N508 Module 7 assignment: NINR priorities, EBP criteria and research proposal paper, a full sample

Drawing Less Blood: NINR Priorities, Criteria for Evidence-Based Practice, and a Proposal to Test Nurse-Led Laboratory Stewardship

Student Name

Master of Science in Nursing Program, Aspen University

N508: Theory and Research

Instructor Name

Month Day, Year

Drawing Less Blood: NINR Priorities, Criteria for Evidence-Based Practice, and a Proposal to Test Nurse-Led Laboratory Stewardship

A research proposal is a plan to answer a question that practice has raised and existing evidence has not settled. This paper places such a question within the priorities of the National Institute of Nursing Research, explains the criteria that distinguish evidence-based practice from research and from tradition, and then proposes a study of nurse-led laboratory stewardship to reduce hospital-acquired anemia on medical units, the research interest that grew from the patient encounter described in Module 1.

NINR Strategic Priorities

The National Institute of Nursing Research, part of the National Institutes of Health, funds research that shapes nursing practice and health policy. Its strategic plan for 2022 to 2026 states its mission as leading nursing science to solve pressing health challenges and inform practice and policy, optimizing health and advancing health equity. Rather than listing diseases, the plan organizes research through lenses that nursing research is expected to apply: health equity, social determinants of health, population and community health, prevention and health promotion, and systems and models of care (National Institute of Nursing Research [NINR], 2022).

The proposed study fits most directly within systems and models of care, because it tests a change in how hospital care is organized, and within prevention, because it aims to prevent a hospital-acquired harm rather than treat it. It also touches health equity: hospital-acquired anemia may affect older adults and people with chronic kidney disease and heart failure, who are often already anemic, more severely than healthier patients. Framing the study within these lenses would strengthen a funding application and clarify its relevance beyond a single hospital.

Criteria for Evidence-Based Practice

Evidence-based practice is the integration of the best available research evidence with clinical expertise and patient preferences and values in making decisions about care (Melnyk & Fineout-Overholt, 2023). Three criteria distinguish it from other approaches. First, the evidence is found systematically and appraised for validity, reliability, and applicability rather than accepted because it is familiar. Second, it is integrated with clinical expertise, the judgment that tells a clinician whether evidence fits a particular patient and setting. Third, it respects the patient's preferences, values, and circumstances.

Evidence-based practice also differs from research. Research generates new, generalizable knowledge through systematic investigation; evidence-based practice applies existing knowledge to practice decisions. When the evidence needed for a practice decision does not yet exist, the appropriate response is research, and that is the situation this proposal addresses: evidence shows that phlebotomy contributes to hospital-acquired anemia, but the effect of nurse-led stewardship on general medical units has not been tested.

Background and Significance

Hospital-acquired anemia is common and consequential. In a study of 188,447 hospitalizations, 74 percent of patients developed hospital-acquired anemia, and moderate and severe anemia were associated with higher in-hospital mortality, longer stays, and higher charges after risk adjustment (Koch et al., 2013). Diagnostic blood loss is one modifiable contributor. Among patients hospitalized with acute myocardial infarction, those who developed moderate to severe hospital-acquired anemia had lost a mean of about 174 mL of blood to phlebotomy, compared with about 84 mL among those who did not, and every 50 mL drawn was associated with an 18 percent relative increase in risk (Salisbury et al., 2011). Much of that blood is drawn by routine, recurring orders that no one reviews once they are written.

Interventions such as small-volume collection tubes have been tested mainly in intensive care, with mixed results, as discussed in Module 1. On general medical units, where nurses collect or coordinate most specimens and are positioned to question standing orders, the effect of a nurse-led approach is unknown.

Research Question and Design

Research question: For adult patients on general medical units, does a stewardship protocol for laboratory orders led by nurses, compared with usual practice, lessen how far hemoglobin falls between admission and discharge? Secondary questions concern total phlebotomy volume per admission, the number of laboratory draws per patient-day, red blood cell transfusions, and length of stay. The hypothesis is that the protocol will shrink the admission-to-discharge fall in hemoglobin and phlebotomy volume without increasing adverse events.

The proposed design is a stepped-wedge cluster randomized trial on six medical units in a composite academic hospital. All units begin with usual practice, and one unit at a time, in random order, crosses over to the intervention every two months until all units have adopted it. The design suits a unit-level practice change, ensures that every unit eventually receives the intervention, and allows comparison both between and within units over time.

Intervention, Measures, and Analysis

The intervention has three components. Each morning the charge nurse reviews all standing laboratory orders with the medical team during interdisciplinary rounds, using a checklist that asks whether each recurring test will change management that day. Small-volume collection tubes replace standard tubes for routine chemistry and hematology. Nurses bundle necessary draws to avoid separate venipunctures and minimize discard volume from central lines. Nurses receive a brief education session and a unit champion supports adoption.

Hemoglobin at admission and discharge, laboratory draws, tube types, transfusions, length of stay, and adverse events, such as missed critical results, will be extracted from the electronic health record. Phlebotomy volume will be estimated from the number and type of tubes drawn. The primary analysis will use mixed-effects regression accounting for clustering by unit and for secular time trends, adjusting for age, admission hemoglobin, kidney function, and diagnosis.

Sample, Setting, and Feasibility

The study population is adults aged 18 and older admitted to six general medical units for at least 48 hours. Patients admitted directly for gastrointestinal bleeding, active hemorrhage, or hematologic malignancy would be excluded, because their hemoglobin changes are driven by the underlying condition rather than by diagnostic blood loss, and patients who transfer to intensive care would be analyzed separately. A composite 450-bed academic hospital with six medical units of about 30 beds each would admit several thousand eligible patients a year, and a 12-month stepped-wedge trial would therefore include thousands of admissions, more than enough to detect a clinically meaningful difference of a few tenths of a gram per deciliter in hemoglobin decline. A formal sample size calculation would use the hospital's own data on baseline hemoglobin change, its variability, and the correlation of outcomes within units.

Feasibility depends on the nurses and physicians who will carry out the protocol. Before the trial, the investigators would meet with nurse managers, hospitalist leaders, and laboratory staff to confirm that small-volume tubes are compatible with the laboratory's analyzers, that daily review of standing orders fits into existing rounds, and that the electronic health record can report the number and type of tubes drawn. A two-week pilot on one unit would test the checklist and data extraction before randomization begins.

Ethical Considerations and Limitations

Because the intervention changes unit processes rather than individual treatment and poses minimal risk, the investigators would request a waiver of individual consent from the institutional review board, with notices posted on participating units and safeguards to ensure that clinically indicated tests are never withheld. Data would be de-identified for analysis. Limitations include the inability to blind staff to the intervention, possible contamination between units whose staff float, and the fact that results from one hospital may not generalize to others. Hemoglobin decline also has causes other than phlebotomy, such as hemodilution and illness, which the analysis can adjust for only partly.

Expected Contribution

If the protocol reduces hemoglobin decline without missed diagnoses, the study would give hospitals a low-cost, nurse-led way to prevent a common harm, and it would add to evidence on patient blood management outside intensive care. If it does not, the study would still be useful, showing whether the problem lies in the protocol's design, in adherence, or in the limited contribution of phlebotomy on medical units compared with other causes of anemia. Either result would be reported following standard guidance for cluster trials and shared with the hospital's nursing research council, the laboratory stewardship committee, and a national nursing audience, so that other units can build on it. The study would also strengthen nursing's role in laboratory stewardship, a field often led by physicians and laboratory professionals, by showing what nurses see and can change at the point of care.

Conclusion

Hospital-acquired anemia is common, associated with worse outcomes, and partly caused by blood drawn for tests that may not be needed. The proposed stepped-wedge trial would test whether a nurse-led stewardship protocol reduces that harm on general medical units, a question that falls within NINR's emphasis on systems and models of care and on prevention. Evidence-based practice cannot answer the question yet because the evidence does not exist; research can, and nurses, who draw and coordinate most of those tests, are well placed to lead it.

References

Koch, C. G., Li, L., Sun, Z., Hixson, E. D., Tang, A., Phillips, S. C., Blackstone, E. H., & Henderson, J. M. (2013). Hospital-acquired anemia: Prevalence, outcomes, and healthcare implications. Journal of Hospital Medicine, 8(9), 506-512. https://doi.org/10.1002/jhm.2061

Melnyk, B. M., & Fineout-Overholt, E. (2023). Evidence-based practice in nursing & healthcare: A guide to best practice (5th ed.). Wolters Kluwer.

National Institute of Nursing Research. (2022). National Institute of Nursing Research 2022-2026 strategic plan. National Institutes of Health. https://www.ninr.nih.gov/aboutninr/ninr-mission-and-strategic-plan

Salisbury, A. C., Reid, K. J., Alexander, K. P., Masoudi, F. A., Lai, S.-M., Chan, P. S., Bach, R. G., Wang, T. Y., Spertus, J. A., & Kosiborod, M. (2011). Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction. Archives of Internal Medicine, 171(18), 1646-1653. https://doi.org/10.1001/archinternmed.2011.361