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GRANDCANYONUNIVERSITY

EffectivenessofAerobicExerciseonAmbulatoryBloodPressureinHypertensivePatients

Chinyere Christiana Pamugo

Has been approved

December 7th, 2022

APPROVED:

Dawn Robinson DNP, MSN, RN, LNHA, DPI Project Chairperson

Khoa Don Nguyen, MD.,DPI Project Mentor

ACCEPTEDANDSIGNED:

________________________________________

Lisa Smith, Ph.D., RN, CNE

Dean and Professor, College of Nursing and HealthCare Professions

_________________________________________

Date

HypertensionisaprevalentdiseaseaffectingmillionsofindividualsintheUnitedStates.Attheprojectsite,therewerenostandardizedguidelinesforeducatinghypertensivepatientsregardingincorporatingexercise(dailyphysicalactivity)asabloodpressure (BP)managementmechanism.Thepurposeofthisquantitative,quasi-experimentalprojectwas to determine if or to what degree the implementation of “theAmericanHeartAssociation’s”guidelineonaerobicexercisewouldimpactambulatory bloodpressurewhencomparedtocurrentpracticeamongadulthypertensivepatientsinaprimarycareclinicinsouthwestTexasoverfourweeks.DorothyOrem’sself-caredeficittheoryandLewin’schangemodelwere the scientific underpinnings.Datawereretrievedfromtheclinic’selectronicmedicalrecords of adult hypertensive patients.(
n-10) and compared at baseline and four weeks post-implementation of the American Herat Association’s guideline on aerobic exercise. A paired-sample
t-test showed a statistically and clinically significant improvement in the systolic blood pressure. Based on the results, the American Herat Association’s guideline on aerobic exercise may improve blood pressure.Onerecommendationforfutureprojectsistoconducttheprojectinothermedicalsettingssuchasmedical-surgicalunits,women’shealth,anddialysispatients.

Keywords:aerobicexercise,AmericanHeartAssociationguideline,DorothyOrem’sself-caredeficittheory,hypertension,hypertension-relatedconditions,KurtLewin’changemodel.

I dedicate this project to God, my life’s author, and finisher. Irrespective of the unsurmountable challenges and moments of despair, your mercy, grace, and love lead me through. Without your divine wisdom, Almighty father, I would not have been here this day.

To my Beloved families here and abroad, my mum, siblings, cousins, and spouse Engr. G. O. Pamugo, I achieved this goal because of your fervent prayers, support, and encouragement that fortified my strength, endurance, perseverance, and resilience not to quit to frustrations and fears. Even with my poor health, I struggled and still made it to this day because you all held my weak parts as I journeyed and ran the race to success. Thank you for believing in me and investing in my success. God bless you all. To my dad-late Chief M.E. Chukwu, I did accomplish your dreams on me, and I know wherever your soul is at this time, it is full of joy; rest in peace, daddy, until we meet again.

To my elder brother in the Lord, Rev. Fr. C. Iwuagwu, words cannot express the magnitude of gratitude I owe you for your fatherly and brotherly love, belief in my abilities, countless hours of encouragement, enormous -uplifts, and renewed determination. You are a blessing and gift to our family; remain blessed.

Acknowledgments

The fruitful journey of my Doctor of Nursing program (DNP) was made possible by the unconditional support of extraordinary and cherished individuals, such as Dr. Khoa and Don Nguyen, MD, for serving as my preceptor/mentor throughout the stages of my direct immersion project. Dr. Dawn Robinson, my Faculty /Chair, for her unshaken patience, quick feedback, and radiant positive energy, together with Dr. Katherine McDermott and faculty in course level review, reading countless revisions and providing knowledgeably expert guidance to the end of this course.

To my colleagues, Jeffrey Souza, Tresa Antony, Mercy Daniel, Lisa Johnson, Marissa Rafael, and Skyler Meyer, thank you for your unfading support. Countless times, I felt like the world has collapsed upon me, desperately seeking the way out in the darkness, lo and behold, your torchlights point through the doors of escape. I recognized each day we journeyed that the race was worth it because you all were there pointing your lights to the proper outlet.

To my supportive friends, Sr. Onyinyechukwu Uba, Ms. Euphemia, Ms. Amaka, Dr. Bashiru, Calista, Sylvia, Vincent, and Ogunbayode. Thank you for your support, encouragement, love, and understanding, especially in moments of desolation, sequestration, and poor communication from me due to loads of assignments on my table.

To my preceptees, Vivian, Michael, Adaeze, Jane, Kate, Esther, Marybeth, Florence, Ebong, Nkele, and others, your understanding when I transfer my frustrations to you humbled me most in my relationship with you as a preceptor. Looking upon the “role model thing” was the driving force that propelled me to this finishing point. You are more than welcome anytime for more guidance in the future in your further studies.

I was also working on my post-graduate certification program in the psychiatric mental health nurse practitioner program, and this is where I thank Dr. Ghislaine Mogo, my preceptor, for her tremendous patience and support.

To my spiritual family, the Daughters of Charity of the Most Precious Blood, God gave me the best opportunity to be among you. Mother Ofelia Marzocca, see what I have become this day because of your decisions in the most challenging moments of my life and humble expression of an arduous journey that would benefit all. Thank you all, and may God reward us according to our deeds.

Table of Contents
Statement of the Problem vii
Chapter1:IntroductiontotheProject 1
BackgroundoftheProject 2
ProblemStatement 3
PurposeoftheProject 4
ClinicalQuestion 6
AdvancingScientificKnowledge 7
SignificanceoftheProject 9
RationalefortheMethodology 11
NatureoftheProjectDesign 11
DefinitionofTerms 13
Assumptions,Limitations,Delimitations 15
SummaryandOrganizationoftheRemainderoftheProject 17
Chapter2:LiteratureReview 19
TheoreticalFoundations 22
ReviewoftheLiterature 25
PrevalenceofHypertension 26
AerobicExerciseHealthIntervention 32
EffectofExerciseonBloodPressure 34
Summary 39
Chapter3:Methodology 40
StatementoftheProblem 41
ClinicalQuestion 42
ProjectMethodology 44
ProjectDesign 44
PopulationandSampleSelection 46
InstrumentationandSourcesofData 48
Validity 49
Reliability 49
DataCollectionProcedures 50
DataAnalysisProcedures 52
PotentialBiasandMitigation 53
EthicalConsiderations 53
Limitations 54
Summary 55
Chapter4:DataAnalysisandResults 57
Chapter 4 summarizes the collected data and how it was analyzed. Other chapter segments include the problem statement, clinical question, and methodology. The results are presented in narrative form along with figures, tables. The last section of the chapter provided a preview of Chapter 5 and its contents. 58
Descriptive Data 58
Data Analysis Procedures 59
Results 60
Chapter5:Summary,Conclusions,andRecommendations 64
At the clinical site, the project manager, Medical Director, and clinic manager collaborated regarding the increased ambulatory blood pressures noted within the past three months. The standard of care at the site is through medication management for their condition. Hence, a unanimous decision was made to utilize a new strategy, implementing the American Heart Association’s guidelines on aerobic exercise to influence hypertensive patients. 64
Chapter 5 reintroduced the project’s topic and summarized the project. Other chapter segments included a summary of the project’s findings and conclusion, theoretical, practical, and future implications. The last portion of the chapter offered recommendations for future quality improvement projects and clinical practices. 64
Summary of theProject 65
Thisquality improvement project was conducted utilizing a quantitative methodology and quasi-experimental design in four weeks. Chapter 1 presented studies such as Adam and Wright (2020), Aung and Htay (2021), Krist et al. (2021), and Saco-Ledo et al. (2020) related to incorporating aerobic exercise to be included in an individual’s HTN management plan.The project contributed to the current body of literature, such as Aung and Htay (2021), Krist et al. (2021), and Saco-Ledo et al. (2020), regarding aerobic exercise being included in hypertension management. The impacted population was adults diagnosed with hypertension in a primary care clinic. The county’s demographics revealed that roughly 60,000 seniors 65 and older comprise the county’s populace (Data USA, 2019). In Texas, the incidence of HTN is at 35.1%, which validates findings from the CDC (2021) and Million Hearts (2021). 65
Chapter 2 discussed Orem’s self-care deficit theory and Lewin’s change model are the theoretical underpinnings for this quality improvement project. Orem’s self-care theory was chosen because it focused on the reciprocal relationship between humans and their environment (Orem, 1995). The theory highlighted that a human could provide self-care, and the primary goal of the healthcare provider should assist them in achieving an optimal level of independence (Orem, 1995). The nursing theory comprises five constructs: universal self-care requisites, normalcy, developmental self-care requisites, and health deviation self-care requisite (Orem, 1995). Implementing this theory permitted the project manager to guide the clinicians regarding their responsibilities in providing the patient with a transparent plan of care. This helped the HTN patients to sustain an appropriate level of self-care (Orem, 1995). 65
Lewin’s change model was selected for this quality improvement project. It was chosen because it emphasized the need for change for clinicians and HTN patients impacted by restraining forces (Lewin, 1947). The change model consists of three phases: unfreezing, change (movement), and refreezing (Lewin, 1947). The first phase, unfreezing, began when the project manager collaborated with the nursing manager, medical director, and a few nursing staff to detect the increase in ambulatory blood pressures in HTN patients within the past three months. The second phase, changing (movement), began when the project manager educated the staff to use the implementation of the American Heart Association (AHA) guidelines related to aerobic exercise. During the phase, the patients were educated by the staff, clinicians were trained, and the project was monitored. The last stage, refreezing, began when the discussion about the AHA guidelines became infused into the organizational culture and a daily habit in the healthcare providers’ clinical practice (Lewin, 1947). 66
The project was implemented once approval was received from Grand Canyon University IRB and the project site. It was implemented in four weeks to examine the impact of AHA guidelines related to aerobic exercise on ambulatory blood pressures. The project came after collaboration with the medical director and some nursing staff showed an increase of 37.1% in diagnosed HTN patients within the past six months. The project contributed to the current body of literature regarding the impact of aerobic exercise on decreasing one’s hypertension (Aung &Htay, 2021; Krist et al., 2021; Saco-Ledo et al., 2020). Other areas affected by regular aerobic exercise are weight loss, improved well-being, and decreased symptoms of depression and anxiety (CDC, 2022). 66
SummaryofFindingsandConclusion 67
Implications 69
The nursing field is a discipline that requires research, which concentrates on issues that affect the nursing practice (Polit & Beck, 2021). Nursing implications are essential in considering when to begin a new medication, intervention, or procedure (Polit & Beck, 2021). Healthcare providers who understand the potential impact they could have on the clinical practice, nursing care, and the patient allows them to provide the best quality care (Polit & Beck, 2021). The implications discussed in the following sections were developed on the project findings. 69
Theoretical Implications 69
PracticalImplications 71
The third implication is for clinicians to use an interactive pictorial wheel to improve self-management in HTN patients. This educational style using pictures can help patients discuss their personalized approach to managing HTN without feeling belittled or embarrassed. Furthermore, this method has been adapted for other diseases such as asthma, heart failure, and stroke (Gan et al., 2022). This communication style would be beneficial for individuals with low health literacy levels. The communication wheel would be based on medication, exercise, weight management, diet, and complications 72
Future Implications 72
Recommendations 72
Recommendations for Future Projects 73
The “next step” in forwarding this project is for the healthcare providers to deliver patient care using culturally competent care for this populace. Unfortunately, many of the patients seen at the clinic are from Black and Brown communities. As mentioned in Chapter 1, the project site’s demographics show a high population of Hispanics (36.72%) and Blacks (18.5%). This confirms the statistics found by the Centers for Disease Control and Prevention (2022), Hispanics (39%), and Blacks (56%). 73
RecommendationsforPractice 74
References 76
AppendixA 90
GrandCanyonUniversityInstitutionalReviewBoardOutcomeDeterminationLetter 90
AppendixB 91
AmericanHeartAssociationPhysicalActivityGuidelines 91
AppendixC 92
Permission to Use the American Heart Association Physical Activity Guidelines 92

List of Tables

Hypertension(HTN)isamedicalconditionassociatedwithhigherbloodpressure,wherebythearteriesthattransportbloodbecomedamaged.Despitetheavailabilityoftreatmentstrategies,lessthanoneinfiveindividualshavetheirbloodpressureundercontrol(Ghatageetal.,2021).Currently,intheUnitedStates(U.S.),thediseaseposesasignificantproblemthataffectsoverhalfoftheadultpopulation(37millionindividuals)(CentersforDiseaseControlandPrevention[CDC],2021;Kristetal.,2021).Complicationsoftheconditionincludemyocardialinfarction,heartfailure,chronicrenaldisease,andstroke(Ghatageetal.,2021).

Attheprojectsite,theprojectmanagercollaboratedwiththeMedicalDirectorandclinicalmanagerregardingtheincreasingambulatorybloodpressuresseenwithinthepastthreemonths.Althoughthesiteprovidepatientswithmedicationmanagementfortheirdisease,itwassuggestedthatanotherstrategybeemployedtohelpreducebloodpressure.TheconversationconcludedwiththeprojectmanagerimplementingtheAmericanHeartAssociation’sguidelinesonaerobicexercisetoinfluencehypertensivepatients.

The project was worth conducting because it helped toincreaseHTNpatients’knowledgelevelsandassistinhelpingthemchangetheirbehaviorstocombatthis“silentkiller”(CDC,2019).Unfortunately,manyindividualsareunawareofthesymptoms,whichmakesthesituationdire.Thisprojectpromotedecreasingthefifthleadingcauseofdeath(CDC,2019).Otherareastheprojectimpactsone’simprovementoftheirqualityoflife,reducingtheirchancesofstroke,protectingtheirkidneys,anddecreasinghealthcarecosts(CDC,2019).

Chapter1introducesthetopicofhypertensionandtheuseofdailyphysicalactivitytocombatthedisease.Othersectionsofthechapterincludetheproblemstatement,purposestatement,andclinicalquestion.Otherareasofthechapterinvolveadvancingscientificknowledgerelatedtothetheoreticalunderpinnings,quantitativemethodology,andquasi-experimentaldesign.Thechapter’slastsegmentscomprisethedefinitionofterms,assumptions,limitations,anddelimitationswithapreviewofChapter2.

Background of the Project

TheprevalenceofhypertensionamongtheadultpopulationintheUnitedStatesincreasedrapidlybetween1988to2010,accountingforhalfofallfatalitiesfromstroke,end-stagerenaldisease(ESRD),andstroke(MillionHearts,2021).AccordingtoMuntneretal.(2020)trendanalysis,theestimatedproportionoftheU.S.adultpopulationsufferingfromhypertensionbetween1999and2000was31.8%.Theadultpopulationaffectedbyhypertensionincreasedfrom31.8%in1999-2000to48.5%in2007and2008(Muntneretal.,2020).ThenumberofaffectedU.S.adultshasbeenontheriseeversince,andbetween2013and2014,whichwas53.8%(Muntneretal.,2020).Thepercentagedroppedslightlyfrom53.8%to43.7%between2017and2018,butthevalueisstillrelativelyhigh(Muntneretal.,2020).ThisdataimplythattheAmericanpopulationisconsiderablyaffectedbyhypertensionatanalarmingrate.

ItwasnotknownifortowhatdegreetheimplementationoftheAmericanHeartAssociation’sguidelineonaerobicexercisewouldimpactambulatory bloodpressurewhencomparedtocurrentpracticeamongadulthypertensivepatients.Attheclinicalsite,therearenostandardizedguidelinesforclinicianstoeducatehypertensivepatientsregardingimplementingdailyphysicalactivityasabloodpressuremanagementmechanism.Collaborationwiththemedicaldirectorandsomeofthenursingstaffshowedanincreaseof37.1%indiagnosedHTNpatientswithinthepastsixmonths.Theclinic’sfindingscorrespondedwiththehealthstatisticsfromtheTexasDepartmentofStateHealthServices(2022),asthecountyranks22intheStateswithdiagnosedhypertensivepatients.Thedata,incombinationwithcurrentliteraturebytheCentersforDiseasePreventionandControl[CDC](2021),emphasizesthathypertensionaffectsapproximately45%ofAmericanadults.

Purpose of the Project

The purpose of this quantitative, quasi-experimental project was to determine if or to what degree the implementation of the American Heart Association’s guideline on aerobic exercise would impact ambulatory blood pressure when compared to current practice among adult hypertensive patients in a primary care clinic in southwest Texas over four week-period.TheindependentvariablefortheprojectistheAmericanHeartAssociation’s guidelines,andthedependentvariableisbloodpressuremeasurements.Conveniencesamplingwillbeusedtochoosetheparticipants.Theprojectwas conductedwithinfourweeksusingaquasi-experimentaldesignandquantitativemethodology.SixhealthcareproviderswillbeeducatedusingtheAmericanHeartAssociation’sguidelinesforaerobicexercise(walking and blood pressure measurement using Oscar 2 Device) for HTN patients. The primary investigation carried out implementation and comparison of data during the project using ambulatory blood pressure baseline and post-implementation data.Datawasretrievedfromtheclinic’selectronicmedicalrecordandinputintoaMicrosoftExcelspreadsheet.An outside statistician not associated with the primary investigator or project analyzed the data.Apairedsamplet-testwasusedtoanalyzethestatisticalsignificanceofthevariablesusingtheStatisticalPackagefortheSocialSciences(SPSS-28).

Theinclusioncriteriafortheparticipantswere18andolder,diagnosedwithHTN,currentclinicpatients,andabletoparticipateinaerobicactivity.Theexclusioncriteriaarepatientswithmusculoskeletaldisabilities,mentaldisorders,andindividualswithcomorbiditiesthatcouldbiastheprojectfindings.Theparticipantsengagedinaerobicexercisefor30minutesin24hours,threedaysaweek,forthefourweeksoftheproject duration. The outcome post-intervention was a reduction in ambulatory bloodpressurereadingoftherecommendedBPbelow140/80mmHg.TheaveragedecreaseinSBPwithaerobicexerciseisapproximately2to4mmHginnormotensivepatientsand5to8mmHginadulthypertensionpatients(Saco-Ledoetal.,2020).

Thepersonswhoimplementedtheinterventionwereonephysician,twonursepractitioners,tworegisterednurses,andonemedicalassistant.Allhealthcareproviderswereeducatedregarding“theAmericanHeartAssociation’s”guidelinetoincludeexerciseinHTNpatients’diseasemanagement.The use of Oscar2 Device for measuring ambulatory blood pressure. The clinicians demonstrated vibrant understandingviatheteach-backmethodtotheprojectmanagertosafeguardalltheparticipantswere taughtthesameway.Theindividualscurrentlyworkfulltimeattheclinicforoveroneyearandhaveaccesstothedocumentationsoftware.

Theprojectsite’sgeographiclocationisinsouthwestTexas,themostpopulouscountyandthethirdmostpopulouscountyintheUnitedStates(U.S.CensusBureau,2020).TheaffectedpopulationwaspatientsdiagnosedwithHTN.ThedemographicsshowadiversepopulationofWhite(28.9%),White-Hispanic(36.72%),Blacks(18.5%),Asians(6.9%),andLatinos(8.98.%)(U.S.CensusBureau,2020).Manyresidentsovertheageof60havechronicdiseasessuchas(chronicobstructivepulmonarydisease,heartdisease,anddiabetes)(UTHealthScienceCenteratHouston,2020).Theagegroupsinthecounty18to34(20,586),35to54(46,513),and55to64reflecttheparticipantsintheproject.

Saco-Ledoetal.(2020)conductedasystematicreviewandmeta-analysis.Theauthorsclaimedthatambulatorybloodpressure(ABP)betterpredictscardiovasculardiseaseandmortalityinadulthypertensivepopulations.Aerobicexerciseplayedasignificantroleinloweringbloodpressure,anditwasbeneficialinloweringambulatorybloodpressureinHTNpatients.Thefollowingclinicalquestionthatguidedthisquantitativeproject:Towhatdegreedidtheimplementationof“theAmericanHeartAssociation’s”guidelineonaerobicexerciseimpactambulatory bloodpressurewhencomparedtocurrentpracticeamongadulthypertensivepatientsinaprimarycareclinicinsouthwestTexas? Theindependentvariableis“theAmericanHeartAssociation’s”guidelineregardingaerobicexercise,andthedependentvariableisambulatory blood pressure.

Advancing Scientific Knowledge

ImplementinganaerobicexerciseeducationprogramtolowerambulatorybloodpressurebyfollowingAHAguidelines,theinitiativeimprovedpopulationhealthoutcomesforhypertensiveindividuals.Completingthisqualityimprovementprojectadvancedourunderstandingofambulatorybloodpressureinhypertensivepatientstoreduceormanageambulatorybloodpressure.Theoverallgoalsofaerobicexercisewalkingincontrollingbloodpressureinhypertensivepatientsweretodecreasemorbidityandincreasethepopulation’swellness, happiness and vitality.Physicalactivitiessuchaswalking,running,swimming,andbikingimprovesymptoms,qualityoflife,functionalstatus,andreduceshospitalizations(CDC,2021).

Inclinicalpractice,managementofcardiovasculardiseasesentailedresolvingcardiovascularetiologiessuchascoronaryheartdiseaseandrelatedconditionssuchasdiabetes,preventativecare,follow-upmonitoringofcardiacstatus,carecoordinationandcasemanagement,educatingandsupportingpatientsforself-management,rehabilitationofheartfunction,andhealthpromotion,amongothers(Jiang&Wang,2021).Thepharmacologicaltreatmentofcardiovasculardiseaseshasimprovedwiththedevelopmentofnewtherapiesandunderstandingitspathophysiology.DespitedevelopingnovelpharmacologicalinterventionsforpatientswithHTN,congestiveheartfailureexistingtreatmentshavenotyieldedsignificantmortalitybenefitsforHFpatientswithheartfailurewithreducedejectionfraction(HFpEF).Instead,thedrugtreatmentstrytocontrolsymptoms,treatcomorbidities,andriskfactorsthatthecausethroughmeasuressuchasaerobicexercise,dietandweightcontrol,bloodpressureself-monitoring,andlowsodiumintake,amongothers(CDC,2021).

Theidentifiedgapistheelevatedambulatorybloodpressureamongthehypertensivegroupbasedontheavailableresearch(Blumenthaletal.,2018;Saco-Ledoetal.,2020).Educationalprogramsonaerobicexercisetodecreaseandmanageambulatorybloodpressureshouldbuildonthefindings(Blumenthaletal.,2018).Otherfactorsthatinfluencebloodpressurearethepresenceofcomorbiditiesandriskybehaviorssuchassmoking,patients’educationlevel,caregiverpresence,andin-patientHTNeducation.As the patients became more aware of the aerobic exercise in lowering blood pressure through the educational program, individuals showed less comorbidities that reduced risk to hypertensive complications and frequent hospitalizations (Saco-Ledo, 2020). TheinitiativefilledthegaporneedbyutilizingtheAHAguidelinesforaerobicexerciseeducationprogramstolowerambulatorybloodpressureforpatientswithhypertension.

TheselectedtheoreticalframeworkforthisqualityimprovementprojectwasDorothyOrem’sself-caredeficittheory.Basedonthetheory,patientsmustengageinself-caretomaintainandimprovetheirqualityofhealth(Orem,1995).Utilizingthistheory,thenursesdidnotseetheirpatientsasinactiveorreceivinghealthservices;instead,theyconsiderthemstrongandreliabletoparticipateindailyactivitiesanddecision-makingprocesses(Orem,1995).ThreenursingsystemsaredefinedinOrem’snursingtheory;theyincludewhollycompensatory,partiallycompensatory,andsupportive-educativestrategies(Khademianetal.,2020).Forthisproject,thefocusisonthelastsystem(supportiveeducationalsystem).Thecliniciansassessedthepatient’sreadinesstolearnsomethingnewbutneedassistanceandguidance.Patientswithchronicillnessesrequiremotivationandtheskillstoconductthebehaviorsneededtomaintainandimprovetheirhealth(Khademianetal.,2020).Hence, the patient gained the capability to learn disease processes and perform activities independently, overcoming seen and unseen limitations.

The significance of the quality improvement project wasimplementingarecommendedevidencebasedstrategyby“theAHA’sguideline”regardingaerobicexercise.ImplementingtheprojecthelpeddecreasethehealthcarecostsassociatedwithHTNintheUnitedStates.Commodore-Mensahetal.(2018)statethatthefinancialpricesaresignificant,approximately$131-198billionannually.Hypertensivepersonsincuranextra$2,000yearlyinhealthcareexpenditurescomparedtonon-hypertensivepersons(Commodore-Mensahetal.,2018).Furthermore,HTNisacrucialriskfactorinvariousdiseases,includingmyocardialinfarction,heartfailure,stroke,andchronicrenaldisease(Commodore-Mensahetal.,2018).

OnenursingimplicationrelatestoLewin’schangemodelincreatingandsustainingchange.Amulti-systematicapproachmustbe drawnfromthemodeltosupporttheimplementationoftheAmericanHeartAssociationguidelinesregardingaerobicexerciseforhypertensivepatients.Themodelhighlightedtheprinciplesrelatingtopeoplechangingfromtheonset,discussingtheirfeelingsregardingthechange,andsupportingtheprocessviacommunicationandcollaboration(Harrisonetal.,2021).

The second nursing implication relates to the participants’ management of their disease process (hypertension). The participants were taught the importance of including aerobic exercise and walking (30 minutes, three times a week) in their private daily schedules.Theprojectmanagerevaluatedtherespondents’understandingandreceptivenesstonewinformationandsafetymeasuresrelatedtoexercising.

Thequantitativemethodologywasusedtoprovideinformationthatusesnumericaldata(StatisticalSolutions,2019).Thismethodbestansweredtheclinicalquestionandaddressingtheproblemstatementforthisprojectbecauseitallowedanin-depthcomparisonoftherelationshipbetweenpre- andpost-interventionresults(Guetterman&Fetters,2018).Itwasusedbecauseitofferedobjective,systematic,andfocuseddataanalysisstrategies(Guetterman&Fetters,2018).Inthisproject,theprojectmanagerevaluated“theAHA’sguidelines”anditsimpactonthebloodpressureofHTNpatients.Thedependentvariableweremeasuredfourweeksbeforeandafterimproving theintervention.Thismethodologywasthemostappropriatebecauseotherinvestigatorscouldreplicatethedata(Creswell&Creswell,2018).

Aquasi-experimentaldesignwasusedinthisqualityimprovementproject.Therationalebehindselectingtheproject,asmentionedabove,wasthatitallowedforcomparingthedependent(bloodpressure)andindependentvariables(implementationstrategyaerobicexerciseeducationguideline.Thedesignwassuitableforscrutinizingtheproject’svariablesanddeterminingtheindependentvariable’seffectonthedependentvariable(Creswell&Creswell,2018).Furthermore,thedesigndidnotallowtheparticipantstoberandomlyassigned(Creswell&Creswell,2018).Forthisproject,thedependentvariable(ambulatory bloodpressure)weremeasuredattwodifferenttimes(oncebeforetheinterventionandonceaftertheintervention(Creswell&Creswell,2018).

Acorrelationaldesignwasnotselectedforthisqualityimprovementproject.Itwasnotchosenbecauseitisanon-experimentaldesignwherethevariablesaremeasuredandevaluatedfortheirrelationship(correlation)(Creswell&Creswell,2018).Thevariablescannotbecontrolled(Creswell&Creswell,2018).Tworationalesfor notusingthistypeofdesignareevaluatingthecausalstatisticalrelationshipsbetweenthevariablesandnotmanipulatingtheindependentvariable(Creswell&Creswell,2018).

The project sample exploredwasadultpatientsdiagnosedwithHTN.Theindividualswere18orolder,spokeEnglish,andwereabletoparticipateinaerobicexercise.Theexclusioncriteriaincluderespondentswithmentalchallenges,musculoskeletaldisabilities,andcomorbiditiesthatcouldbiastheprojectresults.ThesamplesizewascalculatedusingG*Powersoftware,version3.1.9.2,withanalphameasureof0.05,aneffectsizeof0.5,andapowerof80%.TheminimumnumberofparticipantssuggestedfortheprojectwasN=34.

Aqualityimprovementprojectmustofferthereaderanunderstandingoftheterms,concepts,andvariablesused(GrandCanyonUniversity,2021).Newknowledgeiscriticaltosuccessfulsolutions(Polit&Beck,2018).Beloware the words used intermittently throughout the project

Ambulatorybloodpressuremonitoringwasintroducedintheearly1960sandwas usedtoassessone’sbloodpressureinreal-time(Shackelford,2022).Ahealthcareprovidertypically evaluatedthebloodpressureduringroutineactivitiessuchasworking,sleeping,ordoingchores(Shackelford,2022).

The American College of Cardiology Foundation

The American College of Cardiology Foundationisanon-profitmedicalorganizationdedicatedtoimprovingthelivesofcardiovascularpatients(AmericanCollegeofCardiology,2022).Thiswasdoneviacontinuousqualityimprovementmonitoring,patient-carestrategies,paymentinnovation,andprofessionalism(AmericanCollegeofCardiology,2022).

American Heart Association

TheAmericanHeartAssociationwasformedin1924toestablishscientificresearchthatcouldofferhealthcareprovidersandpatientsmethodstotreatcardiacdiseaseandprevention(AmericanHeartAssociation,2022).

Aerobic Exercise

Highbloodpressurereferstothescenarioinwhichanadult’sbloodpressureisabovetheoptimumlevel,whichisusuallyat130/80mmHgforadultpatients.Whenapatient’sbloodpressureexceedstheoptimumshownabove,theyareexposedtotheriskofchronicheartfailure,stroke,myocardialinfarction,andinextremecircumstances,death(Fuchs&Whelton,2020).

Hypertensive Patients

Hypertensivepatientsreferstothepatientsdiagnosedwithhypertensionsincehypertensionhasbeenshowntobeacausativefactorforotherdiseasessuchaschronicheartfailure,stroke,andevenmyocardialinfarction(Schwingshackletal.,2019).

GrandCanyonUniversity(2021)statedthatanassumptionisanindisputablefact.ThefirstassumptionwasthatthisqualityimprovementprojectwasbasedontheAHAguidelineonaerobicexerciseeducationprogramwillenhancetheself-efficacyofadulthypertensivepatientsbyhelpingthemkeeptheirbloodpressureatoptimumlevels.Inturn,theAHAguidelineontheaerobicexerciseeducationprograminterventionwouldplayapivotalroleinlifestyleimprovementandskilldevelopmentwhichwere requiredtoencourageimprovedhealthoutcomesandadaptivehealth-relatedbehavior(Cameronetal.,2018).Thesecondassumptionwasthatallparticipants answeredthequestionshonestly.Tomaintainhonestyfromtheparticipantsduringtheproject,theprojectmanagerdidnotinfluencetheparticipantsanswers.Tomaintainobjectivityandreducethepossibilityofthedatabeingskewed,theinvestigator hiredanoutsidestatisticiantoconductthedataanalysis(StatisticalSolutions,2019).

Thethirdassumptionwasthattherespondentswereengagedandinterestedinparticipatinginthisqualityimprovementproject.Theunderlyingpresumptionwasthatpeoplewereresistanttochange.Toimprovetheparticipants’engagementintheproject,theprojectmanager allowedanopportunityforfeedbackregardingthedatacollectionprocess.AggarwalandRanganathan(2019)emphasizethatcollectingpertinentdatathatcanbereproducedcaninformandcollaboratewiththestaffonevidence-basedstrategiesrelatedtohypertensioncare.

Limitationsaresituationstheprojectmanagercannotcontrol(Creswell&Creswell,2018).Thefirstlimitationwastherestrictedtimetoconducttheproject(fourweeks).Alongitudinalprojectallowsonetoevaluatethetrendsandchangesovertime(Leedy&Ormrod,2020).Secondly,itreviewsthechronologicalsequencingofevents,acriticalcriterionforestablishingcausality(Leedy&Ormrod,2020).

The third limitation was the data analysis. Data were collectedfromthefacility’selectronicrecordandinputintoaMicrosoftExcelspreadsheet(codebook).Ifthedatawasnotinsertedcorrectly,theresultsmayresultinfalseormisleadinginformation(Leedy&Ormrod,2020).Duetotheprojectmanager’slimitedknowledgeandtimeinconductingstatisticalanalysis,anoutsidestatisticiannotaffiliatedwiththeprojectormanager performed the data analysis.

Delimitationsaresituationsthattheprojectmanagercancontrol(Creswell&Creswell,2018).Thefirstdelimitationwastheselectedclinicalsite.Itwaschosenbecauseitwasaccessibleandconvenientfortheprojectmanagerrelatedtotheparticipants.Theseconddelimitationwastheinclusioncriteriaforparticipatingintheproject.Thethirddelimitationwastheselectedtopicbecausetheprojectmanagerwasinterestedinhypertensionandaerobicexerciseinmanagingthedisease.

Summary and Organization of the Remainder of the Project

According to Saco-Ledoetal. (2020), adult hypertension cases were soseverethattheyresultedin$370billioninannualdirectmedicalcostsworldwide.Kristetal.(2021)alsoprovidedaninclinatoryhypothesisthatfullysupportsSaco-Ledoetal.(2020)findingsbynotingthat45%ofAmericanadultssufferedfromhypertension.IntheadultpopulationofAmerica,hypertensionincreasedsteadilybutquicklybetween1988and1994,1999and2000,and2009and2010.AccordingtoresearchbyWangetal.(2019),therewasasharpincreaseinoccurrencesofhypertension.

TheAmericanCollegeofCardiology(ACC)disclosedthatphysicalexerciseeducationandparticipationshouldbeseenasawayofimprovinghealth,modifyinglifestyle,andmaintainingbloodpressureasessentialtopreventinghypertension(ACC,2022).Whiletheconditionwasserious,itwasprimarilyattributedtootherchronicconditionssuchasstroke,end-stagerenaldisease(ESRD),anddeathinextremeinstances.AsaffirmedbyMuntneretal.(2020),between1999and2000,theratewas31.8%,whichfastroseto48.5%between2007and2008.Between2013and2014,theratesrapidlyroseto53.8%(Muntneretal.,2020).

Orem’sself-caredeficittheoryandLewin’schangemodelwerediscussed.Orem’sself-caredeficittheoryguidedcliniciansinrealizingthattheirpatientsare activeparticipantswhocanparticipateindailyactivitiesthatbenefittheirhealthandintheclinicaldecision-makingprocess(Orem,1995).Lewin’schangemodelprovidedanoverviewofhowachangeprocesscould beimplementedandsustainedusingthethreephases(unfreezing,movement,andrefreezing)(Lewin,1947).

Chapter2 reviewedthepreviousandcurrentliteratureontheeffectivenessofaerobicexerciseonAmbulatoryBloodPressure(ABP)amonghypertensivepatients.Thechapterdiscussedthetheoreticalunderpinningsusedintheproject(Orem’sself-caredeficittheoryandLewin’schangemodel).Theprimarythemesweretheprevalenceofhypertension,aerobicexercise,andinterventiontocontrolhypertension.Thesubthemeswillbespecifictothethemesrelatedtohypertensionandaerobicexercise.ThelastsegmentofthechapterofferedapreviewofChapter3anditscontents.

Highbloodpressure,alsoknownashypertension(HTN),isaleadingriskfactorforglobalcardiacdisease(Hoffmannetal.,2020).LowadherencetoHTNtreatmentamonghypertensivepatientsremainsahealthcarechallenge(Hoffmannetal.,2020).Schwingshackletal.(2019)statethathypertensionisaconditioninwhichthepatientsinvolvedhavehighbloodpressureexceedingthesetoptimalBP(140/90mmHg).However,whenapatient’sbloodpressureexceeds180/120mmHg,thentheirconditioncanbetermedassevereandwouldbeexposedtootherchronicconditionssuchasheartdiseaseswhicharearesultofthelong-termforcecausedbythebloodpressureonarterialwalls(Schwingshackletal.,2019).

Increasingclinicians’awarenessofthevariousstrategiesinHTNmanagementandincludingthepatientsintheshareddecision-makingcouldimprovetheirqualityoflife.OnemethodthatcanbeusedinimplementingtheAmericanHeartAssociationguidelineregardingaerobicexercise.Attheprojectsite,therewerenostandardizedguidelinesforeducatinghypertensivepatientsregardingincorporatingexercise(dailyphysicalactivity)asabloodpressuremanagementmechanism.The purpose of this quantitative, quasi-experimental project was to determine if or to what degree the implementation “the American Heart Association’s” guideline on aerobic exercise would impact ambulatory blood pressure when compared to current practice among adult hypertensive patients in a primary care clinic in southwest Texas over four weeks.

Chapter2exploredpreviousandcurrentliteratureregardingambulatorybloodpressureandaerobicexercisebeingincludedinthedailymanagementofhypertension.Orem’sself-caredeficittheoryandLewin’schangemodelwerediscussedindetail.Threeprimarythemesforthetopicofhypertensionaretheprevalenceofhypertension,aerobicexercise,andtheeffectsofexerciseonbloodpressure.Thesubthemesfortheprevalenceofhypertensionincludedsystolicbloodpressuremanagement,diastolicbloodpressuremanagement,anddiastolicbloodpressuremanagement.Thesubthemesforaerobicexercisearepre-aerobicexercisestate,duringaerobicexercise,state,andpost-aerobicexercisestate.Thefinalsubthemesfortheeffectsofexerciseonbloodpressureconsistofliteracylevel,self-efficacy,andlifestylemodification.ThelastfewsentencesofthechapterprovidedapreviewofChapter3.

A literature search was conducted using peer reviewedarticlesfrom2018tocurrent.ThekeywordsandinclusioncriteriaincludedwritteninEnglish,hypertensionadults,aerobicexercise,AmericanHeartAssociationguideline,DorothyOrem’sself-caredeficittheory,hypertension,hypertension-relatedconditions,andLewin’schangemodel.Theexclusioncriteriawerenon-Englisharticlesandpediatrics.ThefollowingdatabaseswereusedduringthereviewCINAHL,CochraneLibrary,EMBASE,GoogleScholar,GrandCanyonUniversityonline,andPubMed.Over374.070resultswerediscovered;however,anexclusionfilterwasused,andthequantitywasreducedto19,431results(Adams&Wright,2020).articleswereusedforthisreview.However,50articleswereusedthatmettheinclusioncriteria.

Ahistoricaloverviewshows1988to2010;hypertensionwasattributedto50%ofdeathswhichwereanextensionoftheirhypertensivenaturethroughend-stagerenaldisease(ESRD)andstroke(Wangetal.,2019).AnotherreportbyMuntneretal.(2020)showsthatthepopulationofpatientsdiagnosedwithhypertensionroseby31.8%between1999and2000.Intheprecedingyears,between2007and2008,therateroseto48.5%(Muntneretal.,2020).Themostrecentonewasin2018,whentherateswereat43.7%,aslightdropfromtheinitial48.5%.Theratesmighthavedroppedslightly;however,therateof43.7%isstillrelativelyhigh,whichcallsfortheadoptionofalternativeinterventionsthatwouldhelpexpeditethedropintherateofthepopulationaffectedbyhypertension.

Saco-Ledoetal.(2020),affirmsthathypertensionisacriticalconditionandiscurrentlytheleadingcauseofprematureglobaldeaths.TheAmericanHeartAssociationsetthenewhypertensiondiagnosisthresholdinthesystematicreviewasaBP≥130/80mmHg(Asayamaetal.,2019).However,theEuropeanSocietyofHypertension(ESH)maintainsthathypertensionisbestdefinedusingathreshold≥140/90mmHg(Saco-Ledoetal.,2020).

Apatientisexposedtootherco-morbiditieswhentheirconditionisnotmaintained.Thisendangerstheirliveswhichcallsforanevidence-basedinterventionthatcanbestbesuitedtohelpingsuchpatientscopewiththeconditioninquestion.Thepatient’ssystolicanddiastolicBPmustbemaintainedattheoptimumlevel,failuretowhichaninterventionwouldhavetobesoughttohelpreducethemtobewithintheoptimalrange.AspertheAHAguidelines,anelevatedBPhasasystolicBP≥140mmHgordiastolicBP≥90mmHg(Saco-Ledo, et al, 2020) However,theinitialclassificationundertakenbytheAHAwas130/80mmHg(Asayamaetal.,2019).

Utilizingapracticalinterventionthatwouldhelpalleviatetheeffectsofhypertensionismainlyattributedtotheknowledgeofthelong-termimpactthattheconditionhasonthepatientinquestion.Whenpatientsareawareofthelong-termeffectsofhypertensionontheirqualityoflife(QoL),theywillbemotivatedtodoastheirdoctorsaysortake medicationsthatthedoctorprescribes.However,inthecaseofthisqualityimprovementproject,theprimaryinvestigator(PI)proposesusing“theAHA’sguideline”foraerobicexerciseeducationprogramtohelpkeeptheBPatoptimallevelsamonghypertensivepatientsinsoutheastTexas.

Oneofthemostproblematicissuesregardingusing“theAHA’sguideline”foraerobicexerciseeducationprogramwaswhethertheusewouldbeinstrumentalinhelpingpatientswithambulatorybloodpressurereducethem.BurnierandEgan(2019)assertthatresearchhasestablishedtherelationshipbetweenhypertensionandcardiovasculardisease.Theauthorsreinforcedtheinherentneedtoascertainthatpatientsstrugglingwithhypertensionarewithintheirmeanstomaintaintheirbloodpressure.

Theoretical Foundations

Thetheoreticalframeworkremainedoneoftheessentialelementsinresearchandqualityimprovementstudies.Itformsthefoundationonwhichallknowledgeintheprojectisunderpinned,servingasthesupportandstructurefortheprojectsrationale,problemstatement,significance,purpose,andresearchquestions(Kivunja,2018).AccordingtoSaco‐Ledoetal.(2020),highbloodpressureisthecauseofmanycasesofhighmortalityratesandcardiovasculardiseasesamongtheadultpopulationintheUnitedStates(U.S.).Therefore,itfittedtopostulatethathypertensionisasignificanthealthcrisisintheU.S.andneedsmoreattention(CentersforDiseaseControlandPrevention,2021).

Orem’sself-caredeficittheoryandLewin’schangemodelarethetheoreticalunderpinningsforthisqualityimprovementproject.Orem’sself-caretheorywasselectedbecauseitemphasizesthemutualrelationshipbetweenhumanbeingsandtheirenvironment(Orem,1995).Thetheoryemphasizesthatallhumansarecapableofself-careandtheprimarygoaloftheclinicianwastohelpthemobtainanoptimumlevelofindependencewiththeirdiseaseprocess(hypertension)(Orem,1995).Itconsistsoffiveareasofself-carerequisites:universalself-carerequisites,normalcy,developmentalself-carerequisites,andhealthdeviationself-carerequisite(Fotokianetal.,2021).Utilizingthistheoryallowedtheprojectmanagertoexplaintothehealthcareproviderstheirrolesandresponsibilitieswhileofferingthepatientaclearoutlineofthecareplan.Inturn,thishelpedhypertensivepatientstoachieveandmaintainasuitablelevelofself-care(Orem,1995).

Khademianetal.(2020)conductedaquantitative,quasi-experimentalstudytoevaluateaself-careeducationalprogramdevelopedandbasedonOrem’snursingtheory.EightyIranianhypertensivepatientsparticipatedinthestudy.Datawascollectedpre-and-posteightweeksofinterventionusingthe
QualityofLifeofCardiacPatientsand
StrategiesUsedbyPeopletoPromoteHealthsurveys(Khademianetal.,2020).Datawereanalyzedusingchi-square,independent
t-test,andAnalysisofVariances(ANOVA)withrepeatedmeasures(Khademianetal.,2020).TheresultsshowedthatthemeanscoreoftheQualityofLifeintheexperimentalgroupwashigherthanthecontrolgrouppost-eight-weekintervention(106.5±26.5vs.85.5±22.5,
p=0.03)(Khademianetal.,2020).Themeanscoresofself-efficacieswerenotstatisticallydifferentfromthoseofthecontrolgroupimmediatelyafter(68.5±12.7vs.66.5±12.2,
p=0.47)andeightweeksaftertheintervention(70.5±13.5vs.65.7±12.0,
p=0.10)(Khademianetal.,2020).TheauthorsconcludedthatusingandeducatinghypertensivepatientswithOrem’snursingtheoryasaguidecouldimprovetheirqualityoflife(Khademianetal.,2020).

Lewin’schangemodelwasselectedforthisproject.Themodelproposesthathypertensivepatientsandcliniciansareinfluencedbyrestrainingforces(Lewin,1947).Thesebarrierscounter-driveforcesthatkeptthepositiveforcesforchangepushedinthedirectionthatwillcausechangetooccur(Lewin,1947).Thetensionbetweenthedrivingandrestrainingforcesmaintainsequilibrium(Lewin,1947).Themodelconsistsofthreeconstructs:unfreezing,changing(movement),andrefreezing(Lewin,1947).

Thefirststage,unfreezing,occurredwhentheprojectmanagercollaboratedwiththemedicaldirector,nursemanager,andsomenursingstaffinidentifyingtheincreaseinambulatorybloodpressuresinhypertensivepatientsoverthepastthreemonths.Thesecondstage,changing,allowedthecollaborationteamtoseekalternativestrategiesinhelpingthispopulaceachieveanoptimallifestyle(Lewin,1947).Hence,theimplementationoftheAHAguidelinesrelatedtoincludingaerobicexercisewasintroduced.Duringthisphase,educatingthepatients,trainingtheclinicians,andmonitoringtheprojectoccurred.Thelaststage,refreezing,integratedthenewstrategyintheorganization’sculture,sothatitbecameahabitinthedailyclinicalpracticeandminimized resistance to change (Lewin,1947).

Smith(2018)conductedaquantitativeprojecttodeterminethecorrelationbetweenbloodpressure(meanarterialpressures)andimplementing30minutesofaerobicexercisethreetimesaweekfor30minutesin30hypertensiveadults.Lewin’schangemodelwasutilizedforeducatingtheoutpatientparticipants(Smith,2018).Theprojectexpectedthattheparticipantswouldlearnaboutthebenefitsofaerobicexerciseandengageinanewbehavior(walking)(Smith,2018).Theauthorstatedtherationaleforusingthechangemodelwastousetheeducationtounfreezetheparticipants’currentbehavior,movingstage(engageinwalking),andrefreezing(adoptingwalkingaspartoftheirlifestyles(Lewin,1947;Smith,2018).Theresultsshowedthatafterfourweeks,eightparticipantshadengagedinregularaerobicexercise,threetimesaweek(Smith,2018).Althoughtheresultswerenotstatisticallysignificant,theprojectshowedhowtheuseofLewin’schangemodelenhancedandguidedtheeducationprocessfortheparticipants.

Thisliteraturereviewofferedanevaluationofevidence-basedstudiesthatvalidatedtheproject’ssubjectmatter.Theprimarythemesandsubthemesarerestrictedtohypertension,ambulatorybloodpressure,andaerobicexercise.Theprimarythemesarepreventionofhypertension,aerobicexercise,andeffectsofexerciseonbloodpressureThesubthemesforpreventionofhypertensionincludesystolicbloodpressuremanagement,diastolicbloodpressuremanagement,andambulatorybloodpressuremanagement.Thesecondsetofsubthemesareaerobicexercisearepre-aerobicexercisestate,duringaerobicexercisestate,andpostaerobicexercisestate.Thelastsubthemesofeffectsofexerciseonbloodpressureincludeliteracylevel,self-efficacy,andlifestylemodifications.

Prevalence of Hypertension

Hypertensionistheresultofone’sbloodpressurebeingtoohigh.CDC(2021)disclosedthatabouthalfofadults(45%)withuncontrolledhypertensionhaveabloodpressureof140/90mmHgorhigher.Thisincludes37millionU.S.adults(Cameronetal.,2018).Itisnotnewsthatsomepatientsdonotgivethemselvestheappropriatehealthcaretheydeserve.SomeHTNpatientsdonotknowtheirbloodpressure(BP)baseline,makingithardtodetectornoticetheincreaseordecreaseintheirBPreadings.Kirklandetal.(2018)opinedthattheestimatedprevalencerateofadultsdiagnosedwithHTNwouldincreasebyapproximatelyninepercentfrom2010to2030;anincreaseinuncontrolledBP-associatedcomplicationswillbecomeasignificanthealthissueamongAmericancitizens(Cameronetal.,2018).

TheWorldHealthOrganization[WHO](2021)statedthatabout1.28billionadultsaged30to70yearsworldwidehaveHTN,andlessthanhalfofadultsdiagnosedwithHTNaretreated(Cameronetal.,2018).Themodifiableriskfactorsincludechangingunhealthyhealthhabitssuchassmoking,inactivity,alcohol/tobaccoconsumption,beingoverweightorobese,andexcesssaltintake;thenon-modifiableareage>65years,coexistingdiseasessuchasdiabetesandfamilyhistory(CentersforDiseaseControlandPrevention,2021).ManagementofHTNinvolvesdecreasedsaltintaketolessthan5gdaily,improvedphysicalexercise,reducedalcohol,andtobaccouse,weightmanagement,andincreasedconsumptionoffruitsandvegetables(CDC,2021;Wheltonetal.,2017).

TheWHOestimatesthatmorethan1.28billionpeopleaged30to79yearsworldwidesufferfromhypertension.Two-thirdsofthesepeoplearefromlow-incomeandmiddle-classhouseholds(CentersforDiseaseControlandPrevention,2019).Furthermore,46%ofadultswithhypertensionareunawarethattheysufferfromthecondition.Therefore,lessthanhalfofadultswithhypertensionarediagnosedandtreated(CentersforDiseaseControlandPrevention,2019).Thenumberofhypertensionpatientswiththehealthconditionundercontrolisalsolow.Itisestimatedthatoneinfiveadultswithhypertensionhasthediseaseundercontrol(Carey&Forsyth,2022).Hypertensionisamongtheleadingcausesofprematuredeathintheworld.Asaresult,itisamongthenon-communicablediseaseswithhealthcaretargetstoreduceitsprevalence.Thegoalistoreducehypertensionprevalenceby33%between2010and2030(Fuchs&Whelton,2020).

IntheUnitedStates(U.S.),hypertensionprevalenceisalarming.HypertensionputsAmericansatahigherriskofheartdiseaseandstrokes.ThesetwoaretheleadingcausesofdeathintheUnitedStates.In2020alone,morethan670,000deathsbecauseofdiabeteswerereportedinAmerica(Fuchs&Whelton,2020).WithnearlyhalfofAmericanadultsintheUnitedStateshavinghypertension,onlyoneinfourpatientshavetheconditionundercontrol(Guirguis-Blakeetal.,2021).HypertensionprevalenceintheUnitedStatesvarieswithgenderandrace.Hypertensioniscommonlynotedinmen,with50%ofmeninAmericahavingthiscondition,while44%ofhypertensionpatientsinAmericaarewomen(Fuchs&Whelton,2020).Furthermore,hypertensionismoreprevalentamongblackAmericanadultsat56%,whiteAmericanadultsat48%,Asianadultsat46%,andHispanicadultsat39%(Guirguis-Blakeetal.,2021).HighbloodpressureisalsocommoninsomeareasoftheU.S.comparedtoothercountries.

MeasurementofSystolicBloodPressureManagement.TheWHO(2021)describedHTNasamedicalconditiondiagnosedwhenbloodpressureismeasuredontwodifferentdays;thesystolicbloodpressurereadingsonbothdaysare≥140mmHg,andthediastolicbloodpressurereadingsonbothdaysare≥90mmHg(Krameretal.,2019).ThefirstofthetwonumbersusedinbloodpressureisknownastheSBP,whichdemonstratesthearterialpressurewhentheheartcontracts(WHO,2021).Primaryhealthclinicsarebetterpositionedtoeducatepatientsonissuesconcerningtheirhealth,treatmentoptions,andpatient-centeredself-management(Yatimetal.,2019).Whenthesystolicbloodpressuremeasurementsareabove140whilethediastolicbloodpressurereadingonapatientisunder90,theconditionisreferredtoassystolichypertension(Krameretal.,2019).Systolichypertensionisseenmoreamongolderadults.

DiastolicBloodPressureManagement(DBP).

TheDBPisthesecondnumberreadingheardthatrepresentsthepressureinthevesselswhentheheartrestsbetweenbeats(Saco-Ledoetal.,2020;WHO,2021).Diastolicbloodpressureisexperiencedwhenthereadingsareconsistentlyover90(Krameretal.,2019). A higher risk of cardiovascular disease and stroke is associated with every 10 mmHg over a diastolic blood pressure reading of 40 to 89. The significance of DBP is therefore emphasized (Saco-Ledo et al., 2020). A patient’s DBP results may indicate an urgent clinical necessity to lessen potential hazards and illnesses. Filling up the knowledge gap requires educating the public on the significance and ramifications of different blood pressure measurements.
AmbulatoryBloodPressureManagement(ABPM)
.

Ambulatorybloodpressuremanagementisaneffectivewayofmonitoringandmanaginghypertensivepatients.Thebloodpressuremeasurementsaretakenover24hours,whetherthepatientisawakeorasleep(Leedy&Ormrod,2020).ItwasintroducedasamethodallowingthecollectionofBPvaluesnumeroustimesanhourover24hours.Forexample,thereadingscanbetakenover20and30-minuteintervalsthroughoutthedayandnight(Mandinietal.,2018).Furthermore,heartratereadingscanbeaddedforenhancedABPM.Afterthat,thereadingsareaveragedforeachday,andchangesinbloodpressurearecalculated.

Additionally,statisticssuchaschangesinheartrateandbloodpressuredistributionpatternsarecalculated.BPmeasureshavelongbeenrecognizedascriticaltoolsfordoctorsindetectingandmanaginghypertension(Asayamaetal.,2019).Incorrectapplication,lackofuniformity,orpatientorfamilyerrorsafterreceivinginstructionswerealleliminatedbytheABPM,whichwasconsideredaccurate.ToevaluatethemeanSBPorDBPrecordedreadings,itwasnecessarytoconsiderABPM’smultiplereadings.AccordingtotheAHAguidelines,Diastolicandsystolicbloodpressurelevelsshouldbelessthan125and75millimetersofmercury,respectively(Mandinietal.,2018).OneoftheadvantagesoftheABPMwasthatitwasmoreaccuratethanaone-timemeasurement(Dadlanietal.,2018).ItispossiblethattheABPMcoulddetectvariationsincircadianrhythms,suchassleep-wakecyclesandbloodpressurefluctuations,inresponsetoenvironmentalandemotionaldisturbances(Dadlanietal.,2018).

Patientswerereluctanttowearthecufffor24hoursbecauseofthediscomfortitcausedandthefactthatittriggeredevery30minutesatnight,makingambulatorybloodpressurecontrol(ABPM)ineffective(González-dePazetal.,2019).Dadlanietal.(2018)alsonotedpractitioners’lackofavailability,understanding,andvaryingawarenessofambulatorymonitoring.Therefore,itispossiblethatusingABPMmadeitmorechallengingtogetanaccuratebloodpressurereadingwhileexercising.

Ambulatorybloodpressuremonitoringprovidedenhancedinformationonhowbloodpressurechangeswithaperson’sdailyactivitiesandsleep.ThismonitoringstyleisrecommendedbytheAmericanHeartAssociationandtheAmericanCollegeofCardiologyasthesuitablemodeforbloodpressuremanagement Mostpeoplerecordadecreaseofaround20%insystolicbloodpressurewhenasleep(MillionHearts,2021).However,someexperiencezerodropsduringsleep (Saco-Ledo, et al., 2020). Inuniqueinstances,somepeoplerecordedariseinsystolicbloodpressureduringsleep. (Million Hearts, 2021).Ambulatorybloodpressuremonitoringisadvantageousbecauseitcandetectbloodpressurechangesthatmightgounnoticedwithotherbloodpressuremanagementtechnology.

Ambulatorybloodpressuremanagementcandetectwhite-coathypertension,maskedhypertension,andsustainedhypertension(Rêgoetal.,2019).Whitecoathypertensioniswitnessedwhenhypertensivepatientswhodon’ttakehypertensivedrugsrecordhighbloodpressurereadings.Thisphenomenoncanleadtothemisclassificationofhypertensivepatientswithnormalbloodpressure.Tentothirty percentofpatientswithhighbloodpressurereadingshaveexperiencedwhitecoathypertensionathealthcarefacilities(Rêgoetal.,2019).GuidelinesinABPMprohibittreatmentwhenbloodpressurereadingsarewithinthenormalrangeoutsidethedoctor’soffice(StatisticalSolutions.,2019).However,itisuptothehealthcareproviderandthepatienttomonitorthebloodpressurereadingsforearlydetection.Ontheotherhand,maskedhypertensionoccurswhenthebloodpressurereadingsareexpectedwhenthepatientisatthedoctor’sofficebutriseswhenthepatientisathome (Rêgo etal., 2019) Maskedhypertensionoccursinmorethan20%ofpeoplewithuntreatedhypertension(Rêgoetal.,2019).

Furthermore,maskedhypertensioncarriesthesameriskassustainedhypertensionandshouldbemanagedwithhypertensionmedications.Lastly,sustainedhypertensionoccurswhenthehighbloodpressurereadingishighatthedoctor’sofficeandathome.Sustainedhypertensionincreasestheoccurrencesofheartandkidneyproblems.Aidingdetectionandmanagementofhypertension,ambulatorybloodpressuremonitoringwasusedtodeterminetheefficacyofvariousantihypertensivemedicationsusedtocontrolhypertension(Rêgoetal.,2019).Bymonitoringbloodpressurereadingsthroughoutthedayandnight,healthcareproviderscandetermineiftheprescribedhypertensivedrugshaveeffectivelycontrolledhighbloodpressure.Asaresult,ahealthcareprovidercanmakepatientdecisionssuchasincreasingthedosageorusingadditionalmedicationstomanagebloodpressure.Additionally,ambulatorybloodpressuremonitoringaidsinthepredictionofthelikelihoodofheartdiseases.Sincehypertensionislinkedtoheartdiseasesandorgandamage,datafromambulatorybloodpressuremonitoringcanbeusedforthepredictiveanalysisofsuchoutcomes(Miaoetal.,2020).

Aerobic Exercis
e Health Intervention

AccordingtoSealsetal.(2019),aerobicexerciseisanyactivityinvolvingcardiovascularconditioningandpertainstorunning,briskwalking,swimming,orevencycling.TheAHAguidelinefocusedonwalking;howmuchexercisewegetdailydependsonhowmuchweknowaboutexercise.Thevariables,includingaerobicexerciseandbloodpressurereadings,was usedasthekeyindicatorsintheanalysissoftware.Saco-Ledoetal.(2020)conductedasystematicreviewandmeta-analysis.Theauthorsclaimedthatambulatorybloodpressure(ABP)isabetterpredictorofcardiovasculardiseaseandmortalityinadulthypertensivepopulations.Thestudiesusedincluded910participantsdiagnosedwithhypertensionandwereexposedtoaerobicexercisesforeightto24weeks,spreadoutthroughouttheweeksasthreetofivesessionseachweek.Within24hoursofbeingsubjectedtoaerobicexercises,thereweresignificantreductionsinparticipants’DBPandSBP{diastolicBP,−3.0mmHg[−5.4to−0.6],systolicBP,−5.4mmHg;[95%CI,−9.2to−1.6]}TheassessmentoftheDBPandSBPwasdoneusingarandom-effectsmodel,whichposednoconflicts.Exercisehadasubstantialimpactonloweringbloodpressurethroughouttheday,includingduringthedaytime(systolicBP,4.5mmHg;[95percentCI,6.6to2.3];diastolicBP,3.2mmHg[4.8to1.5]),evening(systolicBP,4.7mmHg[8.4to1.0];diastolicBP.Allthemeasuresusedonthepatientssubjectedtoaerobicexercisesyieldedsignificantbenefits(p<0.05).Thecurrentresearchreviewdemonstratesthemeasurabledecreasedoutcomeofexerciseonbloodpressurereadings(Saco-Ledoetal.,2020).

Theauthorsproposedwalkingwithanotheraerobicexerciseforpeoplewithhighbloodpressuretobringitdown(Mandinietal.,2018).Physicalactivityhasbeenemphasizedasanessentialcomponentinmanagingcardiovasculardiseases.Studiesinvolvingparticipantswhopracticedmoderatetointensiveexercisesfoundthattheseparticipantsexperiencedalowincidenceofcardiovasculardiseases.Theseparticipantsexperiencedoverallimprovedhealthoutcomes.Additionally,large-scalepopulationstudiesshowthatparticipantswitha15-minutedailyexerciseroutineexperienceareductioninmortalityduetocardiovascularissuesby15%(Muntneretal.,2020).Therefore,physicalactivityhasphysiologicaleffectsonparticipants’cardiovascularsystems.Theseactivitiesimprovevascularendothelialfunctionandenhancedvasodilationduringbloodflow(Viranietal.,2020).

Additionally,physicalactivityreducestherestingheartrateduetoamechanismthatincreasesparasympathetictone(Wheltonetal.,2017).Astudyfoundthataerobicsexercisesandphysicalactivitiesincreasevasculogenicbyusingendothelialprogenitorcells(Severinetal.,2020).Lastly,physicalactivityhasbeenknowntoincreaseaperson’stoleranceforischemiaandreperfusioninjury.AstudyconductedinChinafoundthatthecardiovasculardiseasemortalityratehasincreasedsignificantlybymorethan50%from1990to2009(Sealsetal.,2019).TheincreaseinthecardiovasculardiseasemortalityrateinChinawasattributedtothelackofphysicalactivityamongitscitizens.Suchstudiesindicatethatphysicalactivityplayedacrucialroleinthereductionofcardiovasculardiseaseincidences,whoseriskfactorwasthepresenceofhighbloodpressure(Wangetal.,2019).Therefore,itwasvitaltoperformresearchstudiesevaluatingaerobicexercise’seffectonbloodpressuremanagement.

Aerobicexercisesincreasebreathing,oxygenation,andheartrateduringtheperformanceofaerobicactivities.Asaresult,aerobicexerciseskeeptheheart,lungs,andcirculatorysystemhealthy(Shackelford,2022).Researchdatacreditaerobicexercisesforimprovingcardiovascularhealthandloweringbloodpressure.Additionally,aerobicsexerciseshavebeenlinkedtoregulatingbloodsugar,improvingsleep,andboostingaperson’smood.Anadditionaloutcomeofregularaerobicsexercisesisweightmanagement(Shackelford,2022).

AerobicexerciseshavebeenrecommendedthroughoutEuropeandAmericaaspartoftheguidelinestoreducehypertensionprevalence.Itwascitedthatmoderate-intensityaerobicexerciseseffectivelyreducebloodpressurereadingsinhypertensivepatients(Ansteyetal.,2021).Furthermore,theseexercisescanlowersystolicanddiastolicbloodpressureinhypertensivepatientsofallgenders(Ansteyetal.,2021).Theexercisesareeffectivelyattributedtoreducingbloodpressurelevelsforhypertensivepatientsineitherstageoneorpre-hypertension.However,existingstudiesreportthatexercisetrainingdisruptsthecirculatorysystem(Chobufoetal.,2020).Theresearchshowedthatexercisedisruptsthebalancebetweenvasodilationandvasoconstriction.Thisresearchcitedthatexercisealtersvasodilationandvasoconstriction-relatedcytokinessuchasnitricacid.Thesestudiesconcludedthatnoevidencesupportsthehypothesisthatexercisereducesbloodpressureinhypertensivepatients.

Furthermore,researchontrimesterexercisetrainingshowsnoreductionintheparticipants’bloodpressure.Theexceptiontotheresearchontrimesterexerciseisparticipantswithresistancehypertension(Fordeetal.,2020).Therefore,thisprojectwascrucialindeterminingthedegreetowhichaerobicexerciseswouldimpactbloodpressuremanagementinhypertensivepatients.

Effect of Exercise on Blood Pressure

In2018,thepercentageofU.S.adultsaged18andoverwhometthe2008federalphysicalactivityguidelinesforaerobicactivitywas53.3%(95%confidenceinterval=52.25%-54.27%)whichwasnotsignificantlydifferentfromthe2017estimateof53.1%(Sakhujaetal.,2022).TheAmericanHeartAssociation(AHA)developedandreleasedaprogramin2019called”ExerciseWithinReach”forthepublictouse.Thisapplicationusedmaterialalreadyinthepublicdomainanddidnotrequirepermissiontobeused.Walkingaerobicexercisewaswhatthestudy’sauthorsproposeforpeoplewhohavehighbloodpressuretobringitdown(Mandinietal.,2018).

Regularphysicalexercisehasbeencitedtoreducebloodpressureinhypertensivepatients.Asaresult,physicalexercisehasbeenwidelyrecommendedaspartofthehypertensionguidelinesintheUnitedStates.Hypertensivepatientsareencouragedtoparticipateinaerobicexercisesdaily.Aerobicexercisesvary.Theexercisescaneitherbeintheformofwalking,jogging,orswimming.Thehypertensionguidelinesrecommendoneoftheseexercisesatleastthirtytofortyminutesdaily(Shimboetal.,2020).Innormotensives,regularphysicalexerciseshavebeenrecordedtohavereducedtheaveragesystolicbloodpressurelevelsbybetween3to5mmhg(Vaughanetal.,2022).Ontheotherhand,thediastolicbloodpressurereductioninnormotensivesbecausephysicalexerciseaveragesbetween2to3mmhg(WorldHealthOrganization,2021).Inhypertensive,thedegreetowhichbloodpressurehasbeenrecordedtohavereducedbecauseofphysicalexerciseinmorethaninnormotensives.

However,thereislimitedresearchontheeffectsofexerciseonresistanthypertension.Resistanthypertensionisregisteredwhenthereisafailurebythebloodpressuretoberegulateddespiteusingthreeormoreantihypertensiveagents,includingadiuretic.Therefore,resistanthypertensionisresistanttodrugtherapy.However,itremainsunclearwhethertheresistanceofresistanthypertensiontodrugtherapyappliestootheralternativemechanisms,suchasaerobicsexercises.Additionally,theprevalenceofresistanthypertensionischallengingtoverify.

Inastudytotestthehypothesisthatanaerobicexerciseprogramcanreducebloodpressure,researchersconductedarandomizedcontroltrial(Williamsonetal.,2022).Fiftysubjectsparticipatedinthetrialsbycarryingouttreadmillexercisesfor8to12weeks.Bloodpressurewasmonitoreddayandnightinadditiontopulsewaveanalysis.Resultsshowedthatthetreadmillexercisessignificantlydecreasedtheparticipants’systolicanddiastolicbloodpressure.Furthermore,increasedphysicalperformanceresultedinunchangedarterialcomplianceandcardiacindex.Therefore,theseresultsshowthatphysicalexercisesdecreasebloodpressureinhypertensivepatientsandshouldbeusedtomanageresistanthypertension.

Saco-Ledoetal.(2020)conductedasystematicreviewofthestudyinvolvingadultsinthreegroups.Thefirstgrouphadparticipantswithnormalbloodpressure.Thesecondgroupcontainedparticipantswithprehypertensionsymptoms.Thelastgroupcontainedparticipantswithhypertension.Theresultsfromthisstudyindicatedthatphysicalexercisecausedareductioninthebloodpressurelevelsinparticipantswithhighbloodpressureandapre-hypertensivestate.

LiteracyLevel.

Healthliteracydeterminestheexchangeofcomplexinformationamongpatientsandhealthcareproviders.Lowlevelsofhealthliteracyarestandardinhealthcare.Asaresult,healthcareilliteracyaffectsmanagingconditionssuchashypertension(Leedy&Ormrod,2020).Thefactorswereattributedtolowhealthliteracy,suchasculturalbackground,lackofeducationalresourcesandfinances,dietaryhabits,lifestyle,andlackofawarenessoraccesstohealthcare(Schillinger,2020).Educationenablespatientsandeveryotherindividualthestrengthtounderstandtheirhealthconditions,manage,andseektreatment.

Additionally,lowliteracylevelswerecommonamonghypertensivepatients.Inastudyconductedtodeterminethecorrelationbetweenhealthliteracyandhealthoutcomesinhypertensivepatients,itwasdeterminedthatpatientswithlowliteracylevelsarelikelytohavelimitedknowledgeandunderstandingregardingHTNself-management(Nerenbergetal.,2018).However,thestudywasinconclusiveindeterminingwhetherthelimitedknowledgepossessedbyhypertensivepatientswithlowliteracylevelclinicaloutcomesofbloodpressuremanagement.

Ithasbeendemonstratedthatmaintainingahealthylevelofphysicalactivitycanreduceone’sbloodpressure(BP)(Mandinietal.,2018).Patientswithchronicdiseasesoftenfinditchallengingtomanagetheirhealthconditions;theywillrequireextendedsupporttoattainaqualityoflifebymonitoringtheirBP,medicationcomplaints,decreasingexacerbationswithmorbidandhospitalizations(Carey&Forsyth,2022;Yatimetal.,2019).Itisapredictingfactorintreatmentadherenceforhypertensivepatients.

Self-Efficacy.

Inastudytoexaminetheroleofself-efficacyinmanaginghypertension,atotalof1087participantsintwogroupswereusedtoconductthisresearch(Beaneyetal.,2019).Onegroupcontainedparticipantswithhypertension,whiletheothergroupcontainedpatientswhodidnotdevelophypertension.Thetwogroupswereexaminedusingfivefactorstoassesspatientmanagementwithchronicconditions.Thedomainsincludedailyactivities,emotions,medication,andtreatment.

Thetwoadditionalfactorsusedforthestudyweresocialinteractionsandsymptoms.Thisstudyshowedtheparticipantswithhypertensionreportedchallengesinmanagingday-to-dayactivitiescomparedtothecontrolgroup(Lurbeetal.,2016).Furthermore,participantswithhypertensionshowedthatself-efficacyinfluencesthegeneralqualityoflifeforhypertensivepatients.Theseresultsshowedthatself-efficacypredictshypertensivepatients’physicalandmentalhealth.

LifestyleModification
.

Wheltonetal.(2017),intheirstudyonchronicdiseaseself-managementutilizingtheHypertensiveSelf-ManagementEducationProtocol,disclosedthatApproachestoStopHTN(DASH),dietarysodiumrestriction,activeparticipationinphysicalactivity,moderationofalcoholconsumption,cessationofsmoking,andadherencetomedicationregimestocontrolBP(Schillinger,2020).Self-medicationhasbeentestedtohaveimprovedinreducingPBthroughmedicationadherence,exercise,dietmodification,andweightdecrease(MillionHearts,2021).Lifestylemodificationshavebeencitedashavingadirectimpactonhypertensionmanagement.TheAmericanSocietyofHypertensionoutlinesthehypertensionclinicalguidelines.Theclinicalguidelinesrecommendincorporatingaerobicexercisesandreducingsaltintake.Additionally,theclinicalguidelinesrecommendnoalcoholandsmokingtoreducetheriskofhypertension.Healthydietsforoverweightorobesepeoplehavealsobeenrecommended.

Furthermore,theDietaryApproachestoStopHypertension(DASH)hasbeenwidelyrecommendedforbloodpressuremanagement.TheDASHdietishighinfruitsandvegetables.Itemphasizesincorporatingwholegrains,whitemeat,andlow-fatdairyproducts.Additionally,thedietislowinfat,redmeat,andprocessedfoodssuchassugarydrinksandrefinedcarbohydrates.TheDASHdietaimstoreduceweightandheartrateandlowertheriskofdiabetes.Arecentstudyfoundthatreplacingcarbohydrateintakewithproteinreducedbloodpressureinhypertensivepatients(MillionHearts,2021).Therefore,theriskofcardiovasculardiseaseswasreducedsignificantly.

In the Saco-Ledo (2020) trial, 910 individuals who had been diagnosed with hypertension had aerobic exercise exposure for 8 to 24 weeks, spaced out as 3-5 sessions per week. Within 24 hours of participating in aerobic activity, participants’ DBP and SBP (diastolic BP, 3.0 mm Hg [5.4 to 0.6], systolic BP, 5.4 mm Hg; [95% CI, 9.2 to 1.6]) significantly decreased. A random-effects model was used to evaluate the DBP and SBP, which created no conflicts of interest. Blood pressure was significantly lowered by exercise

NewhypertensiondiagnosticcriteriaissuedbytheAmericanHeartAssociation(AHA)callforabloodpressurereadingof130/80millimetersofmercury(mmHg).AccordingtotheEuropeanSocietyofHypertension,140/90mmHgistheoptimumthresholdfordefininghypertension.Saco-Ledoetal.(2020)suggestedthathypertensivepatientsshouldbeeducatedontheAHArecommendationaerobicexerciseprogramtomaintainoptimalbloodpressurelevels.

Chapter2discussesLewin’schangemodelandOrem’sself-caredeficittheory.Threesignificantconceptswereexaminedindepthwithinthechapter.First,basedonthetheoreticalfoundations,itwasexpectedthattheAHAguidelinesonaerobicexercisewouldsignificantlyimpactambulatorybloodpressurewhentheyareputintopractice.Patientsareencouragedtofeelthattheirhealthcanberestoredorevenenhancedbeforeahealthdiagnosis,whichisthecoreprincipleoftheidea.

Participantsmustaltertheirwayoflifetobeself-efficaciousthroughOrem’sself-caretheoryeffective.Aspartoftheproject’sgoals,smokersanddrinkersdiagnosedwithhypertensioncanstopengagingintheseunhealthyhabits.Threemajorthemeswereexaminedindepthinthischapter.Thefirstwastheprevalenceofhypertension.Thefirstthemeontheprevalenceofhypertensionhasthreesub-themesrelatedtomeasuringtechniquesforhighbloodpressure.Thesub-themesincludesystolicbloodpressuremanagement,diastolicbloodpressuremanagement,andambulatorybloodpressuremonitoring.Themetwowasaerobicsexciseimpactonbloodpressure.Thisthemewassubdividedintothreesub-themes:pre-aerobicexercise,duringaerobicexercise,andpost-aerobicexercisestates.Thethirdthemeistheeffectoftheexercisestate.Thisthemewasdividedintosub-themesthatinfluencetheeffectofexerciseonbloodpressuremanagement.Thesub-themesincludehealthliteracy,self-efficacy,andlifestylechanges.

Chapter3presentstheproject’smethodology,problem,andpurposestatements.Othersegmentsofthechapterincludetheproject’sclinicalquestion,projectdesign,population,andsampleselection.Thechapterexaminestheproject’sdatasources,validityandreliability,datacollectionandanalysisprocedures,andethicalconsiderations,followedbyprojectlimitations.

DuetothegrowingprevalenceofhypertensionintheAmericanadultpopulation,thisprojectfocusedonimplementingAHAguidelinesonaerobicexercises.PhysicalinactivityhasbeenidentifiedasoneofthecriticalfactorsassociatedwiththedevelopmentofHTN;hence,numerousguidelinesrecommendincreasingtheuptakeofphysicalexercisesasaprotectivefactoragainstHTN(Commodore-Mensahetal.,2018).Oneevidence-basedstrategythatcanbeusedtocombatHTNisimplementingAHAguidelinesregardingaerobicexercise.Severalstudies,suchasSaco-Ledoetal.(2020)andSeverinetal.(2020),emphasizetheimportanceofphysicalactivityandthatitcanhelpreduceHTN.The purpose of this quantitative, quasi-experimental project was to determine if or to what degree the implementation “the American Heart Association’s” guideline on aerobic exercise would impact ambulatory blood pressure when compared to current practice among adult hypertensive patients in a primary care clinic in southwest Texas over four weeks.Theindependentvariableisthe“AmericanHeartAssociation’s”guidelineregardingaerobicexercise,andthedependentvariableisbloodpressures.

Thisprojectwasimplementedinfourweeksutilizingaquasi-experimentaldesignandquantitativemethodology.Currently,attheprojectsite,althoughmedicationmanagementandotherstrategiesareprovidedtothepatientsregardingHTNmanagement,theambulatorybloodpressuresoftheHTNpatientswithinthepastthreemonthscontinuedtoincrease.Aftercollaboratingwiththemedicaldirector,nursemanager,andseveralstaffnurses,itwasdecidedthatimplementingtheAHAguidelinesregardingaerobicexercisewouldbebeneficialtothepatients.

Chapter3re-introducestheproject’stopic,clinicalquestion,andproblemstatement.Otherchaptersegmentsincludetheprojectmethodology,design,andpopulationsample/size.Adiscussionoftheinstrument(AHAguidelinesforaerobicexercise),validity,andreliabilityaregiven.Thelastportionofthechaptergivesthedatacollectionandanalysisprocedures,potentialbiases,andmitigationprocedures.AfewsentencessummarizeChapter3andprovideapreludetoChapter4.

Statement of the Problem

It was not known if or to what degree the implementation “the American Heart Association’s” guideline on aerobic exercise would impact ambulatory blood pressure when compared to current practice among adult hypertensive patients.Theaffectedpopulationwereadultpatientsdiagnosedwithhypertension.ThecountywheretheclinicislocatedcorrespondswiththelatesthealthstatisticsfromtheTexasDepartmentofStateHealthServices(2022).Thecountyranks22ndintheUnitedStateswithdiagnosedHTNpatients(TexasDepartmentofStateHealthServices,2022).ThedemographicshighlightadiversepopulaceofBlacks(18.5%),Whites(28.9%),White-Hispanic(36.72%),Asians(6.9%),andLatinos(8.98.%)(U.S.CensusBureau,2020).Thecountyhasmanyindividualsover60diagnosedwithchronicdiseases(UTHealthScienceCenteratHouston,2020).Theadultagegroupsinthecountyrangefrom18to64,whichsignified the actual participants in the project.

Thisqualityimprovementprojectcontributestopreviousandcurrentliteratureregardingaerobicexercisebeingutilizedinhypertensionmanagement(Aung&Htay,2021;Kristetal.,2021;Saco-Ledoetal.,2020).TheCDC(2021)emphasizedthatfrequentphysicalexercisewasnecessaryforoverallwellness,mentalwell-being,andweightloss.Physicalactivitycouldimpactotherareasofone’slife,suchasreducingthesymptomsofanxietyanddepression(CDC,2021).

Aclinicalquestionisdevelopedfromaproblemorneedsthatcouldbeexaminedandevaluatedtoprovideusefulevidence-basedinformation(Leedy&Ormrod,2020).Thefollowingclinicalquestionwillguidethisquantitativeproject:TowhatdegreedidtheimplementationofAmericanHeartAssociationguidelineaerobicexerciseimpactbloodpressurewhencomparedtocurrentpracticeamongadulthypertensivepatientsinaprimarycareclinicinsouthwestTexas within four weeks?TheindependentvariablewastheAmericanHeartAssociationguidelineregardingaerobicexercise,andthedependentvariable was blood pressures.

OncetheprojectmanagerreceivedpermissionfromGrandCanyonUniversityIRBandtheprojectsite,theprojectwasimplementedataprimarycareclinicinfourweeks.Aquasi-experimentaldesignallowedonetoassesstheimpactoftheAHAguidelineregardingaerobicexercise(independentvariable)ontheparticipants’bloodpressures(dependentvariable).Datawasretrievedfromtheclinic’selectronicmedicalrecordfourweeksbeforeandaftertheimplementationoftheintervention.Conveniencesamplingwasusedforeasieraccesstotheparticipantsandfacility.The project manager regarding the AHA guidelines for aerobic exercise in HTN patients educated one physician, two nurse practitioners, two registered nurses, and one medical assistant.

Thedatacollectionprocessconsistedofonegroup.Apatientidentifierwas assignedtoeachpatientandorganizedaccordingtothemeasurementperiod(preorpostimplementation).Theprojectmanagerusednumericcodesforallvariablesentered.Precodedasmeasurementperiod“1”andpostinterventioncodedasmeasurementperiod“2”.Thedatawas exportedbytheoutsidestatisticianintoIBMSPSSversion-28toevaluatethefrequencycounts,rangescores,andcheckedformissingdataandoutliers.TResults were evaluated in light of the AHA recommendations and their influence on participants’ blood pressure readings taken with the Oscar 2 Device ambulatory monitor.Anyhardcopiesofdemographicsorotherinformationwascollecteddailyandkeptinthemedicaldirector’sofficeinalockedfilecabinet.

Theinclusioncriteriaoftheparticipantsareadultpatients18andolder,diagnosedwithHTN,currentclinicpatients,andcanpartakeinphysicalactivity with difficulties.Theexclusioncriteriaareindividualswithmusculoskeletaldisabilities,comorbiditiesthatcouldaffecttheprojectresults,andmentaldisorders.

Aqualitativemethodologywasnotappropriateforthisproject.Theprojectmanagerdidnotfocusonunderstandingtheparticipants’behaviors,livedexperiences,orfeelings(Creswell&Creswell,2018).Themethodissubjectiveandthematic,withthefindingswrittenusingtheparticipants’wordsverbatim(Creswell&Creswell,2018).Dataisanalyzedutilizingacodingtechniquethatseeksthemesandpatterns(Creswell&Creswell,2018).Theresultsareshownintwoorthreecolumnsusingtheparticipant’swords.Thismethodistime-consuming,andasaresult,itisnotsuitableforaquality improvement project.Throughthestatisticalanalysis,thequantitativemethodhelpedestablishthedegreetowhichaerobicexercisescould sustain reductions in BP in hypertensive patients.

Aquasi-experimentaldesignwasselectedforthisproject.Thisdesignallowedtheprojectmanagertocomparetheindependentanddependentvariables(Creswell&Creswell,2018).ThedesignwasthemostappropriateinevaluatingthevariablesanddeterminingtheimpactoftheAHAguidelinesregardingaerobicexerciseontheparticipants’bloodpressures.Therespondentswere not randomly assigned to any group(Creswell&Creswell,2018).Thebloodpressure(dependentvariable)was measuredtwotimesduringthedatacollectionprocess(fourweeksbeforeandaftertheintervention).

Acorrelationaldesignwasnotthemostappropriateforthisproject.Itisanon-experimentaldesignwheretheindependentanddependentvariablesaremeasuredandassessedfortheircorrelationrelationship(Creswell&Creswell,2018).Furthermore,theprojectmanagercannotcontrolthevariablesin correlational research design (Creswell&Creswell,2018).

Thedatacollectiontoolchosenwastheclinicalobservationofoutcomes,whichentailedreviewingABPmeasurementsfromtheABPMlogofparticipants.TheOscar2devicekeepsadigitalABPlogthatcanberetrievedtoacomputertoshowarecordofABPmeasurementsthroughoutthedayandthe24-houraveragecalculated(SunTechMedical,2021).ThisdevicealsohasaninstructionmanualonhowitcouldbeusedforanABPmonitor.ThedigitalABPMdataensuredaccuracyandreliabilitysincesuchinformationisdevoidoferrorsthatarisewhenself-reporteddataareutilized(Nwankwoetal.,2020).

Population and Sample selection

ThetargetedpopulationforthisprojectconsistedofAmericanadultsdiagnosedwithhypertension.Anestimated45%ofAmericanadults,about116million,arehypertensive(CDC,2021).InTexas,theprevalenceofhypertensionis35.1%.HypertensionisprevalentintheU.S.andfrequentlyfoundinAfricanAmericans,Whites,Hispanics,andAsianAmericans(MillionHearts,2021).TheprojectpopulationcomprisedofhypertensivepatientsvisitingaprimarycareclinicinurbanTexas,whichwasthesettingforthisproject.Theclinicprovidesservicestoadiversepopulationbutpredominatelyseesminorities.Approximately20individualsareseenthreetimesperweekatthisclinic.

Conveniencesamplingwasemployedtoenrollparticipants.Thisformofselectionentailsselectingparticipantsbasedontheiraccessibilityandavailabilitytoparticipate(Creswell&Creswell,2018).Thehealthcare staff at the clinic (registered nurse, nurse practitioner, medical assistant, and physician) implemented the project.Thosewhoexpressedinterestinparticipatingintheprojectwereprovidedadditionalinformationforparticipation.Themedicalassistant/nursecalledthepatientshighlightedonthedailylogforthenextdaywithhypertension.Thisindividualwasprovidedabriefdescriptionoftheprojectandhighlightthepatient’snameinblue(toletthehealthcareprovidersknowthepatientwasparticipatingintheproject).TheminimumsamplesizewasevaluatedusingG*Powersoftware,version3.1.9.2,usinganalphameasureof0.05,aneffectsizeof0.5,andapowerof80%computedtheleastnumberofparticipantsneededfortheproject(n=10).

Participantswereprovideinformedconsentbeforeparticipatingintheprojectbecausethisisaqualityimprovementproject,notaresearchstudy.AfteraverbalpresentationoftheprogrambyhealthcarestaffattheclinicaftertheyweretaughtusingaPowerPointpresentation.Participantswereprovidedwithaninformationsheetdetailingtheproject’spurpose,theintervention,andthenatureoftheirparticipation.Afterward,participantswhoexpressinterestinparticipatingintheprojectwere told that their information were de-identified.TheclinicdoesnothaveanIRB,soawrittenprocessandHealthcareInsurancePortabilityandAccountabilityAct(HIPAA)waiverformwas filledoutandsignedbyresponsiblepartiesforGrandCanyonUniversity’sIRBprocess.Theconfidentialityofparticipantswas guaranteedbyde-identifyingthecollecteddata.Patientde-identifierswere used instead of names. The inclusion criteria werebeingatleast18years,HTNdiagnosis,beingaTexasresident,andindependentlyseekinginterventiontomanageHTN,takingmedicationsforHTN.Patientsbelow18years,non-hypertensive,non-Texasresidents,nottakingHTNmedication,andwhocannotperformaerobicexerciseswere excluded from the project.

Data Collection Procedures

AfterapprovalisreceivedfromGrandCanyonUniversityIRB,allpatientsvisitingtheclinicforhypertensionwhomettheinclusioncriteriawereaskedtoparticipateintheproject.The Health Insurance Portability and Accountability Act (HIPAA)waiver authorization form was signed between the PI and site contact person.Afterverbalrecruitmentbythehealthcarestaffattheclinic,participantswereprovidedwithaninformationsheetdetailingtheproject’spurpose,benefitsofparticipation,andrisks.Recruitmentoccurredforoneweek,andenrolledpatientswerefollowedforthefour-weekimplementationperiod.Forthisproject,patientswere not divided into groups; instead, data was collected four weeks before and four weeks after the implementation of the intervention.

The participants wereinstructedthattheyareexpectedtopracticetheirwalkingathomethreetofivetimesweeklyfor20minutesandcontinuetotaketheirantihypertensivemedications.Theparticipantswere informed to continue their routine activities and method of communicating with their primary physician while on the project implementation.Participantstrackedtheirinvolvementviaalogbookduringtheirnon-clinicvisitday(Mondays,Wednesdays,andFridays) to show commitment. Those who have clinic appointments during this time performedtheirexerciseintheclinicwhilewaitingtobeseenbythephysician.

Inweekfour,participantsreturnedtotheclinictoretaketheirABPusingOscar2device.Participantsambulated around the clinic for 20 minuteswearingtheOscar2device.They were monitored for their walking, whether it was intense or moderate. The ABP measurements were takenaftera20-minuterestperiod by the staff.

The deidentified code book was senttoanoutsidestatisticiannotaffiliatedwiththeprojectusingencryptedemail.Theindependentvariableis“theAmericanHeartAssociation’s”guidelineforaerobicexercise,andthedependentvariablesaresystolicanddiastolicbloodpressure.Sincetheprojectdesigninvolvedamatchedsamplewithpre-andpost-implementationBPdata,pairedsamplest-testswereconductedtoaddresstheclinicalquestiontodetermineifthelevelsdeclinedaftertheintervention.Demographicswereanalyzedusingdescriptivestatistics.Thedatawere preparedusingtheStatisticalPackageforSocialSciences28(SPSS-28)fordataanalysis.

Data Analysis Procedures

Thefollowingclinicalquestiondirectedthisquantitativeproject:Towhatdegreedidtheimplementationof“theAmericanHeartAssociation’s”guidelineaerobicexercise impactbloodpressurewhencomparedtocurrentpracticeamongadulthypertensivepatientsinaprimarycareclinicinsouthwestTexas with four weeks?TheindependentvariableistheAmericanHeartAssociationguidelineregardingaerobicexercise,andthedependentvariableisbloodpressures.Descriptivedata(suchasage,gender,andethnicity)wascollectedviatheclinic’selectronicmedicalrecords.Theageswereanalyzedusingthemeanandstandarddeviation.Theparticipants’gender,ethnicity,anddiagnosiswereevaluatedusingfrequencycountsandpercentages.

Thedatawasretrievedfromtheclinic’selectronicmedicalrecordsandinsertedintoaMicrosoftExcelspreadsheet.Apatientidentifierwasassignedtoeachpatientandorganizedaccordingtothemeasurementperiod(preorpostimplementation).Theprojectmanagerusednumericcodesforallvariablesentered.Prewerecodedasmeasurementperiod“1”andpostinterventionwere codedasmeasurementperiod“2”.Theoutside statistician exported data into IBM SPSS version-28 to evaluate the frequency counts, range scores, and check for missing data and outliers.

The participants ’blood pressures( dependent variable)were analyzedusingapairedsample
t-testinweekfour.Theindependentvariablearenominal,andthedependentvariableareaninterval-levelvariable(Schober&Vetter,2019).This
t-testexaminesthemeanscorestakenfromthesameparticipants(Schober&Vetter,2019).Furthermore,thetestalignedwiththequasi-experimentaldesign,whichallowedtheprojectmanagertoassesstheimpactoftheintervention(AHAguidelinesforaerobicexercise)ontheoutcome(bloodpressures)inthetargetedpopulationbybeingrandomlyassigned.Thelevelofstatisticalsignificancewassetto.05toindicatethata
p-valueoflessthan.05 and considered statistically significant.

Ethical Considerations

Therearenoconflictsofinterestbecausenoentityfundedtheproject.Theprincipleofrespectrequiresensuringautonomy.Becausethisisaqualityimprovementproject,noconsentisrequiredfromtheparticipantsasitisvoluntary.Theprincipleofjusticerequiresequallydistributingtherisksandbenefitsoftheproject,whichwas achievedbyensuringthatallpatientspresentingwithHTNweregivenachancetoparticipatesothattheydidnotmissapotentiallybeneficialintervention.Beneficenceisaboutdoinggood.Thisprojectevaluatedapotentiallybeneficialintervention–aerobicsexercises.Uponapprovalofthedocumentbythechairpersonandthecommittee,theproposalwassubmittedforAQRreview.Thedata has beenkeptfollowingGrandCanyonUniversity’sIRBguidelines(threeyears)(August2025).Thecomputerdatawillbedestroyedusingcomputersoftware(ERASER)andthehardcopiesviaIronMountaindocumentationshreddingcompany.

Limitationsarecircumstancesorconditionsthattheprojectmanagercould notcontrol(Creswell&Creswell,2018).Thefirstlimitationofthisprojectwasthe

useofthequasi-experimentdesign.Thelackofrandomizationinthequasi-experimentaldesignshinderedtheabilitytomakecausalconnectionsbetweentheobservedoutcomeandtheinterventionimplemented(Creswell&Creswell,2018).

Thethirdlimitationisthelimitedtimetoconducttheproject(fourweeks).Across-sectionalprojectprovidesasnapshotoftheintervention(Leedy&Ormrod,2020).Alongitudinalprojectwouldallowonetoassesstheobstacles,changes,andtrendsthatoccurovertime(Leedy&Ormrod,2020).Furthermore,aninvestigatorcouldevaluateachronologicalsequenceofevents,whichestablishescausality(Leedy&Ormrod,2020).

ItwasnotknownifandtowhatextentAHAaerobicexerciserecommendationsreduceBPinadulthypertensivepatients.Theprojectaimedatinvestigatingtowhatextentaerobicexercisescouldalleviatebloodpressureinhypertensiveadults.TheindependentvariableforthisprojectistheAHAguidelinesonaerobicexercisesforhypertensivepatients.Ontheotherhand,thisproject’sdependentvariableistheparticipants’bloodpressuremeasurements.Themethodologyusedforthisprojectwasquantitative.Aquantitativemethodologywasutilizedbecauseitallowedstatisticalanalysisofnumericdatacollectedforthisprojectasbloodpressuremeasurements.Theprojectdesignisquasi-experimental,usingthewithin-groupdesign.Aquasi-experimentaldesignwasselectedasitisbothethicalandpracticalforthisproject.

Thedependentvariable,ABP,weremeasuredusingtheOscar2device,whichwere comparedduringthebaseline(pre-intervention)andpost-intervention(weekfour).Participantsweretakenusingconveniencesampling.Anormalsphygmomanometerwasavailableasasecondarytoolformeasuringtheparticipants’bloodpressure.Additionally,the10-itemBriefControlSelfScalebyTagneyetal.(2004)wasusedtoassessandselectparticipantswhoadheretotheaerobicexerciseroutineandtakebloodpressuremeasurements.Theselectioncriteriafortheparticipantsinvolvedadultswithhypertensionovertheageof18visitinganurbanclinicinsouthwestTexas.Themethodology’svalidityandreliabilityforthisprojectdependedonthetoolusedtomeasuretheparticipant’sbloodpressure.TheOscar2deviceproducedvalidandreliableresultsinmeasuringbloodpressure.TheparticipantsweretaughtabouttheOscar2deviceusingthesamemanufacturer’sbookletenclosedinthedevicepackage.

Chapter4deliveredthedescriptivedataoftheparticipants,datacollection,andanalysisprocedures.Theprojectfindingswere displayedusingfigures,tables,andsomenarrativeform.ThelastportionofthechaptersummarizestheresultsandpresentsanintroductiontoChapter5.

The project site is a primary care clinic in urban Texas. A convenience sample of

n
= 10 adult patients with HTN were enrolled in the project. Descriptive data were collected for age, gender, and race. Table 1 displays the descriptive data for age. The mean age was 56.50 (
SD = 7.92) with a range from 43 to 71.

Table 1

Descriptive Data for Age

Note. M = mean;
SD = standard deviation

Gender and race are displayed in Table 2. There were three males (30.0%) and females made up 70.0% (
n = 7). Race was 80.0% (
n = 8) African American, 10.0% (
n = 1) Hispanic, and 10.0% (
n = 1) Caucasian.

Table 2

Descriptive Data for Gender and Race

Note: n = count; % = percentage

This quality improvement project was implemented once approval was received from Grand Canyon University IRB and the clinic site. The following clinical question guided this quantitative project: To what degree does the implementation of American Heart Association guideline aerobic exercise would impact blood pressure when compared to current practice among adult hypertensive patients in a primary care clinic in southwest Texas? The independent variable was the American Heart Association guideline regarding aerobic exercise which was a nominal level variable, and the dependent variable was systolic and diastolic blood pressure, and blood pressure is a ratio-level variable. The clinic’s electronic medical records were used to collect descriptive data (age, gender, and race). The age was analyzed using the mean and standard deviation. The participants’ gender and ethnicity were evaluated using frequency counts and percentages.

Data on the patient outcomes for systolic and diastolic blood pressure were obtained from the clinic’s electronic medical records and inserted into a Microsoft Excel spreadsheet (codebook). Each participant was assigned a patient identifier and organized according to pre and post intervention measurement periods. The project manager used numeric codes for all variables entered. The pre-intervention measurement period was coded as “1,” and post-intervention was coded as measurement period “2”. An outside statistician exported the data into IBM SPSS version-28 to evaluate the frequency counts, range scores, and check for missing data and outliers and conduct statistical analysis.

The participants’ systolic and diastolic blood pressures (dependent variable) were analyzed using paired sample t-tests. This t-test was chosen for statistical analysis because it examines the mean scores taken from the same participants at two different measurement periods (Schober & Vetter, 2019). Furthermore, the test aligns with the quasi-experimental design, which allows the project manager to assess the impact of the intervention (AHA guidelines for aerobic exercise), on the outcome (systolic and diastolic blood pressure) in the convenience sample. The level of statistical significance was set to .05 to indicate that a p-value of less than .05 is considered statistically significant.

Table 3

Paired t-test results for Systolic Blood Pressure Levels

Note. M = mean
; SD = standard deviation

A paired
t-test was conducted on diastolic blood pressure at pre-and post-implementation and results are displayed in Table 4. The results showed a decrease in the mean diastolic BP level from pre (
M = 87.30,
SD = 11.19) to post (
M = 78.10,
SD = 8.45)
, t (9) = 2.56,
p = .031. The
p-value is less than .05 which indicates that the decrease in mean diastolic BP was statistically significant.Clinicalsignificancewassupportedbythe9.20-point mean decline in the systolic mean levels after the intervention.

Note. M = mean
; SD = standard deviation

Data analysis was conducted on systolic and diastolic BP at pre and post implementation. The paired t-test results showed a
p-value of .001 for the systolic BP analysis and a
p-value of .031 for the diastolic BP analysis which indicates that the difference in mean scores was statistically significant. The results also support the clinical significance of the project as reflected in a 26.50-pointmean decline in the systolic and 9.20-point mean decline in diastolic scores after the physical activity intervention.

Summary

This quality improvement project aimed to evaluate the impact of using the American Heart Association guideline on the participants’ blood pressures. The setting was a primary care clinic in Southwest Texas. A convenience sample of
N = 10 adult patients with HTN were enrolled in the project. The mean age was 56.50 (SD= 7.92) with a range from 43 to 71. There were three males (30.0%) and females made up 70.0% (
n = 7). Race was 80.0% (n = 8) African American, 10.0% (n = 1) Hispanic, and 10.0% (n = 1) Caucasian.

Blood pressures were obtained from the electronic medical records which recorded the Oscar 2 device ABPM log. Paired samples t-tests were conducted to analyze the blood pressure scores to see if they declined after the intervention. The results showed a decrease in the mean systolic BP level from pre (
M = 152.60,
SD = 14.42) to post (
M = 126.10,
SD = 19.93),
t (9) = 6.35,
p = .001. There was also a decrease in the mean diastolic BP level from pre (
M = 87.30,
SD = 11.19) to post (
M = 78.10,
SD = 8.45)
, t (9) = 2.56,
p =.031.The
p-value for both outcomes was less than .05 which indicates that the decrease in BP was statistically significant. Clinical significance was supported by a 26.50-pointmean decline in the systolic and 9.20-point mean decline in diastolic scores after the AHA physical activity intervention.

Chapter 5 reestablished the project’s aim and its summary. The chapter discussed the project findings and examined how they answered the clinical question. Other sections of the chapter included the implications (theoretical, practical, and future) for quality improvement projects and clinical practices. The last segment of the chapter presented recommendations for potential improvement projects and healthcare settings.

The staff consisted of one physician, two nurse practitioners, two registered nurses, and one medical assistant. They were educated regarding using the AHA guidelines for aerobic exercise for 30-minute using a slide presentation and provided a brochure explaining the process. In week one, recruitment for the project occurred, with each participant being offered an information sheet that detailed the project’s purpose, benefits, and risks. Patients were given the knowledge about the HIPAA waiver form and their voluntary participation in the project. The participants’ initial blood pressure was taken with an Oscar 2 device as the pre-test, then the participant carried out the aerobic exercise workout in weeks two and three, and post-test blood pressure measurement was taken by the end of the fourth week.

The project manager offered support to the staff regarding the project and reviewed the data collected using the electronic medical record. In week four, each respondent’s aerobic blood pressure was taken and documented in their electronic medical record. In weeks one and four, blood pressure measurements were compared to determine if weekly aerobic exercise impacted the respondent’s blood pressure. A codebook was developed using a Microsoft Excel spreadsheet. The document was sent via encrypted email to a statistician not affiliated with the project or project manager. Descriptive statistics were used to analyze the demographics, and a paired samples t-test was conducted to determine the statistical significance of the intervention.

Summary of Findings and Conclusion

Blood pressures were obtained from the electronic medical records which recorded the Oscar 2 device ABPM log and analyzed in IBM SPSS using paired samples t-tests.
The results showed a decrease in the mean systolic BP level from pre (
M =152.60,
SD = 14.42) to post (
M = 126.10,
SD = 19.93),
t (9) = 6.35,
p = .001
. A paired
t-test also showed a decline in the mean diastolic BP level from pre (
M = 87.30,
SD = 11.19) to post (
M = 78.10,
SD = 8.45)
, t (9) = 2.56,
p =.031.The
p-value for both outcomes was less than .05 which indicates that the decrease in BP was statistically significant. Clinical significance was supported by a 26.50-pointmean decline in the systolic and 9.20-point mean decline in diastolic scores after the AHA physical activity intervention was implemented.

The American College of Cardiology (ACC) disclosed that physical exercise education and participation should be seen as a way of improving health, modifying lifestyle, and maintaining blood pressure as essential to preventing hypertension (ACC, 2022). While hypertension is serious, it is also attributed to other chronic conditions such as stroke, heart failure, impair mobility, daily function, and death if not effectively managed. Hence, hypertension and the use of daily physical activity to main health and manage blood pressure cannot be overemphasized.

Orem’s self-care deficit theory was selected and used for this quality improvement project. It was selected because it underlines the relationship between the patient and their environment (Orem, 1995). The theory states that humans can participate in their self-care and decision-making to improve their chronic or acute disease processes (Orem, 1995). This can be achieved by the healthcare providers guiding the patient using a patient-centered approach to help them gain an optimal level of independence related to hypertension (Orem, 1995). The theory’s four constructs comprise universal self-care requisites, normalcy, developmental self-care requisites, and health deviation self-care requisite (Orem, 1995). The theory allowed the project manager to help the clinicians understand their responsibilities while providing a transparent outline plan of care.

Lewin’s change model was chosen to work with Orem’s self-care deficit theory. The model revealed how HTN patients, and their healthcare providers are impacted by restraining forces (Lewin, 1947). The model consists of three phases: unfreezing, change (movement), and refreezing (Lewin, 1947). Unfreezing occurred once the project manager began the collaboration process with the medical director, nurse manager, and a few nursing staff to identify the problem (elevated ambulatory blood pressures over the past three months) and develop a plan (Lewin, 1947). The changing stage (movement) began when the project intervention (AHA guidelines related to aerobic exercise) was implemented (Lewin, 1947). The healthcare providers educated their patients using a patient-centered approach and monitoring them. Refreezing began integrating the intervention into the organization’s clinical practice until it became a habit (Lewin, 1947).

One strength noted while conducting the project was the buy-in of the healthcare providers to implement the intervention. Buy-in occurred because the project manager discussed and asked the staff for feedback and genuinely listened with an open mind to the suggestions. This made them feel valued and an intricate part of the intervention. The project clearly explained the project plan, timeline, and process for a successful implementation. The second strength was the healthcare providers offering a patient-centered approach to the various and preferred aerobic training. Some of the aerobic training used was walking, running, swimming, and cycling during the patient’s time completing the intervention at home. The aerobic training and intensity were increased if the patient could tolerate them weekly.

The weakness of the project was the time to conduct the project (four weeks). A longitudinal project is more powerful than a cross-sectional (Leedy& Ormrod, 2020). This method would have allowed the project manager to evaluate the variable patterns, trends, and obstacles that occurred over time (Leedy& Ormrod, 2020). It would have ensured focus, flexibility, and validity (Leedy& Ormrod, 2020).

Practical Implications

The second implication is for the clinicians to consider evaluating the patient’s health literacy level during the education process. Low health literacy is a silent epidemic and a subject many patients and families will not discuss; hence healthcare providers should have a simple and fast method to identify patients at risk of not understanding the information given. The assessment could occur utilizing the Newest Vital Sign developed by Pfizer Corporation. The six-item tool is based on the nutrition on an ice cream label and takes less than three minutes to administer. The scoring for the test is zero to six (0 to 1; there is a high likelihood of limited health literacy, 2 to 3 correct answers indicate a possibility of limited health literacy, and a score of 4 to 6 indicates adequate health literacy) (Weiss et al., 2005). Based on the number of correct answers provided, clinicians can evaluate the individual’s health literacy level and adjust the communication style and level with the patient to ensure understanding of the material.

One future implication is reproducing the project in other healthcare settings, such as prisons and outpatients. The second implication is for nurse managers to pay attention to the HTN risk in their older employees (age 40 and above) while providing regular blood pressure checks. The third implication is for clinicians to encourage patients to implement moderate resistance or strength training two days a week in combatting hypertension. The last implication is for healthcare providers to evaluate their patient’s life stressors and family environment. The stressors could include a terminal illness, recent death of a spouse or sibling, loss of job or home, and the long-term effects of COVID-19.

The first recommendation is to conduct a mixed-method study (qualitative/quantitative). This methodology would incorporate an observational and qualitative interview element. A qualitative approach would offer a broader view of the quantitative findings, which rely solely on numerical data from electronic medical records. Furthermore, it would capture the fluctuating attitudes within the HTN population (Leedy& Ormrod, 2020).

The second recommendation is for future quality improvement projects to identify patients with HTN and intervene with a focus on the patient’s lifestyle. Using an evidence-based survey or developing a lifestyle tool that examines the patient’s lifestyle changes in managing their HTN. This strategy could show the association with their blood pressure readings. Also, it is a cost-effective method for assessing the patient post-intervention. The third recommendation is to focus on patient follow-up. Many HTN patients do not return for follow-up appointments, helping them manage their condition. Unfortunately, for many clinics, it is not considered a priority; however, it remains an element of providing high-quality patient-centered care.

Recommendations for Practice

The first recommendation for future advanced nursing practices is to implement cultural competency that uses a cross-cultural approach in treating HTN patients. Health care providers play a significant role in how the patient interacts, experiences, and remains compliant with the suggested HTN regimen (Jongen et al., 2018). For many patients, cultural or linguistic differences between the provider and themselves could result in serious miscommunication, develop mistrust, and affect patient satisfaction (Jongen et al., 2018). The project findings revealed a high influx of Black and Brown patients being treated for the condition. Addressing the healthcare providers’ cultural competence is one way of improving health service and quality care for culturally diverse patients. Classes should be offered annually to clinicians regarding their knowledge, behavior, and attitudes to other populations (Jongen et al., 2018). Furthermore, it should involve the practitioners increasing their awareness regarding sexuality, gender, racism, and healthcare disparities (Jongen et al., 2018).

The second recommendation is to implement motivational interviewing in treating HTN patients. Approximately one-third of HTN patients obtain and sustain blood pressure control (Silveira et al., 2019). Motivational interviewing, created by Miller and Rollnick, focuses on a directive counseling and patient-centered strategy that promotes the individual’s desire to change (Silveira et al., 2019). Healthcare providers would follow the guidelines such as a) listening with empathy, b) being flexible with the patient’s resistance to change, c) resisting argumentation or confrontation, and d) encouraging optimism (Silveira et al., 2019). Using this approach could help to facilitate compliance with the HTN treatment.

The third recommendation is for clinicians to implement mobile apps and technology in educating their patients. For many patients, the discharge process consists of lots of information and terminology they do not understand. Utilizing their smartphones or tablets could make a difference in receiving and understanding the information without pressure or embarrassment regarding their health literacy level. The education would be given in short intervals (four weeks or less) with messages sent to the patient once a week or more dependent on the patient’s need (Timmers et al., 2020).

The fourth recommendation is for healthcare providers and organizations to offer collaborative environments where nurses and other disciplines can learn and practice treating patients diagnosed with HTN. This would include nursing at all levels, from students, and nursing assistants to nursing leaders. The pharmacist, nurse, nutritionist, and patient should also be part of this collaboration team. Smartphones and the internet should also increase team participation to improve communication and efficiency.

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Appendix B

American Heart Association Physical Activity Guidelines