CAP 6003 Module 2 Research Synthesis Example

Noticing Is Not Enough: A Synthesis of Research on Teaching Nursing Students to Escalate Concern About a Deteriorating Patient

Student Name

American College of Education

CAP6003: Capstone in Education Specialist

Module 2 Assignment

Instructor Name

October 19, 2026

Introduction

Module 1 defined a problem of practice in a composite Arkansas associate degree program: fourth-semester students notice deterioration in simulation but delay calling for help, with a median of nine minutes after a programmed sepsis change. This synthesis asks what research says about that gap and about teaching students to close it. Sources were located in CINAHL, MEDLINE and ERIC with combinations of the terms nursing students, speaking up, escalation, deteriorating patient, simulation and team communication, limited to peer-reviewed work in English. The synthesis is organized into five themes, each ending with what it means for the capstone design.

Theme 1: Recognizing and Responding Are Separate Skills

Research on new graduates treats recognition of deterioration and response to it as linked but distinct. In an integrative review of 17 studies of novice and experienced nurses, Purling and King (2012) identified themes that shaped graduates' preparedness, including support from clinical staff, lack of experience, overwhelming workload and the ability to assess the patient as a whole. Several of these themes concern the response rather than the recognition: a graduate may see the warning signs and still lack the support, time or confidence to act.

This distinction matches the local data. Our students' debriefing comments show recognition ("the patient looked off") followed by inaction. An intervention that only teaches students to recognize sepsis would target the step they already perform.

Theme 2: Why Students Stay Silent

A concept analysis by Fagan et al. (2016) defined speaking up as assertive communication in clinical situations that requires action through questions or statements, delivered with appropriate persistence, and noted that most earlier research had studied experienced practitioners rather than students. Their later qualitative study of 53 pre-registration students in Australia found that students considered speaking up the right thing to do and part of their professional responsibility, yet felt confusion and distress when what they had been taught differed from what they saw nurses do on placement, and that the culture of the clinical environment shaped whether they spoke up or stayed silent (Fagan et al., 2020).

Two points stand out for the capstone. First, students' silence is not ignorance of their duty; they know it and feel the tension. Second, the clinical environment teaches as powerfully as the classroom. An intervention confined to the simulation laboratory may be undone by a unit where students learn that waiting is normal.

Theme 3: Structured Communication Can Be Taught

Team communication programs give students words to use under pressure. Greene and Doss (2021) evaluated a TeamSTEPPS workshop followed by two days of simulation with 46 baccalaureate students in a pretest and posttest design and found higher knowledge scores and improved attitudes toward teamwork afterward, including in subscales for situation monitoring and mutual support. The design had no comparison group and measured knowledge and attitudes rather than behavior, so it shows that students learn and endorse the tools, not that they use them at the bedside.

Even with that limit, the finding supports teaching a small set of scripted phrases, such as stating concern, discomfort and a safety issue in rising order, because scripts lower the effort of the first sentence. For students who hesitate because they are unsure how to begin a call, a rehearsed opening line may matter more than additional content knowledge.

Theme 4: Simulation as a Safe Place to Practice the Call

Simulation is the obvious place to practice escalation, and strong evidence supports its use in prelicensure education. In a randomized, controlled study across ten programs, Hayden et al. (2014) randomly assigned students so that simulation replaced no clinical time, 25% of it or 50% of it, and found that well-run simulation at either level produced educational outcomes comparable to traditional clinical experience, including licensure examination pass rates and clinical competence ratings, through the first six months of practice. The study's conditions included trained faculty and structured debriefing, which the authors treated as part of what made the simulation effective.

For this capstone the implication is about quality rather than quantity. The program already holds two simulation days a semester; what it lacks is scenarios built around the decision to escalate and debriefing that returns to the moment of hesitation.

Theme 5: Measuring the Response, Not Only the Recognition

If the capstone is to show change, it needs a measure of the responding phase. Lasater (2007) built her clinical judgment rubric in a simulation laboratory, taking its four phases straight from the Tanner model and describing what beginning, developing, accomplished and exemplary performance looks like in each. The rubric allows faculty to rate the responding phase separately, including the clarity of communication, rather than giving a single global judgment. Combined with a timed measure, such as minutes from the programmed change to a call, it would capture both the speed and the quality of escalation.

Fit With This Program's Students and Sites

The studies above come from settings unlike a rural Arkansas community college in several ways, and the differences shape how their findings should be used. Many of our students work 20 or more hours a week and complete clinical rotations at two regional hospitals where rapid response teams exist but are called less often than in large academic centers; nurses there are more likely to phone the hospitalist directly. A script that tells students to activate a rapid response team would therefore be only partly accurate. The scripts and scenarios will need to name both routes and to match the escalation policies of the two partner hospitals, which I will obtain from their nurse educators.

Our clinical instructors are mostly adjunct faculty who also work as staff nurses, which cuts two ways. They know the units' habits well, including the habit of waiting, and they may carry those habits into how they coach students. They also have credibility with staff that a full-time faculty member lacks. Fagan et al.'s (2020) finding that placement culture shapes silence makes these instructors the most important audience for the clinical part of the intervention, and the least expensive one to reach.

What the Literature Does Not Settle

The research has gaps that matter here. Most speaking-up studies come from Australia, Europe or hospital staff, and few test an intervention's effect on students' behavior in later clinical practice. Team training studies tend to measure knowledge and attitudes immediately afterward. Simulation research supports simulation in general but rarely isolates escalation. The capstone cannot fill these gaps, but it can avoid overclaiming, and its evaluation should include a behavioral measure, not only a survey.

Implications for the Capstone Design

Five implications follow. First, target the response phase: assume students recognize deterioration and focus teaching on what to do next. Second, give students words: a short, rehearsed script for the first sentence of a call. Third, practice the decision in simulation with debriefing that returns to the moment of hesitation, meeting the standard of trained facilitators and structured debriefing set in the national study (Hayden et al., 2014). Fourth, reach the clinical units, since Fagan et al. (2020) showed that placement culture shapes silence; clinical instructors need a simple prompt and an agreed message that calling early is expected. Fifth, measure behavior: time to escalation and the responding phase of the Lasater rubric (Lasater, 2007), alongside students' own confidence.

Conclusion

The literature agrees with what the program's simulation records suggested: recognizing deterioration and acting on it are different skills, and students' silence has social as well as cognitive causes. Structured communication can be taught, simulation provides a safe place to rehearse it and existing rubrics can measure the response. Module 3 will build an intervention from these five implications. That design will have to work within the program's real constraints: two simulation days a semester, adjunct instructors who also staff the units and two partner hospitals with different escalation routes. The evidence does not promise that a short thread will change graduates' behavior years later, but it gives good reason to expect faster and clearer calls in the program's own scenarios.

References

Fagan, A., Lea, J., & Parker, V. (2020). Conflict, confusion and inconsistencies: Pre-registration nursing students' perceptions and experiences of speaking up for patient safety. Nursing Inquiry, 28(1), Article e12381. https://doi.org/10.1111/nin.12381

Fagan, A., Parker, V., & Jackson, D. (2016). A concept analysis of undergraduate nursing students speaking up for patient safety in the patient care environment. Journal of Advanced Nursing, 72(10), 2346-2357. https://doi.org/10.1111/jan.13028

Greene, D. A., & Doss, J. L. (2021). Developing teamwork skills in baccalaureate nursing students: Impact of TeamSTEPPS training and simulation. International Journal of Nursing Education Scholarship, 18(1), Article 20200077. https://doi.org/10.1515/ijnes-2020-0077

Hayden, J. K., Smiley, R. A., Alexander, M., Kardong-Edgren, S., & Jeffries, P. R. (2014). The NCSBN National Simulation Study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5(2), S3-S40. https://doi.org/10.1016/S2155-8256(15)30062-4

Lasater, K. (2007). Clinical judgment development: Using simulation to create an assessment rubric. Journal of Nursing Education, 46(11), 496-503. https://doi.org/10.3928/01484834-20071101-04

Purling, A., & King, L. (2012). A literature review: Graduate nurses' preparedness for recognising and responding to the deteriorating patient. Journal of Clinical Nursing, 21(23-24), 3451-3465. https://doi.org/10.1111/j.1365-2702.2012.04348.x