Development of a Clinical Practice Guideline

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Introduction

Sixty-five million people are affected by hypertension in America and 35 million of these are outpatient visitors annually (Moore, 2005). Mostly asymptomatic, hypertension is easily detected and treated effectively. Of the 53% of patients who have medications, 30% have their pressures lowered as required by the recommendations of the 7th Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood pressure (Lookinland and Beckstrand, 2003). Other studies like the Hypertension Optimal Treatment, Elderly Program Study, and the United Kingdom Prospective Diabetes Study have indicated that patients who have a lower BP have a lower mortality rate (Michaels et al, 2003). Lifestyle modifications are essential in the treatment. It requires exercise and dietary changes (Moore, 2005). All people with hypertension need to follow the guidelines of the recommendations of the JNC 7. Cessation of smoking, physical exercise, reduction of weight, decreasing salt intake, and reduction of alcohol consumption are important considerations. A healthy diet consisting of fresh fruits, vegetables, dairy products with low-fat content, decreased saturated and total fat must be advised (NHLBI, 2003). These factors reduce hypertension and thereby the risk of cardiac disease (Uphold and Graham, 2003). Patients with pre-hypertension have been shown to have a higher risk of myocardial infarction compared to people who have a BP less than 120/80 mm Hg. (Liszka, 2005).

Observing BP over some time helps to diagnose hypertension. Treatment is not necessary during the pre-hypertensive stage. Lifestyle modifications are sufficient to maintain a low BP. The elderly are prone to hypertension. They have systolic hypertension with low diastolic BP caused by “increased systemic vascular resistance and decreased vascular compliance caused by the replacement of elastin by collagen in the arterial walls” (Moore, 2005). The goal of therapy is 140/90mm Hg. for hypertensive patients and 130/80 for diabetic patients and those with progressive renal disease. Patient self-care is the best method to keep BP low. Lifestyle modifications must be impressed upon the patients who are in the pre-hypertensive stage and once diagnosed as hypertensive. According to the recommendations of JNC 7, patients in stage 1 must be encouraged to come for reevaluation after 2 weeks. Those in stage 2 must return in 1 week. The revisits are necessary every month. When the BP is stable, revisits at intervals of 3-6 months are sufficient. Serum potassium or creatinine must be examined every 6 months or once a year. The risk of stroke or cardiovascular illness must be prevented.

Research Question

The PICO format is used to formulate the research question as follows

Patients: those who approach the outpatient department for evaluation and management of hypertension as isolated or as a risk for cardiovascular disease or stroke
Intervention: nurse controlled advice on self-care relating to lifestyle modifications
Comparison: patient-controlled lifestyle features or modifications made so far without nursing advice
Outcome: nurse evaluated low BPs.

The question: Which are the best techniques of lifestyle modifications for lowering blood pressures in hypertensive patients, nurse-controlled advice of self-care, and low BP or patient-controlled reports of lifestyle modifications?

Search terms: Articles and works related to the subject were searched so that the experiences of other researchers and authors could be considered. The World Wide Web and sites like the nursing center.com and the Joanna Briggs Institute were searched using keyword insertions. The specificity of terms was narrowed to reach the research question. The search terms were outpatient blood pressure which revealed 39 articles in nursing center.com,1580000 in google.com, and 39 in the JBI Systematic Reviews. “Outpatient hypertension” revealed 504 articles in nursingcenter.com, 1560000 in Goole.com, and 10 results in JBI Systematic Reviews. Outpatient hypertensive systematic reviews revealed 17 articles in nursing center.com, 669 from google.com, and 11 in JBI Systematic Reviews. A few were selected on the proximity to the subject. Only those which had any relevance were selected. The review was selected from the JBI Systematic reviews.

Relevant articles

One systematic review and six studies were selected. The date of publication and the topic were the selection criteria. The review by Rees and Williams on the promotion and support of self-care management for adults with chronic illnesses has been selected for the main critical review (2009). The other selected articles include Gohar’s article, a survey in an outpatient clinic of hypertension. Self-care and adherence to medication are discussed in this survey (2008). The paper by Ho and Rumsfeld speaks about home-based management as being the management for reducing the global burden of the illness and its risks (2006). Peeples and Saley have stressed the importance of nurses influencing the outcomes of chronic illnesses (2007). Moore has spoken about the guidelines for the treatment of hypertension, JNC 7 (2005). The Framington Heart Study by Elliott has stressed the significance of systolic hypertension about the diastolic (2004). Rasmussen focuses on the various stages of the illness including the prevention strategies using lifestyle changes too (2007).

The review which has been selected for critical appraisal consists of both qualitative and quantitative studies concerning the patient-practitioner encounter (Rees and Williams, 2009). The quantitative studies included systematic reviews, randomized control trials, survey studies, and quasi-experimental studies. The qualitative studies included interview designs, vignette technique, qualitative evaluation, grounded theory, and exploratory descriptive design (Rees and Williams, 2009).

Critical appraisal of systemic review and summary of the article

The global extent of chronic illnesses like hypertension, the complexities of the care management requiring a technique that the patients themselves have to follow to reduce their risks of complicating illnesses were the reasons behind the review (Rees and Williams, 2009). The important clinical illness of hypertension requires effective methods to keep the pressures low in patients with hypertension and pre-hypertension. The review sought to determine the “best available evidence” concerning the promotion and support of self-care management. Hypertension being an illness that requires frequent BP evaluation by the nurse in the outpatient is creating a massive problem of increasing outpatient population. This is the reason for the seeking of a solution for hypertension for self-care management at home whereby the rush in the outpatient clinic is diminished. Aiming to find means of educating the hypertensive public to bring about lifestyle change, several studies were investigated to determine the effectiveness of the patient-practitioner encounter. The individual and organizational factors which promote the self-care management strategies were being searched for. Whether the patients and practitioners considered the same factors as effective was another theme.

Rees and Williams investigated studies which were published from 1990 to 2005

The period selected for the review started with 1990, the period just before the institution of the chronic self-care model where the self-care management concept is used for a chronically ill person. The complex care management of chronically ill patients was slowly withdrawing the idea of the passive patient to one of actively participating or collaborating in his management. Thirty-two papers were first considered from which 16 papers were selected for review of 18 studies. The effective role of nurses in the education of patients and for being facilitators to treatment adherence was highlighted in the review.

Results

The review explored a sensible clinical question of self-care management in a case of chronic illness which could be hypertension or cardiac illness or diabetes mellitus. The results are valid as a wide spectrum of quantitative and quantitative studies were used. A broad range of chronic illnesses had been studied. Studies were from nations all over the world. Participants were from a wide range of socio-economic and cultural backgrounds. The heterogeneity of the studies incorporating several interventions with different schools of thought regarding human behavior and psychology all account for the review being a reliable one for drawing conclusions that stand scrutiny. The search for relevant studies was thereby detailed and exhaustive.

Nine of the papers contributed to the results of more than one of the objectives. A meta-analysis of the quantitative studies was not possible but a meta-synthesis of the qualitative studies was done along with a part of one quantitative study. One study was on a guidebook containing guidelines for supporting self-care and mediating the interactions between the doctor and the patient. Another grounded theory study addressed the expert self-care decision-making in Type 1 diabetes. This paper also went into the details of how a health professional’s interactions and attitudes supported or failed to support self-care decision-making. Semi-structured interviews which were information-rich formed two of the studies. Another grounded theory study had “think aloud” sessions.

The primary studies cannot be considered of high methodological quality. Very little research focuses on the patient-practitioner encounter or the outcomes. Many aspects like communication, information, personnel, and organizational factors were considered and they provide the picture of a complex nature. The papers were all heterogeneous with diverse subjects accounting for many outcome measures like physiological, psychological, sociological, and behavioral self-care. The patient-practitioner encounter has been described in many clinical settings but only 5 studies have the community setting and there was a potential for error in 2 of them. The results however were similar to the other results. Randomized control design was used only in two studies. So there is a difficulty in the application of this to health care settings. Co-relational design studies do not help to give proof of causation but give evidence for a hypothesis. Computerized data have the advantage of storage of information which can be used later for a different type of study. Assessments of studies are therefore reproducible from the database of information.

First objective

The effectiveness of the patient-practitioner encounter in promoting and supporting self-care management of people with chronic illness was the first objective addressed. Three categories were elicited. The various interventions which were targeted at increasing self-care management through the patient-practitioner encounter constituted the first category. The second category was the effectiveness of the nurse in the patient-practitioner interaction. The third category included the interventions investigating the patient-practitioner encounter and the impact on self-care. 5 papers had this information for the first category.

Only one paper that gave the more complete version of the 2 randomized controlled studies but reported the same information was selected. This paper studied four interventions for self-care management for patients with ulcerative colitis and Crohn’s disease (Kennedy et al, 2003). It was the best and investigated if self-management or clinical outcomes of patients with ulcerative colitis or Crohn’s disease could be improved through a whole systems approach. The randomization was done by the treatment center. Of the 700 patients who participated, 297 were at 9 intervention sites and 403 were at control sites. The participants in the intervention group had a guidebook on the illness they were diagnosed with, ulcerative colitis or Crohn’s. The consultants who were treating them were asked to use a patient-centered approach and given a one-page guide to help them. The self-management plan was also imparted by the consultant. Improved access to centers was permitted according to the patient’s wishes. Consultations for the control group were normal. The results showed lesser hospital visits after the interventions. Lesser relapses were seen. 74% of patients wished to continue the system of interventions. It was concluded that physiological symptoms and psychological outcomes likeability to cope can occur following the whole systems approach.

Ovid’s study was a descriptive survey (2000). It compared two models for the treatment of diabetes mellitus in 2 Primary Health Centres with practice nurses. A structured approach was taken by nurses at Rokeby. They had a checklist to consider different quality criteria to be done every year: BP, smoking status, self-management, need for foot care, and fundus photography to rule out retinopathy. 3 visits were to be made to the nurse and one to the practitioner. This kind of regularity was not imposed on the patients at Lyckeby. Generally, 2 visits were to be made to the GP and nurses saw them only if the GP requests the visit. 152 participants were at Rodeby and 242 were at Lyckeby. Clinical data were identically collected by computerized recording systems from 133 patients at Rodeby and 168 at Lyckeby. The investigations were found more correctly recorded and maintained at Rodeby. For all variables, the differences were highly significant except for fasting blood glucose. Self-mediated control was found more at Rodeby. The Rodeby group indicated exercise and diet control as the reasons for their better control of the complications. The Rodeby group also tended to contact the nurse more than the other group. The conclusion was that if the treatment of diabetes mellitus is organized in a structured manner, there is a greater chance of metabolic control. The patient’s knowledge is increased and self-management has a better chance of control. There was also a shift of preference for the nurse. Checklists can affect self-management. Gohar’s article is a survey in an outpatient clinic of hypertension. Self-care and adherence to medication are discussed in this survey (2008).

Generally, the studies showed almost similar results. It was found that different interventions can produce similar results. The effectiveness of a patient-practitioner encounter could occur through the use of some specific technique like a “guidebook, a patient-centered approach, a self-management plan and improved access to services, structure of treatment, education, and support of staff in collaboratives.” The patient-practitioner encounter is complex. The first study of Kennedy (2003) described a guidebook that enabled good outcomes while the second (Ovhid, 2000) used a patient-centered approach.

Five studies gave information on the second category about the effectiveness of the nurse in the encounter: they revealed that well-informed patients believed in the promotion of self-care management by the nurses. Ovhid (2000) has described this. Gary (2003) could not infer that the nurse case manager was more preferred than the health care worker for diabetic patients. Baker et al (2005 cited in Rees and Williams, 2009) investigated having a dedicated heart failure nurse, a recommendation of the chronic care model. However, it was understood that contacting the nurse more often helps to increase the knowledge about the illness and self-management behaviors through the relationship between these two variables is not strong. Other authors concluded that process outcomes are better if knowledge is increased through the nurses’ facilitation. This also proves that better adherence to treatment also can be affected (Renders et al, 2000). Some patients have reported that diabetes specialist nurses are respected for their expertise and practical knowledge about the care of the foot in diabetes (Johnson et al, 2005).

The nurses’ contribution to the patient-practitioner encounter has made a positive effect on the patients. Practical care had better be provided by the nurse. More frequent contact between the nurse and the patient could produce a better outcome for the illness and the chances of self-care management increase.

The third category of the interaction in the encounter and its impact on the outcome was indicated in 7 papers. The variables could be different communication methods and self-care outcomes. One paper spoke of provider-patient interaction while four papers had a patient-centered approach as the theme. The conclusions said that sharing of information can help the patient on self-care management but the patient-provider interactions are understood to have a bigger influence on the outcome of self-care management. Heisler et al (2002) found that provider communication was more effective than participatory decision-making. A systemic review focused on provider interactions for the study (van Dam et al, 2003). The 8 studies in the review focused on different communication methods for the interaction. A direct approach by “assistant-guided patient preparation for doctor visits, empowering group education, group consultations, and automated telephone management seemed to produce a better impact on the patient than the changing of the provider behavior through training. Patient-centered approaches provided better outcomes in self-care management. General communication and diabetic-specific communication both had a positive impact on the self-care management of diabetes. Effective provider communication is related to predicting diabetes self-management. The same principle can be used for hypertensive patients.

Second objective

The second objective of the review was to decide how individual and organizational factors are related to self-care management. Doctors believed that in individual factors, the stable patient would appreciate an attempt at self-management (Kennedy et al, 2003, 2005). The patients with dismissing attachment (high self-reliance and low trust of others) had worse control of their diabetes than those with secure attachment (Ciechanowski, 2001). Dismissing attachment must therefore be associated with poor treatment adherence, lower levels of exercise, lower levels of foot care, and higher levels of smoking. So attachment style does affect outcomes of self-care management. The studies indicated that all patients are not interested in self-management. Self-care interventions must be directed at those who need them. The self-care behavior is related to the patient’s attachment style and the amount of autonomy support by the clinician during the encounter.

Organizational factors include a combination of interventions: professional interventions like education and organization interventions like regular review and follow-up. Patients will feel better and more confident about self-care if they have open access to doctor or nurse appointments. User-friendly information must be selected. Care plans must facilitate holistic self-care also by handling the social and psychological aspects of care. Time and resources must be provided by the organization. Renders et al (2000) systematically reviewed 41 studies on organizational factors. All the studies had similar interventions, participants, settings, and outcomes. 12 studies were aimed at health professionals. The organization was targeted in 9 studies. 20 studies aimed at both the interventions. 15 studies had education along with professional and organizational interventions. “Regular review, clinical prevention services, referrals, record keeping, professional patient communications, educational materials, educational meetings, patient education or combinations” were mentioned. The multiple interventions aimed at the professionals and organizations produced benefits to the process but the effects on patients were not obvious. The guidebook in (Kennedy, 2002) in the study on ulcerative colitis and Crohn’s disease patients improved the interviews between the doctor and the patient. Details of investigations could also be recorded in the guidebook. A shared care management was facilitated. The client-centered approach has been accepted by many researchers who believe that this is a good method in today’s organizational and funding arrangements (Fuller et al, 2004). It was not so much the plans that were to be executed but a gradual, “more personal, “not hurried” and a fuller discussion is possible with the attempt. Client trust is obtained and he can live with his illness and set goals for achievement. Time is an essential factor in an encounter.

The third objective

The third objective is to find similarities and differences in the definition of effectiveness by patients and practitioners. The different perspectives that could be considered were obtained from the studies by Kennedy where patients and consultants were interviewed (2003, 2005). Johnsons’s study (2005) showed that patients’ social expectations of care were slightly different from the professional expectations and advice. Decision-making appeared to be a seek for control by the patient and the professional, especially the former. Consultations for the professional are solely concerned with the illness while the patient expects some discussion on his social life. Professionals can allow their patients to have the freedom of giving reliable and correct information.

Application to patient care

Patient–practitioner encounters are essential for instituting a relationship or partnership for improving self-care management. Doctors and nurses must forget their authority and establish a relationship with the patient so that he can voice his opinions on self-care management. Patients must provide their perspectives of self-care management which may include social routines. Though the professional does not include the social routines in his plan, the patient believes his care is complete only when his social routines are discussed. The risks of complications of hypertension must be impressed upon the patient in the form of education. Education may be provided as oral information or literature or posters or short films.

The patient-practitioner encounter must be so designed as to provide maximum benefit to the patient. The application of interventions would improve the outcome of the patient-practitioner encounter. The use of a guidebook, a patient-centered approach, a self-management plan and improved access to services, structure of treatment, education, and support of staff in collaboratives are the various interventions possible.

The nurse is a very effective personality in the encounter. A meeting with a nurse helps the patient gather more information on what he wants to know, much more than what he would gain from a doctor. The promotion of self-care management was more intensive with the patient-nurse meeting. Outcomes are considered to be better after the nurses’ facilitation. Frequent contact with the nurse produces a positive outcome.

Sharing of information between the patient and provider ensures better self-care management. General communication and specific information about the illness also make that impact positive. The stable patient is better committed to making his self-care management work. Patient education, regular reviews, and follow-ups also motivate improved self-care management. Open access to the doctor or nurse puts the patient in a better position for self-care management. Holistic self-care must be incorporated into self-care plans. Organizations must provide time and resources for patient-practitioner encounters.

Recommendations for change of practice

Practice change is a tedious process that calls for proper planning and step-wise implementation. The need for change must be addressed to the health professional and nurse alike. The patients with hypertension must be given the benefits of the patient-practitioner and patient–nurse encounters. The practice change must be organized at the policy level first before carrying the message down the organization. Detailed plans must be chalked out before the attempt at a change of practice.

Steps for the change:

Preparation of all the health workers in the organization. Cooperation among the workers and frequent meetings to discuss the new strategy are essential.
Patients must also be equally prepared for the potential change. They must be ready to share information and interact with the doctor and nurse.
Education must be imparted to the patient in the form of disseminated literature, display boards, posters, short films, and direct advice.
Lifestyle modifications are essential in the treatment. It requires exercise and dietary changes (Moore, 2005).
All people with hypertension need to follow the guidelines of the recommendations of the JNC 7.
Cessation of smoking, reduction of weight, decreasing salt intake, and reduction of alcohol consumption are important considerations.
A healthy diet consisting of fresh fruits, vegetables, dairy products with low-fat content, decreased saturated and total fat must be advised.

Drivers, barriers, and strategies for practice change

The drivers and problems that could occur in the process of change are considered here

Drivers and barriers	Strategies for practice change
Driver 1 Preventing complications of hypertension	Patient-practitioner encounters must be so designed as to assist the patients for self –care management.
Driver 2 Facilitation by nurses	Patients are happier with interaction with a nurse who can help them acquire practical information about their illness and self management.
Driver 3 Less number of visits to the hospital for evaluation	The change of lifestyle could reduce their pressure and maintain it at a lower level requiring lesser visits to the out patient department
Driver 4 Better quality of life of the patients	The lifestyle modifications could result in a better QOL.
Barrier 1 Uncertainty of the patient on the advice obtained	Disbelieving people may have difficulty in conforming to the changes in lifestyle advised. Moreover they do not want to care for themselves

Conclusion

The effectiveness of self-care management can be investigated through qualitative and quantitative researches. The partnership is conveyed as important in the literature reviewed but it is not fulfilled as the patient is not allowed to speak freely. Patient participation if facilitated, the partnership is achieved. A satisfactory partnership ensures good self-care management. Professionals need to allow the patients to speak about their social routines too. Passing on information about the illness, lifestyle modifications, care plans and adequate listening time would facilitate a good self-care management of the chronic illness.

References

Ciechanowski, P.S. et al, The patient –provider relationship; The attachment theory and adherence to treatment in diabetes, American Journal of Psychiatry, Vol. 158, No. 1, p. 29-35.

Fuller, J., Harvey, P. & Misan, G. (2004). Is client centred care planning for chronic disease sustainable? Experiences from rural South Australia. Health and Social care in the Community, Vol. 12, No. 4, p. 318-326.

Gary, T.L., Bone, L. R., Hill, M.N. et al, (2003). Randomised control trial of the effects of nurse case manager and community health worker interventions on risk factors for diabetes related complication in urban African Americans. Preventive medicine, Vol. 37, No. 1, p. 23-32.

Heisler, M et al, (2002). The relative importance of physical communication. Participatory decision making and patient understanding in diabetes self management. Journal of General Internal Medicine, Vol. 17, No. 4, p. 243-252.

Johnson, M., Newton, P. Jiwa, M., Goyder, E. (2005). Meeting the educational needs of people at risk of diabetes related amputation: A vignette study with patients and professionals. Health Expectations, Vol. 8, No. 4, p. 324-333.

Kennedy, A., Rogers, A., Nelson, E. & Robinson, A. (2005). Uncovering the limits of patient-centredness: implementing a self-management trial for chronic illness. Qualitative Research, Vol. 15, No. 2, p. 224-239.

Kennedy, A., Nelson, E., Reeves, D. et al. (2003). A randomized control trial to assess the impact of a package comprising a patient oriented, evidence based self help guidebook and patient centred consultations on disease management and satisfaction in inflammatory bowel disease. Health Technology Assessment, Vol. 7, No. 28, p. 113.

Kennedy, A.P. & Rogers, A.E. (2002). Improving patient involvement in chronic disease management. The views of patients, GPs and specialists on a guidebook for ulcerative colitis. Patient Education and Counseling, Vol. 47, No. 3, p. 257-263.

Liszka, H.A., Mainous III A.G., King, D.E. et al, (2005). Prehypertension and cardiovascular morbidity. Annals of Family Medicine, Vol. 3, p. 294-299.

Lookinland, S. & Beckstrand, R. (2003). Evidence-based treatment of hypertension: JNC 7 Guidelines provide an updated framework. Advance for Nurse Practitioners, Vol. 11 No. 9, p. 32-40.

Michaels, A. Tracy, C. and Young, J. et al. (2003). Medical knowledge self assessment program (MKSAP 13). Cardiovascular Medicine, Philadelphia, P.A.: American College of Physicians.

Moore, J. (2005). Hypertension: Catching the silent killer. The Nurse Practitioner, Vol. 30. No.10., Lippincott, Williams and Wilkins Publishing.

National Heart, Lung and Blood Institute.(2003) The DASH Eating Plan, 2003. Web.

Ovhid, I., Johansson, E., Odeberg, H. & Rastam, L. (2000). A comparison of two different team models for treatment of diabetes mellitus in primary care. Scandinavian Journal of Caring Sciences, Vol. 14, No. 4, p. 253-258.

Rees, S. &Williams, A. (2009). Promoting and supporting self-care management for adults living in the community with physical chronic illness: A systematic review of the effectiveness and meaningfulness of the patient-practitioner encounter. JBI Library of Systematic Reviews. Vol. 7, No. 13, p. 492-582.

Renders et al, (2000). Interventions to improve the management of diabetes mellitus in primary care outpatient and community settings. Cochrane Databases of Systematic Reviews, Vol. 4.

Uphold, C. & Graham, M. (2003). Clinical guidelines in family practice, 4^th edition. Gainesville, Fla: Barmarrae Book.

Van Dam, H.A. et al. (2003). Provider-patient interaction in diabetes care: effects on patient self care outcomes-a systematic review. Patient Education and Counseling, Vol. 51, No. 1, p. 17-28.

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