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Current Blood Pressure Self-Management: A Qualitative Study
Blood pressure (BP) self-management is advocated to manage hypertension and reduce the risk of a future stroke. The purpose of this study was to identify BP self-management strategies used by individuals who had sustained a stroke or transient ischemic attack (TIA). As part of a mixed-methods study, we conducted six focus groups and achieved saturation with 16 stroke survivors and 12 TIA survivors. Each participant completed a questionnaire regarding current BP management. We analyzed and coded qualitative transcripts from the focus groups and found four emergent themes that were supported by questionnaire results. The four self-management themes include: (1) external support for BP self-management is helpful; (2) BP self-management strategies include medication adherence, routine development, and BP monitoring; (3) BP risk factor management involves diet, exercise, and stress reduction; and (4) taking advantage of the “teachable moment” may be advantageous for behavior change to self-manage BP. This research provides key elements for the development of a successful BP self-management program.
Stroke is the primary cause of disability and the third-leading cause of death for people older than 65 years (Duncan et al., 2005; Wolf et al., 1999). Annually, nearly 200,000 of the 700,000 strokes reported in the United States are recurrent, and one-third of those people who survive a stroke are likely to experience a second stroke within 5 years (Thom et al., 2006). Prevention of a first or second stroke is possible by identifying and intervening around modifiable stroke risk factors including hypertension, dyslipidemia, diabetes mellitus, physical inactivity, obesity, alcohol consumption, and smoking (Sacco et al., 2006).
One of the most prevalent stroke risk factors is hypertension (Goldstein et al., 2006; Sacco et al., 2006; Seshadri et al., 2006). Controlling blood pressure (BP) is an efficacious strategy to prevent future strokes (Andrawes, Bussy, & Belmin, 2005). A 14% reduction in stroke risk may be achieved with just a 5-mmHg decrease in systolic BP (Chobanian et al., 2003) and a 42% reduction with a 5–6-mm reduction in diastolic BP (Collins et al., 1990). Achieving good hypertension control relies on medication management and important lifestyle modifications including physical activity, stress management, weight loss, smoking cessation, and dietary changes (Chobanian et al.; Goldstein et al.).
Stroke survivors are the group at highest risk for a recurrent stroke due to the impact of continued, unhealthy lifestyle choices and practices regarding stroke risk factors (Hoenig, Nusbaum, & Brummel-Smith, 1997). Patient self-management behaviors, including medication adherence, diet, and exercise, have significant effects on BP control. Accordingly, current stroke care guidelines recommend that all patients be provided with self-management education. This exploratory investigation focused on BP self-management practices and preferences among patients who had sustained a stroke or transient ischemic attack (TIA).
Research Design and Participants
This mixed-methods study used a short questionnaire and focus groups to explore current strategies and needs for BP self-management. All study participants had sustained a stroke or TIA and were veterans treated at the Richard J. Roudebush Veterans Administration Medical Center (RVAMC) in Indianapolis, IN. The Indiana University Institutional Review Board and the RVAMC Research and Development Committee approved this study. Each participant was an informed and consented volunteer.
Veterans with a stroke or TIA in the past 2 years were identified through medical records. Each was invited to participate in the focus groups by mail. Responses to participate were completed by mail or phone call. Inclusion criteria included ischemic stroke or TIA in the past 24 months, the ability to communicate orally, a completed questionnaire, and travel to the RVAMC.
Focus Group Guide and Questionnaire
Focus groups were used to gather in-depth qualitative data and were guided using a developed script (Fontana & Frey, 1994). Focus groups began with veterans completing a short questionnaire regarding current BP self-management and the modified Rankin scale (Bonita & Beaglehole, 1988; Rankin, 1957) to assess current stroke severity. We developed both the questionnaire and focus-group guide based on a review of the literature (self-management, stroke, BP, nursing) and clinical experience.
The questionnaire included demographic information, knowledge about target BP, BP-monitoring practices, and currently utilized BP self-management strategies. The questionnaire was used to prompt thinking about BP self-management and facilitate discussion during the focus groups.
The focus-group guide included open-ended questions about current attitudes, practices, and needs for BP self-management. Specifically, the moderator explored current BP monitoring and self-management practices initiated by patients and healthcare providers. Probes were used to ensure depth of coverage of content. The focus-group questionnaire and guide are available upon request from the authors.
Examples of focus-group-guide questions include
Focus groups were all led by a trained moderator. Training and skills of the moderator and researchers helped ensure the trustworthiness of the qualitative work. Focus groups were videotaped and audio recorded. All audiotapes were transcribed and transcripts were placed into a word-processing document.
Quantitative data analyses were completed on questionnaire data with SPSS (version 15.0). Means and standard deviations or frequencies and proportions were used to describe cohort characteristics. Comparisons between those with stroke or TIA were made using t tests and chi-square test, as appropriate.
Three stroke researchers, separate from the moderator, independently reviewed the transcripts and coded the data segments into key themes. Initially, the three researchers identified 12 emergent general themes from the data; all were influenced by supportive literature, clinical experience, and questionnaire results.
Using the 12 emergent themes and an iterative consensus-building process, the researchers generated an agreed-upon set of codes and a code book for coding data. The researchers then agreed upon four primary themes and multiple secondary themes that encompassed all constructs of the focus groups and were derived from the initial 12 emergent themes (see Table 1). Primary or major themes were those that were highly prevalent and discussed in-depth, while secondary themes were less prevalent across groups but still considered relevant. Each researcher then independently reanalyzed and coded supporting quotes under each primary or secondary theme. All comments were synthesized and discussed as needed for consensus regarding coding of each quote, thus ensuring trustworthiness of the analysis. The objective was to detect patterns in data that characterized BP self-management.
A total of 142 veterans were identified as having a stroke or TIA in the previous 2 years. All were invited to participate in the study and 28 (20%) eligible veterans responded and were scheduled for a focus group. Of the 28 veterans, 16 (57%) had sustained a stroke and 12 (43%) had sustained a TIA. We conducted six focus groups, stratified by TIA or stroke; each group was composed of 4–6 participants and achieved content saturation.
There were no significant differences in participant characteristics, target BP, BP monitoring, or BP self-management between those poststroke versus post-TIA (Table 2). All but one participant was male and the average age was 67±13 years. Most participants (79%) knew their target BP should be <140/90 mmHg. Twenty-one (75%) participants reported self-monitoring, with 19 (68%) participants checking BP at home. Frequency of monitoring varied from once/more than once a day (28%) to not at all (11%). Those post-TIA were more likely to monitor BP daily than those poststroke (42% and 19%, respectively).
In addition, all but one veteran took at least one antihypertensive medication. The most common nonpharmacological strategies for BP management were diet (64%), exercise (40%), and stress management (36%). Questionnaire data informed the qualitative analysis.
Qualitative data analysis revealed four primary BP self-management themes: external support for BP management, BP self-management strategies, BP risk- factor management, and the “teachable moment.” We describe each theme, with supporting quotes.
External Support for BP Self-Management
Numerous participants indicated that communication with caregivers or healthcare providers—doctors, nurses, and rehabilitation providers—helped with BP self-management. Communication with medical providers was identified as a key element to improved BP self-management. One participant said, “With their help I’ve been managing my BP and I’m pleased with that…”
However, veterans requested enhanced education and training from healthcare providers to manage BP. One participant commented:
“I don’t know if this goes with this but I know when I was in the hospital, they put me on insulin but I never had anybody actually show me a class or nothin’. Same thing with stroke. I would like to see if you come to the hospital for stroke…they put [you] through the ringer and teach ya this stuff while you’re in the hospital.”
Informal caregiver concern influenced BP self-management. Some veterans were dependent on spousal reminders for medication adherence. Caregiver influence is evidenced by the quote:
“She said, ‘You may not care about being around…but I’d like you around for a little longer.’ So that made me stop and grow up a little bit more…So now I monitor myself regular[ly] every morning, like clockwork, and I take my pills every morning, which I used to never do.”
Stroke and TIA survivors indicated that external support affected BP self-management.
BP Self-Management Strategies
Group discussions confirmed that participants identified medication, medication adherence, and medication routines as important BP self-management strategies. Medication adherence was identified as the most important issue to discuss with a new stroke or TIA survivor. However, others discussed forgetting to take medicine and difficulty with the development of and adherence to a medication routine.
“It’s right there on the counter [pill box] and I walk past it a dozen times and just don’t know it’s there. I’ve got something against pills, I think.”
“Everybody’s taking some sort of medicine to help manage BP. Everybody’s on different stuff but at least something.”
“Well, I have one of these boxes.”
Conversations indicated that many veterans monitored BP, but frequency of monitoring varied. One stroke survivor stated, “Just periodically I check it. I’m not on a regular schedule.” However, others implied more frequent use, “…I monitor it…I check it once a day…”
Many veterans owned a BP-monitoring machine and they encouraged others to obtain a BP-monitoring machine. Although many monitored their own BP, participants reported a lack of knowledge regarding target BP and what to do with elevated BP.
“They [BP-monitoring machines] are very simple and if you want one, your doctor can get you one right here from the VA.”
“Where should it [BP] be? That way I’ll know if me or the missus gotta give a call to an ambulance to come get me…because I don’t know what it’s supposed to be. I don’t know if I should call.”
Reliance on Own Body and Symptoms
Although many participants knew the importance of BP monitoring and medication routines, some were reliant on symptoms to determine a need for monitoring and medication. Study participants discussed the idea of their body “telling” them something was wrong, and then pursuing care or medication.
“…start feeling bad…take my medicine…”
“At no certain time…If I feel like a little light headed or something, I take it…You know your own body. I don’t use the equipment till I start feeling out of place.”
Both those who survived a stroke or a TIA indicated that assistance with the development of a medication and BP-monitoring routine and increased knowledge about target BP and symptom management would be helpful in BP self-management.
BP Risk Factor Management
Diet and Nutrition
Focus group participants indicated that change in diet and nutrition is important in managing BP. Participants learned about diet changes through nutritionists, other medical professionals, or classes.
“The class contains how you should eat—I lost probably 20 lbs…”
“Big, big, red stop sign for me, boy, it was like slow down. This is some serious stuff...I mean it really did put the brakes on for me. I’ve always been a ‘saltaholic.’ I’m a farmer, so there’s eggs and bacon and all that stuff every single day of my life, your cholesterol’s through the roof. And I weighed 50 more pounds than I do today…”
Exercise and Physical Activity
Some participants discussed exercise and physical activity as a way to manage BP. When asked what would be the easiest thing to do to control BP, one veteran stated, “Exercise. It’s so easy just to walk somewhere.”
Some participants did not engage in exercise, either because it is generally unfamiliar or undesirable or because of concerns about possible injury or increased stroke risk:
“…exercise less for a stroke patient you wouldn’t want more. I would think a stroke patient should exercise less…or in a different manner.”
“Exercise…well, that’s a dirty word. I hate it.”
Overall, the veterans reflected knowledge of the importance of diet and exercise to help control BP but had variable success, and possible fear, in actually using these strategies.
Stress Reduction and Management
Many veterans reported a desire to reduce stress to decrease BP and the risk of a second stroke. Stress was related to work, family, finances, and fear of disability and subsequent strokes. One participant stated that stress-reduction classes helped him change his attitude toward people and himself, thus lowering his stress and BP.
“I was always angry and mad…now [after TIA], I try to stay away from anything and anybody that causes me any kind of stress.”
“Quit worrying about everything that comes up or…I just listen to my kids, ‘Dad quit worrying about it. Don’t worry about it, if it happens it happens.’ So I’m getting that attitude now. Cuz it’s to the point now I only get 3 hours of sleep a night. Cuz part [of the] time [I am] scared to go to sleep. So, I don’t get too much sleep.”
Veterans, as a group, were able to identify ways to manage risk factors and addressed barriers and facilitators to changing diet, physical activity, and stress.
The Teachable Moment
Both groups indicated that the period after a stroke or TIA is an important time to gain knowledge and consider lifestyle changes to reduce the risk of a stroke—a “Teachable Moment.” Such a moment indicates a readiness to change and an apt time for education from nurses or other healthcare providers.
“Medicine…before…if it was late in the afternoon, heck forget about it...Yea, I’m scared now. I maintain that schedule now.”
“It changed your life completely.”
“I really don’t know. Maybe because I watch it [BP] closer. I’m more, I’m careful what I do, what I eat. I don’t drink, used to drink. I just…things are different now. Cuz I know one of these days my body’s just gonna shut down. So, I’m trying to take care of it the best I can.”
These quotes suggest that targeting BP self-management, education, and training at the time following a stroke or TIA may be especially effective in facilitating management of secondary stroke risk factors.
Stroke and TIA survivors discussed current BP self-management strategies and experiences. Four emergent themes include: external support for BP management, BP self-management strategies, BP risk-factor management, and the teachable moment.
External Support for BP Management
External support from healthcare providers and informal caregivers may help facilitate BP self-management poststroke or post-TIA. This idea is supported by Ho and Rumsfeld (2006) who discussed the need for the alliance of the patient, provider, and healthcare system to achieve BP self-management. Our results indicate interest in enhanced provider education regarding home-monitoring, routine, and lifestyle modification. Key components of patient-provider communication include having nurses and other practitioners inform patients of their actual BP values during clinic visits, encouraging patients to record their BP values, and educating patients about BP targets and when to contact their healthcare provider about their BP. The finding that informal caregivers are noted as key players in BP management is consistent with findings from Bakas, Austin, Okonkwo, Lewis, and Chadwick (2002), who found that stroke family caregivers wanted to know more about stroke-warning signs, risk factors, recommended lifestyle changes following stroke, and medications.
BP Self-Management Strategies
BP self-management is extremely important to prevent future strokes or TIAs (Sacco et al., 2006). Nursing literature indicates that BP self-management strategies include both general nursing and patient awareness, but also education and techniques for monitoring and management (Davidhizar & Shearer, 2004). According to questionnaire data, the majority of our study participants were aware of their target BP and reported monitoring BP on their own, but lacked the understanding of what the numbers meant or what to do with those numbers. Although the groups are not significantly different, there is an evident trend that those who sustained a TIA were less likely to know their target BP. On the contrary, those with a TIA were more likely to receive nursing information regarding diet and nutrition than those who had survived a stroke. Perhaps those with a TIA have fewer stroke-related medical needs leading practitioners to spend time on education.
A meta-analysis demonstrated decreased BP with home monitoring (Cappuccio, Kerry, Forbes, & Donald, 2004). When working with a BP-monitoring machine, it is important to educate the patient—and caregiver—about their target BP, how to use the machine, how and when to record the BP, and what action to take based on the BP result. Having BP targets and self-monitoring has shown to be associated with improved hypertension control in diabetes (Cappuccio et al.; McManus et al., 2005). Nursing and other healthcare professionals may play a large role in facilitating self-monitoring and management of BP.
BP Risk-Factor Management
Interestingly, all but two participants, both survivors of a TIA, denoted the use of at least one BP-management strategy (e.g., diet, exercise, stress management) on the questionnaire. Many talked about their inability to engage in exercise because of poststroke physical disability or their beliefs that exercise was inappropriate poststroke. Substantial evidence from prospective and randomized-controlled trials suggests that the health benefits of chronic exercise outweigh the acute risks to participants (Gordon et al., 2004; Manini et al., 2006; Petrella, Lattanzio, Demeray, Varallo, & Blore, 2005; Piepoli, Davos, Francis, Coats, & ExTraMATCH Collaborative, 2004). This suggests that there are opportunities for nurses to engage in poststroke patient education regarding exercise.
Idea of the Teachable Moment
The teachable moment—the time directly following poststroke or TIA—is important because during this time, patients may demonstrate a new readiness to change after the event and it is an optimal time to introduce health-improvement activities to curb secondary stroke risk. This concept of the teachable moment is supported by Gillen (2005), who reported increased health awareness as a positive consequence following a stroke. The time poststroke or post-TIA is a critical window for nurses to provide organized materials and education regarding BP management to help prevent a future stroke.
This study involved a selection bias. The 28 participants included in the study self-selected themselves as participants and likely have less physical impairment than those who chose not to volunteer. Those who participated were able to communicate, which excluded those with aphasia. The all-veteran population and small sample size limited possible quantitative, statistical analyses and also decreased generalizability. In addition, all participants were recruited from the local VAMC in Indianapolis, IN, and their care likely differs from treatment received in other settings. One study participant was female. Her data were included but none of her quotes are in the article because they were not perceived to present any significantly different information from other participants’ insights [AU: EDIT OK?]. Despite these limitations, the qualitative aspects of this study have formed a useful framework from which to consider targeted interventions that can be delivered by nurses in the practice setting.
Implications for Rehabilitation Nurses
Nurses play a key role in medication management and health education during inpatient and outpatient care. Because of their significant role in one-on-one patient care, nurses are in a good strategic position to enhance BP self-management practices. (Zernike & Henderson, 1998). Brillhart and Johnson (1997) found that patients perceived rehabilitation nurses as providers who would take every opportunity to teach, which indicated that rehabilitation nurses have the opportunity to modify and enhance BP self-management to assist in secondary stroke prevention.
This research was funded through the VA as a locally initiated project by the National Health Services Research and Development office (HFP-05187).
About the Authors
Arlene A. Schmid, PhD OTR, is a core investigator at the Roudebush VAMC, HSR&D center of Excellence on Implementation of Evidence-Based Practices and the VA Stroke QUERI in Indianapolis, IN; and assistant professor at Indiana University Department of Occupational Therapy in Indianapolis, IN. Address correspondence to her at firstname.lastname@example.org
Teresa M. Damush, PhD, is a research health scientist at the Roudebush VAMC, HSR&D center of Excellence on Implementation of Evidence-Based Practices and the VA Stroke QUERI, in Indianapolis, IN; associate professor at Indiana University School of Medicine in Indianapolis, IN.
Laurie Plue, MS, is a research coordinator at the Roudebush VAMC, HSR&D center of Excellence on Implementation of Evidence-Based Practices and the VA Stroke QUERI in Indianapolis, IN.
Usha Subramanian, MD, is an assistant professor of medicine at Indiana University School of Medicine in Indianapolis, IN.
Tamilyn Bakas, DNS RN FAHA FAAN, is an associate professor in the Department of Adult-Health and codirector of the Center for Enhancing Quality of Life in Chronic Illness at Indiana University School of Nursing in Indianapolis, IN.
Linda S. Williams, MD, is the acting co-director of the Roudebush VAMC, HSR&D Center of Excellence on Implementation of Evidence-Based Practices and the research coordinator of the VA Stroke QUERI in Indianapolis, IN; and associate professor at Indiana University School of Medicine in Indianapolis, IN.
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