Introduction
Medical practice is constantly evolving as a field due to the availability of new information and data. Modern healthcare strongly encourages change through an evidence-based approach. The following paper as part of the Direct Practice Improvement (DPI) Project will focus on a measurable patient outcome of adult hypertension in urban outpatient clinics and introduce change via patient education with the teach-back method. The purpose of this paper is to apply evidence-based Orem’s Self-Care nursing theory and ACE Star change model to evaluate relevance and effectiveness of the DPI project of hypertension improvement through education and determining its value for public health in the community.
Clinical Question and Background
Hypertension is a growing prevalent health problem for U.S. adults. At the same time, it is a condition that can be manageable through health behaviors such as activity, diet, and adherence to medication. However, health literacy and understanding of the underlying biological processes of the condition are lacking as well as lack of comprehension on how to adhere to physician recommendations on this issue. The prevalence of hypertension in New York City is 33.9% which largely matches the expected patient ratios where in 1 in 3 or 1 in 4 adults have the condition (Fei et al., 2017).
Clinical Question
To what degree does the implementation of the Newest Vital Sign (NVS), Hypertension Knowledge-Level Scale (HK-LS) questionnaire, and HEDIS guidelines health literacy tools in the use of teach-back method (intervention) impacts improved hypertension awareness and management (what) when compared to traditional patient education (with no teach-back) among adult patients 18 to 85 years of age with hypertension (population) patients in an out-patient setting (setting) in New York (state)?
Supporting Data
According to National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP n.d.), 6 in 10 Adults in the US have a chronic disease. The Healthcare Effectiveness Data and Information Set (HEDIS) guideline associates blood pressures above 140/90mmHg with increased cardiovascular complications (The National Committee for Quality Assurance [NCQA], 2020). World Health Organization, in a 2019 report on hypertension, stated that hypertension is a serious medical condition, which increases the risks of other chronic health condition such as heart diseases, brain conditions, kidney diseases amongst others and major cause of pre-mature death (WHO, 2019).
Currently, the health care system is complex, specialized, and technologically sophisticated. Health literacy becomes an issue when health care providers expect patients to increase their responsibility for self-care. The presence of chronic illnesses in the community demonstrates the urgency for a change in the way health care is provided in the community setting. Health literacy is a growing area in research to delivering quality care. There are important implications for patient-provider communication and the coordination of healthcare. Health literacy refers to an individual’s ability to understand and make decisions using basic health information and services from healthcare facilities and linkages to community resources (Magnani et al., 2018). Limited health literacy affects people’s ability to navigate the healthcare system thus hindering patients’ compliance with treatment regimens and ability to share in healthcare decision making (Magnani et al., 2018).
Theoretical Foundations
Nursing theories are critical to enabling care for patients by providing a foundational knowledge and offering guidance on clinical decision-making. The theories serve to establish guidelines for nursing practice, both general and specialized. They improve health care provision by positively influencing health and quality of life for patients through nursing actions.
Nursing Theory
The proposed theory of choice is Dorothea Orem’s Self-Care Nursing Theory, more specifically, one of its subsections known as self-care deficit nursing theory. The basics to this were introduced in Orem’s first book back in 1971, and it continues to be actively taught in the medical field. The premise to the self-care deficit nursing theory is that people should be responsible for their care, and self-reliant to the best extent possible. Since patients wish to care for themselves, providing them with the opportunity and tools to do so, they may recover more holistically (Orem, 2001). By meeting self-care requisites, patients may achieve knowledge necessary for self-care behaviors, and illness prevention. It is also important to recognize that self-care are behaviors learned within the socio-cultural context (Petiprin, 2016). Orem defines self-care as activities that people do to improve their capacity to maintain their health, well-being, and quality of life (Petiprin, 2016). Orem bases her assumptions on the ability of humans to adapt to the varying environment (Petiprin, 2016). According to this theory, the teach-back method can encourage self-reliance by improving patients’ literacy levels and their ability to remember instructions (Petiprin, 2016).
Synthesis of Evidence
Orem’s theory is commonly utilized in modern-day nursing. According to Yip (2021), the theory is helpful as a means of improving patient’s health outcomes. In an observational case study of an APN using the self-care deficit nursing theory (SCDNT, the nurse applied practical knowledge by determining how the patient can best practice self-care in the circumstance of their living arrangements and support system. It was determined that the theory is an appropriate theoretical framework for nursing practice, allowing for primary care nurses to care for patients as a component of wider family and society. It enables to use nurse-sensitive metrics when evaluating clinical practice (Yip, 2021).
Meanwhile, Tok Yildiz and Kaşikçi (2020) evaluate a training program based on SCDNT to promote self-care and quality of life with patients with coronary artery disease. A randomized controlled study conducted demonstrated that patients receiving the intervention tested significantly higher on the Self-Care Agency Scale and other indicators than those not in the training program. Nurses are encouraged to use SCDNT to improve self-care agency and effectiveness of education efforts. Finally, a conference presentation by Helou (2019) presented findings on the use of SCDNT in interprofessional collaboration to promote diabetic kidney disease outcomes. She found that the implementation of SCDNT improved quality of life and self-care activities, arguing it should be congruent with nursing practice as it is based on evaluating patient needs and self-care agency.
Summary
The clinical question aligns with Orem’s theory of self-care deficit, as it introduces an intervention that directly aims at increasing self-reliance of patients for self-care for a chronic but manageable condition. The intervention offers the health literacy tools and guidelines for patients to engage in their own decision-making regarding their health activities. Orem’s theory emphasizes that nursing is needed when an adult is limited in the provision of effective self-care. There are several methods of helping, ranging from supporting to creating an environment promoting personal development, and teaching one another. Nursing systems can be fully compensatory, partially, or supportive-educative system (Petiprin, 2016). In this clinical question, the patients are capable of self-care but require support and education to promote that understanding and holistic approach to their health.
Evidence-based Change Model
The growth and innovation of medical practice is founded upon evidence-based change (EBP). EBP models are an effective means to facilitating practice change. For organization to adopt an EBP model that fits their context of care, aligns with care goals, and addresses critical issues provides a systematic collaborative approach to practice changes for the benefit of the patients and the organization.
Change Model
The ACE Star Model of Knowledge Transformation is a model that aims to comprehend the characteristics and cycles of knowledge that are used in various contexts of EBP. It seeks to organize both old and new knowledge on betterment of care and providing a framework which can be used to organize EBP practice. The model consists of 5 points: 1) discovery research, 2) evidence summary, 3) translation to guidelines, 4) practice integration, and 5) process, outcome evaluation (Stevens, 2004). It is a simplistic but logical depiction of the relationship between stages of knowledge transformation. It takes previous scientific work in the context of EBP and serves as an organizational cycle of examining and applying EBP in mainstream nursing practice (Stevens, 2004). Given that the PIP project focuses on implementation of EBP in practical contexts and evaluating interventions on patient populations, the model serves as an excellent tool in the context of developing and presenting the efficacy of the EBP intervention in practice with the foundation of knowledge and data.
Synthesis of Evidence
The ACE Star Model of Knowledge Transformation is a model that aims to comprehend the characteristics and cycles of knowledge that are used in various contexts of EBP. It seeks to organize both old and new knowledge on betterment of care and providing a framework which can be used to organize EBP practice. The model consists of 5 points: 1) discovery research, 2) evidence summary, 3) translation to guidelines, 4) practice integration, and 5) process, outcome evaluation (Stevens, 2004). It is a simplistic but logical depiction of the relationship between stages of knowledge transformation. It takes previous scientific work in the context of EBP and serves as an organizational cycle of examining and applying EBP in mainstream nursing practice (Stevens, 2004). Given that the PIP project focuses on implementation of EBP in practical contexts and evaluating interventions on patient populations, the model serves as an excellent tool in the context of developing and presenting the efficacy of the EBP intervention in practice with the foundation of knowledge and data.
Summary
The clinical question aligns with the model by seeking to evaluate an evidence-based intervention in a clinical context. It essentially goes through all 5 points of the ACE Star Model in terms of developing knowledge into an EBP practice and then applying it to a clinical patient population with evaluation of outcomes.
Linking Nursing Theory, Change, Model, to the Direct Practice Improvement Project
The purpose of this scholarly DPI project is first, to determine if the implementation of the teach-back method is an effective way to improve comprehension and self-care information and second, to assess whether teach-back is associated with better blood pressure control as evidenced by BP less than the Healthcare Effectiveness Data and Information Set (HEDIS) guideline of 140/90 in adults 18 to 85 years old. Orem’s self-care deficit theory suggests that nurses should intervene to help patients maintain autonomy. In the context of care, nurses identify self-care deficits, functions related to health and well-being that a person cannot fulfill due to some impairment. Nurses assess the situation and intervene in cases where needed, but consistently promoting patient’s strengths and creating motivation and goals for a patient to be able to care for themselves and achieve a level of independence. According to the theory, nurses can either act and do something for another, create an environment for personal development, or guide, support, or teach another (Petiprin, 2016).
Research suggests that health care professionals are to use literacy-dependent teaching methods (e.g., the “teach back” method) and reinforcing education about patients’ conditions to ensure patients understanding of treatment recommendations (Miller, 2016). In other studies, teach back method improved hypertension self-care management and overall long-term positive outcomes (Graarup et al., 2016), improved blood pressure self-care management and blood sugar control in patients with diabetes, and improved self-care behaviors such as dietary salt reduction and medication compliance, and directly improved blood pressure in a study with patients with heart failure (Howie-Esquivel, 2015). The teach-back method endorsed by the DIP project is a direct application of self-care deficit theory where nurses provide guidance and teaching to populations to provide them with knowledge of self-care behaviors and autonomy to treat the condition.
The ACE Star Model of Knowledge Transformation also fits into the DIP project as it translates implementation of research into evidence-based practice. The research provided throughout this paper indicates that hypertension is a chronic condition that can be effectively managed independently by the patient, in fact relying more in patient lifestyle activities than any treatment that could be provided by physicians. The effectiveness of patient education and the teach-back method has also shown high efficacy in driving patient understanding. Therefore, taking that research into account, the DIP project develops an intervention which translates into the evidence-based practice, supported by empirical evidence and metrics to determine if the teach-back educational method is effective for urban adults with hypertension.
Conclusion
The DPI project based on the clinical question seeks to determine how the use of patient knowledge evaluation, national guidelines, and the teach-back method as health-literacy patient education tools impacts outcomes in terms of awareness and management among adults with hypertension in NYC. Orem’s SCDNT supports this project purpose since the intervention is aimed at increasing the self-care agency of patients in management of hypertension through nursing education and support. Meanwhile, the ACE Star Model of Knowledge Transformation is applicable as this project seeks to test how the use of teach-in patient education for hypertension can impact a specific population, thus potentially formulating new EBP processes. Both SCDNT and ACE models can work together to support the project purpose. The ACE model takes knowledge of the patient education and its effectiveness in other areas, primarily through teach-back and applies it to EBP practice. At the same time, SCDNT encourages to see gaps in knowledge and how nurses can intervene to push patients’ agency and autonomy. The teach-back method presented alongside guidelines and a questionnaire to determine health literacy, serves as patient-empowering EBP approach that will improve self-care and management of hypertension, resulting in better patient outcomes.
References
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