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RESEARCH METHODOLOGY
What factors influence nurses’ assessment practices? Development of
the Barriers to Nurses’ use of Physical Assessment Scale
Clint Douglas, Sonya Osborne, Carol Reid, Mary Batch, Olivia Hollingdrake, Glenn Gardner &
Members of the RBWH Patient Assessment Research Council
Accepted for publication 8 March 2014
Correspondence to C. Douglas:
e-mail: c2.douglas@qut.edu.au
Members of the RBWH Patient Assessment
Research Council: Kathleen Richter (Chair),
Kate Mason, Catriona Booker, Dale Dally-
Watkins, Elizabeth Main, Robyn Fox, Kath-
rin Peisker, Margaret Buda, Thea-Grace
Collier, Peter Groom, Sandy Jamieson, Mel-
anie Foster. Responsibility for this article
rests with the named authors.
Clint Douglas PhD RN
Lecturer
School of Nursing, Queensland University
of Technology, Kelvin Grove, Queensland,
Australia
Sonya Osborne PhD RN
Senior Lecturer
School of Nursing, Queensland University
of Technology, Kelvin Grove, Queensland,
Australia
and Royal Brisbane and Women’s Hospital,
Herston, Queensland, Australia
Carol Reid PhD RN
Lecturer
School of Nursing, Queensland University
of Technology, Kelvin Grove, Queensland,
Australia
and Royal Brisbane and Women’s Hospital,
Herston, Queensland, Australia
Mary Batch PhD RN
Research Assistant
Royal Brisbane and Women’s Hospital,
Herston, Queensland, Australia
DOUGLAS C., OSBORNE S., REID C., BATCH M., HOLLINGDRAKE O. &
GARDNER G. (2014) What factors influence nurses’ assessment practices? Devel-
opment of the Barriers to Nurses’ use of Physical Assessment Scale. Journal of
Advanced Nursing 70(11), 2683–2694. doi: 10.1111/jan.12408
Abstract
Aim. To develop and psychometrically test the Barriers to Nurses’ use of Physical
Assessment Scale.
Background. There is growing evidence of failure to recognize hospitalized
patients at risk of clinical deterioration, in part due to inadequate physical
assessment by nurses. Yet, little is known about the barriers to nurses’ use of
physical assessment in the acute hospital setting and no validated scales have been
published.
Design. Instrument development study.
Method. Scale development was based on a comprehensive literature review,
focus groups, expert review and psychometric evaluation. The scale was
administered to 434 acute care Registered Nurses working at a large Australian
teaching hospital between June and July 2013. Psychometric analysis included
factor analysis, model fit statistics and reliability testing.
Results. The final scale was reduced to 38 items representing seven factors,
together accounting for 577% of the variance: (1) reliance on others and
technology; (2) lack of time and interruptions; (3) ward culture; (4) lack of
confidence; (5) lack of nursing role models; (6) lack of influence on patient care;
and (7) specialty area. Internal reliability ranged from 070–086.
Conclusion. Findings provide initial evidence for the validity and reliability of the
Barriers to Nurses’ use of Physical Assessment Scale and point to the importance
of understanding the organizational determinants of nurses’ assessment practices.
The new scale has potential clinical and research applications to support nursing
assessment in acute care settings.
Keywords: barriers scale, health assessment, instrument development, nursing
assessment, nursing observation, patient assessment, physical assessment
©2014 John Wiley & Sons Ltd 2683
continued on page 2684
Olivia Hollingdrake RN GDipPH
Research Assistant
Royal Brisbane and Women’s Hospital,
Herston, Queensland, Australia
Glenn Gardner PhD RN
Professor
School of Nursing, Queensland University
of Technology, Kelvin Grove, Queensland,
Australia
and Royal Brisbane and Women’s Hospital,
Herston, Queensland, Australia
Introduction
Clinical deterioration frequently goes unnoticed in hospital-
ized patients (Massey et al. 2009). Growing concerns about
failure-to-rescue rates have prompted government initiatives
and consensus statements designed to improve timely recog-
nition of acutely ill patients in hospital (e.g. National Insti-
tute for Health & Clinical Excellence 2007, Australian
Commission on Safety & Quality in Health Care [ACS-
QHC] 2010). Given that detectable physiological signs
often precede deterioration (Jones et al. 2011), hospitals
have implemented early warning systems and rapid response
teams to identify and respond to patients at risk of clinical
deterioration. Yet, there is insufficient evidence about the
effectiveness of these interventions (Jones et al. 2011, Kyria-
cos et al. 2011). These hospital safety initiatives depend on
Registered Nurses’ (RNs) ability to detect patients at risk of
clinical deterioration through attentive surveillance, a pro-
cess which includes ongoing observation and assessment,
recognition, interpretation of clinical data and decision-
making (Kutney-Lee et al. 2009). The reasons for nurses
failing to recognize and respond to clinical deterioration are
complex (Jones et al. 2009), but a key finding is that nurses
tend to rely on intuitive judgement rather than physiological
signs and physical assessment of the patient (Odell et al.
2009). Reasons for this are unclear and the factors influenc-
ing nurses’ assessment practices are understudied.
Studies investigating acute care RNs’ use of physical
assessment support the above findings. Nursing pro-
grammes typically educate students to perform over 120
physical assessment skills (Giddens & Eddy 2009, Birks
et al. 2013b), yet only a subset of these skills are routinely
used by RNs in clinical practice. Secrest et al. (2005) found
that 925% of physical assessment skills on a 120-item sur-
vey were taught and practised in nursing degree pro-
grammes, yet only 29% of the skills were actually used on
a daily or weekly basis by practising nurses. Giddens
(2007) also found that among 193 RNs, only 30 of 126
physical assessment skills surveyed were reported to be rou-
tinely performed. The remaining skills were performed
occasionally or not at all. A secondary data analysis com-
paring 48 associate degree and 48 bachelor degree-prepared
RNs matched by clinical area and years of experience found
that frequency of physical examinations did not differ by
educational preparation or years of experience (Giddens
2006). Taken together, these findings suggest disconnection
between what is taught and what is practised.
Although there is a paucity of research on the use of
physical assessment by RNs in Australia, the available data
replicate findings from the US. A recent study of 1220
nurses using Giddens’ 121-item survey of physical assess-
ment skills found that only 34% of skills were routinely
used in practice (Birks et al. 2013a). Many skills had been
learnt by nurses, but never performed (355%) or used
rarely (31%) in their clinical practice. However, in contrast
Why is this research needed?
•Acute care nurses are responsible for identifying and
responding to patients at risk of clinical deterioration to
prevent serious adverse events.
•There is growing evidence of failure to recognize hospital-
ized patients at risk of clinical deterioration, in part due to
inadequate physical assessment by nurses.
•Very little is known about the factors that influence nurses’
assessment practices in the acute care setting and presently
no scales exist to measure barriers to nurses’ use of physi-
cal assessment.
What are the key findings?
•Results support the new 38-item Barriers to Nurses’ use of
Physical Assessment Scale as a valid and reliable measure
in the acute hospital environment.
•Barriers to RNs’ use of physical assessment include reliance
on others and technology, lack of time and interruptions,
ward culture, lack of confidence, lack of nursing role mod-
els, lack of influence on patient care and specialty area.
How should the findings be used to influence policy/
practice/research/education?
•This new measure should encourage future researchers and
clinicians to assess the barriers to nurses’ use of physical
assessment, to better understand how to support nursing
assessment in acute care settings.
•Barriers to nurses’ use of physical assessment may impair
timely recognition of patient deterioration and interven-
tions targeting these factors may improve patient out-
comes.
2684 ©2014 John Wiley & Sons Ltd
C. Douglas et al.
to Giddens’ work, the survey also elicited comments by
nurses that use of skills was influenced by lack of time
available to complete assessments, area of clinical practice
or specialty and the presence or absence of other healthcare
workers such as medical and allied health staff. On the
basis of these findings, Birks and colleagues argued that
the relevance of each skill appears to have little bearing on
the frequency of use by nurses and that further research is
needed to explore the barriers to physical assessment.
In this study, we sought to develop and test a measure of
barriers to nurses’ use of physical assessment, defined as the
collection of objective patient data using the techniques of
inspection, palpation, percussion and auscultation (Fennes-
sey & Wittmann-Price 2011). Given its central role in the
recognition of deterioration, the focus of our study was
patient physical assessment, which differs from the broader
concept of health assessment (Lillibridge & Wilson 1999).
Background
Existing research on barriers to RNs’ use of physical assess-
ment is sparse. As physical assessment skills came to occupy
a more prominent role in nursing degree programmes in the
US during the 1980s, a few early small studies investigated
perceived attitudes or barriers to their use among degree-pre-
pared nurses (Barrows 1985, Colwell & Smith 1985, Brown
et al. 1987, Sony 1992) or nursing students (Schare et al.
1988). Although the data reported were limited, key barriers
identified were a lack of confidence or competence to per-
form skills (Colwell & Smith 1985, Brown et al. 1987), the
perception that physical assessment was performed by physi-
cians or was not a nursing responsibility (Colwell & Smith
1985, Sony 1992) and lack of peer support (Barrows 1985).
More recent research into barriers to RNs’ use of physi-
cal assessment is lacking, particularly in acute care areas.
An Australian study of acute care and domiciliary RNs’
health assessment practices found that nurses predomi-
nantly described their role in health assessment as support-
ing medical practice, rather than as the basis for developing
nursing care (Lillibridge & Wilson 1999). Skillen et al.’s
(2001) study of factors constraining the use of physical
assessment among RNs working in long-term care facilities
identified lack of time because of heavy workloads, clients’
unwillingness or inability to participate, lack of peer sup-
port, lack of resources and poor physical environment and
the belief that it is not the nurse’s role. Another qualitative
study of cardiac nurses in the UK found that physical
assessment skills were used selectively, based on their per-
ceptions of role boundaries, the nurse’s role and their own
development and level of support from others (Edmunds
et al. 2010). Studies of nurse practitioners have found that
skills were infrequently performed because they were inap-
propriate to the clinical setting or used only if a problem
was suspected (O’Farrell et al. 2000), a lack of confidence
in assessing certain body systems and lack of acceptance
and support from medical staff (McElhinney 2010). While
these qualitative and small descriptive studies identify
potentially important barriers, there are clear gaps in the
literature. Large cross-sectional studies are needed to deter-
mine the scope and nature of RNs’ perceived barriers to
conducting physical assessment in acute care settings, and
the extent to which they influence nursing assessment prac-
tices. Complex intervention studies designed to address
these barriers and improve nursing assessment skills are
also needed. However, before interventions targeting
nurses’ assessment practices can be developed, a valid and
reliable measure of barriers to physical assessment skills is
required.
Overall, there is growing evidence of suboptimal care of
acutely ill ward patients, in part due to inadequate patient
assessment (Massey et al. 2009, Odell et al. 2009). While
the existing research on RNs’ use of physical assessment
indicates a gap between what is taught and what is prac-
tised, very little research has explored the individual and
organizational barriers to the use of these skills. What does
exist is limited by size, scope and methodology. Validated
measures of barriers to nurses’ use of physical assessment
are also lacking. Investigators have either included open-
ended questions or devised their own checklists of potential
barriers, raising questions about the reliability and validity
of measures and making comparisons between studies diffi-
cult (Lesa & Dixon 2007, Fennessey & Wittmann-Price
2011). To date, no one has inductively developed and psy-
chometrically tested a scale measuring barriers to RNs’ use
of physical assessment in acute care settings. Without such
a measure, it will be impossible to tailor or evaluate the
effects of interventions targeting barriers to nursing assess-
ment practices in the clinical environment. The purpose of
this research, therefore, was to develop and test a measure
of barriers to RNs’ use of physical assessment in the acute
hospital setting. It was part of a larger study examining
RNs’ assessment practices and management of patients at
risk of clinical deterioration.
The study
Aim
To develop and psychometrically test the Barriers to
Nurses’ Use of Physical Assessment Scale.
©2014 John Wiley & Sons Ltd 2685
JAN: RESEARCH METHODOLOGY Barriers to nurses’ use of physical assessment
Methodology
Phase one: item development
We followed DeVellis’ (2012) guidelines for scale develop-
ment to generate an item pool, conduct an expert review of
the item pool and psychometric evaluation of the scale.
First, preliminary items were developed based on a compre-
hensive review of the literature. We searched CINAHL and
MEDLINE databases from 1980–2013 using the following
search terms: nurs*, physical assessment, physical examina-
tion, health assessment, nursing observation, patient assess-
ment, barriers and attitudes. We retrieved 16 original
research and five review articles examining barriers to
nurses’ use of physical assessment. This revealed 13 poten-
tial categories including ward culture, specialty area, time
and opportunities for assessment, organization of nursing
work, resources and physical environment, role boundaries,
peer support, nursing role models, self confidence, influence
on nursing care, influence on patient outcomes, reliance on
technology and patient-related factors. Second, we con-
ducted several focus groups with RNs from the target popu-
lation who were completing continuing education sessions
on health assessment. The purpose was to explore whether
the categories developed from the literature made sense to
nurses working in acute care areas and captured salient bar-
riers to physical assessment from their experience. When
possible, the participants’ actual language was used to gen-
erate possible scale items to enhance item validity (DeVellis
2012). Using these methods, a total of 52 positively and
negatively worded items were developed, representing 13
categories of barriers to physical assessment. The number
of items included reflected a balance of having a large
enough initial pool from which to develop the final scale
(DeVellis 2012) and practical considerations of respondent
burden and response rate.
Phase two: content validation
Following item generation, we sought review by a panel
of eight nurses with expertise in the area including nurse
managers and researchers from the target population, and
nursing academics responsible for teaching postgraduate
health assessment. Participants were given a list of the 52
items and asked to evaluate each item in terms of its clar-
ity and relevance in representing each category (1 =not
relevant, 4 =highly relevant). Participants also provided
written comments if an item was judged to be unclear.
Using ratings of item relevance, we computed the scale
content validity index as 092 (range =090–098) using
the method recommended by Polit and Beck (2006),
which averages the proportion of items rated as 3 or 4
across experts. This exceeds the recommended 090 cut-
off (Polit & Beck 2006). The research team met and eval-
uated each of these responses, modified five statements
and arrived at consensus about the items to include in the
psychometric evaluation of the scale. For example, items
about lack of confidence needed revision to ensure that
there was no conceptual overlap with lack of knowledge
or ability.
Phase three: psychometric evaluation
To evaluate the psychometric properties of the scale we
conducted a hospital-wide survey at a large tertiary referral
teaching hospital located in South-East Queensland, Austra-
lia.
Participants. Eligible participants included all RNs
(Grades 5–8; definitions for grades of nursing practice are
available at www.health.qld.gov.au/qhpolicy/docs/pol/
qh-pol-179.pdf) working in acute care areas in the divisions
of internal medicine, surgery and perioperative services,
cancer services, women’s and newborn services and mental
health services. RNs working in critical care areas were
excluded because our focus was acute ward environments
where support and expertise may differ. From a total of
106 units in the hospital, the eligible sampling frame was
determined to be 40 acute care areas.
Data collection. Participant information sessions were con-
ducted on eligible wards prior to data collection by mem-
bers of the research team. During June–July 2013, all RNs
received anonymous paper-based surveys containing study
information and return self-addressed envelopes through
the hospital internal mail system. Alternatively, RNs could
complete an online version of the survey using work com-
puters or tablets provided in each work area. As an incen-
tive to improve the response rate, respondents could enter a
random prize draw to win a tablet computer at the end of
the data collection period.
Data analysis. Survey data were entered into IBM SPSS
Statistics version 21 (Chicago, IL, USA) and screened for
accuracy and missing values. There was very little missing
data with less than 2% for all scale items. Little’s MCAR
test showed that data were missing at random, so we
imputed missing values using expectation maximization
(Fox-Wasylyshyn & El-Masri 2005). Descriptive statistics
were used to summarize sample characteristics and to
examine frequency distributions for each item. We assessed
2686 ©2014 John Wiley & Sons Ltd
C. Douglas et al.
normality for each variable by inspection of histograms
and computing skewness and kurtosis indices.
To evaluate construct validity, the underlying structure of
the scale was examined by exploratory factor analysis
(EFA) using principal components analysis with varimax
rotation. Determining the number of factors to extract was
informed by examining eigenvalues greater than 1, scree
test and parallel analysis using 100 replications of Monte
Carlo simulations with random datasets of the same size
(DeVellis 2012). Following Hair et al.’s (2010) recommen-
dations, we considered that items were associated with fac-
tors if they had loadings of 040 or higher and were
retained only if they loaded significantly on one factor (at
least 020 difference between loadings). Based on our find-
ings from EFA, we also tested the fit of the hypothesized
measurement model against the data with confirmatory fac-
tor analysis using IBM SPSS AMOS (version 21). After
reverse scoring relevant items, we then performed reliability
testing using Cronbach’s alpha for internal consistency on
the resulting factors.
Mean subscale scores were computed by summing indi-
vidual items and dividing by the number of items in each
subscale, so that each subscale score ranged from 1–5.
Finally, as variables were normally distributed, we exam-
ined associations between nurse and workplace characteris-
tics and perceived barriers to physical assessment using
correlations, t-tests and ANOVAs. For all analyses, the level
of statistical significance was P<005.
Sample
Of the 1591 surveys distributed to our convenience sample,
183 were returned because staff were on leave or no longer
working in that area. A total of 434 RNs completed the
survey and comprised the development sample for this
study, yielding a response rate of 308%. A sample size of
greater than 300 is generally considered adequate for factor
analysis (Tabachnick & Fidell 2007, DeVellis 2012), with
83 participants per item exceeding the minimum 5:1 ratio
recommended by Hair et al. (2010).
Instrument
The final instrument included 52 items. Participants were
asked to read each of the randomly ordered items and indicate
the extent to which they agreed each statement applied to their
practice on a 5-point Likert-type scale (1 =strongly disagree,
5=strongly agree). The survey also contained questions
about participants’ demographic and work characteristics
such as gender, age, education, clinical role and experience.
Ethical considerations
All study procedures were approved by the Hospital and
University Human Research Ethics Committees.
Results
Sample characteristics
Sample characteristics are presented in Table 1. With a
mean age of 389 years (SD 115), the majority of the sam-
ple were women (906%), spoke English as a first language
(857%), employed part-time (537%) and had completed a
bachelor’s degree (624%). Most were RNs (Grade 5,
652%) or clinical nurses (Grade 6, 221%), who had an
Table 1 Sample characteristics (N=434).
Characteristics n%
Gender
Female 393 906
Male 40 92
Age
Mean, SD 389115
Highest level of education
Hospital certificate 59 136
Bachelor’s degree 271 624
Postgraduate 99 228
English first language
Yes 372 857
No 59 136
Clinical role
Registered Nurse/midwife 283 652
Clinical nurse/midwife 96 221
Nurse manager, educator
or researcher
47 108
Division currently employed
Surgical and perioperative 141 325
Internal medicine 119 274
Women’s and newborn 57 131
Cancer care 42 97
Mental health 34 78
Other 38 87
Employment status
Full-time 191 440
Part-time 233 537
Casual 9 21
Years of experience as RN
Mean, SD 137108
≤3 years 69 159
4–5 years 50 115
6–9 years 70 161
≥10 years 232 535
Percentages vary depending on missing data.
©2014 John Wiley & Sons Ltd 2687
JAN: RESEARCH METHODOLOGY Barriers to nurses’ use of physical assessment
average of 85 years’ (SD 68) employment at the hospital
and 137 years’ (SD 108) clinical experience.
Factor analysis
Before the main analysis, the appropriateness of factor
analysis was considered. Examination of the correlation
matrix indicated that many items were correlated at least
030. The Kaiser-Meyer-Olkin measure of sampling ade-
quacy was high at 092 (Hair et al. 2010). Bartlett’s test of
sphericity was also significant, v
2
=640812, P<0001. An
EFA was thus conducted using principal components analy-
sis (PCA) and varimax rotation, with convergence in seven
iterations. Initial solutions revealed that 11 factors had ei-
genvalues greater than 1; however, examination of the scree
plot (Figure 1) and parallel analysis indicated that a 6-fac-
tor solution was probably most appropriate. We deleted the
poorest performing items, one at a time and re-ran the PCA
after each item deletion. We repeated this process until all
40 items retained had a factor loading of at least 040 and
loaded on one coherent factor. Forced 6-, 7- and 8-factor
extractions were analysed and a 7-factor extraction was
determined to be the most appropriate based on factor
interpretability, together accounting for 577% of the vari-
ance in the scale (Table 2). These subscales were named:
(1) reliance on others and technology; (2) lack of time and
interruptions; (3) ward culture; (4) lack of confidence; (5)
lack of nursing role models; (6) lack of influence on patient
care; and (7) specialty area. A further two items were
deleted based on item-level reliability analysis, which did
not alter the scale’s factor structure.
On the basis of these findings, we also conducted a con-
firmatory factor analysis using maximum likelihood estima-
tion to examine model fit. Fit indices provided additional
evidence that our final 7-factor scale represents an adequate
fit of the data: normed v
2
=190, root mean square error
of approximation (RMSEA) =005 (90% confidence inter-
val =004–005) and comparative fit index (CFI) =091.
Recommended cut-offs for goodness-of-fit given the sample
size and number of variables are normed v
2
<3,
RMSEA <007 with CFI >090 (Hair et al. 2010). Inspec-
tion of standardized regression weights showed that all
items loaded significantly (P<0001) on the hypothesized
measurement model and no modifications were warranted
based on the values calculated.
Descriptive statistics and reliability
Summary statistics for each subscale are presented in
Table 3, with mean subscale scores for specialty area
(348), lack of time and interruptions (269) and lack of
nursing role models (263) all exceeding the mid-point (pos-
sible range =1–5). Perceived lack of influence on patient
care (206) in contrast, was scored the lowest. Reliability
analysis showed the scale to be internally consistent (DeVel-
lis 2012), with Cronbach’s coefficient alpha ranging from
070–086 for each subscale; coefficient alpha for the total
38-item scale was 080. The correlations between subscales
14
10
7
6
4
351
Component number
Eigenvalue
4947454341393733
35
312927252321191715119751
0
1
2
3
5
8
9
11
12
13
13
Figure 1 Scree plot from initial princi-
pal components analysis of the Barriers to
Nurses’ use of Physical Assessment Scale.
2688 ©2014 John Wiley & Sons Ltd
C. Douglas et al.
Table 2 Rotated component matrix for the 38-item Barriers to Nurses’ use of Physical Assessment Scale.
Item
Factors
h
2
1234567
43. It’s not the nurse’s role to conduct a physical assessment of
the patient.
065 017 004 009 015 028 000 055
38. I can gather all the physical assessment data I need using
electronic monitoring devices.
062 004 005 011 020 022 004 049
30. Use of technology reduces the need for nurses’ physical
assessment skills.
062 015 019 010 005 005 013 047
31. Nurses don’t need to use many physical assessment skills to do
their job well.
060 010 007 007 024 015 005 046
18. I see physical assessment as something only the doctor does. 060 020 016 024 020 017 006 055
44. I tend to rely on monitoring equipment to collect assessment
data.
058 009 009 011 013 009 012 041
36. I only have time to use physical assessment when a patient
deteriorates.
054 024 022 021 013 009 000 047
27. Physical assessment is the responsibility of medical or allied
health staff.
054 015 003 008 005 015 003 035
45. I don’t use physical assessment skills because of the task-
oriented nature of my work.
053 026 031 019 012 018 009 055
14. Lack of time is a barrier to my use of physical assessment skills. 005 081 000 006 007 006 003 068
16. I usually don’t have time to do an in-depth physical assessment
of my patients.
015 073 004 023 018 001 005 065
3. I don’t have time to use physical assessment skills because of my
workload.
016 072 029 003 013 018 003 068
8. Completing checklists and documentation means I don’t have
time to use physical assessment skills.
011 070 018 017 004 005 009 058
46. Too many interruptions during my work prevent me from doing
physical assessment.
032 065 019 013 001 003 001 058
17. The physical environment (e.g. lighting, noise, privacy) of the
ward makes it difficult to do physical assessments.
019 058 021 011 007 001 002 043
2. The ward culture is a barrier to my use of physical assessment
skills.
005 022 072 006 014 013 000 061
5. Assessment is done a certain way on my ward, which limits the
extent of physical assessment skills I use.
014 025 071 014 010 001 003 062
4. Assessments I make using physical assessment skills are not
valued by my co-workers.
010 022 066 009 025 014 003 059
28. The ward culture discourages nurses from doing physical
assessment in my workplace.
036 009 064 021 023 004 003 066
10. I feel supported by my colleagues to use physical assessment
skills.
005 009 061 016 039 023 007 063
25. Other nurses don’t want to listen when I report my physical
assessment findings.
023 002 057 028 006 033 010 059
23. I lack confidence in accurately performing physical assessment
skills.
016 017 015 082 008 017 004 079
20. I worry about my ability to correctly use physical assessment
skills.
006 022 022 081 005 003 010 078
19. I lack confidence in deciding what physical assessment skills to
use.
026 017 012 077 016 004 009 075
52. I am sure that I can competently use physical assessment skills. 015 014 001 065 022 034 003 064
41. Physical assessment skills are role modelled by experienced
nurses on my ward.
002 008 017 009 074 015 000 062
48. Nurse leaders promote the use of physical assessment skills in
my unit.
015 013 031 016 072 022 000 074
©2014 John Wiley & Sons Ltd 2689
JAN: RESEARCH METHODOLOGY Barriers to nurses’ use of physical assessment
ranged from 003 (specialty area and lack of influence on
patient care) and 061 (lack of nursing role models and
ward culture). Corrected item-total correlations of the 38
items ranged from 034–079. Inspection of item means and
variances also demonstrated adequate item performance
without evidence of floor or ceiling effects.
Associations between sample characteristics and barriers
to physical assessment
No significant associations were found between nurses’ per-
ceived barriers to use of physical assessment skills and age,
gender, level of education or employment status. Having
greater than 10 years’ nursing experience was associated
with lower perceptions of lack of time and interruptions, F
(3, 406) =445, P=0004, and lack of confidence, F(3,
409) =368, P=001. In contrast, having less than 5 years’
experience was associated with greater endorsement of a
lack of nursing role models, F(3, 410) =275, P=004.
RNs from non-English speaking backgrounds scored higher
on reliance on others and technology, t(415) =204,
P=004. Compared with RNs and clinical nurses (Grade 5
or 6), nursing management (Grade 7) was less likely to per-
ceive a reliance on others and technology, F(2, 411) =444,
Table 2 (Continued).
Item
Factors
h
2
1234567
21. Nurses encourage one another to use physical assessment skills
on my ward.
005 010 027 011 072 015 010 065
51. There is a lack of experienced nursing staff to role model
physical assessment skills on my ward.
019 021 020 022 048 014 001 048
24. Information I collect using physical assessment skills is used to
develop a plan of care.
009 009 022 014 002 066 000 053
47. My ability to use physical assessment skills makes a positive
difference to patient care.
030 000 006 007 020 066 004 058
33. My ability to use physical assessment skills improves the quality
of nursing care.
030 001 004 007 018 065 000 056
50. The information I collect using physical assessment skills is used
to make treatment decisions.
024 021 020 014 013 058 006 053
22. I only use physical assessment skills that are relevant to my
specialty area.
010 004 005 001 004 003 084 071
13. I don’t use physical assessment skills that are outside of my
specialty area.
001 007 006 004 004 004 072 054
9. The specialty area I work in determines the physical assessment
skills I use.
012 001 001 003 005 000 064 042
32. The physical assessment skills I use are restricted to my specialty
area.
033 008 002 022 019 007 060 057
49. The physical assessment skills I use are determined by what is
acceptable on my ward.
025 001 017 013 023 014 047 044
Eigenvalue 1045 291 241 192 167 138 117
Per cent of variance explained 275776351443631
All loadings greater than 040 are in bold.
Table 3 Descriptive statistics, reliability and pearson’s correlations of subscales.
Subscale M SD Range a1234567
1. Reliance on others and technology 221 054 100–444 083 –
2. Lack of time and interruptions 269 075 100–500 085 052 –
3. Ward culture 226 061 100–467 084 050 049 –
4. Lack of confidence 245 076 100–500 086 049 044 045 –
5. Lack of nursing role models 263 075 100–500 078 038 041 061 045 –
6. Lack of influence on patient care 206 048 100–400 073 054 029 044 040 041 –
7. Specialty area 348 064 160–500 070 026 017 005 021 003 003 –
2690 ©2014 John Wiley & Sons Ltd
C. Douglas et al.
P=001, or lack of influence on patient care, F(2,
419) =332, P=004, as barriers to physical assessment.
Finally, RNs working in women’s and newborn services or
mental health services both rated specialty area higher
compared with other service divisions as influencing their
use of skills, F(5, 423) =246, P<0001.
Discussion
This is the first study to develop a measure of barriers to
nurses’ use of physical assessment skills in the acute care
setting. Overall, the findings provide initial evidence for
the validity and reliability of the scale, which has poten-
tial clinical and research applications to better understand
the factors influencing nursing assessment and how to sup-
port the use of assessment skills in acute care settings.
The findings also extend the current debate in the litera-
ture about the relevance of teaching physical assessment
skills that are infrequently used by RNs in their daily
work (e.g. Secrest et al. 2005, Giddens 2007, Giddens &
Eddy 2009, Fennessey & Wittmann-Price 2011, Birks
et al. 2013a,b), by revealing salient barriers that shape
nurses’ assessment practices. Counter to recommendations
that nurse educators should limit the teaching of physical
assessment skills to those most frequently used (e.g. Gid-
dens 2007, Giddens & Eddy 2009, Zambas 2010, Ander-
son et al. 2013), we would argue that reductionist
interpretations of the gaps previously identified in the lit-
erature between what is taught and what is practised by
some authors ignore the importance of the broader con-
text where nursing practice is situated. While further
research is needed to confirm whether these barriers pre-
dict RNs’ actual use of physical assessment skills, our
findings suggest the assumption that the physical assess-
ment skills used by nurses in practice reflect those they
feel are most relevant for everyday nursing practice is
overly simplistic. Greater attention to the barriers RNs
encounter in performing physical assessment is needed to
understand nurses’ work practices and failure to recognize
patients at risk of clinical deterioration.
Some of the subscales that emerged in this study clustered
somewhat differently than expected based on the items
originally developed. Accounting for over a quarter of the
variance (275%), the subscale ‘reliance on others and tech-
nology’ suggests the way RNs perceive their role in physical
assessment is largely shaped by both professional bound-
aries (e.g. ‘It’s not the nurses role to conduct a physical
assessment of the patient’, ‘Nurses don’t need to use many
physical assessment skills to do their job well’) and their
relationship with technology in practice (e.g. ‘Use of
technology reduces the need for nurses’ physical assessment
skills’, ‘I tend to rely on monitoring equipment to collect
assessment data’). A reliance on others and technology dis-
tances the nurse from the patient and leads to deskilling of
quintessential nursing tasks such as skilled patient observa-
tion and assessment through the senses (Wheatley 2006). It
also reflects ongoing debate in the literature about whether
physical assessment is even a legitimate role for nurses
(West 2006, Lesa & Dixon 2007, Zambas 2010, Fennessey
& Wittmann-Price 2011). This is problematic for nurses
primarily because of the blurring of professional boundaries
around physical diagnosis and so authors have been careful
to distinguish between the purpose of nursing and medical
assessment (e.g. Crow et al. 1995). In practice, nurses need
to negotiate these tensions and this subscale appears to cap-
ture nurses’ reluctance to incorporate physical assessment
beyond culturally sanctioned skills such as vital signs using
electronic monitoring.
The subscale ‘lack of time and interruptions’ brings
together time and workload pressures (e.g. ‘I don’t have
time to use physical assessment skills because of my work-
load’) and issues around the organization of nursing work
that prevent uninterrupted time for physical assessment
(e.g. ‘Completing checklists and documentation means I
don’t have time to use physical assessment skills’, ‘Too
many interruptions during my work prevent me from doing
physical assessment’). While acute care RNs are busy and
may not have enough time to conduct an in-depth physical
assessment of their patients (Birks et al. 2013a), in contrast
to medicine, the nursing physical examination also tends to
be covert and opportunistic. As Sandelowski’s (2000) his-
torical analysis of the nurse’s role in patient observation
reveals, ‘in contrast to physicians, who performed their
physical examinations in a very public and even intention-
ally dramatic way, nurses learned to disguise the assess-
ments they performed’ (p. 71). These structural factors
influencing the organization of nursing work have contrib-
uted both to a lack of dedicated time for nursing assessment
and to the invisibility of the RN’s contribution to the physi-
cal assessment of the patient.
The remaining barrier subscales including ward culture,
lack of confidence, lack of nursing role models, lack of
influence on patient care and specialty area are readily
interpreted and supported by previous literature (Colwell &
Smith 1985, Brown et al. 1987, Sony 1992, Wilson & Lilli-
bridge 1995, Skillen et al. 2001, Birks et al. 2013a). Inter-
estingly, however, most of the items relating to adequate
resources, patient factors and perceived influence on nursing
care did not cluster to form separate subscales or loaded
weakly on other subscales and thus were not retained.
©2014 John Wiley & Sons Ltd 2691
JAN: RESEARCH METHODOLOGY Barriers to nurses’ use of physical assessment
The finding that specialty area, lack of time and interrup-
tions and lack of nursing role models were rated as the
most significant barriers to use of physical assessment by
RNs in this sample underscores the importance of under-
standing the organizational determinants of nurses’ assess-
ment practices. Specialization and lack of time are two of
the most common barriers to nurses’ use of physical assess-
ment identified in the literature (Skillen et al. 2001, Edm-
unds et al. 2010, Birks et al. 2013a). Giddens’ (2007)
analysis of the frequency of RNs’ use of physical assessment
skills by specialty area suggested that although some skills
were unique to certain subgroups, the core skills used regu-
larly or frequently by the entire sample represented all or
the majority of the core skills for each subgroup, except for
mental health. Birks et al. (2013a) also identified that use
of skills differed for mental health and midwife subgroups,
although data were not reported for each specialty. Thus,
further research is needed to examine whether a minimum
data set for physical assessment among acute care RNs can
be identified and whether regular use of these skills
improves patient outcomes such as failure-to-rescue rates.
Intervention studies targeting these organizational barriers
are also warranted. Our data suggest that a practice devel-
opment framework that incorporates educational and self-
efficacy components may be particularly valuable. A recent
example is Duff et al.’s (2012) intervention study to
improve respiratory assessment skills among RNs working
on surgical wards.
The lack of associations between perceived barriers to
use of physical assessment and many of the sample charac-
teristics examined also points to the importance of these
factors in determining the use of skills, regardless of the
RN’s personal characteristics such as age, gender or level of
education. While surprising, the finding that highest level of
education was not associated with perception of barriers is
consistent with a previous study that found no difference in
use of physical assessment skills between associate and
bachelor degree-prepared RNs in the US (Giddens 2006).
Our data do, however, suggest that the most experienced
RNs and those working in management roles may be less
influenced by barriers such as lack of time and interrup-
tions, lack of confidence, reliance on others and technology
or lack of influence on patient care. Less experienced RNs,
in contrast, were more likely to perceive a lack of nursing
role models as an obstacle to performing assessment skills.
Thus, although very experienced RNs’ use of physical
assessment may be less influenced by these barriers, they
may not be acting as role models for less experienced staff
on the ward. RNs from non-English speaking backgrounds
tended to endorse a greater reliance on others and
technology, which may reflect cultural differences of foreign
nurses, particularly if physical assessment by nurses is not
routinely taught or encouraged in their country of origin.
Finally, like previous studies (Giddens 2007, Birks et al.
2013a), we found RNs working in women’s and newborn
services or mental health were more likely to agree that
they limit the use of skills to their specialty area compared
with other service divisions in the hospital.
Limitations
We acknowledge several limitations in our study. First,
despite the large sample size, participants in the focus groups,
expert panel and development sample were all recruited from
a single hospital, which limits the generalizability of findings
to some extent. Given this, there may be other barriers that
did not emerge in our work that need to be explored in other
settings. Second, further validation testing of the scale is also
needed such as examining its relationship with the frequency
of physical assessment skills actually performed by acute care
nurses, which is part of a larger study in progress. Further
psychometric testing to establish criterion-related validity,
test–retest reliability and sensitivity to change would also
strengthen the utility of the scale. Polit and Beck (2012)
argue that while scale developers should ideally conduct a
second study to undertake validation activities, researchers
should strive to undertake validation techniques such as con-
firmatory factor analysis using data from the development
sample if this is not possible. Developing evidence regarding
the psychometric adequacy of a scale is an incremental
process and future studies will be important to examine the
properties of the scale in new samples.
Conclusion
This research has begun to fill some of the gaps in the liter-
ature on acute care nurses’ use of physical assessment.
Although previous research suggests that only a subset of
physical assessment skills taught in nursing programmes are
routinely used by RNs in daily practice, basic questions
about the factors influencing their use have not previously
been explored. A major contributor to these knowledge
gaps has been a lack of validated measures. This is an area
of great significance for nursing practice given nurses’ cen-
tral role in patient assessment and its incontrovertible link
to improved patient outcomes.
In conclusion, the development and psychometric evalua-
tion of the Barriers to Nurses’ use of Physical Assessment
Scale reported here provide initial support for the validity
and reliability of this new scale. We hope that this measure
2692 ©2014 John Wiley & Sons Ltd
C. Douglas et al.
will encourage future researchers and clinicians to assess the
barriers to nurses’ use of physical assessment, to better under-
stand how to support nursing assessment practices and the
recognition of clinical deterioration in acute care settings.
Funding
This study was funded by a QUT School of Nursing initia-
tive grant.
Conflicts of interest
No conflict of interest has been declared by the authors.
Author contributions
All authors have agreed on the final version and meet at
least one of the following criteria [recommended by the
ICMJE (http://www.icmje.org/ethical_1author.html)]:
•substantial contributions to conception and design,
acquisition of data, or analysis and interpretation of
data;
•drafting the article or revising it critically for important
intellectual content.
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