The Influence of Education Protocol on Non-Compliant Hypertensive Patients

Introduction

Patients with hypertension comprise one of the most populous and vulnerable groups (Dasgupta et al., 2014). 20% of the population in the U.S. suffers from this condition. Center for Community Health and Evaluation (2017) state that adequate management of hypertension relieves patients from further complications. However, less attention has been given to the managing hypertension in patients who fail to comply with doctor’s orders. Several researchers such as Dasguptaet al. (2014), Ma, Zhou, Zhou, and Huang (2014) suggest that patient education might help address this problem. Evidence Based Practice (EBP) is an excellent method of testing such hypothesis in clinical setting. PICOT question is as follows:

PICOT	Questions
Patients	Hypertensive patients who fail to follow treatment rules
Intervention	Educational protocol and counseling session
Comparison	Noncompliant patients who do not receive these interventions
Outcome	Increased adequate treatment rules (compliance) and improved blood pressure
Time	A documented one year of trending results with three-month follow-up intervals

Table 1. PICOT question

The Aim of the Current Research

The study is aimed at ascertaining whether educational protocol and counseling sessions will help non-compliant patients with hypertension improve their patterns of following the treatment rules. This project will help me analyze the problem of non-compliance and the issues patients with hypertension tend to encounter. Additionally, if the achieved results will be evaluated as positive, a new EBP will emerge, which I will use in my clinical practice and, therefore, advance as a professional APRN (Schneider & Whitehead, 2013). Devising, testing, and implementing such a tool will be a huge addition to my CV and benefit my future career propositions.

Literature Search and Review

In the present section, a literary basis will be discussed. A summary of the scientific evidence can be found in appendix 1 named “Table 2. Evidence synthesis.” A table with the evaluation of the theoretical background is in appendix 2 named “Table 3. Evidence evaluation.”

The literature for the current project was found in the Medline, Elsevier, and PubMed Central databases. Free full texts of the researches were published on the websites of the correspondent resources as electronic versions. The search was conducted through Google Scholar Internet resources with a time frame of 2013-2018. The search words used to find suitable evidence included hypertension, patient education, clinical setting, hypertension prevention, hypertension management. These keywords were used in combination with case ‘AND’ and asterisk to increase the chance of finding suitable information.

The quality of evidence in the examined articles was level 1, 2, and 3 as the study designs varied from RCTs to convenience sampling and cluster-randomized trials.

One of the studies that founded the basis for the current project was a convenience sampling study by Babu, Ramachandran, and Maiya (2015). The research featured a report on elaboration and implementation of an education method to raise awareness of pulmonary hypertension and the benefits of physical exercise among its victims. The positive results and the experience of the development of such information booklets are a valuable addition to the current project.

Another practical implication was developed by Beune et al. (2014). This cluster-randomized study focused on developing a culturally sensitive education practice for patients with hypertension. As a result of education sessions, blood pressure in the treatment group improved significantly. An idea of iterative individual sessions has proved to be highly effective and was considered for the current project.

Ma et al. (2014) developed a motivational education session for patients with hypertension, which also proved to be highly effective and decreased systolic and diastolic BP levels to almost normal. The thorough approach the researchers used to implement their project will be an experience the author of the current study would also use. It is paramount to mention that the researchers educated not only patients but also preemptively instructed nurses on how to present the information.

The studied literature gathered positive experience and evidence-based practices to ensure the current project will be effective. The amount of available scientific works vividly illustrates the interest in this sphere of prevention and management of diseases. However, almost no information was found on education for patients exhibiting noncompliance with the treatment plan, which marks an area for the current study.

Methods

Study design

The study will be a controlled trial with an intervention and control group. Patients in the control group will receive care according to set clinical standards while the other group will receive experimental interventions.

Sample

The sample will be chosen among patients experiencing high blood pressure in a clinic where the author of the study is currently employed. A total of 50 patients (25 in each group) will be considered eligible if they meet the following criteria: a) 18 and older patients; b) patients with a diagnosed hypertension with any cause for it except diabetes. Patients with diabetes will be excluded because, according to Beune et al. (2014), they have different treatment needs and, therefore, different education issues.

Confidentiality will be granted to all patients according to clinical standards. The chosen people will only be considered participants if they give their written consent for it. A non-disclosure status will be preserved partially due to the non-collection of names (Melnyk & Fineout-Overholt, 2015).

Intervention

A team of three professional RNs will be chosen to help the author with conducting counseling sessions and developing booklets with information. A preparation for counseling is also in order. It will ensure the quality of education sessions (Ma, Zhou, Zhou, and Huang, 2014). Counseling sessions will feature interactive presentations 15-20 minutes long about common adversities of non-compliance and the benefits of compliance with a treatment plan. A booklet will contain general information about the condition and a treatment plan. Clinic officials will also be contacted to have time and space allocated for involved parties to proceed with the experiment.

Data Analysis and Evaluation

Data will be analyzed before, amid, and after intervention (Ogedegbe et al., 2014). Firstly, all patients who agree to take part in the project will be asked to complete a survey measuring their essential metrics connected to hypertension such as systolic and diastolic blood pressure. There they will also state the frequency and the reason for non-compliance with their treatment plan. Those two metrics will be used to measure the overall success of the project and will be gathered in the intermediate and final measurements (Kjeldsen et al., 2014). Demographics such as age and sex will also be recorded.

Instruments

The primary analysis instrument is SPSS statistical tool. It allows normalizing numerical values such as heartbeat rates and easily measuring mean and mode values for demographics and arranging them into graphs and charts (Leech, Barrett, & Morgan, 2014). The survey will be developed using Google services and then printed and distributed manually among patients. Presentations will be created using Microsoft Office PowerPoint.

Implementation Plan

At the commencement stage, two weeks will be needed to prepare and coach a team of RN colleagues and inform the managers to assist in arranging meetings and sessions. After that, three weeks are needed to select patients and ask for their consent. Next, the author will develop a questionnaire for the above-mentioned demographics and key project performance values (2 days). In two weeks, the team will distribute surveys and gather the necessary information. After that, on the 2nd, 6th, and 12th months of study individual education sessions will be performed. Two weeks would be needed to rearrange the data into a readable and presentable format.

Dissemination

The results will be published in the clinical newspaper and, possibly, in a peer-reviewed journal if the outcomes are positive. The report will also be presented to the instructor in college. If the new practice can be developed from the present research, it would also find its use in the author’s present and future practice. Consequently, it would be a great addition to the clinical policy regarding patient education. If enough effort is applied to promoting this EBP into daily practice, the intervention could significantly boost the clinic’s capacity for addressing the patients’ needs.

References

Babu, A.S., Ramachandran, P., & Maiya, A.G. (2015). Effects of the Pulmonary Hypertension Manual (PulHMan) on awareness of exercise in patients with pulmonary hypertension. Heart, Lung and Circulation, 25(1), 41-45. Web.

Beune, E. J., Charante, E. P., Beem, L., Mohrs, J., Agyemang, C. O., Ogedegbe, G., & Haafkens, J. A. (2014). Culturally Adapted Hypertension Education (CAHE) to improve blood pressure control and treatment adherence in patients of African origin with uncontrolled hypertension: Cluster-Randomized trial. PLoS ONE, 9(3). Web.

Center for Community Health and Evaluation. (2017). Reimagined care case study: Health quality partners & engaging patients in hypertension management. Web.

Dasgupta, K., Quinn, R. R., Zarnke, K. B., Rabi, D. M., Ravani, P., Daskalopoulou, S. S.,… Prebtani, A. (2014). The 2014 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Canadian Journal of Cardiology, 30(5), 485-501.

Kjeldsen, S., Feldman, R. D., Lisheng, L., Mourad, J. J., Chiang, C. E., Zhang, W.,… Williams, B. (2014). Updated national and international hypertension guidelines: a review of current recommendations. Drugs, 74(17), 2033-2051.

Leech, N. L., Barrett, K. C., & Morgan, G. A. (2014). IBM SPSS for intermediate statistics: Use and interpretation. London, UK: Routledge.

Ma, C., Zhou, Y., Zhou, W., & Huang, C. (2014). Evaluation of the effect of motivational interviewing counselling on hypertension care. Patient Education and Counseling, 95(2), 231-237. Web.

Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing and healthcare: A guide to best practice (3rd ed.). Philadelphia, PA: Wolters Kluwer

Ogedegbe, G., Tobin, J., Fernandez, S., Cassells, A., Diaz-Gloster, D., Khalida, C., … Schwartz, J. (2014). Counseling African Americans to control hypertension: Cluster-randomized clinical trial main effects. Circulation, 129(20), 2044-2051. Web.

Schneider, Z., & Whitehead, D. (2013). Nursing and midwifery research: Methods and appraisal for evidence-based practice. Chatswood, Australia: Elsevier Australia.

Appendix 1

	Study 1 (Babu, Ramachandran, & Maiya, 2015)	Study 2 (Beune et al., 2014)	Study 3 (Ogedegbe et al., 2014)	Study 4 (Center for Community Health and Evaluation, 2017)	Study 5 (Ma, Zhou, Zhou, & Huang, 2014)	Synthesis
(P) Population	Patients recruited in the out-patient Department of Cardiology. Age ranged 30 to 60 years old with a 16/14 (male/female) sex distribution. Causes of hypertension were spread amongst various disease types with a variance in the WHO functional classification.	Patients found across four primary care centers. The population had to self-identify as Suriname or Ghanaian and be older than 20 years old. They must have been treated for hypertension and have a systolic blood pressure of ≥140 mmHg	Every patient was African American with a mean age of 56 years old with 28% being male. 59% were diagnosed with obesity and 36% with diabetes mellitus	Hypertension patients across two health centers. Other demographics unknown	Hypertension patients. Chinese nationality. Patients had a mean age of 59. Both groups had an approximately an equal distribution by sex. They had to be taking antihypertensive medication	It is evident that patients with hypertension adhere to certain demographical trends. Minorities, especially of African origin are more susceptible to hypertension. Based on these studies, the average age for the onset of this condition is after 50 years of age. Certain cardiovascular diseases are contributing factors to hypertension as well.
(I) Intervention	A specially developed manual that took into account patient concerns and expert recommendations. The manual discussed pulmonary hypertension management, specifically through exercise.	The intervention consisted of a culturally competent nurse-led education and counseling sessions. Patients were provided materials and given referrals to facilities which could be used to support a healthy lifestyle.	Patients received four modules of interactive patient education, six counseling sessions on healthy lifestyle, and a blood pressure monitor to record weekly measurements	Patients were provided with a blood pressure monitor and educational materials. The main aspect of the intervention included a blood pressure protocol which helped patients to maintain scheduled monitored readings.	Nurses conducted motivation interviewing with patients designed to address hypertension care. It focused on lifestyle behavior. The method sought to connect with the patients, educate them, and provide strategies on the implementation of various changes.	Patient education and counseling interventions are most often focused on training nursing staff to educate patients and providing them with appropriate educational materials. Patients are encouraged to participate in counseling sessions and adhere to lifestyle recommendations.
(C) Comparison	Single-subject study without a control group. However, the study presented baseline data of awareness to be compared to the outcomes.	A control group received regular hypertension care and had baseline measurements collected for comparison.	Half of the participating community health centers provided usual hypertensive care.	Single-subject study without a control group.	Half of the patients were in a control group receiving standard hypertension care.	Studies with both a single-subject design and a control group were used. The control group always received standard hypertension care without any educational interventions.
(O) Outcome	Awareness for pulmonary hypertension and exercise management was evaluated through a validated questionnaire. Scores increased, particularly in exercise-related awareness	After adjustment of results, the reduction of blood pressure in the intervention group was 10/5.7 and 6.3/1.7 in the control group. There was not a significant difference in adherence to lifestyle or medication recommendations	There was no significant intervention effect. BP control rates for the intervention group stood at 49.3% in comparison to 44.5% for the control group.	Patients followed the blood pressure protocol, checking measurements almost daily. Most patients gave positive feedback about the program, indicating that it helped them to understand the condition and make appropriate lifestyle changes.	The intervention group showed increased adherence to lifestyle changes and medication treatment. Blood pressure values dropped 4.92/2.58 for the intervention group while seeing insignificant changes in the control group	The outcome evidence shows certain trends as a result of various intervention strategies. In practically all studies, patients expressed more understanding of hypertension as a condition as well as lifestyle changes necessary to manage it. A large part was able to adhere to these changes. However objective data shows little to no reduction in blood pressure measurements as a result.
(T) Time	Patients were asked to use the manual and participate in the program for three months before evaluation.	Educational sessions were conducted 2, 8, and 20 weeks after baseline assessment. Final measurements were taken six months after assessment.	Measurements were recorded by patients twice a day, three days a week. Patients regularly visited the health center for the study. Final measurements were gathered after 12 months.	The program ran for only 14 days.	The motivational interviewing program was conducted over a period of 6 months after which measurements were taken.	Time varied for all these studies. Outside of the poorly conducted outlier, the studies last several months, and the most extensive investigations lasted as long as six months which was enough to view visible results of the intervention.

Table 2. Evidence synthesis.

Appendix 2

Citation	Design	Sample Size	Major Variables	Study Findings	Level of Evidence	Evidence Synthesis
Babu, A.S., Ramachandran, P., Maiya, A.G. (2015). Effects of the Pulmonary Hypertension Manual (PulHMan) on awareness of exercise in patients with pulmonary hypertension. Heart, Lung and Circulation, 25(1), 41-45. Web.	Convenience sampling	30 patients. The sample size was calculated based on the awareness exercise on a developed questionnaire with a minimum number determined to be 24. Inadequate for a proper evaluation of educational material	Independent: Providing patients with the PulHMan education and exercise manualDependent: Awareness of hypertension as a disease and managing it through exercise	Strengths: the creation of the educational method used input from both patients and clinical experts which made it comprehensible Weakness: Limited exposure and sample size	One study with one intervention group. The evidence was qualitative in the description but used a questionnaire to determine awareness based on self-response of patients.	The PulHMan manual was developed as a holistic patient education method. It is evident that it showed improved awareness from patients about the condition as well benefits of physical activity. Awareness can often be used as a guide for lifestyle behavior changes for patients.
Beune, E. J., Charante, E. P., Beem, L., Mohrs, J., Agyemang, C. O., Ogedegbe, G., & Haafkens, J. A. (2014). Culturally Adapted Hypertension Education (CAHE) to improve blood pressure control and treatment adherence in patients of African origin with uncontrolled hypertension: Cluster-Randomized trial. PLoS ONE, 9(3). Web.	Cluster-randomized trial	146 patients Adequate sample size which was rigorously filtered	Independent variable: Introducing culturally adapted hypertension education Dependent variable: Blood pressure measurements	Strengths: A unique approach to culturally sensitive education. Very detailed and descriptive of the process.Weaknesses: Limited sample of a specific ethnicity which does not indicate if a cultural approach would be effective with other population.	One study with one group. Quantitative data.	Culturally-competent patient education has been very critical in nursing care. Culturally appropriate educational intervention shows improvements in diastolic blood pressure and adherence to behavioral recommendations in hypertension patients.
Ogedegbe, G., Tobin, J., Fernandez, S., Cassells, A., Diaz-Gloster, D., Khalida, C., … Schwartz, J. (2014). Counseling African Americans to control hypertension: Cluster-randomized clinical trial main effects. Circulation, 129(20), 2044-2051. Web.	Cluster-randomized trial	1059 patients Adequate sample size but not a large variety in demographics	Independent variable: multi-level hypertension intervention for blood pressure control Dependent variable: blood pressure measurement over time	Strengths: Large sample size spread across various locations to evaluate program effectiveness. Weaknesses: Low attrition rate of 30%. Low patient adherent to intervention.	One study, two groups with control. Study mostly quantitative but qualitative descriptions such as feedback responses from patients were considered	Most disease interventions consist of one stage and are not complex. This study used a multi-level intervention based on evidence-based practice. However, it is evident that it showed no significant difference in improving blood pressure control and required better strategies to be implemented for vulnerable populations.
Center for Community Health and Evaluation. (2017). Reimagined care case study: Health quality partners & engaging patients in hypertension management. Web.	Convenience sampling	39 patients Inadequate sample size to analyze an educational program	Independent variable: Patient education and care protocols introduced into care Dependent variable: Adherence to healthy lifestyle and tracking blood pressure at home	Strengths: Conducted in collaboration with several health organizations and clinics Weaknesses: Poorly developed case-study without proper preparation or scientific evidence. Extremely short time period.	One study with one group. Evidence was inadequate and practically all qualitative and based on self-responses	Protocol tools are necessary to create a standardized methodology for patients to manage hypertension. It is also critical to increase patient monitoring of blood pressure at home. Programs which encourage this systemically have potential benefits for mass implementation.
Ma, C., Zhou, Y., Zhou, W., & Huang, C. (2014). Evaluation of the effect of motivational interviewing counselling on hypertension care.Patient Education and Counseling,95(2), 231-237. Web.	Randomized controlled trial	120 patients Adequate sample size but researchers admit the sample size was small	Independent variable: Using motivational interviewing patient counseling technique Dependent variable: patient adherence to lifestyle recommendations. Blood pressure measurement.	Strengths: Strong preparation of nursing staff for the intervention. Thorough, multi-stage process of patient counseling. Weakness: Short time period to implement necessary changes for patients. Nurses between groups were not blindly selected to the sample and acquainted with one another, presenting possibilities of bias.	One study with two groups. The study had both qualitative evidence based on patient self-responses on adherence to treatment. Objective evidence was collected using blood pressure measurements	Motivational interviewing is a counseling technique which seeks to encourage behavior and lifestyle changes. The evidence shows that it has a positive impact on sustainable clinical applications for patients. Medical facilities can use this technique for assisting patients with hypertension conditions in controlling blood pressure

Table 3. Evidence evaluation.