Enhancing Health Assessment Skills in Nursing Education Through Structured Practice

Abstract

Background

Various teaching methodologies traditionally have been integrated into the curriculum design of a health assessment course for prelicensure nursing students. A consistent and repetitive practice method often is lacking to help students develop mastery of health assessment skills.

Method

Concepts of structured practice, a concept rooted in deliberate practice, were integrated into the curriculum of a health assessment course. The course design featured clear objectives, students' comprehension of tasks, repeated attempts to reach desired outcomes, immediate group feedback, and individual guidance.

Results

Students actively engaged in their learning, which promoted the development of mastery in their skills. The structured practice approach offered practice opportunities through formative assessments, real-time laboratory sessions, and self-reflective videos, all aimed at delivering constructive feedback and guiding improvement.

Conclusion

Nursing students can develop their skills through structured practice in a controlled, supportive environment that prioritizes continuous improvement through feedback. [J Nurs Educ. 2025;64(X):XXX–XXX.]

Health assessment is a crucial element of nursing education, fundamental to accurately diagnosing and managing patient issues in clinical settings. Effective patient-centered care depends on nurses' ability to identify and analyze key cues, enabling them to develop appropriate solutions (^{National Council of State Boards of Nursing, 2023}). The process of identifying and analyzing these cues serves as the cornerstone of a health assessment course. In the Essentials document outlining core competencies for baccalaureate education, the American Association of Colleges of Nursing (²⁰²¹) emphasizes the integration of assessment skills into practice as a critical subcompetency necessary for providing individualized patient care. Various methodologies have been used to teach a health assessment course. One example is a self-directed learning program. Instead of traditional teaching methods, including lectures, demonstrations and practice, and skill tests, a self-directed learning program was found to promote favorable learning outcomes (^{Chen & Liao, 2024}). However, self-directed programs may be challenging for some students who have difficulty staying focused and navigating a course on their own. Another possible strategy to learn health assessment content is by unfolding case-based learning. This was found to enhance critical thinking and self-confidence among undergraduate nursing students (^{Ma & Zhou, 2022}). Although case-based studies can be effective, they are missing a structured practice approach.

Teaching strategies need to align with relevant clinical practice to be effective (Rhodes et al., 2020). What students are learning in a health assessment course needs to reflect a clinical bedside assessment. Some health assessment courses use traditional nursing students' demonstration of a comprehensive physical examination, but they may not necessarily reflect a clinical bedside assessment. In addition to content alignment, students need structured, repetitive practice to become more proficient with health assessment skills (^{Bosse et al., 2015}; ^{Marshall et al., 2012}). Repetition reinforces learning that may also contribute to the student's confidence in performing in clinical practice.

Structured Practice: An Adaptation of Deliberate Practice Principles

Deliberate practice, as defined by Ericsson and Smith (¹⁹⁹¹), involves activities specifically designed for students to engage with the material taught. It is characterized by four key criteria: (1) individual training by a qualified teacher; (2) clear objectives; (3) the student's understanding of the tasks; and (4) iterative attempts to achieve desired outcomes. A crucial component of deliberate practice is the feedback cycle, which enables both the teacher and the student to assess progress and refine techniques. It should be noted that the definition of deliberate practice has evolved from the original definition (^{Ericsson & Harwell, 2019}). The duration of deliberate practice creates more variance in skill performance. Therefore, the term structured practice seems to more appropriately describe how skills are more consistently achieved.

Incorporating the full spectrum of structured practice in a nursing education context presents significant challenges, particularly due to the large number of students in each course, the extensive content that must be covered, and time constraints within the curriculum. Given the limitations, a structured practice approach in the design of the health assessment course was adopted. Structured practice, as defined for this course, includes the use of a qualified instructor, clear objectives, students' understanding of the tasks being asked of them, iterative attempts to achieve desired outcomes, and a feedback cycle—although it does not encompass the one-on-one training and real-time feedback characteristic of deliberate practice. Table A; available in the online version of this article (created with the support of ChatGPT) summarizes the elements of structured practice as applicable to the design and implementation of the laboratory course.

Table A

Elements of Structured Practice as Applied in the Course

Element of Structured Practice	Course Activities
Qualified Instructor	- Instructors oversee lab sessions, provide immediate group feedback, and offer individualized guidance when possible. - Instructors grade postlab video challenges using rubrics. - Instructors provide ongoing feedback throughout the course, especially during lab sessions.
Clear Objectives	- Rubrics provided for lab practice, postlab video challenges, and the summative assessment clearly define the criteria for success. - The rubric for the summative assessment is given 5 weeks in advance to guide students' preparation and practice.
Students' Understanding of the Tasks	- Prelab preparation involves textbook review and watching instructional videos, ensuring students understand the tasks they will perform in the lab. - Lab sessions provide opportunities for hands-on practice with rubrics, reinforcing task understanding.
Iterative Attempts to Achieve Desired Outcomes	- Students practice skills during lab sessions with rubrics, allowing for repeated attempts and refinement of techniques. - Postlab video challenges offer another opportunity to demonstrate skills and receive feedback for further improvement.
Feedback Cycle	- Immediate feedback is provided during lab sessions to guide students in refining their skills. - Peer feedback is incorporated into the postlab video challenges, creating a continuous feedback loop. - Instructors provide final evaluations and feedback on video challenges and the summative assessment, completing the feedback cycle.

Method

Course Design

To enhance nursing education, a health assessment lab was created for prelicensure baccalaureate nursing students at a 4-year urban university in the United States. The lab served 160 students during their first semester in the nursing program, offering hands-on learning as they started their curriculum. Six lab instructors facilitated the 10-week lab, conducting weekly 4.5-hour sessions with the students. The health assessment lab integrated the principles of structured practice, a concept derived from deliberate practice, to bridge the gap between theoretical knowledge and practical skills. The course was hosted within a learning management system (LMS), facilitating a cohesive learning experience that combined preparation before the lab, hands-on practice, and students' engagement with content after the lab sessions.

Preparation Before Lab Sessions

The course began with a strong emphasis on prelab preparation, a critical step to ensure students' understanding of the tasks ahead. Recognizing the importance of foundational knowledge, students were required to engage with specific chapters from their textbooks that covered relevant health assessment skills. This reading provided the theoretical base necessary for practical application, including the value of assessing for abnormalities and the risks of missing critical pathology. To reinforce their understanding, students watched instructional videos that demonstrated essential assessment techniques. These videos helped students visualize the procedures they would later perform in the lab, ensuring they arrived with a clear understanding of what was expected of them—a key element of structured practice. The use of videos also allowed for repetitive practice to reinforce performance.

Weekly Lab Sessions

The weekly lab sessions were the core of the course, where students transitioned from theory to hands-on practice. During these sessions, students practiced specific health assessment skills, guided by the lab instructor and detailed rubrics that outlined clear objectives and the essential components of each task. The use of rubrics ensured that students were focused on achieving precision and consistency, aligning with the structured practice principle of iterative attempts to achieve desired outcomes. Although one-on-one feedback in real time was not feasible, the structured practice model emphasized immediate group feedback and as much individualized guidance as possible. This approach enabled students to make adjustments and refine their skills during practice, ensuring they improved progressively with each iteration.

Students Engaging With Content After Lab Sessions

To further reinforce learning, postlab video challenges were incorporated, allowing students to demonstrate their competency independently. In these challenges, students recorded themselves performing specific physical assessment tasks, adhering to the same rubrics used during the lab. The video challenges were a short video (5 to 10 minutes) assignment, developed outside of lab time, and uploaded to the LMS. The content of each of six videos included skills related to (1) therapeutic communication; (2) respiratory (3) cardiac; (4) gastrointestinal; (5) head, ears, eyes, nose, and throat (HEENT); and (6) skin assessments. This exercise not only encouraged students' self-assessment but also strengthened their understanding of the tasks by requiring them to apply what they had learned. Alongside the video submissions, students provided written documentation of their assessment findings, which further solidified their clinical documentation skills. According to Holland et al. (²⁰²¹), the opportunity to learn documentation skills should be provided early in the educational program.

The structured practice approach continued with the inclusion of peer feedback, where students reviewed and offered constructive feedback on the videos of two peers. This peer review process fostered a collaborative learning environment and allowed students to learn from each other's experiences. Weaver and Jones (²⁰²¹) found that combining deliberate practice with standardized patient simulation and peer evaluation enhanced the physical assessment skills of first-semester nursing students. The feedback cycle was completed when the instructor graded these assignments using the same rubric, ensuring consistent evaluation and reinforcing the learning objectives.

Putting It All Together

At the end of the semester, students engaged in a simulation scenario adhering to INACSL^TM Standards of Best Practice (^{Watts et al., 2021}). As a culminating experience, students had the opportunity to participate in a simulation activity that allowed them to practice a bedside assessment using health assessment techniques in a safe environment. During this scenario, students gathered both subjective and objective patient data, with a focus on measuring and interpreting vital signs, ensuring patient safety, assessing the respiratory system, and implementing interventions to improve oxygen saturation, such as elevating the head of the bed and providing supplemental oxygen. Prior to entering the patient's room, students underwent a prebriefing session. This session established psychological safety, set expectations, outlined the scenario objectives, defined student roles, and provided room orientation.

Upon completion of the scenario, expert debriefers conducted a debriefing session where students reflected on their feelings during the scenario, evaluated their performance, and discussed the attainment of objectives. The expert debriefers were simulation educators with substantial experience in simulation and debriefing techniques. The debriefing with good judgment framework by Rudolph et al. (²⁰⁰⁶) was used to describe this framework as creating a constructive learning environment that is reflective. Facilitators and learners collaboratively explored performance gaps without assigning blame. This approach integrated curiosity, respect, and a nonjudgmental stance, allowing facilitators to share their observations and judgments transparently while encouraging learners to uncover the reasoning behind their actions, promoting growth and insight (Table A).

Results

The ultimate result of this course design was the evaluation of students' attainment of physical assessment competency. There were two summative assessments in the course. The first assessment was the validation of vital signs performance during the week 4 lab. Students performed complete vital sign measurements (heart rate, respirations, temperature, and blood pressure), including pulse oximetry and documentation. Students were timed and if they were unsuccessful at the first try, they were permitted to remediate the skills one time at a later date. The rubric used in this assessment included critical elements the students needed to perform, such as patient identification, allergies, and safety.

The course culminated in a summative assessment where students demonstrated their competency in performing a targeted assessment on a simulated patient. This assessment was designed to simulate a real-world clinical environment, challenging students to integrate and apply their skills under timed conditions. Structured practice was evident in the advance preparation for this assessment; students received the rubric 5 weeks in advance, allowing them ample time to prepare and align their practice with the clear objectives set out in the rubric. The rubric included both objective and subjective data collection tasks, with certain critical items designated as mandatory pass elements. These criteria ensured that students were well-prepared to meet essential clinical standards.

During the assessment, students were given 20 minutes to complete the physical assessment, reflecting the time-sensitive nature of clinical practice and testing their ability to perform within a realistic time frame. Allowing students 20 minutes to complete this assessment has consistently proven sufficient, with only rare instances of students exceeding the time limit. No significant issues regarding the 20-minute time frame have arisen in the past. Throughout the course, students received ongoing feedback during lab sessions, which helped them to monitor their progress and address any areas of weakness before the final assessment, thus completing the structured practice cycle.

The design and implementation of this health assessment lab underscores the importance of structured practice in nursing education. By adapting elements of deliberate practice to fit the constraints of a large and demanding curriculum, the course provides students with a comprehensive, practice-oriented learning experience. Through prelab preparation, focused practice, postlab reinforcement, and summative assessment, students develop the skills and confidence necessary to excel in their clinical practice, making this approach a valuable model for nursing education.

Implications

Despite the promising potential of structured practice in a health assessment course for undergraduate nursing students, several limitations were identified. First, collection of data to evaluate the effectiveness of this approach was not done. Without empirical evidence, it becomes challenging to measure the true effect on student learning outcomes and overall competency. However, faculty members involved in teaching the lab and simulation activity reported that this structured practice approach was not only successful in improving student performance, but also a very positive experience from the students' perspective. Student evaluations consistently rate this lab experience as highly constructive.

Additionally, the requirement for students to create videos outside of lab hours poses a significant time commitment. This extra workload can be burdensome, especially for students who may already be balancing multiple responsibilities. Similarly, faculty members face the challenge of dedicating time to watch and assess these videos. This added responsibility can strain their schedules, potentially affecting their ability to provide timely and constructive feedback.

Furthermore, the program is experiencing growth, with a projected increase in student admissions within the next 2 to 3 years. This anticipated expansion could exacerbate the aforementioned challenges, as more students will require structured practice opportunities and corresponding evaluations.

Conclusion

Incorporating structured practice into a health assessment course can significantly enhance nursing students' skills and confidence. By providing structured, repetitive practice opportunities and feedback, students are better prepared to perform accurate and comprehensive health assessments in clinical settings. This approach not only improves individual competencies but also contributes to quality patient care.

References

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ChatGPT (GPT-4o) was used for the creation of Table A.