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Helping hypertensive clients help themselves: The nurse's role
108
HELPING HYPERTENSIVE CLIENTS HELP THEMSELVES: THE NURSE'S ROLE ANNE G. HEINE, R.N., B.S.N., F.N.P.
University of Missouri-Columbia Family Nurse Practitioner Program, Columbia, Missouri ABSTRACT Nurses have an important role in helping hypertensive clients accept, understand, and adhere to a therapeutic plan of self-care. This paper examines the nurse's role in helping hypertensive clients help themselves. Strategies include developing a therapeutic relationship, guiding, supporting, and teaching. The nurse can enhance the client-provider relationship by establishing a good rapport, being nonjudgmental, individualizing care, treating the whole person, and creating an effective clinic structure. INTRODUCTION Hypertension is an important public health concern. Approximately one in every five adults,~ or an estimated 60 million Americans, have this condition.2 Although high blood pressure can be controlled, the problem remains that half of all clients under treatment do not adhere to therapy a, 4 and a large number of hypertensive patients remain undetected and thus uncontrolled.5-9 Individuals with uncontrolled hypertension have the greatest risk for development of stroke, heart disease, and kidney failure,v, a0 Without proper treatment, life expectancy is reduced and morbidity and mortality are increased, resulting in an insurmountable cost in health-care dollars and human suffering.S, ~. ao-12 In response to this problem, many health-care professionals are combining their efforts to understand the causes of and methods to improve nonadherence to hypertension treatment regimens. Recently, the National High Blood Pressure Education Program formed an interdisciplinary group consisting of representatives from medicine, nursing, pharmacy, and health education to define the behaviors necessary to achieve blood pressure control? ~, 1, Their report
was a synthesis of current theory and practice on adherence-improving strategies. The three basic premises of this report were: (1) that the active participation of clients in their care favors successful blood pressure control; (2) that clients are ultimately responsible for their own care, and the health-care provider is responsible for helping clients make decisions about their care; and (3) that the client-provider relationship is critical in successful long-term blood pressure control, a4 These premises have been founded on research that supports active client involvement and collaboration with the health-care provider as the basis for improving adherence to therapeutic goals.1~21 Many healthcare professionals are incorporating this approach into their practice. Nurses constitute one group of health-care professionals who base theory and practice on the client's right and responsibility to selfdetermination and collaboration ~"--~' and thus are important resources in helping hypertensive clients help themselves. The purpose of this paper is to review the nurse's role in working with these clients and to discuss methods of assisting them~ Strategies to help clients adhere to a therapeutic regimen of self-care are reviewed. THE NURSE'S ROLE The value of nurses in improving client adherence to 9therapeutic blood pressure control has been widely discussedY, 25 Nurses have demonstrated their effectiveness in working with these clients through community health projects, public health clinics, and various hypertension programs. 5. 6. 9, ~. ag. 20. 2~-~ Since nurses are more "care" oriented and physicians more "cure" oriented, nurses provide an important aspect of care to these clients, who must adapt to the chronic nature of the disease.26 Nurses use education and counselling strategies to help these clients understand and accept their disease, leaving physicians more time to diagnose, treat, and manage more dit~cult clients. Together, physicians and nurses provide well-rounded, cost-effective care for hypertensive clients and increase the likelihood of successful long-term blood pressure control.Z,
PATIENT COUNSELLING AND HEALTH EDUCATION
109 Although some professionals use the terms "compliance" and "adherence" interchangeably, others, ineluding myself, observe a distinction: To comply means to yield to another's wishes and indicates that the client has no choice in the situation. On the other hand, to adhere means to hold closely to an idea or a course of action and indicates that the client may choose or negotiate a plan of care to fit the individual's own lifestyle.2~ This interpretation distinguishes the nurse's relationship with the client. Nurses view clients as active participants with the right and responsibility to perform their own self-care. Clients and nurses mutually agree on priorities and goals in this therapeutic relationship, thus improving the likelihood that clients will adhere to the desired self-care program. Clients are more likely to adhere to a plan they determine and agree upon than to comply with someone else's plan that does not meet their needs.
METHODS OF ASSISTING The goal of nursing is to help clients help themselves. When a client lacks the necessary knowledge, attitude, or skills to do so, the nurse assists that person through developing a therapeutic relationship, through guiding, through supporting, and through teaching him or her to overcome or learn to cope with the self-care deficit.az-~4
Developing a Therapeutic Relationship Developing a therapeutic relationship with the client is the first and the key component to positively affecting adherence behaviors. This entails establishing a good rapport with open, honest communication. Portraying a nonjudgmental attitude encourages clients to express their attitudes and concerns, facilitating appropriate assessment and interventions. ~, 3~ Development of this relationship affects all other interventions with the client. Elements to consider include individualizing care, treating the whole person, and utilizing techniques to improve the clinic structure. Through individualizing and negotiating the plan of care with the client, the nurse recognizes the client's power and responsibility to perform self-care. Although some clients prefer being passive recipients in care, most clients want active involvement in their care. ~8 The nurse needs to assess each client's expectations of this relationship and perceptions of his or her own contributions to care. Another consideration in developing a therapeutic relatignshi p is assessing and treating the whole person. The client is not an isolated being with only one need, to control high blood pressure, but with many needs that should be considered. The client may have other more important problems that need to be ad-
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dressed before progressing to the needs related to hypertension. Although these priorities may not be the nurse's choice, compromises are essential in successfully managing the hypertensive client. ~5 For example, the diagnosis and management of hypertension creates a socioeconomic problem for many of these clients. The cost of medication on a simple regimen of two drugs a day is approximately $200/year. Even the cost of insurance is twice as much as normotensives pay. al Since the majority of hypertensives are black men in low socioeconomic status, these individuals may have the biggest problem in attaining and maintaining adequate care, owing to other financial or social priorities. 2~ The nurse-client relationship must be one in which problems such as these can be openly discussed and solutions formulated. Other elements in developing an effective relationship involve techniques to "maprove the clinic structure. These include providing continuity of care, 29, as encouraging intervisit telephone contacts, 29 using verbal and written information to emphasize the importance of keeping regular clinic appointments, zx and decreasing the client's waiting time in the clinic, a7 These techniques convey an attitude of interest and concern in the client's welfare and promote a trusting, longterm relationship. This facilitates client satisfaction and improves the likelihood of maintaining successful long-term follow-up care/ The development of this therapeutic relationship provides the foundation for successfully implementing other methods of assistance. These include guiding, supporting, and teaching the client to make appropriate decisions, to reach acceptance of the disease, and to understand the therapeutic self-care regimen.
Guidance Guidance is a method whereby the nurse assists clients in making decisions and acquiring skills related to the therapeutic plan. The nurse provides clients with information on the various alternatives for treating hypertension and guides the clients in making choices that fit the individual's lifestyle. Various strategies can be incorporated into the care plan to help clients adhere to their therapeutic self-care. These include tailoring, medication recording, pill dispensers, contingency contracting, and use of community resources. With the client aware of treatment measures, a therapeutic plan can be negotiated and adherence-improving strategies incorporated. Since drug regimens are the least disruptive to preexisting lifestyle, they are frequently used as the first line of therapy/, 21. 29 The problem of adherence to taking medications occurs when the regimen requires several medications a day at different times. 1', ar. 37 Physicians need to consider this and preseribemedica-
110 tions that can be taken less frequently during the day. This decreases the time, the energy, and often the cost the client has to expend in adhering to the medication regimen. Clients will also appreciate the provider's consideration of the cost of medications when prescribing the most cost-effective drug possible. Techniques to help clients adhere to their medication regimens include tailoring, medication recording, and medication container with counselling. Teaching clients about their drugs should be an integral part of each technique. Tailoring refers to helping clients integrate taking medications into their daily routine. One must first identify where certain daily rituals are performed and then negotiate with the client to keep medications in those places and to take them just before performing the ritual. 16 This technique is reviewed during the clinic visit to ascertain its usefulness in helping the client adhere to the medication schedule. With medication recording, the client agrees to record on a calendar the medications and the doses taken and missed each day. 1~ This information is then reviewed at the clinic visit to disclose any problems or concerns the client may have, to revise medications and behavior as needed, and to reinforce the positive actions. It provides an opportunity to teach the client about the importance of the drugs, their side effects, and their expected results. The disadvantage of this technique is that it takes time and requires a motivated client to keep an accurate record. If medication recording is not appropriate, using special pill dispensers with counselling will help the client adhere to the medication regimen? s The special containers would be useful for some clients with difficult regimens who voice an interest, but the decision to use this technique should be made on an individual basis. Counselling and teaching the client about medications is essential and can be accomplished both verbally and with written information. Written information provides good reinforcement for verbal instructions, which are frequently forgotten once the client leaves the clinic. Clients also need to be informed about other self-care measures to control hypertension. Weight reduction, low sodium diet, regular exercise, stress reduction, smoking cessation, and alcohol regulation 11, 84, ~ 2 all have a place in treatment of hypertension, but they require changes in behavior, which are often difficult to accomplish. Time, motivation, and reinforcement are needed to modify one's lifestyle, and these measures are usually recommended as adjunctive therapy. When such behavior modification is desired, the nurse can use two methods to facilitate client adherence: contingency contracting and self-help groups.
Whichever method is chosen, the nurse needs to negotiate realistic short- and long-term goals to be accomplished by certain dates. When goals are achieved, positive reinforcement encourages further adherence to performing the desired behavior. Contingency contracting is a technique that evolved from behavior modification and reinforcement theory and has been successful in improving adherence. 18-z~ It involves negotiation between the client and the nurse on a specific behavior to accomplish and an appropriate reward to be given on successful completion of the contract. It is important that the client chooses goals that are appropriate and realistic. A copy of the contract is given to the client, reinforcing the agreement. Examples of self-help groups include Weight Watchers, Alcoholics Anonymous, exercise clubs, and tobacco-withdrawal clinics. The nurse must be aware of these and other community resources and recommend them to clients needing such help. In providing guidance, the nurse needs to furnish clients with enough information and to support them in making decisions regarding the therapeutic plan.
Support Providing support is necessary in helping clients adjust to the chronic nature of their disease, aT, 37 Nurses need to understand the stages of adaptation to a chronic illness and assess each client's progression through these stages. The five stages of adapting to a long-term illness are: (1) shock and disbelief, (2) developing awareness, (3) reorganization, (4) resolution, and (5) identity change. 1. 7 Nurses should recognize that counselling and teaching must be timely and consistent with the particular stage of adaptation. '~ There is a general consensus that clients need time to work through the diagnosis, as denial and anger are common in the early stages of the disease. '3. ,4 Thus before taking responsibility for controlling the disease, the client must first acknowledge it. Having acknowledged it and developed realization of the disease~ the client progresses to the reorganization phase, in which motivation and readiness to learn are at a peak. In this stage, educational interventions are most effective. Involving the family in counselling and educating the client is another strategy to facilitate adherence.~, s, :s. ~2. 4.~ This social and emotional support tends to increase self-confidence and reduce psychological and somatic stress, thereby lowering blood pressure. 46 In one survey, the majority of hypertensive clients expressed a need for a family member to learn more about their disease, and approximately one third of these clients received no family support? By encouraging family participation, the nurse facilitates
PATIENT COUNSELLING AND HEALTH EDUCATION.
111 learn on their own about their disease and its management at times when they may be most interested in learning. Teaching clients to monitor their own blood pressure has been found to improve adherence to therapeutic self-care.", ~ Using blood pressure charts with well defined goals helps motivate clients to achieve therapeutic control. Family members can also be taught to take blood pressures to reinforce the clients' skills. These interventions are used according to the individual client's desires and needs. Research has yet to determine which clients benefit most from this selfmanagement technique.
an important link to the client's environment, providing a source of support and reinforcement. Without this, a valuable resource is lost for helping the client cope with the physical and emotional aspects of the disease and its treatment. Teaching Without knowledge of the disease and its treatment, clients fail to adhere to a therapeutic regimen? It is essential, therefore, that clients be provided some form of education to help them appreciate the benefits of long-term treatment. 2s," Most researchers agree that knowledge is essential for adherence, but knowledge alone does not necessarily mean the client will perform therapeutic self-care,a, 2. 7. 2o, 4s Likewise, education needs to be combined with other motivational strategies to help clients make the necessary -adaptations in controlling hypertension. Misconceptions about the disease must also be assessed and corrected. Most individuals are asymptomatie at the time of diagnosis and do not understand the importance of treatment. 7, xo, xr. ~6, z7. 43. 47 Other clients may feel worse on medications than they did before treatment and discontinue therapy? ~ Thus the need for continuing treatment must be clarified so clients can adequately meet their self-care demands. Various educational strategies are useful in conveying information to clients. Whatever method is chosen, the nurse needs to incorporate principles of teaching and learning into practice. Nurses must remember that clients can block teaching that is too threatening or too stressful to handle. Thus selective listening occurs, allowing clients to accept only certain information.35 Through assisting the client to cope with the disease and related problems, the nurse will help the client reach a stage of readiness to learn and to accept facts about the disease and its treatment. Continuous feedback is essential to assess the client's understanding and acceptance so reinforcement can be provided. Educational strategies include individual, group, and self-care instruction. Kochar and Daniels 7. 46 recommend individual, personalized educational interventions to convey information and support. In this way, clients progress at their own rate, and the education is tailored to their needs. Group education has also proved effective?, 2.~,45. 47 It allows for peer support, sharing of similar problems and concerns, and saving the professionals' time. Depending on the individual client, the demand, and the resources, both methods can provide an effective route for educating clients to effectively manage their disease. Another educational strategy is self-instruction. Creating a self-care library with audiovisual equipment, pamphlets, and books allows individuals to
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CONCLUSION Nurses play an important role in helping hypertensive clients accept, understand, and perform therapeutic self-care to control high blood pressure. The key to accomplishing this is through the encouragement of active client participation and mutual negotiation in the plan of care. In this way, the clients' priorities and needs are considered rather than the nurse's, thus increasing the likelihood of their adhering to the therapeutic regimen. What motivates human behavior seems to be the key question in understanding clients' adhering to a therapeutic self-care regimen. Behavior modification strategies have been shown to be effective, but research is needed to examine their long-term effectiveness and identify the particular clients for whom these strategies work best. Teaching and supporting clients to accept and understand their disease is a major challenge. Nurses need to determine what methods of teaching are the most effective and what factors facilitate o r hinder the adaptation of clients to their illness. All health-care professionals working with hypertensive clients need to seek ~olutions to the problems of adherence in performing therapeutic self-care to achieve better control of hypertension through effective self-management.
REFERENCES 1. Ackerman AM. Patient education and its relevance to compliance. In: Alderman MH, ed. Hypertension, the nurse's role hz ambulatory care. New York: Springer Publishing Co., 1977; 110-119. 2. Levy RI, Ward GW. What does the public know about high blood pressure? A m Pharm 1979; 19:39. 3. Baile WF, Gross RJ. Hypertension: Psychosomatic and behavioral aspects. Primary Care 1979; 6:267. 4. Webb PA. Effectivenessof patient education and psychosocial counseling in promoting compliance and control among hypertensivepatients. J Fam Pract 1980; 10:1047. 5. Alderman MK. Self-responsibilityin health care/promotion: Motivational factors. J School Health 1980; 10 (January) : 22.
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112 6. Breitmaier E. May is hypertension month. N1 Nurse 1980; 10:9. 7. Kochar MS, Daniels LM. Hypertension control for nurses and other health professionals. St. Louis: C. V. Mosby Co., 1978. 8. Levine DM, Green LW, Deeds SG, et al. Health education for hypertensive patients. I A m Med Assoc 1979; 241:1700. 9. Wyka CA, Levesque PG, Ryan SL, Mattea FA. Group education for the hypertensive. Cardiovasc Nurs 1980; 16:1. 10. Cunningham RM. Keeping them well is good business too. Hospitals 1979; 53:94. I1. Brackett NC. Drug compliance: Some aspects of improving compliance with therapy in the hypertensive patient. J SC Med Assoc 1980; 76:54. 12. Veterans Administration Cooperative Study Group on Antihypertensive Agents. Effects of treatment on morbidity in hypertension: II. Results in patients with diastolic blood pressures averaging 90 through 114 mm Hg. J A m Med Assoc 1980; 213:1143. 13. Deeds SG, Bernheimer E, McCombs NJ, et al. Patient behavior for blood pressure control. J A m Med Assoc 1979; 241:2534. 14. McCombs J, Fink J, Bandy P. Critical patient behaviors in high blood pressure control. Cardiovasc Nurs 1980; 16:19. 15. Bloom JR, Jordon SC. From screening to seeking care: Removing obstacles in hypertension control. Prey Med 1979; 8:500. 16. Sackett DL, Haynes RB, Gibson ES, et al. Patient compliance with antihypertensive regimens. Patient Couns Health Educ 1978; 1:18. 17. Sackett DJ. Compliance with antihypertensive therapy. Can 1 Pub Health 1980; 71:153. 18. Schulman BA. Active-patient orientation and outcomes in hypertensive treatment. Med Care 1979; 17:267. 19. Steckel SB, Swain MA. Contracting with patients to improve compliance. Hospitals 1977; 51:81. 20. Steckel SB, Funnell MM, Dragovan A. How nursing care can increase patient adherence rather than patient compliance. In: Clinical and scientific sessions. Kansas City: American Nurses' Association, 1979; 345-349. 21. Tabala J, Niemila N, Rosti J, Sievers K. Improving compliance with therapeutic regimens in hypertensive patients in a community health center. Circulation 1979; 59:540. 22. Joseph LS. Self-care and the nursing process. Nuts Clin North A m 1980; 15:131. 23. Orem DE, ed. Concept formalization in nursing. 2nd ed. Boston: Little, Brown, and Co., 1979. 24. Orem DE. Nursing: Concepts of practice 2nd ed. New York: McGraw-Hill Book Co., 1980. 25. Brown E, Bloom JR. The nurse practitioner in a hypertension control program. Nurse Practitioner 1978; 3 (May/June) : I0.
26. Coleman VM. New models--algorithms for high blood pressure. In: Alderman MH, ed. Hypertension: The nurse's role in ambulatory care. New York: Springer Publishing Co., 1977; 128-137. 27. Daniels L, Filenius J, Sowinski N, et al. How can you improve patient compliance? Nursing 1978; 8:40. 28. Digan MB, Kazanowski A. Community based patient education program. Health Educ 1978; 9:10. 29. Grancio SD. Strategies for patient education. Mass Nurse 1979; 48:4. 30. Hill MN, Reishgott MJ. Achievement of standards for quality care of hypertension by physicians and nurses. Clin Exp Hypertens 1979; 1:665. 31. Kostas G. The hypertension diet education program for public health nurses. I A m Dietet Assoc 1980; 77:570. 32. Mitchell ES. Protocol for teaching hypertensive patients. A m J Nuts 1977; 5:808. 33. Sr CS. Hypertension: Common questions patients ask. A m J Nurs 1980; 80:926. 34. Weiss SM. Biobehavioral approaches to the treatment of hypertension. I SC Med Assoc 1980; 76 (suppl): 38. 35. Eliopoulos C. Chronic cam and the elderly: Impact on the client, the family, and the nurse. Top Clin Nuts 1981; 3:71. 36. Todd B. Twenty-seven reasons people don't take their meds. R N 1981; 44:54. 37. Ryan C. Controversies in the treatment of hypertension. Compr Ther 1980; 6:65. 38. Rehder TL, McCoy LK, Blackwell B, et al. Improving medication compliance by counseling and special prescription container. A m J Hosp Pharm 1980; 37:379. 39. Dustan HP. Obesity and hypertension. Compr Ther 1980; 6:29. 40. Fairchild C. Hypertension counseling. Occup Health Nurs 1979; 27:25. 41. Margie JD. Dietary management of the patient with hypertension. 1 SC Med Assoc 1980; 76 (suppl): 21. 42. Williams RL. National conference on high blood pressure control. A m Pharm 1979; 19:40. 43. Himmelhoch A. Patient adherence in the treatment of hypertension. Aust Faro Physician 1980; 9:229. 44. O'Brian E. If I had hypertension. Br Med J 1978; 1:1469. 45. Bowler MH, Morisky DE, Deeds SG. Needs assessment strategies in working with compliance issues and blood pressure control. Patient Couns Health Educ 1980; 2:22. 46. Daniels LM, Kochar MS. What influences adherence to hypertension therapy. Nuts Forum 1979; 18:231. 47. Watson DS. Health education for hypertensive patients. Aust Faro Physician 1979; 8:315. 48. Sackett DL, Haynes RB, Gibson ES, et al. Randomized clinical trial of strategies for improving medication compliance in primary hypertension. Lancet 1975; 1:1205.
PATIFNT
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HELPING HYPERTENSIVE CLIENTS HELP THEMSELVES: THE NURSE'S ROLE ANNE G. HEINE, R.N., B.S.N., F.N.P.
University of Missouri-Columbia Family Nurse Practitioner Program, Columbia, Missouri ABSTRACT Nurses have an important role in helping hypertensive clients accept, understand, and adhere to a therapeutic plan of self-care. This paper examines the nurse's role in helping hypertensive clients help themselves. Strategies include developing a therapeutic relationship, guiding, supporting, and teaching. The nurse can enhance the client-provider relationship by establishing a good rapport, being nonjudgmental, individualizing care, treating the whole person, and creating an effective clinic structure. INTRODUCTION Hypertension is an important public health concern. Approximately one in every five adults,~ or an estimated 60 million Americans, have this condition.2 Although high blood pressure can be controlled, the problem remains that half of all clients under treatment do not adhere to therapy a, 4 and a large number of hypertensive patients remain undetected and thus uncontrolled.5-9 Individuals with uncontrolled hypertension have the greatest risk for development of stroke, heart disease, and kidney failure,v, a0 Without proper treatment, life expectancy is reduced and morbidity and mortality are increased, resulting in an insurmountable cost in health-care dollars and human suffering.S, ~. ao-12 In response to this problem, many health-care professionals are combining their efforts to understand the causes of and methods to improve nonadherence to hypertension treatment regimens. Recently, the National High Blood Pressure Education Program formed an interdisciplinary group consisting of representatives from medicine, nursing, pharmacy, and health education to define the behaviors necessary to achieve blood pressure control? ~, 1, Their report
was a synthesis of current theory and practice on adherence-improving strategies. The three basic premises of this report were: (1) that the active participation of clients in their care favors successful blood pressure control; (2) that clients are ultimately responsible for their own care, and the health-care provider is responsible for helping clients make decisions about their care; and (3) that the client-provider relationship is critical in successful long-term blood pressure control, a4 These premises have been founded on research that supports active client involvement and collaboration with the health-care provider as the basis for improving adherence to therapeutic goals.1~21 Many healthcare professionals are incorporating this approach into their practice. Nurses constitute one group of health-care professionals who base theory and practice on the client's right and responsibility to selfdetermination and collaboration ~"--~' and thus are important resources in helping hypertensive clients help themselves. The purpose of this paper is to review the nurse's role in working with these clients and to discuss methods of assisting them~ Strategies to help clients adhere to a therapeutic regimen of self-care are reviewed. THE NURSE'S ROLE The value of nurses in improving client adherence to 9therapeutic blood pressure control has been widely discussedY, 25 Nurses have demonstrated their effectiveness in working with these clients through community health projects, public health clinics, and various hypertension programs. 5. 6. 9, ~. ag. 20. 2~-~ Since nurses are more "care" oriented and physicians more "cure" oriented, nurses provide an important aspect of care to these clients, who must adapt to the chronic nature of the disease.26 Nurses use education and counselling strategies to help these clients understand and accept their disease, leaving physicians more time to diagnose, treat, and manage more dit~cult clients. Together, physicians and nurses provide well-rounded, cost-effective care for hypertensive clients and increase the likelihood of successful long-term blood pressure control.Z,
PATIENT COUNSELLING AND HEALTH EDUCATION
109 Although some professionals use the terms "compliance" and "adherence" interchangeably, others, ineluding myself, observe a distinction: To comply means to yield to another's wishes and indicates that the client has no choice in the situation. On the other hand, to adhere means to hold closely to an idea or a course of action and indicates that the client may choose or negotiate a plan of care to fit the individual's own lifestyle.2~ This interpretation distinguishes the nurse's relationship with the client. Nurses view clients as active participants with the right and responsibility to perform their own self-care. Clients and nurses mutually agree on priorities and goals in this therapeutic relationship, thus improving the likelihood that clients will adhere to the desired self-care program. Clients are more likely to adhere to a plan they determine and agree upon than to comply with someone else's plan that does not meet their needs.
METHODS OF ASSISTING The goal of nursing is to help clients help themselves. When a client lacks the necessary knowledge, attitude, or skills to do so, the nurse assists that person through developing a therapeutic relationship, through guiding, through supporting, and through teaching him or her to overcome or learn to cope with the self-care deficit.az-~4
Developing a Therapeutic Relationship Developing a therapeutic relationship with the client is the first and the key component to positively affecting adherence behaviors. This entails establishing a good rapport with open, honest communication. Portraying a nonjudgmental attitude encourages clients to express their attitudes and concerns, facilitating appropriate assessment and interventions. ~, 3~ Development of this relationship affects all other interventions with the client. Elements to consider include individualizing care, treating the whole person, and utilizing techniques to improve the clinic structure. Through individualizing and negotiating the plan of care with the client, the nurse recognizes the client's power and responsibility to perform self-care. Although some clients prefer being passive recipients in care, most clients want active involvement in their care. ~8 The nurse needs to assess each client's expectations of this relationship and perceptions of his or her own contributions to care. Another consideration in developing a therapeutic relatignshi p is assessing and treating the whole person. The client is not an isolated being with only one need, to control high blood pressure, but with many needs that should be considered. The client may have other more important problems that need to be ad-
TIIIIDI~
I'~1 I A D T I : D
I 1Q~tl
dressed before progressing to the needs related to hypertension. Although these priorities may not be the nurse's choice, compromises are essential in successfully managing the hypertensive client. ~5 For example, the diagnosis and management of hypertension creates a socioeconomic problem for many of these clients. The cost of medication on a simple regimen of two drugs a day is approximately $200/year. Even the cost of insurance is twice as much as normotensives pay. al Since the majority of hypertensives are black men in low socioeconomic status, these individuals may have the biggest problem in attaining and maintaining adequate care, owing to other financial or social priorities. 2~ The nurse-client relationship must be one in which problems such as these can be openly discussed and solutions formulated. Other elements in developing an effective relationship involve techniques to "maprove the clinic structure. These include providing continuity of care, 29, as encouraging intervisit telephone contacts, 29 using verbal and written information to emphasize the importance of keeping regular clinic appointments, zx and decreasing the client's waiting time in the clinic, a7 These techniques convey an attitude of interest and concern in the client's welfare and promote a trusting, longterm relationship. This facilitates client satisfaction and improves the likelihood of maintaining successful long-term follow-up care/ The development of this therapeutic relationship provides the foundation for successfully implementing other methods of assistance. These include guiding, supporting, and teaching the client to make appropriate decisions, to reach acceptance of the disease, and to understand the therapeutic self-care regimen.
Guidance Guidance is a method whereby the nurse assists clients in making decisions and acquiring skills related to the therapeutic plan. The nurse provides clients with information on the various alternatives for treating hypertension and guides the clients in making choices that fit the individual's lifestyle. Various strategies can be incorporated into the care plan to help clients adhere to their therapeutic self-care. These include tailoring, medication recording, pill dispensers, contingency contracting, and use of community resources. With the client aware of treatment measures, a therapeutic plan can be negotiated and adherence-improving strategies incorporated. Since drug regimens are the least disruptive to preexisting lifestyle, they are frequently used as the first line of therapy/, 21. 29 The problem of adherence to taking medications occurs when the regimen requires several medications a day at different times. 1', ar. 37 Physicians need to consider this and preseribemedica-
110 tions that can be taken less frequently during the day. This decreases the time, the energy, and often the cost the client has to expend in adhering to the medication regimen. Clients will also appreciate the provider's consideration of the cost of medications when prescribing the most cost-effective drug possible. Techniques to help clients adhere to their medication regimens include tailoring, medication recording, and medication container with counselling. Teaching clients about their drugs should be an integral part of each technique. Tailoring refers to helping clients integrate taking medications into their daily routine. One must first identify where certain daily rituals are performed and then negotiate with the client to keep medications in those places and to take them just before performing the ritual. 16 This technique is reviewed during the clinic visit to ascertain its usefulness in helping the client adhere to the medication schedule. With medication recording, the client agrees to record on a calendar the medications and the doses taken and missed each day. 1~ This information is then reviewed at the clinic visit to disclose any problems or concerns the client may have, to revise medications and behavior as needed, and to reinforce the positive actions. It provides an opportunity to teach the client about the importance of the drugs, their side effects, and their expected results. The disadvantage of this technique is that it takes time and requires a motivated client to keep an accurate record. If medication recording is not appropriate, using special pill dispensers with counselling will help the client adhere to the medication regimen? s The special containers would be useful for some clients with difficult regimens who voice an interest, but the decision to use this technique should be made on an individual basis. Counselling and teaching the client about medications is essential and can be accomplished both verbally and with written information. Written information provides good reinforcement for verbal instructions, which are frequently forgotten once the client leaves the clinic. Clients also need to be informed about other self-care measures to control hypertension. Weight reduction, low sodium diet, regular exercise, stress reduction, smoking cessation, and alcohol regulation 11, 84, ~ 2 all have a place in treatment of hypertension, but they require changes in behavior, which are often difficult to accomplish. Time, motivation, and reinforcement are needed to modify one's lifestyle, and these measures are usually recommended as adjunctive therapy. When such behavior modification is desired, the nurse can use two methods to facilitate client adherence: contingency contracting and self-help groups.
Whichever method is chosen, the nurse needs to negotiate realistic short- and long-term goals to be accomplished by certain dates. When goals are achieved, positive reinforcement encourages further adherence to performing the desired behavior. Contingency contracting is a technique that evolved from behavior modification and reinforcement theory and has been successful in improving adherence. 18-z~ It involves negotiation between the client and the nurse on a specific behavior to accomplish and an appropriate reward to be given on successful completion of the contract. It is important that the client chooses goals that are appropriate and realistic. A copy of the contract is given to the client, reinforcing the agreement. Examples of self-help groups include Weight Watchers, Alcoholics Anonymous, exercise clubs, and tobacco-withdrawal clinics. The nurse must be aware of these and other community resources and recommend them to clients needing such help. In providing guidance, the nurse needs to furnish clients with enough information and to support them in making decisions regarding the therapeutic plan.
Support Providing support is necessary in helping clients adjust to the chronic nature of their disease, aT, 37 Nurses need to understand the stages of adaptation to a chronic illness and assess each client's progression through these stages. The five stages of adapting to a long-term illness are: (1) shock and disbelief, (2) developing awareness, (3) reorganization, (4) resolution, and (5) identity change. 1. 7 Nurses should recognize that counselling and teaching must be timely and consistent with the particular stage of adaptation. '~ There is a general consensus that clients need time to work through the diagnosis, as denial and anger are common in the early stages of the disease. '3. ,4 Thus before taking responsibility for controlling the disease, the client must first acknowledge it. Having acknowledged it and developed realization of the disease~ the client progresses to the reorganization phase, in which motivation and readiness to learn are at a peak. In this stage, educational interventions are most effective. Involving the family in counselling and educating the client is another strategy to facilitate adherence.~, s, :s. ~2. 4.~ This social and emotional support tends to increase self-confidence and reduce psychological and somatic stress, thereby lowering blood pressure. 46 In one survey, the majority of hypertensive clients expressed a need for a family member to learn more about their disease, and approximately one third of these clients received no family support? By encouraging family participation, the nurse facilitates
PATIENT COUNSELLING AND HEALTH EDUCATION.
111 learn on their own about their disease and its management at times when they may be most interested in learning. Teaching clients to monitor their own blood pressure has been found to improve adherence to therapeutic self-care.", ~ Using blood pressure charts with well defined goals helps motivate clients to achieve therapeutic control. Family members can also be taught to take blood pressures to reinforce the clients' skills. These interventions are used according to the individual client's desires and needs. Research has yet to determine which clients benefit most from this selfmanagement technique.
an important link to the client's environment, providing a source of support and reinforcement. Without this, a valuable resource is lost for helping the client cope with the physical and emotional aspects of the disease and its treatment. Teaching Without knowledge of the disease and its treatment, clients fail to adhere to a therapeutic regimen? It is essential, therefore, that clients be provided some form of education to help them appreciate the benefits of long-term treatment. 2s," Most researchers agree that knowledge is essential for adherence, but knowledge alone does not necessarily mean the client will perform therapeutic self-care,a, 2. 7. 2o, 4s Likewise, education needs to be combined with other motivational strategies to help clients make the necessary -adaptations in controlling hypertension. Misconceptions about the disease must also be assessed and corrected. Most individuals are asymptomatie at the time of diagnosis and do not understand the importance of treatment. 7, xo, xr. ~6, z7. 43. 47 Other clients may feel worse on medications than they did before treatment and discontinue therapy? ~ Thus the need for continuing treatment must be clarified so clients can adequately meet their self-care demands. Various educational strategies are useful in conveying information to clients. Whatever method is chosen, the nurse needs to incorporate principles of teaching and learning into practice. Nurses must remember that clients can block teaching that is too threatening or too stressful to handle. Thus selective listening occurs, allowing clients to accept only certain information.35 Through assisting the client to cope with the disease and related problems, the nurse will help the client reach a stage of readiness to learn and to accept facts about the disease and its treatment. Continuous feedback is essential to assess the client's understanding and acceptance so reinforcement can be provided. Educational strategies include individual, group, and self-care instruction. Kochar and Daniels 7. 46 recommend individual, personalized educational interventions to convey information and support. In this way, clients progress at their own rate, and the education is tailored to their needs. Group education has also proved effective?, 2.~,45. 47 It allows for peer support, sharing of similar problems and concerns, and saving the professionals' time. Depending on the individual client, the demand, and the resources, both methods can provide an effective route for educating clients to effectively manage their disease. Another educational strategy is self-instruction. Creating a self-care library with audiovisual equipment, pamphlets, and books allows individuals to
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CONCLUSION Nurses play an important role in helping hypertensive clients accept, understand, and perform therapeutic self-care to control high blood pressure. The key to accomplishing this is through the encouragement of active client participation and mutual negotiation in the plan of care. In this way, the clients' priorities and needs are considered rather than the nurse's, thus increasing the likelihood of their adhering to the therapeutic regimen. What motivates human behavior seems to be the key question in understanding clients' adhering to a therapeutic self-care regimen. Behavior modification strategies have been shown to be effective, but research is needed to examine their long-term effectiveness and identify the particular clients for whom these strategies work best. Teaching and supporting clients to accept and understand their disease is a major challenge. Nurses need to determine what methods of teaching are the most effective and what factors facilitate o r hinder the adaptation of clients to their illness. All health-care professionals working with hypertensive clients need to seek ~olutions to the problems of adherence in performing therapeutic self-care to achieve better control of hypertension through effective self-management.
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112 6. Breitmaier E. May is hypertension month. N1 Nurse 1980; 10:9. 7. Kochar MS, Daniels LM. Hypertension control for nurses and other health professionals. St. Louis: C. V. Mosby Co., 1978. 8. Levine DM, Green LW, Deeds SG, et al. Health education for hypertensive patients. I A m Med Assoc 1979; 241:1700. 9. Wyka CA, Levesque PG, Ryan SL, Mattea FA. Group education for the hypertensive. Cardiovasc Nurs 1980; 16:1. 10. Cunningham RM. Keeping them well is good business too. Hospitals 1979; 53:94. I1. Brackett NC. Drug compliance: Some aspects of improving compliance with therapy in the hypertensive patient. J SC Med Assoc 1980; 76:54. 12. Veterans Administration Cooperative Study Group on Antihypertensive Agents. Effects of treatment on morbidity in hypertension: II. Results in patients with diastolic blood pressures averaging 90 through 114 mm Hg. J A m Med Assoc 1980; 213:1143. 13. Deeds SG, Bernheimer E, McCombs NJ, et al. Patient behavior for blood pressure control. J A m Med Assoc 1979; 241:2534. 14. McCombs J, Fink J, Bandy P. Critical patient behaviors in high blood pressure control. Cardiovasc Nurs 1980; 16:19. 15. Bloom JR, Jordon SC. From screening to seeking care: Removing obstacles in hypertension control. Prey Med 1979; 8:500. 16. Sackett DL, Haynes RB, Gibson ES, et al. Patient compliance with antihypertensive regimens. Patient Couns Health Educ 1978; 1:18. 17. Sackett DJ. Compliance with antihypertensive therapy. Can 1 Pub Health 1980; 71:153. 18. Schulman BA. Active-patient orientation and outcomes in hypertensive treatment. Med Care 1979; 17:267. 19. Steckel SB, Swain MA. Contracting with patients to improve compliance. Hospitals 1977; 51:81. 20. Steckel SB, Funnell MM, Dragovan A. How nursing care can increase patient adherence rather than patient compliance. In: Clinical and scientific sessions. Kansas City: American Nurses' Association, 1979; 345-349. 21. Tabala J, Niemila N, Rosti J, Sievers K. Improving compliance with therapeutic regimens in hypertensive patients in a community health center. Circulation 1979; 59:540. 22. Joseph LS. Self-care and the nursing process. Nuts Clin North A m 1980; 15:131. 23. Orem DE, ed. Concept formalization in nursing. 2nd ed. Boston: Little, Brown, and Co., 1979. 24. Orem DE. Nursing: Concepts of practice 2nd ed. New York: McGraw-Hill Book Co., 1980. 25. Brown E, Bloom JR. The nurse practitioner in a hypertension control program. Nurse Practitioner 1978; 3 (May/June) : I0.
26. Coleman VM. New models--algorithms for high blood pressure. In: Alderman MH, ed. Hypertension: The nurse's role in ambulatory care. New York: Springer Publishing Co., 1977; 128-137. 27. Daniels L, Filenius J, Sowinski N, et al. How can you improve patient compliance? Nursing 1978; 8:40. 28. Digan MB, Kazanowski A. Community based patient education program. Health Educ 1978; 9:10. 29. Grancio SD. Strategies for patient education. Mass Nurse 1979; 48:4. 30. Hill MN, Reishgott MJ. Achievement of standards for quality care of hypertension by physicians and nurses. Clin Exp Hypertens 1979; 1:665. 31. Kostas G. The hypertension diet education program for public health nurses. I A m Dietet Assoc 1980; 77:570. 32. Mitchell ES. Protocol for teaching hypertensive patients. A m J Nuts 1977; 5:808. 33. Sr CS. Hypertension: Common questions patients ask. A m J Nurs 1980; 80:926. 34. Weiss SM. Biobehavioral approaches to the treatment of hypertension. I SC Med Assoc 1980; 76 (suppl): 38. 35. Eliopoulos C. Chronic cam and the elderly: Impact on the client, the family, and the nurse. Top Clin Nuts 1981; 3:71. 36. Todd B. Twenty-seven reasons people don't take their meds. R N 1981; 44:54. 37. Ryan C. Controversies in the treatment of hypertension. Compr Ther 1980; 6:65. 38. Rehder TL, McCoy LK, Blackwell B, et al. Improving medication compliance by counseling and special prescription container. A m J Hosp Pharm 1980; 37:379. 39. Dustan HP. Obesity and hypertension. Compr Ther 1980; 6:29. 40. Fairchild C. Hypertension counseling. Occup Health Nurs 1979; 27:25. 41. Margie JD. Dietary management of the patient with hypertension. 1 SC Med Assoc 1980; 76 (suppl): 21. 42. Williams RL. National conference on high blood pressure control. A m Pharm 1979; 19:40. 43. Himmelhoch A. Patient adherence in the treatment of hypertension. Aust Faro Physician 1980; 9:229. 44. O'Brian E. If I had hypertension. Br Med J 1978; 1:1469. 45. Bowler MH, Morisky DE, Deeds SG. Needs assessment strategies in working with compliance issues and blood pressure control. Patient Couns Health Educ 1980; 2:22. 46. Daniels LM, Kochar MS. What influences adherence to hypertension therapy. Nuts Forum 1979; 18:231. 47. Watson DS. Health education for hypertensive patients. Aust Faro Physician 1979; 8:315. 48. Sackett DL, Haynes RB, Gibson ES, et al. Randomized clinical trial of strategies for improving medication compliance in primary hypertension. Lancet 1975; 1:1205.
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