Nursing Interventions to Support Low-Income Individuals with Hypertension

Application of Self-Management Theory Using Clinical Data from Nurse Managed Health Centers

Mary Jo Baisch, PhD, RN

Kathleen Sawin, PhD, CPNP-PC, FAAN

Pei-Yun Tsai, PhD, RN

Bev Zabler, PhD, RN

Jean Bell-Calvin, MS, RN

Rachel Schiffman, PhD, RN, FAAN

UWM Nurse Managed

Health Centers

• Founded in 1978 – Community Nursing Centers (CNC) co-located in two

community social service agencies– Serve about 1000 clients per year in 5000 visits– Underserved populations across the lifespan

• Document outcomes of the Lundeen CNC model• Academic/practice model supports student and faculty

community health/primary care practice• Model of advanced practice nursing

Silver Spring Community Nursing Center

House of Peace Community Nursing Center

Documentation of NMHC Practice

• Developed a data system: ACHIS (Automated Community Health Information System) – Relational database– Longitudinally tracks nursing practice (began in 1986) – Includes demographic, billing, provider information

and health services for individuals and groups – Problems, interventions and outcomes coded using

Omaha System (ANA approved standard terminology for nursing)

Research Collaborative• UWM Self Management Science Center (SMSC)

– Initial funding by US National Institute of Nursing Research

– Expands programs of research that enhance the science of self-management in individuals and families

– Supports researchers in development, implementation, & evaluation of self-management interventions.

• UWM Institute for Urban Health Partnerships– Administrative home for CNCs– Mission: Promote health and reduce health disparities– Links practice and research

Goals of This Collaboration• Apply Individual and Family Self-Management

Theory as a conceptual model for improving outcomes in patients with hypertension.

• Determine how the ACHIS/Omaha System captures health care practices at the NMHCs.

Value of Theoretical Models for Practice

• Connects nursing “World-Views”

• Offers a systematic structure for nursing process

• Supports nursing as a discipline – knowledge building

Conceptual Frameworks

http://www4.uwm.edu/nursing/about/centers-institutes/self-management.cfm

Conceptual Frameworks

Specific Aims1. Map the ACHIS/Omaha System data elements

to the components of the Individual and Family Self-Management Theory

2. Describe the context data elements of the IFSMT

3. Determine if there are differences between the context data elements of IFSMT for clients with hypertension and those without.

MethodSetting

– 2 Nurse Managed Health Centers in a US midwestern, urban community

Sample– Hypertension defined in ACHIS/Omaha System

• Domain: Physiological • Focus/Problem Area: Circulation• Symptom: Abnormal blood pressure reading

– Clients identified with hypertension n=432• # of visits: Range 1-714 (M=20.22 + 45.31)

– Matched (age, race) control n=432• # of visits: Range 1-140 (M=7.15 + 10.96)

Data Analysis• Aim 1: A semantic mapping process was conducted

between Individual and Family Self-Management Science and ACHIS/OS data elements

• Aim 2-3: Descriptive statistics

Compared demographics between groups (Chi Square)

Compared groups for contextual and risk factors associated with hypertension (Chi Square)

http://www4.uwm.edu/nursing/about/centers-institutes/self-management.cfm

Complexity of Condition Variables in ACHIS/OS Specific to Hypertension

Significant level: p < 0.001

* Significant level: p < 0.001

IFSMT ACHIS/OS

Non-HTN group

HTN groupChi-

Squaren % n %

Complexity of Condition Specific: HTN

Role change 9 1.1 16 0.6 1.536Respiration 113 13.4 341 13.7 0.040Nutrition 287 34.0 1004 40.3 10.299*Physical activity 36 4.3 86 3.4 1.205Health care supervision

337 40.0 669 26.8 51.652*

Medication regimen

61 7.2 377 15.1 34.352*

* Significant level: p < 0.001

Client ID #

Problem/Focus Area Interventions

Signs and Symptoms

Outcomes Rating Scale

Targets

Omaha System Structure

http://www4.uwm.edu/nursing/about/centers-institutes/self-management.cfm

Physical & Social Environment

IFSMT ACHIS/OS

Non-HTN group

HTN group Chi-

Squaren % n %

Access to Care

Uninsured medical expense

256 40.1 670 46.7 7.700*

Health care supervision

337 52.8 669 46.6 6.799*

Setting and Provider Transitions

Inconsistent source of health care

76 11.9 122 8.5 5.946*

Transportation Transportation barrier

18 2.8 8 0.6 NA

*Significant level: p < 0.05

Physical & Social Environment

IFSMT ACHIS/OS

Non-HTN group

HTN group Chi-

Squaren % n %

Culture EthnicityAfrican AmericanCaucasianHispanicOthersMissing

377276

1012

87%6%1%2%3%

377276

1012

87%6%1%2%3%

Language barrier 6 0.9 4 0.3 NACultural barrier 3 0.5 2 0.1 NA

Social Capital

Neighborhood/workplace safety

4 0.6 14 1.0 NA

Interpersonal relationship 14 2.2 68 4.7 NA*Significant level: p < 0.05

http://www4.uwm.edu/nursing/about/centers-institutes/self-management.cfm

Individual & Family Factors

IFSMT ACHIS/OS

Non-HTN group

HTN group Chi-

Squaren % n %

Developmental Stages, Perspective

Age0-18 years old19-35 years old36-64 years old65 years or older

644

35923

110835

644

35923

110835

Abnormal weight/height/head circumference for age

0 0 0 0

Literacy Education barrier 6 11.5 18 15.9 NAInformation Processing

Cognitive 10 19.2 9 8.0 NA

Capabilities Physical activity 36 69.2 86 76.1 NA

ConclusionImplications for Practice

.

There is added value when applying theory to guide practice

• Systematic documentation of nursing practice and outcomes using standard terminologies is needed

• Standard terminologies used to document nursing practice can be used to test theoretical models for public health nursing.

• IFSMT offers a guide for understanding the context of individual and family self-management