Expanding the Role of Nurses to Improve Hypertension Care and Control Globally

Abstract

The role of the nurse in improving hypertension control has expanded over the past 50 years, complementing and supplementing that of the physician. Nurses' involvement began with measuring and monitoring blood pressure (BP) and patient education and has expanded to become one of the most effective strategies to improve BP control. Today the roles of nurses and nurse practitioners (NPs) in hypertension management involve all aspects of care, including (1) detection, referral, and follow up; (2) diagnostics and medication management; (3) patient education, counseling, and skill building; (4) coordination of care; (5) clinic or office management; (6) population health management; and (7) performance measurement and quality improvement. The patient-centered, multidisciplinary team is a key feature of effective care models that have been found to improve care processes and control rates. In addition to their clinical roles, nurses lead clinic and community-based research to improve the hypertension quality gap and ethnic disparities by holistically examining social, cultural, economic, and behavioral determinants of hypertension outcomes and designing culturally sensitive interventions to address these determinants.

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STATE-OF-THE-ART REVIEW
Expanding the Role of Nurses to Improve
Hypertension Care and Control Globally
Cheryl R. Dennison Himmelfarb, RN, ANP, PhD, FAAN, FAHA, FPCNA,
Yvonne Commodore-Mensah, RN, PhD, Martha N. Hill, RN, PhD, FAAN, FAHA
Baltimore, MD; and Atlanta, GA
Abstract
The role of the nurse in improving hypertension control has expanded over the past 50 years, com-
plementing and supplementing that of the physician. Nurses’involvement began with measuring and
monitoring blood pressure (BP) and patient education and has expanded to become one of the most
effective strategies to improve BP control. Today the roles of nurses and nurse practitioners (NPs) in
hypertension management involve all aspects of care, including (1) detection, referral, and follow up; (2)
diagnostics and medication management; (3) patient education, counseling, and skill building; (4)
coordination of care; (5) clinic or office management; (6) population health management; and (7) per-
formance measurement and quality improvement. The patient-centered, multidisciplinary team is a key
feature of effective care models that have been found to improve care processes and control rates. In
addition to their clinical roles, nurses lead clinic and community-based research to improve the
hypertension quality gap and ethnic disparities by holistically examining social, cultural, economic, and
behavioral determinants of hypertension outcomes and designing culturally sensitive interventions to
address these determinants.
KEY WORDS hypertension, nurse, team-based care, quality
©2016 The Authors. Published by Elsevier Inc. on behalf of Icahn School of Medicine at Mount Sinai. This is
an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
INTRODUCTION
Hypertension is a global public health issue, and it is
estimated that by 2025 more than 1.5 billion indi-
viduals worldwide will have hypertension, account-
ing for up to 50% of heart disease risk and 75% of
stroke risk.
1
Lowering blood pressure (BP) through
lifestyle modification, antihypertensive medications,
or both can substantially reduce an individual’s risk
for subsequent cardiovascular disease (CVD) and
stroke.
2
Even a moderate reduction in systolic BP
(SBP) of 10 mm Hg or diastolic blood pressure
(DBP) of 5 mm Hg has been found to decrease
average risk of mortality from coronary heart disease
and stroke by 22% and 41%, respectively.
3
Despite clear benefits of hypertension treatment
to reduce CVD morbidity and mortality, a large
proportion of diagnosed and undiagnosed patients
with hypertension are not receiving optimal care.
In the United States, despite decades of national
public and professional education, among those
with hypertension, approximately 25% are unaware
and almost 30% are not engaged hypertension
care.
4
Among the 45% with diagnosed hypertension
and in care, BP control is achieved in only 64%
overall, and rates remain as low as 39% among
The authors have no conflicts of interest to disclose. All authors had an active role in writing the manuscript.
From the Johns Hopkins University School of Nursing, Baltimore, MD (CRDH, MNH); and the Nell Hodgson Woodruff School of Nursing, Emory
University, Atlanta, GA (YC-M). Address correspondence to C.R.D.H. (cdennis4@jhu.edu).
Annals of Global Health
ª2016 The Authors. Published by Elsevier Inc.
on behalf of Icahn School of Medicine at Mount Sinai
VOL. 82, NO. 2, 2016
ISSN 2214-9996
http://dx.doi.org/10.1016/j.aogh.2016.02.003

Mexican American men.
4,5
Although control rates
overall have increased over the past 10 years, ethnic
disparities in care and control remain, with Mexican
Americans less likely to be in hypertension care and
African Americans, Hispanics, and Mexican Amer-
icans achieving lower control rates compared with
whites.
5
The difference in hypertension outcomes
achieved with current practices and outcomes possi-
ble using hypertension care best practices is known
as the quality gap, and this gap is at least partly
responsible for the loss of thousands of lives each
year.
6
Expanding the role of nurses is one of the
most effective strategies to improve BP control.
This paper reviews the expanding roles of nurses
in diverse practice settings and in team-based care
and provides examples of nurse-led research aimed
at reducing hypertension health disparities.
7-11
BACKGROUND
The role of nurses has been recognized for nearly
50 years in public and professional education to
improve hypertension control promoted by the US
National High Blood Pressure Education Program’s
Joint National Committee reports and other publi-
cations.
2,12
Nurses’involvement began with measur-
ing and monitoring BP and patient education. The
role expanded in the 1960s and early 1970s to sup-
plement and complement that of the physician as
the number of newly identified patients grew after
Veterans Administration and Hypertension Detec-
tion and Follow-up Program studies demonstrating
the benefits of controlling hypertension.
13,14
Subse-
quently, with evidence-based protocols to guide
practice nurses and training programs, such as those
provided by the American Heart Association, nurses
gained the skills to assess patients’health status,
adjust medications, and address barriers to hyper-
tension care and control, thus becoming more
involved in the assessment and management of
hypertension. The establishment of nurse-run clin-
ics was a further expansion of the nurse’s role.
15
Today around the globe, particularly in underserved
low- and middle-income countries, as the numbers
of people with hypertension and attention to non-
communicable diseases increase, the role of nurses
continues to expand. The role increasingly focuses
on advanced practice nurses, known as nurse practi-
tioners (NPs), who have legal authority to prescribe
antihypertensive and other medications and practice
independently or in teams, which requires attention
to the legal scope of nursing practice.
TEAM-BASED HYPERTENSION
MANAGEMENT
A key feature of the most effective hypertension care
models is a multidisciplinary team that collaborates
in delivering hypertension care services.
16
A team-
based approach is patient centered, with care
tailored to meet patients’needs. It is often imple-
mented as part of a multi-faceted approach, with
systems support for clinical decision making (eg,
treatment algorithms), communication, and patient
self-management. Team-based hypertension care
includes the patient, the patient’s primary care
provider, and other professionals such as nurses,
pharmacists, physician assistants, dieticians, social
workers, and community health workers. These
professionals complement the activities of the
primary care provider by providing process support
and sharing the responsibilities of hypertension
care, which include medication management,
active patient follow-up, and adherence and self-
management support. Team-based hypertension
care has been reported to increase the proportion
of individuals remaining in care with controlled
BP and reduced SBP and DBP.
7-11
Randomized
controlled trials (RCTs) and meta-analyses of
RCTs of team-based hypertension care involving
nurse or pharmacist intervention demonstrated
reductions in SBP and DBP and greater achieve-
ment of BP goals when compared with usual
care.
6-9
Similarly, a systematic review of 52 studies
of team-based primary care for patients with pri-
mary hypertension found reductions in SBP and
DBP and greater achievement of BP goals when
compared with usual care, although team-based
approaches varied greatly across studies.
11
Nonethe-
less, the important findings on the impact of team-
related factors on BP outcomes were identified: (1)
Larger improvements in BP outcomes were found
when team members could make changes to medi-
cations independent of the primary care provider or
provide medication recommendations and make
changes with primary care provider’s approval com-
pared with providing only adherence support and
information on medication and hypertension. (2)
Improvement in the proportion of patients with
controlled BP was similar for studies in both health
care and community settings.
11
A systematic review
of studies, including 8 RCTs, examining the effect
of community health workers in team-based hyper-
tension care found improvements in BP control,
appointment keeping, and hypertension medication
adherence.
17
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Team-based care aims to achieve effective con-
trol of hypertension and reduce the consequences
of uncontrolled hypertension. Delineation of indi-
vidual team member roles based on knowledge, skill
set, and availability, as well as patients’needs, allows
the primary provider to delegate routine matters to
the team, thereby permitting more time to manage
complex and critical issues facing patients with
hypertension. Specific roles of nurses in team-
based hypertension care are delineated next.
SPECIFIC ROLES OF NURSES IN
TEAM-BASED HYPERTENSION CARE
The roles of nurses and NPs in hypertension man-
agement involve all aspects of care, including (1)
detection, referral, and follow up; (2) diagnostics
and medication management; (3) patient education,
counseling, and skill building; (4) coordination of
care; (5) clinic or office management; (6) population
health management; and (7) performance measure-
ment and quality improvement.
12,18
Detection, Referral, and Follow-up. Nurses rou-
tinely measure BP in most health care settings using
BP measurement best practices as part of initial and
ongoing assessments of each patient.
19
In addition,
nurses lead BP screening and verification initiatives
in community, work site, church, school, and other
settings. Once BP is measured and recorded, the
nurse analyzes data to determine if the readings are
in the normal or hypertensive range per site proto-
col. A system to flag records can help ensure that
uncontrolled hypertension is recognized and treated.
In addition, nurses assess the patient’s level of car-
diovascular risk. There are a number of tools, such
as Framingham Cardiovascular Disease Risk
Score,
20
Pooled Cohort Equations,
21
QRISK2,
22
and Reynolds Risk Score,
23,24
that are helpful in
guiding health care providers as they assess car-
diovascular risk; these tools also can be used in
patient education efforts.
25
It may be necessary to
refer the patient to urgent care depending on BP
levels and symptoms or to specialist evaluation for
persistent uncontrolled BP despite intervention or
for abnormal renal or vascular findings.
26
Nurses
play an important role in implementing referrals and
educating patients regarding the purpose and
importance of referral.
Follow-up between visits via telephone, mail, or
digital strategies can be effective to reinforce goals
of entering and remaining in care and engaging in
treatment and can enhance providerepatient rela-
tionship. It is essential to follow up on missed
appointments to maintain contact with the patient
and to reinforce the importance of achieving BP
goals. Nurses often are the first health professionals
to detect hypertension and therefore have a key role
in communicating with patients and other health
professionals to enforce treatment guidelines
through development and appropriate revision of
the patient’s treatment plan.
Diagnostics and Medication Management. Nurses
or NPs are also responsible for the diagnostic and
pharmacological aspects of hypertension manage-
ment. Using well-defined protocols based on
national treatment guidelines, NPs prescribe and
titrate medications to achieve BP control.
2,27,28
As
discussed earlier, nurse-led hypertension manage-
ment has been demonstrated to result in greater
rates of BP control than those achieved with
standard care. These improved outcomes have
resulted from nurses placing a greater number of
patients on medications, altering drug regimens
more often in response to inadequate BP control,
and placing a higher proportion of patients on
multiple drug regimens to achieve greater control.
8,9
In addition to management of hypertension, nurses
have been shown to effectively manage other car-
diovascular risk factors, such as diabetes
29
and
dyslipidemia.
30,31
Patient Education, Counseling, and Skill Building. In
the majority of hypertension care settings, nurses
provide the education, counseling, and skill build-
ing necessary to ensure that patients are undertak-
ing lifestyle changes that may favorably influence
BP.
32,33
Nurses actively engage patients in care
using a combination of strategies to prevent, rec-
ognize, and respond to adherence problems and
thereby maximize long-term adherence and BP
control.
34,35
They also use effective, evidence-
based strategies to promote BP control; these
strategies are identified in Table 1 and are clustered
under the following general approaches: identify
knowledge, attitudes, beliefs, and experiences;
educate about conditions and treatment; indi-
vidualize the regimen; provide reinforcement;
promote social support; and collaborate with other
professionals.
18
It is important to consider that
patient education is a means to an end. That is,
knowledge is necessary but insufficient to bring
about desired behaviors without development of
skills and multiple other reinforcing factors. The
ultimate goal is for the patient to have the neces-
sary skills and resources, including knowledge, to
follow treatment recommendations and achieve
and sustain BP control.
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Table 1. Strategies to Promote Blood Pressure Control
18
Identify knowledge, attitudes, beliefs, and experience
AAssess patient’s understanding and acceptance of the diagnosis and expectations of being in care.
AAssess cultural beliefs and practices that may influence care and adherence.
ADiscuss patient’s concerns and clarify misunderstandings.
Educate about conditions and treatment
AInform patient of blood pressure (BP) level.
AEstablish with patients a goal BP.
AInform patient about recommended treatment, providing specific oral and written information.
AElicit concerns and questions and provide opportunities for patient to state-specific behaviors to carry out treatment
recommendations.
AEmphasize need to continue treatment, that patient cannot tell if BP is elevated, and that control does not mean cure.
ATeach self-monitoring skills.
Individualize the regimen
AActively engage patients in their own care by promoting shared decision making, with emphasis on social and cultural factors,
including health literacy.
AInclude patient in decision making.
ASimplify the regimen.
AIncorporate treatment into patient’s daily lifestyle.
ASet, with the patient, realistic short-term objectives for specific components of the treatment plan.
AEncourage discussion of side effects and concerns.
AEncourage self-monitoring of BP.
APrioritize critical aspects of the regimen.
AImplement treatment plan in steps.
AModify dosages or change medications to reduce side effects.
AMinimize cost of therapy.
AIndicate you will ask about adherence at next visit.
AWhen weight loss is established as a treatment goal, discourage quick weight loss regimens, fasting, or unscientific methods, because
these are associated with weight cycling, which may increase cardiovascular morbidity and mortality.
Provide follow-up and reinforcement
AProvide feedback regarding BP level.
AAsk about behaviors to achieve BP control.
AGive positive feedback for behavioral and BP improvement.
AHold exit interviews to clarify regimen.
AMake appointment for next visit before patient leaves the office.
AUse appointment reminders and contact patients to confirm appointments.
ASchedule more frequent visits to counsel nonadherent patients.
AContact and follow up with patients who missed appointments.
AConsider clinician-patient contracts.
AConsider home visits.
AEstablish regular, structured follow-up mechanisms and reminder systems to monitor patients’progress both in the office and
remotely.
AProvide the most appropriate evidence-based tools and resources designed to maximize self-management (including health behavior
change, lifestyle modification, etc.).
Promote social support
AEducate family members to be part of the BP control process and provide daily reinforcement.
ASuggest small-group activities to enhance mutual support and motivation.
Collaborate with other professionals
ADraw on complementary skills and knowledge of nurses, pharmacists, comm unity health workers, dieticians, optometrists, dentists,
and physician assistants.
AFacilitate communication and care coordination among various team members, patient, family, and caregivers.
AAssure awareness and effective use of evidence-based diagnosis and treatment guidelines by all team members.
AFollow a single, personalized plan of care based on individual patient’s characteristics and needs.
ARefer patients for more intensive counseling or specialty evaluation.
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Identify knowledge, attitudes, beliefs, and
experiences. A classic framework is useful in guiding
nurses and other professionals to provide patient
education, counseling, and skill building and facili-
tate patients’attainment of the following 4 critical
behaviors, which are necessary to achieve and sustain
long-term BP control: (1) Make the decision to
control BP; (2) follow treatment recommendations
(eg, medication taking and lifestyle changes) as
prescribed; (3) monitor progress toward the BP goal;
and (4) resolve barriers that prevent reaching the
goal.
36
The premise of this evidence-based frame-
work is that active participation by the patient as the
decision maker and problem solver with the nurse or
other health professional functioning as advisor or
guide favors successful management of hypertension.
The patient’s understanding and acceptance of the
diagnosis and expectations of being in care are
assessed, patient concerns addressed, and mis-
understandings clarified.
Educate about conditions and treatment. Adequate
knowledge of hypertension, consequences of uncon-
trolled hypertension, and treatment regimen is
essential to achieve BP control. It has been found
that patients who receive education and counseling
on hypertension management exhibit increased
adherence.
34,35
Nurses practice patient-centered
care, engaging the patient in shared decision mak-
ing and establishing mutually agreed on BP goals.
Patients must always be informed of BP and related
diagnostic testing values. This provides an ideal
opportunity to assess patient knowledge, educate,
establish clear goals, and discuss progress toward
goals with the patient. Nurses emphasize the need
to continue treatment even when BP control has
been achieved (ie, control does not mean cure).
Nurses also play a key role in educating patients
regarding the necessary self-monitoring skills (eg,
home BP monitoring). In addition to patient edu-
cation and skill building, effective communication
and a trustful relationship between the patient and
nurse are of paramount importance to achieve sus-
tained BP control.
Individualize the regimen. Successful education
and counseling to promote adherence to treatment
regimen and BP control requires that nurses and
other health professionals individualize care to max-
imize patients’motivation to control their hyperten-
sion by remaining in care, maintaining a healthy
lifestyle, taking prescribed medication, and moni-
toring progress toward goals. Nurse efforts to indi-
vidualize the regimen should focus on social and
cultural factors, including health literacy, self-care
behaviors, and skills necessary to hypertension
control as well as patient response to the treatment
regimen.
36
Nurses assist patients to incorporate the
treatment regimen into his or her daily lifestyle,
which is required for long-term sustainability.
Nurses work with patients to mutually develop
realistic, outcomes-oriented goals and strategies for
attaining the goals. Equally important, nurses follow
up with patients often to assess progress toward
goals and, if necessary, to revise strategies for
attaining goals.
Nurses are trained to provide counseling regard-
ing lifestyle modification, which is recommended
for all hypertensive patients with lifestyle risk factors
(eg, obesity, physical inactivity, high-sodium diet,
and alcohol consumption).
32,33
Weight loss, which
may be the most successful nonpharmacological
technique for lowering BP, requires behavior change
in both diet and physical activity patterns. Such
nonpharmacological approaches include helping
patients to initiate or maintain an aerobic exercise
program and limit sodium intake and alcohol con-
sumption to 1 to 2 drinks per day. In addition,
many hypertensive patients present with multiple
risk factors for cardiovascular disease. Nurses also
provide education and counseling for smoking ces-
sation and lipid reduction to help patients further
lower their risk of cardiovascular disease. Modifying
lifestyle behaviors requires many clinical interven-
tions: assessment of an individual’s baseline behav-
iors; education about how to make the appropriate
changes; counseling to develop strategies such as
setting short-term goals and self-monitoring that
will ensure the achievement and maintenance of
the changes; working with patients to identify and
resolve barriers to adherence and BP control; and
reinforcement of progress toward behavior change
goals.
The extent to which patients are able to adhere
to treatment recommendations is a major issue in
BP control and depends on many factors. Review
of adherence in randomized controlled trials on car-
diovascular disease prevention strategies identified
the following successful approaches: signed agree-
ments, behavioral skill training, self-monitoring,
telephone or mail contact, spouse or other key
person support, self-efficacy enhancement, contin-
gency contracting, exercise prescriptions, external
cognitive aids, persuasive communication, nurse-
managed clinics, and work- or school-based pro-
grams.
34,35
Improving patient and primary provider
adherence to evidence-based guidelines is a multile-
vel challengedthe patient, the provider, the health
Annals of Global Health, VOL. 82, NO. 2, 2016 Himmelfarb et al.
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247

care setting and system, and the societal health care
system. Multiple strategies are required beginning
with patient and provider education, counseling,
and skill building.
37
Another important aspect of individualizing the
regimen to promote BP control involves assessing
potential barriers to BP control. Nurses are moti-
vated and trained to assess and address common
barriers to BP control. Barriers may include knowl-
edge deficits, limited access to health care or phar-
macy, inadequate communication with clinicians,
cost of care and medications, complexity of the reg-
imen, adverse effects of medication, transportation
to and from the visit, work schedule, inconvenient
clinic or office location or difficulty scheduling
appointments, child or elder care, or other compet-
ing life demands.
38-40
After identification of bar-
riers, nurses work with patients and collaborating
health professionals to minimize or eliminate the
barriers, thereby promoting BP control.
Provide reinforcement. It is important to work
with individual patients to ensure that they under-
stand what is necessary to achieve treatment goals
and that they participate in treatment decisions.
Nurse responsiveness to patient concerns, along
with joint problem solving to prevent or minimize
barriers to care and treatment as well as provide
reinforcement and support, is crucial. Provision of
reminders, outreach, and follow-up services are
beneficial. Follow-up on missed visits and between
visits via phone or digital methods can be effective
to reinforce goals and enhance the providerepatient
relationship. Success in implementing the treatment
regimen to achieve BP control requires frequent
monitoring of BP, modification of treatment regi-
men, and interaction with the patient. These roles
require training and dedicated time to provide the
education and counseling necessary to build skills
for and reinforce successful behavior change.
Promote social support. Nurses also effectively
educate family members and friends to participate
in the BP control process. Family members can
play a fundamental role providing daily reinforce-
ment of the patient’s efforts to achieve BP control.
If the patient desires greater family participation,
family members should be encouraged to attend
and participate in clinic visits. In addition, some
patients may benefit from small group activities
(eg, clinic support groups or group visits) to enhance
social support and motivation.
Collaborate with other professionals. In planning
care, nurses work in conjunction with the patient
and members of the hypertension management
team to achieve and sustain BP control. Achieving
and sustaining BP goals over time requires continu-
ous educational and behavioral strategies, an indi-
vidualized regimen, and reinforcement so that
patients have the knowledge, skills, motivation,
and resources to carry out treatment recommenda-
tions. Successful BP control requires that patients
know what behaviors are necessary and develop
skills in problem identification and problem solving
to address barriers. Strategies to help patients
develop these skills need to be adapted so that
they are culturally salient and feasible for staff to
implement.
Coordination of Care. Long-term maintenance of
hypertension control requires continual monitoring
of BP, refilling of prescriptions, provision of coun-
seling and reinforcement of behavior change efforts,
and titration of therapy as indicated. Each patient’s
management must be individualized, with costs
minimized. Patients often see different providers
at several settings for various health problems, fill
prescriptions in more than 1 pharmacy, receive
inconsistent messages, and experience interruption
of therapy and inadequate communication among
providers. Nurses are skilled at building and main-
taining both informal and formal collaborative link-
ages among providers, resources, and services within
and external to their practice setting. Further, nurses
assist patients in understanding complex treatment
regimen and navigating through the challenging
and highly complex health care structure and
systems.
Manage the Clinic or Office. Nurses often are in the
position of managing or planning for the initiation
of a hypertension clinic.
41
Nurses often direct or
coordinate the efforts of other team members who
are working within the clinic or providing direct
consultation. To enhance consistency and quality of
care and to facilitate adherence to treatment
guidelines, decision support systems (electronic and
paper) such as flow sheets, treatment algorithms,
and feedback reminders may be developed. In
addition, it may be the responsibility of the nurse to
hire, supervise, and train the community health
workers to deliver appropriate intervention strat-
egies and other staff, such as office assistants and
receptionists, to measure BP, schedule appoint-
ments, make reminder telephone calls, obtain lab-
oratory results, and enter data to support evaluation
of clinical outcomes. Nurses influence utilization of
resources, including appropriate length of visits and
caseload size, as well as optimizing reimbursement
for services in the hypertension clinic setting.
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It is imperative that all health professionals who
measure BP use correct measurement technique.
19
In addition to ensuring proper BP measurement
technique among staff, nurses often are responsible
for ensuring that BP measurement equipment is
properly calibrated and functioning.
Population Health Management. The paradigm
shift from care of 1 patient at a time, either in the
dyad of 1 physician with 1 patient or, more recently,
the team approach, to the responsibility to care for
large numbers of patients has occurred in the past
decade. New models of managing care promoted
by health systems and governments have focused
on measuring and reimbursing improved outcomes
and controlling costs of care.
Improving health for populations of people to
reduce risk factors, morbidity, and mortality calls
for integration of public health and prevention prin-
ciples with traditional medical care. Hypertension is
a prominent condition being targeted because of its
prevalence and the benefits of controlling it. Public
advocacy to improve health of large numbers of peo-
ple and sensible policy making requires evidence of
effective interventions. The evidence justifying
expanded roles for nurses in hypertension care and
control is abundant.
According to the recent Healthcare Trends and
Forecasts survey,
42
population health management
(56%) ranked highest among 3 key areas of value-
based priorities in 2014 by health professionals.
Population health management requires a variety
of skills, including care coordination, decision mak-
ing, and project management, and is needed in
communities where disparities in chronic conditions
exist. By mapping health care services to the needs
of the population, nurses and NPs formulate an
overall health care strategy that improves hyperten-
sion care quality and reduces health disparities.
Nurses can implement technology to identify and
analyze these populations’most pressing health
needs and, in collaboration with other health care
team members, design appropriate interventions to
preempt or satisfy these needs.
Performance Measurement and Quality
Improvement. The universal need to measure and
improve the hypertension care processes and out-
comes is well established, and often it is the nurse
in the hypertension care setting who has responsibil-
ity for leading these efforts. Efforts to improve subop-
timal hypertension care have included the use of
performance measures, which are a standardized,
validated approach to assess whether correct health
care processes are being performed and desired
patient outcomes are being achieved. Hypertension
quality improvement strategies, including audit and
feedback on performance, provider education, patient
education, self-management support, patient
reminder systems (for follow-up appointments, blood
pressure checks, and self-management), and care
delivery system changes, have been demonstrated to
reduce blood pressure and improve blood pres-
sure.
6,28,43
In addition, multicomponent and multi-
level strategies to improve the organization and
delivery of hypertension care at the local community,
health care delivery system, and national levels and
have been found to improve blood pressure control.
44-
46
With the expanding evolution of health informa-
tion technologies, strategies such as electronic health
records, registry databases, telehealth, digital health
(“eHealth”), and the use of mobile computing
and communication technologies (“mHealth”) are
increasingly deployed by nurses and other members of
the care team as tools to facilitate improvements in
health behaviors and hypertension control.
47-54
Hypertension care teams are using these tools to
enable appointment scheduling, reminders, and
follow-up; tracking BP control trends and large-scale
queries to support population health management
strategies with identification of undiagnosed or
undertreated hypertension; assessing frequency of
clinic visits, emergency room visits, and hospital-
izations; facilitating and monitoring medication
prescriptions and refills; monitoring and promoting
self-management behaviors, including medication
adherence, diet, and physical activity; and provision of
decision support for antihypertensive medication
titration using evidence-based protocols and treat-
ment algorithms. They show promise as adjunctive
strategies to improve hypertension care and
control.
6,28,43
EXEMPLARS OF NURSE-LED RESEARCH
TO REDUCE THE HYPERTENSION
QUALITY GAP AND ETHNIC
DISPARITIES
In addition to their traditional clinical roles, nurses
have been involved in the conduct of clinic- and
community-based research to improve the hyperten-
sion quality gap and ethnic disparities in hyperten-
sion outcomes dating as far back as 1950.
55
In the
21st century, nurses are leading research teams to
examine social, cultural, economic, and behavioral
determinants of hypertension outcomes. The follow-
ing studies are exemplars of nurses’roles in leading
research to improve hypertension care and control.
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249

The Comprehensive High Blood Pressure Care
and Control in Young Urban Black Men Study
39,56,57
was a nurse-led 5-year RCT of hypertensive urban
African-American men (N ¼309) that evaluated
the effectiveness of a more intensive comprehensive
educational-behavioral-pharmacological intervention
by an NPecommunity health workerephysician
(NP/CHW/MD) team and a less intensive education
and referral intervention in controlling BP and mini-
mizing progression of left ventricular hypertrophy
(LVH) and renal insufficiency. At the 36-month
follow-up, the more intensive intervention led to a
lower BP and decreased progression of LVH. At 5
years, LVH prevalence in the more intensive group
was lower compared with the less intensive group
(37% vs 56%, P¼0.02). However, between-group
significant difference in BP control (more intensive
44%, less intensive 31%, P¼0.05) at 3 years was
not sustained to the 5-year follow-up period. By using
a multifaceted, individually tailored, multidisciplinary
team approach with free medications, this study dem-
onstrated that it was possible to recruit and retain a
cohort of inner-city young African-American men
with hypertension, improve BP control, and reduced
barriers to BP control.
With respect to international studies, the HiHi
Study
38,58
was a cross-sectional descriptive study
(N ¼403) of periurban black South Africans that
examined determinants of hypertension care control
to identify opportunities to improve hypertension
outcomes and quality of care. Using the
PRECEDE-PROCEED Model
59
as the guiding
framework, it was observed that significant and
interrelated predictors of lower SBP and DBP or
BP control were fewer antihypertensive medica-
tions, better compliance to hypertension recommen-
dations, younger age, female sex, higher education,
and moderate alcohol consumption.
38,58
Hence,
interventions at the patient, provider, and system
level were identified as important areas to address
to improve hypertension care and control in primary
health care settings in South Africa.
The COACH trial
30
was an RCT evaluating the
effectiveness of a comprehensive program of CVD
risk reduction delivered by NP/CHW teams versus
enhanced usual care to improve lipids, BP, and gly-
cated hemoglobin in primarily low-income patients
in urban community health centers (N ¼525). The
NP/CHW intervention included aggressive phar-
macological management, tailored low-literacy edu-
cational materials, and behavioral counseling for
lifestyle modification and problem solving to
address barriers to adherence and control. A
significantly greater improvement in SBP
(difference ¼6.2 mm Hg), DBP (difference ¼
3.1 mm Hg), and perceptions of the quality of
chronic illness care compared with the enhanced
usual care group was observed.
Commodore-Mensah et al
60,61
conducted a
cross-sectional epidemiological study (N ¼253) to
examine the association between acculturation and
CVD risk factors, including hypertension, in the
growing African immigrant population in the
United States, which is often studied as a homoge-
nous group with the dominant African-American
population. Hypertension diagnosis, treatment,
and control were 40%, 53%, and 50%, respectively,
and prevalence of overweight and obesity was 88%.
African immigrants who identified equally with the
US society and their African culture (integrationists)
were more likely to have controlled BP than those
who identified more with their African culture (tra-
ditionalists) (68% vs 25%; P¼0.011). This study
examined disparities in CVD risk from an ethnic
perspective rather than a racial perspective
62
to
inform the implementation of culturally tailored
public health interventions in this ethnic minority
population.
Using the principles of community-based partic-
ipatory research, the Self-Help Intervention
Program for High Blood Pressure Care (SHIP-
HBP)
63,64
was a 15-month trial that consisted of
6-week behavioral education followed by home tele-
monitoring of BP and bilingual nurse telephone
counseling for 12 months among Korean immi-
grants (N ¼359). The research team adapted and
translated evidence-based hypertension treatment
guidelines and behavioral recommendations into
more culturally relevant education materials for
first-generation Korean immigrants. The interven-
tion resulted in a sharp increase in BP control rates,
which was sustained over 12 months. At baseline,
BP control was achieved in only 30% of the sample.
After the initial education period (approximately 3
months), BP control was achieved in 73% of the
participants, and this level of control continuously
improved over a 12-month follow-up period
(83.2%, P<0.001).
CONCLUSIONS
Nurses have been involved in hypertension care and
control for as long as the field has been formally
addressed by professional societies, voluntary non-
profit organizations, and governments, approxi-
mately 50 years. The roles initially involved
Himmelfarb et al.AnnalsofGlobalHealth,VOL.82,NO.2,2016
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250

assisting in office evaluation by measuring BP and
educating patients. As nurses’skills evolved through
on-the-job or graduate training, their roles in hyper-
tension evolved to include physical assessment,
medication and lifestyle prescription, and greater
independent practice. Nurse-led clinics and team
models of care and research have evolved and
contributed to increasing the number of patients
receiving high-quality hypertension care and con-
trol. Nurses have assumed leadership roles in the
conduct of research to improve hypertension care
quality and reduce ethnic disparities by holistically
examining social, cultural, economic, and behavioral
determinants of hypertension outcomes and
designing culturally sensitive interventions geared
at addressing these factors.
REFERENCES
1. Kearney PM, Whelton M, Reynolds K,
Muntner P, Whelton PK, He J. Global
burden of hypertension: analysis of
worldwide data. Lancet 2005;365:
217e23.
2. James PA, Oparil S, Carter BL, et al.
2014 evidence-based guideline for the
management of high blood pressure in
adults: report from the panel members
appointed to the eighth joint national
committee (JNC 8). JAMA 2014;311:
507e20.
3. Law MR, Morris JK, Wald NJ. Use of
blood pressure lowering drugs in the
prevention of cardiovascular disease:
meta-analysis of 147 randomised trials
in the context of expectations from
prospective epidemiological studies.
BMJ 2009;338:b1665.
4. Guo F, He D, Zhang W,
Walton RG. Trends in prevalence,
awareness, management, and control
of hypertension among United States
adults, 1999 to 2010. J Am Coll Car-
diol 2012;60:599e606.
5. Gillespie CD, Hurvitz KA. Centers
for Disease Control and Prevention
(CDC). Prevalence of hypertension
and controlled hypertensiondUnited
States, 2007-2010. MMWR Surveill
Summ 2013;62(Suppl 3):144e8.
6. Walsh JM, McDonald KM,
Shojania KG, et al. Quality improve-
ment strategies for hypertension man-
agement: a systematic review. Med
Care 2006;44:646e57.
7. Carter BL, Bosworth HB, Green BB.
The hypertension team: the role of the
pharmacist, nurse, and teamwork in
hypertension therapy. J Clin Hyper-
tens (Greenwich) 2012;14:51e65.
8. Clark CE, Smith LF, Taylor RS,
Campbell JL. Nurse led interventions
to improve control of blood pressure
in people with hypertension: system-
atic review and meta-analysis. BMJ
2010;341:c3995.
9. Shaw RJ, McDuffie JR, Hendrix CC,
et al. Effects of nurse-managed proto-
cols in the outpatient management of
adults with chronic conditions: a sys-
tematic review and meta-analysis.
Ann Intern Med 2014;161:113e21.
10. Santschi V, Chiolero A,
Colosimo AL, et al. Improving blood
pressure control through pharmacist
interventions: a meta-analysis of
randomized controlled trials. J Am
Heart Assoc 2014;3:e000718.
11. Proia KK, Thota AB, Njie GJ, et al.
Team-based care and improved blood
pressure control: a community guide
systematic review. Am J Prev Med
2014;47:86e99.
12. Miller NH, Hill MN. Nursing clinics
in the management of hypertension.
In: Oparil S, Weber M, eds. Hyper-
tension. 2nd ed. Philadelphia, PA:
Saunders; 2005.
13. Perry HM Jr, Bingham S, Horney A,
et al. Antihypertensive efficacy of
treatment regimens used in veterans
administration hypertension clinics.
Department of Veterans Affairs
Cooperative Study Group on Antihy-
pertensive Agents. Hypertension
1998;31:771e9.
14. Five-year findings of the hypertension
detection and follow-up program. I.
Reduction in mortality of persons
with high blood pressure, including
mild hypertension. Hypertension
detection and follow-up program coop-
erative group. 1979. JAMA 1997;277:
157e66.
15. Barkauskas VH, Pohl JM, Tanner C,
Onifade TJ, Pilon B. Quality of care
in nurse-managed health centers.
Nurs Adm Q 2011;35:34e43.
16. Brush JE Jr, Handberg EM, Biga C,
et al. 2015 ACC health policy state-
ment on cardiovascular team-based
care and the role of advanced practice
providers. J Am Coll Cardiol 2015;65:
2118e36.
17. Brownstein JN, Chowdhury FM,
Norris SL, et al. Effectiveness of com-
munity health workers in the care of
people with hypertension. Am J Prev
Med 2007;32:435e47.
18. Dennison CR, Hill MN. Multidisci-
plinary management of hypertension
and the role of the nurse. In: Lip G,
Hall JE, eds. Comprehensive Hyper-
tension. Philadelphia, PA: Mosby;
2007:1147e55.
19. Pickering TG, Hall JE, Appel LJ,
et al. Recommendations for blood
pressure measurement in humans and
experimental animals: Part 1: Blood
pressure measurement in humans: a
statement for professionals from the
Subcommittee of Professional and
Public Education of the American
Heart Association Council on High
Blood Pressure Research. Circulation
2005;111:697e716.
20. D’Agostino RBS, Vasan RS,
Pencina MJ, et al. General cardiovas-
cular risk profile for use in primary
care: the Framingham Heart Study.
Circulation 2008;117:743e53.
21. Goff DC Jr, Lloyd-Jones DM,
Bennett G, et al. 2013 ACC/AHA
guideline on the assessment of cardio-
vascular risk: a report of the American
College of Cardiology/American
Heart Association Task Force on
Practice Guidelines. Circulation
2014;129:S49e73.
22. Hippisley-Cox J, Coupland C,
Vinogradova Y, Robson J, May M,
Brindle P. Derivation and validation
of QRISK, a new cardiovascular dis-
ease risk score for the United King-
dom: prospective open cohort study.
BMJ 2007;335:136.
23. Ridker PM, Paynter NP, Rifai N,
Gaziano JM, Cook NR. C-reactive
protein and parental history improve
global cardiovascular risk prediction:
the Reynolds risk score for men. Cir-
culation 2008;118:2243e51. 4p
following 2251.
24. Ridker PM, Buring JE, Rifai N,
Cook NR. Development and valida-
tion of improved algorithms for the
assessment of global cardiovascular
risk in women: the Reynolds risk
score. JAMA 2007;297:611e9.
25. Commodore-Mensah Y,
Himmelfarb CR. Patient education
strategies for hospitalized cardiovascu-
lar patients: a systematic review.
J Cardiovasc Nurs 2012;27:154e74.
26. Calhoun DA, Jones D, Textor S, et al.
Resistant hypertension: Diagnosis,
evaluation, and treatment: a scientific
statement from the American Heart
Annals of Global Health, VOL. 82, NO. 2, 2016 Himmelfarb et al.
MarcheApril 2016: 243–253 Nurses’Role in Global Hypertension Care
251

Association Professional Education
Committee of the Council for High
Blood Pressure Research. Circulation
2008;117:e510e26.
27. Williams B, Poulter NR, Brown MJ,
et al. British Hypertension Society
guidelines for hypertension manage-
ment 2004 (BHS-IV): summary.
BMJ 2004;328:634e40.
28. Go AS, Bauman MA, Coleman
King SM, et al. An effective approach
to high blood pressure control: a sci-
ence advisory from the American
Heart Association, the American Col-
lege of Cardiology, and the Centers
for Disease Control and Prevention.
J Am Coll Cardiol 2014;63:1230e8.
29. Aubert RE, Herman WH, Waters J,
et al. Nurse case management to
improve glycemic control in diabetic
patients in a health maintenance organ-
ization. A randomized, controlled trial.
Ann Intern Med 1998;129:605e12.
30. Allen JK, Dennison-Himmelfarb CR,
Szanton SL, et al. Community out-
reach and cardiovascular health
(COACH) trial: a randomized, con-
trolled trial of nurse practitioner/com-
munity health worker cardiovascular
disease risk reduction in urban com-
munity health centers. Circ Cardiovasc
Qual Outcomes 2011;4:595e602.
31. Hayman LL, Berra K, Fletcher BJ,
Houston Miller N. The role of nurses
in promoting cardiovascular health
worldwide: the global cardiovascular
nursing leadership forum. J Am Coll
Cardiol 2015;66:864e6.
32. Artinian NT, Fletcher GF,
Mozaffarian D, et al. Interventions to
promote physical activity and dietary
lifestyle changes for cardiovascular risk
factor reduction in adults: a scientific
statement from the American Heart
Association. Circulation 2010;122:
406e41.
33. Eckel RH, Jakicic JM, Ard JD, et al.
2013 AHA/ACC guideline on lifestyle
management to reduce cardiovascular
risk: a report of the American College
of Cardiology/American Heart Associ-
ation task force on practice guidelines.
J Am Coll Cardiol 2014;63:2960e84.
34. Gwadry-Sridhar FH, Manias E, Lal L,
et al. Impact of interventions on medi-
cation adherence and blood pressure
control in patients with essential hyper-
tension: a systematic review by the
ISPOR medication adherence and per-
sistence special interest group. Value
Health 2013;16:863e71.
35. Nieuwlaat R,Wilczynski N, Navarro T,
et al. Interventions for enhancing medi-
cation adherence. Cochrane Database
Syst Rev 2014;11:CD000011.
36. Patient behavior for blood pressure
control. guidelines for professionals.
JAMA 1979;241:2534e7.
37. Miller NH, Hill M, Kottke T,
Ockene IS. The multilevel compliance
challenge: recommendations for a call
to action. A statement for healthcare
professionals. Circulation 1997;95:
1085e90.
38. Dennison CR, Peer N, Steyn K,
Levitt NS, Hill MN. Determinants
of hypertension care and control
among peri-urban black South Afri-
cans: the HiHi study. Ethn Dis
2007;17:484e91.
39. Hill MN, Bone LR, Kim MT,
Miller DJ, Dennison CR, Levine DM.
Barriersto hypertensioncare and control
in young urbanblack men. Am J Hyper-
tens 1999;12:951e8.
40. Ogedegbe G. Barriers to optimal
hypertension control. J Clin Hyper-
tens (Greenwich) 2008;10:644e6.
41. Prevention of stroke by antihyperten-
sive drug treatment in older persons
with isolated systolic hypertension.
final results of the Systolic Hyperten-
sion in the Elderly Program (SHEP).
SHEP Cooperative Research Group.
JAMA 1991;265:3255e64.
42. The Healthcare Intelligence Network.
Healthcare trends in 2014: putting
money on population health, care
coordination and integrated care deliv-
ery. Sea Girt, NJ: Healthcare Intelli-
gence Network. Available at: http://
www.hin.com/library/HealthcareTrends
2014.pdf; 2013. Accessed December
21, 2015.
43. Glynn LG, Murphy AW, Smith SM,
Schroeder K, Fahey T. Interventions
used to improve control of blood pres-
sure in patients with hypertension.
Cochrane Database Syst Rev 2010:
CD005182.
44. Jaffe MG, Lee GA, Young JD,
Sidney S, Go AS. Improved blood
pressure control associated with a
large-scale hypertension program.
JAMA 2013;310:699e705.
45. Thomas KL, Shah BR, Elliot-
Bynum S, et al. Check it, change it:
a community-based, multifaceted
intervention to improve blood pressure
control. Circ Cardiovasc Qual Out-
comes 2014;7:828e34.
46. Million Hearts. Tools & protocols.
Atlanta, GA: Centers for Disease
Control and Prevention; 2015. Avail-
able at: http://millionhearts.hhs.gov/
tools-protocols/index.html. Updated
2015. Accessed January 13, 2016.
47. Agarwal R, Bills JE, Hecht TJ,
Light RP. Role of home blood pres-
sure monitoring in overcoming thera-
peutic inertia and improving
hypertension control: a systematic
review and meta-analysis. Hyperten-
sion 2011;57:29e38.
48. Borden WB, Maddox TM, Tang F,
et al. Impact of the 2014 expert panel
recommendations for management of
high blood pressure on contemporary
cardiovascular practice: insights from
the NCDR PINNACLE registry.
J Am Coll Cardiol 2014;64:
2196e203.
49. Burke LE, Ma J, Azar KM, et al.
Current science on consumer use of
mobile health for cardiovascular dis-
ease prevention: a scientific statement
from the American Heart Association.
Circulation 2015;132:1157e213.
50. Li JS, Barnett TA, Goodman E,
Wasserman RC, Kemper AR; Ameri-
can Heart Association Atherosclerosis,
Hypertension and Obesity in the
Young Committee of the Council on
Cardiovascular Disease in the Young,
Council on Epidemiology and Pre-
vention, and Council on Nutrition,
Physical Activity and Metabolism.
Approaches to the prevention and
management of childhood obesity:
the role of social networks and the
use of social media and related elec-
tronic technologies: a scientific state-
ment from the American Heart
Association. Circulation 2013;127:
260e7.
51. Liu S, Dunford SD, Leung YW, et al.
Reducing blood pressure with internet-
based interventions: a meta-analysis.
Can J Cardiol 2013;29:613e21.
52. Omboni S, Gazzola T, Carabelli G,
Parati G. Clinical usefulness and cost
effectiveness of home blood pressure
telemonitoring: meta-analysis of
randomized controlled studies.
J Hypertens 2013;31:455e67. discus-
sion 467e8.
53. Omboni S, Ferrari R. The role of tele-
medicine in hypertension manage-
ment: focus on blood pressure
telemonitoring. Curr Hypertens Rep
2015;17:535.
54. Verberk WJ, Kessels AG, Thien T.
Telecare is a valuable tool for hyper-
tension management: a systematic
review and meta-analysis. Blood Press
Monit 2011;16:149e55.
55. Frant R, Groen J. Prognosis of vascu-
lar hypertension; a 9 year follow-up
study of 418 cases. Arch Intern Med
(Chic) 1950;85:727e50.
56. Hill MN, Han HR, Dennison CR,
et al. Hypertension care and control
in underserved urban African Ameri-
can men: behavioral and physiologic
outcomes at 36 months. Am J Hyper-
tens 2003;16:906e13.
57. Dennison CR, Post WS, Kim MT,
et al. Underserved urban African
American men: hypertension trial out-
comes and mortality during 5 years.
Am J Hypertens 2007;20:164e71.
58. Dennison CR, Peer N, Lombard CJ,
et al. Cardiovascular risk and comor-
bid conditions among black South
Africans with hypertension in public
and private primary care settings: the
HiHi study. Ethn Dis 2007;17:
477e83.
59. Green LW, Kreuter MW, eds. Health
Promotion Planning: An Educational
Himmelfarb et al.AnnalsofGlobalHealth,VOL.82,NO.2,2016
Nurses’Role in Global Hypertension Care MarcheApril 2016: 243–253
252

and Ecological Approach. 4th ed.
New York, NY: McGraw-Hill; 2005.
60. Commodore-MensahY,HillM,AllenJ,
et al. Sex differences and cardiovascular
disease risk of Ghanaian and Nigerian-
born West African immigrants in the
United States: The Afro-Cardiac Study.
J Am Heart Assoc 2016;5(2):e002385.
61. Commodore-Mensah Y, Sampah M,
Berko C, et al. The Afro-Cardiac Study:
cardiovascular disease risk and accultur-
ation in West African immigrants in the
United States: rationale and study
design [e-pub ahead of print].
J Immigr Minor Healt 2015.
62. Commodore-Mensah Y, Dennison
Himmelfarb CR, Agyemang C,
Sumner AE. Cardiometabolic health
in African immigrants to the United
States: a call to re-examine research
on African-descent populations.
Ethn Dis 2015;25:373e80.
63. Kim MT, Han HR, Hedlin H, et al.
Teletransmitted monitoring of blood
pressure and bilingual nurse
counseling-sustained improvements
in blood pressure control during 12
months in hypertensive Korean Amer-
icans. J Clin Hypertens (Greenwich)
2011;13:605e12.
64. Kim MT, Han HR, Park HJ, Lee H,
Kim KB. Constructing and testing a
self-help intervention program for
high blood pressure control in Korean
American seniorsda pilot study.
J Cardiovasc Nurs 2006;21:77e84.
Annals of Global Health, VOL. 82, NO. 2, 2016 Himmelfarb et al.
MarcheApril 2016: 243–253 Nurses’Role in Global Hypertension Care
253