Research Request for Spectrum Health Nursing Services

This request form should be used to request any nursing services related to the study that will not be provided by investigators.
If any questions, please contact Karen Vander Laan, Senior Nurse Researcher at 616.774.7356 or by pager at 616.479.6712.
IRB Number (if available)      
Protocol Title:      

Principal Investigator (PI): Fellow, Resident or

     
(First Name, Last Name, Degree) Student
Primary Email:      
Study Coordinator:      
Primary Email:      
Timeframe of Study (approx): Start Date:      End Date:     
Number of subjects anticipated for
     
this request (approx):

Check all locations, patient care services, and nursing personnel involved in this protocol?
Locations Patient Care Areas
Inpatient Areas Acute Care of the Elderly (ACE)
Blodgett campus Adult Cardiovascular / Cardiology
Butterworth campus Adult Critical Care – Medical
Helen DeVos Children’s Hospital Adult Critical Care – Surgical
Other:       Adult Medical – Surgical
Adult Digestive Diseases
Outpatient Areas Adult Gynecology
Pre-procedure planning Adult Neuroscience
Butterworth outpatient Adult Oncology
Blodgett outpatient Adult Orthopedic
Pediatric Hematology / Oncology clinic Adult Progressive Care
Pediatric Sub-specialty clinic Bariatrics Unit
Radiation oncology Burn Center
Urgent care centers Adult
South Health pavilion Pediatrics
East Paris Surgical Center Critical Care
Lake Drive Surgical Center Acute Care
Endoscopy Inpatient
Lemmon Holton Cancer Pavilion Outpatient
Emergency Services
Continuing Care Areas Hemodialysis
SH Visiting Nurse Association Perioperative Services
SH Infusion Pharmacy Services Preoperative
SH Neuro Rehab Services Intraoperative
SH Rehab & Nursing Centers Post Anesthesia Care Unit (PACU)
SH Special Care Hospital Women & Family Services
SH Hospice Triage
Antepartum
Labor & Delivery
Postpartum
Nursery
Neonatal Intensive Care Unit (NICU)
Pediatrics
Pediatrics Critical Care Unit (PCCU)
Version date: 04-06-2009 Page 1 of 4
Nursing Personnel
Registered Nurses (RN) Clinical Nurse Specialists
Licensed Practical Nurses (LPN) Nurse Educators
Nurse Assistants / Nurse Technicians Critical Care Nurse Rounders
Unit Secretaries Managers / Directors / Supervisors
Check all specific nursing services required in this protocol?
Assessments Interventions (cont’d)
Physical IV Access
Psychosocial Starting
Behavioral Maintaining
Spiritual Discontinuing
Other:       Additional IV access
Keeping IV access in longer
Planning Other:      
Change from current standard of care
Interdisciplinary rounds Tube(s):      
Patient / Family conferences Placement
Other:       Maintenance
Removal
Interventions Additional tube
Monitoring Keeping tube in longer
Vital signs New to system
Post procedure Other:      
Device
Cardiac Dressing(s):      
ECG Placement
Telemetry (continuous) Maintenance
Fetal heart Removal
Intraaortic Balloon Pump Additional dressing
Other:       Keeping dressing on longer
Respiratory New to system
Pulse Oximetry Other:      
Capnography
Ventilator Device(s) / Equipment:      
Other:       Placement
Other:       Maintenance
Removal
Medications New to system
Preparation
Administration Extra Time for Patient Care
Titrating Specific timing of assessments
New to system Specific timing of monitoring
New drug Extra documentation / charting
Experimental drug Safety attendant
New delivery system Restraints
Other:       Accompanying a patient off unit
Follow-up communication
Specimen collection (specify type and frequency):      
Blood Other:      
Urine
Other:       Teaching:      
Other:      Patient

Version date: 04-06-2009 Page 2 of 4

 Family member(s)
Assistance with procedures (specify):       Group(s)
Other:      

Patient Care Area Resources Patient Care Standards of Practice

Use of supplies from unit stock (specify type and Are any nursing services required that are not
quantity):       considered standard care?
No Yes (specify):      
Longer Critical Care stay (specify hours or
days):       Will interventions in this study represent a change
from the current standard of practice?
Longer Inpatient stay (specify hours or days): No Yes (specify):      
     

Additional outpatient visits (specify number):

     

Other (specify):      

Check all specific research activities required in this protocol?

Sharing general information about study Obtaining subject consent for study participation
Identifying potential study subjects Collecting study data

Communication & Training

Provide the plan for communicating information about the study with the involved nursing staff:      
Does this study require additional training for nursing staff? No Yes
If yes, describe the training to be offered: Who will provide training, the training strategy (e.g., in service,
written materials, etc.), the proposed location, and the length of time required for training:      
If applicable, will involved nursing staff be recognized for their contribution to the study?      
Any additional information that may assist evaluation of the nursing impact of this study:      

By signing below you have agreed to support this Research Request for Nursing Services in
accordance with Spectrum Health’s research policies.

_______________________________________________ ____________________
Principal Investigator or Designee Date

Send the research protocol with this Research Request for Nursing Services form to Karen J.
Vander Laan, Senior Nurse Researcher at fax 616-774-7904 or by email to
[email protected].

Within 10 business days of receipt, we will review and inform the Principal Investigator or Study
Coordinator of our ability to fulfill this request.

If you have any questions, please contact Karen J. Vander Laan, Senior Nurse Researcher at
616.774.7356 or by pager at 616.479.6712.

Version date: 04-06-2009 Page 3 of 4

For reviewers use only (Signatures will be obtained from Manager(s), Director(s), and others as
appropriate related to the Patient Care Areas or Nursing Personnel requested.)

Review process (within 10 business days) Initials Date

Received by Senior Nurse Researcher
Sent to Unit/Area Reviewers (within 3 business days)
Reviewed by Unit/Area Reviewers (within 5 business days)
     
     
     
Response to Investigator or Designee (within 2 business days)

Date Reviewers’ Notes

           
           
           

By signing below you have agreed to support this Research Request for Spectrum Health Nursing
Services in accordance with Spectrum Health’s research policies.

[insert Title, Unit/Area] Date

[insert Title, Unit/Area] Date

[insert Title, Unit/Area] Date

Senior Nurse Researcher Date

Version date: 04-06-2009 Page 4 of 4