Physical assessment - Learning chest auscultation through interactive multi media.
AEJNE Volume 3 - No.2 March,1998.
Ron Kerr and Deri Hadler from Charles Sturt University have received a $45000 ($Aust) National Teaching Development Grant from the Committee for University Teaching and Staff Development (CUTSD) to develop a CD- ROM computer program on Physical Assessment Chest Auscultation.
This project is part of a proposed comprehensive multimedia learning package on physical assessment for health professionals. The importance of accurate health assessment and, where indicated, early medical intervention are well recognised as key strategies in maximising the value of every health dollar. Auscultation is acknowledged as an integral part of physical assessment along with inspection, percussion and palpation of the human body. Auscultation being arguably the most difficult of the physical assessment skills to master. To date , learning materials have mostly relied on synthetically generated heart and lung sounds to enhance auscultation skills. Simulated sounds have limited use compared with real heart and lung sounds. Using sick hospitalised clients to develop beginning auscultation skills raises ethical issues, while using healthy fellow students provides only a narrow range of assessments. This project will offer a practical solution for pre-service and practising health professionals to access real clinical sounds in an authentic, purposeful and low stress learning environment. A multimedia package such as this one has the potential to develop both confidence and health assessment skills to a higher degree in students before they practise on real patients.
There are two product versions planned . The one being developed during 1998 will be a non-linear , interactive, cross platform CD-ROM learning package for use with a personal computer and headphones. A later cheaper version could comprise an audio cassette and workbook for use with a personal tape player designed specifically for students without access to a computer or requiring more portability. The CD-ROM product will be designed for use by any health professional licensed to perform health assessment, eg Medical Practitioners, Nurses, Physiotherapists, Personal Trainers. It should be available July 1999.
Auscultation is a difficult skill to master for several reasons: Access to real clinical sounds can present problems coupled with the fact that students need to hear a large range of normal clinical sounds before they can accurately detect abnormalities. Using sick hospitalised clients to develop beginning physical assessment skills (eg auscultation) is not only invasive but ethically questionable. Fellow students or volunteers as 'pretend clients' also have limitations in that most are clinically healthy so the range of assessments are narrow. These strategies along with print materials and pre-recorded audio and video tapes are those traditionally used to enhance auscultation and other physical assessment skills.
The literature supports the need for more effective teaching and learning strategies in the area of physical assessment. An Australian study by Lont (1992) indicates the lack of chest auscultation assessment skills attended by nurses. Results clearly backed up previous studies that physical assessment skills were learnt on the job but more importantly a high number of nurses revealed that they were never taught. Furthermore, the frequency with which nurses perform chest auscultation is poor ( over 50% never or less than once a week), but these same nurses ( 89% ) believed they carried out a physical assessment daily. An American study to evaluate the auscultatory proficiency of U.S. medical students and physicians-in-training also demonstrated a low emphasis on teaching cardiac auscultation. The authors, Mangione, Nieman et al (1993) revealed that Program Directors attributed great importance to cardiac auscultation and thought that more time should be devoted teaching it. However, only 27% of internal medicine and 37% of cardiology programs offered any structured teaching of auscultation. The trainees' accuracy ranged from 0 to 56.2% for cardiology fellows and from 2% to 36.8% for medical residents.
Interestingly residents improved little with a year of training and were never better than third- year medical students.
It becomes clear that students don't have enough opportunity to practise and develop physical assessment skills, notably auscultation, one reason being a lack of authentic learning resources. They only have limited access to willing "pretend clients" with a narrow range of clinical conditions. Most pre-service students arguably have neither the skills nor confidence to accurately perform a comprehensive health assessment of clients whilst on practicum. Our own experience (Kerr, 1997) has reinforced that students prefer to learn the more invasive clinical skills such as physical assessment in a learning environment that has high levels of authenticity and sense of purpose but low levels of stress.
The development of our computer based, multimedia package will enable students to develop auscultation and other physical assessment skills at their own convenience and pace. They will be listening to authentic clinical sounds in a relaxed learning environment and provided with confidential and progressive feedback. So far, the authors having received seed funding in 1996 from Charles Sturt University have already developed a digital recording stethoscope and have just completed a basic working prototype using heart sounds and data from a small number of clients. During 1998 we expect to significantly expand the scope and application of this work to include auscultation of both heart and breath sounds. The Circulatory and Respiratory Systems are linked to the degree that physical assessment must include auscultation of both.
Specific learning outcomes that the interactive multimedia project on auscultation will enable students to achieve include: (a) the correct use of a stethoscope, (b) gaining an understanding of the surface anatomy of the thorax, (c) describing how blood flows through the heart and lungs, (d) correct location of listening sites, ( e) recognising normal heart and breath sounds, (f) differentiating some of the more common heart murmurs, (g) understanding the pathology and effect on human function underlying added heart and breath sounds, (h) correctly documenting findings from auscultation and (i) appreciating that diagnostic reasoning requires consideration of all relevant data and not datum in isolation. Pre-service health professionals licensed to perform physical assessment are the prime target group for the learning resource. Clinicians who wish to maintain or improve their auscultation skills will also be targeted.
Some recent advances in auscultation include: A system for patient monitoring during magnetic resonance imaging (MRI) was reported by Henneberg, Hok et al (1992). This system is based on remote auscultation of heart sounds and respiratory sounds using pick up heads that are positioned on the pericardium or at the nostrils and connected to microphones via polymer tubing. While there is some interference during imaging, the quality of the breath and heart sounds was regarded as acceptable or better. Another approach focussing on teaching and supporting auscultation consists of a portable graphic display system. This system has been evaluated by Tavel, Brown and Shander (1994) who concluded the graphic display system can often provide more information than can be obtained by standard auscultation alone. Permanent records allow for more objective comparison of the auscultatory findings of various examiners at different times. This system provides an excellent means by which auscultation skills may be taught or enhanced, especially since its speed and portability allow immediate feedback for comparison with auditory perception. Closer to home, a CD- ROM computer program by Bauer and Huynh from Victoria University of Technology to assist students to learn and assess blood pressure became available in 1997. There has been a lot written on the use of simulation in medical and nursing education mostly from a positive perspective. One commonly disclosed advantage of using simulation reiterated by Janes and Cooper (1996) is the absolute safety in which students can gain their experiences. They can make and rectify mistakes without causing distress or injury to patients.
Our project intends to use and build on the knowledge gained from these and other advances to produce the most comprehensive learning package on auscultation to date. It will contain levels of difficulty designed to teach and support neophyte physical assessors through to experienced clinicians. It is anticipated that the chest auscultation CD- ROM computer software will be available mid 1999.
If you have any questions or comments, contact the project team.
Bauer, M.and Huynh, M. 1997. How to measure Blood Pressure. CALC Multimedia. Victoria University of Technology
Henneberg, S. Hok, B. Wiklund, L. and Sjodin, G. Remote auscultatory patient monitoring during magnetic resonance imaging. In the Journal of Clinical Monitoring. January 1992 Vol.8 No.1:37-43
Janes, B. and Cooper, J. Simulation in Nursing Education. In the Australian Journal of Advanced Nursing. July 1996 Vol 13 No 4: 35-39.
Kerr, R.J. Professional actors really do enhance nursing skills development: A comparative study of three clinical teaching strategies. In The Australian Electronic Journal of Nursing Education. September 1997 Vol 3 No 1. pp 1 - 9. http://www.csu.edu.au./faculty/health/aejne/vol3-1/no.1.htm
Lont, K.L. Physical Assessment by Nurses: a study of nurses' use of chest auscultation as an indicator of their assessment practices. In Contemporary Nurse. September 1992 Vol.1 No.2:93-97.
Mangione, S. Nieman, L.Z. Gracely, E. and Kaye, D. The teaching and practice of cardiac auscultation during internal medicine and cardiology training. A nationwide survey. In the Annals of Internal Medicine. July 1993 Vol.119 No 1: 47-54.
Tavel, M.E. Brown, D.D. and Shander, D. Enhanced auscultation with a new graphic display system. In Archives of Internal Medicine. April 1994 Vol. 158 No. 8:893-898.
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