Nurse Education on Accurate Blood Pressure Measurement in Veterans

Introduction and Problem Statement

Accurate measurement of blood pressure is critical for making appropriate clinical decisions in the management of high blood pressure, in order to reduce cardiovascular risk and prevent organ damage. This is important because an inaccurate measurement could lead to a patient being falsely classified as hypertensive, or falsely classified as having high-normal or normal blood pressure. It could also lead to faulty clinical decisions regarding patient progression in an exercise program (White et al., 2013). This topic is worth examining because blood pressure reading is one of the most inaccurately performed measurements in clinical medicine (White et al., 2013). Efforts are ongoing to increase hypertension awareness, treatment, and control among adults, but the high prevalence of undiagnosed (22%) and uncontrolled (36%) hypertension remains a challenge (White et al., 2013).

An assessment of literature regarding nurse education on how to properly measure blood pressure serves as the focus of this DNP project. The review aims to impact social change by enhancing nurses' knowledge and awareness concerning blood pressure among veterans—the target demographic. This project supports a mission of promoting positive social change because teaching nurses to accurately measure blood pressure can help improve the health outcomes of veterans by enhancing hypertension management. By improving nurses' knowledge and skills regarding how to measure blood pressure, nurses can perform more accurate diagnoses and make more appropriate treatment decisions (Badeli & Assadi, 2014; Fallon, 2015). If the project proves effective, recommendations can be made for other veterans' centers to include the education program as part of a quality improvement strategy.

Local Nursing Practice Problem

Reading blood pressure accurately is one of the most fundamental types of care that a nurse can provide (Myers, 2014). Blood pressure reveals so much about a patient's condition, and so many approaches to care, intervention, and treatment are based on the initial blood pressure reading. In other words, inaccurate readings can impact how a patient is perceived, diagnosed, and treated. It is essential that nurses be able to provide blood pressure readings accurately, especially for veterans who are a vulnerable population in need of quality care. The problem, however, is that a significant number of nurses are failing to read blood pressure accurately (White et al., 2013).

The author currently works as a Patient Aligned Care Team Coordinator (PACT) at a veteran administration primary care clinic in the Northeastern United States. The primary care clinic provides patients with services including regular annual checkups, blood work, and blood pressure checks and monitoring. As the wars in Iraq and Afghanistan come to an end and the large U.S. military is drawn down, more veterans will need high-quality care as they transition to civilian life (Cooper et al., 2016). However, healthcare providers serving this population often have limited knowledge of veterans' specific health needs, in addition to inadequate knowledge of how to measure blood pressure accurately (Creswell, 2014). Cooper et al. (2016) explained that this inadequacy prompted the American Academy of Nursing (AAN) to initiate the "Have You Ever Served in the Military?" initiative—a program designed to raise awareness and reinforce the need for educating nurses who deliver healthcare to veterans about the unique health conditions of this population so that appropriate care can be provided.

Purpose Statement and Gap

The performance gap related to hypertension measurement is mainly associated with a lack of staff, equipment, and nurse educational resources, as evidenced by an increase in misdiagnoses (Fallon, 2015). Nurses have the responsibility to assess and monitor blood pressure in the clinical setting. However, according to Machado et al. (2017), because of insufficient knowledge about accurate blood pressure (BP) measurement processes, nurses make numerous errors when taking blood pressure readings. Underestimating true blood pressure by just 5 mm Hg would mislabel more than 20 million Americans with prehypertension when true hypertension is present. It has also been predicted that the consequences of an untreated 5 mm Hg excess of systolic blood pressure would be a 25% increase over current levels of fatal strokes and fatal myocardial infarctions (Fallon, 2015). Conversely, overestimating true blood pressure by 5 mm Hg would lead to inappropriate treatment with antihypertensive medications in almost 30 million people. Misclassification of patients leads to an increased number of untreated individuals with hypertension, which in turn contributes to the overall disease burden, including among veterans (Himmelfarb, Commodore-Mensah, & Hill, 2016).

This DNP has the potential to address the gap-in-practice by providing information on how education can help nurses obtain correct blood pressure measurements. If the project shows that such education is effective in producing the desired outcome among the target population, continuing education could be promoted among nurses working with a variety of patient populations.

Guiding Practice-Focused Question

The practice-focused question guiding this study is: Does literature support the use of a continuing education program in blood pressure checks to improve nurses' knowledge, skills, and attitudes necessary to promote patients' quality of life?

Relevance and Significance to Nursing

Hypertension is the most common primary diagnosis in the United States. It is a major risk factor for coronary heart disease, stroke, and renal failure, and affects 29% of the adult U.S. population (Ukpabi & Ewelike, 2017). Twenty-two percent of persons who have hypertension are unaware that they have it (Ukpabi & Ewelike, 2017). Data on hypertension among veterans indicate that 30% of the population has high blood pressure, with 17% of soldiers developing hypertension while in service (Gillespie, Hurvitz, & Centers for Disease Control and Prevention [CDC], 2013). Hypertension is associated with cardiovascular diseases, stroke, and ischemic heart disease, all of which reduce the quality of life of affected individuals. The CDC indicates that 30% of hypertensive patients develop stroke and other cardiovascular complications, underscoring the need for effective screening and management strategies (Gillespie et al., 2013).

Incorrect readings can result in misdiagnosis and inappropriate treatment decisions that may have adverse effects on the health and well-being of patients, including veterans (Badeli & Assadi, 2014; Fallon, 2015; Schonberger et al., 2015). Cooper et al. (2016) noted that nurses providing healthcare services such as blood pressure measurement often lack comprehensive education programs to support their knowledge and enhance their skills. Considering that approximately 44% of the veteran population seeks medical attention at Veterans Affairs centers in the U.S., these nurses need to possess the knowledge and skills required for accurately assessing veterans for high blood pressure so that correct screening can be conducted and appropriate treatment recommended (Nathaniel & Hardman, 2017).

Cooper et al. (2016) showed that an educational program specifically for patient care in primary care settings and other civilian hospitals could increase nurses' knowledge of what constitutes appropriate blood pressure measurements, control, and hypertension self-management practices. With nurses knowledgeable about the needs of their patients and the circumstances under which hypertension developed, they can design appropriate hypertension control and management strategies, thereby reducing the high risk of mortality and morbidity associated with the condition (Badeli & Assadi, 2014; Fallon, 2015; Kertai & Gan, 2015; Schonberger et al., 2015). Additionally, because nurses participate in patient education, improved knowledge, skills, and attitudes regarding consistent blood pressure monitoring can enhance communication and promote patient engagement.

Significance to Practice and Stakeholders

The primary care clinic at which the author works provides patients with services including regular annual checkups, blood work, and blood pressure checks and monitoring. The clinic comprises the microsystem of interest, which includes eight primary care physicians, eight RN care managers, six LPNs, two health technicians, and six clerks. The participants in this project will be the eight registered nurses and the six licensed practical nurses working in the clinic, as they are the professionals who measure blood pressure. The facility provides primary care services to approximately 5,830 veteran patients, and 3,400 of these patients have a hypertension diagnosis (Department of Veteran Affairs, 2015)—each one potentially standing to benefit from this project.

The project could be transferable to similar settings wherever continuing education might benefit nurses who require extra training in conducting a routine procedure that carries a high risk of harm when performed incorrectly. One example of a related issue currently impacting nursing is catheter-related infections, which remain quite high in many clinics because nurses lack a standardized guideline for inserting, maintaining, and removing catheter lines (Zingg et al., 2014; Yazici & Bulut, 2018). In any area where nurses benefit from more training, this project would have transferability because at its root it demonstrates that training and continuing education help ensure that optimal quality care is being provided to patients.