The role of a nurse in the diagnosis and screening, prevention and treatment of hypertension is now a world known fact, and in this manner, the implications in the provision of successful hypertensive treatment are huge. This has led to many medical and nursing related researches and trials, which have shown immense benefits of nursing intervention internationally. The role of nursing is now of value as hypertension is becoming the world’s most prevalent health condition and can lead to significant morbidity and mortality should it be not addressed properly. New interventions will ensure the prevalence of hypertension is reduced, which is predicted to increase many fold in the coming years.
Nursing Contribution towards Hypertension: Preventing Disease and Creating Awareness
HYPERTENSION AND STATISTICS
It is welcoming to see that with the passage of time, the proportion between the untreated and treated hypertensive and normotensive patients respectively has changed. There has been an increase in the number of normotensive patients, a term describing patients who have achieved adequate control of their high blood pressure. The trend is a positive indication of the increasing role that healthcare detection and prevention can play in hypertension. (Ebrahim, 1998)
Nurses have played an important role in the promotion, treatment, prevention and creating awareness about many diseases currently prevalent around the world. These contributions continue to take place and now with more knowledge at the nurses’ disposal, better methods of implementation of various health care techniques can be applied.
Hypertension is one of the most prevalent conditions that are causing significant morbidity and mortality around the world. This increased prevalence is especially seen in the First Nation countries, and contribute a major portion to renal and cardiovascular complications. (Tobe et al, 2006) The statistics in the UK are high as well, where hypertension is prevalent in the one fifth adult populations and the most common risk factors leading to conditions such as coronary heart disease and stroke etc. The most common cause cited for the increased prevalence and risk in this particular group of countries lies in the increased difficulty in getting appropriate medical treatments and support. (Tobe et al, 2006) The total population of hypertensive adults with readings of 140/90 in countries of UK, Germany, France, Italy and Sweden amount to 75 million.(Pater, 2005) The risk of hypertension increases with advancing age, and afro-Carribeans and women folk are likely to have higher blood pressures. Coronary heart disease is twice as prevalent in hypertensive patients. The sad part of the situation is that while the complications of hypertension are well understood, there is very little done in terms of increasing awareness and prevention than should be done. “This is the reason why hypertension has been so popularly termed the silent disease and leads to problems such as coronary heart disease, stroke, renal failure and peripheral vascular disease”. (Let’s Do It Well, 1988)
With increasing understanding about the condition, the methods of management and prevention have also improved. But application and implementation of these preventive measures remain still below expectations and optimal levels. The responsibility lays in the hands of the medical healthcare professionals who must ensure proper identification, diagnosis and treatment and prevention of the condition. Other complications include peripheral vascular disease and renal disease. The role of nurses has increased in the creation of awareness in the many areas of hypertension, and below will be a small glimpse in the huge contribution that nurses have placed in the treatment and prevention of hypertension.
Hypertension ideally would be defined as the condition where the blood pressure exceeds the standards which are applied to each and every individual based on the age and sex of the person. Usually a range of these values is considered, although it must be borne in mind that there is no actual threshold which indicates the start or end of high blood pressure. This variation in the criteria if applied in surveys or studies, can lead to wide range of results, even within the same population, about the prevalence of hypertension. (Ebrahim, 1998)
Hypertension is mainly an asymptomatic condition, and its cause is essentially unknown in the case of primary hypertension. Secondary hypertension, however, is caused by other diseases or conditions such as renal diseases, pheochromocytoma, primary aldosteronism, and coarctation of aorta. Cushing’s syndrome, drugs, acromegaly and pregnancy, and hyperparathyroidism are also among the other conditions that can cause secondary hypertension. (Let’s Do It Well, 1988) Regardless of the cause, hypertension, once established can lead to various complications itself, and this means an increased burden of care for a patient who may have an existing condition in addition to hypertension.
Current hypertensive regimes and guidelines are under much debate and have led for many to look into the various methods to deal with hypertension. The current recommendations remain flawed in many areas, as the treatment regime has been protocolled in to specific sequence of drug administration with out considering the different requirements for each individual case. All the while these guidelines have ignored the fundamental concepts of emphasizing the need for accurate readings, the differences of treatment opinions that may be present among physicians and the variables attached with different drugs. (Pater, 2005) Another concern in all this debate is the futility of all these recommendations and guidelines, since hardly any are actually applied or followed to the full in any area of clinical practice. This is especially evident by looking at the global statistics of treatment provision to a small percentage of the hypertensive population world wide.
These regimes and guidelines have also started to cause conflicts about the cut off points of hypertension readings among the different healthcare professionals themselves, which are causing extreme confusion in creating a clear picture of the total hypertension prevalence. (Pater, 2005)
The importance of hypertension outcomes in patient health has prompted the medical community to devise methods and ways to combat the increasing prevalence of the condition and the complications that follow it. Of the many initiatives and contributions, the recent years and researches have now begun to accept and appreciate the dynamic role that nursing is playing towards the improvement of healthcare among the patients. Now nursing researches and trials are considered to be equal and at par with medical researches and their results and inferences is now an important component in the various strategies devised for the provision of health for the patients.
Focus has also increased in carrying out screenings and hypertension prevention programs for those persons who belong to the minorities or those who are poor. Also aimed is to include persons who currently may not have health insurances. (Ebrahim, 1998)
Due to the increasingly complicated problems that can be caused by hypertension, it has become one of the priorities in medical interventions. These interventions have been very ambitious, but still have been able to target a very minute population of the total hypertensive patients in managing their condition optimally. The recent introduction of National Service Framework’s standards within the healthcare system is expected to help combat the problem. This system includes among other interventions, follow-up programs and audits, which all aim to improve primary healthcare services regarding hypertension control, prevention and treatment. (Let’s Do It Well, 1988)
While these preventive and screening programs may be hailed as the saviour of the currently sinking situation of hypertension prevalence, it shows a serious and dangerous problem that has not been considered seriously up till now. With more and more leaning towards the public healthcare systems, the burden of hypertensive care is increasing worldwide. Such interventions around the world amount to billions of dollars worldwide, along with a significant portion of health budgets allocated to hypertension prevention. This is compounded by the recent addition of the term pre-hypertension, which has increased the number of patients manifold. The problem therefore cannot be expected to be handled through public measures only, and other methods need to be planned. (Pater, 2005) Yet still, the costs of the secondary prevention clinics and nursing interventions are still significantly lower when compared to the different costs of hospital stays and treatments. This is the reason that this method of health care delivery is gaining fast acceptance around the world.
Some of the screening programs have been introduced in the community settings such as the malls. However, even these methods cannot be said to be entirely inclusive of the total hypertensive population. This is because malls and other such areas are not so readily accessible to the disabled groups. This problem is often encountered in the healthcare centres as well, and this group often is missed out in screening programs. (Ebrahim, 1998)
ROLE OF NURSING IN PATIENT OUTCOME DEVELOPMENT
Patient outcome development might not have come to this state that it is today if it weren’t for the efforts of nurses during its various stages of development. The contribution dates back to the time of Florence Nightingale, who conducted various surveys and displayed statistics in identifying the different morbidity and mortality rates during the times of the war. The attitudes and approaches continued to grow and advance with time, and now nursing is an active contributor and participant in the various patient outcome related issues. Nursing interventions especially specialist interventions regarding various diseases and conditions have shown extremely promising results in the overall medical and healthcare. Nurses have helped reduce stress and pain perception in by taking up various home nursing care projects, and the list of patients include hypertensive and elderly, to cancer and terminal health patients. The level of satisfaction and the statistics of positive outcomes continue to vote for the positive effects nurses have on the health outcomes of the patients. (Brooten et al, 1995)
The application of care based approach in the various aspects of patient care have shown positive responses and increased motivation among the patients about curing themselves. Such patients also demonstrate more compliance with their treatment regimes and other such related things such as life style modifications. Among all, the patient satisfaction is perhaps the strongest contribution nurses give in patient outcomes.
While many initiatives such as follow-ups visits and telephone calls have been implemented within the healthcare system with some effect, researches point out that nurses are able to hold patients compliance for short intervals. Most of the time, these strategies are effective for only a month or so. The presence of actual nurses as in house nursing or the continuation or increase in the house visits for the patients can promise much better outcomes than relying on phone calls and distant time span healthcare visits. (Brooten et al, 1995)
All these interventions carried out by nurses cannot be fairly evaluated unless proper researches are carried out that compare the nursing led and the physician led managements of hypertension and hypertension therapy. The trials should also be carried out to study the impact of the interventions introduced and to determine which are the better and more feasible ones economically, health wise and in providing more positive results regarding patient outcomes and self motivation. Researches are required to find out the importance of the various risk factors in the progression of hypertension, which can be carried out through computer aided technologies, and different visual and interactive methods. Such researches will be helpful in pointing out the right directions of investment in terms of healthcare for hypertensive patients. The last type of series of investigations should look in to the effects such initiatives have led to in the overall improvement of the health of the patients. Mostly such trials will be looking in to the practice managements of the different organizations. (Ebrahim, 1998)
NURSE AWARENESS ON HYPERTENSION
Hypertension significantly increases the risk for stroke and therefore preventing stroke would require preventing and treating hypertension. Although the pharmacological approach to treating hypertension is by far one of the most successful approaches, it becomes difficult to apply within the primary care setting for many reasons. Half the problem lies in the fact that much of the data collected from the studies is not applied correctly within the healthcare setting. Primary care does not accurately identify the patients most likely to benefit. (Ebrahim, 1998) Also, not every one may approach primary care or may do so only when the need arises. This means the target population may not be approached effectively through this tactic alone. Poor compliance among the patients about their treatment along with poor adherence among the professionals regarding the guidelines may also complicate problems. The problem of poor compliance in hypertensive patients has been damaging to the healthcare economy, as this costs billions of pounds per year. Less than 10% of the hypertensive patients in the UK show compliance required for the proper treatment of hypertension. (Thrall et al, 2004) The risks of morbidity and mortality in such cases run very high. For the patients, the poor compliance is due to the life long duration of the disease, the side effects of the medication, the complexity of the regime, the symptom less nature of the condition, and the different health beliefs. (Ebrahim, 1998) psychological and emotional factors are perhaps the most prevalent issue in case of compliance. All these above stated factors seriously jeopardize the statistics and findings one gets from trials and studies conducted in primary care, as it does not provide us with the correct and actual picture. Only half of the hypertensive population get diagnosed, and the community effectiveness only amounts to 5% when we include all the above factors in to the equation. This means that primary care is a very poor source to help in preventing and treating hypertension. The economic costs are also a very debatable issue in this entire scheme, as the quality adjusted life year costs may range £900 to £100,000 depending upon the patient. This is to bear in mind that it only includes a part of the hypertensive patients that have access to primary care. (Ebrahim, 1998)
But all these arguments aside, the researches do show that primary care does help in identifying at least half of the hypertensive populations, if not all cases. Modifying these screening methods may lead to improved results in the detection of hypertension. (Ebrahim, 1998) While primary care may not be helping in identification of all cases of hypertension, it is still helping by playing its part.
Many recent interventions have been introduced within the primary care system for nurses in helping them better manage hypertension related issues. It is in this series that the Hypertension Influence Team was introduced in 2000, which in its agenda included the Nurse Learning Pack. This team aims to increase awareness among the public about hypertension and its role in coronary heart disease. The team also aims to improve diagnosis, management and follow-up in the community. The team and other such initiatives by the government are especially focused on addressing the various health and economic issues related to hypertension and to reduce the burden on the healthcare that is imposed by hypertension and its complications. (Let’s Do It Well, 1988)
Other new methods include the use of telemedicine, computer prompts and patient held records. Although these areas are relatively new, they are still considered as good potential contributors in the health care of hypertension. (Ebrahim, 1998)
INTERVENTIONS IN BLOOD PRESSURE CONTROL AND MANAGEMENT: A BRIEF REVIEW
So what are the methods by which nurses provide care to the hypertensive and related cardiovascular and diabetic patients? Some of the common strategies applied are the provision of encouragement and support to the patients, with promotion of active life style pursuit with counselling. Nurses are very good conveyers of the different aspects of the patient’s treatment regimes. They are able to provide and encourage family support for the patient, measure and monitor risk factors and do so with compassion in their heart. The main focus is to help the patient communicate the different emotions or feelings that he or she is feeling regarding his or her treatment, and to gently guide them to a more positive and healthy outcome. The combination of these factors ensures the patient receives the best knowledge about their condition, and is able to identify their own contribution in their health. (Riley, 2003)
There have been many secondary and tertiary prevention models and methods introduced by the nurse, which aim to address hypertension issues. Since cardiac and stroke conditions are closely related to it, many of the interventions carried out in any of these areas overlap the other. Some interventions introduced are mainly patient directed, where increasing the time for education and awareness for the patient is increased. Other more public interventions work on including the various parts of the society, which work together in contributing more knowledge and awareness about hypertension. Such interventions can include a huge variety of people, for example local groups, social sectors, voluntary services, library staff etc. public promotion is aimed to reach out to a larger audience in general, where as one to one consultations and counselling are especially beneficial for patients who are undergoing the disease process. (Riley, 2003)
Nursing intervention studies show a marked improvement in the overall control of blood pressure in the patients. These improvements have been especially noticeable in home caring nurses as compared to home visiting nurses, who mainly carried out only blood pressure measurements. Since these studies are now showing benefit throughout the world, there is increased interest in introducing these methods in the mainstream healthcare. (Tobe et al, 2006)
Nurses are a significant factor in reducing hospital mortality rates in patients with heart conditions, neoplasms, hypertension and cerebrovascular disease among some. More researches continue to provide proof about the contributions of the nursing staff towards controlling hypertension.
NURSES IN THE PROVISION OF QUALITY PRIMARY HEALTHCARE
The potential role of nurses in the healthcare sector was expected long before it was actually noticed by many visionaries. This increased role playing in evidenced by the sharp increase in the number of nurses during the nineties, where nursing first started to make its impression. The nurses were a welcome addition at the right time as they addressed the needs of the then health sector needs regarding care provision. The contributions of nurses in various health care sectors were higher than many other groups of healthcare providers, including the GPs. The trails continued to show the increasingly important role of the nurses in the healthcare sector, which continues till today. (DEST, 2001)
Nurse practitioners are one of the key contributors in the provision of quality healthcare within the primary healthcare settings. Presence of these individuals in the primary healthcare leads to improved access and almost equivalent level of healthcare as the physicians. Studies have helped in identifying some aspects that can lead to improved care provision, for example, the institution of geriatric nursing staff within the nursing homes has been shown to increase positive responses among the patients. These positive outcomes have been especially appreciated in the areas of hypertension prevention and management, where nurses, in addition to increasing patient compliance, also increased the quality of care for nursing patients. Nurses were especially able to help patients reduce excess weight and blood pressure effectively and with long term results. (Brooten et al, 1995)
Patient outcomes have been specifically affected by economic factors such as decreased nursing staff due to staff reduction and increased pressure and work demand on the rest of the nursing staff, increased ages of the nurses and the decrease in the number of fresh graduate nurses entering into the field. Such cost cutting efforts may in fact lead to a downslide in the health outcomes of the patients, as studies demonstrate that decreased mortality rates are seen in places where increased ratios of registered nurses are present. Registered nurses have also shown enhanced organizational effectiveness in patient-nurse-doctor communications, nursing empowerment, and independence for nurses regarding nursing decision making. (Brooten et al, 1995)
There is still much to research and publicize about the effects of nursing interventions on patient outcomes, and also to promote them. But nursing has never the less shown a very positive potential in increasing the quality of care.
One of the biggest problems that nurses come across with their hypertensive patients is the change in the attitude of the patient after knowing his or her condition. For example, such patients may have more absences or sickness leaves, and may not respond to being “labelled” as a hypertensive patient. (Ebrahim, 1998) This leads to a new problem creation for the nurses as they must learn to acknowledge the patient’s mental status and condition and be able to provide support, while at the same time convince them to take a more positive and active role in their maintenance of health.
SKILLS DEMONSTRATED BY NURSING PROFESSIONALS IN HYPERTENSION.
The science of nursing has increased to become a complex field that is now a cornerstone for the advancement of the healthcare sectors around the world. In such a case, the roles and the job demands of the nurses have increased to include a very comprehensive range, which all aim to provide the best care delivery to the patient. Currently, these nursing roles are categorized under four areas; direct comprehensive care, support of systems, education and research. Direct comprehensive care includes the nurse’s ability to do a complete psychological and physical evaluation of the patient, and based on that to reach a differential diagnosis. Nurses now have the authority to carry out and advise various diagnostic tests, make decisions, perform specialty specific procedures and initiate and continue care. In the areas of prevention and awareness, nurses are the main counsellors, advisors and coordinators of patient care. They can authorize referrals, provide preventive care, and use protocols to guide patients. Other working areas include the provision of healthcare education and advice, and research on areas that focus on patient care. (DEST, 2001)
In case of hypertension maintenance, the role of a nurse begins immediately when a patient enters the hospital premises, as a majority of the patients are unaware of their hypertensive status. The nurses are therefore the first persons in diagnosing and identifying a new case of hypertension and any associated complication. Nurses are then responsible for reporting of the case to the superiors as well as the patient, and then proceeds towards compiling of a proper treatment plan based on the patient’s findings. These can be either simple monitoring of the potential hypertensive patients on regular basis, to modified life regimes some, to complete therapeutic interventions in others. Since now nurses are capable to reaching diagnosis and providing treatments, they now hold a very strong position in the care for hypertensive patients, as well as in contributing sound clinical knowledge about the different aspects of hypertensive care.
COST EFFECTIVENESS OF NURSING INTERVENTIONS IN SECONDARY PREVENTION
There is sufficient research and documentation to prove that nursing is a very cost effective measure in secondary prevention regarding many health conditions. Nearly all the intervention clinics and attempts that have been carried out by nurses have shown considerable success in improving the qualities of the patient’s lives. Such interventions reduce the significant numbers of mortality rates and are able to save money that might have been very high should a hospital intervention had taken place. The introduction of a team based strategy in the provision of secondary prevention is now a very popular method among the nurses, as this means a more closer and effective collaboration between the different physicians and nurses. (Editorial BMJ, 2005)
The trials continue to show very positive benefits of secondary nursing interventions. These improvements were especially significant in improving the functional status and reduction in the need for hospital admissions. Such interventions include lifestyle modifications, and medical treatments. Lifestyle modifications include smoking cessation, alcohol cessation, a healthy diet and living style, where as the medical treatments involve anti-platelet agents, blood pressure reduction, lipid reduction and the use of beta blockers and angiotensin converting enzyme inhibitors. For achieving the desired targets, the physicians and nurses are given financial rewards from the UK government. The cost effectiveness of nursing interventions is to be well appreciated when compared to the NICE costs of £ 30,000. Such clinics have shown an increase in the mean life years by 0.110 years and 0.124 QALYs, when compared with their correspondent control groups. The collecting evidence continues to support the nursing interventions that have been introduced in the healthcare systems as a cost effective measure. (Raftery et al, 2005)
There are many loopholes that need to be overcome if correct and accurate diagnosis and treatments are to be decided. For example, due to the large variation in the values of hypertension, as well as different emotional factors that can cause changes in the blood pressure, the nurses should take several readings in different settings and intervals before definitely diagnosing the patient. The white coat hypertension is one of the common incidences at the clinics and nurses are very helpful in this area to ensure no such event occurs. (Ebrahim, 1998)
NURSE PRESCRIBING: THE DIFFERENT VIEWS AND DEBATES
Prescription writing from nurses is a relatively new addition in the healthcare provision. And as yet, the idea still needs to sink in many minds. Where formerly, nurse prescription was devised to compensate for the increased shortage of physician population especially in the rural areas, nursing now has expanded and renewed itself as an active participant in the urban areas as well. The fight to legally give right to prescription to nurse has been present since the early 90s, and it was this time that first saw the development of the modern nurse prescription writing system. This system is now used widely and popularly in many countries around the world and UK is now among the leading promoters of this methodology.
To achieve this goals, the UK government had to ensure that nurses be brought up to date with the recent medication regimes and methods, as well as provide them with education about the different aspects of prescription and prescription writing. Postgraduate continued education and revision courses had not been compulsory in the past, which meant that nurses devoted limited time in increasing their learning capabilities and new advancements in nursing and medicine. Now, the UK government has attempted to overcome this barrier with the introduction of courses which extend to approximately 26 days extended over a period of 3 to 6 months. (Griffiths, 2004) There is no actual formulation of a prescribing curriculum in nursing per se, but a set of guidelines and recommendations are required to be followed through to ensure such is achieved.
Most of these guidelines and teaching courses include the various aspects of nurse prescription and its methods, along with introducing the human factors of accountability and responsibility to ensure a quality performance. Anyone belonging to the nursing profession is eligible to undertake the course, resulting in a diverse mix of nursing professionals working in various areas of healthcare and localities, and providing the most competent services available. The designations allotted to these individuals help in identifying their power in prescription writing. For example, district nurses, health visitors, and extended formulary nurses have the authority to prescribe independently, and are solely responsible for their prescriptions. Meanwhile, the patient group directors and supplementary prescribers are supplementary or dependant in nature. Patient group describers are generally not considered in the prescription area of expertise. (Griffiths, 2004)
Although this introduction to prescribing has been hailed as a positive step among the many, there are still many areas that cause reason for concern or debate and dispute. For many, “the introduction of nurse prescribing breaks down the medical monopoly, and may be viewed as a challenged to the dominance of medicine.” (Griffiths, 2004,Pg43) This has led to fierce debates from the doctors side that nurses be subjected to the same quality assurances that doctors are expected to provide, and in the event of a mishap, must be subjected to same accountability and legal litigation procedures as do the doctors go through under similar circumstances. The lack of any quality nursing prescribing courses and curriculum leaves much to be desired from the nurses when it comes to taking care of complex medical situations. To settle this, the most common method devised is the proper following of the national protocols and guidelines that identify methods of prescriptions. Other concerns that allowance of nursing prescription has raised is the safety of the patients, using nurse prescription methods as a substitute to physician prescribing, and the lack of depth of knowledge that remains between the doctors and the nurses different methods of education. Understanding these issues and handling them accordingly are hoped to improve the outcomes. (Griffiths, 2004)
NURSES AND CARDIOVASCULAR PREVENTION ROLE
Hypertension is a major health factor for many serious conditions. This is why hypertension prevention and awareness is in the top priority in many of the clinical specialties. The cardiovascular risk due to hypertension is very high and therefore requires very serious commitment to treating. Nurses have excelled in this area, where care for patients of cardiac problems concurrent with hypertension are reviewed and maintained with utmost attention. This secondary prevention of coronary heart disease has established itself as a major portion of the healthcare routine. Various studies have shown the improved results in the outcomes of the patients where nursing interventions and practices were introduced. The nurses are able to reduce the risks of any complications through positive modification of the patient’s risk factors. The patients who received nursing interventions were able to report reduction in anxiety and depression, and improvement in the overall quality of life. (Riley, 2003)
NURSES IN OBESITY
As discussed before, obesity is one of the prime factors that lead to hypertension among patients. The reduction of weight and change in the diet plan is one of the most difficult problems that these patients have to undertake. The plan needs continuous monitoring of the condition and guiding and educating the patients in the various phases of the treatment. The role of nurses in the weight management clinics is very important. Nurses provide the encouragement and support, continue monitoring, and work in the areas of nutrition and dietary advice. The positive reinforcement that the patients receive is a very important contributor in the reduction of hypertension in patients.
Nurses are one of the leading health care provision forces in the world. They have shown immense contributions in the areas of prevention and awareness, and have proven to be better than all others in the area of healthcare. Nurses now are the major carers of patients suffering from hypertension. With more and more enhancements in the nursing roles regarding hypertension along with other areas of care, they are more than able to provide excellent care to the patients. This is in addition to the fact that nursing interventions in the area of hypertension have shown more positive results when compared to plain physician prescribing and monitoring methods. The combination of professionalism, empathy, care and gently persuasion are the hall marks of nursing care that are now an integral part in the provision of quality healthcare.
It is in this respect that nurses need to be identified for their contribution and different issues that may be affecting their performance be addressed properly. The shortage of nursing staff around the world is a primary concern in the nursing profession. Such and other related issues are needed to be asserted in order to make nursing a dynamic workforce for the current medical and healthcare system. Hypertension will continue to increase in people with time and will become an epidemic around the globe. The repercussions of this prevalence will be felt in the healthcare system, the economy, the workforce, the global productivity and on the patients themselves. Addressing it with commitment and dedication is the only way this epidemic will be contained.
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