Does Patient Education Control Hypertension?
A Challenge for Change
Literature Review
Hamad Harthi
RN BSN MSN (ANP)
Hemodialysis Unit
King Faisal Specialist Hospital
and Research Center
Supervisor: Professor Leaan Aitken, Griffith University,
Gold Coast, Queensland, Australia
Introduction
Implementing evidence-based change is necessary
across all areas of healthcare including nursing
To implement change it is necessary to consider:
–
–
–
–
Clinical need
Clinical context of care
Quality of the research evidence which will inform practice
Challenges of implementing the change itself
This projects considers an evidence-based change
relating to hypertension control in community-dwelling
adults with existing high blood pressure
Project Overview
Identification of the problem to be addressed
Definition of the clinical question
Identification of search terms and inclusion/exclusion
criteria
Literature search plus selection of relevant articles
Critical appraisal of selected articles
Implementing practice change: processes and practicalities
including planning and evaluation of the project
Conclusions
Rationale
Hypertension constitutes a considerable global
healthcare burden
Worldwide total of 972 million adults with hypertension
in 20001
– No. of affected adults almost 2-fold greater in developing vs
developed countries (639 million vs 333 million)
No. of adults with hypertension expected to increase by
~60% to 1.56 billion by 20251
Evidence suggests there is a lack of understanding of
hypertension among hypertensive patients2
1Kearney
et al. Lancet 2005; 365: 217–23; 2Oliveira et al. J Gen Intern Med 2005; 20: 219–25.
PICO
PATIENTS: Patients with chronic hypertension on
anti-hypertensive therapy in the community healthcare setting
INTERVENTION: Patient education programme designed
to improve self-care in hypertension management
(nurse-led education session plus patient information booklet)
COMPARISON: Blood pressure regulation in patients
participating in educational programme vs patients receiving
usual care alone
OUTCOMES: Reduction in hypertension (two or more
readings within the normal range) plus improved patient
self-efficacy
The Clinical Question
Does patient education reduce
the incidence of continued
hypertension in hypertensive
patients?
Literature search
Strategy:
– Key search terms and limitations identified
Search terms: Hypertension; community health interventions;
health education; patient education and
hypertension
Limitations:
English language articles published within
the last 15 years
– Searches of electronic databases CINAHL,
PROQUEST, MEDLINE and GOOGLE SCHOLAR
performed
Total of 5 relevant articles selected for critical
appraisal
Summary of Selected Articles
Article
Summary
Alm-Rojer et al. Eur J Cardiovasc Nurs 2003; Study to investigate factors affecting
3: 321–30
adherence to lifestyle changes and
medication in patients with coronary heart
disease
Burke et al. Health Edu Res 2008; 23(4):
583–91
Randomised, controlled trial of an
educational intervention (lifestyle change
program) for overweight hypertensive
patients in Australia
Leung et al. J Adv Nurs 2005; 52(6): 631–9
Exploratory study to evaluate a small-group,
nurse-led intervention to improve
hypertension control and outcomes
Mohammadi et al. Int J Nurs Prac 2006; 12:
153–9
Evaluation of a ‘partnership care model’ for
hypertension control
Zernike and Henderson. J Clin Nurs 1998; 7:
37–44
Evaluation of the effectiveness of two
teaching strategies for patients diagnosed
with hypertension
Evidence Supporting Implementation of a
Community-Based Education Program in
Hypertensive Patients
Community-based education programmes are highly
effective in addressing specific health needs1
Community-based interventions for hypertension are
effective as long as they are appropriate to the context
and target population1
Both nurses and patients benefit from small group
education in hypertension control
A study of lifestyle changes in patients with coronary
heart disease showed that greater knowledge of their
condition is one key to improved self-management and
behavioural change2
1Connell
et al. Health Soc Care Community 2008; 16: 165–87; 2Alm-Roijer et al. Eur J Cardiovasc Nurs 2004; 3: 321–30.
Implementing the Change in
Practice
Managing the implementation of change is
challenging in healthcare settings
Planning is needed to introduce the change and
drive it forward1
Process-based change management1
– Focuses on:
What do individual healthcare professionals do?
What are the benefits to patients, staff and the wider
healthcare service?2
1Greasely.
Technovation 2006; 26: 95–103; 2Fullan 2004. Leading in a Culture of Change: Personal Action Guide
and Workbook, Josse Bass CA.
Process Mapping
Use of a process analysis tool to map:1,2
–
–
–
–
Change process
Personnel involved in the change
Those likely to be affected by the change
Anticipatory actions to support the change
Tools derived from the business sector
– Sophisticated, largely computer-based
– Nurses may not possess necessary level of
theoretical and technical expertise
– May be detrimental to the success of the change
1Green.
Nursing Leadership 2003; 15: 27–30; 2Greasely. Technovation 2006; 26: 95–103.
Process Mapping of the
Change Plan
Alternative approach needed:1
– Match process mapping to existing technologies and
capabilities within organisation and its personnel
Steps involved in the process:
–
–
–
–
Development of change plan
Recruitment of relevant personnel
Involvement of management and consultation
Evaluation of change plan
Resources mapped against available provision
and any resource implications presented to
management
1Greasely.
Technovation 2006; 26: 95–103.
Implementing Practice Change:
Application of Theory
Lewin’s Field Theory and Change Theory1,2
– Organisations/departments undergo 3 processes:
Unfreezing:
Change:
Refreezing:
Old ways of working are broken down in light of
new knowledge and in response to the actions
of change agents
Implementation of the change
New ways of working become consolidated into
practice
In this change:
– The force destabilising current practice is the presentation of
evidence about improving practice
– Dissemination of the findings of the literature review will start
the unfreezing process
Requires the identification of ways to do this and the development
of communication tools
1Lewin
1951. Field Theory in Social Science, Harper Row, London; 2Lewin 1958. Group decision and social change.
In: Readings in Social Psychology, Maccoby et al. (eds), Holt, Rinehart & Winston, New York.
Implementing Practice Change:
Application of Theory (2)
Lewin’s Theory of Force Field Analysis1
– Allows the change leader to identify:
Driving forces to push the change forward
Resisting forces which get in the way of change happening
In this change:
– Many of the driving and resisting forces will be
identified during the initial information phase
Allows for interim planning to address these forces
Plan will incorporate activities that address the need to
increase the power of the driving forces and break down,
remove or minimise the resisting forces1,2
1Lewin
1951. Field Theory in Social Science, Harper Row, London; 2Shanley. J Nurs Man 2007; 15: 538–46.
Implementing Practice Change:
Application of Theory (3)
Ottoway Change Cycle1
– Mimics well-known nursing process by using
assessment, planning, implementation and evaluation
– Structured approach which uses terminology that most
nurses are familiar with
May assist with distributive leadership approach
– Planning stage of the model considers:
Nature of the change
Personnel involved
Other social, organisational and political issues which may
affect the change
1Grol
and Wensin. Med J Aust 2004; 180: 57–60..
Implementing Practice Change:
Leadership
Leaders:
– Powerful drivers of the change process1
– Role models2
– Set standards3,4
– Exert influence over others involved in
the change2
Effective leadership is key for successful
implementation of this change5
1Beinicke
& Spencer. Int J Leadership Pub Serv 2007; 3: 4–13; 2Buchanan et al. Int J Manag Rev 2005; 7: 189–205;
3By. J Change Manag 2005; 5: 369–80; 4Hewerd et al. Health Prom Int 2007; 22: 170-8; 5Bass 1990. Bass and Stogdill’s
Handbook of Leadership: Theory, Research and Managerial Applications, Free Press, New York.
Implementing Practice Change:
Leadership (2)
Many leadership theories cite singular leaders1,2
Harris and Spillane Model of Distributive
Leadership:3
– Primary change leader identifies and supports several
leaders in the organisation
– Considers organisational culture
Significant in identifying driving and resisting forces4
– Supports ‘ownership’ of the change at all levels5,6
– Contributes to staff development7,8
1990. Bass and Stogdill’s Handbook of Leadership: Theory, Research and Managerial Applications, Free Press, New York;
Leadership, Harper and Row, New York; 3Harris & Spillane. Manag Edu 2008; 22: 31–4; 4Jackson 2006. The Human Face of
Organisational Change Thesis, Southern Cross University, Australia; 5Carney. J Nurs Man 2000; ?: 265–72; 6Cork. Nurs Stan 2005;
19: 40–2; 7Day. The Leadership Quarterly 2000; 11: 581–63; 8McPhail. J Nurs Manag 1997; 5: 199–205.
1Bass
2Burns.
Leadership Roles in the
Change Plan
Change leaders will initiate, monitor, develop, evaluate
and act as agents for the change1,2
One single change agent will initiate the change by:
– Disseminating information about the change
– Providing education sessions for staff involved in the change
– Presenting the change plan and proposed management of the
change to the manager of the practice and the practice board
Additional change agents will:
– Implement the change within their client groups
– Assist in cascading the change to other staff involved in the
care of patients with hypertension
Use of experienced nursing staff in this role reflects the
need for leaders with the status and credibility to make
them powerful change drivers
1Martin
2003. Leading Change in Health and Social Care, Routledge, London; 2Iverson. Int J Hum Res 1996; 7: 122–49.
Resource Implications of the
Change Plan
Resource implications and the effects on staff
workload/morale of any change plan must be
considered
– Resources are limited within most healthcare services
– Healthcare staff are known to be resistant to change
because they do not like the destabilisation of existing
approaches to care1
– A sense that the change may add to workload may
affect morale and impact on the success of the
programme2
Disseminated leadership will reduce burden on
individual staff and address the above concerns
1Martin
2003. Leading Care in Health and Social Care, Routledge, London; 2Yoder-Wise 2007. Leading and Managing
in Nursing, Mosby, St. Louis.
Project Timelines
Month
Key Actions
1
Development of an patient-centred community educational model to
improve hypertension control
Presentation of model to relevant parties to gather feedback
2
Finalise staff and patient information materials
Implement pilot education programme in 3 selected patients
Amend intervention according to feedback received
3–5
Recruitment and education of change leaders/agents
Preparation for implementation
5
Identification of resisting forces to change and necessary actions to
overcome these
Development of record-keeping procedures and inclusion criteria for
intervention
6–8
Recruitment of patients
Agree evaluation plan (quantitative/qualitative)
9–11
Implementation of intervention
Regular weekly meetings of all staff to discuss emergent issues
12
First evaluation of intervention
15
Final evaluation of intervention
Conclusions
Research highlights the need to improve patient understanding of
hypertension, the symptoms, and the significance of ongoing high blood
pressure readings
Evidence demonstrates the benefits of education programmes in
hypertensive patients
This educational program would support patients with hypertension to
reduce blood pressure readings through an increased understanding of
their condition and normal vs abnormal readings
Potential benefits:
– Improved self-efficacy regarding management of their condition
– Reduced demand on healthcare services
A structured approach will be employed which incorporates classic change
theories to plan, implement and evaluate the change
A successful program will require effective leadership, based on distributive
leadership theory, which gives authority and responsibility to multiple
nursing change agents
Resource implications appear to be minimal
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