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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.Aerobicexercisepla