Development and evaluation of a nurse-led hypertension management model: A randomized controlled trial

Abstract

Background

The hypertension prevalence rate is increasing but the control rate is unsatisfactory. Nurse-led healthcare may be an effective way to improve outcomes for hypertensive patients but more evidence is required especially at the community level.

Objective

This study aims to establish a nurse-led hypertension management model and to test its effectiveness at the community level.

Design

A single-blind, randomized controlled trial was performed in an urban community healthcare center in China. Hypertensive patients with uncontrolled blood pressure (systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg) were randomly allocated into two groups: the study group (n = 67) and the control group (n = 67). The nurse-led hypertension management model included four components (delivery system design, decision support, clinical information system and self-management support). Patients in the control group received usual care. Patients in the study group received a 12-week period of hypertension management. The patient outcomes, which involved blood pressure, self-care behaviors, self-efficacy, quality of life and satisfaction, were assessed at three time points: the baseline, immediately after the intervention and 4 weeks after the intervention.

Results

After the intervention, the blood pressure of patients in the study group decreased significantly compared to those in the control group, and the mean reduction of systolic/diastolic blood pressure in the study and control groups was 14.37/7.43 mmHg and 5.10/2.69 mmHg, respectively (p < 0.01). In addition, patients in the study group had significantly greater improvement in self-care behaviors than those in the control group (p < 0.01). The study group had a higher level of satisfaction with hypertensive care than the control group (p < 0.01). No statistically significant difference in self-efficacy and quality of life was detected between the two groups after the intervention.

Conclusions

The nurse-led hypertension management model is feasible and effective in improving the outcomes of patients with uncontrolled blood pressure at the community level.

Introduction

Hypertension is a major risk factor for cardiovascular and other chronic diseases. In China, the hypertension prevalence rate was 30% in 2010 (Wang et al., 2014). The prevalence rate increased by about 10% in China from 2002 to 2010 (Gao et al., 2013, Li et al., 2005, Wang et al., 2014). However, only 8%–10% patients in China successfully control their blood pressure (BP), which is defined as an average SBP < 140 mmHg and an average DBP < 90 mmHg (Liu & Writing Group of 2010; Chinese Guidelines for the Management of Hypertension, 2011), which is much fewer than in high-income countries (37%–65%) (McAlister et al., 2011, Nwankwo et al., 2013). Doctors play a prominent role in hypertension management. Nurses are also important healthcare providers and have been proved as effective as doctors in improving the outcomes of hypertensive patients (Horrocks et al., 2002, Keleher et al., 2009, Laurant et al., 2005). Carter et al. (Carter et al., 2009) performed a meta-analysis of nurse-led healthcare management and found a 4.8 mmHg reduction in systolic blood pressure (SBP) in hypertensive patients, while other researchers (Clark et al., 2010, Glynn et al., 2010) called for further evaluation of this efficacy.

Generally, hypertensive patients in China receive health care in hospitals or clinics. However, the limited medical resources are not sufficient to meet the great demand. Community-based hypertension management, with its characteristic of highly efficient utilization of medical resources, is recommended by WHO (2002). In China, hypertension management at the community level is a recent development, but studies show that it has achieved preliminary success (Chen et al., 2014, Liang et al., 2014). However, none of these studies included a control group. Other studies (Gao et al., 2015, Lu et al., 2012, Ma et al., 2014) have adopted community-based interventions to investigate the effects of hypertension management via randomized controlled trials (RCT). However, some experimental designs are of poor quality. For example, the generation of the randomized sequence was inadequate in most of the studies (Lu et al., 2012). In addition, due to the lack of standard operational protocols, the practice of hypertension management in China varies widely. Thus, further studies are warranted to verify the results. Additionally, for healthcare providers in hypertension management in community health centers, more studies have focused on doctors and fewer on nurses (Gao et al., 2015, Lu et al., 2012). It is not known whether an approach involving nurses at the community level would be applicable and effective for hypertension management.

This study aimed to develop a nurse-led hypertension management model and to test its efficiency on hypertension patients with comparison to the usual care in community health centers. The BP reduction, self-care behaviors, self-efficacy, quality of life (QoL) and satisfaction of patients were systematically analyzed.

The nurse-led hypertension management model was developed from the Chronic Care Model (Wagner, 1998, Wagner et al., 2001) and the Four-C Model (Wong et al., 2005). Four components in the Chronic Care Model, including delivery system design, decision support, clinical information system and self-management support were adopted in the nurse-led hypertension management model. The Four-C model (comprehensiveness, collaboration, coordination and continuity) (Wong et al., 2005, Wong et al., 2010), reflecting the strength of nursing intervention in hypertension management, was also employed in the nurse-led hypertension management model. It is of note that the nurse-led hypertension management model emphasized patients’ self-management even after intervention.

The team consisted of four trained nurses, one general practitioner, one researcher, and two coordinators. Nurses were in charge of home visits, telephone follow-ups and referral initiation when necessary. The general practitioner was responsible for providing pharmacological treatment for referred patients. The researcher was in charge of support for the nurses’ decision-making and assessment of the quality of care delivered. The coordinators did not directly conduct interventions on patients but were responsible for time and resource allocation to allow the interventions to run smoothly.

A 36-h pre-intervention training program was conducted in this study to enhance the nurses’ decision-making (Zhu et al., 2014). The training contents included knowledge and skills for nurse-led hypertension management.

The Chinese version of the Omaha System (Martin, 2005, Wong, 2012) was adopted for patients’ information collection. The Omaha System records patients’ current health problems and intervention strategies, as well as evaluating their knowledge, their behavior, and the status of their health problem. The Omaha System has been reported to be reliable and feasible (Wong, 2012).

Self-management refers to the self-care behaviors. The trained nurse was asked to i) help patients to understand the importance of self-management; ii) encourage patients to discuss health conditions and set mutual goals; iii) help patients to make plans and perform self-monitoring; iv) provide relevant information and resources for self-management; and v) provide booklets (Zhu et al., 2014) with intelligible text and pictures to enable patients to enhance their knowledge of self-management.