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.

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.

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.

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.

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.

Theory of Lifelong Learning

In its report, the Institute of Medicine (2010) recommends that 80% of RNs possess at least a baccalaureate degree by 2020. The reason for this is that continuing education (CE) is a vital way to maintain high standards and quality of service within the nursing field. As new research, methodologies, strategies, and interventions are constantly being discovered, tried, and validated, it is important for nurses to stay abreast of this research through CE. CE provides nurses with the knowledge they need to help patients in the best manner possible and gives them confidence in the fact that they are at the forefront of their industry in terms of treatments and theoretical approaches to nursing. RNs who do not continue their education run the risk of forgetting important principles, missing out on innovative new ideas in nursing practice, and becoming a weak link in the chain of quality care. Indeed, lifelong learning is recommended by researchers for nurses who want to excel in their field and offer services and talents that will be useful to colleagues and patients alike (Davis, Taylor, & Reyes, 2014).

The problem facing nurses today is that more than half do not go on to continue their education or obtain the kind of degree recommended by the Institute of Medicine. Many take just enough classes to obtain their license or certificate and then do not pursue further formal education, as though education were merely a means to an immediate end. Education is more than just a gateway to one's career—especially when that career is in nursing. Education is to nursing as oxygen is to life: without it, the body and the mind atrophy.

Nurses should therefore be mindful of how vital education is to their success. This is especially true in the 21st century, in which nursing approaches are changing rapidly due to advancements in technology. If nurses do not stay abreast of these changes, they may be unable to utilize the benefits that technological innovation offers.

Kirschling (2017) notes that educated RNs are critical to a country's survival. They provide medical, social, and psychosocial care for many types of individuals in a variety of contexts. Nurses are a valuable asset in health care—but they can also become a liability if they are not trained to be the kind of experts that patients and other health providers expect them to be. Kirschling (2017) states that "RNs make up the single largest segment of the health care workforce" and that "the demand for nurses will continue to increase along with demands on the nation's health care system."

The theory of lifelong learning applies to this DNP because it demonstrates that in order for nurses to conduct accurate blood pressure measurements, they ultimately need to be open to the idea that continuing education is a positive factor. Throughout this project, the goal is not only to educate nurses on the proper measurement method but also to inspire and motivate them to pursue self-actualization in this and other areas of nursing so that quality care remains the primary objective. For that reason, educational content on blood pressure accuracy consistently aims for a positive and supportive tone so that nurses feel encouraged, supported, and empowered to continue pursuing lifelong learning.

As White et al. (2013) show, there is a strong need for the problem of misdiagnosis stemming from misread blood pressure to be addressed in nursing practice. The longer this problem goes unaddressed, the longer patients will be subjected to treatments they do not actually need—treatments that may do more harm than good. For nurses, such a situation should be unacceptable, and a desire to remedy it should be shared by all. Awareness of the option of continuing education could be raised through this DNP.

Lifelong learning and continuing education have been promoted by the Institute of Medicine, and nurses should take note. CE can help to boost confidence—and confidence levels are important when nurses implement evidence-based practices (Wilson, Banner, Austria, & Wilson, 2017). Also important is the need for nurses to have proper guidance and training (Humphrey, 2015). Lifelong learning theory posits that education increases nurses' confidence, which can in turn build self-efficacy and propel them to pursue increasing amounts of nursing knowledge, ultimately enhancing their ability to provide quality care.

Conclusion and Implications

The sources of information used for this DNP are online databases accessed using the Internet. Keyword searches were conducted for literature published between 2013 and 2018 to help ensure that information is relevant and up to date. Data will be organized thematically and open coding will be conducted in order to categorize themes.

A lack of precise and accurate blood pressure readings can result in misdiagnoses of hypertension for patients. One particularly vulnerable population for this problem is the veteran population. This DNP asks whether literature supports 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. The implications for nursing practice are that such a project could improve nurses' ability to provide quality care for patients, regardless of population served.

This blood pressure education project could have implications for social change, as its focus is on enhancing nurses' knowledge and awareness of how to accurately read blood pressure for patients in a population that is currently recognized as not receiving the level of care it requires (Kehle-Forbes, Harwood, Spoont, Sayer, Gerould, & Murdoch, 2017). Veterans are a vulnerable population (Dichter, Haywood, Butler, Bellamy, & Iverson, 2017), and any effort to help them by improving the skills of the nurses who care for them represents a meaningful step toward positive social change.

The theory of lifelong learning is central to this project because it explains why it is important for nurses to continue their education. Information in nursing is constantly being updated, making it crucial that nurses stay abreast of changes by pursuing ongoing learning. This project aims to highlight the beneficial aspects of continuing education with regard to accurate blood pressure reading, thereby contributing to improved hypertension management and better health outcomes for veterans receiving care at VA facilities across the country.

Badeli, H., & Assadi, F. (2014). Strategies to reduce pitfalls in measuring blood pressure. International Journal of Preventive Medicine, 5(1), S17–S20.

Cañadas-De la Fuente, G. A., Vargas, C., San Luis, C., García, I., Cañadas, G. R., & Emilia, I. (2015). Risk factors and prevalence of burnout syndrome in the nursing profession. International Journal of Nursing Studies, 52(1), 240–249.

Cooper, L., Andrew, S., & Fossey, M. (2016). Educating nurses to care for military veterans in civilian hospitals: An integrated literature review. Nurse Education Today, 47, 68–73. doi:10.1016/j.nedt.2016.05.022

Creswell, J. W. (2014). Research design: Qualitative, quantitative, and mixed methods approaches. Sage Publications.

Davis, L., Taylor, H., & Reyes, H. (2014). Lifelong learning in nursing: A Delphi study. Nurse Education Today, 34(3), 441–445.

Deepak, K. K. (1992). Blood pressure simulation model: A teaching aid. Indian Journal of Physiology and Pharmacology, 36, 155–155.

Dichter, M. E., Haywood, T. N., Butler, A. E., Bellamy, S. L., & Iverson, K. M. (2017). Intimate partner violence screening in the Veterans Health Administration: Demographic and military service characteristics. American Journal of Preventive Medicine, 52(6), 761–768.

Fallon, N. (2015). The challenge of measuring blood pressure accurately. British Journal of Cardiac Nursing, 10(3), 132–139. doi:10.12968/bjca.2015.10.3.132

Gillespie, C. D., Hurvitz, K. A., & Centers for Disease Control and Prevention. (2013). Prevalence of hypertension and controlled hypertension—United States, 2007–2010. Morbidity and Mortality Weekly Report Surveillance Summaries, 62(3), 144–148.

Hendrickson, P. (1999). Mechanical model of ocular pulsatile flow for evaluating the ocular blood flow device with known pressure pulsations. Klinische Monatsblätter für Augenheilkunde, 214(5), 272–274.

Himmelfarb, C. R. D., Commodore-Mensah, Y., & Hill, M. N. (2016). Expanding the role of nurses to improve hypertension care and control globally. Annals of Global Health, 82(2), 243–253. https://doi.org/10.1016/j.aogh.2016.02.003

Humphrey, J. S. (2015). Improving registered nurses' knowledge of evidence-based practice guidelines to decrease the incidence of central line-associated bloodstream infections: An educational intervention. The Journal of the Association for Vascular Access, 20(3), 143–149.

Institute of Medicine. (2010). The future of nursing: Leading change, advancing health. National Academies Press.

Kehle-Forbes, S. M., Harwood, E. M., Spoont, M. R., Sayer, N. A., Gerould, H., & Murdoch, M. (2017). Experiences with VHA care: A qualitative study of U.S. women veterans with self-reported trauma histories. BMC Women's Health, 17(1), 38.

Kertai, M. D., & Gan, T. J. (2015). Screening for high blood pressure in the perioperative setting: The role of anesthesiologists in future cardiovascular risk management. International Anesthesia Research Journal, 121(6), 1439–1440. doi:10.1213/ANE.0000000000001014

Kirschling, J. (2017). Well-educated RNs are critical to country's future. The Baltimore Sun.

Machado, J. P., Veiga, E. V., Ferreira, P. A., Martins, J. C. A., Atila, E., & Gimenes, F. R. (2017). Assessment of an educational intervention to improve nurses' knowledge of blood pressure measurement. Journal of Nursing Education and Practice, 8(2), 56. doi:10.5430/jnep.v8n2p56

Mukkamala, R., Hahn, J. O., Inan, O. T., Mestha, L. K., Kim, C. S., Toreyin, H., & Kyal, S. (2015). Toward ubiquitous blood pressure monitoring via pulse transit time: Theory and practice. IEEE Transactions on Biomedical Engineering, 62(8), 1879–1901.

Myers, M. G. (2014). Eliminating the human factor in office blood pressure measurement. The Journal of Clinical Hypertension, 16(2), 83–86.

Nathaniel, A. K., & Hardman, L. (2017). A grounded theory of caring for veterans within the Veterans' Health Administration. The Grounded Theory Review, 16(1), 87–91.

Nitzan, M., Slotki, I., & Shavit, L. (2017). More accurate systolic blood pressure measurement is required for improved hypertension management: A perspective. Medical Devices: Evidence and Research, 10, 157–163. doi:10.2147/mder.s141599

Porr, V. (2017). Real life consequences of stigmatization, misdiagnosis, misunderstanding, and mistreatment of borderline personality disorder. European Psychiatry, 41, S259–S260.

Roy, S. S., Foraker, R. E., Girton, R. A., & Mansfield, A. J. (2015). Posttraumatic stress disorder and incident heart failure among a community-based sample of U.S. veterans. American Journal of Public Health, 105(4), 757–763.

Schonberger, R. B., Dai, F., Brandt, C. A., & Burg, M. M. (2015). Balancing model performance and simplicity to predict postoperative primary care blood pressure elevation. Anesthesia and Analgesia, 121(3), 632–641. doi:10.1213/ANE.0000000000000860

Sepucha, K. R., & Scholl, I. (2014). Measuring shared decision making: A review of constructs, measures, and opportunities for cardiovascular care. Circulation: Cardiovascular Quality and Outcomes, 7(4), 620–626. doi:10.1161/circoutcomes.113.000350

Siu, A. L. (2015). Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 163(10), 778–786.

Ukpabi, O., & Ewelike, I. (2017). The eighth joint national committee on the prevention, detection, evaluation, and treatment of high blood pressure (JNC-8) report: Matters arising. Nigerian Journal of Cardiology, 14(1), 15. doi:10.4103/0189-7969.201909

van Dipten, C., van Berkel, S., de Grauw, W. J., Scherpbier-de Haan, N. D., Brongers, B., van Spaendonck, K., ... & Dees, M. K. (2018). General practitioners' perspectives on management of early-stage chronic kidney disease: A focus group study. BMC Family Practice, 19(1), 81.

Wang, S., Liu, Y., & Wang, L. (2015). Nurse burnout: Personal and environmental factors as predictors. International Journal of Nursing Practice, 21(1), 78–86.

White, J., Mortensen, L. H., Kivimäki, M., Gale, C. R., & Batty, G. D. (2013). Interarm differences in systolic blood pressure and mortality among U.S. army veterans: Etiological associations and risk prediction in the Vietnam experience study. European Journal of Preventive Cardiology, 21(11), 1394–1400. doi:10.1177/20

Wilson, B. L., Banner, M., Austria, M. J., & Wilson, A. (2017). Evaluating the implementation of an interdisciplinary evidence-based practice educational program in a large academic medical center. Journal for Nurses in Professional Development, 33(4), 162–169.

Yazici, G., & Bulut, H. (2018). Efficacy of a care bundle to prevent multiple infections in the intensive care unit: A quasi-experimental pretest-posttest design study. Applied Nursing Research, 39, 4–10.

Zheng, Y. L., Yan, B. P., Zhang, Y. T., & Poon, C. C. (2014). An armband wearable device for overnight and cuff-less blood pressure measurement. IEEE Transactions on Biomedical Engineering, 61(7), 2179–2186.

Zingg, W., Cartier, V., Inan, C., Touveneau, S., Theriault, M., Gayet-Ageron, A., ... & Walder, B. (2014). Hospital-wide multidisciplinary, multimodal intervention programme to reduce central venous catheter-associated bloodstream infection. PloS One, 9(4), e93898.