Nursing Quality Improvement Project paper needs editing.
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RevisedAQR2.docxThe impact of a DASH (Dietary Approach to Stop Hypertension) on African American patients diagnosed with hypertension. Comment by Sharina Sigur: The impact of a DASH what? Diet? Or should this just be the impact of DASH? Comment by Sharina Sigur: The title should be typed in uppercase and lowercase letters. i.e. The Impact of a DASH (Dietary Approach to Stop Hypertension) on African American Patients…
Submitted by
Maurice D. Graham Comment by Sharina Sigur: Revisions to line spacing required on the preliminary pages. Revisions to page margins throughout the manuscript also required. Refer to the DPI Final Manuscript Template and revise. Comment by Sharina Sigur: Highly recommend you seek assistance from an editor/formatter. Several error notes throughout the manuscript.
Direct Practice Improvement Project Presented in Partial Fulfillment
of the Requirements for the Degree
Doctor of Nursing Practice
Grand Canyon University
Phoenix, Arizona
February 10, 2021
© Maurice Devon Graham, 2021 Comment by Sharina Sigur: This requires revisions. Refer to template.
All rights reserved
GRAND CANYON UNIVERSITY Comment by Sharina Sigur: Revisions to line spacing required.
The impact of a DASH (Dietary Approach to Stop Hypertension) has on African American patients diagnosed with hypertension.
by
Maurice Graham
has been approved
February 10, 2021
APPROVED:
Ira L. Martin, DNP, FNP-BC, DPI Project Chairperson
Michelle R. Buchanan (Carter), MD, Project Content Expert
ACCEPTED AND SIGNED
_________________________________________
Lisa Smith, PhD, RN, CNE
Dean and Professor, College of Nursing and Health Care Professionals
_________________________________________
Date
Abstract Comment by Sharina Sigur: Correct the spacing between these lines. Significant revisions required to abstract. Refer to templated abstract in DC Network for guidance and examples.
Background: Hypertension (HTN) is the leading preventable cause of premature death worldwide. In hypertensive individuals, lifestyle modification can serve as initial treatment before the start of drug therapy and act as an adjunct to pharmacological therapy in persons already on drug therapy. An obstacle that medical providers encounter in effectively managing HTN is the lack of dietary lifestyle modification counseling. At the project site there is no lifestyle modification protocol in use for patients diagnosed with HTN. The purpose of this quantitative quasi-experimental project is to determine to what degree the implementation of a DASH (Dietary Approach to Stop Hypertension) education program would impact patients’ blood pressures compared to no education among African Americans diagnosed with hypertension in an outpatient setting in Washington, D.C. Pender’s health promotion model will be used as the theoretical framework for this practice change project. Descriptive statistics was used with 20 participants with statistical and clinical positive results. The results showed in increase in participants knowledge about the dash, better food choices and a decrease in systolic and diastolic blood pressures. These results had a positive impact on the outpatient clinic with recommendations to continue using the DASH program. Future recommendation is to duplicate this project on a larger scale. Comment by Sharina Sigur: The first sentence or two outlines the problem, why is this being addressed? Do not make statements that require a citation as there are no citations in an abstract Comment by Sharina Sigur: Refer to templated purpose statement. Four week timeframe is missing. Comment by Sharina Sigur: Change verb tense to past tense throughout the manuscript. The project has been implemented and is complete. Comment by Sharina Sigur: What about the ACE Star Model described in chapter 2? Comment by Sharina Sigur: State the model or theory using the author and how it applies to the project ONE SENTENCE! Example: Prochaska and DiClemente’s transtheoretical model (TTM) was utilized to evaluate patient motivation to quit smoking and determine appropriate cessation interventions. Comment by Sharina Sigur: This is underdeveloped. Where are the results? Explanation of clinical significance and statistical significance is missing. Refer to templated abstract in the DC Network for guidance and for examples.
Keywords: DASH diet, African Americans, Education, Hypertension, blood pressure, pre-posttest. Comment by Sharina Sigur: Include theoretical model Comment by Sharina Sigur: This doesn’t appear to be a relevant keyword.
Table of Contents Comment by Sharina Sigur: The automatic TOC included in the template was not used. Significant revisions required.
Chapter 1: Introduction to the Project…………………………...……………………………………1
Background of the Project………………………………………...………………………………2
Problem Statement…………………………...……………………………………………………4
Purpose of the Project ……………………..………………………………………………………4
Clinical Question……………………………………………………………………………….....5
Advancing Scientific Knowledge…………………………………………………………………5
Significance of the Project………………………………………………………………………...7
Rationale for Methodology………………………………………………………………………..9
Nature of Design…………………………………………………………………………………10
Definition of Terms………………………………………………………………………………10
Assumptions, Limitations, Delimitation…………………………………………………………11
Chapter 2: Literature Review………………………………………………………………………...14
Theoretical Foundations………………………………………………………………………….15
Application to change……………………………………………………………………18
Star point 1: Discovery Evidence………………………………………………………..18
Star point 2: Evidence Summary………………………………………………………...18
Star point 3: Translation to Guidelines…………………………………………………..18
Star point 4: Practice Integration………………………………………………………...19
Star point 5: Evaluation………………………………………………………………….19
Review of the Literature…………………………………………………………………………20
Dash Diet………………………………………………………………………………...23
Patient Education………………………………………………………………………...28
Summary…………………………………………………………………………………………30
Advantages and Disadvantages of Findings……………………………………………..30
Utilization of Findings in Practice……………………………………………………….31
Chapter 3: Methodology……..………………………………………………………………………33
Statement of the Problem………………………………………………………………………...33
Clinical Question………………………………………………………………………………...34
Project Methodology…………………………………………………………………………….36
Population and Sample Selection………………………………………………………………...36
Instrumentation or Sources of Data………………………………………………………....…...37
Validity…………………………………………………………………………………………..37
Reliability………………………………………………………………………………………...37
Data Collection Procedures………………………………………………………………………38
Data Analysis Procedures………………………………………………………………………..39
Ethical Considerations…………………………………………………………………………...40
Limitations……………………………………………………………………………………….41
Delimitations…………………………………………………………………………….……….41
Summary…………………………………………………………………………………………42
Chapter 4: Data Analysis and Results………………………………………………………………..44
Descriptive Data…………………………………………………………………………………45
Data Analysis Procedures………………………………………………………………………..46
Demographics, Results and Findings……………………………………………………………47
Figure 1…………………………………………………………………………………..47 Comment by Sharina Sigur: Tables and figures are included on a separate page. Refer to template.
Figure 2…………………………………………………………………………………..47
Table 1…………………………………………………………………………………...48
Figure 3………………………………………………………………………………..…49
Figure 4……………………………………………………………………………….….49
Figure 5…………………………………………………………………………….…….50
Figure 6…………………………………………………………………………………..51
Figure 7………………………………………………………………………………..…51
Figure 8…………………………………………………………………………………..52
Table 3…………………………………………………………………………………...53
Table 4…………………………………………………………………………………...53
Table 5…………………………………………………………………………………...54
Summary…………………………………………………………………………………………55
Chapter 5 Summary, Conclusions and Recommendations…………………………………………..56
Summary of the Project………………………………………………………………………….56
Summary of Findings and Conclusions………………………………………………………….57
Implications………………………………………………………………………………………58
Theoretical Implications…………………………………………………………………58
Practice Implications……………………………………………………………………..59
Future Implications………………………………………………………………………59
Recommendations………………………………………………………………………………..60
Recommendations for Future Projects…………………………………………………...60
Recommendations for Practice…………………………………………………………..61
References ……………………………………………………………………………………………63
Appendix A…………………………………………………………………………………………..75
10 Point Strategic Points…………………………………………………………………………75
Appendix B…………………………………….………………...…………………………………..80
DASH diet Education Information………………………………………………………………80
Appendix C…………………………………...…………………………………………….………..81
Intake Survey Tool……………………………………………………………………………….81
Appendix D……………………………….………………………..………………………………...82
Statistics………………………………………………………………………………………….82
Appendix E……………………………….………………………………………………………….84
Food Frequency Questionnaire Approval………………………………….…………………….84
Appendix F………………………………………………………………………………………...…85
Food Frequency Questionnaire…………………………………………………………………..85
Appendix G…………………………………………..……………………………………………....90
DASH Diet Education Session Schedule……………………………………………...…………90
Appendix H…………...…..………………………………………………………………………….91
DASH Education Pamphlets…………………………………………………………….……….91
Appendix I……………………………………………………………………………….…………..92
IRB Approval…………………………………………………………………………………….92
Appendix J………………………………………………………………………………..………….93
Site Approval…………………………………………………………………………………….93
Appendix K…………………………………………………………………………………………..94
What Is My Project Design………………………………………………………………………94
2
Chapter 1: Introduction to the Project Comment by Sharina Sigur: Line spacing between paragraphs is formatted incorrectly. Significant formatting errors noted throughout manuscript. Refer to template and seek assistance from editorial services. Revise where needed throughout the manuscript.
A clinical practice change project will be designed and implemented to educate patients about a dietary approach to stop hypertension (DASH). This practice change project will increase patient’s knowledge and willingness for dietary change to reduce their blood pressures. Comment by Sharina Sigur: Revisions to verb tense required throughout the manuscript. This is no longer the proposal. Comment by Sharina Sigur: If referring to multiple patients, change to plural possessive (i.e. patients’).
According to the American Heart Association (AHA, 2015), hypertension is one of the leading health issues contributing to cardiovascular disease that is a leading cause of morbidity and mortality. Understanding that hypertension is a risk factor that can be modified, 54% of an estimated one million adults that are diagnosed with hypertension are poorly controlled (Center for Disease Control, 2017). Healthcare providers are at the forefront for counseling patients on preventive services (Jarl et al., 2014). Educating patients on a lifestyle modification, such as the DASH has demonstrated a proven strategy to reduce the blood pressures of patients diagnosed with hypertension. The literature strongly suggests that interventions are needed for adherence to the DASH diet among patients diagnosed with hypertension (Jarl et al., 2014).
Patients will be recruited from an outpatient clinic at a private historically black university in Washington, D.C. The participants will consist of African American patients between the age of 18 and 65 diagnosed with hypertension at a primary care clinic in Washington D.C. A pre-posttest designed by DASH will be utilized to gain knowledge of patients before and after the DASH education session, and the practice change will be guided by the Pender's health promotion model for change. Before and after the implementation of the DASH education session, the patients' blood pressures will be measured.
Health education can reduce chronic disease mortality and morbidity (Jarl et al., 2014). Although some studies describe how providers provide health education, few studies have examined how doctors, physician assistants, and nurse practitioners differ in health education delivery. Patients with chronic disease receive health education from physician assistants and nurse practitioners more frequently than physicians, but none of the three categories of clinicians consistently offered health education. Possible reasons include variations in preparation, different positions per form of provider within a clinic, or increased clinical demands on providers. More research is needed to understand the causes of these differences and potential opportunities to provide patients with condition-specific education (Ritsema et al., 2014).
Education meetings alone or in conjunction with other interventions can improve patients’ knowledge and increase patient outcomes. By using a pre-posttest questionnaire to evaluate needs, educators can develop programs that address the information needs and issues of learners more effectively and ultimately help patients (Ebell et al., 2011).
Background of the Project
African Americans are at an increased risk for developing HTN at an early age due to a gene that increases their sensitivity to salt (American Association for the Advancement of Science [AAAS], 2004; Rigsby, 2011). This population is disproportionately affected by HTN when compared to other ethnicities (Rigsby, 2011). As a result, African Americans with HTN have an increased rate of stroke (80%) and heart disease (50%) when compared to other ethnicities (AAAS, 2004). Asante (2015) reported that 84% of African Americans did not understand HTN and chronic diseases related to lack of therapy. Hypertension occurs when the force of the blood flowing through a person’s blood vessels is consistently too high (AHA, 2017). The Center for Disease Control [(CDC], 2018) defines normal blood pressure (BP) as a systolic B/P less than120 mmHg and diastolic B/P less than 80 mm Hg. Hypertension is the leading preventable cause of premature death worldwide (Mills et al., 2016). The principal health issues of four or more office visits to health care providers in the U.S. is for HTN with an estimated direct and indirect cost of $51.billion (CDC, 2019).
According to Healthy People 2020, their goal is to increase compliance and control of hypertension among adults from 43.7% to 61.2% by 2020. This initiative would take place with increased coordinated health promotion along with disease prevention to improve patients’ outcomes. (Healthy People, 2020). This would be a significant increase in controlled blood pressures compared to years 2005-2008 (Healthy People, 2020). Comment by Sharina Sigur: Citation must be included in sentence.
Adopting the DASH diet, a mixed diet of fruits, vegetables, nuts, whole grains, lean fish, poultry, and low-fat dairy foods, contributes to lower blood pressure (NHLBI, 2015). The diet requires reducing less saturated fat, total fat, and cholesterol. In a random control experiment, the diet decreased BP (Appel et al., 1997). Participants adopting the DASH diet systolic blood pressure decreased by an average of 7.7 mm Hg, and average blood pressure decreased by 3.6 mm Hg (Blumenthal et al, 2010). Comment by Sharina Sigur: iIf the name of the group first appears in parentheses, put the abbreviation in brackets after it, followed by a comma and the year for the citation. 1. Example: Children should learn about family finances in age-appropriate ways (American Psychological Association [APA], 2011). Comment by Sharina Sigur: Notice revision made here. Revise where needed.
According to Kim and Andrade (2016), there are major health issues contributed to non-adherence to dietary recommendations and that non-adherence rates are on the decline. There are many barriers that contribute to preventing patients from adhering to a healthy diet although the DASH has proven to reduced blood pressures among patients (Viera et al., 2007). Currently, there are barriers during office visits with patients, such as time restraints, that contribute to limited resources available to educate patients (Matyas et at., 2011). Another barrier would be motivating patients to modify their diets for better hypertension control (Samadian et al., 2016).
The primary objective of this DPI is to investigate if a DASH education intervention for patients would impact patient outcomes by reducing hypertension in African American patients at a primary health clinic in Washington, D.C. Comment by Sharina Sigur: Aim for three to five or more sentences per paragraph. Revise where needed.
Problem Statement
It is not known if or to what degree the implementation of a DASH would impact the patients’ blood pressures when compared to no intervention among African American patients diagnosed with hypertension in an outpatient clinic in Washington, D.C.
High blood pressure (HBP) prevalence in African Americans in the US is among the world's highest. Much of non-Hispanic African American men and women have high blood pressure. High blood pressure also occurs earlier in life and is typically more extreme for African Americans (Maraboto & Ferdianand, 2020). Comment by Sharina Sigur: According to what source? Include citation to support this statement and any other statements that require citations.
Uncontrolled hypertension (HTN) in the USA is particularly prevalent and devastating among Black people who are more vulnerable than people from other racial / ethnic groups to the effects of this disease. Moreover, the findings of many research studies in this population are frequently underrepresented in cardiovascular clinical trials, restricting their ability to accurately apply them. In this analysis, we summarize and examine the information that is currently available regarding risk factors, manifestations, complications and HTN management in this often difficult to treat population (Maraboto & Ferdiannand, 2020). This practice change project seeks to better understand to what degree of increasing patient’s knowledge on the DASH diet is a best approach for treatment of patients with hypertension (Maraboto & Ferdianand, 2020). Comment by Sharina Sigur: We? Who is this referring to? Is this a direct quote from Maraboto and Ferdiannand? If so, this is not formatted correctly.
Purpose of the Project Comment by Sharina Sigur: This section is underdeveloped. Refer to template and DNP DPI project guide for section requirements.
The purpose of this quantitative quasi-experimental project is to determine if or to what degree the implementation of a Dietary Approach to Stop Hypertension education intervention for patients would impact the patients’ blood pressure when compared to no intervention among African American patients diagnosed with hypertension in an outpatient clinic in Washington, D.C.
The independent variable will be defined as the implementation of a Dietary Approach to Stop Hypertension education for patients at a primary care clinic in Washington D.C. The dependent variable will be better management of patients diagnosed with hypertension measured by lowering their blood pressure.
Clinical Question Comment by Sharina Sigur: This section is underdeveloped.
To what degree does the implementation of a Dietary Approach to Stop Hypertension education intervention impact blood pressure of patients diagnosed with hypertension when compared to no intervention among African American patients in an outpatient clinic in Washington, D.C.? This practice change project will take place over a four-week period and aims to reduce the development and increase the management of HTN among African Americans.
The following clinical question guides this quantitative project:
CQ: Does the implementation of a Dietary Approach to Stop Hypertension education intervention impact African American patients diagnosed with hypertension at a primary health clinic in Washington, D.C. over a four-week period?
The independent variable will be defined as the implementation of a Dietary Approach to Stop Hypertension education session for patients that are diagnosed with HTN. The dependent variable will be the blood pressures measurements of patients identified in the QI project at a primary health clinic in Washington, D.C. over a four-week period.
Advancing Scientific Knowledge
This DPI will increase strategies to help patients control their blood pressure (BP) by lowering systolic and diastolic. The goal is to implement education programs for patients in the clinic setting to increase better hypertension management and increase patient outcomes. Dramatic improvement in public health could be gained from enhanced hypertension control (AHA, 2015). Effectiveness and implementation of the DASH intervention by providers will add to ways to effectively increase community efforts to achieve blood pressure control throughout the population and especially among African Americans.
The theoretical framework chosen for this DPI is the Nolan Pender’s health promotion model. According to Petirin (2015), Pender’s health model focuses on changing the unhealthy behaviors of patients and improving patient outcomes. This falls directly in line with educating patients about the use of a DASH diet by increasing their knowledge about dietary intake and the effects that it can have on their blood pressure. Pender’s model has the potential to change this behavior and improve patient outcomes by better management of their hypertension.
This DPI practice change project can further advance the Pender’s health promotion model by showing a successful hypertension management and control. Pender’s health promotion modes could be applicable as a theoretical framework to identify major determinants of adherence to hypertension control recommendations. Future findings of this DPI could possibly represent more legitimacy surrounding self-care practices in hypertension if there is a large enough sample size.
The conceptual-theoretical-empirical (CTE) structure is a system of nursing knowledge that requires attention to elements of substance and process as well as considerable thought, careful planning, and commitment to evidence-based practice that typically changes nursing practice and sets the standard for providing quality patient care (Fawcett & Desanto-Madeya, 2012). The project implementer (PI) will utilize the Health Promotion Model (HPM) by Nola Pender and the ACE Star Model of Knowledge Transformation to guide this project. Pender’s health promotion model (HPM) is one of the widely used models to plan for and change unhealthy behaviors and promote health (Petirin, 2015). Comment by Sharina Sigur: Models/theories are not capitalized in APA. Revise where needed. Comment by Sharina Sigur: This was not included in the abstract..
Using the health promotion model is more advantageous as compared to other strategies since the HPM does not only give findings of research but also aims at improving the health condition of patients and their families. For this DPI project, the primary goal is to provide an alternative way of HTN management with a DASH diet and lifestyle practices to reduce patients’ blood pressure. If the project is successful, it will help people diagnosed with HTN to manage the condition with dieting and exercises, which will enable them to live long, healthy lives.
Significance of the Project
African Americans are identified as a high-risk population for the treatment and management of HTN. This is a multifactorial problem that requires a comprehensive education and treatment program. There are disparities in health care and access to care in African Americans (AHA, 2017). To effectively treat and impact this population, an educational intervention aimed at diet and lifestyle modifications and HTN management is required. A multidisciplinary patient-centered medical approach that incorporates the healthcare provider, nurses, case managers, pharmacists, and dieticians will have the most significant impact on improving patient outcomes.
The significance of this DPI project is to increase patients’s knowledge and behaviors toward change to help reduce HTN cases among African Americans individuals who are at a higher risk of developing HTN. HTN does not always require medical intervention, and quantitative data has provided sufficient evidence that indicates the condition can be managed and prevented using other measures, such as dieting and change to healthier lifestyle practices. The DPI project will also help in the prevention of hypertension in the community and globally, which will significantly reduce the mortality of cardiovascular-related complications around the world.
Changing clinical practice is a challenging task, best demonstrated by the time gap between evidence and usage in practice and the widespread use of low-value treatment. Established frameworks concentrate primarily on obstacles to new information learning and implementation. However, improvements to clinical practice not only entail learning new practices, but also unlearning old and obsolete information. This DPI practice change aims to explain the experience of having to leave old dietary habits in the past and its association with new learning. When a change is introduced, whether through the introduction of new directives or self-imposed changes, patients face different struggles to successfully change their health management practices (Gupta et al., 2017).
Health associations encourage healthcare providers to engage in patients ' blood pressure management services (CDC, 2017). Lifestyle improvements include weight control, exercise, and diet guidelines for HTN management (Matyas et al., 2011). Because of lack of knowledge, many patients do not obey the guidelines. Education of patients regarding improvements in lifestyle may have a big influence on their confidence in DASH diet education regarding HTN, (Matyas et al., 2011). Kwan et al. (2013) reported that a lack of education is a common factor that patients do not adopt dietary education.
Lifestyle improvements with a heavy emphasis on dietary activity focus on the treatment of HTN based on CDC guidelines (2017). The EJNC (2014) has increased its focus on the shift in the lifestyle of hypertension prevention and treatment and listed the DASH diet on hypertension algorithm lifestyle medication. Comment by Sharina Sigur: ??
Rationale for Methodology Comment by Sharina Sigur: This section is underdeveloped.
The participants for this DPI project will be from a primary health clinic in Washington, D.C. The initial group will consist of individuals who are all from the primacy care clinic, African American and have been diagnosed with hypertension. The quantitative DASH education pre-post-test approach will be utilized in measuring before and after the education session for a DASH diet (Harrison, 2014). In addition, patients' blood pressure will be measured before and after provider to patient counseling of the DASH diet to see if there is a correlation between increasing patient knowledge and patient outcomes. Comment by Sharina Sigur: Rephrase for clarity.
The best approach for this DPI project is a quantitative pre-posttest to answer the clinical question. A pre-post-test by design covers will be used for the DPI project because it will cover all the topics which a participant will be learning for the DASH education sessions. While taking the pre-test at the beginning, patients are not expected to know the answers to all the questions; however, they should be expected to utilize previous knowledge to predict rational answers. When taking the same test called a post-test at the end of a DASH education, participants should be expected to answer more questions correctly based on an increase in knowledge and understanding. Comment by Sharina Sigur: Discussion related to project design belongs in the next section.
Investigators can assess reliability by comparing the answers respondents give in one pretest with answers in another pretest. Then, a survey question's validity is determined by how well it measures the concept(s) it is intended to measure. Both convergent validity and divergent validity can be determined by first comparing answers to another question measuring the same concept, then by measuring this answer to the participant's response to a question that asks for the exact opposite answer (Dimitrov & Rumrill, 2003).
Nature of the Design Comment by Sharina Sigur: This section is underdeveloped.
The focus for this quasi-experimental design DPI project is to administer a DASH five-question pre-and-post measuring patients’ knowledge before and after the DASH education to determine effectiveness. Everyone will be granted free access to the pre posttest tool; access and usage of the tool was not required. Guide for Effective Nutrition Interventions and Education (GENIE) developed by the Academy of Nutrition and Dietetics (AND) has been evaluated for its effectiveness (GENIE, 2019). GENIE is a validated online resource tool that offers evidence-based guidelines needed for the implementation of useful nutrition education programs (GENIE, 2019).
By using pre-post test questions to evaluate needs, educators can develop programs that address the information needs and issues of learners more effectively and ultimately help patients (Ebell et al., 2011).
For this DPI Project, patients diagnosed with HTN will be the main participants. They will be asked a series of questions to measure their knowledge of HTN and the DASH diet. This practice change project would broaden their knowledge on the best approaches regarding the effectiveness of a DASH diet thus improving patient outcomes with improved management of HTN. Patients’ blood pressures will be measured before and after the provider to patient DASH counseling and pre-posttest.
Definition of Terms
Below is a list of terminologies encompassed in the DPI project. It relates to providers educating patients on the adoption of the DASH diet to guide them in managing their hypertension.
Hypertension. Is blood pressure greater than 120/80 mm Hg. It is also known as high blood pressure and is responsible for increasing pressure on the blood vessels, (AHA, 2017).
Sodium. A major cation of extracellular fluid in human cells (Chobanian et al., 2003). Iodized sodium chloride is commonly known as salt and is used in food. It is found in many foods as it is essential for the nerve and muscle function in the human body.
Dietary Approach to Stop Hypertension (DASH). Designed to help treat, manage, or prevent hypertension. DASH diet is a meal plan that is designed to lower the blood pressure (Challa et al., 2020). The diet comprises fruits, vegetables, and low-fat dairy products.
Pender's Health Promotion Model. A health promotion model that defines health as a positive dynamic state instead of terming it as the absence of disease. It is also directed at enhancing a patient's level of well-being (Petirin, 2015).
Conceptual Theory Empirical. It is relative to the conceptual framework providing concrete and specific results through various theoretical frameworks derived from empirically tests from experiments (McConnel, 2015).
ACE Star Model of Knowledge. Describes five significant points in the transformation of knowledge into practice (Stevens, 2013). It begins at the top point where discoveries are made, and it serves as the focal point of the project.
Guide for Effective Nutrition Intervention and Education (GENIE). This is a qualitative tool used to design, modify, or compare effective nutrition education programs (GENIE, 2019). Comment by Sharina Sigur: Was this tool used in the project? This project must be quantitative, not qualitative.
Assumptions, Limitations, Delimitations Comment by Sharina Sigur: This section is extremely underdeveloped.
This DPI project assumes that all participants will answer the DASH pre and posttest questions truthfully. The participants will engage in the DASH educational program. Other assumptions are that all participants will answer DASH protest questions truthfully. Limitations are the population sample size and the use of only one primary care clinic for the DPI project. Additional limitations would be the use of a convenience sampling of 20 participants reducing the generalizability no control group and time frame to conduct DPI project may be short.
Delimitations include only using one primary care cline and all participants will be African American, no other ethnic group will be asked to participate in the DPI project. The outpatient clinic patient population is made up of 95% African American.
Summary and Organization of the Remainder of the Project Comment by Sharina Sigur: This section is underdeveloped.
In the United States, the prevalence of hypertension in blacks is among the highest in the world. Blacks develop hypertension at a younger age, their average blood pressure is much higher compared to whites, and they suffer worse severity of the disease (AHA, 2017). As a result, African Americans have 1.3 times higher rates of nonfatal stroke, 1.8 times higher rates of fatal stroke, 1.5 times higher rates of death from heart disease, 4.2 times higher rates of end-stage kidney disease, and 50% higher rates of heart failure; overall, hypertension mortality and its effects are four to five times more common in African Americans than in whites (CDC, 2015). A combination of genetic and most likely, environmental factors is responsible for the increased prevalence of hypertension and excessive target organ damage (AHA, 2017).
A healthy diet and portion control are promoted by the DASH diet. It supports the introduction into your daily diet of more fruits and vegetables, whole-grain foods, fish, poultry, nuts, and fat-free or low-fat milk items (DASH, 2013). Foods high in saturated fat, cholesterol, trans fats, candy, sugary beverages, sodium (salt), and red meat should be reduced (DASH, 2013). Owing to family background, some individuals have high blood pressure (DASH, 2013). For some it may be to blame for unhealthy diets, lack of exercise, or another medical problem. People who have hypertension also take medication. However, diet and exercise, even if it is part of your family background, can help lower high blood pressure (DASH, 2013)
A pre-and post-test, defined as a before & after assessment will be used to measure whether the anticipated improvements will take place in the participants in the DASH education. Program, it is the simplest evaluation design appropriate for the intended DPI project. A standard test questionnaire is applied (pre-test or baseline) and re-applied after a given time or at the end of the program (post-test or end line). The pre- and post-tests will be given in writing.
The value of hypertension understanding continues to be emphasized by existing recommendations on hypertension management. To improve treatment effectiveness, more effort should be made to increase patient knowledge and patients' willingness to comply with physical examinations (Harrison, 2014). As clinicians, if we want to convince patients to concentrate on their long-term wellbeing, we need to build a relationship of confidence. By sharing as much of our information as possible, the trust will be strengthened (Harrison, 2014).
African Americans are identified as high-risk HTN treatment and management populations (AHA, 2017). This is a multi-factor challenge involving a robust education and care program. In African Americans, there are inequalities in health insurance and access to treatment. To treat this population effectively, an educational intervention to modify diet and lifestyle and to manage HTN is needed. Increased screening and more rigorous recommendations in this population are required. The biggest effect on better patient outcomes would be the multidisciplinary patient-centered medical approach involving a primary care professional, nurse, case managers, pharmacists, and dietitians. The DPI project will take place of a four-week period of time. The next chapter will further discuss the review of literature, the methodology in which the DPI project will use, purpose of the DPI project and practice implications. The primary objective of this DPI is to investigate if a DASH education intervention for patients would improve the management of patients diagnosed with HTN at a primary health clinic in Washington, D.C. Comment by Sharina Sigur: Carefully review all comments and revisions made in the abstract and chapter 1. These same errors may exist throughout the remaining chapters without reviewer revisions/comments. Follow the feedback in the abstract and chapter 1 and apply to all remaining chapters.
Chapter 2: Literature Review Comment by Sharina Sigur: This chapter should be minimum 20 pages
Early onset HTN is a significant contributor to a shortened life expectancy of African American men (AHA, 2017). Hypertension is one of the leading factors for cardiovascular disease and is the leading risk factor for the overall global burden of diseases. Evidenced data has demonstrated that lifestyle modification and changes are known to reduce blood pressure (BP) (AHA, 2015). The purpose of this chapter is to provide an integrative review of literature identifying the best evidence-based literature to support lifestyle modification interventions in hypertensive African Americans to increase knowledge and decrease blood pressure.
A literature search was performed using Cumulative Index and Allied Health Literature (CINAHL), American Heart Association, Google Scholar, Medline, and PubMed. Keywords included HTN, DASH diet, patient knowledge, African Americans, lifestyle modification, provider education, and various combinations of the aforementioned. The search focused on evidence-based nursing articles and quantitative studies that had human peer reviewed, used English language, were full text, and within the last fifteen years. The search criteria were used to obtain the current body of literature and ascertain if an evidence-based practice change was supported.
The literature search resulted in approximately 60 articles. Articles were reviewed for relevance to PICO, inclusion, and exclusion criteria and 20 articles remained. The level of evidence were determined from (Fineout-Overholt’s, 2015) evidence hierarchy (1) Level I: Evidence from systematic review or meta-analysis of all random clinical trials (RCT), (2) Level II Evidence obtained from well-designed RCTs, (3) Level III Evidence obtained from well-designed controlled trials without randomization, (4) Level IV Evidence from well-designed case control and cohort studies, (5) Level V Evidence from systematic reviews and descriptive and qualitative studies (6) Level VI Evidence from single descriptive or qualitative studies, and (7) Level VII Evidence from the opinion of authorities and/ or reports of expert committees. The studies with evidence rated I through IV were utilized. Inclusion criteria used to select articles included studies that focused on lifestyle modification or nonpharmacological management of HTN, knowledge and education, management, or self-management in reference to or combination of HTN in African Americans, education for patients and patients attitudes toward change. Exclusion criteria included participants under 18 years of age. Comment by Sharina Sigur: This section is underdeveloped. Where is the background information?
Theoretical Foundations Comment by Sharina Sigur: Review all sentences for structure and flow. Ensure information presented is clear to the reader.
The Nola Pender’s health promotion model (HPM) and the ACE star model of knowledge transformation will be utilized to guide this project. Pender’s health promotion model (HPM) is one of the widely used models to plan for and change unhealthy behaviors and promote health (Petirin, 2015). The use of evidence-based practice (EBP) and national guidelines improve the quality of patient care and close the gap between quantitative patient outcomes and practice (Dontje, 2007). The conceptual-theoretical-empirical (CTE) structure is a system of nursing knowledge that requires attention to elements of substance and process as well as considerable thought, careful planning, and commitment to evidence-based practice that typically changes nursing practice and sets the standard for providing quality patient care (Fawcett et al., 2012). An EBP model or theory is used to guide the process of translating quantitative evidence into clinical practice. The clinical problem identified was hypertension in African American adults. The PICO question identified for this EBP is as follows; in African American patients diagnosed with hypertension, does an educational overview regarding a Dietary Approaches to Stop Hypertension (DASH) diet improve patient outcomes by lowering blood pressures? The purpose of this chapter is to analyze a conceptual-theoretical-empirical (CTE) structure and theory that supports or guides the implementer’s EBP. Health promotion is defined as lifestyle modification and behaviors recommended by the healthcare provider to promote one’s health and prevent disease. Health promotion is imperative in EBP to decrease blood pressure and increase patient knowledge while improving patient health outcomes. Health promotion as a concept is supported by Nola Pender’s health promotion model (HPM) that is directed toward positive health outcomes, such as optimal well-being, healthy eating habits, and regular exercise (Tomey & Alligood, 2002). The project implementer (PI) will explore this concept even further by focusing on healthy eating diet plans for hypertensive patients.
The project intervention is a pretest-posttest design guided by the theoretical framework Pender’s health promotion model. The tool chosen was validated in a pilot study of the DASH “Fruits and Vegetables” classroom lesson included a five question pre- and posttest as a tool for measuring the effectiveness of the lesson plan (Apovian et al., 2010). Hypertension is a chronic disease that is in the top three diagnosis of all outpatient clinic visits annually (Mahmood et al., 2018). The current body of evidence supports the integration of an educational overview on DASH to increase patient knowledge and management of HTN. This model was chosen to guide this EBP because healthcare providers are the most influential in motivating others to change their lifestyle (Petirin, 2015). Therefore, by implementing an educational intervention to patients on the benefits of DASH in controlling HTN has the potential to reduce healthcare cost associated with co-morbid chronic health conditions to include morbidity, mortality, coronary artery disease, renal disease, cerebrovascular accidents (Jiang et al., 2015). The patients will gain a better understanding of nutritional knowledge of the DASH, influence lifestyle change, and create a more accepting and empathic learning environment with the implementation of this EBP (Petirin, 2015).
Pender invented the original HPM described in the first edition of the text, Health Promotion in Nursing Practice, published in 1982 (Tomey & Alligood, 2002). The significance of this model is to assist patients in understanding the significant determinants of health behaviors as a basis for promoting healthy lifestyles (Petirin, 2015). Tomey & Alligood (2002) suggest the importance of Pender’s health promotion model is directed toward positive health outcomes such as optimal well-being, healthy eating habits, and regular exercise. Pender believed that prevention of these health problems could improve the patient's quality of life, and health care dollars could be saved by the promotion of healthy lifestyles (Petirin, 2015).
The HPM motivates people to make lifestyle modifications for a healthy lifestyle (Petirin, 2015). People are more likely to commit to and engage in health-promoting behaviors when significant others model the behavior, expect the behavior to occur, and aid and support to enable the behavior (Tomey & Alligood, 2002). The HPM is an excellent theoretical choice for the project because the evidence reports that hypertension affects more than 50 million people in the United States with health care costs totaling 42.9 billion in 2010 (Sacks et al., 2001).
Hypertension (HTN), also known as the “silent killer,” affects one out of every three African Americans. The reason for higher incidence of high blood pressure (B/P) in African Americans is unknown. On average, African Americans with high blood pressure have a much higher rate of stroke, heart failure, and other diseases than whites (CDC, 2018).
A clinical practice change project will be designed and implemented to educate patients about a Dietary Approach to Stop Hypertension (DASH). This project focuses on increasing patient knowledge and improving HTN management by lowering patient blood pressures. Patients will be recruited from an outpatient clinic in Washington D.C. The participants will consist of approximately 30 African American patients diagnosed with hypertension. A pre-posttest design will be utilized and guided by the Nola Pender health promotion model.
The ACE star model of knowledge transformation was developed to offer a comprehensive yet straightforward approach to translate evidence into practice. The model emphasizes five crucial steps to convert one form of knowledge to the next and incorporate the best quantitative evidence with clinical experts and patient preference thereby achieving evidence-based practice (Stevens, 2013). This model was chosen to guide the EBP in all phases.
Application to practice change. The model emphasizes crucial steps that will be used to allow evidence that can be translated into daily practice such as DASH education. The ACE Star Model is one of the most used models when transforming evidence into daily practice (Star Model, 2015).
Star point 1: Discovery Evidence. This is the knowledge-generating stage (Star Model, 2015). In this phase, the PI will conduct a thorough integrative literature review that resulted in supporting this EBP. EBP quantitative data is a continuous process that will continue throughout the life of the practice change project.
Star point 2: Evidence Summary. A systematic review and synthesis of research is performed, and knowledge is generated (Star Model, 2015). In this phase, the PI will spend quality time analyzing and reviewing the latest evidence and research supporting of the evidence-based clinical change project. A summary and synthesis of the findings indicate a DASH diet has been established as an effective modality to reduce blood pressure. Current evidence supports the lack of provider counseling on DASH and patient lack of knowledge concerning DASH benefits.
Star point 3: Translation to Guidelines. This point requires two stages that include a translation into practice recommendations and integration into practice. The aim is to provide a useful and relevant package of summarized evidence to patients in a form that suits the time, cost, and care standard (Star Model, 2015). This phase will include an educational overview to patients on the DASH diet, selection of the best questionnaire to assess patient’s knowledge on DASH, and utilization of the most current guidelines for HTN management using JNC8 guidelines. The data supports the need to educate patients on effective HTN management and recommend incorporating DASH into their daily lifestyle (Schwingshackl & Hoffmann, 2015).
Star point 4: Practice Integration. This point involves changing both individual and organizational practices of HTN management incorporating the DASH diet into daily practice (Star Model, 2015). This phase included an educational overview on DASH diet to patients, educational posters, patient education booklets, and statistical data analysis where the PI will make recommendations in support of the EBP to result in improved patient outcomes by bringing the best evidence into practice (Star Model, 2015).
Star point 5: Evaluation. The impact of evidence-based practice on patient satisfactory, provider satisfactory, patient health outcomes, economic analysis, efficiency, efficacy, and health status will be measured and analyzed. In this stage, there will be an evaluation of the success or failure, strengths, and weakness of the project. This practice change project will be focused on lowering patients' blood pressures after receiving education by providers on how a DASH diet can help with the management of their hypertension. Patients knowledge will be measured using five question posttests. Questions will be analyzed by comparing aggregate pre- and post-means. Also, individual question item analysis will be completed to determine which questions the participants scored the highest and lowest on. The benchmark for this outcome is a 20% increase in posttest scores and a decrease in patients’ blood pressure after the intervention. A four-week posttest will be administered. The DASH test aggregate means will be computed. These means will be compared with the first post-test results. The benchmark for the retention of knowledge is 80%. The findings related to this outcome will be visually displayed by using bar graphs. The PI will assess patient willingness to incorporate the DASH diet. The PI will also analyze patients’ blood pressures before and after the intervention. This outcome will be measured by a 5-point Likert-style question on each pre and post-test. The pre and posttest will measure patient’s knowledge about the DASH before and after the education session; The benchmark associated with this outcome is 50%. The findings related to this outcome will be visually displayed by using graphs (Apovian et al., 2010). Comment by Sharina Sigur: Should this be satisfaction?
In conclusion, a C-T-E structure will be created to support the evidence-based practice change project. The concept, health promotion is any activity that tries to improve one’s health by providing increased awareness through education on the risk factors of hypertension and healthy eating habits. The chosen theory, Pender’s HPM, empowers individuals to make healthy lifestyle modifications (Petirin, 2015). A DASH developed questionnaire will be utilized as the empirical indicator to evaluate the change in health promotion with African Americans diagnosed hypertension. The ACE Star model of knowledge transformation will guide the process. The CTE structure and evidence-based practice theory in this chapter provided a clear definition pathway of the concept, theory, and empirical indicator to support the practice change project (Petirin, 2015).
Review of the Literature Comment by Sharina Sigur: This chapter is extremely underdeveloped. It should provide adequate support from scholarly research/literature for the DPI project. (2-3 themes; then 2-3 subthemes for each theme) Chapter 2 needs to include a minimum of 50 scholarly sources with 85% from the past 5 years. Additional sources do not necessarily need to be from the past 5 years. It should not include any personal perspectives. Review sentences for structure and flow. Several paragraphs are underdeveloped. Formatting errors noted.
Review and synthesis of the literature revealed that education and the implementation of a healthy lifestyle is imperative in managing HTN and improving patient outcomes. The DASH was created 20 years ago, and over 30 clinical trials support DASH effectiveness in lowering blood pressure across a diverse range of patients with HTN and pre-hypertension (Steinberg et al., 2017). In the United States (US) dietary patterns contribute to the incidence of HTN (Steinberg et al., 2017). The optimal goal in the management and treatment of HTN is to educate and treat patients to achieve and maintain blood pressure however, a key obstacle is the lack of knowledge in patients diagnosed early with appropriate interventions including therapeutic lifestyle changes (Apple, 1997). The DASH diet is particularly beneficial in all populations and has proven to reduce systolic blood pressure (SBP) and diastolic blood pressure (DBP) respectively by 13.2 mmHg and 6.1 mmHg among African American participants with HTN (Jiang et al., 2015).
In a systematic review and random effects meta-analysis of 17 randomized controlled trials (RCT) Saneei et al. (2014), there was an evaluation conducted on the effects of the DASH used as a management tool for patients’ blood pressure and the results revealed the DASH diet had a beneficial effect on both systolic and diastolic BP. This study evaluated the effectiveness of the DASH diet in 2561 participants. Meta-analysis showed that the DASH diet significantly reduced systolic blood pressure by 6.74 mmHg and diastolic blood pressure by 3.54 mmHg. The blood pressure reducing impact from the DASH diet was more significant among men (Saneei et al., 2014). Harrison (2014) conducted an exploratory observational study with 114 participants to test a companion (web-based learning) to classroom nutrition education on DASH diet knowledge using this tool. At the completion of the study’s pre-and posttest, average scores ranged from approximately 34% to 78% respectively. Comment by Sharina Sigur: Rephrase for clarity.
Providers should strongly recommend the DASH diet to all African American patients, with or without high blood pressure, and provide educational materials, which are readily available (Jiang et al., 2015). Barriers to patients incorporating DASH diet into their hypertensive management is lack of provider knowledge and training, and patients lack awareness of potential DASH benefits. Challenges that providers incur in nutritional counseling are an overbooked clinic, lack of DASH knowledge, increased willingness to prescribe medications rather than provide counsel of DASH (Steinberg et al., 2017).
Hicks and Murano (2016) conducted an exploratory study with a convenience sample (n=54) to ascertain if Texas physicians incorporated dietary counseling into their medical plan. Results revealed 89% of physicians do not incorporate nutritional counseling into their medical practice. The lack of dietary counseling by physicians can be explained by the fact that one-half of all medical schools offer 17 hours or less of nutritional education and 9% of medical schools have no nutritional based training incorporated into the curriculum. Nutrition education is harder to obtain after medical school graduation (Aggarwal et al., 2018). Over half of the physicians surveyed (52%) reported that their practice did not counsel or promote patient nutritional counseling. There is evidence that supports a lack of physician patient directed nutritional counseling (Hicks and Murano, 2016). Continuing Medical Education (CME) nutritional offerings, as well as evidence based nutritional class, can bridge the gap in knowledge and increase nutritional interventions. Valderrama et al. (2010) conducted a survey (n=5,399) 25.8% had HTN with 79.8% taking medications with only 21% reported nutritional counseling by their provider. The DASH diet has been utilized in the clinical setting to improve HTN; however, lack of provider patient counseling results in inadequate patient knowledge. Therefore, dietary modalities are not being utilized as a modality to reduce HTN.
Several lifestyle interventions have been proven to reduce blood pressure (Weber et al., 2014). Favorable effects on SBP and DBP in adults due to DASH diet are of considerable public health importance because this dietary pattern can be easily adopted, has the greatest effect on men and is cost effectively aids in the prevention of HTN and its complications (Saneei et al., 2014). A DASH-like diet can knowingly reduce the risk for cardiovascular disease (CVD), coronary heart disease (CHD), stroke, and heart failure (HF) by 20%, 21%, 19%, and 29% respectively (Salehi-Abargouei et al., 2013). Effective HTN management must include DASH counseling as a proven modality to prevent and aid in HTN treatment. Incorporating DASH counseling with HTN patients gives them the best possible chance to control and reduce their blood pressure, which will reduce end organ disease. For all persons with hypertension, the potential benefits of a healthy diet can improve BP control and even reduce medication needs (James et al., 2014).
Dash diet. The first DASH diet clinical project by Apple et al. (1997) was a multicenter 11-week feeding study that assessed the effects of dietary patterns on blood pressure. The participants in the study included 459 adults over the age of 22 with systolic blood pressures of less than 160 mm Hg and diastolic blood pressures of 80-95 mm Hg (Apple et al., 1997).
At the beginning of the study, all participants consumed a control diet low in fruits, vegetables, and dairy products for three weeks (Apple et al., 1997). For the next eight weeks, the participants received either the control diet, a diet rich in fruits and vegetables, or a combination diet that included fruits, vegetables, and low-fat dairy with decreased total fat (Apple et al., 1997). The blood pressure reduction began within two weeks of initiation of the diet and was maintained for six weeks (Apple et al., 1997).
The blood pressure realized with the combination diet was similar in magnitude to that observed in trials of drug monotherapy for mild hypertension.
The results of the DASH trial showed that a diet rich in fruits, vegetables, and low-fat dairy products, with reduced statured and total fat, lowered systolic blood pressure by 5.5 mm Hg and DBP by 3.0 mm Hg more than the control diet. The DASH diet emphasizes foods rich in protein, fiber, potassium, magnesium, and calcium, such as fruits, vegetables, beans, nuts, whole grains, and low-fat dairy products. The study concluded that the DASH diet reduces blood pressure.
Another RTC by Blumenthal et al. (2010) compared the DASH diet to a control diet randomized into two groups. The first group was the DASH diet alone, and the other group was the DASH diet with weight management. The DASH alone group received only guidelines for their diet and were asked not to exercise. The DASH weight management group received a controlled menu plan with cognitive behavior weight loss intervention and supervised exercise program sessions. The controlled group consisted of the participants’ usual diet. These participants were instructed to maintain normal diets for four months. The study spanned two weeks and included 144 participants over the age of 35 in a tertiary medical facility. Blood pressure measurement in the clinic was obtained using a manual cuff method. Measurement was obtained four times daily in each individual’s home environment with an automatic blood pressure machine and twice at night. The mean BP was used.
Food frequency questions were used for nutritional assessment. The questionnaire
recalled typical consumption in a four-week period and four-day food diary. This study found that the DASH diet both significantly lowered SBP (p < 0.001) and DBP (p < 0.001), compared to a control group. DASH with weight management also lowered SBP (p = 0.10) and DBP (p = 0.06). At the end of the study, six participants were clarified as hypertensive in the DASH with a weight management group and seven in the DASH alone group. This study concluded that DASH was more effective in lowering blood pressure with exercise, but that DASH alone was effective in lowering blood pressure as well.
Another study that evaluated the effects of the DASH diet was conducted by Azadbakht et al. (2005). It examined the effects of the DASH diet on patients with metabolic syndrome. This study was different because the patients used a weight management intervention with the DASH diet. This study enrolled 116 patients (34 men and 82 women) with metabolic syndrome. Three diets were prescribed for six months: a control diet, a weight-reducing diet, and the DASH diet with a sodium restriction to 2,400 mg daily. The participants were overweight or obese and had not participated in weight reduction during the past six months. The study spanned six months of interventional feedings, and the patients were followed monthly. The DASH diet resulted in higher HDL cholesterol (7 and 10 mm/dl), lower triglycerides (-18 and -14 mg/dl), lower systolic blood pressure (12- and -11-mm Hg), lower diastolic blood pressure (-6- and -7-mm Hg), and decreased weight (-16 and -15 kg) respectively (p <0.001). This study concluded the DASH diet could likely reduce metabolic risk in men and women with metabolic syndrome.
Seangpraw et al. (2018) performed another study that evaluated the effects of the DASH diet. This study used behavior modification instead of weight management intervention. A quasi-experimental study was employed with two groups of elderly patients aged 60-80 in a rural community in Thailand. Ninety participants were in the intervention group, and 80 were in the controlled group.
The intervention group used behavior modification guidelines of the DASH program with self-efficacy for three months, including a 45-minute group education meeting, a 25-minute group activity training session, and a 15-minute individual checklist. The controlled group received no intervention. The DASH diet, along with behavior modification, showed increased self-efficacy while SBP and DBP had decreased (p = 0.002). The results showed that self- efficacy increased, as did awareness regarding the severity of complications of hypertension.
In a 3-period randomized crossover trial in free-living healthy individuals who consumed in random order a control diet, a standard DASH diet, and a higher-fat, lower-carbohydrate modification of the DASH diet (HF-DASH diet) for 3 week each, separated by 2-wk washout periods. Laboratory measurements, which included lipoprotein particle concentrations determined by ion mobility, were made at the end of each experimental diet. Thirty-six participants completed all 3 dietary periods. Blood pressure was reduced similarly with the DASH and HF-DASH diets compared with the control diet. The HF-DASH diet significantly reduced triglycerides and large and medium very-low-density lipoprotein (VLDL) particle concentrations and increased LDL peak particle diameter compared with the DASH diet (Chiu et al, 2016). The DASH diet, but not the HF-DASH diet, significantly reduced LDL cholesterol, HDL cholesterol, apolipoprotein A-I, intermediate-density lipoprotein and large LDL particles, and LDL peak diameter compared with the control diet. In conclusion, the HF-DASH diet lowered blood pressure to the same extent as the DASH diet but also reduced plasma triglyceride and VLDL concentrations without significantly increasing LDL cholesterol (Chiu et al, 2016).
Ozemek et al. (2018) noted that appropriate prevention and management of hypertension was supported by adopting a diet rich in plant-based foods with whole grains, low-fat dairy products, and low sodium in accordance with the recommendations of the DASH diet. The Ozemek et al. (2018) review also found the DASH diet was more effective when paired with dietary counseling. In comparison, three studies found benefits from the DASH diet. In two studies, lifestyle modifications were added to the DASH diet intervention and found a greater reduction in the systolic and diastolic blood pressures. The original DASH study showed favorable effects on the reduction of BP but did not test diet adherence. All studies found the DASH diet to be effective in lowering blood pressure in participants. This was consistent with a meta-analysis conducted by Ndanuko et al. (2016), who compared several studies of dietary patterns in lowering blood pressure and concluded that the DASH diet lowers blood pressure.
In a recent RCT investigating the effects of the DASH diet on cardiovascular risk factors and providing information on the energy and macronutrient contents of both DASH and control interventions were included in the meta-analysis. The minimum duration of the RCT for inclusion in the meta-analysis was 2 weeks. An important inclusion criterion was that the DASH and control diet interventions had to be comparable in terms of energy intake and other lifestyle interventions, e.g. physical activity. In other words, RCT were included only if both control and DASH diet interventions involved a similar degree of energy restriction and/or physical activity to avoid the confounding effects of changes in body weight on cardiovascular risk factors. In addition, RCT were included if they altered minor components of the DASH interventions (e.g. modified DASH) but retained the core characteristics of the archetypical DASH dietary plan (Bricarello et al., 2018). Examples of DASH dietary plan modifications include reduction of salt intake, increased consumption of lean red meat, and combination with other interventions such as weight loss or physical activity. Similarly, RCT having either a typical dietary pattern or a healthier dietary pattern (healthy diet) as a control were included, provided that these patterns matched the DASH intervention in terms of both energy intake and physical activity level. Finally, RCT were not excluded according to dietary Na intake, as information regarding this variable was not consistently reported across trials; this approach was intended to minimize the risk of publication bias (Bricarello et al., 2018).
In conclusion, the DASH diet interventions resulted in significant improvements in systolic and diastolic BP along with significant reductions in total cholesterol and LDL concentrations. However, these interventions did not affect TAG, glucose, and HDL concentrations (Bricarello et al., 2018). The responses of both systolic and diastolic BP to the DASH diet were greater in participants with higher BP or BMI at baseline. The responses appeared to be independent of differences in dietary Na intake. Importantly, measures of the effectiveness of the DASH diet were not modified by the type of study design or feeding protocol and the characteristics of control diet (Bricarello et al., 2018).
According to Challa et al., (2020), the DASH diet is an essential strategy for lowering blood pressure in patients with diabetes mellitus type 2. The American Diabetic Association recommends that patients with diabetes who are at risk should achieve the US Department of Agriculture’s Dietary Reference Intake (DRI) for fiber, whole grains, and macronutrients. Moreover, these patients should limit saturated fat to < 7% total daily calories, reduce trans-fat intake, reduce cholesterol to < 200 mg/day, and limit sugar-sweetened beverages. Because the DASH diet meets these recommendations, adherence in patients with diabetes mellitus should be advocated for adequate blood pressure control (Challa et al., 2020).
Based on these studies, it is safe to say that when combined with pharmacological intervention, DASH can be a very useful tool for physicians to tackle these diseases more efficiently (Challa et al., 2020). When compared to some other diet patterns, it has an added advantage of having clear guidelines on the serving sizes and food groups, which makes it easier for the physicians to prescribe and monitor their patient's improvement (Challa et al., 2020).
Patient education. There are several methods of offering patient education. One of the most cost-effective means is face-to-face counseling. This technique lets provider’s answer questions without delay in communication. According to Magadza et al. (2009), a pamphlet is a cost-effective way to provide education in summary. Magadza et al. (2009) evaluated the patient’s understanding of HTN using motivational intervention questions. In their study, 45 patients were interviewed and completed a questionnaire. This study showed that educational intervention could positively impact patient adherence. The participants received a questionnaire pre- and post-education. The questionnaire was composed of four parts: the concept of HTN, antihypertensive medication, adherence to medication, and diet and lifestyle recommendations. In their case-controlled study, they found motivational interviewing and questionnaires increased participant knowledge about HTN and the importance of medication. These findings suggest that patient education provides patients with the opportunity to have questions answered, thus improving adherence to education.
Delichatsios and Weity (2005) performed a study on providing participants with resources to improve dietary habits. The resource was a dietary patient education booklet that focused on fruits and vegetables, red meat, and dairy foods. Booklets were mailed to patients’ homes. The patient then had two motivational counseling sessions by telephone at two-week and four-month intervals. For the control group, their servings were increased by an average of 1.1 servings per day compared to 0.3 serving per day for the intervention group. The finding showed no changes in the amount of red and processed meats.
The intervention group increased fiber by 1 gram per day. The study concluded that 71% of the participants discussed the educational booklets with their primary care providers. This study addressed a lack of time in the primary care setting and alternative means of educating by mailing booklets and having telephonic follow up (Delichatsios & Weity, 2005).
Wong et al. (2015) performed a study on 556 Chinese patients who were newly diagnosed with hypertension. The participants received DASH-based dietary counseling tailored to a Chinese diet and were given 25-minute dietary counseling and DASH diet pamphlets. The outcome data were evaluated after six months and showed lower blood pressure. Wong et al. (2015) concluded that a self-monitoring tool that reinforces the implementation of dietary counseling would be more effective.
Summary
A literature review provides a more comprehensive understanding of the healthcare problem for this chapter. A review and synthesis of the current literature support the DASH as an evidence-based patient education tool used in the management of patients with HTN to improve patient outcomes. The DASH is an effective way to reduce blood pressure. Lifestyle modifications recommendations of diet and exercise can be difficult if patients are not given specific guidelines. Diet and lifestyle changes are more effective when healthcare providers give patients clear and concise guidance. The DASH intervention offers patients clear dietary guidance and assists with meal planning. The DASH can significantly impact on HTN especially in the African American population and should be used as a primary intervention to decrease HTN.
Hypertension continues to be a worldwide health problem. HTN is one of the most common conditions treated in primary care and can lead to myocardial infarction, stroke, renal failure, and death if not detected early and treated appropriately (Oza & Garcellano, 2015). Quantitative data suggests that HTN rates in African Americans is higher than any other ethnic group, and BP control remains inadequate in this population. The DASH dietary pattern can be easily educated and adopted by all population groups offering the most cost-effective intervention to serve as the primary and secondary prevention of elevated blood pressure and its complications (Saneei et al, 2014).
Advantages and disadvantages of findings. The DASH diet has been shown to reduce both systolic and diastolic blood pressure in hypertensive and pre-hypertensive patients across subgroups, genders, races, and ethnicities. Further studies have found that adherence to the DASH diet improves changes in cholesterol and reduce the risk of coronary heart disease and stroke. The DASH diet has shown eating whole foods, rather than processed foods, lowers blood pressure due to their lower sodium content. The DASH diet is beneficial, is well tolerated in these studies, and has yielded results with positive health outcomes in reducing blood pressure, with or without other interventions. The literature review of the DASH diet, however, has shown that the DASH diet is not well followed and that there is low adherence to the DASH diet. Increasing adherence to the DASH diet and improving education and implementation of the diet poses a challenge. Comment by Sharina Sigur: Are these subsections of the summary?
Utilization of findings in practice. Promoting a DASH diet education is vital for the clinician to encourage and motivate patients to make lifestyle changes in dietary choices and to develop ways to improve adherence and education on the DASH diet. One can tailor these implementation strategies to improve adherence by translating some of the clinical findings into practice. One way to do this is by providing more DASH diet educational material to patients. Another suggestion is to provide more DASH diet education on initial clinic visits. A further solution is to offer DASH diet educational counseling, along with DASH diet material, to improve knowledge and awareness of the DASH diet. These DASH diet pamphlets can be reproduced and utilized in other outpatient clinics.
Providing patient education in a primary care setting through face-to-face counseling is a cost-effective means. This technique allows providers to answer questions without delay in communication and to follow the discussion with a pamphlet. Providing a pamphlet while imparting educational information lifestyle changes increases the retention of information (Magadza et al., 2009).
Many healthcare providers are not educating patients on the recommended dietary guidelines for HTN (Sessoms, Reid, Williams, & Hinton, 2015). Therefore, the clinician needs to encourage patients to make lifestyle changes in dietary choices and to develop a DASH diet education session, along with pamphlets that will increase DASH diet knowledge and awareness for both patients and providers. Implementing this project will be beneficial to patients in the outpatient clinic setting, and it will increase their knowledge and awareness about DASH and will subsequently improve hypertension outcomes.
Chapter 3: Methodology
Hypertension (HTN) is the leading preventable cause of premature death worldwide (Mills et al., 2016). In hypertensive individuals, lifestyle modification can serve as initial treatment before the start of drug therapy and act as an adjunct to pharmacological therapy in persons already on drug therapy (Appel, 1997). An obstacle that medical providers encounter in effectively managing HTN is the lack of dietary lifestyle modification counseling. According to the AHA, 2015, hypertension is one of the leading health issues contributed to cardiovascular disease that is a leading cause of morbidity and mortality. Also, these major health issues are contributed to non-adherence which has been linked to time constraints for providers to provide education to patients during their clinic visit (Kim & Andrade, 2016). The purpose of this quantitative quasi-experimental project is to determine if or to what degree the implementation of a Dietary Approach to Stop Hypertension education intervention for patients would impact the blood pressure readings of patients diagnosed with hypertension at an outpatient health clinic in Washington, D.C. over a four-week period of time. Comment by Sharina Sigur: This is not formatted correctly.
Statement of the Problem
High blood pressure (HBP) prevalence in African Americans in the US is among the world's highest. Much of non-Hispanic African American men and women have high blood pressure. High blood pressure also occurs earlier in life and is typically more extreme for African Americans (Maraboto & Ferdianand, 2020).
Uncontrolled hypertension (HTN) in the USA is particularly prevalent and devastating among Black people who are more vulnerable than people from other racial / ethnic groups to the effects of this disease. Moreover, the findings of evidenced based data in this population are frequently underrepresented in cardiovascular clinical trials, restricting their ability to accurately apply them. In this analysis, we summarize and examine the information that is currently available regarding risk factors, manifestations, complications and HTN management in this often difficult to treat population. This practice change project seeks to better understand to what degree of increasing patient’s knowledge on the DASH diet is a best approach for treatment of patients with hypertension (Maraboto & Ferdianand, 2020)
Health organizations urge healthcare providers to participate in programs that help patients control high blood pressure (CDC, 2017). Lifestyle changes recommendations to treat HTN include weight management, exercise, and diet (Yang et al., 2015). Many patients do not adhere to the recommendations because of insufficient education. Educating patients about lifestyle modifications can have a significant impact on their beliefs about hypertension (Yang et al., 2015). Patel et al. (2016) indicated that lack of education was a common reason that patients did not adhere to diet education.
There are many barriers to the management of patients with hypertension, and one that is see daily by health care providers is lack of patient education. It was not known if or to what degree the implementation of a Dietary Approach to Stop Hypertension (DASH) intervention education program would impact the patients’ blood pressure when compared to no intervention among African American patients diagnosed with hypertension in an outpatient clinic in Washington, D.C.
Clinical Question
The primary objective of this practice change project is to determine if a diet approach that emphasizes rich fruits, vegetables, and low fat significantly reduces the development and increased the management of HTN among African Americans. The study also evaluates if lifestyle practices such as exercise and physical therapy significantly reduce the development and management of HTN among black Americans. The PICOT question is: Does the implementation of a Dietary Approach to Stop Hypertension education intervention for patient’s impact blood pressure readings for patients diagnosed with hypertension at an outpatient clinic in Washington, D.C. over a four-week period of time?
The following clinical question guides this quantitative project:
CQ: To what degree does the implementation of a Dietary Approach to Stop Hypertension education intervention for patient’s impact blood pressure readings for patients diagnosed with hypertension at an outpatient clinic in Washington, D.C. over a four-week period?
The independent variable will be defined as the implementation of a Dietary Approach to Stop Hypertension education for approximately 30 African American adult patients with hypertension. The dependent variable will be defined as mean systolic and diastolic blood pressure before and after the intervention. The question leads to a search for the best evidence that can contribute to a decision about the patient’s care (Harmic, 2009).
This DPI project will employ a pretest posttest design guided by the theoretical framework Pender’s health promotion model. All patients will be given a 20-minute educational overview on HTN and the effectiveness of the DASH diet. There will be a 5-question pre-posttest designed by DASH “Fruits and Vegetable” given to patients about the DASH diet. Provider will then counsel and educate patients with hypertension about the DASH and patients' blood pressures will be evaluated before and after the intervention of the DASH diet. The DASH was created 20 years ago, and quantitative data demonstrates it consistently lowers BP across a diverse range of patients with HTN and prehypertension (Steinberg, Bennett, & Sevetkey, 2017). Barriers to patients incorporating the DASH diet into their hypertensive management could possibly be lack of provider knowledge and training, and patients lack awareness of the potential benefits of the DASH diet as a means of hypertension management.
Project Methodology Comment by Sharina Sigur: This section is underdeveloped.
A clinical practice change project will be designed and implemented to educate patients about a dietary approach to stop hypertension (DASH) diagnosed with hypertension. This project focuses on increasing patient knowledge and improving HTN management. Patients will be recruited from an outpatient clinic in Washington, D.C. The participants will consist of approximately 10 African American adults diagnosed with hypertension. A pre-posttest design will be utilized and guided by Nolan Pender health promotion model.
Quantitative methods are most appropriate in the following circumstance: a) clearly defined study variables. b) large sample size available in a cost-effective manner, c) validated instrument available for data collection, and d) a desire to generalize study findings (Leedy, Ormrod, & Johnson, 2019). Quantitative data follow a linear sequence in obtaining answers to quantitative questions (Polit & Beck, 2017). Quantitative methodology is most appropriate for this DPI project, as the focus of quantitative data is to determine the relationship or trends between independent and dependent variables (Polit & Beck, 2017).
Population and Sample Selection Comment by Sharina Sigur: Underdeveloped.
The target population for this EBP practice change are African American patients between the age of 18 to 65, patients diagnosed with hypertension. The beneficiaries seen in this clinic include all patients that have been diagnosed and currently being treated for HTN. The clinic is made up of 95% African Americans. A convenience sample of 10 patients diagnosed with hypertension will be the target goal on a volunteer basis from an outpatient clinic in Washington, D.C.
Participant’s personal information nor protected data will be recorded. The targe patients will be identified through the clinic’s electronic health record reports. Only patients that are fluent in English will be asked to participate in the project. Medical contraindications for blood pressure measurements in either arm (i.e., double mastectomy, poor circulation, arteriovenous shunt) will be excluded from the DPI.
Recruitment strategies will include email, verbal and written announcements, and invitations. Patients will be emailed through the patient portal in the electronic health record by clinical staff. Other strategies included posters that will posted outside the clinic door and building.
Instrumentation, Validity and Reliability Comment by Sharina Sigur: This should be 3 separate sections. Refer to template. Underdeveloped.
The evidenced based evaluation tool that will be used in this quality improvement project is a validated food frequency questionnaire from the DASH Eating Plan manual from the National Institute of Health (NIH, 2006). The pre-intervention questionnaires are to assess their knowledge and belief of the DASH diet pre-intervention. The post-intervention questionnaires are to evaluate the effectiveness of education by re-evaluating knowledge and belief after DASH education. The post-intervention questionnaires are to be administered at the end of the 4-week session. The post-intervention evaluates the effectiveness of the DASH diet session. Blood pressure measurement is taken pre-and post-educational intervention. Blood pressure will be measured pre-intervention and post-intervention to allow adequate time for adjustment. The blood pressure is taken using a mercury manual sphygmomanometer. A blood pressure reading by auscultation is considered the gold standard according to (NHLBI, 2017). Blood pressure will be measured in the left and right arms in the sitting position. Medical contraindications for blood pressure measurements in either arm (i.e., double mastectomy, poor circulation, arteriovenous shunt) will be excluded from the DPI. Blood pressures will be taking in the morning on arrival. The patient’s blood pressure will be documented in the electronic health record in the vital signs section. The blood pressure will be measured to evaluate if the significant reduction in blood pressure is obtained in the patients that followed the DASH. Blood pressure will be recorded on paper, then entered on an Excel flow sheet in the computer system. Comment by Sharina Sigur: In general, APA style recommends using words to express numbers below 10 and using numerals when expressing numbers 10 and above.
The plan for evaluation of this practice change project is to administer a five question pre-and post-test measuring the effectiveness of the lesson, educating patients on the use of the DASH diet for HTN management and measuring patients’ blood pressures before and after the intervention. The validated DASH pre-post-test tool is free to use and does not require the author’s permission to use it. The DASH questionnaire, created by the DASH for Health team, was initially used in an online format and validated against the well-known Block Food FFQ by Apovian et al. (2010). The Block FFQ and the DASH online questionnaire (OLQ) were found to have significant positive correlations among all eleven DASH food groups (Apovian et al., 2010). Weighted kappa statistics found the level of alignment between the DASH OLQ and the Block FFQ by energy level to have a value of 0.48 (95% CI 0.38, 0.57; P < 0.0001) meaning moderate agreement was observed (Apovian et al., 2010). The DASH questionnaire is based on a diet recall from the previous 24 hours only and encompasses 11 dietary categories with additional questions to determine sodium and fat intake (Apovian et al., 2010). The estimated time for the questionnaires would take participants approximately 20 minutes to complete and would not feel burdensome and could be given on paper. The DASH questionnaire tools, are free for public use (NHLII, 2006).
Data Collection Procedures Comment by Sharina Sigur: Underdeveloped.
The DPI student will oversee storing and securing the intake data for all participants. The demographic data collected for this project will include the following: 1) age, 2) ethnicity, and 3) gender. Other demographics that will be collected for the electronic health record is the participants systolic and diastolic numbers of patients that are diagnosed with hypertension and will participate in the DPI. Onsite de-identified data will be collected by the clinical staff. The clinical staff will provide the education intervention and give the pre-posttest to patients before and after the education intervention. The clinical staff will also obtain de-identified blood pressures from patients at the beginning and end of quality improvement project. Data collection will also include the number of hypertension patients that received the counseling for the DASH diet during their visit to the clinic. Clinical staff will include Registered Nurses and Medical Assistants.
The questionnaires will be placed in a labeled folder and placed, secured, and locked in a file cabinet. The intake surveys and questionnaires will be coded with number and each participant will be given a separate number that will not contain any identifying patient’s information. All data collected will remain secured until the data can be entered into the Excel spreadsheet and the SPSs program. Once the DPI project has completed, the pre-post questionnaires will be shredded in the office locked shred box 6 months after intervention and sent out for bulk disposal. The SPSS Excel information will be stored on the designated office computer that requires username and password for access. The Excel spreadsheet will also be password protected.
Data Analysis Procedures Comment by Sharina Sigur: This section is underdeveloped.
To answer the clinical question, “Does the implementation of a Dietary Approach to Stop Hypertension education intervention impact African American patients diagnosed with hypertension at a primary health clinic in Washington, D.C. over a four-week period?”, SPSS statistical software will be used examine the correlation between the independent and dependent variables. Comment by Sharina Sigur: Indent the first line of each paragraph of text 0.5 in. from the left margin.
The independent variable will be defined as the implementation of a Dietary Approach to Stop Hypertension education session for patients that are diagnosed with HTN. The dependent variable will be the blood pressures measurements of patients identified in the QI project at a primary health clinic in Washington, D.C. over a four-week period.
The patient's blood pressures before and after the intervention will be entered into an Excel spreadsheet. Data analysis will be performed using SPSS statistical software. The research department of clinical investigation at the clinical site will provide statistician assistance. At the end of the four-week evaluation, the posttest scores will be compared to prior posttest scores using descriptive statistics and T-test to compare retained knowledge and rate of DASH counseling with a percentage value of .05 as the benchmark. This project may not reach statistical significance therefore a percentage change will be collected from the pre-and post-test to determine the amount of knowledge gained and the number of patients' blood pressures that will be measured. This data will provide the information to ascertain if the intervention of the DASH from patients had a positive patient outcome for those patients diagnosed with HTN over the four-week period.
Collected data will be presented in tables and pie and chart graphs and analyzed by the computer software statistical package (SPSS version 27) using appropriate statistical methods. Frequency means and standard deviation will be used to summarize the data. Categorical data will be analyzed by using chi-square test. Descriptive frequency and statistics will be used to compute Demographics.
Ethical Considerations Comment by Sharina Sigur: Potential Bias and Mitigation section is missing.
The principles of the Belmont Report; respect, beneficence, autonomy, and justice will always be implemented (Polit & Beck, 2017). Anonymity will be achieved with de-identifiers to protect patient Health Information Portability Privacy Act (HIPPA) protected health data. All data collected will be kept in a locked drawer in the PI’s office until project completion. De-identified data will be transferred from the EHR to a password protected Excel spreadsheet for storage. Any protected health information will be shredded using the clinical practice site resources.
This DPI project involves minimal risk, with the design (Polit & Beck, 2017). This DPI project does not increase risk to participants any more than the standard of care. The purpose of this quantitative quasi-experimental project is to determine if or to what degree the implementation of a DASH education intervention for patients would impact blood pressure readings for patients diagnosed with hypertension at an outpatient clinic in Washington, D.C. over a four-week period of time. The quasi-experimental project was chosen to evaluation if patient education about the DASH diet decreases blood pressures in patients with HTN. Patient information with be collected for the electronic health record which requires a password to gain access. IRB and site approval in appendix J.
Limitations and Delimitations Comment by Sharina Sigur: Refer to template for correct section titles. Underdeveloped and written as proposal.
With the ongoing global pandemic, there is limited access to healthcare facilities; hence the desired number of participants may not be obtained. There may also be an issue regarding patients not completing the necessary pre-posttests needed for the DPI or DASH education to patients during their visit. The location was also limited to one clinic.
Delimitations include the DPI only being conduct at one outpatient clinic. Also, only African Americans adults between the age of 18 and 65 years of age enrolled at the university with no prior education about the DASH diet will be participants in the project. Patients with contraindications (i.e., doble mastectomy, poor circulation) will be excluded from the project. The clinic patient population is 95% African Americans.
Summary
In conclusion, a C-T-E structure was created to support an evidence-based practice change project. The concept, health promotion is any activity that tries to improve one's health by providing increased awareness through education on the risk factors of hypertension and healthy eating habits. The chosen theory, Pender's HPM, empowers individuals to make healthy lifestyle modifications. The DASH food frequency questionnaire served as the empirical indicator to evaluate patient knowledge and examine how it relates to the change in health promotion with African Americans diagnosed with hypertension.
The ACE Star model of knowledge Transformation will guide the process. The CTE structure and evidence-based practice theory in this chapter will provide a clear definition pathway of the concept, theory, and empirical indicator to support the practice improvement project. Hopefully, in the future the project will seek to eliminate limitations and improve the data collection methods. The entire project advocates for proper dietary habits and healthy lifestyle to reduce the risks of getting hypertension and improving the management of hypertension.
The purpose of this chapter was to provide an overview of the pre-implementation process for this EBP. Hypertension is a common diagnosis within this outpatient clinic. DASH diet has been established as a useful modality to reduce blood pressure. Current evidence supports lack of provider counseling on DASH and patient lack of knowledge concerning DASH benefits. This clinical site was assessed for its HTN population and current treatment modalities. Through a retrospective chart review it was identified that HTN patients were being managed primarily with pharmacological agents with little or no documentation on diet and lifestyle modifications. Addressing conjunctive HTN management such as DASH gives the patients a better chance at optimal blood pressure instead of pharmacological agents alone. This EBP has support of key stakeholders and the opportunity to improve patient outcomes.
Chapter 4: Data Analysis and Results
The quality improvement project aimed to evaluate the effectiveness of DASH diet education into the nutritional plans of hypertensive patients at an outpatient primary care clinic. The project increased patient awareness and knowledge of the DASH diet, and its relationship with blood pressure improvements, food selection and DASH awareness. This project determined that DASH education was effective in implementing a change in diet education in the outpatient clinic and increased self-efficacy in hypertensive patients by changing food habits that can promote better blood pressure management.
The practice change project’s primary objective was to determine if a diet approach that emphasizes rich fruits, vegetables, and low fat significantly reduces the development and increased the management of HTN among African Americans. The quality improvement project also evaluated if lifestyle practices such as healthy food options significantly reduce the development and management of HTN among black Americans. The PICOT question is: Does the implementation of a DASH program intervention for patient’s impact blood pressure readings for patients diagnosed with hypertension at an outpatient clinic in Washington, D.C. over a four-week period of time?
A clinical practice change project was designed and implemented to educate patients about a dietary approach to stop hypertension (DASH) for hypertension patients. This project focused on increasing patient knowledge and improving HTN management. Patients were recruited from an outpatient clinic in Washington, D.C. The participants consisted of approximately 20 African American adults diagnosed with hypertension. A DASH pre-posttest design was utilized and guided by Nolan Pender health promotion model. Comment by Sharina Sigur: Rephrase. Comment by Sharina Sigur: How many participants were there? The project is complete. You have the final number.
This chapter will discuss the methodology or design as to exactly how the project study was carried out. It includes: 1) project purpose; 2) project management, that will cover organizational readiness for change, interprofessional collaboration, and organization approval process; 3) informational technology that was used to implement the project; 4) plans for Institutional Review Board approval and process obtained; 5) project evaluation that include demographic information collected; 6) defining and discussing the outcome measurements; and 7) a discussion of the evaluation tool used to evaluate outcomes. Comment by Sharina Sigur: Be sure that you change wording from “study” to “project” throughout document and avoid referring to the project as research or you as the researcher.
Descriptive Data Comment by Sharina Sigur: Where is the narrative summary of the population, sample characteristics, and demographics? Where are the graphic organizers for the descriptive data?
The project participants recruited were African American adult patients that use the primary care clinic with a diagnosis of hypertension identified through the electronic medical records quality improvement reports. The project was limited to English speaking African American adult patients with a diagnosis of hypertension. The participant's age, race, and ethnic background was be collected. The participants were asked to provide gender identity. This information was collected using an intake survey tool. The results are illustrated with the use of graphs, bar charts, pie charts, and a table format. Comment by Sharina Sigur: Age group?
The purpose of collecting data was 1) to determine if the nutritional educational intervention had a significant effect on knowledge, understanding, and retention of the DASH diet. 2) To determine if the intervention will increase patient educational knowledge of DASH. 3) To determine the likelihood that patients will follow DASH recommendation. 4) To determine if the patient will be able to adopt recommendations. 5) To evaluate the effectiveness of an education program in changing patient behavior 6) To determine if a decrease in systolic and diastolic blood pressure could be achieve post DASH education. Evidence has shown that lifestyle change and teaching of the DASH improved a patient’s hypertensive state, increased knowledge about the DASH and increases healthier food choices. These outcome measures are to promote healthy eating following the DASH diet education to improve blood pressure from patients that follow the diet plan. Blood pressure will be taken pre-DASH diet initiation and post-DASH diet initiation. Studies have shown that following the DASH diet has lowered blood pressure systolic and diastolic in people with hypertension. According to NHLBI (2017), there could be and 8-14 mm Hg reduction in blood pressure. Lifestyle modification has been useful in the control of hypertension through a healthy diet (AHA, 2015). Comment by Sharina Sigur: This is confusing. The purpose of collecting patients’ demographic data helped to determine and evaluate all of this information?
Data Analysis Procedures Comment by Sharina Sigur: This section is underdeveloped.
Collected data is presented in tables and pie and chart graphs and analyzed by the computer software statistical package (SPSS version 27) using appropriate statistical methods. Frequency means and standard deviation will be used to summarize the data. Categorical data will be analyzed by using chi-square test. Descriptive frequency and statistics will be used to compute Demographics.
All intake data was stored and secured. The Primary Investigator placed both the pre-questionnaire and post questionnaire in a vanilla folder and place them in the locked filed cabinet with a secured, locked door. The intake surveys and questionnaire where were coded with a letter and numbers and each participant will be given a separate number. The questionnaire was stored in a secured place until the data was collected and entered in the Excel spreadsheet and the SPSS program. The pre/post questionnaires will be shredded in the private office shredder and sent out for bulk disposal 60 days after the project is completed. The SPSS and excel information were stored on the department private drive.
Demographics, Results and Findings Comment by Sharina Sigur: This is not a section title. Refer to template for guidance. Why aren’t the demographic data included in the descriptive data section? Lots of information presented here, but where are the actual statistical findings? Lots of revisions required here. Refer to template and DNP DPI project guide.
The DASH project showed an increase in the participants' knowledge and awareness of DASH and its relationship to blood pressure and a decrease in participants systolic and diastolic blood pressures. The DASH intervention was structured to support the needs of the participants. Post- DASH food frequency questionnaires indicated that participants had changed some dietary habits during their participation in the DASH education.
Figure 1. The age range of the DASH participants at the clinic site.
Figure 2. The age groupings of DASH participants.
Table 1 Comment by Sharina Sigur: This should not be double spaced. Revise where needed.
Participants Pre- and Post-DASH Intervention Blood Pressure Measurements
|
Participant Number |
Pre-Education Systolic BP |
Post-Education Systolic BP |
Percentage Of Systolic Change |
Pre-Education Diastolic BP |
Post- Education Diastolic BP |
Percentage Of Diastolic Change |
|
H001 |
140 |
136 |
-2.86 |
100 |
96 |
-4.00 |
|
H002 |
130 |
126 |
-3.08 |
98 |
94 |
-4.08 |
|
H003 |
128 |
124 |
-3.13 |
86 |
78 |
-9.30 |
|
H004 |
132 |
130 |
-1.52 |
88 |
88 |
0.00 |
|
H005 |
130 |
130 |
0.00 |
92 |
88 |
-4.34 |
|
H006 |
146 |
138 |
-5.48 |
104 |
96 |
-7.69 |
|
H007 |
124 |
126 |
1.61 |
86 |
82 |
-4.65 |
|
H008 |
118 |
122 |
3.39 |
84 |
86 |
2.38 |
|
H009 |
136 |
130 |
-4.41 |
100 |
92 |
-8.00 |
|
H010 |
140 |
132 |
-5.71 |
100 |
94 |
-6.00 |
|
H011 |
144 |
136 |
-5.56 |
102 |
98 |
-3.92 |
|
H012 |
132 |
134 |
1.52 |
86 |
84 |
-2.33 |
|
H013 |
146 |
140 |
-2.74 |
98 |
92 |
-6.12 |
|
H014 |
124 |
128 |
3.23 |
82 |
84 |
2.44 |
|
H015 |
138 |
138 |
0.00 |
88 |
90 |
2.27 |
|
H016 |
136 |
130 |
-4.41 |
88 |
84 |
-4.55 |
|
H017 |
130 |
132 |
-1.54 |
90 |
90 |
0.00 |
|
H018 |
128 |
122 |
-4.69 |
96 |
94 |
-4.17 |
|
H019 |
130 |
128 |
-1.54 |
96 |
90 |
-6.25 |
|
H020 |
142 |
144 |
1.41 |
102 |
104 |
1.96 |
|
Note. Gray cells indicate the percentage of reduction of BP measurements pre- and post-intervention. 13 participants had lower systolic measurements and 14 participants had lower diastolic measurements post DASH intervention. |
Considering the above table of descriptive statistics. The sample consists of 20 individuals whose systolic BP and diastolic BP is recorded, once before the education and once after the education.
Figure 3 Comment by Sharina Sigur: This is not formatted correctly. Refer to template for guidance.
Figure 4
Figure 5
Looking at the Systolic BP levels, the sample had a mean of 133.70, before undergoing the education. The sample mean for systolic BP declined to 131.30 levels post the education program. The median systolic BP level also declined by 2 units post the education for the sample. The mode systolic BP level remained unchanged at 130, that means most people having 130 level of systolic BP level in our sample, in the pre-education and post education. If we look at the percentage change in Systolic BP levels of the sample from pre-education to post education periods, we observe that the mean change of Systolic BP declined by about 1.78%. Thus, the education reduces the levels of systolic BP by about 2% for the sample observations.
Figure 6
Figure 7
Figure 8
Now, considering the Diastolic BP levels, the diastolic BP level mean declines from 93.40 to 90.20, after the education program. The median diastolic BP levels also fall post education by almost 4 units. The mode diastolic BP levels decline from 86 to 84, which is also a great sign for the education program. Looking at the percentage change, the mean change of diastolic BP levels declined by 3.3%. This shows how effective the education program was.
The standard deviation for post education program, for both diastolic and systolic BP levels decline meaning, the data tends to get more towards the mean, which is a great sign, and the probability of eliminating outliers is high once the individuals go through the education program.
Table 3
Pre-DASH Education Questionnaire Responses
|
Questions 1-5 |
Completely Disagree |
Somewhat Disagree |
Neither Agree Nor Disagree |
Somewhat Agree |
Completely Agree
|
|
I know what DASH stands for |
12 |
4 |
1 |
2 |
1 |
|
I know about The benefits of DASH diet |
10 |
6 |
0 |
3 |
1 |
|
I can identify Foods in the DASH diet |
8 |
6 |
1 |
3 |
2 |
|
It is important to understand DASH diet |
6 |
1 |
7 |
1 |
6 |
|
Following the DASH diet can improve my blood pressure |
6 |
2 |
5 |
2 |
5 |
|
Note. Number represents the number of participants who chose the response on a 5-point Likert-type scale that elicited baseline DASH knowledge. |
Table 4
Post-DASH Education Questionnaire Responses
|
Questions 1-5 |
Completely Disagree |
Somewhat Disagree |
Neither Agree Nor Disagree |
Somewhat Agree |
Completely Agree
|
|
I know what DASH stands for |
2 |
2 |
0 |
12 |
4 |
|
I know about The benefits of DASH diet |
0 |
0 |
0 |
11 |
9 |
|
I can identify Foods in the DASH diet |
0 |
0 |
0 |
9 |
11 |
|
It is important to understand DASH diet |
0 |
0 |
0 |
6 |
14 |
|
Following the DASH diet can improve my blood pressure |
0 |
0 |
0 |
5 |
15 |
|
Note. Number represents the number of participants who chose the response on a 5-point Likert-type scale after the DASH Intervention. |
Before the DASH program intervention, following was the statistics observed. Before the education program most participants did not have any idea about what DASH stood for. Post the education program, most participants knew somewhat what DASH meant, thus the program bought about awareness among sample observations on what DASH meant.
Before the program, most participants did not know the benefits of DASH. Post the awareness program on DASH, majority people understood the benefits of DASH. Most people could not identify foods with DASH before the program, but they started understanding that post the program. Participants did not feel there was a need to understand DASH diet before the program, but post the program, they agreed to the importance of understanding the DASH diet.
Very importantly, before the education program, only a few strongly agreed to the fact that DASH diet could improve BP levels. But post the education program, almost half the sample shifted to strong agreement that DASH diet could in fact improve BP levels.
Table 5
Response to Food Frequency Questionnaire Pre and Post DASH Intervention
|
Participants Self-Reported Daily Food Intake by Food Group |
||||
|
|
1 Serving |
2 Servings |
3 Servings |
4 or more Servings |
|
|
Pre Post |
Pre Post |
Pre Post |
Pre Post |
|
Grains |
13 8 |
5 6 |
2 3 |
0 2 |
|
Vegetables |
15 6 |
4 6 |
1 6 |
0 2 |
|
Fruits |
16 8 |
2 9 |
0 1 |
2 2 |
|
Note. Numbers represent the number of participants who chose the number of daily servings for each food group. |
Observation showed that grain consumption mean increases from 1.45 times to 2.05 times, and the median increases from 1 to 2. This shows more people are inclined towards consuming more times grains during a day. The mean and median consumption times for Vegetables also increases from pre-event to post event. Consequently, more people are preferring high times consumption of fruits post event than pre-event. Thus, the event generated awareness about the health benefits of consuming fruits, vegetables and grains more times in a day to better BP levels and health of individual.
Summary Comment by Sharina Sigur: Underdeveloped.
There were improvements in the participants' responses to increasing daily servings of grains, vegetables, and fruits. The results of the pre- and-post-questionnaires showed that DASH education enhanced participants' knowledge, awareness, and the likelihood of making dietary changes. The DASH education also showed there was a significant decrease in participants systolic and diastolic blood pressures post DASH program intervention. The findings indicated that the structured DASH educational intervention presented increases the knowledge, awareness, and attitudes of change in nutritional habits after the DASH intervention.
Chapter 5 Comment by Sharina Sigur: Refer to template for correct title. This chapter requires revisions to include discussion related to statistical findings.
Hypertension remains a growing problem among the African American workforce, especially in production facilities, where there is limited access to healthy food choices due to long shifts and short break periods. According to Blumenthal et al. (2010), lifestyle modification, such as the adoption of the Dietary Approach to Stop Hypertension (DASH) diet has the potential to reduce blood pressure. Dietary modification is often discussed with patients and can provide a significant benefit in blood pressure management. The objective of this quality improvement was to determine whether post DASH education will show a reduction in the participants’ systolic and diastolic blood pressure. This project was centered around a DASH diet intervention aimed to improve awareness and knowledge of nutritional components in hypertensive African American patients in an outpatient clinic.
This project implementation introduced the DASH diet and education on the nutritional components of DASH at an outpatient primary care clinic. This chapter will discuss the significance of the findings, strengths, weaknesses, and challenges that took place during the planning and implementation of this DPI project in the clinic.
Summary of the Project
The strategies that were implemented through this quality improvement project focused on the contributions that nutritional education and subsequent adoption of the DASH program can play in blood pressure reduction for individuals. The results of this project answered the clinical question; “To what degree does the implementation of a Dietary Approach to Stop Hypertension program impact blood pressure of patients diagnosed with hypertension when compared to no intervention among African American patients in an outpatient clinic in Washington, D.C.?” and showed that some participants exhibited a reduction in blood pressure and low to moderate modifications in daily servings of grains, vegetables, fruits and increased knowledge about the DASH.
The increase in the food frequency intake as recommended by the DASH diet could demonstrate improved nutritional knowledge and awareness of the benefits of increasing servings in grain, fruits, and vegetables, which are essential components of the DASH. The findings indicated that some individuals simply lacked knowledge about dietary benefits prior to the DASH education program. Once the education was provided, these individuals used their newly acquired education to increase their daily intake of beneficial foods. These findings have the potential to support a need for ongoing structured nutritional education programs for pre-hypertensive and hypertensive patients in the outpatient clinic setting. The aim of this quality improvement project was to show that participants will be better prepared to adopt some recommendations of the DASH diet, including appropriate amounts of sodium, potassium, calcium, magnesium, and fiber. All these components affect blood pressure.
Studies have shown that DASH diet adherence reduces hypertension and can lower cardiovascular risk factors such as strokes, heart attacks, and congestive heart failure, which are high dollar emergency room visits (CDC, 2017). As such, patient’s understanding of the DASH diet can reduce the long-term disease burden of hypertensive diagnoses. The goals for this quality improvement project were to show there is a need for expanding the services of the outpatient clinic to include nutritional education with patients. This quality improvement project has improved patient activation for self-management of hypertension.
Summary of Findings and Conclusions
Hypertension continues to be a growing problem in America. There is an increasing need to reduce the burden of chronic disease associated with hypertension, including the increased risk of death and the costs related to treating and managing the hypertension-related disease. According to NHLBI (2015), initiating lifestyle modification, such as dietary changes, can have a significant effect on the reduction of blood pressure.
This quality improvement project demonstrated an effective way to increase patient’s knowledge and adherence of the DASH diet for participants in an outpatient primary are clinic. Another aim for this quality improvement project was for patients to have a lower diastolic or systolic blood pressures at the end of the 4-week DASH diet education series. This was an indication of positive benefits from the DASH education program for patients diagnosed with hypertension. This project provided participants with face-to-face education on hypertension and the DASH diet, as well as DASH diet pamphlets that could be used to guide food choices.
The DASH program provided education sessions that were interactive and motivational. Based on participants’ self-report, the project goal was to enhance participant knowledge, adherence, and self-efficacy in making meaningful changes in dietary habits. Sustainability of this project required interprofessional team, minimal financial resources, and increased staff support to provide patients with ongoing DASH education in the primary care clinic.
Implication
Theoretical Implications. The HPM that is used universally for science, education, and practice was developed by Pender. The aim of this model used in this DPW was to help people achieve higher levels of well-being and to recognize background factors influencing health behavior. It promotes the provision of supportive services by health providers to help patients make specific behavioral improvements. Using the model in the outpatient clinic setting and working with the patient/client in partnership, the provider and other clinic staff can encourage the client to adjust habits and maintain a healthier lifestyle. The HPM's goal, therefore, is not only to help patients avoid disease through their actions, but to look at ways a person can pursue better health, specifically better hypertension management.
Practice Implications. Teaching the DASH eating plan as a health promotion initiative can support healthy dietary habits that patients can use throughout life. Education on the DASH has been shown to prevent other serious medical conditions such as heart attack, strokes, heart failure, kidney disease, and colon cancer (CDC, 2017). Creating a structured approach to educating patients on this diet is an easy, low-cost health promotion initiative for any size outpatient primary care clinic. While DASH is primarily known to lower blood pressure, it may also promote weight loss (CDC, 2017). This could help decrease healthcare costs associated with obesity and obesity-related diagnoses. An additional benefit of DASH diet education is the mental and physical health benefits experienced by patients due to increased energy from proper nutrition. Improved nutrition could help to combat stress-related work-life balances.
Future Implications. This DASH education quality improvement project can be a lifelong eating plan that focuses on consuming fruits, vegetables, lean proteins, whole grain, and the reduction of foods high in sugar or sodium. Providing nutritional education in the clinic increases accessibility to patients during their visit. Another benefit is participants were distributed DASH diet pamphlets that can be used as ongoing guides to assist in maintaining adherence to DASH diet recommendations. Outpatient clinic interventions, such as those used in this quality improvement project, can improve the provider-patient relationship, which can increase the likelihood that patients will maintain healthy eating habits.
Recommendations
Recommendations for Future Projects. After implementation, data recommended that this quality improvement project be replicated at other clinics as an intervention to increase participants’ motivation and self-efficacy toward pre-hypertension and hypertension self-management. The result of this project could bridge the gap to offer a more structured nutritional program to empower patients to optimize wellbeing through dietary choices. This project could open a collaboration with health insurance companies to negotiate nutritional services to be covered in an outpatient clinic. Outpatient primary care clinic settings should include prevention of chronic disease and other health promotion activities, as well as treatment and management of chronic diseases.
At the end of this quality improvement project, it is recommendation that an interprofessional group provide education and counseling sessions to assist patients in changing dietary habits that contribute negatively to pre-hypertension and hypertension. It is also recommended that patients be given time during their office visit to receive or attend education and counseling sessions. This will likely maximize patient participation. Empowering patients to optimize their wellbeing through diet education would be best achieved with the addition of health coaches or nutritional coaches. Health coaches promote wellness and lifestyle changes, including dietary counseling, lifestyle modification through behavior change, and chronic disease self-management sessions.
Another recommendation would be the onboarding of nutritional health promotion through telephonic or virtual nutritional counseling. Providing service at this level could support the health, nutrition, and stress management of the employees. This could allow patient spouses and family to be integrated into the nutritional education process; spouses may be shopping for food or preparing the meals. Providing spouses with nutritional counseling could have a direct impact on family health. Costs for the nutritional health promotion staff could be minimized by other clinic staff members such as nurse educators, nursing students or interns.
Recommendations for Practice. Interprofessional collaboration for improving patient and population health outcomes is essential. The focus would be on inter-professional collaboration with inter-professional teams to improve patient, population, and health care delivery system outcomes (AACN, 2006). The growing complexity of health care often requires a collaborative approach to best address patient needs. The successful implementation of this project could possibly involve collaboration between providers and the health system, specifically the primary care outpatient clinics and a DNP prepared clinical education director.
Communication with leaders of the organization was necessary to be granted permission to implement this project at the outpatient clinic locations. Clinical prevention and population health for improving the nation’s health. After the quality improvement project, the investigator was able to analyze data on individual and population health and synthesize concepts related to health promotion and illness prevention (AACN, 2006). Healthcare providers will be able to use education on the DASH diet to address health promotion and population health among a hypertensive and pre-hypertensive population in the outpatient wide health care settings. The risks associated with hypertension are significantly reduced when blood pressure is decreased. This quality improvement project has shown that it could contribute to decreasing the burden of hypertension through participants' awareness of the DASH diet as lifestyle modification.
The project’s goal was to increase dietary knowledge, adherence and increase patient self-efficacy of hypertension, and self-management through education on the DASH eating plan. The application of this knowledge resulted in improvements in systolic and diastolic blood pressure, increased knowledge of the DASH and improved patient food choices. The work that was invested in this quality improvement project enhanced my current knowledge of nutrition and uncovered new knowledge because of the DASH diet education. This DPI project has generated new knowledge for practice through the integration of systematic literature review and utilizing clinical expertise and patient preference to make changes in the outpatient care clinics. These changes lead to improved patient hypertensive outcomes and increase providers professional development.
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Appendix A 10 Strategic Points Comment by Sharina Sigur: Appendix A is the 10 Strategic Points for the proposal and then, it is replaced with the GCU QI/IRB determination (approval) letter for final manuscript
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10 Strategic Points |
Comments/Feedback |
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Broad Topic Area |
The impact of a DASH (Dietary Approach to Stop Hypertension) has on African American patients diagnosed with hypertension
African Americans are at an increased risk for developing HTN at an early age due to a gene that increases their sensitivity to salt (American Association for the Advancement of Science (AAAS), 2004; Rigsby 2011). This population is disproportionately affected by HTN when compared to other ethnicities (Rigsby, 2011). As a result, African Americans with HTN have an increased rate of stroke (80%) and heart disease (50%) when compared to other ethnicities (AAAS, 2004). Asante (2015) reported that 84% of African Americans did not understand HTN and chronic diseases related to lack of therapy. Hypertension occurs when the force of the blood flowing through a person’s blood vessels is consistently too high (AHA, 2017). The Center for Disease Control ([CDC], 2019) defines normal blood pressure (BP) as a systolic B/P less than120 mm Hg and diastolic B/P less than 90 mm Hg. Hypertension is the leading preventable cause of premature death worldwide (Mills et al., 2016). The principal health issues of four or more office visits to health care providers in the US is for HTN with an estimated direct and indirect cost of in 2014 is $51.0billion (CDC, 2019).
The main reason HTN goes untreated is that it can be asymptotic, thus affecting multiple organs and leading to chronic disease (Zollellner et al., 2014). Uncontrolled HTN increases morbidity and mortality systemically, causing cardiovascular (CV) disease (heart failure, heart attack), cerebrovascular (stroke. transient ischemic attack), and end-organ damage (left ventricular hypertrophy (LVH), hypertensive retinopathy and peripheral arterial disease. (Chobanian et al., 2003). An analysis from the Framingham Heart Study showed that compared with those with optimal blood pressure (BP) (SBP120/b80mm Hg), persons with BP in the prehypertension range (systolic BP 130-139 mm Hg, diastolic BP 85-89 mm Hg) had a higher 10-year incidence of cardiovascular disease (CVD; hazard ratios of 1.6 for men) (Vason et al., 2001). The United States prevalence of hypertension is 43.0% among African American men compared with 33.9% among Caucasian men (Chobanian et al., 2003). Practical use of dietary interventions in patients with pre-hypertension could lead to more optimal pressure (Ard, Sevetkey, & Durham, 2005). A 5 mm Hg reduction in systolic blood pressure (SBP) in the population would lead to a 9% to 14 % reduction in CVD related mortality rates (Suhui, Bruen, Lantz, & Mendez, 2015).
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Literature Review |
Background of the problem/Gap: A literature review provides a more comprehensive understanding of the healthcare problem for this chapter. A review and synthesis of the current literature support the DASH as an evidence-based patient education tool used in the management of patients with HTN to improve patient outcomes. The DASH is an effective way to reduce blood pressure. Lifestyle modifications recommendations of diet and exercise can be difficult if patients are not given specific guidelines. Diet and lifestyle changes are more effective when healthcare providers give patients clear and concise guidance. The DASH intervention offers patients clear dietary guidance and assists with meal planning. The DASH can have a significant impact on HTN especially in the African American population and should be used as a primary intervention to decrease HTN. Hypertension continues to be a worldwide health problem. It is the most common condition treated in primary care and can lead to myocardial infarction, stroke, renal failure, and death if not detected early and treated appropriately (Oza & Garcellano, 2015). Research suggests that HTN rates in African Americans is higher than any other ethnic group, and BP control remains inadequate in this population. The DASH dietary pattern can be easily educated and adopted by all population groups offering the most cost-effective intervention to serve as the primary and secondary prevention of elevated blood pressure and its complications (Saneei et al.,2014).
Theoretical Foundation Pender’s Health Promotion Model. This model focuses on behavioral change and improving patient outcomes.
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Problem Statement |
It was not known if or to what degree the implementation of dietary approach to stop hypertension (DASH) practice change would impact the patients’ blood pressure when compared to no intervention among African American patients diagnosed with hypertension in an outpatient clinic in Washington, D.C. |
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Clinical/PICO Questions |
Does an educational overview regarding Dietary Approaches to Stop Hypertension (DASH) diet increase patient knowledge thus improving patient’s management of hypertension? |
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Sample |
· Patients between the age of 18 and 65 years old. · Patients diagnosed with hypertension. · Patients that are African American. · Patients that are fluent in English. · Patients with no history of other medical conditions that might alter their blood pressure (i.e., double mastectomy, poor circulation, arteriovenous shunt). · Informed consent needed as data will be collected by clinical staff and given to principal investigator for quality improvement project.
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Define Variables |
Independent Variable: DASH diet intervention Dependent Variable: Patients blood pressure readings before and after the DASH diet intervention. |
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Methodology and Design |
This project will use a quantitative methodology with a quasi-experimental. |
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Purpose Statement |
Is to determine if or to what degree the implementation of a Dietary Approach to Stop Hypertension education intervention for patients would impact the patients’ blood pressure and dietary compliance when compared to no intervention among African American patients diagnosed with hypertension in an outpatient clinic in Washington, D.C.
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Data Collection Approach |
· Onsite de-identified data collection from staff (Demographic questionnaire) · Utilize the clinical staff to provide the education intervention to patients. · Utilize the clinical staff to give pre-posttest to patients before and after the education intervention. · Work with the clinical staff to obtain de-identified blood pressure measurements from patients at the beginning and end of the quality improvement project. · Access to the clinic’s Electronic Health Record (EHR) to review charts to collect de-identified data. · Clinical staff will include Registered Nurses and Medical Assistants. Data will be collected for 4 weeks and destroyed 6 months post intervention by locked shredder box. |
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Data Analysis Approach |
IBM SPSS Statistical Software for percentage change of blood pressures from the pre-and-post test of DASH and to determine the amount of knowledge gained. |
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Appendix B Comment by Sharina Sigur: This should be bolded. Refer to template and revise where needed. Comment by Sharina Sigur: Is this a consent form? Informed consent is not included as an appendix (it is located in IRB packet) Appendix B is the resource/instrument (toolkit, screening tool, clinical practice guideline, etc.) used in the evidence-based intervention
DIETARY APPROACH TO STOP HYPERTENSION (DASH) Diet Program Comment by Sharina Sigur: This should not be in all caps.
The is a quality improvement education project to improve your knowledge of the DASH diet recommendation. This information may improve your blood pressure outcomes because you have high blood pressure or want knowledge on ways to prevent high blood pressure. By participating in this project, I hope that you learn that the DASH diet education may have a significant impact on your dietary compliance to prevent or improve your blood pressure.
The education session will be weekly for a total of four sessions. The total amount of time for each session should be about 45 minutes. Your blood pressure will be taken at the beginning of the first session and at the end of the fourth. You will be asked to complete a pre- and post-education questionnaire. No identifying or confidential data will be shared.
Thank you for your participation,
Participant’s Name (Print)___________________________________
Participant’s Name (Signature)________________________________
Clinical Staff (Signature)______________________________
Appendix C Comment by Sharina Sigur: Appendix C is the evidence of permission to use the resource/instrument Additional appendices may include other resources/instruments; permissions to use resources/instruments as applicable; and educational material that is relevant to the intervention
Intake Survey Tool
CODE#_______
1. What is your age?
a. 21-29
b. 30-39
c. 40-49
d. 50-59
e. 60-69
f. 70 or older
2. What is your Gender?
a. Male
b. Female
3. What is your race?
a. White
b. African American
c. Asian or Pacific Islander
d. American Indian
e. Other. Please specify__________
Appendix D Comment by Sharina Sigur: Descriptive title is missing. Why isn’t this included in chapter 4?
Sample size 20.
n = 20
d = 0.5
sig.level = 0.05
power = 0.337939
alternative = two.sided
NOTE: n is number in *each* group
Power for T Test would be 0.33 for sample size.
Appendix E
Appendix F
DASH Diet Food Frequency Questionnaire tool
Appendix G
DASH Diet Education and DASH Education Sessions
Session 1 (Week 1)
· Introduction
· Blood pressure checks
· Prequestionnaire distributed
· Distribute handouts
· Overview of hypertension
· Summarize material and answer questions
Session 2 (Week 2)
· Review any questions from the initial session
· Prequestionnaire distributed if not completed the last session
· Distribute handouts
· Overview of sodium (salt)
· Comparing and Reading food labels
· Summarize material and answer questions
Session 3 (Week 3)
· Review any questions from the previous session
· Distribute handouts
· Introduction to DASH diet eating plan
· Overview of Grains, Vegetables, Fruits and Meats
· Plan recipes and review creating a menu
· Distribute DASH diet pamphlets
Session 4 (Week 4)
· Review any questions from the last session
· Discussion about DASH diet menus created
· Overview of the other components of DASH
· Discuss Nuts, Low fat dairy, Sweets and Oils
· Blood pressure checks
· Summarize DASH recommendations
· Complete post-education questionnaires.
Appendix H
Appendix I Comment by Sharina Sigur: Site authorization letter is not included as an appendix.
Appendix J Comment by Sharina Sigur: Site authorization letter is not included as an appendix.
Appendix K Comment by Sharina Sigur: This can be removed.
Racial Diversity of DASH Participants African American Caucasians Hispanics Asian or Pacific Islanders American Indian 20 0 0 0
Age Range of DASH Participants 18-29 30-39 40-49 50-59 60 and Over 7 6 5 2 0
What is my DPI project design? Does the project have a practice improvement or intervention? YESIs the treatment tightly controlled by the investigator? YESWill a randomly assigned control group be uses? NOQuasi-Experimental DesignNon-Randomized Control Group Design.
What is my DPI project design?
Does the project have a practice improvement or intervention?
YES
Is the treatment tightly controlled by the investigator?
YES
Will a randomly assigned control group be uses?
NO
Quasi-Experimental Design
Non-Randomized Control Group Design.
