The research results emphasised on the physical assessment techniques used by registered nurses in their workplace [15]. It shed the light on the necessity to scrutinize the scope of physical assessment techniques taught in nursing education since these techniques do not always reflect the scope of practice of registered nurses or nursing students [1,2,8,15,18].
Literature review of newer studies focusing on physical assessment in undergraduate nursing curricula suggests that most techniques taught to nurses in their pre-service programs are not used in clinical [1,2,19]. Merely subsection of obtained physical assessment techniques is been used by RNs [2,14,19].
The results of these studies indicate that there may be a gap between what is taught, and the actual content needed to begin nursing practice and this has been further affirmed by the findings of Giddens & Eddy study in 2009 [20].
Consequently, it appears more suitable to delineate the physical assessment techniques performed by the RN in clinical practice to more precisely focus on the assessment techniques required for entry-level practice.
Physical health assessment material encompassed in physical textbooks has been continuously expanding to meet health needs. Hence, Giddens & Eddy [20] argue that consideration should be given to how students and nursing staff use textbooks. They claim that many teachers, especially novice teachers, may be obliged to cover all physical assessment techniques described in textbooks [20]. Due to their lack of experience, it is often difficult for students to distinguish important learning techniques from those not related to entry-level practice. This makes many students swamped with a large amount of study material which they are unable to learn [20].
All in all physical assessment is an integral aspect of almost all clinical experiences, providing knowledge vital to the client's care and management [21].
However, there were few studies dealing specifically with the amount of utilization of physical assessment techniques following graduation, especially in Jordan.

Statement of Problem
In Jordan physical assessment techniques are taught usually as part of the undergraduate Bachelor of Nursing degree programme. Graduates of nursing programs necessities various skill base and they should have the ability to work within various clinical settings. Nevertheless, within the nursing profession there is a continuing dilemma regarding the overwhelming physical health assessment content in the nursing curricula in one hand and the preparedness of nursing graduates to enter practice in the other. Hence, there is a necessity to determine the breadth to which physical assessment content should be taught in undergraduate nursing education?
In order to decide how confident are Jordanian registered nurses are about undertaking physical assessments and how frequently do they apply them?
To address Jordanian RNs' current knowledge of physical health assessment and the frequency they apply its techniques in their practice, we decided to conduct this research.

Research Questions
What are the physical assessment techniques performed by Jordanian RNs?
Is there a difference in performing these techniques among Jordanian RNs working in public vs privet hospitals?
Is there a difference in performing these techniques among male vs female RNs?
Is there a difference in performing these techniques according the years of experience?
Is there a difference in performing these techniques among Jordanian RNs working in different practice units?

Justification of Study
The purpose of this study was to determine physical assessment techniques performed by practicing Jordanian RNs to achieve better comprehension of the competencies needed by graduates of nursing programs. Determining the frequency of RNs performing specific physical assessment techniques and employ the results in the nursing curricula will taper their scope of focus teaching to focus on much needed nursing techniques and practices. This study derives its importance through its scientific addition, which can be used to raise the competencies required for nursing graduates by developing the study plan in Nursing faculties and providing them with the necessary skills that qualify them for safe practice when practicing their work.

Methodology
A descriptive approach has been conducted using a Likert survey questionnaire due to its compatibility to the objectives of this study.

Procedure & Method
Prior to data collection participants were informed about the study and that their participation was voluntary and assured of anonymity. Data were collected in November 2019. The survey does not contain a personal identification code, but is directly handled and collected by the researcher, which prevents other individuals (such as nurse managers) from observing the individually filled out forms.
Participants & Sampling Stratified simple random sampling has been applied to select participants (n = 138) from units providing direct patient care in inpatient settings, who were employed by 4 large public & privet health care hospitals in Amman who agreed to participate in the study. Excluded from the sample were nursing supervisors, nurse administrators, managers, educators, and nurses in advanced nursing practice (i.e., clinical nurse specialists, nurse practitioners, nurse-midwives, nurse anaesthetists).

Measurement
The aim of this study was to evaluate Jordanian RNs performance of physical assessment techniques in their clinical settings. The questioner was developed for this study by the researcher. After a literature review, a set of 30 most frequently performed 'core physical assessment techniques' identified by Giddens in 2007 [15] were selected to generate preliminary items of the instrument.

Instrument Validity
To validate the study questionnaire and to ensure its suitability to the Jordanian culture and to make sure of its usability, it was presented to a group of experts (clinical experts & lecturers).
Content validity index of the questionnaire was evaluated by the experts. They were asked to assess the items in relation to the objectives and to provide critique of the questionnaire. The experts determined the suitability of the questionnaire for the purpose of this study.
Each questionnaire item was assessed for relevance on a score of 1~4 (1=not relevant, 2=somewhat relevant, 3= quite relevant, and 4=very relevant). Therefore, all preliminary 30 core physical assessment techniques were included as content-validated items in questionnaire.

Instrument Reliability
Reliability of the instrument was examined using internal consistency and test-retest reliability. Cronbach's alpha coefficient was analysed using SPSS for the instrument and test-retest reliability was conducted in two weeks interval with a sample consisted of 20 subjects (who were excluded from the study).
The reliability coefficient according to Cronbach's alpha was 0.85 while it was 0.89 according to test-retest reliability which were considered acceptable for the applicability of the study.
A 30-item Likert scale survey of physical assessment techniques was used for data collection. Participants were asked to indicate the frequency they performed the physical assessment techniques using the following 5-point scale: Results classification: The results were converted into a triple rating scale to describe the values of the arithmetic averages (low / medium / high), as shown in Table 1:

Return Rates
Among the 150 surveys circulated, a total of 138 surveys have been completed and returned, with a total return rate of 90%.

Limitations
Even Though findings from this study are interesting, further research is necessary to better understand the findings in the context of educational practice and learning. A longitudinal study following individuals from their educational program to professional practice, concentrating on the use of physical health assessment techniques, would be mostly interesting.
The participants of this study were recruited from convenience sampling procedure which limits the generalization of the study results. Hence, this study should be repeated with a wider range of RN samples from different geographic regions and different practical environments. The main physical health assessment techniques practiced by nurses in various clinical environments must be examined, and the differences in techniques performed by nurses should be compared based on educational background or years of experience. The decision-making process for determining which techniques should be used for the physical assessment should also be studied.

Demographic Characteristics
In section one of the questionnaire, the questions were concerned with collecting socio demographic data from participants to determine whether the participants were a homogenous or heterogeneous group of Jordanian RNs in terms of several factors. These factors were healthcare sector (Privet, Public), Gender (Male, Female), work experience as an RN (≤ 10, > 10), & practice unit (Maternal-infant, Adult, Pediatric, Perioperative) as it shown in Table 1 below.
The socio demographic data provides an overview of the Jordanian RNs who agreed to participate because they had particular interest in the study area or who considered they were able to significantly contribute to the topic in this study. Those who volunteered came from a diversity of nursing backgrounds, practice unites, ages and year of experience. Majority of participants were females (62%) and 38% were males. 53% of the participants worked in privet healthcare sector while 47% of subjects worked in public healthcare sector. 30% of participants are working in pediatric units, 27% working in internal medicine, 22% in Maternal-infant and 21% surgical unit. About 69% had less than or equal 10 years of work experience though 31% of them had more than 10 years of work experience (Table 2).

Results
This study aimed at evaluating physical assessment techniques among registered nurses in Jordan. This chapter will present the study results and their interpretation according to the sequence of its questions.
Results related to the first question: What are the physical assessment techniques performed by nurses?
To answer this question, the means, and standard deviations of the study questionnaire items were calculated for the responses of the study sample individuals to the paragraphs. Table 3 shows the mean values and standard deviations of the physical assessment techniques paragraphs in descending order.  Table 3 shows the mean values and standard deviations for participants' responses to the questionnaire items related to the physical assessment techniques. It is evident that the physical assessment techniques rank was high as the total estimated mean value was (3.37) with a percentage of 84%.
The mean values ranged between (2.52 -3.90). Item No. (1) "Inspect overall skin color" achieved the first rank which is considered high with a mean value of (3.90) & a percentage of 98%, while Item No. (30) "Assess for PERRLA (Pupils equal, round, reactive to light and accommodation)" came last which is considered medium with a mean value of (2.52) & a percentage of 63%. In total the number of items that achieved high rank was 24 while the remain 6 achieved medium ranks the thing that indicate a high frequency of Jordanian RNs performance regarding the physical assessment techniques included in the questionnaire.
Results related to the second question: Is there a difference of performing physical assessment techniques among nurses according to the type of healthcare sector?
To answer this question, the means, and standard deviations of the responses to the questionnaire of the study were calculated. t.Test analysis was used to compare between health assessment techniques carried out by Jordanian RNs according to the healthcare sector variable (private vs public). Table 4 displays that.  Table 4 shows that there are significant differences at the level of (α = 0.05) between the mean values of the study sample responses to the questionnaire items in terms of the healthcare sector variable (private vs public), and this is based on the calculated t-value of (3.11), as well as the level of significance (0.001) for the total score of the questionnaire, hence, these results considered statistically significant and in favor of the study sample RNs working in public hospitals based on the mean value of (4.02) in comparison with the mean value of (3.68) for the RNs working in the privet sector.
Results related to the third question: Is there a difference in performing physical assessment techniques among nurses according to the gender?
To answer this question, the means, and standard deviations of the responses to the study questionnaire were calculated t.Test analysis was used to compare between the health assessment techniques carried out by nurses according to the gender variable (male vs female). Table 5 shows that.  Table 5 shows that there are significant differences at the level of (α = 0.05) between the mean values of the study sample responses to the questionnaire items in terms of the gender variable, based on the calculated t-value of (2.73), and with a significant level of (0.007) for the total score of the questionnaire, hence, these results considered statistically significant and in favor of female RNs based on the mean value of (4.54) which was greater than the mean value of the males RNs that was (4.24).
Results related to the fourth question: Is there a difference in performing physical assessment techniques among nurses according to the years of experience?
To answer this question, the means, and standard deviations of the responses to the study questionnaire were calculated. t.Test analysis was used to compare between the health assessment techniques carried out by Jordanian RNs according to the years of experience variable. Table 6 shows that.  Table 6 shows that there are significant differences at the level of (α = 0.05) between the mean values of the study sample responses to the questionnaire items in terms of the years of work experience variable (10 years or less, more than 10 years) based on the calculated value of T (3.12), and with a level of significance (0.001) for the total score of the questionnaire, hence, these results considered statistically significant and in favor of RNs with 10 years or less of experience based on the mean value of (3.41), whereas the mean value for nurses with 10 years or more of experience was (3.12).
Results related to the fifth question: Is there a difference in performing physical assessment techniques among nurses according to the practice unit?
To answer this question, the means and standard deviations of the responses to the study questionnaire were calculated. t.Test analysis was used to compare between the health assessment techniques carried out by Jordanian RNs according to the practice unit variable. Table 7 shows that. To find out whether there were statistically significant differences at the level of (α = 0.05) between the means of the study sample responses to the questionnaire items in terms of the practice unit variable (Maternal-Infant, Adults, Paediatrics, Perioperative), One-WAY ANOVA has been used and Table 8 shows it.  Table 8 shows the results of one-way analysis of variance, that has been applied to find out whether there are significant differences at the level of (α = 0.05) between the mean values of the study sample responses to the questionnaire items in terms of the practice setting variable (Maternal-Infant, Adults, Paediatrics, Perioperative).
The F value was (1.08), and the level of significance was (2.11) for the total score of the questionnaire, which indicates that this result is not statistically significant, and that the health assessment techniques performed by RNs do not differ according to their practice unit.

Discussion
These results indicate that although this sample of Jordanian RNs integrates quite small set of physical assessment techniques into their practice, but they perform all of them either on a regular or frequent bases.
These results seem congruent with the results of three other studies which suggest that only small set of techniques are consistently implemented in clinical practice [14,22].
One could argue that the quantity and the quality of material taught in nursing programs is suitable, but that RNs are not performing adequate comprehensive assessments on their clients, due to lack of either time or supposed need. Likewise, it is likely that nursing programs are offering of a wide range of techniques far greater than is required in clinical practice. The relationship amongst the range of techniques taught in a nursing programs and the techniques performed by RNs is not tackled in the literature, nor was clarified by this study. Even Though this study did not relate what nurses learned in nursing school, particularly in the physical assessment course, with what they did in practice, one would claim that most nursing programs teach physical assessment in much greater depth, well beyond the 30 core skills assessed by these participants.
Findings from data analysis indicate that female RNs were performing physical assessment techniques more than male RNs and this is might be due to the higher number of female nurses practicing nursing in Jordan as shown in the WHO [23] recent reports which indicated that female nurse represent (60%) of the nursing workforce whereas male nurses represent only (40%). And this is could be also rendered to the widespread perception that nursing is a female profession nursing is considered a female profession and predominantly occupied by female nurses.
As it shown in the results Jordanian RNs working in the public sector seemed to perform physical assessment techniques far more than the ones working the privet sector and this is might be rendered to the fact that RNs working in the public sector are offered far more opportunities to attend educational courses, workshops and training sessions funded totally by the government. It also may be argued that RNs working in privet sector has less autonomy and are not able to discuss doctors` instructions or offer them any advice or suggestions based on the physical assessment they performed and the nursing diagnoses they articulated.
The results also indicated that Jordanian RNs with less than ten years of experience in the field were performing physical assessment techniques far more than the ones with equal or more than ten years of experience and this may be rendered to the progress in the Jordanian nursing programs in terms of concentrating more on enhancing critical thinking, decision making and competency-based learning as a method of educating graduate. Benner [24] stated that the number of years on the job in the same or similar situations may establish competence, yet it would not provide a complex reflexive thinking aspect of learning which most of the recent Jordanian nursing curriculum are keen to pass it to their newly graduate [25].
Finally, the results showed no difference in performing different physical assessment techniques by Jordanian RNs according to their practice unit. While some physical assessment techniques are exclusive to specific practice units, the techniques assessed by the entire sample embody all or most of the techniques of the included practice units. And this is due to the discrepancies in the assessment techniques performed by RNs in different practice units, given the demands of the health clients served; still, several techniques are used with all health clients in all practice units.

Implications for Nursing Education
The core of nursing education should mirror tangible nursing practice. The results of this study illuminate the frequency of physical health assessment techniques performed by Jordanian RNs in the practice environment of this sample and may provide an in-depth understanding of the physical health assessment content and the techniques targeted in the nursing curricula. Nurse educators should evaluate the existing anticipations of the physical health assessment techniques taught in their courses and contemplate the logic of these anticipations.
Reducing the content of the physical health assessment techniques taught may be beneficial to nursing students. It may be the time for nurse educators to put down goniometers, picometers, tuning forks, and ophthalmoscopes, while helping students acquire more techniques to observe and identify subtle and obvious clues that indicate changes in the client's condition. Simultaneously, nurse educators must avoid overly simple assessment methods. When circumstances permit, nurses need to understand when and how to execute additional assessment techniques as the situation demands.

Conclusion
This study evaluated the practice of physical health assessment techniques among Jordanian RNs where nursing roles are still evolving. The frequency of performing these techniques varied for the 30-core physical health assessment techniques items selected for this study.
RNs have limited time with each client as well as limited time to learn and master the techniques required for safe and competent practice. Hence, nurses are displaying the physical health assessment techniques that they believe are most relevant to daily nursing practice to improve client prognosis.
Considering the issue regarding the saturation of nursing education content and the gap between the physical health assessment techniques taught and the techniques commonly used in practice, it seems clear that nurse educators should assess and reassess the physical health assessment content taught in the nursing programs and consider revising the curriculum and course expectations.
It seems unrealistic to assume that nursing graduates will possess and master all the techniques required in all areas of nursing practice. Possibly in this case, less is more. It is recommended that nurse educators consider teaching fewer techniques and limit the teaching of physical health assessment techniques to those areas considered most relevant to daily nursing practice, focusing more on interpreting the results of physical health assessment and the development of clinical judgment in the undergraduate nursing curriculum. Further techniques can be learned in the specific environment where the practice takes place according the clinical setting needs.
Graduates who have basic physical assessment techniques and the ability to comprehend interpretation of the physical health assessment findings should be able to learn and apply other health assessment techniques that reflect professional practice.

Conflict of Interest
All the authors do not have any possible conflicts of interest.