Running head: CLINICAL QUESTION 1

Clinical Question (PICOT) Paper

Abigail R. Fish

Ferris State University

CLINICAL QUESTION 2

Abstract

This paper seeks to find concrete evidence to support the PICO question: Does telelmonitoring

blood pressure in African Americans with hypertension improve blood pressure control during

the first year of treatment compared to those who do not use telemonitoring? African Americans

are much more likely than any other race to develop hypertension and suffer health

complications related to uncontrolled blood pressure. Telemonitoring refers to individuals self-

monitoring their blood pressure at home, then transmitting the blood pressure readings over

existing telephone lines using a toll-free number. Articles will be reviewed to determine the

effectiveness of this potential treatment therapy for hypertensive African American patients. The

information found is supported by the ANA and their scope and standards of nursing practice.

Results show the implementation of in-home telemonitoring may promise to be an effective

technique to help manage uncontrolled blood pressure in combination with medications and

healthy lifestyle changes.

CLINICAL QUESTION 3

Clinical Question (PICOT) Paper

Asking the right questions about patients or their conditions can often be a difficult skill

to learn, especially for new nurses. However, this concept is crucial in the evidence-based

practice critical thinking process. By developing a PICOT question, nurses are prepared to

implement the most current and valid evidence into their clinical skills. By using strategies such

as PICOT questions, healthcare professional’s communication and collaboration is enhanced, as

well as increases the satisfaction and safety of their patients. The purpose of this assignment,

according to Singleterry (2014), “is to reflect how nursing knowledge is disseminated for use in

personal and professional practice” (p. 11). If this kind of expertise is shared throughout a

facility, the teamwork and communication that results can be remarkable.

Clinical Problem

Developing a good clinical question can help patient treatment outcomes become more

effective and help healthcare providers obtain new knowledge to advance their practice along

with medical technology around the globe. This process requires research to gain the information

needed to reach these goals. According to Flemming (2007), “Clinical nursing problems selected

for inquiry are generally those encountered in nursing practice and those that deal with

modalities of patient care such as support, comfort, prevention of trauma, promotion of recovery,

health screening, appraisal and/or assessment, health education, and coordination of health care”

(p. 62). This involves the help of nurses by formulating a research question, understanding the

results, and implementing the research findings into their clinical practice. This collaboration

between health care providers and researchers increases the chance that the research conducted

will be relevant to practice (Flemming, 2007).

CLINICAL QUESTION 4

A clinical problem that nurses deal with on the regular is caring for patients with

hypertension. Studies have consistently reported a higher frequency of hypertension in African

Americans more than any other race. According to the American Heart Association (2013),

hypertension can lead to adverse health conditions such as damage to the heart or coronary

arteries, stroke, kidney damage, vision loss, erectile dysfunction, memory loss, retention of fluid

in the lungs, angina and peripheral artery disease (pp. 4-5). For this reason, nurses might wish to

gain more knowledge on blood pressure control during a patient’s course of treatment therapy. A

valid PICOT question might ask: Does telelmonitoring blood pressure in African Americans with

hypertension improve blood pressure control during the first year of treatment compared to those

who do not use telemonitoring? Nurse-managed telemonitoring can be an effective tool that

gives hope to African Americans facing difficulty receiving regular care to monitor their blood

pressure. They may struggle to find transportation to their appointments, may not have health

insurance, or could be in danger if they live in an area with a high crime rate. Telemonitoring

could possibly decrease barriers for these patients trying to receive follow-up care on their

hypertensive conditions.

The PICOT acronym can be used in many different clinical problems if the definitions

are first understood. Population (P) is the sample of subjects that will be studied. Intervention (I)

refers to the treatment or plan of care that will be given to the subjects within the study.

Comparison (C) can be described as the control group; this is the reference group that will be

compared to the group who obtained the treatment intervention that was used. Outcome (O) is

used to describe the results of the study that can be measured and used to determine the

effectiveness of the study. Finally, time (T) is defined as the duration that the data collection took

place (Riva, Keshena & Busse, 2012).

CLINICAL QUESTION 5

Preventing illness or getting patients back to their current state of health is one of the

main goals of health care providers, but improving patient quality and safety is also very

important. The improvement of these two elements can increase patient compliance and

hopefully promote their health. If a client senses that their feelings are being validated and their

best interests are being considered, they are more likely to become involved in their health. The

health belief model states that an individual’s perception of their health is based on areas such as

the severity of a potential illness, their susceptibility to that illness, the benefits of taking any

preventative action, and any barriers to taking action (Maville & Huerta, 2013, p. 42). By finding

an answer to this PICOT question, significant medication compliance could be possible, which

will keep hypertensive, African American patients safe. Uncontrolled hypertension is a serious

health problem and those suffering from it are not safe, because it could lead to unexpected

outcomes, such as a heart attack. If a nurse establishes a trusting relationship with a patient, they

are more likely to listen and take the time to learn how to control their hypertension with

medications and/or a healthy lifestyle. Education on their condition and what they can do to

manage it should be given in a way that the patient does not feel rushed or unable to ask

questions. This will lead to improved patient quality of care.

Methodology

Nurses have access to research findings at their fingertips and some have many years of

clinical practice behind them, adding to their level of knowledge and nurses intuition. There are

different ways to find nursing research, but it is very important that the credibility of the sources

is determined. The methodology used to search for evidence to answer this PICOT question

included searching for published literature in CINAHL and PubMed databases. The articles must

be written by nurses, the nurse-monitored telemonitoring on blood pressure must pertain to

CLINICAL QUESTION 6

nursing education, assessment or teaching and the research results must be implemented by

nurses. The main keywords used were: telemonitoring, telehealth, African Americans, blacks,

hypertension and synonyms relating to these keywords. The literature was searched for in

English and published between January 2007 and April 2014 (Clark, Smith, Taylor & Campbell,

2010, p. 1).

The use of nursing research is a crucial part of adapting the evidence into the clinical

practices they perform. According to Niewsiadomy (2012), for a source to give any significance

to the nursing profession it should be nursing research, which is the systemic, objective process

of analyzing the phenomena of importance to nursing. This can include studies that relate to

nursing practice, nursing education, nursing administration or studies about nurses themselves.

Nursing research is the systemic analysis designed to develop knowledge about issues that are

important to the nursing profession (p. 3). This allows nurses to gain evidence-based knowledge

that will guide their practice and improve the health and quality of each patient they encounter.

This is why it is important to obtain evidence solely from nursing research, since nurses have

specific duties, certain diagnoses, and closer relationships with their patients.

Levels of evidence must also be considered when determining the credibility of nursing

research. According to the AACN evidence-leveling system (2009), the highest level of evidence

is level A. This level includes meta-analyses of multiple controlled studies all related to a certain

action, intervention or treatment. A meta-analysis, or systematic review, is a type of research

where previously published studies are gathered and the results are reanalyzed to find the validity

of these preceding studies (p. 72). The higher the level of research, the more acceptable it is to

incorporate into the clinical setting and be used as evidence-based research. When searching for

an answer about the results of telelmonitoring blood pressure in African Americans with

CLINICAL QUESTION 7

hypertension during the first year of treatment, systematic reviews and random controlled trials

will be reviewed. Random controlled trials are the gold standard in research and systematic

reviews are an evidence level A. Anything less than a level D based on the AACN evidence-

leveling system will not be considered.

Discussion of Literature

Nurses must decide the appropriateness and adequacy of research for use in clinical

practice (Singleterry, 2014 p. 9). While searching for concrete evidence to answer questions, it is

crucial that nurses review peer-reviewed, nursing research with reliable levels of evidence. Three

articles will be reviewed to determine the answer to the PICOT question and to identify the

effectiveness of implementing these strategies into practice.

Article One

Article one, “Effects of nurse-managed telemonitoring on blood pressure at 12-month

follow-up among urban African Americans,” is a nursing research article because the authors all

have their Bachelor’s degree in nursing; some have obtained their Master’s and PhD. The article

comes from a nursing journal, Nursing Research, available through Wolters-Kluwer Health. The

study was also approved by an institutional review board. The purpose statement in this article is

to “test the hypothesis that individuals who participate in usual care plus blood pressure

telemonitoring will have a greater reduction in blood pressure from baseline to 12-month follow-

up than would individuals who only receive usual care” (Artinian, Flack, Nordstrom, Hockman,

Washington, Fathy & Jen, 2007, p. 312). This was easily found in the introduction of the article.

The research design used for the study was a random controlled trial, making it a level C

according to the AACN level of evidence (2009, p. 72). This level makes the design appropriate

and reliable.

CLINICAL QUESTION 8

Three hundred eighty-seven African American patients recruited from free blood

pressure screenings offered at community centers, thrift stores, drug stores, and grocery stores

located on the east side of Detroit were included in this study. (Artinian, et al., 2007, p. 315).

This is an appropriate sample size, considering any reliable study should generally include over

30 participants. Members of the trial did drop out throughout the year of the study without any

given reason. After starting the study some participants were not able to be reached for follow-

up, which could be due to attrition. The participants were divided into two groups, one receiving

enhanced usual care, which included scheduled visits to their physicians along with prescribed

medications. The second group received usual care as well as the telemonitoring, which was

implemented by registered nurses. The blood pressure monitor and telemonitoring link device

were brought to the patient homes and they were taught how to use them and the schedule to

report their blood pressures to the nurse.

The data for this study was collected by a 3-month, 6-month and 12-month follow-up

appointment. During these appointments, the participants from both groups took part in a 2-hour

interview process and a physical exam. The final results of the study showed a greater decrease

in systolic blood pressure in the telemonitored group than the enhanced usual care group reported

from the beginning of the study to the 12-month follow-up appointment. The telemonitored

intervention group also had a greater reduction in diastolic blood pressure compare to the

enhanced usual care group, however the differences were not highly significant. The nurse-

managed telemonitoring group experienced significant decreases in their hypertension during the

12-month period. This is a very encouraging outcome for those suffering from uncontrolled

hypertension. The results of this study are better than other studies that have tested other methods

to reduce blood pressure (Artinian, et al., 2007, p. 320).

CLINICAL QUESTION 9

Article Two

Article two, “Racial differences in two self-management hypertension interventions,” is

another research article used to answer the PICOT question. The authors of this article are

nurses. Although the article did not come from a nursing journal, it does contribute to nursing

care and the importance of nurses educating, assessing and teaching about the importance of

blood pressure control. The study took place at a university-affiliated medical center in North

Carolina, where the study was approved by an institutional review board. The purpose of this

study is to “to examine the effectiveness of 2 patient-directed interventions designed to improve

blood pressure control within white and African Americans” (Bosworth, Olson, Grubber,

Powers, & Oddone, 2011, p. 468.e2). The research design used was another randomized

controlled trial with six hundred thirty-six eligible participants, making this an evidence level C

according to the AACN level of evidence (2009) is a very reliable sample size in the gold

standard approach to obtaining research evidence (p. 72). The references used in this article are

all current and include some nursing research articles (Bosworth et al., 2011).

The participants were divided into four groups: usual care, behavioral phone intervention

alone, home blood pressure monitoring alone, or both tailored behavioral phone intervention and

home blood pressure monitoring. A baseline interview was conducted to determine each

participants age, race, socioeconomic status and level of education. Usual care was implemented

by primary care providers, the behavioral intervention included social support, dietary and

physical activity changes, and reduction of sodium intake. The home blood pressure monitoring

group received an arm monitor to obtain their own biweekly pressures. The combined group also

received a blood pressure monitor and received bimonthly phone calls from nurses who

CLINICAL QUESTION 10

discussed lifestyle changes. At 12 months, all intervention groups compared with usual care had

significantly lower mean diastolic blood pressures (Bosworth et al., 2011).

Article Three

Finally, article three, “Nurse-led disease management for hypertension control in a

diverse urban community: a randomized trial,” is also a nursing research article. The authors are

nurses and the study pertains to clinical practice of reduction in blood pressure, which is a

nursing based intervention. The article does not mention approval consideration by an

institutional review board. The purpose of the study is to “test the effectiveness on blood

pressure of home blood pressure monitors alone or in combination with follow-up with a nurse

manager” (Hebert, Sisk, Tuzzio, Casabianca, Pogue, Wang, & McLaughlin, 2011, p. 630). This

study design is a random controlled trial, just like the other articles reviewed, so it will also be a

level C according to the AACN’s level of evidence evaluation (AACN, 2009, p. 72).

Four hundred and sixteen African American patients from a community clinic and four

local hospitals in New York City with uncontrolled hypertension were the participants in this

trial. The patients were randomly selected for different study groups including a usual care

group, an in-home blood pressure monitoring group, and then a combination of in-home

telemonitoring and counseling sessions with a register nurse. The Hawthorne effect could have

taken place here, because in two of the groups, the nurses were coming into the patient homes. A

majority of the references used in this article were update within the past 5 years. The results of

the study concluded that there was a significant drop in systolic blood pressure in those who

were in the combined intervention group. However, the diastolic measurements were unchanged

(Hebert, et al., 2011).

Significance to Nursing

CLINICAL QUESTION 11

Based on the results from each study reviewed, the effects of telemonitoring prove to be

very promising in managing blood pressure control. If these evidence findings are implemented

into clinical practice, the quality and safety of hypertensive, African Americans could improve

significantly. According to the Quality and Safety Education for Nurses (QSEN, 2014), quality

improvement occurs when “data is used to monitor the outcomes of care processes and use

improvement methods to design and test changes to continuously improve the quality and safety

of health care systems” (para. 13). In this case, the data monitored was the drop in blood

pressures and which intervention-group each participant was included in. By examining the data

between each group, improvement methods can be designed to best suit the patient. In this case,

most participants benefited from the telemonitored therapy.

Safety is another valuable tool when considering patient care. Patient safety should be

held above all other nursing competencies, because nothing is more important than providing

safe, evidence-based care for patients to aid in health and healing. QSEN (2014), defines safety

as “minimizing the risk of harm to patients and providers through both system effectiveness and

individual performance” (para. 17). Patients with uncontrolled blood pressure are at risk for

unsafe health outcomes related to kidney damage, vision loss, angina or even death by a sudden

heart attack or stroke. By using resources such as telemonitoring devices in patient homes, these

risks can be significantly reduced. This treatment method can reduce the costs for urban African

Americans while still maintaining facility healthcare policies in regards to patient rights,

information and care.

The American Nurses Association has numerous standards of practice that all nurses are

expected to exercise in their daily care. Evaluation, Standard 6, is very crucial when determining

the results of an evidence-based trial. Results must not simply be taken for their word; the nurse

CLINICAL QUESTION 12

must also evaluate the effectiveness or danger it could have on the patient. Registered nurses can

collaborate with other health care providers to determine the most appropriate and safest way to

implement the intervention. (ANA, 2010, pp. 45 & 54). Standards 8 and 9 should also be

considered to manage blood pressure control. Standard 8 deals with Education, meaning nurses

must gain the new knowledge of a studies outcome, so they can educate hypertensive patients

about medications and proper use of the telemonitoring device. Finally, Standard 9 is related to

the importance of using evidence-based practice through research findings. When nurses change

care methods they must be backed up by recent knowledge to guide patient care, this will allow

nurses to deliver the most current practices to keep patients safe and improve their quality of care

(p.51).

While current evidence does show telemonitoring to be highly effective, more studies

could be performed. More random-controlled trials on this treatment therapy could appeal to

physicians with hypertensive, African American patients. This could cut down on healthcare

costs with the patients could monitor their own blood pressures and simply report them to a

nurse. This way, patients are being observed closely, but are also given more independence and

responsibility for their own health. This study does have the potential to be replicated, making it

possible to gain even more evidence-based research on the telemonitoring intervention.

CLINICAL QUESTION 13

References

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CLINICAL QUESTION 14

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