All master's degree nursing programs with direct care components are required to offer graduate-level coursework in three content areas: physical health assessment (PHA), pathophysiology, and pharmacology. Physical assessment is traditionally taught face-to-face (F2F) with both didactic and skills laboratory (lab) components. F2F instruction allows for both faculty-to-student and student-to-student interaction. Typically, during the skills lab component, students work in pairs practicing their physical assessment skills using low-fidelity simulation, either with each other as simulated patients or with a task trainer manikin. Student pairs observe each other and provide peer feedback on skill performance.
There are approximately 219 Registered Nurse to Master's (RN to MS) degree nursing programs (American Association of Colleges of Nursing [AACN], 2019). With many RN to MS programs offered largely online or in a hybrid format (AACN, 2011) a physical health assessment (PHA) course becomes a challenge. Students need to learn the knowledge of PHA and practice the skills. Furthermore, faculty need to evaluate students' assessment skills remotely. Nurse educators teaching in the online learning environment need to develop innovative strategies that replicate the F2F lab experience for students to meet learning objectives and to evaluate students' skill acquisition. This article describes an online asynchronous physical assessment lab (OAPAL) using low-fidelity simulation with peer feedback.
Simulation is an active learning experience whereby sets of conditions are created to resemble authentic, real-life situations (International Nursing Association for Clinical Simulation and Learning Standards Committee, 2016). There are several advantages of using simulation as a teaching strategy: 1) it encourages nursing students to develop or improve their professional knowledge, skills, and attitudes before entering the clinical setting to deliver safe, quality patient care; 2) it allows students' learning outcomes to be met; 3) it enables nurse faculty to create a realistic, safe environment for students; and 4) it promotes faculty to become facilitators of student-centered learning (Eyikara & Baykara, 2017; Faulcon, 2015).
ONLINE PHYSICAL ASSESSMENT LAB
The "Advanced Physical Assessment Across the Lifespan" course is a fully online 10-week course with both a didactic and lab component in a newly developed RN to MS nursing program. During the course design, faculty recognized the need to ensure students were practicing and learning advanced PHA skills. Furthermore, faculty had to create a method for evaluating these skills for adequate preparation for the final comprehensive physical assessment examination.
The goal of the course design was to offer an OAPAL experience that mimicked the lab experience offered in an advanced F2F PHA course. Faculty specifically were seeking to 1) provide students the ability to demonstrate practice of weekly physical assessment skills with low-fidelity simulation and engage in peer review feedback, providing and receiving feedback on their performance, and 2) enable faculty evaluation of students' physical assessment skills. To accomplish these tasks, faculty created the OAPAL using low-fidelity simulation with peer feedback using self-recorded videos.
In the first week of the course, students are assigned a lab partner and purchase physical assessment lab supplies. Students who do not have someone to practice with in their home environment may purchase an inflatable manikin as a task trainer. The OAPAL consists of weekly self-recorded videos of students practicing a system-focused physical assessment on either the inflatable manikin or a significant other. Students upload their self-recordings to the learning management system. These videos are worth 10 percent of the course grade.
Once uploaded, lab partners review each other's videos and provide peer feedback of the other's technique using the advanced PHA skills checklist provided by faculty. Lab partners submit their completed peer-reviewed checklist to the learning management system for faculty evaluation. Students receive 1.67 points for their peer feedback, worth 10 percent of the grade.
Faculty provide narrative written feedback on the skills checklist to mimic the verbal feedback provided in an F2F skills lab. Students who miss and/or submit late more than three lab assignments (self-recorded videos and/or peer review) fail the lab portion of the course, which must be passed for students to pass the course. The final submission is a comprehensive head-to-toe, self-recorded physical assessment video in the last week of the course; it is graded by faculty and represents 50 points, 40 percent of the course grade.
EVALUATION
This course has been taught three times since implementation of this innovative OAPAL. To determine if students believed this was a valuable learning experience, faculty developed a 10-item evaluation survey using the first two levels of the Kirkpatrick Model of Evaluation as a guiding framework (Kirkpatrick, 1996). After approval by the university's institutional review board, 25 students who completed the course with OAPAL were invited to take the survey; 9 completed the survey for a 36 percent response rate.
Kirkpatrick's Level 1: Reaction
The first level of Kirkpatrick's model determines the effectiveness of training by measuring the degree of students' favorability, relevance, and engagement of learning an activity (Kirkpatrick, 1996). Seventy-eight percent of students agreed/strongly agreed that the OAPAL, using low-fidelity simulation with peer feedback, was a valuable learning experience. Furthermore, 78 percent agreed/strongly agreed that the peer feedback of their weekly skills practice was meaningful to improve upon their physical assessment skills; 89 percent agreed/strongly agreed the feedback prepared them for the final comprehensive head-to-toe physical assessment. Finally, 78 percent felt the OAPAL was as effective as the F2F physical assessment lab from their prelicensure nursing program.
An open-ended comment by a student that aligned to the relevance of the learning activity was "the advanced assessment skills learned in the course enabled application in current clinical practice." An open-ended comment aligning to favorability was "I believe the online physical assessment was very helpful for my clinical practice. The feedback from my peer was constructive and helpful." Another student comment, "At first, there was hesitation from all in my cohort about having to record ourselves[horizontal ellipsis]After the first one was out of the way, you come to realize it really is no different than doing an F2F demonstration, with an added technological component[horizontal ellipsis]outcome was a fun and interactive experience."
Kirkpatrick's Level 2: Learning
The second level of Kirkpatrick's model determines students' acquisition of the intended knowledge, skills, attitude, confidence, and commitment (Kirkpatrick, 1996). Seventy-eight percent of students agreed/strongly agreed that the self-recorded practice with peer feedback improved their physical assessment skills; all students agreed/strongly agreed that watching their peers' videos and providing feedback helped to improve their physical assessment skills.
CONCLUSION
Students in an online PHA course are required to meet the same learning outcomes as students in an F2F learning environment. The use of simulation as a learning strategy can enhance patient care skills among both prelicensure (Hayden et al., 2014) and postlicensure nursing students (Niemeyer, 2017). Creation of active and collaborative learning environments is key to successful online courses (Simonson et al., 2011; Sowan & Jenkins, 2013). Students found the OAPAL, using low-fidelity simulation with peer feedback, to be a valuable and engaging learning strategy that was relevant to their current practice. Furthermore, students found that both the practice with low-fidelity simulation along with receiving peer feedback as well as the observation of peer practice and provision of peer feedback assisted in their skill acquisition.
This is the first known article to report the use of an OAPAL using low-fidelity simulation with peer feedback in a PHA course conducted in a completely online learning environment with a small group of postlicensure nursing students. Because of the small sample and low response rate, this strategy needs further evaluation to gather evidence from a larger sample of postlicensure nursing students. Future research is needed to assess the effectiveness of an OAPAL in comparison to F2F skills lab effectiveness with regard to students' learning of physical assessment skills. It is also important to gather perspectives from nurse faculty on the OAPAL.
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