Beyond the Flow Meter: A Learning Needs Assessment for Medical-Surgical Nurses Caring for Patients on High-Flow Nasal Oxygen
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Master of Science in Nursing Program, Aspen University
N584: Curriculum Development, Implementation and Evaluation
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Month Day, Year
Beyond the Flow Meter: A Learning Needs Assessment for Medical-Surgical Nurses Caring for Patients on High-Flow Nasal Oxygen
Two years ago, a composite 300-bed community hospital began allowing patients on heated high-flow nasal oxygen to remain on its two medical-surgical units instead of transferring them to intensive care, as long as flow and oxygen settings stayed within agreed limits. The change freed intensive care beds, but it placed a therapy for acute respiratory failure in the hands of nurses who had rarely used it. The nursing professional development department has been asked to create a continuing education program. Before designing it, the department must establish what nurses actually need to learn.
This paper presents that learning needs assessment. It explains the approach, describes four sources of data and their findings, identifies the gap between current and desired practice, and sets priorities that will shape the program's outcomes in the next module.
Approach
A learning needs assessment identifies the gap between what learners currently know and do and what they need to know and do, so that education targets that gap rather than what learners say they want or what educators assume. Grant (2002) cautioned that relying only on learners' self-reported wants tends to miss what they do not know they need, and recommended combining several methods, such as observation of practice, review of records and critical incidents, and tests of knowledge, alongside learners' own views. The assessment therefore used four sources, chosen to capture both perceived and unperceived needs.
Findings From Four Sources
The table summarizes each source and its main finding.
| Source | Method | Main finding |
|---|---|---|
| Safety reports | Review of 14 months of reports involving high-flow patients on the two units | Three delayed escalations; in each, the patient's respiratory rate had risen for hours while oxygen saturation stayed near target |
| Chart review | 40 consecutive high-flow patients on the units | Settings documented hourly in 90% of charts; respiratory rate documented every two hours in 45%; a combined oxygenation and respiratory rate index documented in 12% |
| Knowledge survey | 20-item test completed by 62 of 88 nurses | Mean 71%; strong on equipment and humidification, weak on signs of failure and escalation criteria (48% correct on those items) |
| Interviews | Six respiratory therapists and four charge nurses | Nurses often call for help when saturation falls rather than when breathing effort rises; nurses report confidence with the device but uncertainty about when to worry |
The Gap
The sources converge on one gap. Nurses are comfortable operating the equipment but are less able to recognize when high-flow therapy is failing. The clinical significance is well established. Among 191 patients with pneumonia treated with high-flow oxygen, Roca et al. (2019) found that an index combining oxygen saturation, inspired oxygen and respiratory rate predicted which patients would need intubation, with lower values at 2, 6 and 12 hours predicting failure and higher values associated with a lower risk of intubation. Because the therapy can hold oxygen saturation near target while a patient tires, saturation alone can reassure falsely, and respiratory rate and work of breathing become essential signals. The chart review showed that the units documented settings reliably but documented respiratory rate inconsistently and rarely used the combined index; the safety reports showed the consequence.
Stated as a learning need, the gap is this: medical-surgical nurses need to assess and document respiratory rate, work of breathing and the combined index at defined intervals, interpret trends as signs of improving or failing therapy, and escalate according to the unit's criteria before saturation falls. Secondary needs include understanding the physiological effects of high flow, such as dead space washout and modest positive airway pressure, that explain why it works and why it can mask decline (Ashraf-Kashani & Kumar, 2017).
Learner Characteristics and Constraints
The assessment also gathered information about the learners and their setting, which will shape design. The 88 nurses range from new graduates to nurses with more than twenty years of experience and work twelve-hour shifts, a third on nights. Most prefer short sessions on the unit to classroom days, and staffing makes it difficult to release more than two nurses at a time. The units have access to a simulation room and a high-fidelity manikin that can display respiratory rate and saturation. Any program must therefore be brief, repeated across shifts, practical and focused on recognition and escalation rather than equipment setup.
Nurses' own perceptions, gathered through the survey's open-ended question, add a further layer. Most respondents asked for more training on the device's settings and alarms, which the chart review and safety reports suggest they already handle well, and few asked about recognizing failure. This mismatch between perceived and actual need is exactly what a multimethod assessment is meant to reveal. It also has design implications: if the program focuses on recognition and escalation, it must explain why, using the unit's own data, or nurses may see it as missing what they asked for.
Priorities for the Program
Three priorities follow. First, recognizing failure: every nurse caring for high-flow patients should be able to calculate and interpret the combined index and recognize rising work of breathing as a warning sign. Second, escalation: nurses should know and apply the units' escalation criteria, including when to call the rapid response team without waiting for saturation to fall. Third, documentation: the electronic record should prompt respiratory rate and the combined index at defined intervals, which requires collaboration with the informatics team as well as education. Equipment training, though often requested, is a lower priority because nurses already perform it well.
Conclusion
A learning needs assessment that relied on what nurses asked for would have produced an equipment course. Combining safety reports, chart review, a knowledge test and interviews revealed a different and more dangerous gap: recognizing when high-flow therapy is failing and escalating in time. The evidence on predicting failure explains why that gap matters. The continuing education program designed in the following modules will therefore target recognition, escalation and documentation, delivered in short, repeated sessions that fit the realities of nurses' shifts.
References
Ashraf-Kashani, N., & Kumar, R. (2017). High-flow nasal oxygen therapy. BJA Education, 17(2), 63-67. https://doi.org/10.1093/bjaed/mkw041
Grant, J. (2002). Learning needs assessment: Assessing the need. BMJ, 324(7330), 156-159. https://doi.org/10.1136/bmj.324.7330.156
Roca, O., Caralt, B., Messika, J., Samper, M., Sztrymf, B., Hernández, G., García-de-Acilu, M., Frat, J.-P., Masclans, J. R., & Ricard, J.-D. (2019). An index combining respiratory rate and oxygenation to predict outcome of nasal high-flow therapy. American Journal of Respiratory and Critical Care Medicine, 199(11), 1368-1376. https://doi.org/10.1164/rccm.201803-0589OC
How this N 584 Module 3 example is structured
Aspen does not publish N584 module prompts, so check your classroom for the exact instructions. This example explains why the need arose, sets out a multimethod approach, reports four data sources in a table, states the gap in behavioral terms with supporting evidence, describes learner characteristics and constraints, and sets three priorities for program design.
N584 Module 3 questions, answered
What does N584 Module 3 usually ask for?
Aspen's N584 description centers on developing, implementing and evaluating a continuing education program, and a learning needs assessment is the first step. Check your classroom for the audience and topic you must use.
Why not simply survey learners about what they want?
Because learners often do not know what they do not know. Combining observation, record review, incident data and knowledge tests with learners' views reveals needs that self-report misses.
What is the ROX index?
A ratio of oxygen saturation divided by the fraction of inspired oxygen, divided by respiratory rate, used to help predict whether patients on high-flow nasal oxygen are improving or likely to need intubation.
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