Content area
Background
The shift to competency-based education (CBE) creates a need to examine methods of teaching and evaluating physical health assessment competencies in entry-level and advanced-level nursing courses.
Method
A national survey, guided by backward design, gathered data on behaviors indicative of physical assessment competency, assessment strategies, and teaching and learning approaches that foster competency development.
Results
Respondents from 54 entry-level and 27 advanced-level programs completed the survey. Data analysis used descriptive statistics to calculate frequencies and percentages. Key findings include a lack of standardized assessment instruments, a limited focus on younger populations, barriers to inclusive and specialized assessments, and time constraints in competency evaluation.
Conclusion
Although some programs have integrated elements of CBE into their physical assessment courses, several gaps must be addressed to ensure the successful implementation of CBE and the preparation of practice-ready graduates.
Full text
The 2021 release of The Essentials by the American Association of Colleges of Nursing (AACN) called for nursing education to transition to competency-based education (CBE). The Essentials outline 10 domains of nursing competence, each encompassing broad competencies to prepare practice-ready nurses. Entry-level subcompetencies identify the abilities required for individuals beginning their professional nursing practice, while advanced-level competencies detail the expertise necessary for advanced nursing practice (AACN, 2021). Building on The Essentials, the National Organization of Nurse Practitioner Faculties (NONPF) updated its core nurse practitioner (NP) competencies in 2022, aligning them with advanced-level subcompetencies and incorporating NP-specific subcompetencies. As a result, nursing faculty must reassess their teaching strategies and evaluation methods to effectively develop student competencies across all domains. Ensuring proficiency in physical assessment presents particular challenges.
Physical Assessment Competency
Physical assessment is a fundamental skill for evidence-based nursing practice (Morrell et al., 2021) and a core component of entry-level and advanced-level nursing curricula (AACN, 2021). However, few published studies address physical assessment competencies in nursing education. Health assessment, including history taking and physical examination, is essential for demonstrating nursing competency (Alizadeh et al., 2023). Although much of the literature focuses on psychomotor skill development, it also points to a lack of standardization in assessing affective skills. A significant challenge remains in determining physical assessment competency due to the wide range of skills taught in nursing programs (Morrell et al., 2021).
In advanced-level nursing curricula, physical assessment is a core competency that students must master before formulating differential diagnoses and making clinical decisions. However, research on assessing competencies related to health history and physical assessment remains limited (Higgins et al., 2019). Costa and Monger (2024) examined competency evaluation in simulation, often an initial step in competency development before clinical rotations. Their findings indicate a lack of standardization in competency evaluation across advanced-level programs in the United States. Additionally, existing instruments fail to comprehensively measure students' skills, attitudes, and behaviors in health history-taking and physical examinations, making accurate competency evaluation challenging (Costa & Monger, 2024; Higgins et al., 2019). As advanced-level programs increasingly incorporate more online components and nurse practitioner education transitions to the Doctor of Nursing Practice (DNP) as the entry-level degree, the need for standardized tools to evaluate physical assessment competence is more critical than ever. Addressing these challenges requires a paradigm shift with faculty first identifying student learning outcomes and then designing instructional strategies to achieve these outcomes, an approach aligned with backward design.
Backward Design Model
CBE implementation follows a backward design approach (Wiggins & McTighe, 2005), beginning with the identification of desired outcomes and specifying what learners should achieve by the end of the learning process. Assessment strategies are then developed to evaluate the achievement of these outcomes, followed by the design of learning activities to support their attainment. In nursing education, backward design involves: (1) identifying specific student behaviors that demonstrate the attainment of nursing competencies (desired outcomes); (2) designing assessments to evaluate competency achievement (acceptable evidence); and (3) integrating learning activities into nursing curricula that foster the acquisition and demonstration of these competencies (learning activities) (NONPF, 2024).
Purpose
The purpose of this study was to examine current approaches to teaching and evaluating physical assessment competencies in entry-level and advanced-level nursing programs across the U.S. Guided by backward design, the study explored behaviors indicative of competency (desired outcomes), assessment strategies (acceptable evidence), and teaching and learning approaches that foster competency development (learning activities). The research questions were:
What behaviors indicate to nursing faculty that students have attained physical assessment competencies at entry levels and advanced levels? What methods do nursing faculty use to evaluate the achievement of physical assessment competencies? What learning activities do faculty use to support student acquisition and demonstration of physical assessment competencies, and where are these activities integrated within nursing curricula?
Method
Design and Survey Instrument
This descriptive study used an electronic survey to collect data. A team of 10 experienced nursing faculty from the Competency-Based Nursing Education (CBNE) National Network developed the survey instrument to examine how faculty teach and assess physical assessment competencies for both entry-level and advanced-level nursing students.
Grounded in backward design, the survey collected data on student behaviors that demonstrate the acquisition of physical assessment competencies, assessment strategies, and learning activities currently used. Multiple-choice survey questions were designed based on AACN (2021) and NONPF (2022) competencies and a comprehensive literature review. Additional questions explored planned course modifications to support the implementation of CBE and resources used by nursing programs to address life span and diverse populations. Respondents were invited to submit comments and share their physical assessment course syllabi. The researchers reviewed and revised the initial pool of survey questions to ensure clarity, relevance, and alignment with study objectives. Redundant items were removed to streamline the survey and maintain respondent engagement. Through an iterative review process, the wording of questions was refined to improve precision and eliminate ambiguities.
Sample
The target population was faculty teaching physical assessment in entry-level and advanced-level nursing programs across the U.S. Convenience sampling was used to select participants from this population. Inclusion criteria required participants to be faculty who taught physical assessment and completed all survey questions.
Distribution of the Survey
The study received Institutional Review Board approval from Madonna University. Surveys were administered electronically through a secure online platform. An electronic invitation to participate was distributed using listservs for the AACN Organizational Leadership Network, Sigma Theta Tau, the CBNE National Network, and the National League of Nursing. Recipients of the invitation were encouraged to forward the survey hyperlink to faculty teaching entry-level and advanced-level physical assessment courses at their institutions.
Data Analysis
Survey data were exported to Excel® for analysis. Descriptive statistics were calculated to determine frequencies and percentages, and to summarize participants' demographics and survey responses. Submitted comments were summarized, and syllabi were reviewed for program level (i.e., entry level and advanced level), textbooks used, course content organization, additional resources (e.g., commercial nursing assessment simulation tools, and digital clinical encounters), course delivery format (e.g., face-to-face and online), and evaluation methods.
Results
Demographics
Faculty from 54 entry-level programs completed the full survey and represented all nine U.S. geographic regions. At the advanced-level, advanced-practice RN (APRN) programs were analyzed separately from the non-APRN programs due to differing physical assessment course requirements. Faculty from 27 APRN programs completed the survey, representing seven of the nine regions. Although faculty from five non-APRN programs completed the full survey, their responses were excluded from analysis due to the low sample size. Thirty-four of the 120 respondents did not meet inclusion criteria.
Competency Behaviors
All 16 surveyed competency behaviors were used by programs to demonstrate physical assessment competency, with usage rates ranging from 50% to 98.1% (Figure 1). The majority of entry-level (88.9% to 98.1%) and advanced-level (88.9% to 96.3%) programs require students to: (a) perform a physical examination in an organized and logical sequence; (b) conduct a comprehensive head-to-toe examination; (c) demonstrate empathy and respect through verbal and nonverbal behaviors; (d) ensure patient privacy, comfort, and safety; and (e) communicate the physical examination process to the patient.
Figure 1. - Student behaviors that demonstrate physical assessment competency. APRN = advanced-practice RN; PE = physical examination.
Compared with entry-level programs, considerably more advanced-level programs require students to: (a) identify physical assessment focus based on patient history; (b) identify subtle or unusual findings; (c) prioritize findings to formulate a problem list; (d) differentiate between normal and abnormal findings; (e) document findings accurately; and (f) prioritize pertinent findings in written and oral communications. Neither entry-level nor advanced-level programs emphasized obtaining patient permission before assessing sensitive areas or adapting physical examinations to patient limitations.
Assessment Strategies
The assessment strategies employed by entry-level and advanced-level physical assessment nursing courses are outlined in Table 1.
| Competency Strategy | Entry Level | Advanced Level |
|---|---|---|
| Observer types | n (%) | |
|
| ||
| Peers | 15 (27.8) | 6 (22.2) |
| Faculty | 53 (98.1) | 27 (100) |
| Graduate aids/staff | 5 (9.3) | 2 (7.4) |
| Clinical preceptors | 12 (22.2) | 8 (29.6) |
| Standardized patients | 6 (11.1) | 6 (22.2) |
| Observation modalities | ||
| In-person demonstration | 40 (74.1) | 15 (55.6) |
| Asynchronous, recorded demonstration | 20 (37.0) | 19 (70.4) |
| Synchronous, online demonstration | 2 (3.7) | 8 (29.6) |
| Assessment instruments | ||
| Rubric | 38 (70.4) | 23 (85.2) |
| Checklist | 36 (66.7) | 16 (59.3) |
| Virtual health assessment programs | 2 (3.7) | 10 (37.0) |
| Standardized evaluation | 14 (25.9) | 12 (44.4) |
| Assessment methods | ||
| Total head-to-toe assessment | 47 (87.0) | 26 (96.3) |
| Demonstrate randomly assigned body system | 13 (24.1) | 6 (22.2) |
| Focused assessment | 17 (31.5) | 14 (51.9) |
| Patient types | ||
| Low-fidelity manikin | 20 (37.0) | 2 (7.4) |
| High-fidelity manikin | 12 (22.2) | 3 (11.1) |
| Virtual patient | 7 (13.0) | 7 (26.0) |
| Fellow student | 45(83.3) | 12 (44.4) |
| Standardized patient | 10 (18.5) | 8 (29.6) |
| Family member/friend | 12 (22.2) | 17 (63.0) |
| Faculty member | 4 (7.4) | 3 (11.1) |
| Failure strategies | ||
| Repeat assessment | 46 (85.2) | 11 (40.7) |
| Remediation activity | 41 (75.9) | 22 (81.5) |
| Automatic course failure | 5 (9.3) | 3 (11.1) |
| Methods of ongoing assessment after course completion | ||
| Clinical preceptor | 48 (88.9) | 24 (88.9) |
| Simulation/OSCE | 36 (66.7) | 15 (55.6) |
| Not assessed | 4 (7.4) | 3 (11.1) |
Observer types and observation modalities. Faculty observe and provide feedback on students' physical assessment competency in nearly all entry-level (98.1%) and advanced-level (100%) programs. Entry-level (74.1%) faculty most commonly observe these demonstrations in-person, whereas advanced-level (70.4%) faculty most frequently review asynchronous, recorded demonstrations.
Assessment methods and patient types. Many programs use rubrics (70.4% entry-level and 85.2% advanced-level programs) and checklists (66.7% entry-level and 59.3% advanced-level programs) to evaluate students' physical health assessment competencies. Moreover, most programs require students to demonstrate complete head-to-toe physical assessments (87% entry-level and 96.3% advanced-level). Some programs also require demonstrations of focused physical examinations based on clinical scenarios to assess students' ability to apply focused assessments in specific contexts. In entry-level (83.3%) programs, students often demonstrate physical assessment skills on fellow students, while advanced-level (63%) demonstrations frequently are performed on family members or friends.
Failure strategies. Most entry-level programs (85.2%) permit students to repeat failed assessments, whereas fewer advanced-level programs (40.7%) offer this opportunity. Additionally, the majority of entry-level (75.9%) and advanced-level (81.5%) programs assign remediation activities to students who do not meet competency standards.
Methods of ongoing assessment. After students complete a physical assessment course, most entry-level and advanced-level programs (88.9%) continue to evaluate physical assessment competency during clinical courses with preceptor input. A significant proportion of entry-level (66.7%) and advanced-level (55.6%) programs assess physical examination competency through simulations and objective structured clinical examinations (OSCEs).
Survey comments regarding competency assessment strategies. Respondents' comments highlight challenges with conducting online assessments and the significant time required to observe and grade student demonstrations. Additional comments address: (a) using tests and quizzes; (b) implementing both formative and summative evaluations; (c) assessing students' abilities to measure vital signs; (d) evaluating patient assessments during clinical rotations and at structured intervals throughout the program; (e) incorporating artificial intelligence-generated case studies; and (f) enforcing course failure policies after two unsuccessful competency assessment attempts.
Teaching and Learning Approaches
The teaching and learning approaches employed by entry-level and advanced-level physical assessment nursing courses are described in Table 2.
| Learning Activity and Teaching Strategy | Entry Level | Advanced Level |
|---|---|---|
|
| ||
| Course components | n (%) | |
|
| ||
| Didactic | 54 (100.0) | 25 (92.6) |
| Laboratory | 48 (88.9) | 17 (63.0) |
| Clinical practicum | 15 (27.8) | 9 (33.3) |
| Simulated physical examinations | 28 (51.9) | 23 (85.2) |
| Case studies | 35 (64.8) | 22 (81.5) |
| Documentation teaching methods | ||
| Narrative notes | 16 (29.6) | 18 (66.7) |
| Non-narrative notes | 11 (20.4) | 1 (3.7) |
| Both narrative and non-narrative notes | 26 (48.1) | 13 (48.1) |
| Documentation not taught | 6 (11.1) | 1 (3.7) |
| Genitalia examination teaching methods | ||
| Standardized patients | 1 (1.9) | 7 (25.9) |
| Manikins | 23 (42.6) | 8 (29.6) |
| Genitalia training models | 21 (38.9) | 11 (40.7) |
| Not taught | 12 (22.2) | 5 (18.5) |
| Approaches to addressing physical assessment for LGBTQIA+ | ||
| Manikins/models | 1 (1.9) | 2 (7.4) |
| Videos | 6 (11.1) | 11 (40.7) |
| Standardized patients | 3 (5.6) | 3 (11.1) |
| Case studies | 18 (33.3) | 12 (44.4) |
| Role-playing | 1 (1.9) | 3 (11.1) |
| Didactic | 30 (55.6) | 16 (59.3) |
| None | 19 (35.2) | 6 (22.2) |
| Methods of representing diverse populations | ||
| Manikins/models | 31 (57.4) | 7 (25.9) |
| Videos | 24 (44.4) | 14 (51.9) |
| Standardized patients | 7 (13.0) | 7 (25.9) |
| Case studies | 34 (63.0) | 20 (74.1) |
| Role playing | 5 (9.3) | 3 (11.1) |
| Didactic | 39 (72.2) | 17 (63.0) |
| None | 1 (1.9) | 1 (3.7) |
| Skin overlays | 11 (20.4) | 2 (7.4) |
| Learning Activity and Teaching Strategy | Entry Level | Advanced Level |
|---|---|---|
| Barriers to representing diversity in physical assessment laboratory | n (%) | |
|
| ||
| Financial | 14 (25.9) | 7 (25.9) |
| State restrictions | 0 (0) | 0 (0) |
| Religious considerations | 3 (5.6) | 2 (7.4) |
| Lack of cultural resources | 12 (22.2) | 6 (22.2) |
| Faculty motivation/attitudes | 5 (9.3) | 1 (3.7) |
| None | 25 (46.3) | 14 (51.9) |
| Course exemptions/waivers | ||
| None | 46 (85.2) | 21 (77.8) |
| Transfer credit | 5 (9.3) | 5 (18.5) |
| Test-out: written | 0 (0) | 0 (0) |
| Test-out: demo | 2 (3.7) | 0 (0) |
| Test-out: written and demo | 0 (0) | 1 (3.7) |
Course components and documentation teaching methods. Most courses include didactic (100% entry-level and 92.6% advanced-level programs) and laboratory (88.9% entry-level and 63% advanced-level programs) components. Many programs employ simulated physical examinations (51.9% entry-level and 85.2% advanced-level programs) and case studies (64.8% entry-level and 81.5% advanced-level programs). Nearly half (48.1%) of entry-level and advanced-level programs teach students to document physical examination findings using both narrative and non-narrative notes. Respondent comments indicate many programs require students to practice documenting findings using electronic health records.
Genitalia examination teaching methods. Genitalia examination techniques are taught using live, standardized patients (1.9% entry-level and 25.9% advanced-level programs), manikins (42.6% entry-level and 29.6% advanced-level programs), and training models (38.9% entry-level and 40.7% advanced-level programs). Respondent comments indicate many programs include video demonstrations of head-to-toe and system-focused examinations, including genitalia assessments.
Addressing physical assessment specific to lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual and more (LGBTQIA+) and diverse populations. Many programs include LGBTQIA+ physical assessment content (55.6% entry-level and 59.3% advanced-level programs) and represent diverse populations (72.2% entry-level and 63% advanced-level programs) in their didactic course components.
Barriers to representing diversity in the physical assessment laboratory. Some programs face financial barriers (25.9%) to representing diversity in the physical assessment laboratory or lack access to cultural resources (22.2%). Respondents also identified limited time and inadequate access to diverse patient populations as barriers to representing diversity.
Course exemptions and waivers. Most of the programs (85.2% entry-level and 77.8% advanced-level programs) do not allow exemptions or waivers for the required physical assessment course. One entry-level program reviewed syllabi from prior coursework but rarely granted exemptions. Another program waived the physical assessment course requirement for baccalaureate nursing students already certified as RNs. Similarly, several advanced-level programs waive this requirement for post-Master of Science in Nursing students who completed an equivalent course during their master's program.
Age Groups
Patient age groups (i.e., newborn, infant, child, adolescent, adult, and older adult) included in entry-level and advanced-level physical assessment nursing courses are described in Table 3. Didactic instruction, skills practice, and competency demonstrations most often involved adults and older adult patient populations.
| Level | Newborn (Birth to 4 Weeks) | Infant (1 to 12 Months) | Child (1 to 12 Years) | Adolescent (13 to 17 Years) | Adult (18 to 64 Years) | Older Adult (65+ Years) |
|---|---|---|---|---|---|---|
| Age groups included in the didactic component of physical assessment course, n (%) | ||||||
| Entry level | 16 (29.6) | 21 (38.9) | 27 (50.0) | 29 (53.7) | 53 (98.1) | 49 (90.7) |
| Advanced level | 21 (77.8) | 22 (81.5) | 22 (81.5) | 23 (85.2) | 26 (96.3) | 26 (92.6) |
|
| ||||||
| Age groups on which students practice physical assessment skills, n (%) | ||||||
|
| ||||||
| Entry level | 4 (7.4) | 3 (5.6) | 7 (13.0) | 7 (13.0) | 54 (100) | 31 (57.4) |
| Advanced level | 8 (29.6) | 11 (40.7) | 13 (48.1) | 19 (70.4) | 27 (100) | 21 (77.8) |
|
| ||||||
| Age groups on which students demonstrate physical health assessment competency, n (%) | ||||||
|
| ||||||
| Entry level | 2 (3.7) | 3 (5.6) | 5 (9.3) | 5 (9.3) | 54 (100) | 23 (42.6) |
| Advanced level | 2 (7.4) | 5 (18.5) | 6 (22.2) | 10 (37.0) | 27 (100) | 16 (59.3) |
Planned CBE Course Modifications
Less than half of the nursing programs (44.4% entry-level and 40.7% advanced-level programs) reported plans to change their physical assessment courses to support CBE implementation. Comments indicated some programs were actively learning more about CBE and were in the process of making changes, including rewriting course objectives, adding more assessments, and incorporating virtual simulation. However, several respondents were unsure whether any CBE changes were planned (37% entry-level and 44.4% advanced-level programs), and other respondents indicated no changes were planned (20.4% entry-level and 11.1% advanced-level programs). One respondent expressed a desire for standardized CBE.
Course Syllabi
Thirteen respondents provided copies of their physical assessment course syllabi. Review of the submitted syllabi indicated most of the courses organized content using a body systems approach. Common assignments included performing comprehensive physical examinations, documenting patient histories and physical examinations, and demonstrating physical assessment knowledge through tests and quizzes. Differences were noted between syllabi based on course level, with entry-level courses typically offering didactic content and skills practice in a face-to-face format, while some advanced-level courses delivering content and conduct assessments online. Although most syllabi required physical assessment textbooks, the use of additional electronic resources varied (e.g., digital clinical encounters, commercial nursing education assessment, and simulation tools).
Discussion
Guided by the principles of backward design, this study explored how entry-level and advanced-level nursing programs approach physical assessment competencies. This discussion is structured around the three phases of backward design: (1) behaviors that demonstrate competency (desired outcomes); (2) assessment strategies (acceptable evidence); and (3) teaching and learning approaches that foster competency development (learning activities).
Competency Behaviors
Study findings indicate widespread integration of the 16 surveyed competency behaviors across nursing programs, reflecting a shared understanding of performance expectations for students in health assessment courses. Both entry-level and advanced-level programs emphasize foundational skills, such as conducting head-to-toe assessments, preserving patient dignity, and communicating effectively. Published literature highlights the importance of performing proficient, comprehensive physical assessments using an organized approach (Rhodes et al., 2021).
Compared with entry-level programs, advanced-level programs place greater emphasis on complex clinical reasoning behaviors, such as recognizing subtle or atypical findings, distinguishing normal from abnormal findings, and prioritizing clinical data (AACN, 2021; NONPF, 2024). These distinctions suggest that advanced-level programs are effectively scaffolding competencies to strengthen students' critical thinking and clinical decision making, preparing them for more complex patient care responsibilities. Additionally, neither entry-level nor advanced-level programs emphasized obtaining patient permission before assessing sensitive areas or adapting physical examinations to patient limitations, a gap that could negatively affect the delivery of patient-centered care (AACN, 2021).
Assessment Strategies
Most programs require students to demonstrate head-to-toe physical assessments, developing the comprehensive skill set essential for clinical practice (Fontenot et al., 2022; Rhodes et al., 2021). Additionally, some programs require students to perform focused physical examinations based on clinical scenarios, thus demonstrating their ability to apply targeted assessments in specific contexts (AACN, 2021; Rhodes et al., 2021).
Competency assessment primarily is conducted through direct faculty observation, either in-person or via asynchronous video review. Entry-level programs favor in-person assessments, while asynchronous video assessments are more commonly used in advanced-level programs. These findings align with previous research indicating video technology is an effective tool for teaching and assessing physical examination skills in advanced-level students, who report increased confidence and satisfaction with this method (Purpora & Prion, 2018; Yang et al., 2022).
In line with accrediting body requirements for faculty oversight, nearly all programs require faculty to observe and provide feedback on students' physical assessment competency (Accreditation Commission for Education in Nursing, 2023; Commission on Collegiate Nursing Education, 2024). Feedback from other observers, such as non-faculty preceptors, is less common, likely due to limitations in their availability or training.
Rubrics and checklists are the primary tools used to evaluate competency demonstrations. However, few of these instruments have established reliability or validity, highlighting ongoing concerns in the literature about the lack of standardized tools for evaluating physical assessment competencies (Costa & Monger, 2024; Wu et al., 2015).
Patient types differ between entry-level and advanced-level courses, reflecting a progression from more controlled and predictable scenarios (e.g., fellow students and manikins) to more complex and realistic interactions (e.g., family members, friends, and standardized patients). The use of standardized patients has been shown to be an effective method for increasing student satisfaction and motivation in learning physical examination skills (Jaberi & Momennasab, 2019). Progression to increasing complexity aligns with the needs of advanced-level training and the differing availability of patient types for students who are primarily online versus those who are primarily on-campus.
Most entry-level and advanced-level programs provide remediation activities for students who do not pass physical examination competency assessments. Remediation opportunities align with CBE principles (AACN, 2021), ensuring students master essential competencies before progressing in their programs.
After students complete a physical assessment course, most programs assess competency during clinical courses through clinical faculty or preceptor feedback, highlighting the importance of ongoing evaluation to ensure effective skill application in clinical settings (Schroers et al., 2023). Many programs also use simulations to assess competency, reflecting an increasing focus on consistent, standardized methods for evaluating student performance (Weaver & Jones, 2021).
Teaching and Learning Approaches
The widespread use of didactic instruction across programs highlights its effectiveness in efficiently delivering foundational content. Laboratories serve as the primary setting for practicing and demonstrating physical assessment skills. Clinical practicums are less frequently included course components due to logistical challenges, such as limited access to preceptors and clinical sites.
Didactic instruction, skills practice, and competency demonstrations are primarily focused on adult and older adult patient populations. Few programs provide adequate instruction or practice in assessing younger populations during the physical assessment course, which may affect students' readiness to deliver pediatric and adolescent care.
Most programs instruct students on documenting physical examination findings, with some requiring the use of electronic health records, aligning with the expectation that nurses effectively use electronic communication tools (AACN, 2021). Nearly half of programs require both narrative (e.g., SOAP [Subjective, Objective, Assessment, and Plan] notes and SBAR [Situation, Background, Assessment, and Recommendation]) and non-narrative (e.g., flowsheet and checklist) formats. The emphasis on documentation tools underscores the importance of student proficiency in widely used methods essential for effective communication and clinical practice.
Some advanced-level programs incorporate live standardized patients for instruction in genital examinations. However, these techniques are primarily taught using manikins, models, or videos, particularly at the entry level. Use of these teaching methods likely reflects resource constraints and differences in competence expectations between entry-level and advanced practice roles.
Approaches to addressing physical assessment of LGBTQIA+ and diverse populations vary. While programs incorporate relevant didactic instruction, case studies, and video content, barriers such as inadequate financial resources, restricted access to these populations, and limited faculty expertise exist. These findings align with identified educational gaps (Bloompott et al., 2023) and could affect nurses' ability to provide inclusive care and perform accurate physical assessments. Furthermore, although faculty often assume that students will transfer classroom-learned physical assessment skills to clinical settings (Schroers et al., 2023), limited exposure to diverse populations in assessment practice may result in inadequate preparation for real-world application.
Most programs do not grant credit for physical assessment competencies acquired in other nursing programs or through practice experience. This lack of recognition of prior competency achievement hinders the development of individualized learning pathways in CBE.
Planned Course Modifications
Although several programs reported planned course modifications to support CBE implementation, many appeared to be in the precontemplation and contemplation stages of the trans-theoretical model of change (Prochaska & DiClemente, 1983), indicating either uncertainty about planned changes or no plans for change at this time. Targeted support and guidance are needed to help these programs advance to the action stage required for effective CBE implementation.
Significance of Findings
Study findings indicate many programs now require students to demonstrate physical assessment competency behaviors, offer remediation opportunities for failed evaluations, and conduct ongoing assessments during clinical courses to ensure effective skill application. These established practices can facilitate the transition to CBE (AACN, 2021) and reassure nursing faculty that this shift might be less challenging than initially anticipated.
Gaps and implications for nursing education. The study identified several gaps in teaching and assessing physical assessment competencies in entry-level and advanced-level nursing programs:
Lack of standardized assessment instruments. Reliable and valid tools for evaluating student physical assessment competency are lacking, highlighting the need for instrument development. Standardizing evaluation methods could facilitate greater acceptance of physical assessment competencies attained through other nursing programs or prior experience. Limited focus on younger populations. Limited competency development in assessing younger populations highlights the need for greater emphasis on pediatric and adolescent care to ensure nurses are prepared to deliver care across the life span. Nursing programs should review their curricula to ensure health assessment skills are taught and practiced for all age groups. Barriers to inclusive assessments. Logistical and resource constraints limit instruction on genital examinations, LGBTQIA+ physical assessments, and the representation of diverse populations. To better prepare nurses to provide comprehensive and inclusive care, nursing programs should explore innovative strategies to address these challenges. Time constraints in competency evaluation. The considerable time required to observe and assess student demonstrations poses a significant challenge. Nursing programs should leverage technology and other innovative solutions to make frequent competency assessments feasible and sustainable.
Limitations
Limitations of this study include the use of convenience sampling, a lack of APRN programs in the New England and East South Central regions of the U.S., and limited responses from non-APRN advanced-level programs. Future research on physical assessment competencies would benefit from a larger, more diverse sample. Additionally, a detailed examination of planned changes to support CBE implementation was beyond the scope of this study, and further investigation is warranted.
Conclusion
This study highlights both strengths and areas needing improvement in how nursing programs teach and evaluate physical assessment competencies. Although many programs have incorporated some elements of CBE, challenges remain in standardizing assessment instruments, fostering inclusivity, expanding competency development opportunities with younger and diverse patient populations, and managing time constraints required for evaluation.
With many programs still in the early stages of CBE adoption, targeted support and strategic innovations are essential for a successful transition. Addressing the identified gaps will help students develop the physical assessment skills needed for high-quality, patient-centered care and ensure nursing graduates are practice-ready.
Accreditation Commission for Education in Nursing. (2023). Standards and criteria. https://www.acenursing.org/accreditation/standards-and-criteria
Alizadeh, S., Zamanzadeh, V., Ostovar, S., Ghaffari, R., Moonaghi, H. K., Johnston, A., & Valizadeh, L. (2023). The development and validation ofastandardised eight-station OSCE for registration of undergraduate nursing students:ADelphi study. Nurse Education in Practice, 73, 103817. 10.1016/j.nepr.2023.103817 PMID: 37913683
American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing education. https://www.aacnnursing.org/Portals/0/PDFs/Publications/Essentials-2021.pdf
Bloompott, K., Dyck, M. J., Kim, M., Schafer Astroth, K., Stockmann, C., & Reitz, O. E. (2023). The scope of LGBTQIA+ health content in prelicensure nursing curricula. Journal of Nursing Education, 62(11), 623–630. 10.3928/01484834-20230906-04 PMID: 37934683
Commission on Collegiate Nursing Education. (2024). Standards for accreditation of baccalaureate and graduate nursing programs. https://www.aacnnursing.org/Portals/0/PDFs/CCNE/CCNE-Education-Standards-2024.pdf
Costa, L. A., & Monger, E. J. (2024). Criteria to evaluate graduate nurse proficiencies in obtainingahealth history and perform physical assessment in simulation-based education:Anarrative review. Nurse Education in Practice, 77, 103984. 10.1016/j.nepr.2024.103984 PMID: 38678870
Fontenot, N. M., Hamlin, S. K., Hooker, S. J., Vazquez, T., & Chen, H. M. (2022). Physical assessment competencies for nurses:Aquality improvement initiative. Nursing Forum, 57(4), 710–716. 10.1111/nuf.12725 PMID: 35434794
Higgins, K., Kirkland, T., Le-Jenkins, U., & Rutledge, C. (2019). Preparing students to be ready for practice: An innovative approach to teaching advanced physical assessment skills online. Journal of the American Association of Nurse Practitioners, 31(11), 640–647. 10.1097/JXX.0000000000000332 PMID: 31584509
Jaberi, A., & Momennasab, M. (2019). Effectiveness of standardized patient in abdominal physical examination education:Arandomized, controlled trial. Clinical Medicine & Research, 17(1–2),1– 10. 10.3121/cmr.2019.1446 PMID: 31160473
Morrell, S., Giannotti, N., Pittman, G., & Mulcaster, A. (2021). Physical assessment skills taught in nursing curricula:Ascoping review. JBI Evidence Synthesis, 19(11), 2929–2957. 10.11124/JBIES-20-00086 PMID: 34100826
National Organization of Nurse Practitioner Faculties. (2022). Nurse practitioner role core competencies. https://cdn.ymaws.com/www.nonpf.org/resource/resmgr/np_competencies_&_ntf_standards/nonpf_np_role_core_competenc.pdf
National Organization of Nurse Practitioner Faculties. (2024). Competency implementation guide for nurse practitioner faculty. https://www.nonpf.org/resource/resmgr/np_competencies_&_ntf_standards/Revised_Comps_Implementation.pdf
Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51(3), 390–395. 10.1037/0022-006X.51.3.390 PMID: 6863699
Purpora, C., & Prion, S. (2018). Using student-produced video to validate head-to-toe assessment performance. Journal of Nursing Education, 57(3), 154–158. 10.3928/01484834-20180221-05 PMID: 29505073
Rhodes, K., Carr, K., McElwain, S., & Douglas, K. (2021). Health assessment validation: Challenging tradition. Nursing Forum, 56(2), 429–432. 10.1111/nuf.12531 PMID: 33231870
Schroers, G., Shrikanth, S., & Pfieffer, J. (2023). Undergraduate nursing student experiences in American clinical learning environments:Adescriptive study. Nurse Education Today, 129, 105895. 10.1016/j.nedt.2023.105895 PMID: 37451031
Weaver, K., & Jones, A. R. (2021). An innovative educational trio for physical assessment in an undergraduate nursing course. Nursing Education Perspectives, 42(4), 257–258. 10.1097/01.NEP.0000000000000639 PMID: 32404770
Wiggins, G., & McTighe, J. (2005). Understanding by design(2nd ed.). Association for Supervision and Curriculum Development.
Wu, X. V., Enskär, K., Lee, C. C., & Wang, W. (2015).Asystematic review of clinical assessment for undergraduate nursing students. Nurse Education Today, 35(2), 347–359. 10.1016/j.nedt.2014.11.016 PMID: 25497138
Yang, T.-Y., Huang, C.-H., An, C., & Weng, L.-C. (2022). Construction and evaluation ofa360 degrees panoramic video on the physical examination of nursing students. Nurse Education in Practice, 63, 103372. 10.1016/j.nepr.2022.103372 PMID: 35644047
From College of Nursing, Purdue University Northwest, Hammond (AS, BP, DS), College of Nursing, Purdue University Northwest, Westville, Indiana (AS, DS); Johns Hopkins University School of Nursing, Baltimore, Maryland (JM); Madonna University, Livonia, Michigan and School of Nursing, Oakland University, Rochester, Michigan (TC); University of Southern Indiana, Evansville, Indiana (CC); University of Illinois at Chicago, College of Nursing, Chicago, Illinois (TK); The University of Toledo, Toledo, Ohio (JS); Rush University College of Nursing, Chicago, Illinois (JD); and School of Nursing, Concordia University, Mequon, Wisconsin (DA).
Disclosure: The authors have disclosed no potential conflicts of interest, financial or otherwise.
Copyright 2025, SLACK Incorporated