NUR09400 Chronic Disease: Nurse-Led Hypertension Management Model

Aims:

.To provide a comprehensive grounding in research paradigms and methods.

.To critically consider the relationship between the research context, research question, method and knowledge development.

.To develop critical appraisal skills of different forms of research

.To support the development of students as critical users of evidence

Critical Appraisal of Zhu, Wong, and Wu (2018) Paper on Development and Evaluation of Nurse-Led Hypertension Management Model

Introduction

In this review, we will focus on a quantitative paper done by Zhu, Wong, and Wu in 2018. The title of the paper was, ‘Development and evaluation of a nurse-led hypertension management model: a randomized controlled trial’ and it was published by Elsevier in the International Journal of Nursing Studies. The keywords in the article are hypertension, model, management, nurse and randomized controlled trial. This was a randomized controlled trial comparing between a nurse-led hypertension management frameworks compared to the standard care model in a community health setting. The importance of undertaking this study was to develop and evaluate a better model of managing hypertension by significantly reducing their blood pressure levels, increasing their satisfaction, providing enough health care support, and increasing self-care efficacy among other reasons. In the subtopics below, the paper will be critically reviewed to identify the strengths and weaknesses of the methods and procedures used (Greenhalgh, 2010).

Focus

This is a scientific paper on a randomized clinical trial focusing on the development and evaluation of a nurse-led hypertension management system. Based on the topic, a reader can be able to identify measurable variables, hence having a clear understanding of the main objective. For instance, just by reading the topic, we are able to understand that it is a randomized clinical trial and the main measurable variable will be how well hypertension is managed on nurse-led hypertension management compared to another standard or existing framework. It is an important topic for research because hypertension creates a huge burden on global health. Huffman and Lloyd-Jones (2017) and Forouzanfar et al. (2017) outlined that the burden of systolic blood pressure and hypertension was rising, using data from 844 population-based studies done in 154 countries. They indicated that the number of people having blood pressure above 140 mmHg has risen from 442 to 874 million between 1990 and 2015. Therefore, based on this evidence, we could firmly state that this topic is significantly relevant in developing the best framework to manage hypertension.

Background

The researchers have argued highlighted the main factors supporting the importance of conducting the study. First, they have outlined the burden of hypertension in China and how it has changed over time. They also indicated that hypertension is not being managed well because of a few doctors, who have a high burden of providing support to the increasing number of people having hypertension in reference to various studies provided by the research in support of the claim that nurses would highly improve the management of hypertension. Based on previous research, they have indicated that very few individuals having hypertension are able to manage it correctly. Therefore, we could outline that there is a serious problem, which needs to be solved by conducting further research. Sufficient literature has been provided in the background to indicate that nurse-led hypertension management frameworks have effectively worked before (Halcomb, 2011).

Further, recommendations have been outlined on these studies to evaluate the efficacy of using these frameworks. Other existing frameworks have been described in the background to show an overview of the various frameworks which have been developed to improve hypertension care. They include delivery system design, decision support, clinical information support, and self-management support. The main variables measured in the study included blood pressure reduction, quality of life, satisfaction and self-efficacy were outlined in the background. The variable was clear as stated and could be easily understood in reference to measurements.

Aim

The main objective of the study was clearly stated in the background chapter, indicating that the study aimed at developing a nurse-led hypertension management framework and later testing its efficacy and efficiency in comparison to the standard care at community health care centers. To achieve the objective, the researcher test a nurse-led hypertension management framework and compare the findings with the standard care in a community-based health center.

Methodology

The study adopted an experimental design, with the aim of correcting information on the quality of care, blood pressure reduction, self-efficacy and satisfaction of the patients based on a nurse-led hypertension management framework and comparing the findings with a standard case at community health centers (Denzin and Lincoln, 2000). According to the objective, the chosen study design is sufficient to answer the questions and provide sufficient evidence. After the recruitment of the study participants, the nurses were to visit the patients homestead with the aim of collecting detailed information to be used in the analysis. During this meeting, the nurses would inform and educate the families and patients on hypertension management through teasing and guidance on hypertension management procedures and treatment. Among the main points on the management of hypertension, the nurses emphasized self-management and its importance.

The study was also designed to allow phone call follow-ups after the first visit. The discussions of the nurses and the patients or patient families were guided by the screened results. Further, it was also recommended that the patients would visit the clinics and they would be referred if they met the referral criteria. The referral criteria were defined as patients reported to have increased blood pressure. In such situations, the nurse would evaluate their adherence and determine the possibility of any other illnesses leading to the outcome. On the other side, the participants in the control group received sponsored check-up annually and reading material to enhance their knowledge of hypertension management. Later, the nurses would make follow-ups on the patients, if needed, after the end of the study. As a result, they would support them effectively in cases of failed hypertension management (Medications and Changes, 2014).

Data collection tools

The data collection tools used in this study had been used other studies and were accepted within Chinese health guidelines (Hart, 2007; Lessler et al., 2014). The measurements were conducted immediately after the recruitment, named as T0 and T1 which was 12 weeks after the intervention and then T1, 16 weeks after the intervention. In measuring blood pressure, calibrated stethoscope and sphygmomanometer were used. These tools are accepted under the Chinese guidelines and had been used in previous studies. Similarly, tools used to collect data on self-care, quality of life, self-efficacy, and satisfaction assessment had been used by previous studies. The rationale for the tools used was that they were the standard tools accepted by the Chinese health care guidelines.

Methods of data analysis and presentation

The statistical software used for the data analysis was stated together with its version. Statistical methodologies used to answer the research questions were discussed and justified. The research findings were presented well in tables. However, the researcher did not consider using graphs for the data presentation. A table comparing the results from T0 with T1 and T0 with T2 was shown. Summary statistics were clearly presented in a table. The table is shown general characteristics of the study participants in the intervention and control groups (Cook, Netuveli and Sheikh, 2004). 

Sample

The researcher had indicted a potential dropout rate of 20%, hence controlling for that effect in the sample calculation stage. Based on the chosen parameter of calculating the sample, a size of 92 was obtained, and after controlling for the anticipated dropout rate, a minimum size of 115 participants was achieved. After assessing the potential study participants, 134 met the criteria, who were then randomized into the control and intervention groups. Several people were a loss to follow-up due to various reasons in both groups. Regardless of the loss to follow-up, an intention-to-treat analysis was performed, hence including all the 134 (67 in the intervention and 67 in the control groups) participants (Noordzij et al., 2009). The researchers stated the inclusion and exclusion criteria statements. It was stated that individuals above 18 years who had uncontrolled blood pressure and were able to access the community health care centers. Patients who could not be contacted over the phone, those who took medications which could increase their blood pressure and those with secondary hypertension were excluded from the study (Holloway and Wheeler, 2010). Also, pregnant or those planning from pregnancy, patients with comorbidity in contradiction and those diagnosed with a terminal illness were also excluded.

In reference to the nature of the study, the inclusion and exclusion criteria provided were sufficient for generalizable research.  The research included individuals who were 18 years old and above. Therefore, as much as the research can be generalizable to other the population, it can only be persons who are 18 years and above. The exclusion criteria were mainly based on ethical issues and ensure that the study does no harm to the study participants (LoBiondo-Wood and Haber, 2014). The criteria do no limit the quality of the study. The inclusion criteria were used to screen for patients within the population to participate in the study. All of those who met the criteria was included in the study. There might be sampling errors which might be due to unequal distribution of potential confounders, for example, age and geographical location. A more rigid method such as randomization and stratification could have been used to balance the potential confounders (Habib et al., 2014).

Ethical considerations

It is stated that ethical approval was sought from The Hong Kong Polytechnic University and all the participants were allowed to read, understand and sign an informed consent before participating. The researcher did not mention anything about the confidentiality of the patients’ information in the paper. Therefore, the study was not very rigorous in ensuring that the participants were respected and all the research guidelines were followed, amongst ensuring that patients’ information was kept secure and confidential (Holloway and Wheeler, 2010; LoBiondo-Wood and Haber, 2014).

Main findings

The researcher found that there was a significant reduction in systolic blood pressure for the patients in the intervention group compared to the control group between T0 and T1. This significance was also observed for the diastolic blood pressure. There was a significant interaction between time and group in the average value of diastolic and systolic blood pressure. Both the standard and nurse-led frameworks had positive results for managing hypertension (Smulyan and Safar, 2000; Egan, Li, and Wagner, 2016). Further, the diastolic and systolic blood pressure decreased significantly with time in both groups.

At all the three time points, there was no significant difference in the adherence to the anti-hypertensive drug. Comparing time points zero (T0) and one (T1), there as a significant increase in adherence score in the study group compared the control. Also, the significance was also observed to T0 and T2. The median adherence scores in the study group were significantly higher in T1 and T2 compared with the control group.

A significant difference was found between the groups based on self-efficacy at T0. Therefore, they were included in two-way repeated measures ANOVA, and no significant difference was found between time and group (Faraway, 2002; Ross and Willson, 2017).

In the analysis of the quality of life data, time and group interaction was not found to be significant in the two-way repeated measures ANOVA. However, within group effects were found to be significant; which include, physical role, bodily pain, general health, social functioning, emotional role, and mental health. Generally, a significant increase in the mentioned within group effects was observed between T0 and T2. Finally, the satisfaction levels for the study participants in the study group increased significantly from 3 to 28 while for those in the control group increased from 0 to 7 (Cook, Netuveli and Sheikh, 2004).

Strengths and limitations

However, the researcher acknowledged that the study was limited to just community health and they recommended further research could be done, covering a wide scope to improve on generalisability. Since the study was single-blinded, there is a possibility that the participants were they were in either group, hence influencing dropout or switching medication. The study setting was urban. Hence it would raise concerns whether the results could be generalized in the rural areas. The rates of hypertension and its control are slightly different from northern China compared to the south where the study was located. The main advantage of the study is that it highly influences the health, research, and service for future improvement on hypertension management.

Study Validity

Within the manuscript, there was no clear description and justification of the study designs and methods. However, based on the strength of research evidence in reference to the study design, randomized control trials (RCTs) are at the top after systematic reviews and meta-analysis. For this reason, we would affirm that the chosen study design would provide strong evidence against the research question. The study could have been done better by performing systematic reviews and combine the evidence with the findings of the RCTs. The findings of the study and their presentations made sense and were directly linked to the study objective, and with the best of my knowledge, they were authentic and genuine.

Conclusions and recommendations

In conclusion, it was stated that self-care behaviors were critical in enhancing the management of hypertension. The study showed that nurse-led hypertension management framework enhanced self-care behaviors among the patients who improved hypertension management. Comparing the standard care of hypertension and nurse-led framework, it was found that patients were highly satisfied with the latter. Therefore, it created an impression that the framework should be adopted to improve on hypertension care — finally, the findings of the study and how they were communicated made sense and could be much use in the management of hypertension. However, the stated limitations call for more research in other areas, which have a different setting to allow for generalisability and potentiality of validating the results.

Application to practice

This research informs the way to manage hypertension. The results indicate that there is better methodology which can be applied – hence improving the quality of life, satisfaction and reducing blood pressure more effectively compared to the standard care framework adopted by the health care system. Therefore, more research can be done to improve the generalizability of the results, which can then be used to inform policy on hypertension management. As a suggestion, the study could have been expanded a little bit to capture other characteristics in the community. As a result, this could have improved the generalizability of the findings.

References

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Zhu, X., Wong, F. K. Y. and Wu, C. L. H. (2018) ‘Development and evaluation of a nurse-led hypertension management model: A randomized controlled trial,’ International Journal of Nursing Studies. Elsevier, 77(October 2017), pp. 171–178. doi: 10.1016/j.ijnurstu.2017.10.006.