NURS 6321 Week 2 Needs Assessment Example

Needs Assessment: Recognizing and Escalating Patient Deterioration Among Newly Hired Nurses on a Medical-Surgical Unit

Student Name

College of Nursing, Walden University

NURS 6321: Curriculum Development, Assessment, and Evaluation

Instructor Name

Month Day, Year

Needs Assessment: Recognizing and Escalating Patient Deterioration Among Newly Hired Nurses on a Medical-Surgical Unit

Purpose

This assessment examines one learner group, nurses newly hired onto the adult medical-surgical floor of a composite 250-bed community hospital, and one capability: recognizing early signs that a patient is deteriorating and escalating care in time. It describes what the learners can do at hire, what the unit requires of them and by when, three sources of evidence, and the gap between current and required capability. It closes with problems that teaching cannot fix. It does not propose a course; design comes later.

Learner Profile

The unit hires about 24 nurses a year, and 20 are new graduates within six months of licensure. At hire, they can obtain and document a full set of vital signs, perform a head-to-toe assessment, recite the parameters of the hospital's early warning score and describe the rapid response team's role. All have passed the licensure examination, most within the past three months. What they cannot yet reliably do is connect several modest abnormal findings, such as a respiratory rate of 24, a new confusion and a urine output that has fallen over two shifts, into a judgment that the patient is getting worse, and act on that judgment by calling for help. They know the parts; the whole is what is missing.

This profile matches what a large academic medical center found when it assessed more than 5,000 new graduates over five years: only 23% demonstrated entry-level competencies and readiness for practice on a performance-based assessment of clinical reasoning (Kavanagh & Szweda, 2017).

Their current orientation adds little to this capability. It consists of 12 weeks paired with a preceptor, a four-hour classroom session on the early warning score and the rapid response process during the first week, and online modules on documentation and medication safety. None of it asks a new nurse to work through a deteriorating patient from first cue to call and then be told how the decision compared with an expert's. The classroom session explains the score; it does not rehearse the judgment the score is meant to prompt.

What the Setting Requires

The unit requires every new nurse, by the end of a 12-week orientation, to take independent responsibility for four or five patients on day or night shift, with the charge nurse available but not at the bedside. In practice that means recognizing deterioration without a preceptor present. The requirement is anchored to a published model rather than a manager's opinion. The national licensing body's clinical judgment model describes six cognitive operations: recognize cues, analyze cues, prioritize hypotheses, generate solutions, take action and evaluate outcomes (Dickison et al., 2019). For this capability, the unit requires the full chain, from recognizing the cues to taking the action of escalation, within minutes, not hours.

Evidence Source 1: Published Model and Literature

The clinical judgment model supplies the standard, and an integrative review of ward nurses' recognition of and response to deterioration supplies the known barriers. Recognition depended on assessing the patient, knowing the patient, education and the environment, while response depended on nontechnical skills, access to support and negative emotions such as fear of being wrong (Massey et al., 2017). Limitation: neither source measures this unit's learners. They describe what is required and why it fails in general, not how far these nurses are from it.

Evidence Source 2: Structured Simulation Observation

In their first week, the last 24 new hires completed the same simulation: a postoperative patient developing sepsis over 20 minutes, with the early warning score rising from 2 to 6. Two observers recorded the time from the first abnormal cue to a call for help. Nine of the 24 escalated within 10 minutes of the score reaching the hospital's calling threshold of 5. Eleven escalated later, most after the patient became hypotensive, and four did not escalate before the scenario ended. Most who delayed had documented each abnormal value correctly, which shows that the failure lies in connecting and acting rather than in measuring. Limitation: a simulation is not a shift. Learners know something will happen, which may improve recognition, and they carry no other patients, which removes the competing demands that delay escalation on the unit.

Evidence Source 3: Preceptor Survey

Sixteen of the unit's 19 preceptors answered a five-item survey. Asked to rate how often new nurses in the final month of orientation recognized deterioration before the preceptor did, 11 answered rarely or sometimes. Asked what delayed escalation, 13 named reluctance to call a physician or the rapid response team, and 9 named difficulty seeing a pattern across several readings. Limitation: preceptors' ratings are impressions, not measurements, and preceptors who intervene early may never see whether the new nurse would have recognized the problem alone.

Gap Statement

At hire, 9 of 24 new nurses (38%) escalate a deteriorating simulated patient within 10 minutes of the calling threshold; the unit requires all of them to do so by the end of a 12-week orientation, a gap of 62 percentage points in a capability the preceptors say is still weak in the final month. The three sources point to two components of the gap: seeing a pattern across several abnormal readings, and acting on the pattern despite reluctance to call.

The gap is not evenly spread. The four nurses who did not escalate in the simulation were all new graduates, while the four experienced hires escalated within 10 minutes. The design stage should therefore expect a range of starting points within each orientation group.

Outside the Reach of Teaching

Some contributors to delayed escalation cannot be fixed by any course, and naming them now prevents a later design from being blamed for them. Nurse staffing ratios of five or six patients on some night shifts limit how often each patient is seen. Twelve-hour shifts concentrate fatigue in the early morning hours. Only eight of the unit's rooms have continuous pulse oximetry. And the culture of the physician group, if a new nurse is rebuked for calling, will outweigh anything taught in orientation. These are reported to the unit's leadership separately.

References

Dickison, P., Haerling, K. A., & Lasater, K. (2019). Integrating the National Council of State Boards of Nursing Clinical Judgment Model into nursing educational frameworks. Journal of Nursing Education, 58(2), 72-78. https://doi.org/10.3928/01484834-20190122-03

Kavanagh, J. M., & Szweda, C. (2017). A crisis in competency: The strategic and ethical imperative to assessing new graduate nurses' clinical reasoning. Nursing Education Perspectives, 38(2), 57-62. https://doi.org/10.1097/01.NEP.0000000000000112

Massey, D., Chaboyer, W., & Anderson, V. (2017). What factors influence ward nurses' recognition of and response to patient deterioration? An integrative review of the literature. Nursing Open, 4(1), 6-23. https://doi.org/10.1002/nop2.53