All rights reserved.

GRAND CANYON UNIVERSITY

Effectiveness of Aerobic Exercise on Ambulatory Blood Pressure in Hypertensive Patients

Chinyere Christiana Pamugo

has been approved

January 11, 2023

APPROVED:

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

Khoa Don Nguyen, MD., DPI Project Mentor

ACCEPTED AND SIGNED:

________________________________________

Lisa Smith, Ph.D., RN, CNE

Dean and Professor, College of Nursing and Health Care Professions

_________________________________________

Date

Keywords: aerobic exercise, ambulatory blood pressure, Saco-Ledo et al.’s research on aerobic exercise, Dorothy Orem’s self-care deficit theory, hypertension, hypertension-related conditions, Kurt Lewin’s change model, evidence based practice.

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 the 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. I want to thank Dr. Dawn Robinson (Faculty /Chair), for her unshaken patience, quick feedback, and radiant positive energy, together with Dr. Sandi 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, Ubong, Nkele, and others, your understanding when I transferred 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.

During this program, I also worked 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
Chapter 1: Introduction to the Project 1
Background of the Project 2
Problem Statement 3
Purpose of the Project 4
Clinical Question 7
Advancing Scientific Knowledge 7
Significance of the Project 10
Rationale for the Methodology 11
Nature of the Project Design 12
Definition of Terms 13
Assumptions, Limitations, Delimitations 15
Summary and Organization of the Remainder of the Project 17
Chapter 2: Literature Review 19
Theoretical Foundations 22
Review of the Literature 25
Prevalence of Hypertension 26
Aerobic Exercise Health Intervention 31
Effect of Exercise on Blood Pressure 34
Summary 39
Chapter 3: Methodology 41
Statement of the Problem 42
Clinical Question 43
Project Methodology 44
Project Design 45
Population and Sample Selection 47
Instrumentation and Sources of Data 48
Validity 49
Reliability 50
Data Collection Procedures 50
Data Analysis Procedures 52
Potential Bias and Mitigation 53
Ethical Considerations 54
Limitations 55
Summary 55
Chapter 4: Data Analysis and Results 58
Descriptive Data 59
Data Analysis Procedures 60
Results 61
Summary 63
Chapter 5: Summary, Conclusions, and Recommendations 65
Summary of Findings and Conclusion 68
Implications 70
Theoretical Implications 70
Practical Implications 72
Future Implications 73
Recommendations 73
Recommendations for Future Projects 74
Recommendations for Practice 75
References 77
Appendix A 93
Grand Canyon University Institutional Review Board Outcome Letter 93
Appendix B 94
Saco-Ledo et al.’s Research Article 94
Appendix C 95
Permission to Use Saco-Ledo et al.’s Research Article 95

Hypertension (HTN) is a medical condition associated with higher blood pressure, whereby the arteries that transport blood become damaged. Despite the availability of treatment strategies, less than one in five individuals have their blood pressure under control (Ghatage et al., 2021). Currently, in the United States (U.S.), the disease poses a significant problem that affects over half of the adult population (37 million individuals) (Centers for Disease Control and Prevention [CDC], 2021; Krist et al., 2021). Complications of the condition include myocardial infarction, heart failure, chronic renal disease, and stroke (Ghatage et al., 2021).

At the project site, the project manager collaborated with the Medical Director and clinical manager regarding the increasing ambulatory blood pressures seen within the past three months. Although the site provided patients with medication management for their disease, it was suggested that another strategy be employed to help reduce blood pressure. The conversation concluded with the project manager translating and implementing Saco-Ledo et al.’s (2020) research on aerobic exercise to impact the blood pressure of hypertensive patients.

The project was worth conducting because it helped to increase HTN patients’ knowledge levels and assist in helping them change their behaviors to combat this “silent killer” (Centers for Disease Control and Prevention [CDC], 2019). Unfortunately, many individuals are unaware of the symptoms, which makes the situation dire. This project promoted decreasing the fifth leading cause of death (CDC, 2019). Other areas the project impacted were improving their quality of life, reducing their chances of stroke, protecting their kidneys, and decreasing healthcare costs (CDC, 2019).

Chapter 1 introduced the topic of hypertension and the use of daily physical activity to combat the disease. Other sections of the chapter included the problem statement, purpose statement, and clinical question. Other chapter areas encompassed advancing scientific knowledge related to the theoretical underpinnings, quantitative methodology, and quasi-experimental design. The chapter’s last segments comprised the definition of terms, assumptions, limitations, and delimitations with a preview of Chapter 2.

The prevalence of hypertension among the adult population in the United States (U.S.) increased rapidly between 1988 to 2010, accounting for half of all fatalities from stroke and end-stage renal disease (ESRD) (Million Hearts, 2021). According to Muntner et al. (2020) trend analysis, the estimated proportion of the U.S. adult population suffering from hypertension between 1999 and 2000 was 31.8 %. The adult population affected by hypertension increased from 31.8 % in 1999-2000 to 48.5 % in 2007 and 2008 (Muntner et al., 2020). The number of affected U.S. adults has been on the rise ever since, and between 2013 and 2014, which was 53.8 % (Muntner et al., 2020). The percentage dropped slightly from 53.8% to 43.7% between 2017 and 2018, but the value is still relatively high (Muntner et al., 2020). This data imply that the American population is considerably affected by hypertension at an alarming rate.

It was not known if or to what degree the translation of Saco-Ledo et al.’s (2020) research on aerobic exercise would impact systolic and diastolic blood pressures when compared to current practice among adult hypertensive patients. At the clinical site, there were no standardized guidelines for clinicians to educate hypertensive patients regarding implementing daily physical activity as a blood pressure management mechanism. 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 clinic’s findings corresponded with the health statistics from the Texas Health and Human Services Commission (2022), as the county ranks 22 in the States with diagnosed hypertensive patients. The data, in combination with current literature by the Centers for Disease Prevention and Control [CDC] (2021), emphasizes that hypertension affects approximately 45% of American adults.

The purpose of this quantitative, quasi-experimental quality improvement project was to determine if the translation of Saco-Ledo et al.’s research on aerobic exercise would impact systolic and diastolic blood pressures when compared to current practice among adult hypertensive patients in a primary care clinic in southwest Texas over four weeks. The independent variable for the project was the translation of Saco-Ledo et al.’s (2020) research on aerobic exercise, and the dependent variable was blood pressure measurements. Convenience sampling was used to choose the patients during office visits. The project was conducted within four weeks using a quasi-experimental design and quantitative methodology. Six healthcare providers were educated to offer aerobic exercise using a translation of Saco-Ledo et al.’s research on aerobic exercise. The impact was measured using an Oscar 2 blood pressure monitoring device for HTN patients. The primary investigation carried out the implementation and comparison of data during the project using ambulatory blood pressure collected baseline and postimplementation. Patient blood pressures measured by the Oscar-2 were automatically imported into the patient’s medical record. Data were retrieved from the clinic’s electronic medical record and inputted into a Microsoft Excel spreadsheet. A statistician not associated with the primary investigator or project analyzed the data. A paired sample t-test was used to analyze the statistical significance of the variables using the Statistical Package for the Social Sciences (SPSS-28).

The inclusion criteria for the patients were 18 and older, diagnosed with HTN, current clinic patients, and able to participate in aerobic activity. The exclusion criteria are patients with musculoskeletal disabilities, mental disorders, and individuals with comorbidities that could bias the project findings. The patients engaged in aerobic exercise for 30 minutes in 24 hours, three days a week, for the four weeks of the project duration. The postimplementation outcome was a reduction in ambulatory blood pressure reading of the recommended BP below 140/80mmHg. The average decrease in SBP with aerobic exercise is approximately 2 to 4 mm Hg in normotensive patients and 5 to 8 mm Hg in adult hypertension patients (Saco-Ledo et al., 2020).

The individuals who implemented the intervention were one physician, two nurse practitioners, two registered nurses, and one medical assistant. All healthcare providers were educated to include aerobic exercise within office visits with HTN patients. Aerobic exercise was offered as translated from Saco-Ledo et al.’s (2020) research on aerobic exercise. The use of Oscar 2 Device for measuring ambulatory blood pressure. The clinicians demonstrated understanding via the teach-back method to the project manager to safeguard all the patients were taught the same way. They currently work full-time at the clinic for over one year and have access to the documentation software.

The project site’s geographic location is in southwest Texas, the most populous county and the third most populous county in the United States (U.S. Census Bureau, 2020). The affected population was patients diagnosed with HTN. The demographics show a diverse population of White (28.9 %), White-Hispanic (36.72%), Blacks (18.5%), Asians (6.9 %), and Latinos (8.98. %) (U.S. Census Bureau, 2020). Many residents over the age of 60 have chronic diseases such as (chronic obstructive pulmonary disease, heart disease, and diabetes) (UT Health Science Center at Houston, 2020). The age groups in the county 18 to 34 (20,586), 35 to 54 (46,513), and 55 to 64 reflect the patients in the project.

Saco-Ledo et al. (2020) conducted a systematic review and meta-analysis. The authors claimed that ambulatory blood pressure (ABP) better predicts cardiovascular disease and mortality in adult hypertensive populations. Aerobic exercise played a significant role in lowering blood pressure and was beneficial in lowering ambulatory blood pressure in HTN patients. The following clinical question guided this quantitative project: To what degree does the translation of Saco-Ledo et al.’s (2020) research on aerobic exercise impact systolic and diastolic blood pressures compared to current practice among adult hypertensive patients in a primary care clinic in southwest Texas?


The independent variable was the translation of Saco-Ledo et al.’s (2020) research on aerobic exercise, and the dependent variable was ambulatory blood pressure.

Implementing an aerobic exercise education program to lower ambulatory blood pressure improved population health outcomes for hypertensive individuals (Saco-Ledo et al., 2020). Completing this quality improvement project advanced the understanding of ambulatory blood pressure in hypertensive patients to reduce or manage ambulatory blood pressure. The overall goals of aerobic exercise walking in controlling blood pressure in hypertensive patients were to decrease morbidity and increase the population’s wellness, happiness, and vitality. Physical activities include walking, running, swimming, and biking, which improves symptoms, quality of life, and functional status, and reduces hospitalizations (CDC, 2021).

In clinical practice, management of cardiovascular diseases entailed resolving cardiovascular etiologies such as coronary heart disease and related conditions such as diabetes, preventative care, follow-up monitoring of cardiac status, care coordination and case management, educating and supporting patients for self-management, rehabilitation of heart function, and health promotion, among others (Jiang & Wang, 2021). The pharmacological treatment of cardiovascular diseases has improved with the development of new therapies and understanding its pathophysiology. Despite developing novel pharmacological interventions for patients with HTN, congestive heart failure existing treatments have not yielded significant mortality benefits for HF patients with heart failure with reduced ejection fraction (HFpEF). Instead, the drug treatments try to control symptoms, treat comorbidities, and risk factors that the cause through measures such as aerobic exercise, diet and weight control, blood pressure self-monitoring, and low sodium intake, among others (CDC, 2021).

The identified gap is the elevated ambulatory blood pressure among the hypertensive group based on the available research (Blumenthal et al., 2018; Saco-Ledo et al., 2020). Educational programs on aerobic exercise to decrease and manage ambulatory blood pressure should build on the findings (Blumenthal et al., 2018). Other factors that influence blood pressure are the presence of comorbidities and risky behaviors such as smoking, patients’ education level, caregiver presence, and in-patient HTN education. As the patients became more aware of aerobic exercise in lowering blood pressure through the educational program, they showed fewer comorbidities that reduced their risk of hypertensive complications and frequent hospitalizations (Saco-Ledo et al., 2020). The initiative filled the gap or need by utilizing Saco-Ledo et al.’s (2020) research on aerobic exercise for aerobic exercise education to lower systolic and diastolic blood pressures for patients with hypertension.

The selected theoretical framework for this quality improvement project was Dorothy Orem’s self-care deficit theory. Based on the theory, patients must engage in self-care to maintain and improve their quality of health (Orem, 1995). Utilizing this theory, the nurses did not see their patients as inactive or receiving health services; instead, they considered them strong and reliable to participate in daily activities and decision-making processes (Orem, 1995). Three nursing systems are defined in Orem’s nursing theory; they include wholly compensatory, partially compensatory, and supportive-educative strategies (Khademian et al., 2020). For this project, the focus is on the last system (supportive educational system). The clinicians assessed the patient’s readiness to learn something new but needed assistance and guidance. Patients with chronic illnesses require motivation and the skills to conduct the behaviors needed to maintain and improve their health (Khademian et al., 2020). Hence, the patient gained the capability to learn disease processes and perform activities independently, overcoming seen and unseen limitations.

The significance of the quality improvement project was implementing a recommended evidence-based strategy using a translation of Saco-Ledo et al.’s (2020) research on aerobic exercise. Implementing the project helped decrease the healthcare costs associated with HTN in the United States. Commodore-Mensah et al. (2018) state that the financial prices are significant, approximately $131-198 billion annually. Hypertensive persons incur an extra $2,000 yearly in healthcare expenditures compared to non-hypertensive persons (Commodore-Mensah et al., 2018). Furthermore, HTN is a crucial risk factor in various diseases, including myocardial infarction, heart failure, stroke, and chronic renal disease (Commodore-Mensah et al., 2018).

One nursing implication relates to Lewin’s change model in creating and sustaining change. A multi-systematic approach must be drawn from the model to support the implementation of the translation of Saco-Ledo et al.’s (2020) research on aerobic exercise for hypertensive patients. The model highlighted the principles relating to people changing from the onset, discussing their feelings regarding the change, and supporting the process via communication and collaboration (Harrison et al., 2021).

The second nursing implication relates to the patients’ management of their disease process (hypertension). The patients were taught the importance of including aerobic exercise and walking (30 minutes, three times a week) in their private daily schedules. The project manager evaluated the respondents’ understanding and receptiveness to new information and safety measures related to exercising.

The quantitative methodology was used to provide information that uses numerical data (Statistical Solutions, 2019). This method best answered the clinical question and addressed this project’s problem statement because it allowed an in-depth comparison of the relationship between baseline and postimplementation results (Guetterman & Fetters, 2018). It was used because it offered objective, systematic, and focused data analysis strategies (Guetterman & Fetters, 2018). In this project, the project manager evaluated the translation of Saco-Ledo et al.’s (2020) research on aerobic exercise and its impact on the systolic and diastolic blood pressures of HTN patients. The dependent variable was measured four weeks before and after improving the intervention. This methodology was the most appropriate because other investigators could replicate the data (Creswell & Creswell, 2018).

A quasi-experimental design was used in this quality improvement project. As mentioned above, the rationale behind selecting the project was that it allowed for comparing the dependent (blood pressure) and independent variables (implementation strategy aerobic exercise education guideline). The design was suitable for scrutinizing the project’s variables and determining the independent variable’s effect on the dependent variable (Creswell & Creswell, 2018). Furthermore, the design did not allow the patients to be randomly assigned (Creswell & Creswell, 2018). The dependent variable (ambulatory blood pressure) was measured at two different times (once before the intervention and once after the intervention (Creswell & Creswell, 2018).

A correlational design was not selected for this quality improvement project. It was not chosen because it is a non-experimental design where the variables are measured and evaluated for their relationship (correlation) (Creswell & Creswell, 2018). The variables cannot be controlled (Creswell & Creswell, 2018). Two rationales for not using this type of design are evaluating the causal statistical relationships between the variables and not manipulating the independent variable (Creswell & Creswell, 2018).

The project sample explored were adult patients diagnosed with HTN. The individuals were 18 or older, spoke English, and were able to participate in aerobic exercise. The exclusion criteria include respondents with mental challenges, musculoskeletal disabilities, and comorbidities that could bias the project results. The sample size was calculated using G* Power software, version 3.1.9.2, with an alpha measure of 0.05, an effect size of 0.5, and a power of 80%. The minimum number of patients suggested for the project was N=34.

A quality improvement project must offer the reader an understanding of the terms, concepts, and variables used (Grand Canyon University, 2021). New knowledge is critical to successful solutions (Polit & Beck, 2018). Below are the terms used intermittently throughout the project.

Aerobic exercise refers to any activity involving cardiovascular conditioning and pertains to running, brisk walking, swimming, or even cycling. This project applied aerobic exercise to help hypertensive patients reduce their ambulatory blood pressure (Seals et al., 2019). The intervention using a recommendation for 30 minutes of aerobic exercise was implemented as translated from Saco-Ledo et al.’s (2020) research on aerobic exercise.

Ambulatory Blood Pressure Monitoring (ABPM)

Ambulatory blood pressure monitoring was introduced in the early 1960s and was used to assess one’s blood pressure in real-time (Shackelford, 2022). A healthcare provider evaluates blood pressure during routine work, sleep, or chores (Shackelford, 2022). The outcome of the quality improvement project was the systolic and diastolic blood pressures measured using ambulatory blood pressure monitoring (Saco-Ledo et al., 2020).

The American College of Cardiology Foundation

The American College of Cardiology Foundation is a non-profit medical organization dedicated to improving the lives of cardiovascular patients (American College of Cardiology, 2022). This was done via continuous quality improvement monitoring, patient-care strategies, payment innovation, and professionalism (American College of Cardiology, 2022).

American Heart Association

The American Heart Association was formed in 1924 to establish scientific research that could offer healthcare providers and patients methods to treat cardiac disease and prevention (American Heart Association, 2022).

High blood pressure occurs when an adult’s blood pressure is above the optimum level, usually at 130/80mmHg for adult patients. When a patient’s blood pressure exceeds the optimum shown above, they are exposed to the risk of chronic heart failure, stroke, myocardial infarction, and in extreme circumstances, death (Fuchs & Whelton, 2020).

Hypertensive Patients

Hypertensive patients refer to the patients diagnosed with hypertension since hypertension is a causative factor for other diseases such as chronic heart failure, stroke, and even myocardial infarction (Schwingshackl et al., 2019).

Grand Canyon University (2021) stated that an assumption is an indisputable fact. The first assumption was that this quality improvement project was based on the translation of Saco-Ledo et al.’s (2020) research on aerobic exercise education programs that would enhance the self-efficacy of adult hypertensive patients by helping them keep their blood pressure at optimum levels. In turn, the aerobic exercise education program intervention would play a pivotal role in lifestyle improvement and skill development, which were required to encourage improved health outcomes and adaptive health-related behavior (Cameron et al., 2018). The second assumption was that all patients answered the questions honestly. To maintain honesty from the patients during the project, the project manager did not influence the patients’ answers. To maintain objectivity and reduce the possibility of skewed data, the investigator hired an outside statistician to conduct the data analysis (Statistical Solutions, 2019).

The third assumption was that the respondents were engaged and interested in participating in this quality improvement project. The underlying presumption was that people were resistant to change. To improve the patients’ engagement in the project, the project manager allowed an opportunity for feedback regarding the data collection process. Aggarwal and Ranganathan (2019) emphasize that collecting pertinent data that can be reproduced can inform and collaborate with the staff on evidence-based strategies related to hypertension care.

Limitations are situations the project manager cannot control (Creswell & Creswell, 2018). The first limitation was the restricted time to conduct the project (four weeks). A longitudinal project allows one to evaluate the trends and changes over time (Leedy & Ormrod, 2020). Secondly, it reviews the chronological sequencing of events, a critical criterion for establishing causality (Leedy & Ormrod, 2020).

The third limitation was the data analysis. Data were collected from the facility’s electronic record and input into a Microsoft Excel spreadsheet (codebook). If the data is not inserted correctly, the results might result in false or misleading information (Leedy & Ormrod, 2020). A statistician not affiliated with the project or manager performed the data analysis.

Delimitations are situations that the project manager can control (Creswell & Creswell, 2018). The first delimitation was the selected clinical site. It was chosen because it was accessible and convenient for the project manager related to the patients. The second delimitation was the inclusion criteria for participating in the project. The third delimitation was the selected topic because the project manager was interested in hypertension and aerobic exercise in managing the disease.

According to Saco-Ledo et al. (2020), adult hypertension cases were so severe that they resulted in $370 billion in annual direct medical costs worldwide. Krist et al. (2021) also provided an inclinatory hypothesis that fully supports Saco-Ledo et al. (2020) findings by noting that 45% of American adults suffer from hypertension. In the adult population of America, hypertension increased steadily but quickly between 1988 and 1994, 1999 and 2000, and 2009 and 2010. According to research by Wang et al. (2019), there was a sharp increase in occurrences of hypertension.

The American College of Cardiology (ACC) disclosed that physical exercise education and participation should be seen as a way of improving health, modifying lifestyle, and maintaining blood pressure as essential to preventing hypertension (ACC, 2022). While the condition was severe, it is attributed to other chronic conditions such as stroke, end-stage renal disease (ESRD), and death in extreme instances. As affirmed by Muntner et al. (2020), between 1999 and 2000, the rate was 31.8%, which fast rose to 48.5% between 2007 and 2008. Between 2013 and 2014, the rates rapidly rose to 53.8% (Muntner et al., 2020).

Orem’s self-care deficit theory and Lewin’s change model were discussed. Orem’s self-care deficit theory guided clinicians in realizing that their patients are active patients who can participate in daily activities that benefit their health (Orem, 1995). Lewin’s change model provided an overview of how a change process could be implemented and sustained using the three phases (unfreezing, movement, and refreezing) (Lewin, 1947).

Chapter 2 reviewed the previous and current literature on the effectiveness of aerobic exercise on Ambulatory Blood Pressure (ABP) among hypertensive patients. The chapter discussed the theoretical underpinnings used in the project (Orem’s self-care deficit theory and Lewin’s change model). The primary themes were the prevalence of hypertension, aerobic exercise, and intervention to control hypertension. The subthemes were specific to the themes related to hypertension and aerobic exercise. The last segment of the chapter offered a preview of Chapter 3 and its contents.

High blood pressure, also known as hypertension (HTN), is a leading risk factor for global cardiac disease (Hoffmann et al., 2020). Low adherence to HTN treatment among hypertensive patients remains a healthcare challenge (Hoffmann et al., 2020). Schwingshackl et al. (2019) state that hypertension is a condition in which the patients involved have high blood pressure exceeding the set optimal BP (140/90mmHg). However, when a patient’s blood pressure exceeds 180/120 mmHg, then their condition can be termed as severe and would be exposed to other chronic conditions such as heart diseases which are a result of the long-term force caused by the blood pressure on arterial walls (Schwingshackl et al., 2019).

Increasing clinicians’ awareness of the various strategies in HTN management and including the patients in the shared decision-making could improve their quality of life. One method identified from the literature involved implementing a translation of Saco-Ledo et al.’s (2020) research on aerobic exercise. At the project site, there were no standardized guidelines for educating hypertensive patients on incorporating exercise as a blood pressure management mechanism. The purpose of this quantitative, quasi-experimental quality improvement project was to determine if the translation of Saco-Ledo et al.’s research on aerobic exercise would impact systolic and diastolic blood pressures when compared to current practice among adult hypertensive patients in a primary care clinic in southwest Texas over four weeks..

Chapter 2 explored previous and current literature regarding ambulatory blood pressure and aerobic exercise being included in the daily management of hypertension. Orem’s self-care deficit theory and Lewin’s change model were discussed in detail. Three primary themes for the topic of hypertension are the prevalence of hypertension, aerobic exercise, and the effects of exercise on blood pressure. The subthemes for the prevalence of hypertension included systolic blood pressure management, diastolic blood pressure management, and ambulatory blood pressure management. The subthemes for aerobic exercise are pre-aerobic exercise state, during aerobic exercise state, and post-aerobic exercise state. The final subthemes for the effects of exercise on blood pressure consist of literacy level, self-efficacy, and lifestyle modification. The last few sentences of the chapter provided a preview of Chapter 3.

A literature search was conducted using peer-reviewed articles from 2018 to current. The keywords and inclusion criteria included written in English, hypertension adults, aerobic exercise, American Heart Association hypertension guideline, Dorothy Orem’s self-care deficit theory, hypertension, hypertension-related conditions, and Lewin’s change model. The exclusion criteria were non-English articles and pediatrics. The following databases were used during the review CINAHL, Cochrane Library, EMBASE, Google Scholar, Grand Canyon University online, and PubMed. Over 374.070 results were discovered; however, an exclusion filter was used, and the quantity was reduced to 19,431 results (Adams & Wright, 2020). articles were used for this review. However, 50 articles were used that met the inclusion criteria.

A historical overview shows that from 1988 to 2010, hypertension was attributed to 50% of deaths, an extension of their hypertensive nature through end-stage renal disease (ESRD) and stroke (Wang et al., 2019). Another report by Muntner et al. (2020) shows that the population of patients diagnosed with hypertension rose by 31.8% between 1999 and 2000. Between 2007 and 2008, the rates rose to 48.5%. The rate rose to 48.5% (Muntner et al., 2020). The rates might have dropped slightly; however, the rate of 43.7% is still relatively high, which calls for adopting alternative interventions that would help expedite the drop in the population affected by hypertension. Saco-Ledo et al. (2020) affirm that hypertension is a critical condition and is currently the leading cause of premature global deaths. The American Heart Association set the new hypertension diagnosis threshold in the systematic review as a BP ≥ 130/80 mmHg (Asayama et al., 2019). However, the European Society of Hypertension (ESH) maintains that hypertension is best defined using a threshold ≥ 140/90 mmHg (Saco-Ledo et al., 2020).

A patient is exposed to other co-morbidities when their condition is not maintained. This endangers their lives which calls for an evidence-based intervention that can best be suited to helping such patients cope with the condition in question. The patient’s systolic and diastolic BP must be maintained at the optimum level, failure to which an intervention would have to be sought to help reduce them to be within the optimal range. As per the AHA guidelines, an elevated BP has a systolic BP ≥ 140 mmHg or diastolic BP ≥ 90 mmHg (Oprail, 2016). However, the initial classification undertaken by the AHA was 130/80 mmHg (Asayama et al., 2019).

Utilizing a practical intervention that would help alleviate the effects of hypertension is mainly attributed to the knowledge of the long-term impact that the condition has on the patient in question. When patients are aware of the long-term effects of hypertension on their quality of life (QoL), they may be motivated to do as their doctor says or take medications that the doctor prescribes. However, in the case of this quality improvement project, the primary investigator (PI) proposes using the staff to offer the exercise recommendations based on Saco-Ledo et al.’s (2020) research using aerobic exercise to help maintain BP at optimal levels among hypertensive patients in southeast Texas.

One of the most problematic issues regarding using the translation of Saco-Ledo et al.’s (2020) research for aerobic exercise education programs was whether the use would be instrumental in helping patients with ambulatory blood pressure reduce them. Burnier and Egan (2019) assert that research has established the relationship between hypertension and cardiovascular disease. The authors reinforced the inherent need to ascertain that patients struggling with hypertension are within their means to maintain their blood pressure.

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 selected because it emphasizes the mutual relationship between human beings and their environment (Orem, 1995). The theory emphasizes that all humans are capable of self-care and the primary goal of the clinician was to help them obtain an optimum level of independence with their disease process (hypertension) (Orem, 1995). It consists of five areas of self-care requisites: universal self-care requisites, normalcy, developmental self-care requisites, and health deviation self-care requisite (Fotokian et al., 2021). Utilizing this theory allowed the project manager to explain to the healthcare providers their roles and responsibilities while offering the patient a clear outline of the care plan. In turn, this helped hypertensive patients to achieve and maintain a suitable level of self-care (Orem, 1995).

Khademian et al. (2020) conducted a quantitative, quasi-experimental study to evaluate a self-care educational program developed and based on Orem’s nursing theory. Eighty Iranian hypertensive patients participated in the study. Data was collected pre-and-post eight weeks of intervention using the
Quality of Life of Cardiac Patients and
Strategies Used by People to Promote Health surveys (Khademian et al., 2020). Data were analyzed using chi-square, independent
t-test, and Analysis of Variances (ANOVA) with repeated measures (Khademian et al., 2020). The results showed that the mean score of the Quality of Life in the experimental group was higher than the control group post-eight-week intervention (106.5±26.5 vs. 85.5±22.5,
p=0.03) (Khademian et al., 2020). The mean scores of self-efficacies were not statistically different from those of the control group immediately after (68.5±12.7 vs. 66.5±12.2,
p=0.47) and eight weeks after the intervention (70.5±13.5 vs. 65.7±12.0,
p=0.10) (Khademian et al., 2020). The authors concluded that using and educating hypertensive patients with Orem’s nursing theory as a guide could improve their quality of life (Khademian et al., 2020).

Lewin’s change model was selected for this project. The model proposes that hypertensive patients and clinicians are influenced by restraining forces (Lewin, 1947). These barriers counter-drive forces that keep the positive forces for change pushed in the direction that cause change to occur (Lewin, 1947). The tension between the driving and restraining forces maintains equilibrium (Lewin, 1947). The model consists of three constructs: unfreezing, changing (movement), and refreezing (Lewin, 1947).

A quantitative study by Henry et al. (2021) evaluated how to improve patient safety by implementing a referral process from the emergency department to reduce the risk of loss to follow-up. The authors focused on patients with seizure-related or suspected epileptic, cardiogenic, or acute symptomatic (Henry et al., 2021). The authors selected Lewin’s change model to guide the interaction to implement the project. The
t test results showed that the median waiting time pre-implementation was 65.0 days (range 37 days to 163 days), and the median waiting time post-intervention was 31.0 days (range eight days to 175 days) [
t(30.9) = 9.42; p<0.001]. Process measures were met with 100% compliance (Henry et al., 2021). The project concluded with the emergency department making significant improvements using Lewin’s change model to manage seizure patients. The model was essential for managing a large healthcare organization with multiple stakeholders (Henry et al., 2021).

Smith (2018) conducted a quantitative project to determine the correlation between blood pressure (mean arterial pressures) and implementing 30 minutes of aerobic exercise three times a week for 30 minutes in 30 hypertensive adults. Lewin’s change model was utilized to educate the outpatient participants (Smith, 2018). The project expected that the patients would learn about the benefits of aerobic exercise and engage in a new behavior (walking) (Smith, 2018). The author stated the rationale for using the change model was to use the education to unfreeze the patients’ current behavior, moving stage (engage in walking), and refreezing (adopting walking as part of their lifestyles (Lewin, 1947; Smith, 2018). The results showed that after four weeks, eight participants had engaged in regular aerobic exercise three times a week (Smith, 2018). Although the results were not statistically significant, the project showed how the use of Lewin’s change model enhanced and guided the education process for the participants.

Hypertension is the result of one’s blood pressure being too high. CDC (2021) disclosed that about half of adults (45%) with uncontrolled hypertension have a blood pressure of 140/90 mmHg or higher. This includes 37 million U.S. adults (Cameron et al., 2018). It is not news that some patients do not give themselves the appropriate health care they deserve. Some HTN patients do not know their blood pressure (BP) baseline, making it hard to detect or notice the increase or decrease in their BP readings. Kirkland et al. (2018) opined that the estimated prevalence rate of adults diagnosed with HTN would increase by approximately nine percent from 2010 to 2030; an increase in uncontrolled BP-associated complications is a significant health issue among American citizens (Cameron et al., 2018).

The World Health Organization (WHO, 2021) stated that about 1.28 billion adults aged 30 to 70 years worldwide have HTN, and less than half of adults diagnosed with HTN are treated (Cameron et al., 2018). The modifiable risk factors include changing unhealthy health habits such as smoking, inactivity, alcohol /tobacco consumption, being overweight or obese, and excess salt intake; the non-modifiable are age > 65years, coexisting diseases such as diabetes and family history (CDC, 2021). Management of HTN involves decreased salt intake to less than 5 g daily, improved physical exercise, reduced alcohol, and tobacco use, weight management, and increased consumption of fruits and vegetables (CDC, 2021; Whelton et al., 2018).

The WHO estimates that more than 1.28 billion people aged 30 to 79 years worldwide suffer from hypertension. Two-thirds of these people are from low-income and middle-class households (Centers for Disease Control and Prevention, 2019). Furthermore, 46% of adults with hypertension are unaware that they suffer from the condition. Therefore, less than half of adults with hypertension are diagnosed and treated (Centers for Disease Control and Prevention, 2019). The number of hypertension patients with the health condition under control is also low. It is estimated that one in five adults with hypertension has the disease under control (Carey & Forsyth, 2022). Hypertension is among the leading causes of premature death in the world. As a result, it is among the non-communicable diseases with healthcare targets to reduce its prevalence. The goal is to reduce hypertension prevalence by 33% between 2010 and 2030 (Fuchs & Whelton, 2020).

In the United States (U.S.), hypertension prevalence is alarming. Hypertension puts Americans at a higher risk of heart disease and strokes. These two are the leading causes of death in the United States. In 2020 alone, more than 670,000 deaths because of diabetes were reported in America (Fuchs & Whelton, 2020). With nearly half of American adults in the United States having hypertension, only one in four patients have the condition under control (Guirguis-Blake et al., 2021). Hypertension prevalence in the United States varies with gender and race. Hypertension is commonly noted in men, with 50% of men in America having this condition, while 44% of hypertension patients in America are women (Fuchs & Whelton, 2020). Furthermore, hypertension is more prevalent among black American adults at 56%, white American adults at 48%, Asian adults at 46%, and Hispanic adults at 39% (Guirguis-Blake et al., 2021). High blood pressure is also common in some areas of the U.S. compared to other countries.

Measurement of Systolic Blood Pressure Management.

The WHO (2021) described HTN as a medical condition diagnosed when blood pressure is measured on two different days; the systolic blood pressure readings on both days are≥140 mmHg, and the diastolic blood pressure readings on both days are ≥90 mmHg (Kramer et al., 2019). The first of the two numbers used in blood pressure is the SBP, which demonstrates the arterial pressure when the heart contracts (WHO, 2021). Primary health clinics are better positioned to educate patients on issues concerning their health, treatment options, and patient-centered self-management (Yatim et al., 2019). When the systolic blood pressure measurements are above 140 while the diastolic blood pressure reading on a patient is under 90, the condition is referred to as systolic hypertension (Kramer et al., 2019). Systolic hypertension is seen more among older adults (Fuchs & Whelton, 2020).

Diastolic Blood Pressure Management (DBP).

The DBP is the second number reading representing the pressure in the vessels when the heart rests between beats (Saco-Ledo et al., 2020; WHO, 2021). Diastolic blood pressure is experienced when the readings are consistently over 90 (Kramer et al., 2019). Each increase of 10 mmHg in diastolic blood pressure from 40 to 89 increases the risk of heart disease or stroke. Hence, emphasis also is put on DBP (Saco-Ledo et al., 2020). The DBP readings of an individual can suggest a critical clinical need to reduce risks, mortality, and morbidity. Educating the population on the variations and impact of each blood pressure reading improves the knowledge gap.

Ambulatory Blood Pressure Management (ABPM)
.

Ambulatory blood pressure management is an effective way of monitoring and managing hypertensive patients. The blood pressure measurements are taken over 24 hours, whether the patient is awake or asleep (Leedy & Ormrod, 2020). It was introduced as a method allowing the collection of BP values numerous times an hour over 24 hours. For example, the readings can be taken over 20 and 30-minute intervals throughout the day and night (Mandini et al., 2018). Furthermore, heart rate readings can be added for enhanced ABPM. After that, the readings are averaged for each day, and changes in blood pressure are calculated.

Additionally, statistics such as changes in heart rate and blood pressure distribution patterns are calculated. BP measures have long been recognized as critical tools for doctors in detecting and managing hypertension (Asayama et al., 2019). Incorrect application, lack of uniformity, or patient or family errors after receiving instructions were all eliminated by the ABPM, which was considered accurate (Asayama et al., 2019). To evaluate the mean SBP or DBP recorded readings, it was necessary to consider ABPM’s multiple readings. According to the AHA guidelines, diastolic and systolic blood pressure levels should be less than 125 and 75 millimeters of mercury, respectively (Mandini et al., 2018). One of the advantages of the ABPM was that it was more accurate than a one-time measurement (Dadlani et al., 2018). The ABPM could detect variations in circadian rhythms, such as sleep-wake cycles and blood pressure fluctuations, in response to environmental and emotional disturbances (Dadlani et al., 2018).

Patients were reluctant to wear the cuff for 24 hours because of the discomfort it caused and the fact that it triggered every 30 minutes at night, making ambulatory blood pressure control (ABPM) ineffective (González-de Paz et al., 2019). Dadlani et al. (2018) also noted practitioners’ lack of availability, understanding, and varying awareness of ambulatory monitoring. Therefore, it is possible that using ABPM made it more challenging to get an accurate blood pressure reading while exercising.

Ambulatory blood pressure monitoring provides enhanced information on how blood pressure changes with a person’s daily activities and sleep. This monitoring style is recommended by the American Heart Association and the American College of Cardiology as the suitable mode for blood pressure management (Whelton et al., 2018). Most people record a decrease of around 20% in systolic blood pressure when asleep (Million Hearts, 2021). However, some experience zero drops during sleep (Million Hearts, 2021). In unique instances, some people recorded a rise in systolic blood pressure during sleep (Million Hearts, 2021). Ambulatory blood pressure monitoring is advantageous because it can detect changes that might go unnoticed with other blood pressure management technology (Million Hearts, 2021).

Ambulatory blood pressure management can detect white-coats, masked, and sustained hypertension (Cohen et al., 2019). White coat hypertension is witnessed when hypertensive patients who do not take hypertensive drugs record high blood pressure readings (Cohen et al., 2019). This phenomenon can lead to the misclassification of hypertensive patients with normal blood pressure. Ten to 30% of patients with high blood pressure readings have experienced white-coat hypertension at healthcare facilities (Cohen et al., 2019). Guidelines in ABPM prohibit treatment when blood pressure readings are within the normal range outside the doctor’s office (Cohen et al., 2019). However, it is up to the healthcare provider and the patient to monitor the blood pressure readings for early detection.

On the other hand, masked hypertension occurs when the blood pressure readings are expected when the patient is at the doctor’s office but rises when the patient is at home (Aung & Htay, 2019). Masked hypertension occurs in more than 20% of people with untreated hypertension (Aung & Htay, 2019). Furthermore, masked hypertension carries the same risk as sustained hypertension and should be managed with hypertension medications. Lastly, sustained hypertension occurs when blood pressure readings are high at the doctor’s office and home. Sustained hypertension increases the occurrences of heart and kidney diseases. Detection and management of hypertension, ambulatory blood pressure monitoring was used to determine the efficacy of various antihypertensive medications used to control hypertension (Aung & Htay, 2019). By monitoring blood pressure readings throughout the day and night, healthcare providers can determine if the prescribed hypertensive drugs have effectively controlled high blood pressure. As a result, a healthcare provider can make patient decisions such as increasing the dosage or using additional medications to manage blood pressure. Additionally, ambulatory blood pressure monitoring aids in the prediction of the likelihood of heart diseases. Since hypertension is linked to heart diseases and organ damage, data from ambulatory blood pressure monitoring can be used for the predictive analysis of such outcomes (Miao et al., 2020).

According to Seals et al. (2019), aerobic exercise involves cardiovascular conditioning and pertains to running, brisk walking, swimming, or even cycling. The variables, including aerobic exercise and blood pressure readings, were used as the key indicators in the analysis software. Saco-Ledo et al. (2020) conducted a systematic review and meta-analysis. The authors claimed that ambulatory blood pressure (ABP) is a better predictor of cardiovascular disease and mortality in adult hypertensive populations. The studies used included 910 participants diagnosed with hypertension and were exposed to aerobic exercises for eight to 24 weeks, spread out throughout the weeks as three to five sessions each week. Within 24 hours of being subjected to aerobic exercises, there were significant reductions in participants’ DBP and SBP {diastolic BP, −3.0 mm Hg [−5.4 to −0.6], systolic BP, −5.4 mm Hg; [95% CI, −9.2 to −1.6]} The assessment of the DBP and SBP was done using a random-effects model, which posed no conflicts. Exercise had a substantial impact on lowering blood pressure throughout the day, including during the daytime (systolic BP, 4.5 mm Hg; [95 percent CI, 6.6 to 2.3]; diastolic BP, 3.2 mm Hg [4.8 to 1.5]), evening (systolic BP, 4.7 mm Hg [8.4 to 1.0]; diastolic BP. All the measures used on the patients subjected to aerobic exercises yielded significant benefits (p<0.05). The current research review demonstrates the measurable decreased outcome of exercise on blood pressure readings (Saco-Ledo et al., 2020).

The authors proposed walking with another aerobic exercise for people with high blood pressure to bring it down (Mandini et al., 2018). Physical activity has been emphasized as an essential component in managing cardiovascular diseases. Studies involving participants who practiced moderate to intensive exercises found that these participants experienced a low incidence of cardiovascular diseases. These participants experienced overall improved health outcomes. Additionally, large-scale population studies show that participants with a 15-minute daily exercise routine experience a reduction in mortality due to cardiovascular issues by 15% (Muntner et al., 2020). Therefore, physical activity has physiological effects on participants’ cardiovascular systems. These activities improve vascular endothelial function and enhanced vasodilation during blood flow (Virani et al., 2020).

Additionally, physical activity reduces the resting heart rate due to a mechanism that increases parasympathetic tone (Whelton et al., 2018). A study found that aerobics exercises and physical activities increase vasculogenic by using endothelial progenitor cells (Severin et al., 2020). Lastly, physical activity has increased a person’s tolerance for ischemia and reperfusion injury. A study conducted in China found that the cardiovascular disease mortality rate has increased significantly by more than 50% from 1990 to 2009 (Seals et al., 2019). The increase in the cardiovascular disease mortality rate in China was attributed to its citizens’ lack of physical activity. Such studies indicate that physical activity is crucial in reducing cardiovascular disease incidences, whose risk factor is high blood pressure (Wang et al., 2019). Therefore, it was vital to perform research studies evaluating aerobic exercise’s effect on blood pressure management.

Aerobic exercises increase breathing, oxygenation, and heart rate during physical activities. As a result, aerobic exercises keep the heart, lungs, and circulatory system healthy (Shackelford, 2022). Research data credit aerobic exercises for improving cardiovascular health and lowering blood pressure. Additionally, aerobics exercises have been linked to regulating blood sugar, improving sleep, and boosting a person’s mood. An additional outcome of regular aerobics exercises is weight management (Shackelford, 2022).

Aerobic exercises have been recommended throughout Europe and America as part of the guidelines to reduce hypertension prevalence. It was cited that moderate-intensity aerobic exercises effectively reduce blood pressure readings in hypertensive patients (Anstey et al., 2021). Furthermore, these exercises can lower systolic and diastolic blood pressure in hypertensive patients of all genders (Anstey et al., 2021). The exercises are effectively attributed to reducing blood pressure levels for hypertensive patients in either stage one or pre-hypertension. However, existing studies report that exercise training disrupts the circulatory system (Chobufo et al., 2020). The research showed that exercise disrupts the balance between vasodilation and vasoconstriction. This research cited that exercise alters vasodilation and vasoconstriction-related cytokines such as nitric acid. These studies concluded that no evidence supports the hypothesis that exercise reduces blood pressure in hypertensive patients.

Furthermore, research on trimester exercise training shows no reduction in the participants’ blood pressure. The exception to the research on trimester exercise is participants with resistance hypertension (Forde et al., 2020). Therefore, this project was crucial in determining the degree to which aerobic exercises would impact ambulatory blood pressure in hypertensive patients.

In 2018, the percentage of U.S. adults aged 18 and over who met the 2008 federal physical activity guidelines for aerobic activity was 53.3% (95% confidence interval = 52.25%-54.27%) which was not significantly different from the 2017 estimate of 53.1% (Sakhuja et al., 2022). The American Heart Association (AHA) developed and released a program in 2019 called Exercise Within Reach for the public to use. This application used material already in the public domain and did not require permission to be used with patients. Walking aerobic exercise was what the study’s authors proposed for people who have high blood pressure as a means to bring it down (Mandini et al., 2018).

Regular physical exercise has been cited to reduce blood pressure in hypertensive patients. As a result, physical exercise has been widely recommended as part of the hypertension guidelines in the United States. Hypertensive patients are encouraged to participate in aerobic exercises daily. Aerobic exercises vary. The exercises can either be in the form of walking, jogging, or swimming. The hypertension guidelines recommend one of these exercises at least thirty to forty minutes daily (Shimbo et al., 2020). In normotensives, regular physical exercises have been recorded to have reduced the average systolic blood pressure levels by between 3 to 5 mm hg (Vaughan et al., 2022). On the other hand, diastolic blood pressure reduction is normotensives because physical exercise averages between 2 to 3 mm hg (World Health Organization, 2021).

However, there is limited research on the effects of exercise on resistant hypertension. Resistant hypertension is registered when there is a failure by the blood pressure to be regulated despite using three or more antihypertensive agents, including a diuretic. Therefore, resistant hypertension is resistant to drug therapy. It remains unclear whether the resistance of resistant hypertension to drug therapy applies to other alternative mechanisms, such as aerobics exercises. Additionally, the prevalence of resistant hypertension is challenging to verify.

In a study to test the hypothesis that an aerobic exercise program can reduce blood pressure, researchers conducted a randomized control trial (Williamson et al., 2022). Fifty subjects participated in the trials by carrying out treadmill exercises for eight to 12 weeks. Blood pressure was monitored day and night in addition to pulse wave analysis. Results showed that the treadmill exercises significantly decreased the participants’ systolic and diastolic blood pressure. Furthermore, increased physical performance resulted in unchanged arterial compliance and cardiac index. Therefore, these results show that physical exercises decrease blood pressure in hypertensive patients and should be used to manage resistant hypertension.

Saco-Ledo et al. (2020) conducted a systematic review of the study involving adults in three groups. The first group had participants with normal blood pressure. The second group contained participants with prehypertension symptoms. The last group contained participants with hypertension. The results from this study indicated that physical exercise caused a reduction in the blood pressure levels in participants with high blood pressure and a pre-hypertensive state.

Literacy Level.

Health literacy
determines the exchange of complex information among patients and healthcare providers. Low levels of health literacy are standard in healthcare. As a result, healthcare illiteracy affects managing conditions such as hypertension (Schillinger, 2020). The factors were attributed to low health literacy, such as cultural background, lack of educational resources and finances, dietary habits, lifestyle, and lack of awareness or access to health care (Schillinger, 2020). Education enables patients and every other individual the strength to understand their health conditions, manage, and seek treatment.

Additionally, low literacy levels were widespread among hypertensive patients. A study on the correlation between health literacy and health outcomes in hypertensive patients determined that patients with low literacy levels are likely to have limited knowledge and understanding regarding HTN self-management (Nerenberg et al., 2018). However, the study was inconclusive in determining whether the limited knowledge possessed by hypertensive patients with low literacy level clinical outcomes of blood pressure management.

In summary, it has been demonstrated that maintaining a healthy level of physical activity can reduce one’s blood pressure (BP) (Mandini et al., 2018). Patients with chronic diseases often find it challenging to manage their health conditions; they may require extended support to attain a quality of life by monitoring their BP, medication complaints, decreasing exacerbations with morbid and hospitalizations (Carey & Forsyth, 2022; Yatim et al., 2019). It is a predicting factor in treatment adherence for hypertensive patients.

Self-Efficacy.

In a study examining self-efficacy’s role in managing hypertension, 1,087 participants in two groups were used to conduct this research (Beaney et al., 2019). One group contained participants with hypertension, while the other group contained patients who did not develop hypertension. The two groups were examined using five factors to assess patient management with chronic conditions. The domains include daily activities, emotions, medication, and treatment.

The two additional factors used for the study were social interactions and symptoms. This study showed that the participants with hypertension reported challenges in managing day-to-day activities compared to the control group (Lurbe et al., 2016). Furthermore, participants with hypertension showed that self-efficacy influences the general quality of life for hypertensive patients. These results showed that self-efficacy predicts hypertensive patients’ physical and mental health.

Lifestyle Modification
.

Whelton et al. (2018), in their study on chronic disease self-management utilizing the Hypertensive Self-Management Education Protocol, disclosed that Approaches to Stop HTN (DASH), dietary sodium restriction, active participation in physical activity, moderation of alcohol consumption, cessation of smoking, and adherence to medication regimes to control BP (Schillinger, 2020). Self-medication has been tested to have improved in reducing PB through medication adherence, exercise, diet modification, and weight decrease (Million Hearts, 2021). Lifestyle modifications have been cited as having a direct impact on hypertension management. The American Society of Hypertension outlines the hypertension clinical guidelines (Unger et al., 2020). The clinical guidelines recommend incorporating aerobic exercises and reducing salt intake. Additionally, the clinical guidelines recommend no alcohol and smoking to reduce the risk of hypertension. Healthy diets for overweight or obese people have also been recommended.

Furthermore, the Dietary Approaches to Stop Hypertension (DASH) has been widely recommended for blood pressure management. The DASH diet is high in fruits and vegetables. It emphasizes incorporating whole grains, white meat, and low-fat dairy products. Additionally, the diet is low in fat, red meat, and processed foods such as sugary drinks and refined carbohydrates. The DASH diet aims to reduce weight and heart rate and lower the risk of diabetes. A recent study found that replacing carbohydrate intake with protein reduced blood pressure in hypertensive patients (Million Hearts, 2021). Therefore, the risk of cardiovascular diseases was reduced significantly.

The study by Saco-Ledo et al. (2020) with 910 participants diagnosed with hypertension were exposed to aerobic exercises for eight to 24 weeks, spread out throughout the weeks as three to five sessions each week. Within 24 hours of being subjected to aerobic exercises, there were significant reductions in participants’ DBP and SBP {diastolic BP, −3.0 mm Hg [−5.4 to −0.6], systolic BP, −5.4 mm Hg; [95% CI, −9.2 to −1.6]} The assessment of the DBP and SBP was done using a random-effects model, which posed no conflicts. Exercise has a substantial impact on lowering blood pressure.

In summary, the topic of lifestyle modification was selected because it is an intricate part of managing one’s blood pressure. The DASH diet is suggested to help an individual to select the proper fruits, vegetables, and meats to maintain the disease. The studies by Saco-Ledo et al. (2020) and Whelton et al. (2018) support implementing aerobic exercise in reducing hypertension.

New hypertension diagnostic criteria issued by the American Heart Association (AHA) call for a blood pressure reading of 130/80 millimeters of mercury (mmHg). According to the European Society of Hypertension, 140/90mmHg is the optimum threshold for defining hypertension. Saco-Ledo et al. (2020) suggested that hypertensive patients should be educated on aerobic exercise to maintain optimal blood pressure levels.

Chapter 2 discussed Lewin’s change model and Orem’s self-care deficit theory. Three significant concepts were examined in depth within the chapter. First, based on the theoretical foundations, it was expected that translating Saco-Ledo et al.’s (2020) research on aerobic exercise would significantly impact systolic and diastolic blood pressures when put into practice. Patients are encouraged to feel that their health can be restored or even enhanced before a health diagnosis, which is the core principle of the idea.

Through Orem’s self-care theory, participants must effectively alter their way of life to be self-efficacious. As part of the project’s goals, smokers and drinkers diagnosed with hypertension can stop engaging in these unhealthy habits. Three major themes were examined in depth in this chapter. The first was the prevalence of hypertension. The first theme on the prevalence of hypertension has three sub-themes related to measuring techniques for high blood pressure. The sub-themes include systolic blood pressure management, diastolic blood pressure management, and ambulatory blood pressure monitoring. Theme two was aerobics excise impact on blood pressure. This theme was subdivided into three sub-themes: pre-aerobic exercise, during aerobic exercise, and post- aerobic exercise states. The third theme is the effect of the exercise state. This theme was divided into sub-themes that influence the effect of exercise on blood pressure management. The sub-themes include health literacy, self-efficacy, and lifestyle changes.

Chapter 3 presented the project’s methodology, problem, and purpose statements. Other chapter segments included the project’s clinical question, design, population, and sample selection. The chapter examined the project’s data sources, validity and reliability, data collection and analysis procedures, and ethical considerations, followed by project limitations.

Due to the growing prevalence of hypertension (HTN) in the American adult population, this project focused on implementing aerobic exercise as translated from Saco-Ledo et al.’s (2020) research on aerobic exercise. Physical inactivity has been identified as one of the critical factors associated with the development of HTN; hence, numerous guidelines recommend increasing the uptake of physical exercises as a protective factor against HTN (Commodore-Mensah et al., 2018). One evidence-based strategy that can be used to combat HTN is implementing aerobic exercise. Several studies, such as Saco-Ledo et al. (2020) and Severin et al. (2020), emphasize the importance of physical activity and that it can help reduce HTN. The purpose of this quantitative, quasi-experimental quality improvement project was to determine if the translation of Saco-Ledo et al.’s research on aerobic exercise would impact systolic and diastolic blood pressures when compared to current practice among adult hypertensive patients in a primary care clinic in southwest Texas over four weeks. The independent variable was the translation of Saco-Ledo et al.’s (2020) research on aerobic exercise, and the dependent variable was the patient’s ambulatory blood pressure.

This project was implemented in four weeks utilizing a quasi-experimental design and quantitative methodology. Currently, at the project site, although medication management and other strategies are provided to the patients regarding HTN management, the ambulatory blood pressures of the HTN patients within the past three months continued to increase. After collaborating with the medical director, nurse manager, and several staff nurses, it was decided that implementing a translation of Saco-Ledo et al.’s (2020) research on aerobic exercise would benefit the patients.

Chapter 3 re-introduced the project’s topic, clinical question, and problem statement. Other chapter segments include the project methodology, design, and population sample/size. The data sources, their validity, and their reliability were discussed. The last portion of the chapter shares the data collection, analysis procedures, potential biases, and mitigation procedures. The conclusion provides a summary of Chapter 3 and a prelude to Chapter 4.

It was not known if or to what degree the translation of Saco-Ledo et al.’s (2020) research on aerobic exercise on aerobic exercise would impact systolic and diastolic blood pressures when compared to current practice among adult hypertensive patients. The affected population was adult patients diagnosed with hypertension. The county where the clinic is located corresponds with the latest health statistics from the Texas Health and Human Services Commission (2022). The county ranks 22nd in the United States with diagnosed HTN patients (Texas Health and Human Services Commission, 2022). The demographics highlight a diverse populace of Blacks (18.5%), Whites (28.9%), White-Hispanic (36.72%), Asians (6.9 %), and Latinos (8.98. %) (U.S. Census Bureau, 2020). The county has many individuals over 60 diagnosed with chronic diseases (UT Health Science Center at Houston, 2020). The adult age groups in the county ranged from 18 to 64, signifying the project’s actual participants.

A clinical question is developed from a problem or needs that could be examined and evaluated to provide useful evidence-based information (Leedy & Ormrod, 2020). The following clinical question guided this quantitative project: To what degree does the translation of Saco-Ledo et al.’s (2020) research on aerobic exercise impact systolic and diastolic blood pressures compared to current practice among adult hypertensive patients in a primary care clinic in southwest Texas?


The independent variable was the translation of Saco-Ledo et al.’s (2020) research using 30 minutes of aerobic exercise, and the dependent variable was ambulatory blood pressure using systolic and diastolic readings.

Once the project manager received permission from Grand Canyon University IRB and the project site, the project was implemented at a primary care clinic in four weeks (see Appendix A). A quasi-experimental design allowed assessment of the impact of the translation of Saco-Ledo et al.’s (2020) research using aerobic exercise on the patients’ systolic and diastolic blood pressures. Data were retrieved from the clinic’s electronic medical record four weeks before and after the implementation of the intervention. Convenience sampling was used for easier access to the patients and facility. The project manager referenced Saco-Ledo et al.’s (2020) research on aerobic exercise to educate one physician, two nurse practitioners, two registered nurses, and one medical assistant (see Appendix B). Permission was granted to translate the evidence in this project (see Appendix C).

The data collection process consisted of one sample. A patient identifier was assigned to each patient and organized according to the measurement period (pre or postimplementation). The project manager used numeric codes for all variables entered. Baseline coded as measurement period “1” and postimplementation coded as measurement period “2”. The statistician exported the data into IBM SPSS version 28 to evaluate the frequency counts and range scores and checked for missing data and outliers. The translation of Saco-Ledo et al.’s research on aerobic exercise was implemented, and its impact on the patient’s blood pressure was measured using the Oscar 2 Device ambulatory monitor. Blood pressures were imported automatically into the electronic record. Any hard copies of demographics or other information were collected daily and kept in the medical director’s office in a locked file cabinet.

The project manager was not involved with the HTN patients to reduce confirmation bias. This helped to ensure that pre-existing beliefs or opinions would be independent, allowing one to remain open-minded and consider all the data during the evaluation phase and analysis of the project. The inclusion criteria of the patients are adult patients 18 and older, diagnosed with HTN, current clinic patients, and can partake in physical activity with difficulties. The exclusion criteria are individuals with musculoskeletal disabilities, comorbidities that could affect the project results, and mental disorders.

A qualitative methodology was not appropriate for this project. The project manager did not focus on understanding the respondents’ behaviors, lived experiences, or feelings (Creswell & Creswell, 2018). The method is subjective and thematic, with the findings written using the subject’s words verbatim (Creswell & Creswell, 2018). Data is analyzed utilizing a coding technique that seeks themes and patterns (Creswell & Creswell, 2018). The results are shown in two or three columns using the patient’s words.
This method is time-consuming, and as a result, it is not suitable for a quality improvement project. Through the statistical analysis, the quantitative method helped establish the degree to which aerobic exercises could sustain reductions in BP in hypertensive patients.

A quasi-experimental design was selected for this project. This design allowed the project manager to compare the independent and dependent variables (Creswell & Creswell, 2018). The design was the most appropriate in evaluating the variables and determining the impact of the translation of Saco-Ledo et al.’s research using aerobic exercise on the patients’ blood pressures. The respondents were not randomly assigned to any group (Creswell & Creswell, 2018). The blood pressure (dependent variable) was measured two times during the data collection process (four weeks before and after the intervention).

A correlational design was not the most appropriate for this project. It is a non-experimental design where the independent and dependent variables are measured and assessed for their correlation relationship (Creswell & Creswell, 2018). Furthermore, the project manager cannot control the variables in correlational research design (Creswell & Creswell, 2018).

The data collection tool chosen was the clinical observation of outcomes, which entailed reviewing ABP measurements from the ABPM log of patients. The Oscar 2 device keeps a digital ABP log that can be retrieved to a computer to show a record of ABP measurements throughout the day and the 24-hour average calculated (SunTech Medical, 2021). This device also has an instruction manual on how it could be used for an ABP monitor. The digital ABPM data ensured accuracy and reliability since such information is devoid of errors that arise when self-reported data are utilized (Nwankwo et al., 2020).

The targeted population for this project consisted of American adults diagnosed with hypertension. An estimated 45% of American adults, about 116 million, are hypertensive (CDC, 2021). In Texas, the prevalence of hypertension is 35.1%. Hypertension is prevalent in the U.S. and is frequently found in African Americans, Whites, Hispanics, and Asian Americans (Million Hearts, 2021). The project population comprised hypertensive patients visiting a primary care clinic in urban Texas, which was the setting for this project. The clinic provides services to a diverse population but predominately sees minorities. Approximately 20 individuals were seen three times per week at this clinic.

Convenience sampling was employed to enroll patients. This form of selection entails selecting patients based on their accessibility and availability to participate (Creswell & Creswell, 2018). The healthcare staff at the clinic (registered nurse, nurse practitioner, medical assistant, and physician) implemented the project. Those who expressed interest in participating in the project were provided additional information for participation. The medical assistant/nurse called the patients highlighted on the daily log for the next day with hypertension. This individual was provided a brief description of the project and highlighted the patient’s name in blue (to let the healthcare providers know the patient was participating in the project). The minimum sample size was evaluated using G* Power software, version 3.1.9.2, using an alpha measure of 0.05, an effect size of 0.5, and a power of 80% computed the least number of patients needed for the project (n=10).

Patients were not required to sign an informed consent before participating in the project because this was a quality improvement project, not a research study. After a verbal presentation of the program by healthcare staff at the clinic after they were educated regarding the topic using a slide presentation. Patients were provided with an information sheet detailing the project’s purpose, the intervention, and the nature of their participation. Afterward, patients who expressed interest in participating in the project were told their information was de-identified. The clinic does not have an IRB, so a written process and Healthcare Insurance Portability and Accountability Act (HIPAA) waiver form were filled out and signed by responsible parties for Grand Canyon University’s IRB process. The confidentiality of patients was guaranteed by de-identifying the collected data. Patient de-identifiers were used instead of names. The inclusion criteria were being at least 18 years, having a HTN diagnosis, being a Texas resident, and independently seeking intervention to manage HTN, taking medications for HTN. Patients below 18 years, non-hypertensive, non-Texas residents, not taking HTN medication, and who cannot perform aerobic exercises were excluded from the project.

The Oscar 2 device was used to collect 24-hour ABP data from patients. This device was fitted to patients at the clinic. At the end of 24 hours, healthcare providers removed the device from the participants’ hands and stored them in the physician’s office for the day site. Data from Oscar 2 were downloaded into a password-secure computer, and de-identified
information was used to save them
. The healthcare providers took the 24-hour ABP measurements at two time points: baseline without aerobic exercise in week one and week four after the workout. These measurements were compared to determine if weekly aerobic exercise reduced the patient’s blood pressure.

The patients were instructed that they are expected to practice their walking at home three to five times weekly for 20 minutes and continue to take their antihypertensive medications. The patients were informed to continue their routine activities and method of communicating with their primary physician while on the project implementation. Participants tracked their involvement via a logbook during their non-clinic visit day (Mondays, Wednesdays, and Fridays) to show commitment. Those who had appointments during this time performed their exercise while waiting to be seen by the physician. In week four, the patients returned to the clinic to retake their ABP using Oscar 2 device. Participants ambulated around the clinic for 20 minutes wearing the Oscar 2 device. They were monitored for their walking, whether it was intense or moderate. The ABP measurements were taken after a 20-minute rest period by the staff.

The de-identified codebook was sent to an outside statistician not affiliated with the project using an encrypted email. The independent variable was the translation of Saco-Ledo et al.’s (2020) research on aerobic exercise, and the dependent variables were the systolic and diastolic blood pressure. Since the project design involved a matched sample with baseline and postimplementation BP data, paired samples t-tests were conducted to address the clinical question to determine if the levels declined after the intervention. Demographics were analyzed using descriptive statistics. The data were prepared using the Statistical Package for Social Sciences 28 (SPSS-28) for data analysis.

The following clinical question directed this quantitative project: To what degree does the translation of Saco-Ledo et al.’s (2020) research on aerobic exercise impact systolic and diastolic blood pressures compared to current practice among adult hypertensive patients in a primary care clinic in southwest Texas?


The independent variable was the translation of Saco-Ledo et al.’s (2020) research on aerobic exercise, and the dependent variables were the systolic and diastolic blood pressures. Descriptive data (such as age, gender, and ethnicity) was collected via the clinic’s electronic medical records. The ages were analyzed using the mean and standard deviation. The patients’ gender, ethnicity, and diagnosis were evaluated using frequency counts and percentages.

The data was retrieved from the clinic’s electronic medical records and inserted into a Microsoft Excel spreadsheet. A patient identifier was assigned to each patient and organized according to the measurement period (baseline or postimplementation). The project manager used numeric codes for all variables entered. The baseline was coded as measurement period “1,” and postimplementation was coded as measurement period “2”. The statistician exported data into IBM SPSS version 28 to evaluate the frequency counts and range scores and check for missing data and outliers.

The patients’ blood pressures (dependent variable) were analyzed using a paired sample
t-test in week four. The independent variable was nominal, and the dependent variable was ratio level variable (Schober & Vetter, 2019). This
t-test examines the mean scores taken from the same patients (Schober & Vetter, 2019). Furthermore, the test aligned with the quasi-experimental design, which allowed the project manager to assess the impact of the intervention using a translation of Saco-Ledo et al.’s (2020) research using aerobic exercise on the outcome of systolic and diastolic blood pressures in the targeted population. The level of statistical significance was set to .05 to indicate a
p-value of less than .05 and considered statistically significant.

There were no conflicts of interest because no entity funded the project. The principle of respect requires ensuring autonomy. Because this is a quality improvement project, no consent is required from the patients as it is voluntary. The principle of justice requires equally distributing the risks and benefits of the project, which was achieved by ensuring that all patients presenting with HTN were given a chance to participate so that they did not miss a potentially beneficial intervention. Beneficence is about doing good. This project evaluated a potentially beneficial intervention – aerobics exercises. Upon approval of the document by the chairperson and the committee, the proposal was submitted for academic quality review. The data has been kept following Grand Canyon University’s IRB guidelines (three years) (August 2025). The computer data will be destroyed using computer software (ERASER) and the hard copies via Iron Mountain documentation shredding company.

Limitations are circumstances or conditions that the project manager cannot control (Creswell & Creswell, 2018). The first limitation of this project was the use of the quasi-experiment design. The lack of randomization in the quasi-experimental designs hindered the ability to make causal connections between the observed outcome and the intervention implemented (Creswell & Creswell, 2018).

The third limitation was the limited time to conduct the project (four weeks). A cross-sectional project provides a snapshot of the intervention (Leedy & Ormrod, 2020). A longitudinal project would allow one to assess the obstacles, changes, and trends that occur over time (Leedy & Ormrod, 2020). Furthermore, an investigator could evaluate a chronological sequence of events, establishing causality (Leedy & Ormrod, 2020).

It was not known if and to what extent the translation of Saco-Ledo et al.’s (2020) research on aerobic exercise would impact systolic and diastolic blood pressures when compared to current practice among adult hypertensive patients. The project aimed to investigate how aerobic exercises could alleviate blood pressure in hypertensive adults. The independent variable for this project is the translation of Saco-Ledo et al.’s (2020) research on aerobic exercise for hypertensive patients. On the other hand, this project’s dependent variable is the patients’ blood pressure measurements measured using ambulatory blood pressure equipment, e.g., Oscar -2. The methodology used for this project was quantitative. A quantitative methodology was utilized because it allowed statistical analysis of numeric data collected for this project as blood pressure measurements. The project design is quasi-experimental, using the within-group design. A quasi-experimental design was selected as it is both ethical and practical for this project.

The dependent variable, ABP, was measured using the Oscar 2 device, which was compared during the baseline (pre-intervention) and postimplementation (week four). Participants were taken using convenience sampling. A normal sphygmomanometer was available as a secondary tool for measuring the patient’s blood pressure. The 10-item Brief Control Self Scale by Tagney et al. (2004) was used to assess and select patients who adhered to the aerobic exercise routine and took blood pressure measurements. The selection criteria for the patients involved adults with hypertension over the age of 18 visiting an urban clinic in southwest Texas. The methodology’s validity and reliability for this project depended on the tool used to measure the patient’s blood pressure. The Oscar 2 device produced valid and reliable results in measuring blood pressure. The patients were taught about the Oscar 2 device using the same manufacturer’s booklet enclosed in the device package.

Chapter 4 delivered the descriptive data of the patients, data collection, and analysis procedures. The project findings were displayed using figures, tables, and narrative forms. The last portion of the chapter summarizes the results and presents an introduction to Chapter 5.

The project site is a primary care clinic in urban Texas. A convenience sample of
n= 10 adult patients with HTN was enrolled in the project. Descriptive data were collected for age, gender, and race. Table 1 displays the descriptive data for age. The mean age was 56.50 (
SD = 7.92), ranging from 43 to 71.

Descriptive Data for Age

Note. M = mean;
SD = standard deviation

Gender and race are displayed in Table 2. Three males (30.0%) and seven females made up the sample (
n = 7, 70%). Race was 80.0% (
n = 8) African American, 10.0% (
n = 1) Hispanic, and 10.0% (
n = 1) Caucasian.

Note: n = count; % = percentage

This quality improvement project was implemented once approval was received from Grand Canyon University IRB and the clinic site. The following clinical question guided this quantitative project To what degree does the translation of Saco-Ledo et al.’s (2020) research on aerobic exercise impact systolic and diastolic blood pressures compared to current practice among adult hypertensive patients in a primary care clinic in southwest Texas?


The independent variable was the translation of Saco-Ledo et al.’s (2020) research on aerobic exercise, a nominal level variable, and the dependent variable was ambulatory blood pressure. The ambulatory blood pressures included systolic and diastolic blood pressures measured at a ratio level. The clinic’s electronic medical records were used to collect descriptive data (age, gender, and race). The age was analyzed using the mean and standard deviation. The patients’ gender and ethnicity were evaluated using frequency counts and percentages.

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

The patient’s systolic and diastolic blood pressures (dependent variable) were analyzed using paired sample t-tests. This t-test was chosen for statistical analysis because it examines the mean pressures taken from the same patients at two different measurement periods (Schober & Vetter, 2019). Furthermore, the test aligns with the quasi-experimental design, which allows the project manager to assess the impact of the intervention using a translation of Saco-Ledo et al.’s (2020) research on aerobic exercise on the outcome of systolic and diastolic blood pressures in the convenience sample. The level of statistical significance was set to .05 to indicate that a p-value of less than .05 was considered statistically significant.

Note. M = mean
; SD = standard deviation, **
p is statistically significant at 05 or less

A paired
t-test was conducted on diastolic blood pressure at baseline and postimplementation. The results are displayed in Table 4. The results showed a decrease in the mean diastolic BP level from pre (
M = 87.30,
SD = 11.19) to post (
M = 78.10,
SD = 8.45)
, t (9) = 2.56,
p = .031. The
p-value is less than .05, which indicates that the decrease in mean diastolic BP was statistically significant. Clinical significance was supported by the 9.20 mm Hg decline in the diastolic blood pressure after the intervention.

Note. M = mean
; SD = standard deviation, **
p is statistically significant at 05 or less

Data analysis was conducted on systolic and diastolic BP at pre and postimplementation. The paired
t-test results showed a
p-value of .001 for the systolic BP analysis and a
p-value of .031 for the diastolic BP analysis, indicating that the difference in mean pressures was statistically significant. The results also support the clinical significance of the project as reflected in a 26.50 mm Hb decline in the systolic and a 9.20 mm Hg decline in diastolic scores after the physical activity intervention.

This quality improvement project aimed to evaluate the impact of implementing a translation of Saco-Ledo et al.’s (2020) research using aerobic exercise on the patients’ systolic and diastolic blood pressures. The setting was a primary care clinic in southwest Texas. A convenience sample of
n = 10 adult patients with HTN was enrolled in the project. The mean age was 56.50 (
SD= 7.92), ranging from 43 to 71. There were three males (30.0%), and females made up 70.0% (
n = 7). The race was 80.0% (
n = 8) African American, 10.0% (
n = 1) Hispanic, and 10.0% (
n = 1) Caucasian.

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

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

The project manager, Medical Director, and clinic manager at the clinical site collaborated regarding the increased blood pressures noted within the past three months. The standard of care at the site was through medication management for their condition. Hence, a unanimous decision was made to utilize a new strategy, implementing the translation of Saco-Ledo et al.’s (2020) research on aerobic exercise to influence hypertensive patients.

Summary of the Project

This quality improvement project was conducted utilizing a quantitative methodology and quasi-experimental design in four weeks. Chapter 1 presented studies such as Adams 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 validated findings from the CDC (2021) and Million Hearts (2021).

Chapter 2 discussed Orem’s self-care deficit theory and Lewin’s change model were 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 in providing the patients with a transparent care plan. This helped the HTN patients to sustain an appropriate level of self-care (Orem, 1995).

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 implement the translation of Saco-Ledo et al.’s (2020) research on 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 impact of aerobic exercise became infused into the organizational culture and a daily habit in the healthcare providers’ clinical practice (Lewin, 1947).

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 the translation of Saco-Ledo et al.’s (2020) research on aerobic exercise on systolic and diastolic 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).

The staff consisted of one physician, two nurse practitioners, two registered nurses, and one medical assistant. They were educated regarding using aerobic exercise for 30 minutes using a slide presentation and provided a brochure explaining the process (Saco-Ledo et al., 2020). In week one, recruitment for the project occurred, with each patient being offered an information sheet that detailed the project’s purpose, benefits, and risks. Patients were given knowledge about the HIPAA waiver form and their voluntary participation in the project. The patient’s initial blood pressure was taken with an Oscar 2 device as the baseline measure, then the patient carried out the aerobic exercise workout in weeks two and three, and postimplementation blood pressure measurement was taken by the end of the fourth week.

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

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

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

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

Lewin’s change model was chosen to work with Orem’s self-care deficit theory. The model revealed how HTN patients and their healthcare providers are impacted by restraining forces (Lewin, 1947). The model consists of three phases: unfreezing, change (movement), and refreezing (Lewin, 1947). Unfreezing occurred once the project manager began the collaboration process with the medical director, nurse manager, and a few nursing staff to identify the problem (elevated ambulatory blood pressures over the past three months) and develop a plan (Lewin, 1947). The changing stage (movement) began when the project intervention involving the translation of Saco-Ledo et al.’s (2020) research using aerobic exercise was implemented (Lewin, 1947). The healthcare providers educated their patients using a patient-centered approach and monitoring them. Refreezing began integrating the intervention into the organization’s clinical practice until it became a habit (Lewin, 1947).

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

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

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

The third implication was 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.

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

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

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

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 confirmed the statistics found by the Centers for Disease Control and Prevention (2022) for Hispanics (39%) and Blacks (56%).

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

The second recommendation was to implement motivational interviewing in treating HTN patients. Approximately one-third of HTN patients obtain and sustain blood pressure control (Bischof et al., 2021). Motivational interviewing, created by Miller and Rollnick, focuses on a directive counseling and patient-centered strategy that promotes the individual’s desire to change (Bischof et al., 2021). Healthcare providers would follow the guidelines such as a) listening with empathy, b) being flexible with the patient’s resistance to change, c) resisting argumentation or confrontation, and d) encouraging optimism (Bischof et al., 2021). Using this approach could help to facilitate compliance with the HTN treatment.

The third recommendation was for clinicians to implement mobile apps and technology in educating their patients. For many patients, the discharge process consists of lots of information and terminology they need help understanding. Utilizing their smartphones or tablets could make a difference in receiving and understanding the information without pressure or embarrassment regarding their health literacy level. The education would be given in short intervals (four weeks or less) with messages sent to the patient once a week or more dependent on the patient’s need (Timmers et al., 2020).

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

Adams, J., & Wright, J. (2020). A national commitment to improve the care of patients with hypertension in the U.S.
Journal of the American Medical Association, 324(18), 1825-1826. https://doi.org/10.1001/jama.2020.20356

Saco-Ledo, G., Valenzuela, P., Ruiz-Hurtado, G., Ruilope, L., & Lucia, A. (2020). Exercise reduces ambulatory blood pressure in patients with hypertension: A systematic review and meta-analysis of randomized controlled trials.
Journal of American Heart Association, 15(9), 1-18. https://doi.org/10.1161/JAHA.120.018487

Discuss at least two other theories (one nursing and one change theory) that you could have used instead.

Compare and contrast theories used to those analyzed. Using hindsight, discuss which theories (Nursing and Change) would be the be to support your project and why?

Use five to six scholarly, academic references to support your paper that are less than 5 years old.