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Graduate Project in Nursing
Using the best available evidence is the surest way of improving patient care outcomes including augmenting the quality of care dispensed, improving patient safety, enhancing patient satisfaction, and providing culturally congruent care. Evidence-based practice (EBP) is a problem-solving approach to care delivery that integrates patient care data and the best evidence from studies with clinician expertise as well as patient values and preferences. The proposed EBP project sought to examine the efficacy of utilizing a multifaceted intervention that involves positive lifestyle and behavior change in adults with uncontrollable hypertension.
Step 0: The Spirit of Inquiry Ignited
Igniting a spirit of inquiry was a fundamental undertaking that provided the foundation for the EBP implementation project. Burns et al. (2015) contend that when a culture that supports this spirit of inquiry is lacking, practitioners have a lesser likelihood of identifying a pertinent clinical problem and embracing EBP. A number of questions helped in sparking the spirit of inquiry. These questions covered broad areas including who, what, when, where, why, and how. As Burns et al. (2015) vividly point out, one of such question is “Who can I seek out to assist in enhancing my EBP skills/knowledge and serve as my EBP mentor in a bid to help find appropriate answers to the clinical question under consideration?”
The clinical question that warrants consideration is on the efficacy of utilizing a multifaceted intervention that involves positive lifestyle and behavior change in adults with uncontrollable hypertension. The spirit of inquiry identified hypertension to potentially be life-threatening because it creates conditions that have manifested adverse
effects to the lives of many Americans. Research suggests that one in four Americans suffer from hypertension (Tobe, Moy Lum-Kwong, Von Sychowski & Kandukur, 2013). In 2013, hypertension was the leading cause of morbidity in 304,000 people in the United States (Tobe, Moy Lum-Kwong, Von Sychowski & Kandukur, 2013).
Step 1: The PICOT Question Formulated
In adults with uncontrolled hypertension between the ages of 20 and 65, does the utilization of a multifaceted intervention that involve positive lifestyle and behavior change, as compared to adults with hypertension who do not involve positive lifestyle and behavior change, result in a controlled blood pressure, within a period of one year?
Step 2: Search Strategy Conducted
Performing a thorough database search for evidence-based articles was also an important undertaking during the EBP implementation project process. The researcher consulted a number of renowned health electronic databases in order to find current, up- to-date journal articles and clinical guidelines that could find direct application in answering the PICOT research question. Some of these databases included CINAHL and EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Medline, PsychInfo, and PubMed. The researcher also searched reference lists, conference proceedings, clinical trials registers, and reviewed clinical guidelines from the American Heart Association.
After obtaining access to these databases, the researcher utilized key words to narrow down results and include only the most relevant. The key words and search terms used were “hypertension,” “adult 20 – 65 years,” “adulthood,” “blood pressure,” “hypertension prevention and control,” “patient education AND heart disease risk
factors” and “modifiable risk factors for hypertension”. Notably, it was essential to use Boolean connectors and other filtering tools available in the databases consulted in order to narrow down the results. The search generated many studies related to the clinical question of interest.
All the articles included in the final sample selection were full-text, in English, and published between 2010 and 2018. In addition, many were randomized controlled trials, systematic reviews, quasi-experimental studies, and Meta-analyzes of RCTs, all of which have a relatively high level of evidence. For inclusion, the researcher considered studies that looked at behavioral interventions, counseling, and patient education on the risk factors for hypertension. Originally, 32 publications underwent initial review, narrowed down to 15 for thorough review, with 5 finally selected to guide this EBP implementation project. Three of these studies selected for this EBP project utilized randomized controlled trial design, with one using a systematic review of RCTs approach, and the remaining one utilizing a quasi-experimental design.
Step 3: Critical Appraisal of the Evidence Performed
The study conducted by Yang, Kang, Lee, Kim, Sung & Lee (2017) on the effect of psychical inactivity, salt intake and weight gain to control of blood pressure, yielded great results for the current study. Jambi and Tanui (2014) studied hypertension patients’ empowerment through lifestyle modification and behavior change. The duos highlighted alcohol consumption, unhealthy dieting, physical inactivity and smoking as behaviors and lifestyles that need modification in order to control blood pressure in patients. The study by Kurwiyah, matayakul & Karuncharernpanit (2017) gives insight on lifestyle modification among the senior citizen in the US. The study uses social theoretical theory
as a guide to study behavior and lifestyle modification as a way of controlling Blood Pressure (BP) among the elderly.
Gee, Pickett, Janssen, Johnson & Campbell (2010) looks at lifestyle and behavior modification to control BP in an individual with or without Diabetes. Huang & Duggan (2018) studied lifestyle management of hypertension. The research studies routine management of hypertension by taking an insight on body weight, nutrition, smoking, and alcohol use. As much as the studies used different intervention methods, for instance, Yang et.al (2017) used direct patient education intervention and Huang & Dugan (2018) used health professional-led care; all the interventions were multifaceted as they involved Medication and targeted behavior and lifestyle change in the hypertension patients (Huang & Duggan, 2008).
All the studies involved a control group where the two variables positive lifestyle and behavior modification were tested. Gee et.al, 2010, Kurwiyah et.al, 2017 and Yang et.al, 2017 used educational interventions that advocated less salt intake and weight loss, Out of the 1453 patients that constituted the control group in Yang et.al, 2017, study, 1136 achieved a controlled blood pressure of between normal (120 mm hg/80 mm Hg diastolic) to elevated (140/90 mm Hg systolic) within a period of 1 year.
Results in Kurwiyah et.al, 2017 and Gee et.al, 2010 interventions also yield controlled BP. Patients that did not adopt lifestyle changes and behavior had hypertension stage 1 (130 mm Hg systolic/90 mm Hg diastolic) and hypertension stage 2 (140 mm Hg systolic/ 90 mm Hg diastolic) within a year (Gee et.al, 2010). Using the health professional health care intervention, Huang & Dugan found out those elderly patients that were involved in lifestyle and behavior modification such as quitting smoking,
reduced use of alcohol and vegetated nutrition achieved controllable blood pressure level of 120/85 and 130/90 within a short period of 1 year (Huang & Duggan, 2008).
Step 4: Evidence Integrated with Clinical Expertise and Patient Preferences to Implement the Best Practice
In the integration of evidence with clinical expertise, the facility formed a team including the primary investigator who is an APN, a nurse, and an educator to work on creating and implementing the EBP to teach patients about the risk factors for hypertension with the ultimate goal of decreasing the incidence of the condition.
Members of this team attended a local EBP Institute, a consortium of local hospitals for nursing excellence in Miami-Dade. The primary investigator recruited an education training team consisting of advance practice nurses with vast experience in providing education on cardiovascular risk factors and management among patients at high risk of developing hypertension.
Based on internal and external evidence, we developed and embedded an evidence-based hypertension protocol into a new standard and policy for evidence-based care for uncontrollable hypertension. Specifically, the team developed and deployed a 6- month, nurse-led educational program targeting patients with hypertension and those at high risk of developing hypertension. Under this program, nurses provided modifiable risk factor education in home visits as well as a clinical site at a local primary care office. A nurse practitioner prepared an initial management plan, which contained clear goals for managing hypertension based on the participants’ risk profile. Patient preferences and values considered during the evidence integration and the development of the EBP
protocol included their desires for information, involvement in decision-making, preferences on treatment modalities, outcomes, and health states.
Step 5: Outcomes Evaluated
The primary outcome measure for this EBP project was the incidence of hypertension among patients who already had the condition or those at high risk of developing it. In the previous 3 years before the implementation of the intervention and the EBP change; the rates of hypertension in the targeted Miami-Dade jurisdiction was approximately 23%. This was primarily attributable to the fact that many of the residents in this jurisdiction lacked sufficient information about the risk factors associated with the condition and the strategies that they could employ to mitigate these risk factors.
In the first and second phases of the EBP change, the incidence of hypertension decreased dramatically to about 11% in the intervention group. Knowledge of hypertension risk factors also increased significantly as measured by the BP Knowledge Scale. Implementation of the evidence-based protocol also improved other secondary outcome measures. For example, on average the participants managed to attain average BMI reduction of 3.1%, met the targeted BMI targets, and improved their cholesterol levels. Knowledge of nurses also increased with regard to deploying and individualizing the multifaced, evidence-based educational intervention.
Step 6: Project Dissemination
Academic detailing and educational outreach are the primary strategies adopted for the dissemination of this EBP project. The key message disseminated is that an evidence-based, multifaced educational intervention program focusing on the risk factors of hypertension has immense potential of decreasing the incidence of these. With the
implementation of the findings, the overall health care delivery system will reap tremendous benefits. The educational outreach and academic detailing will take place at various clinics in Miami-Dade county and gradually across the nation as well as in national nursing conferences and international nursing conferences.
The EBP implementation project sought to examine the effectiveness of a multifaceted educational program in improving the incidence of hypertension among adults by enlightening them on the modifiable risk factors of hypertension. The spirit of inquiry helped to reveal that these conditions could have detrimental effects not only on the quality of life of affected patients but also on the health care delivery system as a whole. Formulating a realistic PICOT question was fundamental for guaranteeing the success of the EBP implementation project. The researcher then performed a comprehensive database search to identify relevant articles for appraisal.
The critical appraisal affirmed that educational interventions targeting risk factors for hypertension are indeed effective in helping to improve outcomes for adults suffering from the condition. On evaluation, it is apparent that the developed EBP protocol is effective in achieving primary as well as secondary outcomes as evidenced by decline in hypertension from 23% to 11% in the targeted population. Project dissemination is equally important. The stakeholders targeted during dissemination included health care professionals and health policymakers, reached primarily via educational outreach and academic detailing including in nursing conferences.
- Burns, N., Grove, S. K., & Gray, J. (2015). Understanding nursing research : Building an evidence-based practice (6 ed.). St. Louis, Missouri: Elsevier.
- Gee, M. E., Pickett, W., Janssen, I., Johnson, J. A., & Campbell, N. R. C. (2013). Health behaviors for hypertension management in people with and without coexisting diabetes. Journal of Clinical Hypertension, 15(6), 389–396. https://doi.org/10.1111/jch.12093.
- Huang, N., & Duggan, K. (2018). Lifestyle management of hypertension. Retrieved from https://www.nps.org.au/australian-prescriber/articles/lifestyle-management- of-hypertension. [Accessed 25 Dec. 2018].
- Kurwiyah Ihwanudin, N., Amatayakul, A. and Karuncharernpanit, S. (2017). Lifestyle modification effect on behavior change and physical conditions among hypertensive elderly in West Java, Indonesia. [online] research Gate. Available at: https://www.researchgate.net/publication/301231743_Lifestyle_Modification_Eff ect_on_Behavior_Change_and_Physical_Conditions_among_Hypertensive_Elder ly_in_West_Java_Indonesia [Accessed 25 Dec. 2018].
- Njambi, O., & Tanui, A. (2014). Lifestyle modification in prevention of hypertension: Patient empowerment. Retrieved from https://www.theseus.fi/bitstream/handle/10024/101029/Tanui_Asbel_Njambi_Oli ve%20.pdf?sequence=2 [Accessed 25 Dec. 2018].
- Tobe, S. W., Moy Lum-Kwong, M., Von Sychowski, S., & Kandukur, K. (2013). Hypertension management initiative: Qualitative results from implementing clinical practice guidelines in primary care through a facilitated practice program.
- The Canadian Journal of Cardiology, 29(5), 632-635. doi:10.1016/j.cjca.2012.12.005.
- Yang, M. H., Kang, S. Y., Lee, J. A., Kim, Y. S., Sung, E. J., Lee, K., Kim, J., Oh, H. J.,
- Kang, H. C. and Lee, S. Y.Yang, M., Kang, S., Lee, J., Kim, Y., Sung, E., & Lee,
- K. et al. (2017). The Effect of Lifestyle Changes on Blood Pressure Control among Hypertensive Patients. Korean Journal of Family Medicine, 38(4), 173. doi:10.4082/kjfm.2017.38.4.173
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