DNP 850B Module 8 Final Proposal: Literature and Methods Example

Proposal Chapters Two and Three: Nurses Titrating Treatment From Home Readings in a Community Health Center Clinic

Student Name

Doctor of Nursing Practice Program, Aspen University

DNP 850B: Project Proposal

Instructor Name

Month Day, Year

Proposal Chapters Two and Three: Nurses Titrating Treatment From Home Readings in a Community Health Center Clinic

Chapter Two: Review of the Literature

The review was built from searches of PubMed, CINAHL and the Cochrane Library using terms for home and self-measured blood pressure, telemonitoring, nurse-led and team-based care, and medication titration, limited to trials and evidence syntheses in English. Sources found through reference lists were added when they met the same criteria. The evidence is organized here by the questions the project needs answered rather than by study.

What the Evidence Establishes

Four findings carry the case for the project. First, readings taken at home lower blood pressure in proportion to the support built around them: pooled data from individual patients across 25 trials showed a negligible effect for monitoring on its own and a clearly larger effect when monitoring was combined with systematic medication titration (Tucker et al., 2017). Second, nurses can manage hypertension effectively when a treatment algorithm structures their decisions; a meta-analysis of nurse-led trials linked stepped algorithms and nurse prescribing with larger reductions than usual care (Clark et al., 2010). Third, team-based strategies work among low-income patients: in a cluster trial across 36 federally qualified health center clinics, a bundle that included protocol-based management and home monitoring cut systolic pressure by roughly 6 mm Hg more than guideline education alone over a year and a half (Mills et al., 2026). Fourth, the benefit depends on the protocol being followed, which is why process and fidelity must be measured alongside outcomes.

Gaps and Framework

The literature leaves three questions that this project can address only in part: whether nurse titration by transmitted readings works in a safety-net clinic, whether results hold for Spanish-speaking patients, and whether short-term gains last. The Chronic Care Model provides the conceptual framework (Bodenheimer et al., 2002). It explains why the project should work by redesigning delivery between visits, supplying decision support through the protocol and using the portal and registry as clinical information systems, while self-management teaching keeps home readings accurate. The revised Iowa Model, described in chapter one, guides the process of piloting the change.

Chapter Three: Methods

The design compares each patient before and after the program, sets the results beside the same clinic's usual care one year earlier, and follows process measures week by week on run charts. Designs of this kind rank above uncontrolled before-and-after studies in the hierarchy of quasi-experimental methods because the comparison group helps separate the program's effect from change that would have occurred anyway (Harris et al., 2006). The design does not withhold care from anyone and can be completed at one clinic within the course timeline.

Setting and Sample

The setting is one clinic of a community health center that serves mainly uninsured and Medicaid patients, 38% of whom prefer Spanish. Eligibility requires age 18 through 75 and an average of at least 140/90 mm Hg across two office visits, an established relationship with the clinic and the ability to report readings; exclusions include pregnancy, advanced kidney disease under specialist care, a screening systolic reading of 180 mm Hg or higher, and hospice enrollment. About 330 patients are expected to be eligible. To detect a 5 mm Hg mean change with 80% power, 73 patients with complete data are needed, and the project will enroll 85 to allow for attrition.

Intervention

Nurse care managers trained and signed off on the protocol will enroll patients at a 45-minute visit that includes cuff fitting, teach-back of technique and portal setup, with telephone reporting for patients without smartphones. Patients will take paired morning and evening readings at least three days a week. Each week the nurse will average the readings and, when the average reaches 135/85 mm Hg or more and adherence is confirmed, take one step in the protocol, with laboratory checks after drugs that affect potassium or kidney function. Findings such as a systolic average below 100 mm Hg or abnormal laboratory values will hand the decision back to the treating clinician that day. The program ends with a standardized office reading at week 12 and a handoff note.

Measures and Analysis

The primary outcome is the change in office systolic pressure from baseline to week 12, each the average of two readings taken by trained medical assistants using the technique in the national scientific statement (Muntner et al., 2019). Secondary measures cover control under 140/90 mm Hg, weekly reading transmission, days from a high average to action, titration steps, balancing events and scores on the Hill-Bone adherence scale. The primary analysis is a paired t-test, with a nonparametric alternative if its assumptions fail. The comparison with the historical group will use regression adjusted for baseline pressure and will be reported as an estimate with its confidence interval. Run chart rules will be used to read the weekly process data.

Ethics and Timeline

The project meets published criteria for improvement rather than research yet it goes to the health center's quality committee first and then to Aspen's institutional review board once the defense is passed. Patients will give written agreement in their preferred language and may decline without any change in care. Data will be coded, encrypted and reported only in aggregate. Human subjects training has been completed. The timeline runs from two weeks of staff preparation through four weeks of enrollment, 12 weeks of program delivery per patient and two weeks of data extraction and reporting, about 18 weeks in total.

Decisions Requested at the Defense

The committee is asked to approve three things: the design and its secondary, descriptive comparison with usual care; the protocol's escalation thresholds, which the medical director has reviewed; and the plan to submit the review board application within two weeks of approval. Any change the committee requests will be made and circulated before submission.

Conclusion

Chapters two and three show that the literature supports nurse-managed home monitoring with protocol titration in a safety-net clinic and set out methods that can test it safely and honestly at one site. With committee approval, the project is ready for review and implementation.

References

Bodenheimer, T., Wagner, E. H., & Grumbach, K. (2002). Improving primary care for patients with chronic illness. JAMA, 288(14), 1775-1779. https://doi.org/10.1001/jama.288.14.1775

Clark, C. E., Smith, L. F. P., Taylor, R. S., & Campbell, J. L. (2010). Nurse led interventions to improve control of blood pressure in people with hypertension: Systematic review and meta-analysis. BMJ, 341, Article c3995. https://doi.org/10.1136/bmj.c3995

Harris, A. D., McGregor, J. C., Perencevich, E. N., Furuno, J. P., Zhu, J., Peterson, D. E., & Finkelstein, J. (2006). The use and interpretation of quasi-experimental studies in medical informatics. Journal of the American Medical Informatics Association, 13(1), 16-23. https://doi.org/10.1197/jamia.M1749

Mills, K. T., Krousel-Wood, M., Peacock, E. M., Chen, J., Allouch, F., Carreras, A. K., Geng, S., Cyprian, A., Davis, G., Fuqua, S. R., Gilliam, D., Greer, A., Mitchell, T., Gray-Winfrey, W., Williams, S., Wiltz, G. M., Winfrey, K. L., He, H., Whelton, P. K., & He, J. (2026). Multifaceted strategies for hypertension control in low-income patients. New England Journal of Medicine, 394(14), 1376-1387. https://doi.org/10.1056/NEJMoa2504068

Muntner, P., Shimbo, D., Carey, R. M., Charleston, J. B., Gaillard, T., Misra, S., Myers, M. G., Ogedegbe, G., Schwartz, J. E., Townsend, R. R., Urbina, E. M., Viera, A. J., White, W. B., & Wright, J. T., Jr. (2019). Measurement of blood pressure in humans: A scientific statement from the American Heart Association. Hypertension, 73(5), e35-e66. https://doi.org/10.1161/HYP.0000000000000087

Tucker, K. L., Sheppard, J. P., Stevens, R., Bosworth, H. B., Bove, A., Bray, E. P., Earle, K., George, J., Godwin, M., Green, B. B., Hebert, P., Hobbs, F. D. R., Kantola, I., Kerry, S. M., Leiva, A., Magid, D. J., Mant, J., Margolis, K. L., McKinstry, B., . . . McManus, R. J. (2017). Self-monitoring of blood pressure in hypertension: A systematic review and individual patient data meta-analysis. PLOS Medicine, 14(9), Article e1002389. https://doi.org/10.1371/journal.pmed.1002389