Does Change in Pelvic Examination Sequence Promote Cervix Visualization Among Advanced Practice Nursing Students?

Purpose: The purpose of this clinical inquiry project was to determine if there is a difference in the ease of cervix visualization when the bimanual examination is performed prior to the speculum examination among advanced practice registered nursing (APRN) students. Data Sources: Thirty seven participants were recruited from a convenience sample of APRN students participating in a pelvic skills lab in an advanced assessment course. Seventeen participants performed a pelvic examination with bimanual occurring before speculum examination. The remaining 20 participants performed a pelvic examination with speculum examination occurring before the bimanual examination. Visualization of the cervix was measured by participants’ responses to the Ease of Cervical Visualization Questionnaire II. Results were analyzed using a Mann Whitney U test for independent samples. No statistically significant difference was detected in ease of cervical visualization between the bimanual-first technique group (Md=4.0, n=17) and the speculum-first technique group (Md-3.5, n=20), u=150, z=-0.615, p=.539, r=.101 [r = effect size]. The number of times the speculum was repositioned was positively correlated with the perceived difficulty of cervix visualization (Spearman rho .56, p = 01, n = 20). Conclusions: The results of this study did not show a significant difference between the groups regarding the ease of cervical visualization. The participants, however, who palpated the cervix prior to speculum examination, reported decreased instances of speculum repositioning, which was correlated with an increased ease of visualization of the cervix. DOES CHANGE IN PELVIC EXAMINATION SEQUENCE PROMOTE 7 Does Change in Pelvic Examination Sequence Promote Cervix Visualization Among Advanced Practice Nursing Students? The pelvic assessment of the female reproductive organs is a difficult skill for a novice or a student examiner to acquire (Carr & Carmody, 2004). For the majority of students, learning how to perform the pelvic examination causes stress and anxiety (Hendrickx et al., 2005; Pugh, Obadina, & Aidoo, 2007). Physical assessment educators use many different teaching strategies to help students in advanced physical assessment classes learn to perform pelvic assessments on female patients (Levi, 2008; Theroux & Pearce, 2006). Two methods, in particular, have proved effective: (a) standardized patients and (b) mannequin-based simulators. Other strategies used to teach the pelvic examination include didactic lectures, instructional videos, student peer examinations, and hands-on examinations of female patients under the guidance of a preceptor (Dull & Haines, 2003). Standardized patients or clinical teaching associates are women who have been trained to instruct and support students who are learning to perform a pelvic examination (Theroux & Pearce, 2006). In addition, standardized patients facilitate learning the pelvic examination by providing feedback to students during the procedure regarding the student’s technique (Theroux & Pearce, 2006). Novice nurse practitioner students who performed their first pelvic examination on standardized patients while a preceptor was present reported increased comfort with performing the pelvic examination and increased confidence in exam techniques (Carr & Carmody, 2004), and a positive learning experience with standardized patients (Theroux & Pearce, 2006). DOES CHANGE IN PELVIC EXAMINATION SEQUENCE PROMOTE 8 Instructors have also used mannequin-based simulators to teach gynecologic procedures, such as the pelvic examination technique (Pugh, Heinrichs, Dev, Srivastava, & Krummel, 2001). A study by Pugh et al. (2007) revealed that when novice students practiced on simulators prior to performing examination on standardized patients, their anxiety levels decreased and their performance levels improved. Although the proper performance of pelvic examination increases patient comfort and improves the quality of specimen collection (Carr & Carmody, 2004), evaluation of the effects of different sequencing of pelvic examination on patient comfort has not been examined in the medical literature. Ryden (2002) listed the standard sequence for performing a female pelvic examination as: (a) an inspection of the external genitalia, (b) a speculum examination, and (c) a bimanual examination. When an examiner is unable to visualize the cervix promptly with a first attempt at speculum examination or by manipulating the depth or the angle of the speculum, the clinician has been instructed to remove the speculum, perform a bimanual examination, and then reinsert the speculum in an attempt to visualize the cervix (Carter, 2010; Heath & Sulik, 2010). Many researchers noted that visualization of the cervix, an essential part of the pelvic examination, is a skill that students often struggle to acquire (Siwe, Wijma, Stjernquist, & Wijma, 2007). Carter (2010) reported a significant mean difference on number of times specula required repositioning to visualize the cervix and ease of cervix visualization among APRN students. Results favored performing the bimanual examination first rather than after speculum examination. Pugh et al. (2007) proposed that creative methods could enhance the novice performance of the pelvic examination and improve the comfort of the patient experiencing the examination. DOES CHANGE IN PELVIC EXAMINATION SEQUENCE PROMOTE 9