University of Alberta

Awareness, Measurement, Treatment and Control of Hypertension

by
Donna Lee McLean

A thesis submitted to the Faculty of Graduate Studies and Research

in partial fulfillment of the requirements for the degree of

Doctor of Philosophy

Faculty of Nursing

Donna Lee McLean

Fall 2012
Edmonton, Alberta

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Dedication
Although there is only one name on this thesis, work of this undertaking is a much
supported effort, and this is monumentally true of this one. Without the continued
support of my parents, Emilie and Andrew Horboway and my children, Carson, Cierra
and Savannah, this endeavor would never have been accomplished. Thank you for
staying the course with me.
I would also like to dedicate this work to my grandparents who are now deceased, but
live in my memory, Lena and Zek Zaderey, Mary and Steve Horboway, who came to
Canada from the Ukraine, so our families would have a better life. They always
believed in having an education and supported me dearly, knowing it would open new
doors to opportunity.
Carson, Cierra and Savannah, I only wish that your future will hold similar
opportunities to pursue your educational dreams so you too can help others. There are
no short cuts to any place worth going.

Abstract
Hypertension is a complex, chronic condition that is often referred to as the
"silent killer". Most cases of hypertension either are not diagnosed or go untreated.
The condition is a key contributor to the development of cardiovascular and
cerebrovascular disease, with nearly two-thirds of all cases of stroke and one-half of all
cases of ischemic heart disease being directly attributable to hypertension.1
The purpose of this paper-based thesis was to explore and design a communitybased approach to improve blood pressure control. Given the great burden of illness of
cardiovascular disease in patients with high blood pressure, investment in novel
community-based strategies to improve the management of hypertension were and are
still greatly needed. As such, a multicentre randomized trial utilizing advanced nurse
practitioners and community pharmacists identified patients with diabetes and elevated
blood pressure using recommended screening methods, and acted as a liaison between
the patient and their primary care physician, and assisted in follow-up of these patients
to achieve the recommended target blood pressure.
This final dissertation consists of 5 papers related to blood pressure
measurement and hypertension management, whereby, four papers have already been
published. The final fifth paper (unpublished) uses historical method to review
selected nursing literature on blood pressure measurement between 1945 and 2000.

Lawes, C., Vander Hoorn, S. & Law, H. Blood pressure and the global burden of
disease 2000. Part II: Estimates of attributable burden. Journal of Hypertension, 24,
423-430.

The purpose of this historical research project was to undertake a beginning study of
the history of blood pressure measurement in nursing.
Treatment and control of blood pressure is a major public health problem.
Given the magnitude of this problem it is clear that traditional methods of patient
screening and management, primarily through family physicians have been inadequate
we need innovative community-based solutions whereby nurses and nurses
practitioners play a role. Improvements to the delivery of primary care must go
beyond the confines of the family physician's office and consider the important role
that other community-based healthcare professionals can play.
Word Count: 338

Acknowledgements
I wish to acknowledge the guidance and expertise of by both my thesis supervisors,
Dr. Pauline Paul and Dr. Rene Day. Your belief in the process and your gentle
sound research advice made this project evolve into an exceptional learning
experience. I am grateful for your support and encouragement. I wish to extend a
special thank you and gratitude to my supportive committee members:
Dr. Florence Myrick, Faculty of Nursing, University of Alberta
Dr. Brenda Cameron, Faculty of Nursing, University of Alberta
Dr. Caroline Ross, Faculty of Nursing, University of Alberta
Dr. Elizabeth Taylor, Faculty of Rehabilitation Medicine, University of Alberta
Dr. Sean Clarke, Faculty of Nursing, McGill University (External Member)
I wish to extend a special thank you to the research participants who took time from
their busy schedules to participate in my research. I would also like to gratefully
acknowledge the financial assistance I received from the Alberta Registered Nurses
Educational Trust, Canadian Diabetes Association, the Heart and Stroke
Foundation of Canada, the Canadian Council of Cardiovascular Nurses, Merck
Frosst Canada Ltd, Covenant Health, Alberta Health Services and my CIHR
TORCH traineeship (Tomorrow's Research Cardiovascular Health
Professionals) and the World Heart Federation.
Finally I want to thank all my colleagues, friends far and near, and family members
who have supported, encouraged and inspired me to pursue my studies.

TABLE OF CONTENTS
Page Number
CHAPTER 1: INTRODUCTION AND BACKGROUND

My Motivation

12

Outline of the Dissertation

14

References

18

CHAPTER 2: TREATMENT AND BLOOD PRESSURE CONTROL IN 47,964

PEOPLE WITH DIABETES AND HYPERTENSION: A SYSTEMATIC
REVIEW
OF OBSERVATIONAL STUDIES
Introduction

23

Methods

24

Literature Search

24

Analyses

32

Results

25

Discussion

26

Appendix 1: Search Strategy for Identification of Studies

29

References

30

Table 1: Hypertension Treatment and Achievement of Targets

41

Figure 1: Flow Diagram of Study Inclusion and Exclusion

43

Figure 2: Overall Treatment and Blood Pressure Control in Subjects with

44

Diabetes and Hypertension

CHAPTER 3: COMMUNITY PHARMACIST PRACTICES IN HYPERTENSION
MANAGEMENT
Introduction

45

Methods

46

Stage 1

46

Stage 2

47

Training of the Standardized Patients

48

Results

49

Discussion

50

Conclusions

51

Appendix A: Determining Practice Standards for Community Pharmacists

58

Appendix B: Standardized Patient Scenario

59

References

61

CHAPTER 4: IMPROVING BLOOD PRESSURE MANAGEMENT IN PATIENTS

WITH DIABETES: THE DESIGN OF THE SCRTP-HTN STUDY
Background and Rationale

63

Methods

63

Discussion

66

Figure 1: Protocol Summary

68

Figure 2: Opinion Leader Statement

69

References

70

CHAPTER 5: A RANDOMIZED TRIAL OF THE EFFECT OF COMMUNITY

PHARMACIST AND NURSE CARE ON IMPROVING BLOOD PRESSURE
MANAGEMENT IN PATIENTS WITH DIABETES MELLITUS: STUDY OF
CARDIOVASCULAR RISK INTERVENTION (SCRJP-HTN)
Introduction

71

Methods

73

Results

76

Discussion

79

Conclusion

83

References

87

Figure 1: Trial Profile

90

Figure 2: Trial Flow Diagram

91

Figure 3: Primary Endpoint

92

Figure 4: Achieving Goal Blood Pressure <130/80 mm Hg

93

Table 1: Patient Demographics by Randomized Groups

94

CHAPTER 6: A HISTORICAL REVIEW OF SELECTED NURSING

LITERATURE ON BLOOD PRESSURE MEASUREMENT BETWEEN 1945 AND
2000
Abstract

96

Introduction

97

Early 20th Century Blood Pressure Measurement

98

Purpose of the Study

105

Method of Data Collection

106

Data Analysis, Synthesis and Exposition

110

External and Internal Criticism

111

Overview of Primary Article Search

113

Analysis

116

Chronological Trends and Findings

116

1945-1955

116

1956-1965

137

1966-1975

154

1976-1985

170

1986-1995

192

1996-2000

210

Conclusion

220

Standardized Practice Presented in CN and AJN

229

Nursing Roles Presented in the CN and AJN

231

Limitations of the Study

233

Significance of the Study

234

References

237

Appendix A: Primary Articles Central Topic Description by Decade and Journal 252

CHAPTER 7: Conclusion
How the Papers are Connected Together

268

Main Conclusions

269

Future Nursing Implications

274

Nursing Practice Recommendations

276

Nursing Research Recommendations

279

Recommendations for Continuing Education

281

Limitations

285

In Conclusion

285

References

287

CHAPTER 1:
INTRODUCTION AND BACKGROUND
Cardiovascular disease is the major cause of death and disability in Canada.
Cardiovascular disease (CVD) is the number one cause of death and disability
in Canada and hypertension is a major contributor, accounting for two-thirds of
strokes and half of coronary disease events.1 In 2003, 33% of all deaths in Canada
were due to CVD. 2 CVD imparts a profound burden on the health of Canadians
and the healthcare system. The high prevalence of the major risk factors for
CVD continues to contribute to the epidemic of heart disease and stroke in
Canada. Many of these risk factors are modifiable, and numerous studies have
conclusively demonstrated the efficacy of aggressive treatment of risk factors
such as hypertension, hyperglycemia, smoking cessation and dyslipidemia in
reducing death and disability from CVD.4

' Health Canada, Health Protection Branch-Laboratory Centre for Disease

Control. Economic burden of illness in Canada. Catalogue No. 1993 H21136/1993E. Ottawa, 1997; Public Health Agency of Canada. 2009 Tracking
Heart Disease and Stroke in Canada. Retrieved from http://www.phacaspc.gc.ca/pubIicat/2009/cvd-avc/index-eng.php
2 Statistics

Canada. Mortality: Summary list of causes 2003. Catalogue number

84F0209XIE. Ottawa: Minister of Industry, 2006. Retrieved from
http://www.statcan.ca
3 Wielgosz

A, Arango M, et al, eds. The Changing Face of Heart Disease and

Stroke in Canada 2000. Ottawa, Ontario: Heart and Stroke Foundation of
Canada; 1999. Retrieved from: http://www.hc-sc.gc.ca: Tarride, J., Lim, M.,
DesMeules, M., Luo, W., Burke, N., O'Reilly, D., Brown, J., & Goeree, R.
(2009). A review of the cost of cardiovascular disease. Canadian Journal of
Cardiology, 25, el95-e202.
4 Statistics

Canada. Mortality: Summary list of causes 2003; Canadian Heart

and Stroke Surveillance System On-line, 1999; A joint editorial statement by the
American Diabetes Association; the National Heart, Lung, and Blood Institute;
1

Hypertension is a strong and independent risk factor for cardiovascular disease

and despite being the most important avoidable cause of death worldwide,
hypertension remains sub-optimally managed.
Hypertension is a highly prevalent and strong, independent risk factor for the
development of coronary heart disease. Hypertension is a 'silent killer' as
individuals may have the disease for years without knowing it. In Canada in 2001,
it has been estimated that 4.1 million Canadians (21.1%) have high blood pressure
(BP >140/90 mm Hg). Amazingly, 43% of these individuals are unaware (not
diagnosed) of their condition.5 Even in those patients diagnosed with
hypertension, the Canadian Heart Health Surveys have demonstrated very poor
management of hypertension: > 43% of hypertensive patients are unaware (and
untreated) and 22% are neither treated nor controlled.6 Although hypertension is
the most important avoidable cause of death worldwide and treatment
dramatically improves patient outcomes, only 13% of individuals with
hypertension have been diagnosed, treated and controlled; having reached their
target values for blood pressure (<140/90 mm Hg). Stated another way, over 3.5

the Juvenile Diabetes Foundation International; the National Institute of Diabetes

and Digestive and Kidney Diseases; and the American Heart Association. (1999).
Diabetes mellitus: a major risk factor for CVD. Circulation, 100,1132-1133.
5 Joffres,

M., Hamet, P., & MacLean, D.R., (2001). Distribution of blood pressure
and hypertension in Canada and the United States. American Journal of
Hypertension. 14, 1099-1105.
6 Ibid.

million Canadians (87% of those with hypertension) have poorly controlled blood
pressure. Clearly, the poor detection and treatment of hypertension represents a
significant evidence to practice care gap with important public health
implications. Poor adherence to prescribed antihypertensive medications and
clinical inertia are major barriers to achieving blood pressure (BP) control. In
order to reduce the burden of CVD, there must be a greater focus on identification
and control of hypertension.
Recent data have suggested Canada is likely the world's leading country in
the prevention and control of hypertension with a fivefold increase in treatment
and control of hypertension in Ontario between 1992 and 2006.8 The recently
completed Heart and Stroke Foundation survey of blood pressure awareness,
treatment and control from the province of Ontario found unprecedented levels of
blood pressure control with 2 out of 3 people with hypertension under control.
However, for people with diabetes, rates of control were only 1 in 3, with twothirds above the target of less than 130/80 mm Hg.9

7 Wielgosz

A et al., The Changing Face of Heart Disease and Stroke in Canada

2000; Canadian Heart and Stroke Surveillance System On-line, 1999; A joint
editorial statement by the American Diabetes Association Circulation; Joffres et
al., American Journal of Hypertension; Haffner, S.M., Lehto, S., Ronnemaa, T.,
Pyorala, K., & Laakso, M. (1998). Mortality from coronary heart disease in
subjects with type 2 diabetes and in nondiabetic subjects with and without prior
myocardial infarction. New England Journal of Medicine, 339, 229-234.
11 Campbell,

N.R., Brandt, R., & Johansen, H. (2009). Increases in

antihypertensive prescriptions and reductions in cardiovascular events in Canada.
Hypertension, 55, 128-134.
9 Leenen,

F., Dumais, J., Mclnnis, N., Turton, P., Stratychuk, L., Nemeth, K.,
Lum-Kwong, M., & Fodor, G. (2008). Results of the Ontario survey on the
3

Diabetes is also a strong risk factor for cardiovascular disease.

Over two million Canadians have diabetes, and its prevalence increases with
age.10 The true prevalence of diabetes in Canada is substantially underestimated
because of high numbers of undiagnosed cases of diabetes, a situation similar to
that described for hypertension above. The incidence, prevalence and mortality
from all forms of CVD are markedly increased in patients with diabetes compared
to those without. The relative risk for CVD is 2-6 fold higher in patients with
diabetes than in nondiabetics ,n In fact, patients with diabetes have equal risk for
cardiovascular events as nondiabetics with a previous myocardial infarction.12
Moreover, when patients with diabetes develop clinical CVD, they have a much
worse prognosis than patients without diabetes.

1^

Eighty percent of people with

prevalence and control of hypertension. Canadian Medical Association Journal,

178, 1441-1449.
10 Canadian

Diabetes Association. Canadian Diabetes Association 2003 Clinical

Practice Guidelines for the Prevention and Management of Diabetes in Canada.
S1-S152; Canadian Diabetes Association. Canadian Diabetes Association 2008
Clinical Practice Guidelines for the Prevention and Management of Diabetes in
Canada. Retrieved from: http://www.diabetes.ca/files/cpg2008/cpg-2008.pdf
11

Ibid.

12

Haffner et al., New England Journal of Medicine.

13 A

joint editorial statement by the American Diabetes Association, Circulation;

Sowers, J.R., Epstein, M., & Frohlich, E.D. (2001). Diabetes, hypertension, and
cardiovascular disease: An update. Hypertension, 37, 1053-1059.
4

diabetes die of some form of heart or blood vessel disease.14 Over 25% of the
healthcare costs for people with diabetes are related to CVD.15
Diabetes and hypertension are a lethal combination of risk factors.
Hypertension is frequently associated with diabetes.16 There are numerous
published population studies confirming that the prevalence of hypertension is
much higher in individuals with diabetes than in the general population.17 The
prevalence of hypertension in patients with diabetes is estimated at 40-50% in
Canada, about twice that of the nondiabetic population.18 In one US study, about
73% of adults with diabetes have blood pressure readings >130/80 mm Hg or use
prescription medications for hypertension.19 In the Framingham Heart Study 20

14 Sowers

et al., Hypertension.

15 Simpson,

S.H., Jacobs, P., Corabian, P., & Johnson, J.A. (2003). The cost of
major co-morbidities in a cohort of Saskatchewan residents with diabetes.
Canadian Medical Association Journal 168, 1661-1667.
16 Leenen

et al., Canadian Medical Association Journal; United Kingdom

Prospective Diabetes Study III. (1985). Prevalence of hypertension and
hypotension therapy in patients with newly diagnosed diabetes. Hypertension, 7
(suppl II), 118-1113; Standi, E., Stiegler, H., Roth, R., Schultz, K., & Lehmacher,
W.(1989). On the impact of hypertension on the prognosis of NICCM results of
the Schwabing GP-Program. Diabetes Metabolism, 15, 352-358.
17 Krolewski,

A.S., Warran, J.H., & Cupples, A. (1985). Hypertension, orthostatic

hypotension and microvascular complications of diabetes. Journal of Chronic
Disease, 38, 319-326.
18 Health

Canada, Health Protection Branch-Laboratory Centre for Disease

Control; Joffres et al., American Journal of Hypertension; Leenen et al., Canadian
Medical Association Journal.
19 The

National Center for Chronic Disease Prevention and Health Promotion.

National estimates on diabetes. Retrieved from:
http://www.cdc.gov/diabetes/pubs/estimates.htm
20 Kannel,

W.B., Neaton, J.D., Wentworth, D., Thomas, H.E, Stamler, J., &
Hulley S.B. (1986). Overall and coronary heart disease mortality rates in relation
5

the prevalence of hypertension in individuals with diabetes was 50%, but in the
San Antonio Heart Study 21 it was 85%. The clustering of risk factors in persons
with diabetes produce synergistic negative effects leading to a greater risk for
cardiovascular events.22 Gardner et al reports a synergistic relationship between a
history of diabetes and hypertension in risk of ischemic heart disease mortality.23
A number of prospective studies have shown the clinical benefits of treating
hypertension, specifically among individuals with diabetes. The United Kingdom
Prospective Diabetes Study (UKPDS) 3824 intervention study of type 2 diabetics
showed reduced mortality, macro vascular and microvascular complications. This
study closely monitored blood pressure in those with diabetes (144/82 compared
with 154/87 mm Hg, a difference of 10/5 mm Hg). In the UKPDS 38 intervention
study, the risk of diabetic complications was associated with elevated systolic
blood pressure of 110 to 170 mm Hg. For a 10 mm Hg difference in blood
pressure there was a risk reduction of 12% in all diabetic complications. The
to major risk factors in 325,348 men screened for MRFIT. American Heart
Journal, 112, 825-836.
21

Mitchell, B.D., Stern, M.P, Haffner, S.M., Hazuda, H.P., & Patterson, J.K.
(1990). Risk factors for cardiovascular mortality in Mexican Americans and nonHispanic whites. San Antonio Heart Study. American Journal of Epidemiology,
131, 423-433.
22 Wingard,

D.L., Barrett-Connor, E., Criqui, M.H. & Suarez, L. (1983).

Clustering of heart disease risk factors in diabetic compared to nondiabetic adults.
American Journal of Epidemiology, 117,19-26.
23 Gardner,

L.I., Wagner, H.A., & Tyroler, C.H. (1980). Diabetes and

hypertension synergism in the Evans County Study population. Preventive
Medicine, 9,525-533.
24 UK

Prospective Diabetes Study Group. Tight blood pressure control and risk of
macrovascular and microvascular complications in type 2 diabetes: UKPDS 38.
(1998). British Medical Journal, 317, 703-713.
6

Hypertension Optimal Treatment study (HOT) also showed that treatment aimed
at lowering diastolic pressure to 80 mm Hg or less, was associated with
significant reduction in cardiovascular events when compared with treatment
aimed at lowering diastolic pressure to a level of 90 mm Hg or less.25
Recognizing the increased risk imparted by diabetes, national organizations
advocate aggressive risk factor management in people with diabetes.26
Recommendations of the Canadian Hypertension Education Program (2005,
2009) 27and the Joint Committee on Prevention, Detection, Evaluation, and

25 Hansson,

L., Zanchetti, A., Carruthers, S., Dahlof, B., Elmfeidt, D., Julius, S., et
al. (1998). Effects of intensive blood-pressure lowering and low-dose aspirin in
patients with hypertension: Principal results of the Hypertension Optimal
Treatment (HOT) randomised trial. Lancet, 351, 1755-1762.
26 American

Diabetes Association. (2000). Management of dyslipidemia in adults

with diabetes. Diabetes Care, 23(Suppl 1), S57-S60; Meltzer, S., Leiter, L.,
Daneman, D., Gerstein, H.C., Lau, D., & Ludwig, S. (1998). 1998 clinical
practice guidelines for the management of diabetes in Canada. Canadian Diabetes
Association. Canadian Medical Association Journal, 159, S1-29; Fodor, J.G.,
Frohlich, J.J., Genest, J.J.G., & McPherson, P.R., for the Working Group on
Hypercholesterolemia and Other Dyslipidemias. (2000). Recommendations for
the management and treatment of dyslipidemia. Canadian Medical Association
Journal, 162, 1441-1447; Wood, D., de Backer, G., Faergeman, O., Graham, I.,
Mancia, G., & Pyorala, K. (1998). Prevention of coronary heart disease in clinical
practice. European Heart Journal, 19, 1434-1503.
27 The

Canadian Hypertension Society. The 2005 Canadian recommendations for

the management of hypertension. Retrieved from http://hvpertension.ca/chep/:
Padwal, R.S., Hemmelgarn, B.R., Khan, N.A., Grover, S., McKay, D.W., Wilson,
T., Penner, B., Burgess, E., McAlister, F.A., Bolli, P., Hill, M.D.,Mahon, J.,
Myers, M.J., Abbott, C., Schiffrin, E.L., Honos, G., Mann, K., Tremblay, G.,
Milot, A., Cloutier, L., Chockalingam, A., Rabkin, S.W., Dawes, M., Touyz, R.,
Bell, C., Burns, K.D., Ruzicka, M., Campbell, N.R.C., Vallee, M., Prasad, R.,
Lebel, M., & Tobe, S.W. for the Canadian Hypertension Education Program. The
2009 Canadian Hypertension Education Program recommendations for the
management of hypertension: Part 1 - blood pressure measurement, diagnosis and
assessment of risk. (2009). Canadian Journal of Cardiology, 25, 279-286.
7

Treatment of High Blood Pressure (JNC VII)(2003)28 both suggest that

individuals with diabetes should have lower blood pressure targets of <130/80
mm Hg (compared to <140/90 mm Hg for nondiabetics).
Hypertension control is even poorer in individuals with diabetes than in those
without.
Despite the established importance of hypertension management in patients
with diabetes, observational studies suggest that BP control is very poor. Data
from the Canadian Heart Health Study revealed that only 9% of patients with
diabetes were treated and controlled to meet a BP goal of <140/90 mm Hg,
compared to 13% in the general population. Of note, this target is higher than the
current Canadian recommendation of 130/80 mm Hg, suggesting it
underestimates the degree of control.29 Two thirds of diabetic Ontarians (and
likely other Canadians) who are hypertensive have uncontrolled blood pressure.
People with diabetes and hypertension represent one of the highest cardiovascular
risk groups for primary prevention and also have the greatest potential benefit
from lowering blood pressure.30 In 2006, we performed a systematic review to

28 Joint

Committee on Prevention, Detection, Evaluation, and Treatment of High

Blood Pressure. (2003). The sixth report of the Joint Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). Journal of
the American Medical Association, 289, 2560-2572.
29 Joffres

et al., American Journal of Hypertension.

30 Canadian

Diabetes Association. Canadian Diabetes Association 2008 Clinical

Practice Guidelines for the Prevention and Management of Diabetes in Canada.
Retrieved from: http://www.diabetes.ca/files/cpg2008/cpg-2008.pdf

examine BP treatment and control rates in patients with diabetes mellitus.31 In

this analysis of 44 studies, (77,649 subjects with diabetes mellitus), we observed
that overall, less than 37% achieve treatment targets. In those studies using a BP
target of <130/85, only 12% reached target. This is likely still an overestimate,
as all studies used BP targets higher than the current recommendations. Clearly,
this is a very large treatment gap which needs to be closed.
Review of the literature has revealed there are few data available on
important factors such as patient awareness of blood pressure targets, medications
used, or other factors associated with poor blood pressure control, all of which
would be important for the development of targeted interventions to improve
hypertension management by nurses.
We need a proactive, community-based approach to improve BP control.
Both diabetes and hypertension arise in communities, therefore it is clear that
a community-based solution is necessary. Such a solution should take into
consideration the barriers to provision of such preventive care from the
perspective of primary care physicians. Hutchison, et al performed a survey of
family physicians in Southern Ontario to determine the barriers to provision of
preventive medical care.

31

McLean, D.L., Simpson, S.H., McAlister, F.A., & Tsuyuki, R.T. (2006).
Treatment and blood pressure control in 47,964 people with diabetes and
hypertension: A systematic review of observational studies. Canadian Journal of
Cardiology, 22, 855-860.
32

Hutchison, B.G., Abelson, J., Woodward, C.A., & Norman, G. (1996).

Preventive care and barriers to effective prevention: How do family physicians
see it? Canadian Family Physician, 42, 1693-1700.
9

The most commonly cited reasons why appropriate preventive care was not
provided were that patients do not present for such care and that there Eire no
reminder systems for physicians and patients for whom preventive care is
necessary. As such, improvements to the delivery of primary care must go
beyond the confines of the family physician's office and consider the important
role that other community-based healthcare professionals could play.
Registered nurses have knowledge and skills that address the client's
ongoing health situation within the context of the person's wholeness, including
biophysical, psychological, emotional, social, cultural and spiritual dimensions.
Registered nursing practice is individualized focused on identifying the client's
uniqueness and facilitating the achievement of specific health goals of a client.
Registered nurses have excellent patient assessment and communications skills
which are well-suited to community-based screening and management programs.
They work closely and collaboratively with members of the health-care team and
contribute to improving health and preventing illness with enhanced knowledge.
Community pharmacists are also well-placed to assist in the identification
of at-risk patients for preventive care. Indeed, pharmacists are often the first point
of contact for patients, are highly accessible, and often see their patients more
frequently than family physicians. In two recently published studies, SCRIP and
SCRIP-plus, the EPICORE research group has conclusively demonstrated proof
5-7

of the concept that pharmacists can play a major role in preventive health care.

33 Tsuyuki,

R.T., Johnson, J.A., Teo, K.K., Simpson, S.H., Ackman, M.L., Biggs,
R.S., Cave, A.J., Chang, W.C., Dzavik, V., Farris, K.B., Galvin, D., Semchuk,
10

The Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP) was a

675-patient, 54-centre randomized trial of community pharmacist intervention
versus usual care on cholesterol risk management in patients at high risk for CVD
events. Pharmacist intervention included identification of patients at high risk for
CVD events, point of care cholesterol measurement, patient education regarding
cardiovascular risk factors, referral of the patient to their primary care physician
for further assessment/management, and regular follow-up for four months.
Notably, this study was terminated early due to a large impact of pharmacist
intervention. Pharmacist intervention led to a 3-fold increase in the odds of
improvement in cholesterol management (measurement of full fasting lipid profile
by the family physician or institution/dosage increase of lipid-lowering therapy).
Therefore, given the great burden of illness of cardiovascular disease in
patients with diabetes, investment in novel community-based strategies to
improve the management of hypertension are greatly needed. Hence, there is
limited data and few rigorous studies describing the prevalence of elevated blood
pressure in individuals with diabetes with regards to the extent to which it is being
treated and meeting specific diabetic target blood pressure values. It appears that

W., & Taylor, J.G. (2002). A randomized trial of the effect of community
pharmacist intervention on cholesterol risk: The Study of Cardiovascular Risk
Intervention by Pharmacists (SCRIP). Archives of Internal Medicine, 162, 11491155; Tsuyuki, R.T., Olson, K.L., Dubyk, A.M., Schindel, T., & Johnson, J.A.
(2004). Effect of community pharmacist intervention on cholesterol levels in
patients with high risk of cardiovascular events: The second Study of
Cardiovascular Risk Intervention by Pharmacists (SCREP-p/ws). American
Journal of Medicine, 116, 130-133.
11

achieving optimal blood pressure target values in individuals with diabetes is very
poor and broad-based efforts are needed to improve blood pressure control.
My Motivation
My motivation to conduct this series of studies (chapters #2-3) began
during the beginning courses of my Ph.D. I conducted a number of smaller
studies relating to the "prevalence" and "mechanisms" of undertreatment of
hypertension. These studies provided valuable insight to me into the development
of a randomized trial of a community-based, multidisciplinary approach to the
detection and treatment to target of hypertension (chapters #4-5). I was
responsible for the development of the study protocols, funding applications
(including budgeting), study implementation (working with our data management
team and research coordinators), data collection, day-to-day study conduct (as a
Project Officer), data analysis (under the direction of our biostatisticians and
faculty), abstract and manuscript preparation and presentation.
The first step in addressing the gap between the evidence of a condition
and its application in clinical practice, is to accurately describe the extent of the
problem. As such, we performed a systematic review to examine the
contemporary management of hypertension in patients with diabetes from 19902000 (chapter #2), including a comparison of BP treatment and control rates
between health care settings and countries. We found that fewer than one in eight
people with diabetes and hypertension have adequately controlled BP, with
remarkable uniformity across studies conducted in a variety of settings. This

12

suggests that there is an urgent need for multidisciplinary, community-based

approaches to manage these high-risk patients.
In a broader context we demonstrated that BP control in individuals with
diabetes is infrequently achieved in all settings, meaning that improvements in BP
control will require novel approaches that extend beyond the four walls of the
primary care physician's office. Interdisciplinary, community-based programs
hold particular promise for chronic and common conditions such as diabetes.
Given the result data, the development of such programs as SCRIP-HTN (chapter
#4-5) for the management of cardiovascular risk factors in patients with diabetes
is a research and public health imperative.
On a personal level, in part because of the role I play as a nurse
practitioner, I was interested in the roles that nurses have played historically with
regards to blood pressure management (chapter #6). I was interested in
understanding if nursing practice and nursing roles had changed over time in the
last 50 years with regards to hypertension management.
My short-term goal is to make a significant contribution to knowledge and
to the cardiovascular health of Canadians as a cardiovascular nurse researcher
with the projects I have completed. I have recognized the need and benefit of
having a multidisciplinary approach as well as a patient-tailored approach.
My long-term goals are to contribute and increase the capacity of the
Canadian health research community by continuing to develop my knowledge
base, skill set and attitudes which are fundamental to embarking on a successful

13

career as a cardiovascular nurse researcher. I would like to be a future mentor to

other nurse research students and participate in developing a network of
cardiovascular nurse researchers.
Outline of the Dissertation
Chapter 1 is the introductory chapter to this topic surrounding
hypertension and the outline of the series of studies.
Chapter 2 is a systematic review of observational studies focusing on the
treatment and blood pressure control in 47,964 people with diabetes and
hypertension. Databases and hand searches of bibliographies of relevant studies
were conducted from 1990-2004. Data sources included: MEDLINE, EMBASE,
HealthSTAR, CINAHL, Web of Science, Clinical Evidence including
Government Health/Statistical Sites. A total of 44 studies found less than 1 in 8
people with diabetes and hypertension had adequately controlled blood pressure.
That meaning, blood pressure controlled to recommended levels <130/80 mmHg.
Overall, these results demonstrated the failure of our healthcare system to
adequately address the significant risk of hypertension for those with diabetes. A
novel multidisciplinary approach needed to be developed and tested to address
this risk.
Chapter 3 reports on the current practices of community pharmacists with
regards to the management of hypertension. A cross-sectional, observational study
of 101 community pharmacists'practices using unannounced standardized patients
with hypertension was done and reportedon pharmacists: knowledge of current

14

blood pressure target values; review of patient medical histories; accuracy and
confirmation of blood pressure readings; education and lifestyle measures, and
referrals. It was found that pharmacists took reasonable steps to determine the
accuracy of the blood pressure measurement, explained the diagnosis of
hypertension and did refer patients to a physician. Major deficiencies were noted
in medical history taking and assessment of target blood pressures. Pharmacists
in collaboration with other health professionals were identified as be able to play a
role in identifying, screening and managing individuals with hypertension.
Chapter 4 describes in detail the design of the randomized controlled trial
SCRIP-HTN. SCRIP-HTN is a multicentre randomized trial that evaluated a
unique program of nurse intervention and community pharmacists, within a
multidisciplinary team, to improve management of blood pressure in patients with
diabetes. The trial began in May 2005. This paper provided a brief summary of
the design of the trial including: methods, inclusion and exclusion criteria, patient
recruitment strategies, randomization, and outcome measures. Treatment and
control of hypertension is a major public health problem and a key goal of the
Canadian Hypertension Education Program (CHEP). Novel ways of identifying
and treating this population to current blood pressure guidelines are urgently
needed and suggested.
Chapter 5 reports the results of the trial SCRIP-HTN. The trial purpose
was to determine the efficacy of a community-based multidisciplinary screening
and intervention program on blood pressure control in patients with diabetes.
Recognizing that blood pressure control in individuals with diabetes is poor, with
15

few patients reaching the recommended target of <130/80 mmHg. Registered

nurses and nurse practitioners, with community pharmacists were identified as
being well-positioned to help identify and follow-up patients with diabetes and
hypertension. With a total of 227 patients enrolled, the intervention group had a
5.6 mmHg greater reduction in systolic blood pressure at 6 months compared to
the control group. At 6 months, 33% of control patients achieved target blood
pressures, compared to 47% of intervention patients. Recognizing that even in a
relatively well-controlled group of patients with diabetes and hypertension, an
intervention based on nurse and pharmacist team care including opinion leader
endorsed evidence summaries for primary care physicians resulted in a clinically
significant improvement in blood pressure.
Chapter 6 focuses on a thorough review and historical critique of the
writing about blood pressure taking and management in two nursing journals from
1945-2000 using historical method. This review speaks to the roles nurses played
in blood pressure measurement and management. This is a beginning study of the
history of blood pressure measurement in nursing. The study was limited to two
journals in nursing: The Canadian Nurse and The American Journal of Nursing
as these were the most widely circulated journals in Canada and the United States
and were likely information sources for staff nurses. A total of 88 primary articles
were identified out of 365 which identified blood pressure measurement and
management as a central topic. A chronological overview shows how the roles of
nursing have evolved over the years and were linked to the developments in

16

nursing education and the healthcare organization of the current time.

Historically, nurses have focused on preventing hypertension.
Chapter 7 serves as the overall conclusion to the series of studies
completed with a focus of the findings of the studies on the future implications for
nursing research, administration and education.

17

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22

CHAPTER 2
Treatment and Blood Pressure Control in 47,964 People with Diabetes and
Hypertension: A Systematic Review of Observational Studies1
INTRODUCTION
In 2000, there were 171 million people with diabetes worldwide; by 2030
this figure is expected to more than double (1-3). Diabetes is a strong risk factor
for atherosclerosis and approximately 50% to 75% of deaths in patients with
diabetes are cardiovascular (4-5).
More than half of North Americans with diabetes also have elevated blood
pressure (BP); reducing BP reduces the risks of both cardiovascular disease and
renal dysfunction in patients with diabetes (6). There is a direct relationship
between systolic or diastolic BP and cardiovascular risk in individuals with
diabetes, and antihypertensive therapy reduces the relative risk of cardiovascular
events by approximately 25% to 30% in those with blood pressures exceeding
130/80 mm Hg (6-10). Many clinicians feel that BP control actually confers
greater cardiovascular benefits in patients with diabetes than control of blood
glucose (6-13). However, we suspect that the management of diabetes in clinical
practice continues to be largely focused around achieving glycemic control. For
example, data from the Canadian Heart Health Study suggested that less than 9%
of individuals with diabetes had a BP < 140/90 mm Hg (compared to 13% in nondiabetics) (11).

'A version of this chapter was publish as: McLean, D.L., Simpson, S.H.,
McAlister, F.A., & Tsuyuki, R.T. (2006). Treatment and blood pressure control
in 47,964 people with diabetes and hypertension: A systematic review of
observational studies. Canadian Journal of Cardiology, 22, 855-860.
23

The first step in addressing any gap between the evidence and its
application in clinical practice is to accurately describe the extent of the problem.
As such, we performed a systematic review to examine the contemporary
management of hypertension in patients with diabetes from 1990 to 2004
including a comparison of blood pressure treatment and control rates between
health care settings and countries.
METHODS
We included all studies published, in any language, between January 1,
1990 and June 30, 2004 that reported BP treatment and/or control rates in adult
patients with diabetes. As we were interested in BP control rates in clinical
practice, studies were excluded if they only reported data from clinical trials, only
included patients with gestational diabetes, or if they did not contain original data
(that is, we excluded editorials, review articles, or guidelines). As we were also
interested in exploring whether gaps were unique to particular health care settings
or providers, we sought all relevant articles, irrespective of setting.
Literature Search
A search of MEDLINE (1966-2004), EMBASE (1980-2004), CINAHL,
HealthSTAR, Web of Science, Clinical Evidence, and Government Health and
statistical sites was conducted using the key words: "diabetes", "hypertension"
and "epidemiology" (see Appendix 1 for full search strategy). The reference lists
of retrieved articles were hand-searched for other relevant studies and content
experts were consulted. All articles potentially meeting the inclusion criteria were
reviewed by 2 reviewers (D.M. and S.S.) independently; disagreements were

24

resolved by consensus. Both reviewers also independently extracted the data

from the included publications.
Analyses
We used the definitions of BP control specified in each study (160/90,
140/90, or 130/85). Weighted averages (by number of subjects with diabetes)
and observed ranges are reported. Studies were stratified by type of practice
(general or specialty) and region.
RESULTS
Of the 3803 publications initially identified, 44 met our inclusion criteria
(14-57) (Figure 1). These 44 studies were from 19 countries and included data
from 12 different health care settings- these studies enrolled 77,649 subjects with
diabetes, 47,964 (62%) of whom had hypertension. The characteristics of each
study are outlined in Table 1.
In the 5 studies (11,339 patients) which used < 160/90 mm Hg to define
control, 68% (range 53% to 97%) of patients received antihypertensive drug
therapy and 37% (range 31% to 60%) achieved target BP. In the 26 studies
(66,833 patients) which used
< 140/90 mm Hg to define control; 83% of patients (range 32% to 100%) received
antihypertensive drug therapy and 30% (range 5% to 59%) had achieved target
BP. In the 24 studies (49,420 patients) with the most stringent definition of BP
control (< 130/85 mm Hg), 87% (range 53% to 100%) of_patients were receiving
antihypertensive drug therapy and 12% (range 6% to 30%) had achieved target
BP (Figure 2). Blood pressure treatment rates and control rates did not differ
appreciably between countries or health care settings (Table 1).
25

DISCUSSION
Despite evidence that aggressive lowering of BP in people with diabetes
reduces cardiovascular morbidity and mortality, we found that BP control in
individuals with diabetes is sub-optimal, with less than one seventh of patients
having BP's controlled to the levels currently suggested by hypertension and
diabetes guidelines (1, 59). Further, our systematic review has revealed that this
sub-optimal treatment pattern is not restricted to certain locales or physician
specialties, at least in the 44 studies from 19 countries we identified.
The 2 best-known North American population studies of BP treatment and
control are the Third National Health and Nutrition Examination Survey
(NHANES in 1988-1994) and the Canadian Heart Health Survey (CHHS 19861992). NHANES III enrolled 1440 patients with diabetes and reported that 71 %
were treated for hypertension (42). The Canadian Heart Health Survey suggested
that control was even poorer in individuals with diabetes and hypertension, with
9% having a BP < 140/90 mm Hg compared to 13% in nondiabetics (11). This
study could not be included in this analysis, because we could not extract numbers
for individuals with diabetes or the proportion of hypertensive subjects treated.
It is sobering to note that control in diabetes may even be worse than our
figures suggest, since in Canada only about two-thirds of those with diabetes are
diagnosed (60), and one can surmise that people with undiagnosed diabetes have
poorer BP control.
Poor achievement of BP control in people with diabetes could be due to a
number of factors, including the possibility that a strong emphasis on glucose
control in diabetes has resulted in an inadvertent under-emphasis of treatment for
26

associated risk factors (such as hypertension) in these patients. In addition,

inadequate access to follow-up care and prescription medications, inappropriate
and/or ineffective treatments, poor adherence to prescription medication and
lifestyle modifications, or a combination of these factors may be responsible (6162). Given that randomized trials have proven that most patients will require 2 or
3 agents to control their blood pressure (10, 63-64), physician concerns over the
potential for polypharmacy in patients who are already on medications for other
conditions may also be relevant (65). It is difficult to control blood pressure in
patients with diabetes. Several randomized control trials suggest that 3-4
antihypertensive medications are required to control blood pressure in diabetics
(13, 66). Some clinicians and patients may be weighing the risk of polypharmacy
with optimal blood pressure control.
While we employed Cochrane methodology, 2 independent reviewers, and
explicit case definitions to ensure the validity of our systematic review, we cannot
exclude the possibility of publication bias. However, we would anticipate that
unpublished studies may well have shown worse control rates than those studies
that did get published (although one could argue that there may be more of a bias
towards publishing those studies which document small area variations or the
underuse of proven efficacious therapies in health services research).
While we used the authors' definition of control as we did not have access
to individual patient data, we also recognize that BP goals are a "moving target"
with lower targets recently. Nevertheless, this further highlights the need for
strategies to help attain these new lower targets.

27

Having demonstrated that BP control in individuals with diabetes is

infrequently achieved in all settings, we believe that improvements in BP control
will require novel approaches which extend beyond the four walls of the primary
care physician's office. Interdisciplinary, community-based programs hold
particular promise for chronic and common conditions such as diabetes. For
example, patients at high risk for cardiovascular disease could be identified when
they present with marker medications to their community pharmacists and
enrolled into interdisciplinary risk reduction programs. This model has been used
very successfully in the past in the Study of Cardiovascular Risk Intervention by
Pharmacists (SCRIP), a 52 center randomized trial of cholesterol risk
management by community pharmacists for patients at high cardiovascular risk
(67). Given our data, the development of such programs for the management of
other cardiovascular risk factors in patients with diabetes is a research and public
health imperative.

Acknowledgements: The authors thank Jeanette Buckingham, Janice Varney, and

Liza Chan who provided assistance with the literature search.

28

Appendix 1: Search Strategy for Identification of Studies

1. DIABETES MELLITUS, TYPE W or DIABETES MELLITUS/ or DIABETES
MELLITUS, TYPE 1/
2. diabetes.ti,ab,hw.
3. 1 or 2
4. Hypertension/
5. hypertens$ (ti,ab,hw)
6. blood pressure.ti,ab,hw.
7. 4 or 5 or 6
8. 3 and 7
9. limit 8 to (all adult <19 plus years> or adult <19 to 44 years> or middle age
<45 to 64 years> or middle aged <45 plus years> or aging <65 to 79 years> or "all
aged <65 and over>" or "aged <80 and over>")
10. exp Adult/
11. 8 and 10
12. Epidemiology/
13. exp Morbidity/
14. (epidemiol$ or prevalen$ or inciden$).ti,ab,hw.
15. exp Population Surveillance/
16. "Epidemiologic Methods"/
17. epidemiologic studies/ or case-control studies/ or cohort studies/ or crosssectional studies/
18. (population studies or population study).mp. [mp=title, abstract, name of
substance, mesh subject heading]
19. ep.fs.
20. 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19
21. 11 and 20
22. 12 or 13 or 14 or 19
23. 22 and 11
24. 15 or 16 or 17 or 18
25. 23 and 24
26. (pc or th or dt or dh).fs.
27. (control$ or manag$ or detect$ or treat$ or aware$ or determin$).ti,ab,hw.
28. 26 or 27
29. 25 and 28
30. 29 not pregnan$.ti,ab,hw.
31. limit 30 to yr=1990-2004

29

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Morrish NJ, Stevens LK, Head J, Fuller JH, Jarett RJ, Keen H. A
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channel blockade in older patients with diabetes and systolic hypertension.
N Engl J Med 1999; 340:677-84.

8.

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risk of macro vascular and microvascular complications in type 2 diabetes:
UKPDS 38. BMJ 1998; 317:703-13.

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40

Table 1
Hypertension Treatment and Achievement of Target BP in Patients with
Diabetes and Hypertension
NORTH AMERICAN
Type of Practice
On Hypertension Treatment
Achievement of Target BP (range, %)
(range, %)
140/90
130/80
General Practice(26,29,34,37,38,42,43,60)
27-58.6
10.3-53.5

62.4-98.1

Specialty Practice(47,57)
29.6-51.7
14.9-21.8

61.3

General Population(21,41,44,58)
30.6-45
12.0-24.2

57-69.4

Other(23)

96.5

160/90

60.1

EUROPEAN
Type of Practice
On Hypertension Treatment
Achievement of Target BP(range,%)
(range, %)
140/90
130/80
General Practice(31,35,39,49,52,59,61)
15.5-19.4
6-28

75.7-93

Specialty Practice(25,30,32,45)
12.3-75.4

53-94.7

General Population(33,48,51,56)
32-56.7
9-22.2

96-97.8

Other(28)

63.7
8.3

41

160/90

OTHER
Type of Practice
On Hypertension Treatment
Achievement of Target BP(range, %)
(range, %)
140/90
130/80
General Practice(22,27,50,54,55)
9.9-10.9
6.1-12.5

78.2-100

Specialty Practice(21,24,37,40,46,62)
18.3-59.4
11.4-24.2

51.3-93.8

General Population(36,53)
15.5
11.7

32.4-62.5

Other

42

Figure 1: Flow diagram of study inclusion and exclusion

3803 reports identified
by librarian-assisted
literature search

1259 excluded
-1259 duplicate citations

^*

2544 abstracts
identified
2216 excluded
-1988 controlled trials
-228 editorials, review
articles, guidelines
328 potential abstracts
reviewed for specific
inclusion criteria

64 studies obtained for

more detailed evaluation

46 studies provisionally
included

264 abstracts excluded

-unable to extract required
numbers (# of patients
with diabetes, # of
patients that hypertensive
with diabetes)
-excluded studies with
gestational diabetes
20 excluded
-16 unable to extract # of
treated patients with
diabetes
-4 abstracts not published
in English
2 excluded
-Correspondence
attempted with 2 authors
for number clarification,

44 studies included in
final analysis

43

Figure 2: Overall treatment and blood pressure control in subjects with

diabetes and hypertension

Overall treatment and BP control in subjects

with diabetes and hypertension
Definition of
"Controlled BP"

Treated *

Controlled *

<160/90

68%

5 studies
n = 11,339

(range 53-97%)

^ 37%
(range 31-60%)

<140/90

83%

26 studies
n = 66,833
<130/85
24 studies
n = 49,420

(range 32-100%)

C87%

(range 53-100%)

*Weighted average of all subjects with diabetes

44

^ 29%
(range 5-59%)

^ 12%
(range 6-30%)

CHAPTER 3
Community Pharmacist Practices in Hypertension Management1
INTRODUCTION
Hypertension is a highly prevalent, strong and independent risk factor for
cardiovascular disease, the leading cause of death in the Canadian population and
worldwide (1-3). Hypertension has been shown to be poorly managed and
controlled in Canadians. In the Canadian Heart Health Survey, Joffres et al (4),
found that while approximately 21% of Canadians have hypertension, 43% are
not aware of their condition. In the 56% of the hypertensive individuals that were
aware of their diagnosis of hypertension, it was found that 21% of these
individuals were treated but not controlled, with 22% being neither treated nor
controlled. There has been little indication that awareness or control of
hypertension has changed significantly over time (5).
Hypertension treatment and control needs to be improved. Community
pharmacists are in a unique position and accessible resource in the community to
actively identify and screen individuals with high blood pressure (6).
Contemporary pharmacy practice suggests that pharmacists take
responsibility for medication management and patient outcomes (6). Community
pharmacists are uniquely positioned in the health care system to assist with
improving blood pressure control by utilizing strategies to solve medication-

A version of this chapter was published as: McLean, D.L., Bungard, T.J., Hui,
C., & Tsuyuki, R.T. (2006). Community Pharmacists Practices in Hypertension
Management. Canadian Pharmacy Journal, 139, 38-44.
45

related problems. Studies within integrated health systems have demonstrated

that when pharmacists are included as members of health care teams, control rates
for hypertension increase. In one older study (7) and three more recent studies (810) found that blood pressure control was improved when community pharmacists
assisted with patient education, blood pressure monitoring, drug therapy
management, and medication adherence assessment. In two of these studies, blood
pressure control, based on measurements in the physicians' offices, was improved
(7,10). In addition, two studies found that quality of life improved among patients
who were followed by a pharmacist for 4-6 months (9,10).
Based on the aforementioned studies, a pharmacist could help improve
blood pressure control, yet hypertension management remains suboptimal in the
population. While several studies have demonstrated the value of pharmacists in
improving blood pressure control, the extent to which pharmacists have changed
their practices to incorporate these findings are unknown. The purpose of this
study was to determine the current state of practice of pharmacists in hypertension
management.
Methods
Stage 1 of our study was necessary to determine practice standards for
pharmacists for hypertension management. Until very recently (6) there were no
formal practice guidelines pertaining to hypertension management (or any specific
disease conditions) for pharmacists. As such, we conducted a survey of
professional opinions pertaining to pharmacy practice expectations for the
management of hypertension in the Capital Health Region in Edmonton, Canada

46

from May 27, 2003 to June 25, 2003. We used a convenience sample of family
physicians, general internists with expertise in hypertension management,
Canadian Hypertension Education Program panellists, pharmacists from
professional/regulatory associations, clinical pharmacists and front-line
community pharmacists. The interviewees were selected based on their area of
practice. Each interviewee was presented with a hypothetical scenario, similar to
that which was portrayed in Stage 2 of this study. Two open-ended questions
based on the scenario were asked to elicit opinions on reasonable pharmacy
practice for the management of hypertension in community pharmacies
(Appendix A). Interviews were conducted until saturation of responses occurred
(15 interviews).
The primary outcome was to gain a consensus on what a reasonable
pharmacist should do for patients with hypertension. For the purposes of this
analysis, the range of responses from the interviews were compiled and
qualitatively examined for common themes in expected practices. These common
practices were then compiled to become the list of reasonable standards by which
pharmacists' actions were evaluated.
Stage 2 of the study was a cross-sectional, observational study of
community pharmacists' current practices using a standardized patient (SP)
posing as a patient at risk for hypertension.
The study involved one-on-one encounters between two SPs and
pharmacists. It took place at 101 randomly selected community pharmacies in the
metropolitan Edmonton and surrounding area. These pharmacies were selected

47

by randomized stratified sampling by pharmacy type. The pharmacy types (chain,

independent, etc.) were obtained from the 2003 Pharmacy Sourcebook (11).
Pharmacists who were registered under the Alberta College of Pharmacists,
working at any community pharmacy in Edmonton and surrounding area were
candidates for the study. Consent was not obtained from pharmacists. A general
bulletin in a quarterly newsletter was sent to all Alberta pharmacists informing
them of the study and its objectives.
Training of the standardized patients. Two middle-aged male SPs were
selected and trained for the scenario by the Standardized Patient Program, Health
Sciences Council, University of Alberta. They were trained to act as a walk-in
customer, who was curious and concerned about their blood pressure reading
from his friend's home blood pressure monitor. The SP was provided with a
script for the encounter. The researchers created a medical history and medication
profile that was memorized by the SPs (Appendix B). The SP was taught his
medical history and pertinent life history, in preparation for the pharmacist
inquiring about the patient's past. If asked physician and prescription history, the
patient would provide the explanation that he was new in town, and does not have
regular family physician in the Edmonton area, nor has he ever filled a
prescription at the pharmacy. The SP was taught to deal with situations expected
to occur during the encounter with the pharmacist. The SP was also trained to pay
attention to the pharmacist's actions according to the practices outlined in the
guidelines, and was trained using simulations to accurately recall the encounter
and document the pertinent details of the encounter on a recall form, based on the

48

checklist of hypertension management practice standards developed in Stage 1.

We also recorded general comments from the SPs about the pharmacists' general
demeanour.
The SP waited until the pharmacist was not busy before approaching. He
inquired about a blood pressure reading (150/100 mm Hg) taken last weekend on
his friend's blood pressure monitor, and asked "what it means". The SPs
approached each pharmacist with the identical, scripted scenario (Appendix B).
No information about the patient's medical history or medication history was
volunteered, but was available if the pharmacist asked. The pharmacists'
responses were documented by having the SP complete a recall form immediately
after the encounter.
The primary outcome of the study was to determine the proportion of
community pharmacists meeting practice standards as determined in Stage 1.
Results
From Stage 1 of the study, the suggested practice standards for
hypertension for pharmacists from the interviewed pharmacists' and physicians'
responses for reasonable pharmacist practices for hypertension management fell
into five categories. First, pharmacists should know current blood pressure
guidelines (and target values) and be able to interpret them for the patient.
Secondly, pharmacists should inquire about the patient's history (cardiovascular,
medications, previous elevated blood pressure or hypertension diagnosis).
Thirdly, pharmacists should confirm the accuracy of the blood pressure
measurement. Fourthly pharmacists should provide some form of brief patient

49

education on blood pressure and hypertension. Fifthly, pharmacists should refer

the patient to a physician if deemed necessary. There was a remarkable
consistency of responses by all interviewees, regardless of their practice or
specialty.
One hundred and one pharmacists were visited by the SPs between
January 15 and February 28, 2004. Pharmacy types included 27% independents,
23% supermarkets, 18% franchises, 13% chains, 11% department stores, 8%
banners, and 1% wholesalers. On average the SP waited to speak with a
pharmacist 4.1 minutes; with the total duration of the visit averaging 6.3 minutes.
Knowledge of current blood pressure target values: Of the 101
pharmacists who were visited by the SPs, 69% offered a general blood pressure
target value to the SP
(< 120/80 mm Hg). Seven percent of the pharmacists stated the correct target
blood pressure value for the scenario (< 140/90 mm Hg). Only 14% of
pharmacists requested enough patient history to properly determine the target
blood pressure for this scenario.
Review of medical history: Few of the pharmacists questioned the SPs on
their medical history. Twenty-two percent of the pharmacists queried the SPs
regarding a previous diagnosis of hypertension. Twenty percent asked about
previous elevated BP readings. Less than 20% of pharmacists inquired about a
family history of cardiovascular disease or a medication profile or medical
history.

50

Accuracy and confirmation of BP reading: Half of the pharmacists (53%),

inquired about the conditions under which the BP was taken, with 39% of the
pharmacists offering to retake the blood pressure at the pharmacy.
Education and lifestyle measures: Most of the pharmacists discussed how
hypertension was diagnosed (76%) and the impact of lifestyle measures on the
blood pressure (60%). Nearly half of the pharmacists explained what
hypertension was (46%) and how to take a BP properly (46%). Some (29%)
pharmacists gave supplemental educational material to the SPs.
Referral: Most pharmacists (83%) advised the SP to make an appointment
to see their physician.
General demeanour: The SPs were generally very impressed with their
interactions with pharmacists, describing them as approachable (88%), easy to
understand (78%), helpful (69%), attentive (66%), patient (62%), happy (58%)
and concerned (43%).
Discussion
Overall, pharmacists took reasonable steps to determine the accuracy of
the blood pressure measurement, explain the diagnosis of hypertension and refer
that patient to a physician for further evaluation. Unacceptable deficiencies were
identified in the pharmacists' assessment of medical and medication history,
identification of appropriate target blood pressures and accuracy/confirmation of
the blood pressure reading. As such, most pharmacists did not perform up to the
expected standard for contemporary hypertension management.

51

To our knowledge, this is the first study to use unannounced SPs to assess
community pharmacists' practices in cardiovascular disease. Similar
methodologies have been used to evaluate physician and nursing practices in other
disease entities (12-15), although usually with the consent of the participant,
potentially leading to a volunteer bias and a Hawthorne effect.
Standardized patients are simulated patients who have been carefully
coached to present their illness in a standardized way. Much is known about the
use of SPs in medical education (16,17). Research comparing the SP method with
other data collection methods is scarce. Usually, the SP technique is used for the
first contact with the patient only, as was done in this study. Gerritsma and Smal
(18), consider the SP method less appropriate to study the medical decision
making process. They believe that a series of patient encounters reveal more
about the way medical decisions are made. Similarly, Tamblyn et al. (19) has
studied this 'first visit bias' in a case of osteoarthritis combined with gastritis (an
acute problem) and in a case of osteoarthritis paired with chronic hip complaints
(none acute problem). The quality score for two successive consultations was
higher than the first-visit score. Although our study design is different, this may
suggest that the pharmacists, like physicians' performance, may have been
underestimated as the SPs only visited each pharmacist once and perhaps a series
of encounters may have resulted in better pharmacist performance.
A study by Holde et al. (20) used undetected SPs to identify the frequency
and quality of certain prevention-oriented counseling skills of resident physicians
and compared these skills with the residents' attitudes towards and knowledge

52

about primary prevention. Trainees' attitudes towards and knowledge about

certain prevention activities were captured by an instrument designed for this
study using 127 Likert scales. Counseling skills were assessed with one of two
standardized patients. Residents were unaware of the simulation, which occurred
in their routinely scheduled ambulatory care setting. They found that resident
physicians' skill levels were inadequate to accomplish routine counseling
interventions in the primary care setting. This may suggest that pharmacist
training and continuing professional development should focus on more patientcentered clinical skills.
The use of unannounced SPs to evaluate pharmacists' practices has
several advantages. It can provide an unbiased assessment of real world practice.
Asking pharmacists what they would do in a hypothetical hypertension scenario
would almost certainly lead to an overestimation of their activities (social
desirability bias). Using the same clinical scenario allows for meaningful
combining of data across a sample of pharmacists (e.g., proportion of pharmacists
complying with guidelines), and also allows a comparison of practice between
pharmacists. The advantages of using an unannounced, "blinded" approach to
evaluate practice is lost if the SP is "discovered" by the clinician. To our
knowledge the SPs were not detected by the pharmacists in our study. Because
we used two different SPs, it is possible that there were some differences in how
the scenario was played out and/or documented. To minimize this, most of the
interactions were scripted and data were collected on standardized case report
forms.

53

At the time of this study, there were no official standards of practice for
pharmacists for the management of hypertension. As such, it may be viewed as
being "unfair" to evaluate pharmacists' practices without such a standard. We did,
however, interview a wide variety of clinicians to determine what a reasonable
pharmacist should do for a patient with hypertension. In these focus groups there
was a remarkable consistency of responses regarding ideal pharmacy practice in
hypertension. Indeed, the findings from this study, in part, stimulated the
development and recent publication of the Canadian Hypertension Education
Program/Canadian Pharmacists Association practice guidelines for the
management of hypertension by pharmacists (6).
Unsystematic "secret shopper" evaluations of pharmacists are already
being conducted by the media and even other professional organizations.
Pharmacists may not like this, but that choice is not being offered. The choice that
pharmacists do have is whether to rise to the challenges of a higher standard of
practice, one which is patient-centered and outcomes focused.
Community pharmacists can serve as an important link between physician
and patient, although it is clear from the present study that the average community
pharmacist, and by extension, the whole profession, still has a long way to go.
Hypertension is an important risk factor for cardiovascular disease that is highly
prevalent, yet remains poorly identified, treated, and controlled. The new
standards of practice for pharmacists in hypertension management include
identification of patients with elevated blood pressure, measurement/assessment
of blood pressure in relationship to recommended targets, lifestyle education,

54

recommendations for drug therapy, assisting patients in achieving their blood

pressure goals, and encouraging medication adherence (6).
It should be noted that the SPs were very impressed with their interaction
with pharmacists, describing them as approachable, easy to understand and
generally caring. As such, we remain encouraged that pharmacists could be part
of the solution; however this opportunity will be lost unless we take bold steps
forward.
We must be realistic about the current and future state of pharmacy
practice. There will be little need for dispensing pharmacists in the very near
future. Yet, many pharmacists are complacent about the need to change their
practice. In their paper, "Leading Change in Pharmacy Practice: Fully Engaging
Pharmacists in Patient-Oriented Healthcare", Tsuyuki and Schindel (21) outlined
steps towards changing the profession towards these goals. Change is virtually
impossible if there is not a sense of urgency for change. We hope this paper has
provided some of that urgency. Pharmacy organizations, managers and
pharmacists need to lead change by clearly articulating a vision for the profession:
"Pharmacists engaged in patient-centered care, supported by high quality research
evidence of its efficacy, supported in their work environment, continuously
learning, and recognized for their important contributions to primary healthcare"
(21). Future work should focus on identifying other gaps in practice, providing
pharmacists with professional development opportunities to change their practice,
addressing barriers (real and perceived) to practice change, and evaluation of
disease management programs by pharmacists and in multidisciplinary teams.

55

Conclusions
Community pharmacists took reasonable steps to determine the accuracy
of blood pressure measurement, explain the diagnosis of hypertension, and refer
to a physician, however had major shortcomings in evaluation of past medical
history, assessment of target blood pressure and confirmation of the accuracy of
the BP measurement. A major change in pharmacy practice is needed if
pharmacists are to fill the gap in hypertension care and improve patient outcomes.

56

Why we did this study:

Hypertension is poorly controlled. Community pharmacists could play a major
role in the identification and management of hypertension, however current
pharmacist practices are not known. We evaluated this using unannounced
standardized patients with a hypertension case scenario.
What we found:
Most pharmacists did not perform up to the expected standard for hypertension
management.
What these findings mean for pharmacy practice:
A major change in pharmacy practice must occur if pharmacists are to fill the gap
in hypertension care and improve patient outcomes.

57

Appendix A: Determining Practice Standards for Community Pharmacists

Date:

Interviewee:

Job title/Position:

Objective: To establish standards of pharmacy practice for the management of

hypertension.
Situation: A 50 year old male approaches a community pharmacist in a local drug
store, and claims that his blood pressure, taken on the in-store BP machine, is
150/100. He asks "what does this mean?".
Questions:
1. What do you think would be reasonable practices to expect from a community
pharmacist in the above situation?

2. In the ideal situation, what do you think the role of the community pharmacist
should be, when faced with the above situation?

58

Appendix B: Standardized Patient Scenario

Scenario: The SP asks to speak with the pharmacist on duty: "Hi there. I was
wondering if you could help me out. I don't know much about high blood
pressure, but 1 took mine on my buddy's blood pressure machine last Sunday and
it told me my blood pressure was 150 over 100. I was just wondering what those
numbers mean.. .1 mean, are they good or bad? I read an article in the Journal a
while ago about how high blood pressure can be bad for your heart."

Clinical Background:

Age: 52 years

Gender: male

Weight: average (not noticeably obese or skinny)

Diet: no special regimen

Alcohol: 6-8 beers/week

Non-smoker

Father died of myocardial infarction at age 64

Past medical history: nil

No allergies

Medications: none

Non-Clinical Background:

Works as a pressman at a local printing press (shift work)

59

New patient to the pharmacy (no prescriptions filled), shopping for his
wife
No family physician, goes to local walk-in clinic if has ailments
Married, 2 kids, both in college
Appearance: casual, clean
Behaviour: curious, eager, not in a rush
Wants to know more re: BP reading, what normal ranges are, what
happens if BP too high / low
Not particularly knowledgeable about blood pressure, hypertension or
cardiovascular health, but friend stated it 'could be bad for his heart'

60

References
1. Chobanian A, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL, Jones
DW, Materson BJ, Oparil S, Wright JT, Roccella EJ and the National High Blood
Pressure Education Program Coordinating Committee. The 7th Report of the Joint
National Committee on Prevention, Detection, Evaluation and Treatment of High
Blood PressureJAMA. 2003; 289 (19): 2560-2572.
2. Health Canada, Health Protection Branch - Laboratory Centre for Disease
Control. Economic Burden of Illness in Canada. Catalogue No. 1993 H21136/1993E. Ottawa, 1997.
3. Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJL, the
Comparative Risk Assessment Collaborating Group (2002) "Selected major risk
factors and global and regional burden of disease" Lancet, 360: 1347-1360.
4. Joffres MR, Ghadirian P, Fodor JG, Petrasovits A, Chockalingam A, Hamet P.
Awareness, treatment and control of hypertension in Canada. Am J Hypertens.
1997; 10(10 Pt. 1): 1097-1102.
5. Feldman, Ross. The Canadian Hypertension Education Program
Recommendations: what's new, what's old but still important in 2003. (2003).
Evidence Based Recommendations Task Force of the Canadian Hypertension
Education Program. London, ON.
6. Tsuyuki RT, Semchuk W, Poirier L, et al. 2006 Canadian Hypertension
Education Program Guidelines for the management of hypertension by
pharmacists. CPJ/RPC. 2006;139(3):S11-S13.
7. McKenney JM, Slining JM, Henderson HR, et al. The effect of clinical
pharmacy services on patients with essential hypertension. Circulation.
1973;48(5):1104-1011.
8. McKenney JM, Brown ED, Necsary R, et al. Effect of pharmacist drug
monitoring and patient education on hypertensive patients. Contemp Pharm Pract.
1978;1:50-56.
9. Park JJ, Kelly P, Carter BL, et al. Comprehensive pharmaceutical care in the
chain setting. J Am Pharm Assoc. 1996;36(7):443-451.
10. Carter BL, Barnette DJ, Chrischilles E, et al. Evaluation of hypertensive
patients after care provided by community pharmacists in a rural setting.
Pharmacotherapy. 1997;17(6):1274-1275.
11. Pharmacy Group @ Rogers Media. 2003 Pharmacy Sourcebook. Rogers
Media Healthcare and Financial Publishing. Toronto, 2003.
61

12. Gorter S, Van Der Linden S, Brauer J, Van Der Heijde D, Houben H, Rethans
J, Scherpbier A, Van Der Vleuten C, Van Der Horst-Bruinesma I, Linssen A, Van
Santen-Hoeufft M, Van Der Tempel H and Westgeest T. Rheumatologist's
Performance in Daily Practice. Arthritis Care and Research. 2001; 45 (1): 16-27.
13. Woodward CA, Hutchison B, Norman GR, Brown JA, Abelson J. What
factors influence primary care physicians' charges for their services?. CMAJ. 158
(2): 197-202.
14. Hutchison B, Woodward CA, Norman GR, Abelson J, Brown JA. Provision of
preventive care to unannounced standardized patients. CMAJ. 158 (2): 185-193.
15. Carney PA and Ward DH. Using unannounced standardized patients to assess
the HIV preventive practices of family nurse practitioners and family physicians.
The Nurse Practitioner. 2003 (2); 56-76.
16. Kopelow ML, Schnabl GK, Hassard TH. Assessing practicing physicians in
two settings using standardized patients. Acad Med 1992; 67: S19-S21.
17. Tamblyn RM. Use of standardized patients in the assessment of medical
practice. CMAJ. 1998:158:205-7.
18. Gerritsma JM, Smal JA. An interactive patient simulation for the study of
medical decision-making. MedEduc 1988: 22:118-123.
19. Tamblyn RM, Abrahamowicz M, Berkson L. First-visit bias in the
measurement of clinical competence with standarized patients. Acad Med 1992;
67: S22-S24.
20. Hoppe RB, Farquhar Lj, Henry R, Stoffelmayr B. Residents' attitudes towards
and skills in counseling: using undetected standardized patients. J Gen Intern
Med. 1990 Sep-Oct;5(5):415-20.
21. Tsuyuki RT, Schindel TJ. Leading change in pharmacy practice: Fully
engaging pharmacists in patient-oriented healthcare. (2004)
(www.epicore.ualberta.ca. accessed June 20, 2006},.

62

CHAPTER 4
Improving Blood Pressure Management in Patients with Diabetes:
The Design of the SCRIP-ZJFiV study1
I. Background/Rationale
Cardiovascular disease (CVD) is the leading cause of mortality in Canada.
Diabetes is a strong risk factor for CVD; approximately 80% of people with
diabetes mellitus will die as a result of a vascular event (1). Although people with
diabetes have a particularly high risk for CVD, important risk factors such as
blood pressure (BP) control are poor, with less than 12% having their BP
controlled to <130/80 mm Hg (2). The objective of SCRIP-HTN is to evaluate the
efficacy of a program of intervention by community pharmacists and nurses to
improve the BP control in people with diabetes.
II. Methods
SCRIP-//77V is a randomized, community-based, multicentre trial that compares a
program of pharmacist and nurse intervention with usual care (Figure 1).
Patients: Adult patients with diabetes (either type 1 or type 2) will be identified
and approached by their community pharmacist from Medicine Shoppe
Pharmacies in the Edmonton area for possible entry into the study. Diabetes will
be defined as those patients presently taking either oral hypoglycemic agents;
insulin therapy or diet-controlled (with physician confirmation of diagnosis.
Exclusion criteria consist of current enrollment of the patient in a diabetes or

1A

version of this chapter was published as: McLean , D.L., McAlister, F.A.,
Johnson, J.A., King, K.M., Jones, C.A., & Tsuyuki, R.T. (2006). Improving
Blood Pressure Management in Patients with Diabetes: The Design of the
SCRJP-HTN Study. Canadian Pharmacy Journal, 139, 26-29.
63

hypertension study, patients that are institutionalized or given medications by a

professional caregiver. The study protocol has been approved by the University of
Alberta Health Research Ethics Board.
Patient Identification/Recruitment: Patients will be recruited via: 1) pharmacists
screening for eligible patients by generating lists of all their patients taking
diabetes marker medications from their prescription databases, and, 2) referrals
via Capital Health Regional Diabetes Intake Program. Patients will be invited by
telephone to attend an in-pharmacy BP clinic by a pharmacist and nurse.
At Visit #1, the nurse or pharmacist will complete a history and physical exam
(including a BP taken using the BPTru device(VSM MedTech, Vancouver, BC),
with 6 readings performed 1 minute apart in the arm with the highest reading, and
last 5 readings averaged. Each patient's medication history will also be reviewed.
If the averaged readings are >130/80 mm Hg, the patient will be invited to attend
a 2nd clinic in 2 weeks. If the averaged BPs from both visits are >130/80 mm Hg,
the patient will be approached for consent to participate in the randomized trial.
Randomization: Patients will be randomized to intervention or usual care on a 1:1
basis. Variable block randomization, with stratification by study centre
(pharmacy), will be carried out according to a computer-generated sequence and
accessed via a secure internet site.

Usual Care: The usual care group will receive: a BP wallet card with recorded BP
measures, a pamphlet on diabetes, general diabetes advice and usual care by their
physician. Follow-up: No scheduled follow up visits. The subject will receive a
telephone call at 12 weeks to inquire about changes to BP management, and a

final in person visit will occur at week 24 to re-evaluate BP and to offer the
intervention program.
Intervention: The intervention group will receive: a BP wallet card with
discussion about the BP measures, CVD risk reduction counselling, a
hypertension education pamphlet, and referral to their primary care physician for
further assessment/management. The BP results will then be faxed along with
any recommendations to the patient's primary care physician. Written
recommendations from local opinion leaders will be used to reinforce the latest
hypertension guidelines (Figure 2). Follow-up: Patients will be followed up at 6
weeks to ensure they have made an appointment with their physician and to remeasure BP, and at 6-week intervals thereafter (with faxing of BP results and
recommendations to the physician), and a final follow-up visit at Week 24.
Outcome Measures: The primary endpoint will be the difference in change in
systolic BP between intervention and usual care groups at 6 months. Secondary
endpoints will include: change in antihypertensive therapy (new medication or
dosage increase), proportion of patients achieving BP target of <130/80 mm Hg,
and proportion of patients using ACE inhibitors or angiotensin receptor
antagonists.
Sample Size: A change in systolic BP was the primary dependent variable used to
calculate sample size. A sample size of 85 patients per group will provide 90%
power (assuming a standard deviation of 20 mm Hg) to detect a 10 mm Hg
difference in the primary endpoint with alpha level of significance of 5% for a
two-sided test. To account for dropouts or loss of patients to follow-up, the

65

sample size has been adjusted to 110 patients per group, for a total sample size of
220.

Training and Support: This study is being conducted in partnership with

Medicine Shoppe Canada and involves 14 pharmacies in the Edmonton area. The
training program consists of an accredited web-based educational modules on
hypertension and diabetes (PHARMALeam.com) and a workshop. Upon
completion of the web-based modules, the pharmacists will attend a workshop,
which includes didactic and case-based materials as well as the use of the
BPTru and the study protocol.

Registered nurses who have the education and skills to practice at an advanced
level will be recruited for this study. Nurses will receive the same training as the
pharmacists, including the workshop.
III. Discussion
SCRIP-//77V is an ongoing, randomized, multicentre trial that is evaluating a
unique program of community pharmacist and nurse intervention, as part of a
multidisciplinary team, to improve the management of blood pressure in patients
with diabetes. Treatment and control of hypertension is a major public health
problem and a key goal of the Canadian Hypertension Society. Novel ways of
identification and treatment to guideline targets in this patient population are
urgently needed.
Current Status: Thirteen centers in the Edmonton and surrounding area are
participating in

66

SCRTP-HTN. The first patient was randomized in May 2005. As of November

29, 2005,
101 patients have been randomized. The study is scheduled for completion later
in 2006.

Word Count: 959

67

Figure 1. Protocol Summary

14 Urban Pharmacies

'f"

* rxic.mn.ITY

1 Pharmacists

Nov Eligible:
EXCLUDE

contact all potential subjects by telephone to determine eligibility,

1 and verbal consent to attend BP Clinics
- type 1 or type 2 diabetes
- available to attend BP clinics
i , - taking diabetes marker meds
- understands and speaks English
'-age > 18 years
- not institutionalized
- not enrolled in other DM or BP trials

YES
CONSENT FOR STUDV OBTAINED

V
BP Clinic Visit #1
BP measured according to
2005 CHEP Recommendations
BP wallet card given

EXCLUDE if: Averaged BPs from Visit ft I

Systolic ^ 130 OR diastolic <80 minHg

BP measurement recorded on wallet

card

& b'2:

-N

"V

i f " " " BP Clinic Visit #2

-r:BP measured according to
CI
11,2005 CHEP Recommendations),

J\
-v

WEEK -2

WEEK 0

Averaged BPs from Visit #1 & #2: Systolic >130 QR

Diastolic 80 mm Hg then:

Patient is RANDOMIZED

Patient History, Physical Assessment, Medication

History completed

Intervention-Enhanced Care

Usual Care

BP wallet card given with BPs recorded

General diabetes advice

Diabetes education pamphlet give to patient

WEEK 6

Follow Up Phone Call lo Patient by Pharmacist

Inquire about change in BP management

WEEK 121

BP wallet card with patient BP measures

BP measures with Treatment recommendations faxed to
GPs (includes opinion leader recommendations)
Hypertension lifestyle counselling
Hypertension education pamphlet given to patient
Patient encouraged to have other BPs "out of study times"
and to take BP wallet card to their GP

* Follow Up Visit 1 s

Follow Up Visit #'2 *

:
P x!
j WEEK 18-

Follow Up Visit 3 *

't

FINAL Follow Up Visit #3

Repeat BP measures, if Systolic >130 OR

diastolic >80 mm Hg, then

Offer Is1 phase of Intervention Program

(see above right)

f:' WEEK 24

FINAL Follow Up Visit 4

Follow Up Visits will include;

BP measured/recorded in patient BP wallet card

Patient lifestyle counselling for hypertension

BPs measured along with Treatment recommendations faxed to GPs

Patient encouraged to make appt. to see their GP and to show BP wallet card
November28, 2005

a
R = Randomization

68

Figure 2. Opinion Leader Statement

Overview: 2005 Canadian Guidelines for the Treatment of Hypertension in

Patients with Diabetes Mellitus*
1. Target BP for patients with diabetes is < 130/80 mm Hg
2. Drug Therapy:
with
Nephropathy

ACE Inhibitor or
Angiotensin
Receptor Blocker

Addition of Thiazide or
Long-acting Calcium
Channel Blocker

Multiple Combination Therapy

Diabetes
And BP > 130/80
mm Hg
without
Nephropathy

ACE-lnhibitor or
Angiotensin
Receptor Blocker

Combination of Thiazide with ACElnhibitor or Angiotensin Receptor

Blocker

The Canadian Hypertension Education Program (CHEP) is sponsored by The Canadian Hypertension Society,
The Canadian Coalition for High Blood Pressure Prevention and Control, The College of Family
Physicians of Canada, The Heart and Stroke Foundation of Canada, and The Adult Disease Division
of the Public Health Agency of Canada.

E
Pifi

kit

Alberta representatives on the CHEP Recommendations Task Force

and the SCRIP-HTA/ Advisory Committee are:
Dr. R Lewanczuk, Dr. F McAlister, Dr. R Padwal & Dr. N Campbell

'Adapted from 2005 Canadian Hypertension Education Program Recommendations (www.hypertension.ca)

April 22, 2005

69

References
1. Barrett-Connor E, Pyorala K. Long-term complications: diabetes, coronary
heart disease, stroke and lower extremity arterial disease. In: Ekoe J-M, Zimmet
P, Williams R, eds. The Epidemiology of Diabetes Mellitus: An International
Perspective. Chichester, UK: John Wiley & Sons 2001:301-319.
2. McLean, D., Simpson, S., McAlister, F. & Tsuyuki, R. (2004). Treatment to
blood pressure targets in persons with diabetes mellitus: A systematic review.
Unpublished manuscript.

70

CHAPTER 5
A Randomized Trial of the Effect of Community Pharmacist and Nurse Care
on Improving Blood Pressure Management in Patients with Diabetes:
SCRIP-//77V [NCT00374270]1
INTRODUCTION
Diabetes mellitus is a coronary artery disease-equivalent: patients
suffering with diabetes mellitus without prior coronary events have the same risks
for myocardial infarction and coronary artery disease-related mortality as
nondiabetic patients with prior myocardial infarction [1], The combination of
diabetes and hypertension markedly increases the risk of premature cardiovascular
disease.[2-4] Although hypertension is a stronger risk factor for macrovascular
cardiovascular events in patients with diabetes than glucose control[5], control of
blood pressure in patients with diabetes is often suboptimal.[6]
Thus, there is a need for a new model of care to improve BP control. Our
research group has demonstrated that pharmacists can play a major role in
preventive health care [7], For example, the Study of Cardiovascular Risk
Intervention by Pharmacists (SCRIP) was a 675-patient, 54-centre randomized
trial of community pharmacist intervention versus usual care on cholesterol risk
management in patients at high risk for CVD events which was terminated early
due to the large magnitude of the treatment effect of pharmacist intervention.

A version of this chapter was published as: McLean , D.L., McAlister, F.A.,
Johnson, J.A., King, K.M., Jones, C.A., & Tsuyuki, R.T. (2008). A randomized
trial of the effect of community pharmacist and nurse care on improving blood
pressure management in patients with diabetes mellitus: Study of Cardiovascular
Risk Intervention (SCRIP-//77V). Archives of Internal Medicine, 168, 2355-2361.
71

Registered nurses are trained in patient assessment and communications skills

which are well-suited to community-based screening and management programs
and their skill set is complementary to that of pharmacists. The purpose of
SCRJP-HTN was to evaluate the efficacy of a multidisciplinary screening and
intervention program by registered nurses and community pharmacists to identify
patients with diabetes whose blood pressure control was sub-optimal, to
collaborate with patients and their primary care physicians on strategies to achieve
blood pressure reductions, and thereby address the gap between research
evidence, guidelines, and clinical practice for these patients at high risk of
cardiovascular events.

72

METHODS
Detailed methods of this study have been published previously [8] (Figure 1).
In brief, we conducted a multicentre randomized trial comparing a program of
pharmacist and nurse intervention with usual care in 14 community pharmacies in
Edmonton, Alberta. Randomization was at the level of the patient (stratified by
pharmacy and using a varying block design); randomization was done centrally to
preserve allocation concealment using a computer-generated sequence over a
secure Internet service at the EPICORE Centre. Although patients and their
pharmacists were not blinded to group allocation, the outcome assessments for
this trial were objective and blinded.
All diabetic adult patients with blood pressure > 130/80 mm Hg on two
screening visits separated by 2 weeks were identified in participating pharmacies.
Diabetes was identified by community pharmacists through the use of diabetes
indicator medications in each pharmacy's prescription database (e.g., use of
insulin or oral hypoglycemic medications for > 6 months, thereby excluding those
with steroid-induced or gestational diabetes). Blood pressure was measured using
the BP Tru (VSM Medtech, Vancouver, BC), which was set to report the
average of 5 measurements of BP taken 1 minute apart. Patients were excluded
from the study if they were currently enrolled in other diabetes or hypertension
trials, were institutionalized (or had their medications administered by a
professional caregiver), refused consent or declined attendance at follow-up visits
for BP measurements.

73

The intervention was delivered by multiple nurse/pharmacist teams at various

pharmacy sites [8]. Patients randomized to the intervention were assessed by a
nurse/pharmacist team. Cardiovascular risk reduction counseling was provided
by a nurse/pharmacist team using a hypertension education brochure and
cardiovascular risk reduction counseling consisting of: (1) reviewing BP as a risk
factor, (2) discussing the causes of high BP, (3) describing the importance and
consequences of high BP, (4) explaining the effect of diabetes on high BP, and (5)
focusing on the lifestyle strategies the patient could undertake to improve their
BP. The patient was encouraged to make an appointment with their primary care
physician for further BP and cardiovascular risk assessment, and to facilitate this
the nurse/pharmacist team gave the patient a wallet card listing their BP and faxed
a two-page form to each patient's physician which documented the patient's
modifiable and nonmodifiable risk factors, medications, BP and any suggestions
for further testing or management based on the Canadian Hypertension Education
Program guidelines.[9-11] In addition, a one page summary of the evidence for
management of BP in patients with diabetes endorsed by 4 local opinion leaders
was also included in the fax to the primary care physician. Intervention group
patients were seen at 6 week intervals by the study nurse and pharmacist for
counseling, measurement of BP, and the study team communicated results of
these BP assessments to each patient's primary care physician.
Patients randomized to usual care received the same BP wallet card with
their recorded BP measures documented, a pamphlet on diabetes (Staying Healthy
with Diabetes; Canadian Diabetes Association), and general diabetes counseling

74

from the registered nurse/pharmacist. Usual care patients received telephone

follow-up at 12 weeks, and no other follow-up until the in-person visit at 24
weeks.
Follow-up for the primary outcome in both arms of the trial was similar:
an in-person visit to the pharmacy for BP measurement using the BP Tru device
at 24 weeks. The primary outcome was the change in systolic BP between
baseline and 24 weeks in each study arm. We chose a 24 week follow-up period
for our primary outcome to allow comparability with other studies of quality
improvement initiatives. Secondary outcomes included the comparison of the
following parameters in patients randomized to intervention versus usual care: (1)
the achievement of BP targets of <130/80 mm Hg, (2) the addition, or dosage
increase, of antihypertensive drug therapy, and (3) the proportion of patients
prescribed an ACE inhibitor or angiotensin receptor antagonist.
Our sample size was based on the following assumptions: we wanted to
detect (or rule out) a 10 mm Hg change in systolic BP, assuming a SD of 20 mm
Hg, with a 2 sided alpha of 5% and 90% power. To account for dropouts or loss
of patients to follow-up, the sample size was adjusted upwards from 85 to 110 per
group. All analyses were conducted according to the intention-to-treat principle
with the p value set at 0.05. The mean change in SBP from baseline was
calculated for each study arm, and compared using analysis of covariance
(ANCOVA). Multivariate linear regression with change in SBP as the dependent
variable was calculated to adjust for baseline imbalances between treatment
groups (p< 0.20). Missing data at the 24-week follow-up assessment was imputed
75

with a 'last-observation carried forward' strategy. This approach conservatively

assumes that all subjects lost to follow-up have no change in their BP. All
analyses were conducted using SPSS version 13.0 (SPSS Inc. Chicago, IL).
Ethics approval was obtained from the research ethics boards of the
University of Alberta, Edmonton, Alberta. Written informed consent was obtained
from all participants.
RESULTS
Between May 2005 and February 2007 we screened 480 patients with
diabetes and randomized 227 subjects (115 to intervention and 112 to usual care)
(Figure 2). Of the 256 patients who were not randomized, 210 were ineligible on
the basis of BP <130/80 mm Hg and 46 did not return for a second BP screening
measurement.
At baseline, there were no appreciable differences between the patients in
the intervention and usual care arms (Table 1). As expected, the majority of
patients in both arms had multiple cardiovascular risk factors. Although 78
patients (68%) randomized to the intervention and 78 patients (70%) randomized
to usual care reported not adding salt at the table on the baseline questionnaire, 48
patients (42%) randomized to the intervention and 48 (43%) randomized to usual
care reported not using salt in cooking. Of the 227 trial participants, 192 (85%)
were aware that they had hypertension. Among these 192 patients, 81 (42%) were
taking at least one antihypertensive agent at baseline (55 (29%) were on two
antihypertensives and 16 (8%) were on three or more) and only 4 (2%) reported
that they had seen a medical specialist for their BP.

76

Systolic BPs declined in both arms of the trial over 6 months (Figure 3),
but the reduction in the intervention group (10.1 mm Hg) was significantly greater
than that in the usual care group (5.01 mm Hg). After adjusting for baseline SBP,
an adjusted difference of 5.6 mm Hg was found to be statistically significant (SE
2.10, p = 0.008 for the comparison). Multivariate linear regression to adjust for
baseline imbalances between the treatment groups confirmed that the change in
systolic BP was significantly and substantially related to the intervention (OR
2.29, 95% CI 1.28 to 4.20, p = 0.005). In the subgroup of patients with systolic
BP >160 mm Hg at baseline (n = 22), the effects of the intervention were even
more marked: a 27.4 mm Hg reduction in the intervention group compared to a
3.4 mm Hg reduction in the usual care group; after adjustment for baseline SBP,
the adjusted difference of (25.3 mm Hg) was statistically significant (SE 9.25, p =
0.014 for the comparison).
The proportion of patients meeting guideline-recommended BP targets
(i.e. 130/80 mm Hg) increased in both arms of this trial (Figure 4): from 3 (2.6%)
to 54 (47%) (p < 0.001) in patients randomized to the intervention and from 4
(3.6%) to 37 (33%) (p < 0.001) in usual care patients. Thus, the intervention was
associated with a statistically significant 14% absolute improvement (46% relative
improvement) in the proportion of diabetic patients achieving BP targets
compared to controls (p = 0.025). Over the course of this study, the use of
antihypertensive medications by trial participants increased in both arms: from
72% to 79%

77

(p = 0.07) in patients randomized to the intervention and from 72% to 77% (p =

0.26) in usual care patients. Use of ACE inhibitors or angiotensin receptor
blockers increased in both study arms as well: from 62% to 70% (p = 0.07) in
patients randomized to the intervention and from 65% to 70% (p = 0.22) in usual
care patients.

78

DISCUSSION
Even in a relatively well-controlled group of patients with diabetes and
elevated BP, we found that a community pharmacist and nurse-based intervention
which empowered patients to take charge of their BP and communicated BP
measurements and guideline-based recommendations to family physicians
conferred an adjusted 5.6 mm Hg greater reduction in systolic BP over 6 months
compared to usual care. Of particular note, in those patients with poorest control
at baseline, our intervention was extremely efficacious (conferring an adjusted
25.3 mm Hg reduction in systolic BP in those patients with systolic pressures >
160 mm Hg at baseline).
Since medical management is the cornerstone of the treatment of
hypertension, it makes sense that pharmacists, who are accessible drug therapy
experts, should be engaged in the fight to control this important public health
problem. In 2003 Chabot et al [12], conducted a 9-month non-randomized pilot
study involving 9 community pharmacies located in Quebec City. This study
reported similar reductions in systolic BPs (-7.8 mm Hg vs 0.5 mm Hg; p = 0.01)
with a pharmacist-based intervention which involved a computerized decision-aid
BP management software program integrated into pharmacy prescription
management systems. Pharmacists were prompted each time the patient refilled a
prescription for antihypertensive agents to perform BP measurements, evaluate
adherence and propose written and verbal interventions. The HOME study [13]
was a randomized control trial of a high intensity (HI) versus low intensity (LI)
intervention in 125 patients to evaluate the effectiveness of a community

79

pharmacist-based home BP monitoring program in 12 community pharmacies

over 3 months. The HI intervention included 4 face-to-face visits with a trained
pharmacist who provided patient specific education about hypertension.
Following the first and third visits, patients were required to take home BP
measurements once a day for 1 month. Home BP measurements were used by the
pharmacists to develop treatment recommendations for the patient's physician.
The LI intervention, pharmacists measured patients BP in the pharmacy and
referred them to their physician for evaluation. At the final visit, the difference in
systolic BP change between the high and low intensity groups was -4.5 mm Hg
(p= 0.12), similar to our findings. Our current study took this work a step further
by adding in the complementary skills of nurses, in a team-based approach.
The degree of BP control in patients with diabetes in our community was
greater than expected, with 43% of those screened excluded for having BP <
130/80 mm Hg - this proportion is much higher than older studies suggesting
control rates in the order of 12% [5]. Furthermore, the baseline BPs of eligible
patients was lower than expected, about 142/77 mm Hg. This may reflect a
volunteer bias in that those patients most interested in control of BP may have
been more likely to agree to participate in this trial (indeed, over 80% were aware
that hypertension is a risk factor for cardiovascular disease). It may also explain
why the intensity of drug therapy was not significantly improved - physicians
may have felt that the BP in these patients was "close enough". Interestingly, we
observed a significant reduction in systolic BP without large changes in the use of
antihypertensive therapy, which suggests that patients may have been more

80

adherent with their prescribed drug therapy and/or lifestyle maneuvers. We did
not collect data on these parameters, so cannot be certain of the mechanisms for
the improved BP control.
Pharmacists and nurses that participated may be different from those that
did not participate - an investigator volunteer bias which may limit
generalizability of the program. However, pharmacists were selected on the basis
of a corporate partnership with Medicine Shoppe Canada, rather than any specific
pharmacist selection criteria. Furthermore, the activities of the pharmacists and
nurses are in accordance with recently published profession-specific guidelines
for the management of hypertension by the Canadian Hypertension Education
Program [11,14],
Other potential limitations of our trial include the fact that all of the
participating pharmacies were in urban locations and the vast majority of our
patients were from metropolitan areas. Further, our intervention involved
substantial in-person contact time between patients and study personnel and future
studies will need to define whether less intensive interventions are as efficacious.
By necessity, the subjects and investigators could not be blinded to the
intervention. The outcome measures were, however, objective, using the BP Tru
validated and automated device for accurate BP measurements. The use of a
randomized, controlled study design does, however, give our study a high degree
of causal inference, and to our knowledge, this is the largest such trial conducted
to date.

81

The results of our study demonstrate the value of community pharmacist

and nurse teams working in collaboration with patients and physicians to achieve
better blood pressure control. Since many patients with hypertension do not
present to their physician and primary care physicians today are already
overwhelmed, such approaches should be seriously considered. What is needed
now are systems of remuneration for chronic disease management which will
allow patients to have access to these multidisciplinary services. This
responsibility rests with health policy makers.
We were disappointed that the intensity of antihypertensive drug therapy
and use of ACE inhibitors or angiotensin receptor antagonists were not increased
in our trial. Future studies should focus on these aspects of hypertension
management - perhaps "stronger" interventions are needed [15]. The role of the
patient in improving antihypertensive therapy is probably under-recognized.
Indeed, we are planning a trial which will even more fully engage patients by
giving them the recently released Canadian Hypertension Education Program
Public Guidelines (www.hvpertension.ca) - in essence, providing the key features
of the guidelines to patients so they can be more involved in their own care. In
addition, future studies should follow BP control over a longer period of time to
confirm that the changes we demonstrated in 6 months can be maintained longterm, and to assess the cost-effectiveness of such programs.

82

CONCLUSION
SCRIP-//77V provides strong evidence that a community pharmacist and
nurse team, working collaboratively with patients and primary care physicians,
can have a major impact on hypertension management in patients with diabetes
and suboptimal BP control in the community. Extrapolating our findings on the
basis of published large population-based epidemiologic studies, a sustained 5
mm Hg reduction in systolic blood-pressure would be expected to reduce strokes
by 30%, coronary events by 23% and mortality by 13% [16].

83

ACKNOWLEGEMENTS
The authors wish to thank SCRIP-HTN Investigators, the SCRIP-//77V Nurses, the
SCRIP-HTN Advisory Committee and the EPICORE Centre/COMPRIS Staff for
their involvement.

The SCRIP-HTN Advisory Committee included: David Bougher, BSP, MHSA

(Chair, Centre for Community Pharmacy Research and Interdisciplinary
Strategies (COMPRIS), University of Alberta), Debra Allen, RN (College and
Association of Registered Nurses of Alberta), Elaine Andrews (Merck Frosst
Canada Ltd.), Norm Campbell,.MD (Canadian Hypertension Education Program),
Greg Eberhart, BSc(Pharm) (Registrar, Alberta College of Pharmacists), Beth
Horsburgh, RN, PhD (Dean, Faculty of Nursing, University of Alberta), Bill
Hyndyk, MD (Alberta Medical Association), Richard Lewanczuk, MD, PhD
(Canadian Hypertension Society), Ken Gardener (Medical Affairs, Capital Health
Region), Murray McKay, MA (Research and Evidence Branch, Alberta Health
and Wellness), Ross McKay, BSc(Pharm) (Medicine Shoppe Canada), Glen
Monteith, MA (Director, Pharmaceutical Policy and Programs, Alberta Health
and Wellness), Franco Pasutto, PhD (Faculty of Pharmacy and Pharmaceutical
Sciences, University of Alberta), Theresa Schindel, BSP, MCE (Director,
Outreach Education, Faculty of Pharmacy and Pharmaceutical Sciences,
University of Alberta), Richard Spooner, MD (Chair, Department of Family
Medicine, University of Alberta), Laura Stearns (ManthaMed).

84

CONFLICT OF INTEREST
Financial Disclosure:
Donna McLean: No disclosures. She was supported by the Heart and Stroke
Nursing Research Fellowship, Alberta Association of Registered Nurses Doctoral
Award and CIHR Tomorrow's Research Cardiovascular Health Professional
(TORCH) Traineeship Tomorrow's Research Cardiovascular Health Professional
(TORCH) Traineeship
Finlay McAlister:. No disclosures. He is supported by a research chair in Patient
Health Management funded by Aventis, the Alberta Heritage Foundation for
Medical Research, and the CIHR.
Jeff Johnson: No disclosures. He is supported by a Canada Research Chair in
Diabetes Health Outcomes and the Alberta Heritage Foundation for Medical
Research.
Kathryn King: No disclosures. She is supported by the Alberta Heritage
Foundation for Medical Research
Charlotte Jones: No disclosures.
Ross Tsuyuki: Has received grants from Apotex, AstraZeneca, Bayer, BristolMeyers Squibb, Merck Frosst, Pfizer, and Sanofi-Aventis. He is supported by a
research chair in Patient Health Management funded by Merck Frosst.

85

Author Contributions:
Ross Tsuyuki: concept and design, interpretation of the data, preparation of the
manuscript
Donna McLean: concept and design, coordinator of the project, analysis and
interpretation of the data, preparation of the manuscript
Finlay McAlister: concept and design, interpretation of the data, preparation of
the manuscript
Jeff Johnson-, input into study, interpretation of results, review and editing of
manuscript
Kathryn King: input into study, interpretation of results
Charlotte Jones: input into study, interpretation of results, review and editing of
manuscript

Sponsor's for the Study : This study was supported by grants from Heart and
Stroke Foundation of Canada; Canadian Diabetes Association; Canadian Council
of Cardiovascular Nurses; ManthaMed; Alberta Heritage Foundation for Medical
Research and Merck Frosst Canada Ltd.

86

REFERENCES
1. Haffner SM, Lehto S, Ronnemaa T, Pyroala K, Laakso M. Mortality from
conronary heart disease in subjects with type 2 diabetes and in nondiabetic
subjects with and without myocardial infarction. N Engl J Med 1998;
339:229-34.
2. Henry P, Thomas F, Benetos A, Guize L. Cardiovascular mortality
associated with impaired fasting glucose and the role of blood pressure. J
Am Coll Cardiol 2001; 37(Suppl A):240A.
3. Kannel WB, D'Agostino RB, Wilson PWF, Belanger AJ. Diabetes,
fibrinogen and risk of cardiovascular disease: The Framingham experience.
Am Heart J 1990: 120:672-76.
4. Sowers JR, Epstein M, Frohlich ED. Diabetes, hypertension and
cardiovascular disease. Hypertension 2001:37:1053-1059.
5. U.K. Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose
control with sulphonylureas or insulin compared with conventional
treatment and risk of complications in patients with type 2 diabetes (UKPDS
33). Lancet 1998; 352: 837-53.
6. McLean DL, Simpson SH, McAlister FA, Tsuyuki RT. Treatment and
blood pressure control in 47,964 people with diabetes and hypertension: A
systematic review of observational studies. Can J Cardiol 2006; 22:855-60.
7. Tsuyuki RT, Johnson JA, Teo KK, Simpson SH, Ackman ML, Biggs RS,
Cave AJ, Chang W-C, Dzavik V, Farris KB, Galvin D, Semchuk W, Taylor
JG. A randomised trial of the effect of community pharmacist intervention

87

on cholesterol risk: The study of cardiovascular risk intervention by

pharmacists (SCRIP). Arch Intern Med 2002;162:1149-155.
8. McLean DL, McAlister FA, Johnson JA, King DM, Jones CA, Tsuyuki RT.
Improving blood pressure management in patients with diabetes: The
design of the SCRIP-HTN study. Can Pharm J 2006; 139(4):36-9.
9. The Canadian Hypertension Society (2006). Canadian Clinical Practice
Guidelines. 2006 Canadian Hypertension Education Program (CHEP)
Recommendations. Retrieved September 13, 2007,
http://www.hvpertension.ca/chep/docs/CHEP 2006 complete.pdf
10. The Canadian Hypertension Society (2007). Canadian Clinical Practice
Guidelines. 2007 Canadian Hypertension Education Program (CHEP)
Recommendations. Retrieved September 13, 2007,
http://www.hvpertension.ca/chep/en/SlideIGts.asp
11. Tsuyuki RT, Semchuk W, Poirier L, Killeen RM, McAlister FA, Campbell
NR, Drouin D, Lewanczuk RZ. 2006 Canadian Hypertension Education
Program Guidelines for the management of hypertension by
pharmacists. Can Pharm J 2006;139:S11-S13.
12. Chabot I, Moisan J, Gregoire JP, Milot A. Pharmacist intervention program
for control of hypertension. Ann Pharmacother 2003;37: 1186-93.
13. Zillich A, Sutherland J, Kumbera A, Carter B. Hypertension outcomes
through blood pressure monitoring and evaluation by pharmacists (HOME
Study). J Gen Intern Med 2005; 20:1091-96.

88

14. McLean DL, Kingsbury K, Costello J, Cloutier L, Matheson S. 2007

Canadian Hypertension Education Program (CHEP) Recommendations:
Management of Hypertension by Nurses. Can J Cardiovasc Nurs 2007;
17:10-16.
15. Alter DA. Therapeutic lifestyle and disease-management interventions:
pushing the scientific envelope. CMAJ 2007;177 887-889
16. Staessen JA, Gasowski J, Wand JG, Thijs L, Hond ED, Boissel JP, Coope J,
Ekbom, Gueyffier F, Liu L, Kerlikowske K, Pocock S, Fagard R. Risks of
untreated and treated isolated systolic hypertension in the elderly: meta
analysis of outcome trials. Lancet 2000; 355: 865-72.

89

Figure 1. Tried Profile.

Regional diabetes program referrals

Pharmacies

Screening/Eligibility: Contact by
pharmacist
Type 1 or 2 diabetes
>18y

Clinic visit #1 (BP measurement)

BP>130/80
BP< 130/80. exclude

Clinic visit #2 (BP measurement)

BP> 130/80

BP< 130/80, exclude

CONSENT
RANDOMIZATION
Enhanced Care:
BP wallet card
BP and Tx recommendations to family physician
Opinion leader statements
Patient education: lifestyle, pamphlet
Referral to family physician

Usual Care:
BP wallet card
General DM advice,
DM pamphlet

Follow-up: 6,12,18 weeks

24 weeks: Close out visit
Endpoints: reduction in BP, achievement of target BP, ACEI use

90

Figure 2: Trial Flow Diagram

483
256 Ineligible for reasons of:

Pre-Screened Patients with

210 BP < 130/80 mm Hg

227

46 Did not return for 2nd

measurement

112

115
Intervention Arm
(Baseline Data)

108

7 Early
withdrawals
i
1 protocol
violation

Usual Care
(Baseline Data)

103

*A11 randomized patients included in

intention-to-treat (ITT) analysis

9 Early
withdrawals

4 protocol
violations

91

Figure 3: Primary Endpoint: Adjusted * Difference in SBP over 6 months

aA= 5.6 mm Hg (SE 2.10)

p=0.008

0
-2

-4
A BP
mm Hg

SM-8

-10

-10.1
-12
Intervention

Usual care

'Adjusted for: age, gender, heart rate @ Visit 1, BP arm, Ml, stroke,
1st degree relative Ml angina & cholesterol

92

Figure 4: Achieving Goal Blood Pressure < 130/80 mm Hg

p=0.025
50%
45%

35%
30%

%of
pts

25%

.A 29.7%

A 43.5%

20%
15%

10%

Usual Care

Intervention

I baseline

93

O 6 months

Table 1: Patient Demographics by Randomized Groups*

Usual Care
n=l 12

Intervention
n=l 15

61 (55)

75 (65)

63.2 12.7

65.7 + 11.3

143 16/76 + 9

140+ 12/78 9

10(15)

9(13)

64 (56)

69 (62)

-current

11(10)

12(11)

- ex-smoker

55 (48)

48 (43)

Body Mass Index

32 3

33 3

106 21

106+18

89 (77)

77 (69)

Alcohol (> 2 drinks / day)

8(7)

Sedentary lifestyle (< 30-60

mins of
moderate exercise 4 / week)

55 (46)

48 (43)

23 (20)

26 (23)

4(4)

5(5)

Atrial Fibrillation

20(17)

25 (22)

Prior Stroke, TLA, or Carotid

Revascularization

11(10)

3(3)

Chronic Kidney Disease

19 (17)

13 (12)

Peripheral Arterial Disease,

including prior
revascularization

13 (12)

15(14)

Variable
Demographics
Male
Age, mean + SD, y
Cardiovascular Risk Factors
Mean BP at baseline (mm Hg)
Premature atherosclerotic
event
(MI or stroke in 1st degree relative)

Hyperlipidemia (self reported)

Smoking

Waist Circumference (cm)

Elevated waist circumference
(>102 cm in men, 88 cm in women)

Self-reported CV CoMorbidities+
CAD (including prior MI, angina,
or
coronary revascularization)

Heart Failure

* All data are given as numbers (percentages) unless otherwise indicated. + Not mutually exclusive.

94

CHAPTER 6

A Historical Review of Selected Nursing Literature on Blood Pressure

Measurement Between 1945 and 2000

95

Abstract
The purpose of this article is to review selected nursing literature in order to shed
light on what occurred during the period of 1945 to 2000 with regards to nurses
and blood pressure measurement and management, and to reflect and critically
analyze the past technological trends and the nursing role in hypertension.
Historical design was utilized to examine content related to blood pressure
measurement in two widely circulated nursing journals in Canada and the United
States; the Canadian Nurse (CN) and American Journal of Nursing (AJN).

96

Introduction
To a nurse entering the medical wards of a hospital for the first time,
measuring blood pressure appears to be a simple routine procedure. Yet the
evolution of this important common clinical test required more than a century of
research and experimentation by many physiologists and physicians to point to the
solution of an ongoing problem of accurate clinical blood pressure measurement.
The measurement of blood pressure (BP) is a universal and essential tool of
healthcare practitioners and is commonly used in today's clinical practice. This
development was described in ancient times starting with the measurement of the
pulse. The transformation of feeling the pulse to recording it covers a long period
in medical history. However, present day instruments evolved over a single
century and since the early 1900s there has been no major discovery or
advancement in "sphygmomanometry", only technological refinements and the
introduction of electronics.
Sphygmos is the Greek word for 'pulse'; palpare is the Latin word for
'feel'.1 The development of BP measurement has not progressed from one
technique or device to the next. Many blood pressure measurement instruments
often developed simultaneously and at times independently in different locations
around the world. The evolution of "clinical sphygmomanometry" or BP
measurement, as it is more commonly known, has been documented in the

Blackburn, S. (2005). Oxford dictionary of Latin. Oxford: Oxford University

Press.

97

literature. However, how and when nurses learned to measure BP, and what was
their involvement remains relatively unknown and unsourced historically. It was
found through a systematic literature search, done in the context of a graduate
course, that only brief editorials and short references with reference to the history
of the subject in nursing and blood pressure device development were present in
the nursing literature prior to 1945. This is surprising considering nurses have
always used a variety of tools, instruments, and machinery to assess, treat, and
care for patients. It would be difficult to think about nursing practice without the
nursing tools of the trade. Nurses were the ones who put new diagnostic
technologies and treatments in to use, such as, thermometers, antisepsis,
anesthesia and hospitalization itself. 2
Although nurses have typically appeared (if they appeared at all) as no
more than footnotes in the history of medicine, nurses were indispensable
to the early scientific and technological transformation of health care and
medicine in Canada and the United States.3
Early 20th Century Blood Pressure Measurement
Scientific, technological and societal movements of the early twentieth
century had a significant effect on the development of health care and nursing.
Many diseases were eradicated. Scientific advances increased life spans;
diagnostic methods permitted visualization of the body's internal structures;

Sandelowski, M. (2000). Devices and desires: Gender, technology and

American Nursing. Chapel Hill: University of North Carolina Press.

3 Sandelowski,

M. (2000). Ibid., p.l.

98

anesthetic agents and improved asepsis changed which made surgeries successful
and hospitals moved from being contaminated to comprehensive health facilities.4
Other societal events had many effects on the delivery of health and the
roles and functions of nurses. There were many improvements in the twentieth
century in the general standard of living, progress in transportation,
communication and industrialization which changed Canada and the United States
into urban societies. Numerous changes in the world affected nursing as well as
occurred in nursing throughout the early twentieth century: world wars, selforganization of nurses, government and nursing legislation, problems of social
welfare and changes within medicine. These factors, alongside changes within
nursing such as roles, and the drive for professionalism had an effect on the role
of nursing.3 New drugs, new techniques and new technologies placed new
responsibilities on nurses and radical changes occurred in nursing care. As a
result of the introduction of new innovations and technologies in healthcare,
nurses were required and expected to perform many tasks formerly done by
physicians.
'Measurement' in the early part of the 20th century became the focus of
nursing and medical practices. The measurement concept included components of
'objectivity' and 'standardization'. Both objectivity and standardization had an
effect on the autonomy and personal judgment of physicians and nurses.
Scientific objectivity resulted in patterns for nursing and medical knowledge, and

Sandelowski, M. (2000). Ibid.

S. J. (1978). The social context of nursing. Nursing Outlook, 22(1),
240-244.

5 Reeder,

99

standardization led to routine patterns for practice. It was not only about what new
measurements physicians began to make, but also about those that they stopped
making. Nurses in hospitals started to use a number of measuring tools, like the
thermometer, that physicians had earlier kept to themselves. The conflicts that
arose as new tools were picked up by nurses revealed some of the tension between
objective, standardized measurement and individual medical judgment and
autonomy.6
The work of measurement in the 20th century increased rapidly as it was
shaped into routine practices. Daily, twice daily or even hourly records of the
temperature, the pulse, the quantity of urine and body weight became frequent,
expected or routine. With the growth in the work of measuring, and the
emergence of professional nurses in the 1900s in the United States and 1910s in
Canada, a dilemma began for physicians. Inside the world of a hospital, work like
the repeated measurement of the patients' temperature could be easily transferred
to non-physicians by standardizing the procedures and instruments.
Redistributing some of the physician's traditional work to the hospital's nurse
became a way to increase monitoring of patients.
The transfer of a task like measuring body temperature to the hospital
nurse meant redefining the part of the physician's work as no longer the exclusive
domain of the physician. It was Harvey Cushing (1903) an academic physician
who lectured on the future of continued transfer of standardized techniques into

Crenner, C. (2002). Diagnosis and authority in the early twentieth-century

medical practice. Bulletin of the History of Medicine, 76(1), 30-55.
100

the hands of nurses.7 Other physicians worried that the movement of tasks and
tools from physicians to the hands of nurses reflected poorly on the general status
of the physician's work. The use of thermometers and later blood pressure cuffs
in routine fashion by nurses drew concerns from the medical profession.8
Gender also distinguished the work of physicians and nurses in the
hospital. In the hospitals where the movement of tools took place, the physicians
were men and the nurses were women. The status of the physician's work was
protected by the existing inequality between women and men in social power and
prestige.9 Nurses' work was women's work and physicians' work was not.
Feminine versions of the thermometer, and later the stethoscope, appeared in the
hospital to demonstrate this distinction.
Technical language also distinguished the work of physicians and nurses
in hospitals. Measurements expressed in quantitative, technical language became
a routine part of the physicians' work. This change included the increasing use of
routine measurements by the nurses. The distinction between these two forms of
measurement preserved the status of the physicians' work, even as a portion of it
was being delegated away. Nurses routinely handled quantities which could be
registered on numbered scales outside the body. The measurements were
displayed clearly to the nurse, the physician and the patient. The professional
nurse used tools like the thermometer, the watch, and the scale to objectively take
7 Cushing,

H. (1903). On routine determination of the arterial tension in operating

room and clinic. Boston Medical and Surgical Journal, 148, 250-256.

Naqvi, N. H. & Blaufox, M. D. (1998). Blood pressure measurement: An

illustrated history. New York: Parthenon Publishing.

Sandelowski, M. (2000). Ibid.

101

and record the values about the patient. Physicians, however, gathered complex
measurements related to the body itself using the stethoscope or the touch of a
hand to extract the information in a way that was neither physically obvious nor
easily standardized. Measurements with the stethoscope appeared differently to
the patient differently from the measurements of the nurse. The physician, rather
than mapping data against instrumental scales, measured them against the scales
of the body. 10
If a patient was in hospital, control over measuring weight or body
temperature fell to the nurses in the 20th century. While the collection of this data
gave the nurse authority over the patient, it also reinforced her subordinate
position to the physician. The routine quality of these measurements and the
manner in which they created a schedule for the activities of the nursing staff fit
the needs of a "nurses' training" school.11 In an unsigned editorial, "The Trained
Nurse and Her Position," the editorials' opinion was "the usefulness of the nurse
is and always will be gauged by her faithfulness as a subordinate intelligently
carrying out the directions of the physician".12 The funneling of all information
from the nurses to the physician through numbers and graphs was one way for
making nurses labour "intelligently" subordinate.
New instruments like the Riva-Rocci sphygmomanometer (blood pressure
cuff), met with even more widespread challenges regarding routine use in nursing
10 Sandelowski,

M. (2000). Ibid.

" Ibid.
12 Author

Unknown. (1901). Editorial. The trained nurse and her position. Journal
of American Medical Association, 78(1), 982.
102

and medical practice. Pulse palpation using a watch was an exclusive

measurement, the 'tactus eruditus' (learned touch) of a physician that assessment
of the pulses and the exchange between physician and patients a kind of measured
closeness.13 This task was taken over as a regular duty by nurses by 1910.14
The sphygmomanometer was more like the thermometer. It appealed to
physicians as a 'suitably professional operation' but it also followed the path of
the thermometer into the hands of the nursing staff. Under prompting from the
Surgeon General of the Army, the United States Bureau of Standards began
investigation of medical sphygmomanometers in 1917. By 1927, the Bureau
published guidelines that were reproduced in documents published by the
Metropolitan Life Insurance Company and that were used in the certification of
instruments.13
The general acceptance for the nurse's use of the blood pressure cuff came
very gradually.16 Taking blood pressure did not become part of routine practice
until the 1930s.17 More general use came only slowly. Perhaps the symbolic

13 Riva

Rocci, S. (1896). Un nuovo sfigmomanometro. Gazz Medi di Torino, 50,

981-996. (Retrieved through John Scott Library Archival Acquisition serviceEnglish translation).

14 Sandelowski,

M. (2000). Ibid.

15

Author Unknown. (1917). Instructions to medical examiners. Metropolitan

Life Insurance Company. Milwaukee: The Company, 40.
16 Maxwell,

A. C. & Pope, A.E. (1914). Practical nursing: A textbook for nurses.

G.P. Putman's Sons; Maxwell, A. C. & Pope, A.E. (1923). Practical
nursing: A textbook for nurses. (4th ed.). G.P. Putman's Sons; McCrae, A.
(1925). Procedures in nursing. Preliminary and advanced parts 1 and 2.
Boston: M. Barrows & Company.

(3rd ed.).

17 Sandelowski,

M. (2000). Ibid.
103

power of the stethoscope as a physician's tool slowed the spread of its use by
nurses. The stethoscope measured up differently from the thermometer and
pocket watch. The stethoscope was something closer to medical opinion than
objective quantitative data. It was not an obvious instrument for nursing use. A
physician representing the nurses' training school at the Massachusetts General
Hospital stated that, "nursing students use their hands, eyes, ears, and brains in
their observations. They are taught clinical medicine omitting the use of the
stethoscope."18 The omission of the use of the stethoscope was to set apart the
nurses' understanding of "clinical medicine" from the physicians' understanding.
Consequently, how nurses learned to measure BP and what their
involvement was in the clinical areas remains relatively unsourced historically.
History is not linear and change takes a long time to occur. It is therefore
important to look at what was done historically when assuming that one is
creating something new. This alone is justification for this paper. Blood pressure
measurement is a subject that is often misunderstood. The measurement of BP
has been controversial throughout its history and remains a currently debated
clinical topic today.19 It is recognized that many factors have influenced nursing
and medical practices aimed at controlling blood pressure. This perhaps, is
because of the difficulty of defining what a "normal" BP is and who should be
measuring it.
18

Badger, G. (1906). The ideal curriculum for a training school. The Nursing
History Review, 3, 199.

19Grover,

S., Coupal, L. & Lowensteyn, I. (2008). Preventing cardiovascular

disease among Canadians: Is the treatment of hypertension or dyslipidemia costeffective? Canadian Journal of Cardiology, 24( 12), 891-897.
104

Therefore, selected nursing literature on blood pressure measurement from

1945 to 2000 was reviewed to provide a historical perspective on blood pressure
measurement and management in nursing. Knowledge of nursing history
provides valuable lessons on the nature of nursing practice; it encourages us to
think critically and contextually about contemporary issues, it helps us understand
the relationship between nursing practice and politics, and how gender has
impacted nursing.20 Nursing history can help remind us that nursing is an art as
well as a science.
Purpose of the Study
The purpose of this historical research project was to undertake a
beginning study of the history of blood pressure measurement in nursing. A
thorough review and historical critique of writings about blood pressure taking
and management in selected nursing literature from 1945 to 2000 has been
conducted. This review sheds light on the role(s) played by nurses in blood
pressure measurement and management and provides insight that could be useful
in shaping future directions with respect to nursing practice, nursing research and
nursing education. The historical method was chosen as it provided a systematic
way to examine the writings of this selected era.

20 McPherson,

K., & Stuart, M. (1994). Writing nursing history in Canada: Issues

and approaches. Canadian Bulletin of Medical History. 77(1), 3-23.

105

Method of Data Collection

Procedures
An initial point of interest for this project was to examine what has been
written about nurses/nursing and blood pressure practices during the period of
1945 to 2000. During the context of coursework for Nursing 684 History and
Politics in Nursing [(January-April 2009), University of Alberta, Faculty of
Nursing], whereby, a historical account of the events and ideas which led up to
BP measurement until early 1945 with a critical reflection of nursing'acquisition
of technological skills relating to measuring blood pressure and to patient care up
until the mid-twentieth century was examined. It was determined little was
written during this era with regards to nursing and this topic. It then followed that
looking at later literature would be of interest.
Data were collected and analyzed according to the historical method of
inquiry. Data collection commenced with a thorough critical examination and
systematic review of publicly available documents from (1) University of Alberta,
(Edmonton, Alberta) John W. Scott Health Sciences Library, (2) University of
Alberta Book and Record Repository (BARD) (8170-50 Street Edmonton,
Alberta, T6B 1E6). The Book and Record Depository (BARD) is a library storage
facility. The Facility houses less frequently used library materials belonging to
the University of Alberta Libraries. The BARD provides enhanced indexing to
complete collections of the journals in question, starting with the very first issues,
many of which date from the 1800's. The American Journal of Nursing and the

106

Canadian Nurse were both retrieved from the BARD for bound journal issues
beginning from 1945.
The Canadian Nurse and The American Journal of Nursing were the two
journals systematically reviewed from 1945-2000. The two journals were selected
as they were the most widely circulated nursing journals in Canada and the United
States and thus likely sources of information for staff nurses. They were received
by registered nurses in Canada and the United States respectively, as part of
membership in their nursing professional association. Of significance, these
journals were the most accessible to staff nurses, and are the oldest nursing
periodic publication in each country. It was apparent that the two journals do
differ from each other. The AJN which was first published in 1900 provided
broad-based nursing knowledge. Probably because, the United States had a larger
population of nurses there were more articles published per issue in the AJN on a
monthly basis compared to the CN. Also, articles in the AJN seemed to be more
physiologically and disease orientated whereas the articles in the CN had a
general interest nursing focus whereby more psycho-social articles were
published.
Specific questions were formulated and addressed and these provided a
framework to this research project and guided the data retrieval. The research
questions that guided the review included:
1. What views about blood pressure measurement and management were
presented in the Canadian Nurse and the American Journal of Nursing
from 1945 to 2000?

107

2. What were the roles of nurses depicted in the selected journals about blood
pressure measurement and management between 1945 and 2000?
The articles were reviewed with the following search strategies. The
indexes were searched for the terms: blood pressure, hypertension, pulse,
sphygmomanometry, cardiology, and heart disease. If no index was available,
chapter titles were read and references on blood pressure or hypertension were
reviewed. Manual hand searches and paging of journals were also conducted in
order not to miss data. Reference lists and bibliographies were also reviewed for
pertinent citations. These citations were then retrieved and reviewed for data.
The literature was placed and referenced into a broader historical context. Events
and social trends of the period under investigation were also considered in an
attempt to understand the context.21 Of particular importance was to place the
literature reviewed within the broader context of the state of nursing during the
period under investigation. For example, in 1948 in The Canadian Nurse we see
an example that speaks to nurses starting to "watch with special care the pulse,
temperature, blood pressure, and general reaction of patient's with
thyroidectomies....great disturbances would need noting and drawing to the

21

Glass, L. (1998). Historical research (p. 356-374). In P. Brink & M. Wood

(Eds.).(2nd ed.). Advanced design in nursing research. Thousand Oaks, CA:
Sage.; Streubert-Speziale, H. & Carpenter, D. (2007). Qualitative research in
nursing: Advancing the human perspective. (4th ed.). Philadelphia, PA:
Lippincott Williams & Wilkens.; Lewenson, S. (2008). Doing historical research
(p. 25-43). In S. Lewenson & E. Herrmann (Eds.) Capturing nursing history. A
guide to historical methods in research. New York: Springer.
108

attention of the doctor".22 In Canada, at this time when more surgeries were being
done, there was a serious shortage of nurses and the status of the nursing
profession was relatively poor. But at the same time, nursing was starting to be
recognized by society as being an "immense and essential value to the
community".23 It was Dr. Scarlett who stated, "The nurse should be more of a
colleague and less the servant of the doctor. There should be direct contact
between nurses and the governing bodies of hospitals. There must be
improvement in economic conditions, in hours of work, in better remuneration,
and in a freer life for all ranks of nurses".24
All articles were read and identified as either a primary or a secondary
article. Primary articles are typically defined as and include "the words from an
author, a witness to or first recorder of an event".25 Further with this definition
and for this research project a 'primary article' was taken to mean, the central
topic of blood pressure and hypertension, was discussed in detail. This meant that
more was discussed than a lone reporting of blood pressure within a vital signs
reading in a case study. Although I identified the secondary articles in this paper
and who authored them, the primary articles were the only articles taken forward
and examined critically in this analysis. Secondary articles were articles that
documented specific blood pressure measurement recordings within a vital signs
measurement (i.e., 160/90 mmHg) such as in a case study. These blood pressure
22

Grace, A. (1948). Thyroidectomy. The Canadian Nurse, 44, 169-173, p.171.

23 Scarlett,

E. (1948). Values old and new. The Canadian Nurse, 44, 15-19, p.15.

24

Ibid., p.16.

25

Glass, L. (1998). Ibid.

109

recordings were considered a secondary topic as the recording was an indice of a

patient assessment with no further discussion in the article.
Eighty-eight actual primary articles were then gathered and examined in
the search for answers to the research questions. Once collected, the documents
were reviewed, classified and interpreted. Data were kept if the "relationship to
or if it fit with the whole picture", or by repeated findings that identified trends or
patterns.26 Each document was judged using external and internal criticism and
reviewed for authenticity and credibility. Notes were kept in detail documenting:
(1) the content of the document (what was being written about blood pressure and
hypertension), (2) who wrote the document (nurse or physician), (3) the document
itself and its location, (4) whether the topic of blood pressure/hypertension was a
central or a secondary topic within the article and the (5) the type of nursing care
and nursing practice being associated with blood pressure measurement and
management.
Data Analysis, Synthesis and Exposition
The data extracted from the journals were examined once collected to
identify topics, themes and trends; and then it was determined if the information
contained was "truly solid".27 Synthesis was the process whereby the data were
organized, documented, and the meaning of the facts then determined with the
relationships revealed. Results were constructed into answers to the research
questions. Repeated findings were identified that focused on trends and patterns.

26 Glass,
27

L. (1998). Ibid.

Ibid.
110

Interpretations were based in the time period of the events discussed and on data
available and selected. Supplementary data on events were sought and used to
further explain situations, strengthen arguments and provide context. Data were
then judged using external and internal criticism for authenticity and credibility.
After conducting this analysis and synthesis of the data, the exposition or
narrative was written. One of the final steps was to revisit the original research
questions and to formulate answers based on the findings. Footnotes were
completed to be used to document and explain sources, as a source trail, and to
provide verification.28
External and Internal Criticism
All data extracted were subject to the measures of external and internal
criticism to assure authenticity, accuracy, and reliability or in other words, to
establish the truth of an event. To establish the truth two criteria must be met,
external and internal criticism.29

28 Glass,

L. (1998). Ibid.; Lynaugh, J. & Reverby, S. (1987). Thoughts on the

nature of history. Nursing Research 36(1), 4-69.; D'Antonio, P. (1999).
Rethinking, the rewriting of nursing history. Bulletin of the History of Medicine,
73, 268-290.
29 Ross

Kerr, J. (1986). Historical nursing research (p. 28-40). In S. Stinson and

J. C. Ross Kerr (Eds.). International issues in nursing research. Philadelphia:
Charles Press.; Christy, T. (1975). The methodology of historical research: A
brief introduction. Nursing Research, 24, 189-192.; Glass, L. (1998). Ibid.;
Lewenson, S. (2008). Ibid.; Carr, E. H. (1964). What is history? New York:
Knopf.
Ill

External Criticism
External criticism establishes the authenticity of documents.30 External
criticism in this study was validated by recording: the date, identification of the
author, and the place of origin of the document. In this study, the authenticity of
documents was a minimal issue as data were published in nursing journals which
establishes in itself establishes authenticity. Authenticity is more an issue when
examining archival material such as letters and personal journals.
Internal Criticism
Internal criticism or credibility has been defined as that which probably
happened based on critical examination of the best available evidence from the
best available sources. Truth in this project was ascertained as probable by the
researcher by using common sense based on the knowledge of these events today,
and taking into consideration the knowledge available at the time of the event.
Since documents from journals were acquired, it was necessary to examine the
nature of each piece to consider the level of evidence. For example, when
multiple authors suggested a particular practice it was possible to state that this
practice was likely the norm. Similarly, multiple articles on a specific topic may
indicate that it was possible that the topic was a key issue at the time. In some
cases, it was possible to confirm that it was by reviewing other sources, while in
other cases it was not possible to do so.
30 Glass,

L. (1998). Ibid.; Lewenson, S. (2008). Ibid.; Fitzpatrick, L. (2007).

Historical research: The method (p.375-386). In P. Munhall (Ed.). (4th ed.).
Nursing research: A qualitative perspective. Boston, MA: Jones and Bartlett.;
Lynaugh, J. & Reverby, S. (1987). Ibid.

112

Overview of Primary Article Search

After systematically hand searching a total of 365 articles relevant to the
topic were found in the CN and AJN during the period of 1945-2000. Of the 183
articles found in the CN, 170 were secondary and 13 were identified as being
primary articles. In the AJN 182 articles were found, 107 were secondary and 75
were identified as being primary articles (Figure 1 and Table 1).

Figure 1. Total Number of Primary and Secondary Articles Identified

Canadian Nurse

American Journal of Nursing

365

107
# of Primary
Articles Identified

# of Secondary
Articles Identified

113

# of Primary
Articles Identified

# of Secondary
Articles Identified

Table 1. Primary Articles Identified per Decade per Journal

Canadian Nurse

Decade
1945-1955

Total # of
Articles
Found
63

American Journal of Nursing

# of Primary
Articles
Identified
3

Total# of
Articles Found
57

# of Primary
Articles
Identified
7

1956-1965

59

42

15

1966-1975

22

23

1976-1985

31

36

27

1986-1995

14

10

1995-2000

10

183

13

182

75

Totals

114

Table 2. Role Identification of Authors Writing Articles on BP Measurement

and Management During 1945-2000
Canadian Nurse

Decade
Primary
Author
1945-1955

Nurses

Nursing

American Journal of Nursing

Role of
Authors
29/63 (46.0%)

Primary
Author

1 .Graduate /Staff Nurses

20/29 (69.1%)

2.Nurse Supervisors
3. Nurse Instructors
4. Nurse Consultant

4/29(13.8%)

Nurses

Role of
Authors
1.Graduate /Staff Nurses

6/24 (25.0%)

2. Nursing Instructors
3. Head Nurses

6/24 (25.0%)

2/29 (6.9%)

24/57 (42.1%)

1/29 (3.4%)

4. Nurse Professors

3/24(12.5%)

5. Head Nurse

1/29 (3.4%)
1/29 (3.4%)

5. RNs
6. Nursing
Supervisor/Nursing
Director

3/24(12.5%)

5. Post Graduate Nurse

1. Staff Nurses

19/24(79.2%)
5/24 (20.8%)

4/24 (16.7%)

2/24 (8.3%)

18/63 (28.6%)

Students

1956-1965

Physicians

16/63 (25.4%)

Nurses

29/59 (49.1%)

1. Graduate/Staff Nurses
2. Sisters/Nuns
3. Nurse/Physician Team
4. Assistant Professor
5. Nurse Clinical
Coordinator
6. Nursing Instructor
7. Head Nurse
8. Nurse Supervisor

1966-1975

18/29(62.1%)
4/29 (13.8%)
2/29 (6.9%)
1/29 (3.4%)
1/29 (3.4%)

Physicians

33/57 (57.9%)

Nurses

24/42 (57.1%)

2. Nurse-led Physician
Teams

1/29 (3.4%)
1/29 (3.4%)
1/29 (3.4%)

Nursing
Students

23/59 (39.0%)

Nursing
Students

1/42 (2.4%)

Physicians

7/59(11.9%)

Physicians

17/42 (40.5%)

Nurses

17/22 (77.3%)

Nurses

15/23 (65.2%)

1. Head Nurses
2. Graduate/Staff Nurses
3. Nursing Supervisors
4. Research Assistant

9/17 (52.9%)
4/17(23.5%)
3/17(17.6%)
1/17(6.0%)

1. Nurse Instructors
/Professors with MN
Degree

8/15 (53.3%)

2. Staff Nurses with BScN

Degree
3. Nurse/Physician Team
4. Research Team of 2

5/15 (33.3%)
1/15 (6.7%)
1/15 (6.7%)

Nurses and a PhD Nurse

1976-1985

1986-1995

Physicians

5/22 (22.7%)

Nurses

30/31 (96.8%)

Physicians

1/31 (3.2%)

Nurses

6/6(100%)

Physicians

8/23 (34.8%)

Nurses

34/36 (94.4%)

1. Staff Nurses

11/30 (36.7%)

2. Nursing
instructors/Unit
Supervisors with BScN
Degree

9/30 (30.0%)

(Includes: Nursing
Instructors. Clinical Nurse
Specialists. Professors and
Hypertension Practitioners

6/30 (20.0%)

2. BScN Prepared Nurses

3. Nurse/Physician Teams

13/34 (38.2%)
4/34 (11.8%)

1. MN Prepared Nurses
(Includes: Lecturers.

9/14 (64.3%)

3. MN Prepared Nurses
4. Nurse-Run Teams

4/30 (13.3%)

1. Staff Nurses with BScN

3/6 (50.0%)

Degrees
2. Professor/Nurse
Midwife with MN Degree

2/6(33.3%)

3. RN

1/6(16.7%)

Physicians

2/36 (5.6%)

Nurses

14/14(100%)

1. MN Prepared Nurses

17/34 (50.0%)

Nurse Educators. Clinical

Nurse Specialists.
Hypertension Clinicians
2. Nurse-led Physician
teams

3/14(21.4%)

3. Staff Nurses with BScN

2/14(14.3%)

Degrees

1996-2000

Physicians

0/6 (0.0%)

Nurses

1/2 (50.0%)

1. Nurse/Physician Team
Hypertension Clinicl

1/2 (50.0%)

Physicians

0/14 (0.0%)

Nurses

10/10(100%)

1. MN Prepared Nurses
(Includes: Staff Educators,

6/10(60.0%)

Nurse Instructors, Nurse

Practitioners)
2. Nurse/Physician Teams
3. MN Prepared Nurses
Physicians

1/2 (50.0%)

Physicians

115

0/10(0.0%)

2/10(20.0%)
2/10(20.0%)

Analysis
Chronological Trends and Findings
1945-1955
At the end of World War II (WW II) there was more emphasis in the CN
on world events such as the atomic bombs on Hiroshima and Nagasaki, with
emphasis on the number of people injured. Much of Europe was in ruins and
there were chronic shortages of all goods. The United States, by contrast was
booming and the standard of living was very much improved. It was a time of
prosperity for the average American. This was similar in Canada but not to the
same extent as the United States.31 The unemployment rate in the United States
and Canada was low. With effort to provide employment for returning men,
governments on both sides of the border mounted campaigns to encourage women
to return to the more traditional role of mother and wife. In turn, this had an
effect on women in all professions, that is, women chose to return to childbearing
and marriage rather than continue in employment outside the home.32
Nursing in this decade was enhanced with an explosion of knowledge and
technology. Nursing was effected by social movements, such as civil rights and,
student, consumer and women's movements; increased scientific advances;
advances in technology; changes in the healthcare delivery system and the roles of

31 Phillips,

C. (1999). The 20th century, year by year: The guide to the people and
events that shaped the last hundred years, (p.164-194). Vancouver: New
Millennium.; Cherry, B. & Jacob, S. ( 2002). Contemporary Nursing: Issues,
trends, & management, (p.17-49). (2nd ed.).
St. Louis: Mosby.
32 Cherry,

B. & Jacob, S. (2002). Ibid.

116

providers and recipients of health care, progress in public health, and development
of voluntary and government health organizations.
With the advent of new drugs, new techniques and new technologies this
placed new responsibilities on nurses and resulted in many changes in nursing
care. Nurses were doing more tasks and procedures due to the introduction of new
innovations in health care. Nurses were expected to perform many tasks formerly
done by physicians. During this decade, nursing functions included BP
measurement (only "specially trained" nurses could take blood pressures and
under specific circumstances prior to 1945), suctioning in a variety of conditions,
transfusion assistance, oxygen administration, and giving medication by injection.
Nurses were assisting in operating rooms, delivery rooms and outpatient clinics.
More people were being admitted to hospitals and procedures were considered
safer.33
The progress in transportation and communication, inventions and
scientific achievements had an, influence on keeping individuals healthy, initiating
changes in the care of the sick, expanding the healthcare field in general and
refining nursing. Alongside this was the improvement in the general standard of
living, the lengthening of the lifespan, identification of the causes of many
diseases, and plans of care for patients and families. Social movements; civil
rights; and student, consumer and women's movements influenced direction of
health care.

33 Dolan,

J. (1968). History of nursing. (12th ed.). Philadelphia: Saunders.

117

Healthcare Organization-Nursing Care Delivery

After the war, there was a nursing shortage as women were encouraged to
return to the more traditional role of mother and wife. Nursing labour at that time
offered few rewards, long hours, hard physical labour and low salaries. Towards
the end of WW II and after WW 13 there was a large amount of intervention
federally into health care across both borders. The Nursing Training Act of 1943
was the first instance of federal funding in the United States used to support nurse
training. The passage of the Hill-Burton Act or the Hospital Survey and
Construction Act of 1946 was a huge contribution of federal dollars to health care
in the United States history.34 This funding was to construct hospitals and to plan
for other health care facilities based on the needs of the communities. This in
turn, led to an increased demand for professional nurses to provide care in
hospitals.
In Canada, federal health care legislation occurred in 1948 through the
National Health Grants Program. The program provided assistance for hospital
construction, public and mental health programs and professional training.35 Prior
to the 1950's, nursing students primarily staffed the hospitals. Canadian hospitals
grew in size and the student workforce was no longer sufficient or considered
adequate. The nursing shortage brought the introduction of additional patient care
personnel such as attendants, nursing aides, licensed practical nurses, nursing

34 Cherry,

B. & Jacob, S. (2002). Ibid., p.17.

35 Paul,

P. & Ross Kerr, J. (2011). Nursing in Canada, 1600 to the present, (p.1841). In J. Ross Kerr and M. Wood (Eds.). Canadian nursing: Issues and
perspectives. (5th ed.). Toronto: Elsevier.
118

assistants, who began to take tasks that had been delegated to nursing students or
nursing staff.
In the post years of WW n, Canadian hospitals grew in size and in
complexity, making it difficult to only have student nurses as the main source of
labour in the hospitals; as there were not enough of them and their skill set was
lacking to meet increasing technological demands of the times.36 Biomedical
advances meant there were new hospital wards and units and federal hospital
construction grants helped expand municipalities' health facilities. More
technical tasks were beginning to be assigned to nursing staff and nursing
specialties, such as public health, mental health and neurology were starting to
develop.37
Nursing Education
Immediately after WW II hospital schools of nursing continued to educate
most nurses in Canada. Nursing students worked in the hospitals while they also
learned.38 "In the formative years between 1940 and 1955, university schools of
nursing became firmly established and began to accommodate ever-increasing
numbers of students and administer increasingly larger budgets."39 The first

36 McPherson,

K. (2005). The Nightingale influence and the rise of the modern

hospital, (p.73-87). In C. Bates, D. Dodd & N. Rousseau (Eds.). On all frontiers:
Four centuries of Canadian nursing. Ottawa: University of Ottawa Press.
37

Ibid.

38 McPherson,

K. (2005). Ibid.

39

Wood, M. (2011). Entry to practice, striving for the baccalaureate standard. In

J. Ross-Kerr & M. Wood. (Eds.). Canadian nursing: Issues & perspectives. (5th
ed.). Toronto: Elsevier, p. 364.
119

master's degree in nursing in Canada began to be offered at the University of

Western Ontario in 1959.40
After WWII there were many new advances in nursing, as psychiatry,
public health and neurology became modern specialty areas.41 In the United
States, the National Nursing Accrediting service established minimal national
standards for nursing. State Board Test Pools were being used and are still used
today. 'Nursing for the Future' written by Esther Lucile Brown in 1948
recommended nursing education being moved from hospitals to universities.
Nursing baccalaureate programs grew and associate degree programs developed
in junior colleges.42 Of relevance to this paper, The National Heart Act
authorized aid for research, training and established the National Heart Institute at
National Institutes of Health (NIH).43
Overall Synopsis 1945-1955
In total, sixty-three journal articles were identified through a systematic
hand search and paging of all articles published in the CN during the period of
1945 and 1955 (Table 1). The indexes, titles, the body of the articles and
references were manually hand searched to identify the following terms within the
articles: blood pressure, hypertension, pulse, sphygmomanometry, blood pressure

40 Paul,

P. & Ross Kerr, J. (2011). Ibid., p.46.

41 Deloughery,

G. (1995). History in the nursing profession, (p. 1-54). In G.

Deloughery (Ed.). (2nd ed.). Issues and trends in nursing. St. Louis: Mosby.

42 Cherry,
43

B. & Jacob, S. (2002). Ibid.; Deloughery, G. (1995). Ibid.

Deloughery, G. (1995). Ibid., p. 46.

120

cuff, cardiology, heart disease and diabetes. If any of the identifying terms were
found within an article, the article was copied and kept for further review and
analysis. This process of searching occurred similarly for each decade and also
for both journals.44 Not all journal years contained articles. For example,
between 1945 and 1947, no published articles were found in the CN that
addressed the area of blood pressure measurement and management.
The majority of articles of the sample published between 1948 and 1955 in
the CN were written by nurses (29/63, 46.0%). Within this group of nurses who
published, the majority were graduate and staff nurses (20/29, 69.1%); followed
by: nurse supervisors (4/29,13.8%); nurse instructors (2/29, 6.9%); a nurse
consultant (1/29, 3.4%); a head nurse (1/29, 3.4%) and a post graduate nurse45
(1/29, 3.4%). Much writing was also being done by the nursing students (18/63,
25.4%). All the articles were either case studies or anecdotal secondary articles
that depicted only a blood pressure reading in the assessment of a patient's
condition. Physicians also wrote articles in this topic area (16/63, 25.4%) in the
CN between 1948 and 1955 (Table 2). The majority of physicians were either
thoracic/cardiac surgeons or neurologists.
In total, 57 journal articles were identified through a similar systematic
hand search and paging of all articles published in the AJN during the period of
1945 and 1955 (Table 1). Similarly as with the CN, if any of the identifying terms

44

Note: The same process was used for all decades that are presented in this
paper.

45 Post-graduate

nurse in this article refers to a registered nurse who has earned a

one-year certificate in public health nursing post-graduation.

were identified within an article, the article was copied and kept for further review
and analysis.
The majority of articles published between 1945 and 1955 in the AJN
period were written by a physician as the primary author (33/57, 57.9%). Of the
physicians who published, the majority were from general medicine (12/33,
36.4%), or from another discipline (cardiac/thoracic surgery, internal medicine,
neurology) (11/33; 33.3%) or were part of a physician-led team (10/33, 30.3%)
Nurses also wrote and published articles in the AJN during this time frame of
1945 and 1955 (24/57,42.1%). The articles were evenly authored by graduate
and staff nurses (6/24, 25.0%) and nursing instructors (6/24, 25.0%).
Interestingly, one male nursing instructor wrote an article in 1948. The remaining
articles were written by head nurses (4/24, 16.7%); nurse professors (3/24,
12.5%), registered nurses (3/24, 12.5%), a nursing supervisor and a nursing
director (2/24, 8.3%) (Table 2).
It would appear there were more nurse authors in the CN and more
physician authored articles in the AJN. As stated above, nursing students were
also being published in the CN. Typically, the articles reflected a case study more
than likely, their write-up of a patient who they had nursed and studied on the
unit. The AJN did not contain any nursing students' work. Although it cannot be
confirmed it may be a possible hypothesized that the editor (Margaret E. Kerr
M.A., R.N.) from the CN may have encouraged students to write and share their
experiences with other nurses. Slightly fewer articles (57) were written per year
in the AJN on blood pressure compared to CN (63) but one can also note blood

122

pressure measurement and management type articles appeared in the literature

earlier (1947 versus 1950) in the United States in the AJN.
Canadian Nurse
Of the articles located during the initial identifying term search described
above, the discussion of BP measurement and management, technological trends
and the nursing role in hypertension in Canada was a primary and central topic of
discussion only within three articles (3/63, 4.8%) written between 1948 and 1955
in the CN (Appendix A).46 No research study articles were found. Two of the
three articles were hypertensive case studies and the third article discussed
pathology relating to the mechanisms involved in the regulation of blood pressure
(Appendix A). Primary or central in nature is taken to mean in this paper, that
the published article is discussed with detail, that is, more was discussed than a
lone reporting of blood pressure within a vital signs reading in a case study.
Interestingly, all three articles from this decade came from the same year, same
issue. On further investigation, the monthly editorials in the CN entitled 'Between
Ourselves' would give a short introductory synopsis of written articles in the
journal along with a few notations from the Canadian Nurses Association
meetings. For example, in June 1950 in the editorial Kerr wrote:
While there are no figures available on the actual incidence of increased
blood pressure, it is found very commonly. Primary or essential

46 These

articles are: Sigmundson, M.& Einarson, C. (1950). Nursing the

hypertensive. The Canadian Nurse, 46(6), 455-458; Beamish, R. E., Adamson, J.
D., & Griffin, D. L. (1950). Hypertension. The Canadian Nurse, 46(6), 449-453;
Petursson, S. (1950). Public health nurse's role with the hypertensive. The
Canadian Nurse, 46(6), 458-460.
123

hypertension is a separate clinical entity. Hypertension develops without

any determinable pathological changes in the beginning. With the
persisting high blood pressure, eventually the clinical picture of damage to
the blood vessels and other organs appears.
Solving some of the problems of hypertension, while at the same time
providing a place for treatment, is the role of the special clinic established
at the Winnipeg General Hospital. Dr. R. E. Beamish and Dr. J. D.
Adamson have prepared an excellent digest of the relevant facts for your
information. Supplementary nursing care information is contained in the
article by Margret Sigmundson and Clara Einarson. One aspect of the
community problem in hypertension is described by Suzanne Petursson.47
On reviewing other yearly volumes before or after this volume of articles, there
does not appear to be monthly or yearly similarities in topic themes that happen
on a yearly basis. The only similarities appear in each monthly volume, that is,
common headings offered in issues for the year of 1950 include: New products;
Nursing profiles, Trends in nursing, Book reviews; Work conferences; News
notes and Official directory.
The editor of the CN, Margaret Kerr, appeared to respond to Canadian
nurses suggestions as seen in her editorial from July 1950:
We occasionally have had nurses tell us that they prefer to read medical
journalsthey want the more detailed, scientific approach and explanations.
For these nurses, and, indeed, for everyone, we recommend that you read
the article on heart catheterization secured by the Committee on Private
Nursing for their Page. It is a complete reprint of the material as it appeared
in The Canadian Medical Association Journal.48
It may be hypothesized from this comment of that time why we see many articles
written and
published by physicians in the journal at that time.
47

Kerr, M. (1950). Editorial. Between ourselves. The Canadian Nurse, 46(6),

428.
48 Kerr,

M. (1950). Editorial. Between ourselves. The Canadian Nurse, 46(1),

516.
124

Sigmundson and Einarson (1950), two head nurses who worked on the
women's and men's medical wards published an article discussing the
management of hypertension through two case studies using sodium thiocyanate
and lumbodorasal sympathectomy. It is unknown as to what other educational
background other than being a nurse that these authors had as this was not
documented in these early articles. Typically, the nurses' job title and at what
hospital they were practicing were documented. No references or sources were
used in this paper and this was similarly so in this decade of articles in this topic
area. Most articles during this time were case- based and shared experiential
knowledge of the authors. No further articles were found that were authored by
these two nurses.
Interesting to note, the treatments described by Sigmundson and Einarson
would have been credible in 1950s for 'malignant hypertension' but these
treatments today are no longer suggested and not followed with regards to BP
treatment. Sodium thiocyanate, the drug used in 1950 is known today as a
chemical found in herbicides and is an antidote to cyanide poisoning.49 More
often today medications such as: ace inhibitors, thiazide diuretics, angiotensin
receptor blockers, and long-acting calcium channel blockers are prescribed to
lower BP.

49

McGraw-Hill Encyclopedia of Science and Technology. (2011). (5th ed.). The

McGraw-Hill Companies.
http://www.answers.co m/librarv/Sci-Tech+Encvclopedia-letter-lT-first10 l#ixzz1mEMrc3Bk
125

Sigmundson and Einarson stated: "Hypertension, the commonest and

most important of all heart diseases, causes more deaths than cancer and
tuberculosis combined"50 This statement although made in the 1950s remains
relevant today. In 2000, Elliot wrote: "Raised blood pressure is one of the most
important underlying risk factors for morbidity and mortality in the world today,
ranking alongside tobacco in estimates of the worldwide attributable burden of
mortality".51 In actuality, systolic blood pressure increases linearly with age.
More than half of Canadians over age 60 have hypertension and it is estimated
that 9 in 10 Canadians will develop hypertension within an average lifespan.52 All
adults require ongoing assessment of blood pressure and Canadians with high
normal blood pressure require annual blood pressure assessment as over xh will
develop hypertension within 4 years.53

50 Sigmundson,

M. & Einarson, C. (1950), Ibid., p. 455.

51

Elliot P.(2000) High blood pressure in the community, (p.8). In Bulpitt C. J,

(Ed.). Handbook of hypertension Vol. 20. Epidemiology of hypertension.
Amsterdam, the Netherlands: Elsevier Scientific, 1-18.

52 Vasan,

R .S., Beiser, A, Seshadri, S, Larson, M., Kannel, W. & D'Agostino R

.B. (2002). Residual Lifetime Risk for Developing Hypertension in Middle-aged
Women and Men. Journal of the American Medical Association, 287(8), 10031010.

53 Padwal,

R. S., Hemmelgam, B. R., McAlister, F. A., McKay, D .W., Grover, S.,

Wilson T. (2007). The 2007 Canadian Hypertension Education Program
recommendations for the management of hypertension: Part 1 - Blood pressure
measurement, diagnosis, and assessment of risk. Canadian Journal of Cardiology
23(7), 529-538.
126

Hypertension in many of the earlier decade papers and in Sigmundson and

Einarson paper, referred to blood pressure as a 'type of heart disease'54. In
contrast, today we consider that hypertension is 'an actual risk factor for the
development of cardiovascular disease' and is not considered a type of heart
disease.55 Sigmundson and Einarson referred to the nurse's role in the treatment
of a patient with hypertension
The nurse plays an important role in the treatment of any patient with
hypertension. It is she who aids the patient in attaining the proper mental
attitude toward his illness by providing pleasant, peaceful surroundings,
cheerful atmosphere, and repeated reassurance regarding his condition.
While he is in hospital, the nurse must use every opportunity to help the
patient adapt his life to his disease, without stressing his illness to the
point where he considers himself a permanent invalid. It should be
pointed out that he may lead a long and useful life provided he avoids all
excesses. Moderation in exercise, eating, drinking, and smoking; freedom
from worry; rest and complete relaxation are the prime factors to be
considered.56
Sixty-one years later, The Canadian Hypertension Education Program
(CHEP) 2011, recommendations for nurses and other health care professional still
advocate for moderate lifestyle change to achieve blood pressure control.
Teaching patients about healthy lifestyle improves cardiovascular risk and reduces
blood pressure in the prevention and treatment of hypertension. Healthy eating,
regular physical activity, low risk alcohol consumption, reductions in dietary
sodium and in some, stress reduction can prevent or treat hypertension as well as

54 Sigmundson,

M. & Einarson, C. (1950). Ibid.

55 Kaplan,

N. (2010). Primary hypertension: Natural history and evaluation. In

Kaplan's clinical hypertension. (10th ed.). Lippincott Williams & Wilkins:
Wolters Kluwer, 108-140.

56 Sigmundson,

M. & Einarson, C. (1950). Ibid., p. 455-456.

127

other cardiovascular risks. The nurse's role today has definitely changed and
taken an alternative approach from the 1950s whereby providing pleasant,
peaceful surroundings and a cheerful atmosphere were considered a treatment
action by nurses for hypertension management.
A final statement in the Sigmundson and Einarson paper notes that...
"through routine physical examinations, diagnosis will be made earlier of
hypertension".57 Again, current hypertension recommendations and main
message for CHEP 2011 suggests, "Assessing blood pressure at all appropriate
visits".58 New medications being developed over the decades have provided more
options to patients for the treatment and control of hypertension, but what has not
changed is the recognition that all individuals should be screened for hypertension
because it contributes to the development of cardiovascular disease and an
increased risk profile.

57 Ibid.,

p. 458.

58 Canadian

Hypertension Education Program. Rabi DM, Daskalopoulou SS,

Padwal RS, Khan NA, Grover SA, Hackam DG, Myers MG, McKay DW, Quinn
RR, Hemmelgarn BR, Cloutier L, Bolli P, Hill MD, Wilson T, Penner B, Burgess
E, Lamarre-Cliche M, McLean D, Schiffrin EL, Honos G, Mann K, Tremblay G,
Milot A, Chockalingam A, Rabkin SW, Dawes M, Touyz RM, Burns KD,
Ruzicka M, Campbell NR, Vallee M, Prasad GV, Lebel M, Campbell TS, Lindsay
MP, Herman RJ, Larochelle P, Feldman RD, Arnold JM, Moe GW, Howlett JG,
Trudeau L, Bacon SL, Petrella RJ, Lewanczuk R, Stone JA, Drouin D, Boulanger
JM, Sharma M, Hamet P, Fodor G, Dresser GK, Carruthers SG, Pylypchuk G,
Gilbert RE, Leiter LA, Jones C, Ogilvie RI, Woo V, McFarlane PA, Hegele RA,
Poirier L, Tobe SW. The 2011 Canadian Hypertension Education Program
Recommendations: The Scientific Summary - An Update of the 2011 theme and
the science behind new CHEP recommendations. Canadian Journal of
Cardiology, 27(4), 415-433.
128

What is striking about this article is, although the current day treatment of
hypertension is extremely different than in the 1950s with regards to blood
pressure management the authors were sharing two current day treatments of
hypertension. Nursing texts used during this period to teach nurses about
hypertension would not have mentioned how elevated blood pressure was treated.
More often than not, defining arterial and venous blood pressure, discussing
"normal" blood pressure, factors causing variation in blood pressure, method of
taking blood pressure, the equipment used to take a blood pressure, and what to
teach a patient with high blood pressure would only be discussed. 59
In the second substantive article of the CN, Beamish, Adamson and
Griffin, three cardiologists, defined hypertension, and gave a historical synopsis
of the condition.60 They discussed factors "to maintain normal blood pressure:
the cardiac output, the peripheral resistance, the total blood volume, the viscosity
of the blood and the elasticity of the arterial walls".61 Variations in blood pressure
were diagrammed, systolic and diastolic blood pressure was discussed with
labelling levels "exceeding 140/90 mm Hg to be abnormal and would denote
hypertension".62 Strikingly, CHEP 2011 still suggests today to lowering blood

59 Price,

A. (1959). The art, science and spirit of nursing, (p. 484-493). (2nd ed.).
Philadelphia: W.B. Saunders Company.; Harmer, B. & Henderson, V. (1955).
Textbook of the principles and practice of nursing, (p. 299-309). ( 5th ed.). New
York: Macmillan Company.; Day, Sister M. (1947). Basic science in nursing
arts. (p. 75-76). (2nd ed.). St. Louis: C.V. Mosby Company.

60 Beamish,

R. E., Adamson, J. D. & Griffin, D. L. (1950). Ibid.

61

Ibid., p.450.

62

Ibid., p.450.
129

pressure to <140/90 mmHg, and in people with diabetes to <130/80 mmHg using
a combination of lifestyle modifications and medication.
Beamish, Adamson and Griffin described three groups of symptoms in
hypertensive patients (psychoneurotic, vasospastic and organic) in this article.
Interestingly, psychoneurotic symptoms were described as:
Many hypertensive patients are high-strung, overactive people who suffer
from a psychoneurosis as well as hypertension. As a result of emotional
problems and various maladjustments to their environment they complain
of symptoms referable to any or all parts of the body: headaches,
dizziness, inability to relax, palpitation, pain in the left chest, etc. These
symptoms are invariably due to the psychoneurosis and not to the
accompanying hypertension. This can be proven by treating such patients
with a placebo (i.e. colored water) and noting dramatic relief of
symptoms.64
Today, symptoms of hypertension are not discussed in the literature; one
cannot feel high blood pressure. This is why hypertension is often referred to as
"the silent killer". Moreover, the focus is predominantly on the 'factors' that have
an effect on blood pressure.65
My impression of this article is it served as an educational piece to provide
advanced knowledge for nurses from a medical model perspective. Physicians
were starting to realize they needed to work cooperatively with nurses as they
were unable to hang on to all tasks and medical devices as their world in medicine
was also becoming more inundated with newer technology. Therefore, educating

63 Canadian
64

Hypertension Education Program (CHEP). (2011). Ibid.

Beamish, R. E., Adamson, J. D. & Griffin, D. L. (1950). Ibid., p. 451.

65 Canadian

Hypertension Education Program (CHEP). (2011). Ibid.

130

nurses around blood pressure management would in turn free up physicians to do

other tasks of interpretation and initiating clinical action. Nurses were eager to
learn and were very precise and uniform with following protocols.66
The third article by Petursson, a Victorian Order Nurse in Winnipeg,
Manitoba, discussed the public health nurse's role in caring for the hypertensive
patient in the home.67 This VON nurse shared a case history of a patient who on
closer inspection would more likely today be suffering from congestive heart
failure. Interestingly, in no part of her case does she share BP readings or even
suggest that a BP was taken. Petursson stated:
Mrs. Bird.. ..complained to the nurse that she had had a severe cold for a
month, a cough that kept her awake at night, and shortness of breath. In
addition, her ankles were edematous and she complained of a small
urinary output.
In hospital the patient was treated with mercurials, thoracentesis, and bed
rest. She was told to report to the hypertension clinic every two weeks and
the VON was requested to give her "2cc. salyrgran twice weekly at
home.68
What is striking about the content in this article and of the other two
articles in the CN, is hypertension in the 1950s was being treated when already
much organ damage had already occurred as obviously, blood pressure screening
was not a regular part of every patient visit. Being diagnosed with hypertension
in this time period was a severe event and quite distressing as the sequelae for the

66 Sandelowski,

M. (2000).Ibid., p. 48.

67

Petursson, S. (1950). Ibid.

68

Ibid., p.459.

131

patient affected their quality of life. Petursson at the end of the article suggests
that there is,
a great need for expanding diagnostic and treatment facilities in rural
areas
The greatest difficulty the public health nurse meets in working
with hypertensive patients is finding these patients early. The service
which she can offer in the home is not often recognized until the patient
actually needs bedside care.69
Currently, 2011 key Canadian Hypertension Education Program messages
suggest 'all patients should have their blood pressure assessed at all appropriate
visits'. This means, early diagnosis is key to prevention of sequelae of
hypertension: cerebrovascular disease, coronary artery disease, congestive heart
failure, renal failure, peripheral vascular disease, dementia and atrial fibrillation.
American Journal of Nursing
Of the articles identified during the initial identifying term search as
described above, the discussion of BP measurement and management,
technological trends and the nursing role in hypertension in the United States was
a primary and central topic of discussion within seven articles (7/57, 12.3%)
written between 1945 and 1955 in the AJN (Appendix A).70 No research study

69 Ibid.,

p. 460.

70 These

articles are: Smithwick, R. H., & Kinsey, D. (1947). Surgical treatment

of hypertension. American Journal of Nursing, 47(3), 153-155; Fedder, H.
(1948). Nursing the patient with sympathectomy for hypertension. American
Journal of Nursing, 48(10), 643-646; Ellis, L. B. (1948). Underlying causes of
heart disease. American Journal of Nursing, 48(11), 697-698; Takayoshi, M.
(1953). Nursing care of patients with portal hypertension. American Journal of
Nursing, 53(10), 1208-1209; Christensen, S. P. (1953). Portal hypertension.
American Journal of Nursing, 53(10), 1206-1207; Jay, A. N. (1953). What is a
routine physical examination? American Journal of Nursing, 53(3), 320-321;
132

articles were presented in this decade in the AJN. Six of the 7 articles presented
pathophysiology relating to the mechanisms associated with hypertension and
clinical manifestations (i.e., portal hypertension). Only one article described the
appropriate technique and equipment required for measuring blood pressure
(Appendix A).
Within these identified primary articles, the article by Ellis a physician
alludes to hypertension as a "type of heart disease".71 This was similarly
recognized practice in Canada as noted earlier by the authors Sigmundson and
Einarson.72 However, hypertension today is no longer seen as a type of heart
disease. Ellis suggests that hypertension is more common, "in square-chested,
heavy set, overweight individuals than in the "string-bean" type, and the level of
the blood pressure is frequently much improved by weight reduction".73 This fact
remains true today, with lifestyle modifications such as weight loss as the
cornerstone of both antihypertensive and antiatherosclerotic therapy. Obesity is a
reversible risk for hypertension.74 No references were used in this paper, but the
content was credible to current day thought.
In another article, Jay, a physician, describes how to take a blood pressure
during a routine physical exam. "[A blood pressure] is commonly done with the
Freis, E. D., & Lodge, M. P. (1954). Treatment and nursing care of hypertension.
American Journal of Nursing, 54(11), 1336-1339.
71 Ellis,

L. B. (1948). Ibid., p. 697.

72 Sigmundson,
73 Ellis,
74

M. & Einarson, C. (1950), Ibid.

L. B. (1948). Ibid., p. 698.

Miller, E. R. (1999). Journal of Clinical Hypertension, 12( 1), 191-198.

133

blood pressure cuff placed on the left arm

and under certain conditions; the

physician may desire to check it in the legs as well".75 It would appear from
nursing texts of the time that nurses were taking blood pressures only from
arms.76
Christensen, a chief surgical resident, and Takayoshi, a surgical head nurse
discuss what is portal hypertension and the nursing care of these patients.77 The
syndrome of portal hypertension, also referred to as Banti's syndrome, is that of
secondary anemia, thrombocytopenia, leukopenia, splenomegally, and recurrent
severe gastrointestinal hemorrhages due to ruptured esophageal varices.78
Patients with portal hypertension have an increase in pressure within the vessels
which make up the portal system and this results in the blockage of the portal
blood flow. Interestingly, no references were used in either article which appears
to be common form in the AJN at this time.
Smithwick and Kinsey, two surgeons, and Fedder an instructor and
supervisor of surgical nursing, address surgical treatment of hypertension and the
nursing care for a patients with a lumbosacral sympathectomy.

Surgeons were

referred to treat severe hypertension with surgery using a procedure that would
interrupt the sympathetic nervous pathways to the vascular bed. This procedure

75 Jay,

A. N. (1953). Ibid, p.321.

76 Price,

A. (1959). (p.488). Ibid.; Day, Sister M. (1947). Ibid., p.77.

77 Christensen,

S. P. (1953). Ibid.; Takayoshi, M. (1953). Ibid.

78 Christensen,

S. P. (1953). Ibid.

79 Smithwick,

R. H & Kinsey, D. (1947). Ibid.; Fedder, H. (1948). Ibid.

134

modified the magnitude of the reflex responses which occur as a result of stimuli
which activate the sympathetic nervous system and secondly that the tone of
smooth muscle would be decreased.80 Nurses during this time were providing the
post-operative care to monitor these patients by taking frequent blood pressures
and monitoring the pulse. "It would be extremely important that nurses caring for
patients with sympathectomy be unusually skillful, careful, thorough, and kind at
all times. A nurse should never try to explain conditions of a patient unless she
herself has accurate and complete knowledge of the subject. Any misinformation
may only confuse and excite the patient unduly".81 This procedure is not written
about or discussed as an option for hypertension management today. These two
articles did have references. Fedder's references were from medical journals
{Journal of American Medical Association; Bulletin of New York Academic
Medicine), and she also referred to Smithwick and Kinsey's paper published in
AJN.62 Smithwick and Kinsey referred to previously published papers by
Smithwick in medical journals.83
Freis and Lodge, a physician and a nursing professor, also wrote about the
treatment and nursing care of patients with postural hypotension and specific
drugs which produce a medical sympathectomy. 84 The drugs he mentions are no

80 Smithwick,

R. H., & Kinsey, D. (1947). Ibid.

81 Smithwick,

R. H., & Kinsey, D. (1947). Ibid.; Fedder, H. (1948). Ibid., p.646.

82

Fedder, H. (1948). Ibid., p.646.

83 Smithwick,
84

R. H., & Kinsey, D. (1947). Ibid., p.155.

Freis, E. D., & Lodge, M. P. (1954). Ibid.

135

longer currently on today's formulary, but would have been the only choices at
that time. They included: hexamethonium chloride, veratrum viride,
hydrazinophthalazine (apresoline) and rauwolfia serpentine (Serpasil).85 This
article was the first to mention patients taking their own blood pressures at home.
Some non-specific details were given on how the patient should perform this
"He inflates the bag until the mercury column or dial needle reaches the top and
then he manipulates the air release valve so that the bag deflates slowly. He notes
the systolic and diastolic pressures as he simultaneously listens for the sounds and
observes the movement of the mercury column or the dial needle".86 CHEP
(2011) advises patients that home blood pressure measurement should be
encouraged to increase patient involvement in care, especially patients with
uncomplicated hypertension, those suspected of non adherence, patients with
white-coat effect, and those with masked hypertension.87
In comparison to the CN literature, we see that BP measurement and
management as a primary central topic was found in the literature about 3 years
earlier in the United States in the AJN. The hypertension topic was more
consistently discussed than its counterparts in Canada. The CN articles suggest a
clinical supportive role of nursing to a patient and their family, mentioning more
global ways of hypertensive management such as, reduced mental stress and
lifestyle modification whereas, specific surgical procedures to treat patients with

85 Ibid.,

p.1338.

86Ibid.,p.l338.
87 Canadian

Hypertension Education Program (CHEP). (2011). Ibid.

136

hypertension are discussed and the skill of taking a blood pressure are reviewed
with the AJN. A greater focus on the medical model and on pathophysiological
information and detail is provided within the AJN articles. This is also reflected
to this day in the United States entry to practice examinations.
It was interesting to note, that articles from both journals had sporadic
referencing, typically, to nursing and medical textbooks used at that time to teach
students and to medical journals. This would be the last decade that the CN would
publish reading times addressing how long it would on average take a reader to
read an article.
1956-1965
The postwar home was now more efficient; houses were full of laboursaving machines to make housework easier. There were toasters, food mixers,
electric irons, washing machines, colored televisions, and vacuums. Homes were
centrally heated with running hot water, new style furniture was available. Doorto-door salesmen and Hula hoops were all the rage. The decade was known for
rapid scientific and technological progress and huge social change. The first
satellite to orbit the earth was launched in 1957 by the Soviet Union, and was
called Sputnik 1. The Russians had Sputnik 2 launched Explorer I was launched
in 1958 by the United States. Alouette 1 was Canada's first satellite launched in
1962. The St. Lawrence Seaway opened, enabling ships to sail from the Atlantic
Ocean inland through Canada.88

88 Phillips,

C. (1999). Ibid.; Canadian space history, (n.d.). Retrieved February 29,

2012, from http://spaceistheplace.ca/hist.html
137

The contraceptive pill was approved in 1960 and an end to the 'baby
boomer' stage by 1964. Beatle mania was prevalent. In 1964, the Beatles,
Britain's Fab Four, and sensation of Europe set foot in US where their single "I
Want to Hold Your Hand" hit No. 1. Dr. Christiaan Barnard in 1967 performed
the first heart transplant. J.F. Kennedy was assassinated in the USA in 1963.
Tragic babies, thalidomide to blame, had been a drug that was prescribed to
pregnant women for nausea, was withdrawn in Canada and Europe.89
Healthcare Organization-Path to Government Health Insurance
There were many improvements in technology during this decade.
Effective antibiotics and improved surgical techniques gave medicine more
control over certain diseases. Improvements in technology of blood transfusions,
laboratory analysis, x-rays and ECGs contributed to the advancement of scientific
medicine.
These developments were reflected in an increasing proportion of the
population escaping infection and surviving any given episode of illness.
As a result, infant mortality and life expectancy began to take on modern
dimensions and brought about a shift in the prevailing patterns of disease
from acute to chronic illness. These changes ushered in a second stage in
the evolution of modern health care systemsmaking medical care more
accessible to wider segments of the population. The key sequence of
events is the emergence of hospital and medical insurance programs and
the increase in importance of government involvement in health services.90
A nationwide program for health insurance developed in Canada with
public pressure in the mid-1950s. The provinces were pressuring the federal
government to help pay for costs of providing hospital services. It was in 1957,
89

Ibid.

90Baumgart,

A. (1992). Evolution of the Canadian health care system, (p. 23-41).

In A. Baumgart & J. Larsen. (Eds.). Canadian nursing faces the future. (2nd ed.).
St. Louis: Mosby-Year Book.
138

that a cost-sharing hospital insurance program was proposed and the Hospital and
Diagnostic Services Act was passed. This led to the building of many hospitals
and to a period of shortage of nurses. During this decade there was a struggle in
Canada to expand the nursing workforce. Married women and married women
with children were recruited back into nursing positions. Male nurses began to
fill hospital vacancies in staff nursing positions.91 By 1961, all provinces and
territories were participating in the program providing federally assisted hospital
insurance (universal coverage, reasonable accessibility, portability of coverage
from province to province, and comprehensive coverage for in-hospital care) to
all Canadians.92 In 1961, the Royal Commission on Health Services was
established to investigate health care services in Canada; it emphasized having
medical care in the national health insurance program. In its 1964 and 1965
Reports, the Commission recommended the creation of a universal health
insurance program which was to become a reality in 1968 93
Federal legislation enacted in the United States in the 1960s also had a
long lasting effect on nursing and health care. In 1965, the Medicaid program
was enacted to serve as medical insurance for those families, primarily women
and children, with an income below the federal poverty level. Medicaid became

91 Dolan,

1968, Ibid.

92 Ross-Kerr,

J. (2011). The Canadian health care system, (p.4-17). In J.RossKerr & M. Wood. (Eds.). Canadian nursing: Issues & perspectives. (5th ed.).
Toronto: Elsevier.
93 Ibid.

139

the largest public assistance program in the United States. 94 Public health nurses
were to provide the care required by children and pregnant women in the
Medicaid program. Services included: family planning, well-child assessments,
immunizations, and prenatal care.
An amendment also occurred to the Medicare program in 1965 which
provided hospital insurance and medical insurance to all people age 65 and older
who were eligible to receive Social Security benefits, people with disabilities and
those with end-stage kidney disease. Medicare provided reimbursement. This
increased hospital-bed occupancy, which in turn led to increasing numbers of
nurses needed to staff hospitals. Nursing at this time, moved away from the
community as the preferred practice area as more nurses were needed in hospital
settings.95
Nursing Education
The Royal Commission on Health Services (Hall Commission) also
reported on the state of nursing education in 1964 and recommended that schools
of nursing be independent from hospitals and provided the impetus that led to
nursing education programs moving into the mainstream education system over
the next three decades.96
The educational system for nursing should be organized and financed like
other forms of professional education
not only [so] that we shall
94 Cherry,

B. & Jacob, S. (2002). Ibid., p.18.

95 Ibid.
96 Paul,

P. & Ross Kerr, J. (2011). The origins and development of nursing

education in Canada, (p. 328-358). In J. Ross-Kerr & M. Wood. (Eds.). Canadian
nursing: Issues & perspectives. (5th ed.). Toronto: Elsevier.
140

obtain equally, if not better, qualified personnel in shorter time, but that a
substantial part of hospitalized patient-care will no longer depend , as it
does now, upon apprentices. 97
Executive Director Helen K. Mussallem for the Canadian Nurses
Association stated,
Whether nursing education should be placed within the general
educational system can no longer be considered a point of debate. It is
possible and it can be done
The Canadian Nurses' Association, in
cooperation with its provincial counterparts, should take steps to
implement the plan present in the study.. ..leading to the inclusion of all
nursing education within the general educational system of each
province.98

The need for nurses increased as the number of hospitals expanded in the
United States. Nursing education in the late 1950s started to change to respond to
social, political and educational changes in society. Like in Canada, with the
increasing complexity and expansion of medical care, nurses needed to be better
prepared. The decision was made to develop 2-year nursing programs in
community colleges, which required courses in arts and sciences along with an
integrated approach to nursing content and clinical learning. The rationale was
that nursing belonged in a "college setting along with other disciplines to provide
a better education for nurses/women and to establish more respect and recognition
for nursing's contribution to the community's health."99 Differences between the
community college and the hospital program were: the length (two years vs three)
because of emphasis on educational experiences rather than hospital service; the
governing body and the supervision of the faculty. Community college students
97 Government

of Canada. (1964). Royal Commission on Health Sevices. (p. 6449). Ottawa: Queen's Printer.
98 Government of Canada. Ibid., (p. 183-185).

99 Cherry,

B. & Jacob, S. (2002). Ibid., p.86.

141

were predominantly older; single students were allowed to marry after admission;
married students were accepted for admission; an on-campus residency was not
required.100 This was an example of how change in society influenced the
evolution of nursing education.
Nursing and Blood Pressure Management
During this decade, physicians continued to introduce new technologies
and were responsible for these technologies until the volume of treatments
increased or became burdensome to medical staff. Physicians always retained
power to order the medical technology but nurses became the primary and more
proficient user of it. By 1954, blood pressure became a standard skill expected of
all nurses in Canada.101
In the late 1960s companies began to advertise stethoscopes for sale
directly to nurses for the first time in the pages of the professional nursing
journals (ie., AJN), in much the way that clinical thermometers had been sold
through similar nursing journals in the 1890s. This was the start to
acknowledging more widely the nurses' use of stethoscopes. These
advertisements encouraged each nurse to individually have his/her own
stethoscope. Prior to having each nurse own their own, one stethoscope was often
kept in a central location for use by all the nurses on that unit. When stethoscopes
began to be sold widely to nurses in the 1960s, one of the instruments advertised
100 Grippando,

G. & Mitchell, P. (1989). Nursing perspectives and issues. (4led.). New York: Delmar Publishers.
101 Toman, C. (2005). Body work, medical technology, and hospital nursing
practice, (p.89-105). In C. Bates, D. Dodd, & N. Rousseau (Eds.). On all
frontiers: Four centuries of Canadian nursing. Ottawa: University of Ottawa
Press.
142

was, "the assistoscope

designed with the nurse in mind: slim, dainty, light and

flexible....fits in your pocket or purse".102 It would appear that gender and work
influenced how the stethoscope was viewed much like the thermometer as either a
tool of physicians or of nurses.
Overall Synopsis 1956-1965
In total, fifty-nine journal articles were identified through a systematic
hand search and paging of all articles published in the CN during the period of
1956 and 1965 (Table 1).
The majority of articles published between 1956 and 1965 in the CN
during this time period were written by nurses (29/59, 49.1%). Within this group
of nurses who published, the majority were graduate and staff nurses (18/29,
62.1%). Sisters/nuns who were nurses (4/29, 13.8%); nurse/physician teams
(2/29, 6.9%); assistant professor (1/29, 3.4%); nurse clinical coordinator (1/29,
3.4%); nursing instructor (1/29, 3.4%); head nurse (1/29, 3.4%) and a nurse
supervisor (1/29, 3.4%) also published papers. High numbers of nursing student
case studies and anecdotes were being published that typically discussed a blood
pressure reading in the assessment section of their workup of a patient and were
considered secondary sources (23/59, 39.0%). Physicians also wrote articles in
this topic area (7/59, 11.9%) in the CN between 1956 and 1965 (Table 2).
In total, forty-two journal articles were identified through a similar
systematic hand search and paging of all articles published in the AJN during the
period of 1956 and 1965 (Table 1).
102 Author

Unknown. (1968). Advertisement. Assistoscope. American Journal of

Nursing, 68( 1), 1180.
143

The majority of articles published between 1956 and 1965 in the AJN
during this time period were written by nurses (24/42, 57.1%). Within this group
of nurses who published, the majority were staff nurses (19/24, 79.2%), and
nurse-headed physician teams (5/24, 20.8%). There was one article published by
a nursing student in the AJN (1/42, 2.4%). Physicians also wrote, and published a
number of secondary articles in the AJN on the topic area (17/42, 40.5%) during
this time period (Table 2). The physicians represented endocrinology, medicine,
neurosurgery, internal medicine, nephrology, anesthesiology, risk reduction
clinics and obstetrics.
Nearly the same number of articles (59) were being published in Canada
during the period of 1956 and 1966 that addressed issues surrounding BP
measurement and management, technological trends and/ or the nursing role in
hypertension as was ten years prior (63). Fewer articles were published in the
United States. Compared to the decade prior there was an overall decline in the
number of articles published within this topic area. Physicians were no longer
publishing more articles than the nurses in the AJN. Nursing students contributed
the most in Canada with regards to publishing in this area versus graduate and
staff nurses in the United States. Physicians who were publishing in the nursing
journals were now being seen from more diverse areas of medical practice such as
endocrinology, obstetrics, anesthesiology and risk reduction clinics.
Canadian Nurse
Of the articles identified during the initial term search, the discussion of
BP measurement and management, technological trends and the nursing role in

144

hypertension in Canada was a primary and central topic of discussion only within
two articles (2/59, 3.4%) written between 1956 and 1965 in the CN (Appendix A).
103

No research study articles were published. One article was a case study on

hypertensive heart disease and the second focused on the pathophysiology and
mechanisms involved in low blood pressure (Appendix A).
Schweisheimer, an American physician in New York, published a short
physiological article on hypotension or low blood pressure in a Canadian nursing
journal. No references were used in the paper. According to two nursing texts of
the time, hypotension was not discussed at length, but only mentioned with
regards to shock-like situations.104
Schweisheimer stated:
Some persons whose blood pressure is normal when they are lying down
may feel weak, dizzy or they may even faint because of a sudden drop in
the pressure when they jump up quickly. This postural hypotension has no
serious significance.105
Postural hypotension, or what is more commonly referred to today as
'benign orthostatic hypotension,' and is often diagnosed in an elderly population
and is concerning especially, if patients are symptomatic. Fifty years later there
are EFNS (European Federation Neurological Society) guidelines available to

103 These

articles are: Schweisheimer, W. (1956). Hypotension. The Canadian

Nurse, 52(1), 53-54.; Frances, M. (1963). Hypertensive heart disease. The
Canadian Nurse, 59(5), 443-445.
104

Price, A. (1959). Ibid., p. 484-493.; Harmer, B. & Henderson, V. (1955). Ibid.,

p. 299-309.
105 Schweisheimer,

W. (1956). Ibid., p.53.

145

help manage this condition, which today would be considered serious and
significant. 106
Orthostatic (postural) hypotension (OH) is a frequent cause of syncope
and may contribute to morbidity, disability and even death, because of the
potential risk
of substantial injury. It may be the initial sign of autonomic failure and
cause major symptoms in many primary and secondary diseases of the
autonomic nervous
system (ANS)[e.g. pure autonomic failure (PAF), multiple system atrophy
(MSA), Parkinson's disease and diabetic autonomic neuropathy]. It
occurs frequently in elderly patients because of therapy (vasoactive drugs,
antidepressants), reduced fluid intake
and decreased ANS function. In Parkinson's disease the prevalence of OH
may be as high as 60%.Falls with injuries may result.107
Sister Marguerite Frances discussed a specific case of hypertensive heart
disease with angina pectoris, reviewing treatment and nursing care. The article
suggested a nurse's main objective was to create a 'therapeutic environment' that
would help lower blood pressure in a patient.108 "Bed rest with bathroom
privileges" was suggested as having a therapeutic effect to lower blood pressure.
It was the nurse who should relieve tension by providing a daily bath, and
ensuring that the door should remain closed to keep out noise, and, restricting
visitors. It was also the "nurse's duty to supplement the physician's teachings to
the best of her ability".109 The nurse would teach the patient to "seek the
assistance of her family in those undertakings too strenuous for her heart; to rest
106 Lahrmann,

H., Cortelli, P., Hilz, M., Mathias, D. J., Struhal, W. & Tassinari,
M. (2006). EFNS guidelines on the diagnosis and management of orthostatic
hypotension. European Journal of Neurology, 13(9), 930-936.
107 Ibid.,

p.930.

108 Frances,
109

M. (1963). Ibid., p. 444.

Ibid., p.444.

146

during the day for at least two hours in order to meet home problems with a more
optimistic outlook".110
Similarly today, this type of nursing management of hypertension would
fall into the area of stress management. In hypertensive patients in whom stress
may be contributing to blood pressure elevation, stress management should be
considered as an intervention . Individualized cognitive behavioural interventions
are more likely to be effective when relaxation techniques are used.111
Nurses' current care for the hypertensive patient has changed over the last
fifty years. They are recognized to have the knowledge, skills and caring, as well
as breadth and diversity to contribute to client care management of hypertension.
Nurses today, are often a critical conduit of high-quality health information within
their families, neighbourhoods and communities and they have excellent
opportunities to proactively affect the care and outcomes of patients that are
hypertensive.112
American Journal of Nursing
Of the articles found during the initial identifying term search, the
discussion of BP measurement and management, technological trends and the
nursing role in hypertension in the United States was a primary and central topic
of discussion within 15 articles (15/42, 35.7%) written between 1956 and 1965 in

110 Ibid.,

p.444.

111 Canadian

Hypertension Education Program (CHEP). (2011). Ibid.

D. L. (2007). Nurses managing high blood pressure in patients with
diabetes in community pharmacies. Canadian Journal of Cardiovascular Nursing,
77(2),17-21.
112 McLean,

147

the AJN (Appendix A).113 No research study articles were presented in this
decade in the AJN Eight of the articles focused primarily on the
pathophysiological mechanisms associated with primary hypertension and
regulation of blood pressure; four articles described strategies and procedures on
how to take a blood pressure accurately; and three were specific case studies
(Appendix A).
The majority of the articles during this time period focused on monitoring blood
pressure using electronical devices and on the technique of how take a proper
blood pressure reading using a sphygmomanometer and stethoscope.114 This was
in keeping with the decade of advanced monitoring and the development of

113 These

articles are: Davidson, S. (1957). Diet and cardiovascular disease.

American Journal of Nursing, 57(2), 194-196.; Knowles, H. C., & Goff, A. B.
(1957). Periarteritis nodosa. American Journal of Nursing, 57(3), 344-346.;
Raney, R. B. (1957). The minor concussion. American Journal of Nursing,
57(11), 1444-1445.; Connolly, A. F. (1958). Hear that beat! American Journal of
Nursing, 58(5), 688-689.; Ansell, J. S. (1958). Nephrectomy and nephrostomy.
American Journal of Nursing, 5<S(10), 1394-1396.; Bean, M. A., Krahn, F. A.,
Anderson, B. L. & Yoshida, M. T. (1963). Monitoring patients through
electronics. American Journal of Nursing, 63(4), 65-69.; Blodi, F. C. (1963).
Glaucoma. American Journal of Nursing, 63(3), 78-83.; Dean, V. (1963).
Measuring venous blood pressure. American Journal of Nursing, 63(10), 70-72.;
Eggleston, J. M. (1963). It's all in the approach. American Journal of Nursing,
65(11), 112.; Thomas, J. & Holiday, E. (1964). Detecting secondary
hypertension. American Journal of Nursing, 64(2), 94-96.; Callow, A. D. (1964).
A surgeon talks about hypertension. American Journal of Nursing, 64(12), 74-78.;
Kelly, A. E. & Gensini, G. G. (1964). Renal arteriography. American Journal of
Nursing, 64(2), 97-99.; George, J. H. (1965). Electronic monitoring of vital signs.
American Journal of Nursing, 65(2), 68-71.; Malcolm, B. & Glor, B. (1965).
Correcting common errors in blood pressure measurement. American Journal of
Nursing, 65(10), 133-166.; Malcolm, B. & Miller, M. (1965). Intravenous
infusion of vasopressors. American Journal of Nursing, 65(11), 129-152.
114

Bean, M. A., Krahn, F. A., Anderson, B. L. & Yoshida, M. T. (1963). Ibid.;

Connolly, A. F. (1958). Ibid., Dean, V. (1963). Ibid.; George, J. H. (1965). Ibid.;
Eggleston, J. M. (1963). Ibid.; Malcolm, B. & Glor, B. (1965). Ibid.
148

devices.115 During the 1960s in the AJN, Malcolm and Glor, two nurses, offered
step-by-step instruction in the procedures of ausculatory blood pressure
measurement with the stethoscope. 116 By this time the nursing schools made
these procedures fairly common knowledge.117 To demonstrate this knowledge in
the semi-public forum of the journal was a step toward claiming the procedure.

The control of blood pressure remains a major challenge in clinical practice

today. Current research studies suggest specialized hypertension clinics staffed
by nurses show significant improvements in hypertension control compared with
usual care. Hypertensive nurse care in hypertension clinics have nurses
counselling patients' on the correct use of an automated BP device, monitoring
regular return of automatically printed BP reports, enhancing drug adherence by
giving medication taking tips, and recognizing potential drug side effects. Nurses
help extend their instruction by giving printed materials, and having patients
confirm their ability to operate the BP device. Nurses in hypertensive clinics
today do follow up phone contacts to inquire about each medication dosage and
any problems experienced since their previous contact in clinic. Some
hypertension nurses and nurse practitioners today can implement guideline

1,5 Phillips,

C. (1999). Ibid.

116 Malcolm,

B. & Glor, B. (1965). Ibid. p.133-164. Technical articles on blood

pressure appeared in nursing journals long before this time. These articles,
typically written by physicians were clearly aimed to inform about blood pressure
rather than to instruct in measurement. Such is the article by: Sutter, C. (1914).
Blood pressure. American Journal of Nursing 75(1), 7-13.
117 Price,

A. (1959). Ibid., p. 484-493.; Harmer, B. & Henderson, V. (1955). Ibid.,

p. 299-309.
149

algorithms based on patients' current medications, laboratory values, and BP

measurements. Nurse- managed hypertension care facilitates and expands the
reach and scope of traditional care. It reduces the need for physicians to mediate
the routine tasks of managing antihypertensive therapy and encourages physicians
to focus their energies on problem cases, such as those individuals who fail to
achieve satisfactory control. Nurse-managed hypertension care today reinforces
the value of collaboration among teams of health professionals.118

Treatment of hypertension was also discussed among the articles

reviewed. More treatment options were discussed beyond the sympathectomy
suggested from the last decade. Weight loss was now recognized in the literature
as a means to decreasing blood pressure. 119 Davidson stated,

"there is no

doubt that obesity predisposes to hypertension, even though we cannot always be

sure that we can reduce the blood pressure by bringing about a loss in weight."120
Going forward several years, lifestyle management, specifically weight reduction,
is considered an optimum risk factor strategy for blood pressure control today.121
CHEP 2011 guidelines suggest height, weight and waist circumference should be
measured and body mass index calculated for all adults. The maintenance of a

118 Rudd,

P., Miller, N., Kaufman, J., Kraemer, H., Bandura, A., Greenwald, G. &
Debusk, R. (2004). Nurse management for hypertension: A systems approach.
American Journal of Hypertension, 77(10), 921-927.
119 Davidson,
120 Ibid.,
121

S. (1957). Ibid.

p. 194.

Canadian Hypertension Education Program (CHEP). (2011). Ibid.

150

healthy body weight (body mass index 18.5 to 24.9 kg/m2 and waist
circumference less than 102 cm for men and less than 88 cm for women) is
recommended for non-hypertensive individuals to prevent hypertension and for
hypertensive patients to reduce blood pressure. All overweight hypertensive
individuals should be advised to lose weight with weight loss strategies that
employ a interdisciplinary approach that includes dietary education, increased
physical activity and behavioural intervention.122

Other primary articles identified in the AJN discussed patient presentations

and disease states that had an effect of increasing blood pressure, for example, a
minor concussion, periarteritis nodosa, and glaucoma.123
Finally, two articles discussed detecting secondary hypertension and the
focus on the kidney.124 Two physicians, Thomas and Holiday, stated

"at the

present time no cause or adequate therapy for primary hypertension was found.
However, patients with secondary hypertension can be diagnosed and treated for
such conditions

The nurse's role is to help the hypertensive patient through

the often long and laborious studies."125 The article goes further to describe such
conditions as coarctation of the aorta, pheochromocytoma, Cushing's syndrome
and renovascular hypertension. Tests are described in detail to help with the
122 Ibid.
123 Raney,

R. B. (1957). Ibid.; Knowles, H.C., & Goff, A. B. (1957). Ibid.; Blodi,

F. C. (1963). Ibid.
124 Thomas,

J. & Holiday, E. (1964). Ibid.; Kelly, A. E. & Gensini, G. G. (1964).

Ibid.
125 Thomas,

J. & Holiday, E. (1964). Ibid., p.94.

151

diagnosis. References are not provided by the authors, which now appears to be
uncustomary to most articles presented in the AJN. Interesting today to read,
these physicians stated the nurse's role:
The nurse must be alert for any emergency, such as ventricular fibrillation
or cardiac arrest, which can occur as a result of the patient's disease or as a
complication following a procedure.
Finally, when the patient is to be discharged from the hospital, the nurse
should be certain that he understands the routine he is to follow, the
medication he is to take, and the time he is to return for the follow-up. 126

Nurse's role in hypertension management today is much more encompassing

than presented in the 1960s. Bengtson and Drevenhom in their review on nurses
in hypertension care, described the role of the nurse in hypertension programs as
a, "team member, an educator in nonpharmacological treatment, and a translator
for the physician with a holistic and psychosocial approach." The authors
suggest programs for hypertension care should be developed that take into
account "nurses' holistic psychosocial approach and skills".127 Given the
prevalence of hypertension today and the large patient care demands already
placed on family physicians, one solution for the screening and care of patients
with hypertension is to take full advantage of the special knowledge, skills, and
abilities of other members of the health care team, more specifically, nurses. The
changing scope of practice for nurses and nurse practitioners is facilitating their
greater involvement in chronic disease management. Nurses must be ready and

126 Ibid.,

p. 96.

127 Bengtson,

A. & Drevenhom, E. (2003). The nurse's role and skills in

hypertension care: A review. Clinical Nurse Specialist, 17(5), 260-268.
152

willing to accept additional responsibility, but they also need to feel empowered
to take on additional tasks. In addition, patients need to be educated about
expectations from nurses and how nurses can have a greater role and
responsibility for their care. The ultimate goal is to enable patients to become
ambassadors for their own hypertension management and to approach nurses
and nurse practitioners for ongoing support and education when required.

This was the decade that showed an explosion of electronical monitoring,

including dialysis equipment, inhalation therapy, radio, and televisions.
Preventative, rehabilitative and curative aspects of patient care received attention.
Major advances were seen in healthcare with development of the heart-lung
machine, open heart surgery, cardiac catheterization, renal dialysis, new vaccines
and medications, and monitoring devices. Post-anesthesia and recovery rooms
were established, followed by ICUs then self-care, long-term care, and home care
units. This was viewed as "progressive patient care" and created the need for
nurses with special skills which further contributed to a nursing shortage.128
The automobile, airplane and helicopter created many occupational
opportunities for nurses as they could bring nursing assistance to patients more
quickly. Travel opportunities broadened knowledge but also allowed contact with
new diseases and increased accident rates. Nursing became more complex.
Nurses were identifying very subtle changes in patients' status, and were learning

128 Dolan,

J. (1968). Ibid.; Dolan, J., Fitzpatrick, M., & Herrmann, E. (1983).

Nursing in society: A historical perspective. (15th ed.). Philadelphia: Saunders.
153

new treatment techniques, interpreting lab data and recognizing interrelationships

of care.
When comparing the number of articles and the type of articles published
between the two journals, there were more primary articles published on blood
pressure in the AJN than the CN. The articles in the AJN were typically longer,
with acute clinical topics that focused on building clinical skills such as
completing accurate blood pressure measurement, and were written with more
detail in comparison to the two identified in the CN. It appears that more articles
were directly being published that address the primary topic and in more detail in
the AJN. One can surmise more articles were published each month in the AJN
because there were more nurses in the United States whose registration fees
helped to support a larger journal.
1966-1975
In 1966, the Canada Pension Plan (or CPP) was created, requiring
contributions from both employers and employees for a publicly financed
retirement saving plan. Expo 67, the Montreal world's fair, attracted more than
55 million visitors from April to October. Pierre Elliott Trudeau succeeded
Lester Pearson as prime minister and leader of the Liberal Party in 1968.
"Trudeaumania" swept the country in the subsequent federal election. In 1969,
English and French were both recognized as official languages by the federal
government. In 1970 the greatest change ever in crop planting came with the
introduction of canola, a plant able to produce a more desirable oil for the food
trade. Canola became the dominant crop on the Canadian prairies, causing the

154

greatest change ever in crop planting. In 1972 Anik 1 Geo-stationary Commercial

Satellite was launched by Telesat, making Canada the first country in the world to
use satellites for domestic communications.129
In 1968, in the United States, Martin Luther King, Jr., civil rights leader,
was slain in Memphis. Senator Robert F. Kennedy was shot and critically
wounded in a Los Angeles hotel after winning the California primary. In 1969
Apollo 11 astronautsNeil A. Armstrong, Edwin E. Aldrin, Jr., and Michael
Collinswere the first men on the moon. In 1971 a new product, a set of
microchips, were used to build everything from calculators to postage metres.
They were considered electronic Lego blocks. The Watergate scandal began in
1972. Five men were apprehended by police in an attempt to bug the Democratic
National Committee headquarters in Washington, D.C.'s Watergate complex. The
Supreme Court ruled the death penalty was unconstitutional. The Vietnam War
ended with the United States pulling out in 1973.130
In the United States the dominant focus and approach in health care in
this time period was, 'if it helps at all, do it".131 This was encouraged by the rapid
pace of technological changes during this era. Physicians' earnings were tied to
the number of procedures performed. Allocation of services to those with the
highest need was not the prominent philosophy in use. Instead, there were

129 Canada

history (2010). Retrieved March 6, 2012, from

http://www.canadahistorv.com/sections/timelines/timeline.htm
130United

States history 1950-1999. (n.d.). Retrieved March 6, 2012, from

http://www.infoplease.com/ipa/A0903597.html
131

Cherry, B. & Jacob, S. (2002). Ibid., p.l 13.

155

economic incentives in place allowing as much care as possible and the highest
available quality of care. Some have suggested that this caused an overuse of
health services and cost inflation.
In Canada, the Lalonde Report was published inl975, and suggested a
shift from curing disease to preventing disease and maintaining health. The
escalating costs of care in hospitals, surgical innovations and technological
changes led to modifications in the delivery of care. For example, day surgery,
ambulatory care, and home care became increasingly common where much of the
care was and is still today done by nurses.132
Healthcare Organization-Health Care Coverage
The cost of health care had continued to increase over the decades, with
economic issues taking a greater role in health care decision-making.
Governments determined that better insurance should be available for people.
Canada chose a universal approach while the United States focused on certain
groups in the population.
In 1968, the Medical Care Act in Canada was enacted under the
government of Prime Minister Lester Pearson. The law provided a cost-sharing
program where there was reimbursement to provincial health insurance plans for
physicians' services. The provinces were required to meet four criteria.
The coverage had to be comprehensive; that is, it had to provide all
services rendered by a physician without dollar limits or other restrictions
provided there was medical need. The plan had to be universally
available to all residents of a province and cover at least 95% of the

132 Paul,

P. & Ross Kerr, J. (2011). Nursing in Canada, 1600 to the present: A

brief account, (p. 18-41). In J. Ross-Kerr & M. Wood. (Eds.). Canadian nursing:
Issues & perspectives. (5th ed.). Toronto: Elsevier.
156

eligible population. The plan also had to be portable among provinces

for beneficiaries temporarily absent from their own province or moving to
another. Finally, the plan had to be operated on a nonprofit basis and
publically administrated by an agency accountable to the provincial
government for its financial transactions.133

In the United States, Medicare and Medicaid provided financial access to

health care for older citizens and others deemed financially eligible. These
programs made care more available and accessible to people needing access on a
regular basis. In the late 1960s, 'prepaid comprehensive health care' or managed
care was established by the Health Maintenance Organizations (HMO) legislation
An HMO is both an insurer and a provider. That means, that the consumer,
employer, or government pays annual premiums to the HMO. In return, the HMO
directly takes responsibility for providing care-basic medical, hospital and drugs,
when needed. These HMOs can place limits on medical care coverage or on the
site of care delivery. 134
Nursing Education
In Canada, two-year nursing schools were being transferred into college
diploma programs. In Quebec, the Parent Commission in 1966 suggested
transferring nursing programs to the general system of education. The Colleges
d'Enseignement General et Professionnel (CEGEP) became the home of the
diploma nursing program. Similar changes occurred in the same era in Ontario.

133 Baumgart,
134 Jacobs,

(Ed.).

A. (1992). Ibid., p. 31.

P. (1995). Economics of health care, (p.97-126). In G. Deloughery

Issues and trends in nursing. St. Louis: Mosby.

(2nd ed.).

157

Nursing students received educational benefits similar to other professions.135 In

Ontario, Ryerson Polytechnical Institute in Toronto was the first nursing diploma
program in Canada to be started in an educational institution. In 1967, the
Ontario government started 20 colleges of applied arts and technology (CAATs)
where nursing diploma programs were transferred.136 In Western Canada, the
transfer of nursing programs from hospitals to colleges happened more gradually.
For example, in Alberta, Mount Royal College in Calgary was the first college to
welcome a nursing diploma program in 1967. In was not until the 1990s that all
hospitals programs were discontinued.137 Changes to the basic nursing education
in Canada affected relationships between nursing education and nursing practice.
"Old dogmas about how to prepare nurses were challenged, and partnerships
between nursing educators and nursing employers had to be recognized."138 In
Canada, this decade saw basic, graduate, and continuing education for registered
nurses expand in scope, size, and resources. By 1979, eight master's programs
were available for nurses in Canada.
In the United States the rapid changes in society wass seen to affect the
nursing profession. No longer were old methods of educating nurses satisfactory
135

Paul, P. & Ross Kerr, J. (2011). Nursing in Canada, 1600 to the present: A
brief account, (p. 18-41). In J. Ross-Kerr & M. Wood. (Eds.). Canadian nursing:
Issues & perspectives. (5th ed.). Toronto: Elsevier.

136 Ibid.
137

Ibid.

138

Larsen, J. & Baumgart, A. (1992).Overview: Issues in nursing education, (p.

383-371). In A. Baumgart & J. Larsen. (Eds.). Canadian nursing faces the
future. (2nd ed.). St. Louis: Mosby-Year Book.

158

to meet the demands of society due to the explosion of knowledge and new
techniques in medicine and health care. National and professional nursing
organizations were seen to be constantly adjusting educational standards so that
nurses would be able to function more effectively. In 1979, in the United States,
nurses made up the largest group of health care professionals in the country (1.4
million). Nurses struggled to take on more autonomy and more decision-making
responsibilities. Upgrading of nursing education is symbolic of a trend happening
across both borders. More nurses were entering the profession with at least a
college-level degree in nursing. The traditional hospital school, offering a twoyear, post-high school training and diploma was being phased out. The 1970s
showed an expansion of the nursing fields in the United States, allowing for more
specialties as well as the need for nurses in Vietnam.139
In the mid-1960s in the United States, a need for advanced nurse
practitioners was identified and certificate programs were developed to prepare
the nurse practitioner. Since 1975 these programs have moved into university
settings and are part of Masters' programs. 140
In both the United States and Canada, intensive care units became more
common. These units used more technically oriented tools to monitor which
allowed information to be instantly availableabout changes to a patient's
physiological parameters. In the late sixties, physicians realized early preventable

139

Nursing in Transition-1970s Medicine and Health, (n.d.). Retrieved April 19,

2012, from http://www.enotes.com/197O-medicine-health-americandecades/nursin g-transition.html
140 Deloughery,

G. (1995). Ibid.
159

death from myocardial infarction was due to the occurrence of arrhythmias.

Hearts would survive the initial hyperexcitability stage if the arrhythmias were
monitored and treated in time. The purpose of monitoring a myocardial infarction
in a patient during the first 24, 48 and 72 hours after the infarct was aimed at
looking for these developments in coronary intensive care units.141
Overall Synopsis 1966-1975
In total, 22 journal articles were identified through a systematic hand
search and paging of all articles published in the CN during the period of 1966
and 1975 (Table 1). Interestingly, as identified before between 1945 and 1947,
no published articles were found in the CN that addressed the area of blood
pressure measurement and management during the years of 1973 and 1975.
The majority of articles published between 1966 and 1975 in the CN were
written by nurses (17/22, 77.3%). Within this group of nurses who published, the
majority were unit head nurses (9/17, 52.9%), followed by graduate and staff
nurses (4/17, 23.5%), nursing supervisors (3/17, 17.6%), and a research assistant
(1/17, 6.0%). Physicians also wrote articles in this topic area (5/22, 22.7%)
between 1966 and 1975 (Table 2). These physicians practiced in the areas of
anesthesiology, surgery, nephrology and internal medicine.
In total, 23 journal articles were identified through a similar systematic
hand search and paging of all articles published in the AJN during the period of
1966 and 1975 (Table 1). The majority of articles published between 1966 and
141

Intensive care unit. (n.d.). Retrieved April 19, 2012, from

http://www.ispub.com/ioumal/the-internet-iournal-of-health/volume-3-number2/intensive-care-unit.html

160

1975 in the AJN were written by nurses as the primary author (15/23, 65.2%). Of
the nurses who published, the majority were nurse instructors and professors with
a masters degree (8/15, 53.3%), staff nurses with a baccalaureate degree (5/15,
33.3%), a nurse/physician team (1/15, 6.7%), and a research team consisting of
two nurses and a PhD nurse (1/15, 6.7%). Physicians also wrote and published
articles in the AJN during this time frame of 1966 and 1975 (8/23, 34.8%) (Table
2). They were practicing in the disciplines of internal medicine, anesthesiology,
transplant surgery, and cardiology.
One can now identify that both the CN and the AJN nurses are publishing
the same number of articles per year but the volume of articles on this topic has
dropped in half from the previous ten years. In the United States we are starting to
see the influence of master degree nurses in publishing but to a lesser degree in
Canada. In Canada, we see a transition of the authors from nursing students to
staff nurses and instructors.
Canadian Nurse
None of the 22 articles written between 1966 and 1975 had blood pressure
management as the main area of focus (Appendix A). The topic was only
addressed as a secondary topic. That is, the articles mentioned a BP reading
within a vital reading or the word 'hypertension' but not in the context that it was
a central theme within the published article.
American Journal of Nursing
Of the articles identified during the initial identifying term search, the
discussion of BP measurement and management, technological trends and the

161

nursing role in hypertension in the United States was a primary and central topic
of discussion within nine articles (9/23, 39.1%) written between 1966 and 1975 in
the AJN (Appendix A).142 Still no research study articles concerning blood
pressure were being published in either journal. The majority of the articles in
this decade still focused on the mechanisms involved in the regulation of blood
pressure, but now more articles were starting to describe nursing management of
the patient with hypertension, emphasizing patient teaching (Appendix A).
Interestingly to note, one article by Petursson in the CN, had published an article
reflecting on patient teaching in a rural setting 16 years earlier.143
Two articles written by two physicians addressed the physiological
measures affecting BP and hypertensive heart disease in their published
articles.144 Rawlings, a cardiovascular specialist, wrote an overview article
discussing heart disease at the time, including a discussion about hypertensive

142 These

articles are: Rawlings, M. S. (1966). Heart disease today. American

Journal of Nursing, 66(2), 303-307; Stamler, J., Hall, Y., Mojonnier, L., Berkson,
D. M., Levinson, M, Lindberg, H. A.,... & Burkey, F. (1966). Coronary
proneness and approaches to preventing heart attacks. American Journal of
Nursing, 66(8), 1788-1793; Avery, D. (1966). Hypertension secondary to renal
artery stenosis. American Journal of Nursing, 66(12), 2685-2687; Aagaard, G. N.
(1973). Treatment of hypertension. American Journal of Nursing, 73(4), 620-623;
Griffith, E. W., & Madero, B. (1973). Primary hypertension patients' learning
needs. American Journal of Nursing, 75(4), 624-627; Conte, A., Brandzel, M., &
Whitehead, S. (1974). Group work with hypertensive patients. American Journal
of Nursing, 74(5), 910-912; Finnerty, F., JR. (1974). Aggressive drug therapy in
accelerated hypertension. American Journal of Nursing, 74(12), 2176-2180;
Federspiel, B. (1975). Renin and blood pressure. American Journal of Nursing,
75(9), 1462-1464.
143 Petursson,

S. (1950). Ibid.

144 Rawlings,

M. (1966). Ibid.; Federspiel, B. (1975). Ibid.

162

heart disease. This physician used his strong opinion to voice concern over the
proliferation of diagnostic equipment. He strongly expressed that 'gadgetry'
should take the backseat and not be a substitute to informed nursing care and
judgment. He used two references, both his own published articles published in a
medical journal entitled Diseases of the Chest. Rawlings stated:
There is a tendency today, both in medicine and nursing, to emphasize the
rare and exotic heart diseases, rather than the more common circulatory
conditions that take a much greater toll of our lives and that are very likely to
afflict most of us personally sooner or later. Furthermore, this preoccupation with
the unusual seems paralleled by a relative neglect of bedside diagnostic
techniques and an increasing reliance on "gadgetry" and computers. To be
familiar with all of the highly technical tests and equipment that are available
today calls for the combined talents of an electronic genius and biochemist, even
in the relatively small field of diseases of the heart and blood vessels
In my
opinion, however, clinical diagnosis, careful thought, and enlightened care and
observation are much more important to the patient's welfare than all of the
gadgetry combined. A good clinical history, supplemented by the findings of a
careful physical examination, will often provide far more helpful and reliable
information than all the x-rays and electrocardiograms in the world.145
One can surmise this physician, Rawlings, must have had many years of
experience practicing medicine. He alludes to the role of the nurse and
recognizes that it is a changing one.146 He put forth his opinion, stating the
nurse's responsibility lies primarily with the patient and only secondarily with the
gadgets. "New procedures, machines, and gadgetry are also expanding the nurse's
responsibilities and taxing her ingenuity: pacemakers, resuscitators, respirators,
electric recorders of blood pressure and temperature, electrocardiograms, central
monitoring of the heart with televised EKG patterns, et cetera

145 Rawlings,

M. (1966). Ibid., p. 303.

146 Rawlings,

M. (1966). Ibid., p. 306.

163

We must never

forget that none of our new equipment should replace the human mind and that
none of the computers can replace the human thought that created them."147
Strong assessment skills are critical to all nurses. Rawlings believed,
"

of significance is the nurse's ability to estimate the patient's blood pressure

by compressing the pulse with her fingers. Easy obliteration of the pulse between
two fingers indicates low blood pressure; the opposite, a high one. The character
of the pulse is usually weak in failure or shock but may be bounding in
hyperthyroidism or hypertension."148 Still today, nurses combine history taking
with accurate and thorough physical assessment techniques by beginning with a
firm foundation of evidence and scientific knowledge. With experience and
support, patient assessment becomes an art. An accurate history and physical
examination creates an essential foundation for complete and individualized
care. 149
Three articles were published with a focus on treatment related to blood
pressure.150 Nonpharmacologic control measures are discussed alongside drug
therapy. All three articles were primarily written by physicians for nurses. One
article included a registered nurse as part of its writing team; she was the last

147 Ibid.
148 Ibid.
149 Stephen,

T., Skillen, L., Day, R & Jensen, S. (2012). Canadian Jensen's

nursing health assessment: A best practice approach. Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins.
l50Stamler,

J., Hall, Y., Mojonnier, L., Berkson, D., Levinson, M., Lindberg,
H., Andelman, S., Miller, W. & Burkey, F. (1966). Ibid.; Finnerty, F. (1974).
Ibid.; Aagaard, G. (1973). Ibid.
164

author listed.151 It would appear that in the decade before nurses were focused on
taking an accurate blood pressure and recording it properly. This decade had
more articles that focused on recognizing healthy blood pressure ranges and
interpretating these readings for treatment.
Aagaard was the first author in the primary articles who was identified in
the AJN, to use published quantitative research studies to support his statements
relating to healthy diastolic blood pressure range.
The Veterans Administration Cooperative Study demonstrated a
significant decrease in morbidity and mortality in male patients who
received drug treatment. Among those men with initial diastolic pressures
above 105 mmHg, significantly fewer complications, such as stroke and
episodes of congestive heart failure and a decreased number of deaths
occurred in the treated patients as compared with the untreated control
group. For men with diastolic pressures below that level, the differences
were not statistically significant but did suggest that drug treatment was
beneficial.152
Although it was new to see evidence-based research appearing in the literature,
diastolic targets are much lower today, especially for patients with diabetes.
Hypertension Canada's current guidelines are to lower blood pressure to <140/90
mmHg, and in people with diabetes to <130/80 mmHg using a combination of
lifestyle modification and medication. The target diastolic blood pressure is based
on a secondary analysis of the diabetic subgroup of the Hypertension Optimal
Treatment (HOT) trial. In this group, 1501 diabetic patients were randomized to 3
different target diastolic blood pressure thresholds: <90 mmHg, <85 mmHg, and
<80 mmHg. The group assigned to <80 mmHg had a >50% reduction in major
151 Stamler,

J., Hall, Y., Mojonnier, L., Berkson, D., Levinson, M., Lindberg,
H., Andelman, S., Miller, W. & Burkey, F. (1966). Ibid.
152

Aagaard, G. (1973). Ibid., p.621.

165

cardiovascular events and cardiovascular mortality than the group assigned to the
conventional target of <90 mmHg.153
In another article, Stalmer et al., identified hypertension as a 'coronary
risk factor' alongside hypercholesterolemia, smoking, diabetes, obesity, and a
positive family history of premature vascular disease. Typically in the literature
from prior decades, hypertension had been reported to be a disease, such as
hypertensive heart disease.154 Stalmer and group were now suggesting that the
'best treatment of coronary heart disease is prevention'.155
Similarly today and according to the CHEP 2011 recommendations,
identification of cardiovascular risk is very important to address in patients with
hypertension. Health practitioners need to assess and manage overall
cardiovascular risk in all people with hypertension including: smoking, unhealthy
eating, physical inactivity, abdominal obesity, dyslipidemia, and dysglycemia
(e.g. glucose intolerance, diabetes). CHEP recommends consideration of the use
of a risk assessment that incorporates cardiovascular or vascular age as tool to aid
patient adherence and understanding of an individual's cardiovascular risk. The
vast majority of hypertensive Canadians have other cardiovascular risks.

153 Campbell,

N., Poirier, L., Tremblay, G., Lindsay, P., Reid, D., Tobe, S. on
behalf of the Canadian Hypertension Education Program. (2011). Position
statement: Canadian Hypertension Education Program: The science supporting
the new 2011CHEP recommendations with an,emphasis on health advocacy and
knowledge translation. Canadian Journal of Cardiology, 27(5), 407-414.
154 Stamler,

J., Hall, Y., Mojonnier, L., Berkson, D., Levinson, M., Lindberg,
H., Andelman, S., Miller, W. & Burkey, F. (1966). Ibid.
155 Ibid.

166

Comprehensive screening and management of other risk factors in addition to

hypertension can double the reduction in
cardiovascular risk, lower the blood pressure target and change the types of
antihypertensive medications recommended. Many people with multiple
cardiovascular risks or cardiovascular disease have uncontrolled blood pressures,
and those who smoke are less, rather than more, likely to be treated.
Pharmacotherapy has the greatest potential for absolute benefit and cost
effectiveness in these higher risk patients.156
A healthy lifestyle today is still advocated and does improve
cardiovascular risk and reduces blood pressure in the prevention and treatment of
hypertension. Healthy eating, regular physical activity, low risk alcohol
consumption, reductions in dietary sodium and in some, stress reduction can
prevent or treat hypertension as well as other cardiovascular risks. The Heart and
Stroke Foundation's eHealth tool, "My Heart&Stroke Blood Pressure Action
Plan" (www.heartandstroke.ca/BP) is designed to assess hypertensive patients'
lifestyles, provide personalized e-mail support, and facilitate self-management
through its interactive portal that allows people to track their BP and progress and
achievements in their selected lifestyle area of focus. The CHEP theme in 2011
highlights the need for people with hypertension, clinicians, and scientists to

156

Hypertension Canada. (2011). 2011 Canadian Hypertension Education

Program Recommendations: The short clinical summary - An annual update.
Retrieved March 7, 2012, from
http://www.hvpertension.ca/images/stories/dls/2011 Resources En/2011 CHEPS
hortClinicalSummarvEN.pdf
167

advocate for healthy policy changes to facilitate Canadians choosing healthier

lifestyles.157
Two articles, published in theAJN, by nurse instructor discussed the
experience of hypertensive patients. This was the first time where the nurse
authors examined more indepth the patients' understanding of hypertension and
some misconceptions and concerns this specific population may have had.
Patients' misunderstandings constitute an obstacle that they themselves,
their families, nurses, and physicians need to be aware of. Since both case
finding and teaching are part of nursing practice, perhaps nurses can
intensify their efforts to help patients start and then continue in
treatment
[As nurses]....we have become aware, in our continuing
care of these patients, of differing interpretations, misconceptions, and
certain patterns of reasoning which indicate common learning needs.158
Adjusting to primary hypertension often begins with developing an
awareness of the condition, a phase common to nearly all patients in their
adjustment to chronic illness. The realization that one is hypertensive
many not come easily. Difficulty may arise because patients frequently
feel well; they cannot associate their sense of well-being with their usual
concept of the presence of illness.159
The nurses were quick to recognize from their experience with teaching
hypertensive patients in their clinics that several factors were important for these
patients to carry out lifelong control measures.
Ongoing assessment of each person provides the basis for action and
interaction. Not every patient needs to know everything about hypertension to
adapt well. Sufficient knowledge for some to participate and feel confident in
their care is insufficient for others
Many patients believe the diagnosis of
hypertension means nervousness and emotional tension, not high blood pressure.
Patients with labile pressures may think that medical personnel err in
157

Ibid.

158 Griffith,

E. W., & Madero, B. (1973). Ibid., p. 624,; Conte, A., Brandzel, M., &
Whitehead, S. (1974). Ibid.
159 Griffith,

E. W & Madero, B. (1973). Ibid., p. 626.

168

measurement and are unreliable

Other patients become apprehensive as they
remember relatives who had high blood pressure and strokes that were followed
by invalidism or death. They fear that hypertension requires withdrawal from
their usual lifestyles and that the disease or its therapy will damage their bodies.160
Avery, a clinical nurse instructor and a nursing student, developed
a nursing care plan including the therapeutic rationale written by the instructor
and nursing care presented from the student's perspective for a patient with renal
artery stenosis.161
Within the primary articles identified in this decade, we see for the first
time that nurses are exploring what is the experience of having hypertension.
Physicians to this point in the nursing literature have described and identified
what was high blood pressure, how to diagnose hypertension and the treatment
required. There appears to be a breaking point in the literature whereby the nurses
are recognizing the importance of exploring the thoughts of their patients and
helping them get in touch with a relatively intangible situation. Nurses have their
patients discuss experiences they have in common with other patients, which
makes hypertension more real. 16^~ Nurses talk to their patients to help them
become aware of the change in their bodies. Nurses encourage their patients to
express fears and search for a cause as this reveals a patient's view of his/her
problem, his/her knowledge and misconceptions, his attitudes and motivation and
aspects of his personality. Nurses at this time were recognizing that teaching
patient content appropriate to the patient's and family's understanding and

160 Ibid.,
161

p. 626.

Avery, D. (1966). Ibid.

162 Griffith,

E. W., & Madero, B. (1973). Ibid., p. 626

169

attitudes was important. Specific learning experiences were being arranged to

recognize that information-giving wass not equivalent to the ongoing process of
learning.
In summary, in comparison to the CN literature, the AJN published more
primary articles focusing on pathologic processes and the principles underlying
the treatment during the period of 1966 and 1975. New topics were emerging in
the AJN that were more nurse specific such as nurses addressing lifestyle
modification learning and teaching needs for patients who were hypertensive.
More information was being published by the physicians for nurses regarding
drug therapy and secondary causes of hypertension in the AJN.
1976-1985
Inflation continued to be a problem around the world. The Concorde
entered service which cut transatlantic flying time to 3.5 hours. One year after
Microsoft was formed Apple was formed by Steve Jobs and Steve Wozniak.
Nadia Comaneci scored the first ever perfect score in Gymnastics. In 1977,
Quebec adopted French as the official language. Jimmy Carter was elected as the
President of United States and the first oil flowed through the Trans Alaskan Oil
Pipeline. Elvis Presley died from a myocardial infarction at age 42. In 1978,
following on from the oil crisis Japanese car imports accounted for half the US
import market. The first ever cellular mobile phone was introduced in Illinois and
Space Invaders appears in arcades launching a craze for computer video games.
One other notable was the release of the Pac-Man arcade game. Sweden was the
first country in the world to recognize the effect of aerosol sprays on the ozone

170

layer and banned the sale. For the first time in history in 1979 a woman, Margaret
Thatcher was elected prime minister of the United Kingdom.163
As technology become smaller Sony released the Walkman, a worldwide
success costing $200 which at that time was a significant amount of money. Also,
the first snowboard was invented in the USA. As the miniaturization continued,
new technology allowed for new consumer products that could never have existed
before, including domestic camcorders and fax machines. Politics entered the
Olympic Games with the boycott by the US of the Moscow Olympics and war
broke out between Iraq and Iran.164
During this decade, many notable technological advances happened. In
1981, one of the most exciting was the first flight of the Space Shuttle Columbia.
This was also the first year that the word "Internet" was mentioned and MS-DOS
was released by Microsoft along with the first IBM PC. On the world stage the
events that captured the imagination included Lady Diana Spencer marrying
Charles, the Prince of Wales. In 1982, new technology continued to change
buying habits with smaller and cheaper electronic gadgets appearing including the
first CD player. Genetic engineered human insulin produced by bacteria was sold
for the first time. The first person to receive an artificial heart, Barney Clark of the
US died after 112 days. In 1985, The Food and Drug Administration approved a

163 The

people history, (n.d.). Retrieved March 15, 2012, from

http://www.thepeoplehistorv.com
iM Ibid.

171

blood test for AIDS. Recession continued to be a problem in the United States
and 70 US banks failed in just one year.165
Healthcare Delivery
The Declaration of Alma Ata in 1978 in Ottawa (sponsored by WHO and
UNICEF) set out a 'goal of health for all by the year 2000.'166 The Lalonde
Report described the 'difference between health and health care and the need for
intersectoral collaboration if the health status of the Canadian population was to
improve in a significant way'.167 The focus shifted to health promotion rather than
on treatment of disease.
At that time, health promotion in Canada focused mostly on the reduction
of behavioural risk factors. Less focus was on the other health determinants such
as environment or the social conditions influencing health. It was during the
1980s where a more social conceptualization of health blossomed with the
introduction of 'Achieving Health for All: A Framework for Health Promotion'
and the Epp Report. This report came after the Canada Health Act in 1984, which
had a larger focus on accessibility, universality, portability, comprehensiveness

163 Ibid.
166 Paul,

P. & Ross Kerr, J. (2011). Nursing in Canada, 1600 to the present: A

brief account, (p. 18-41). In J. Ross-Kerr & M. Wood. (Eds.). Canadian nursing:
Issues & perspectives. (5th ed.). Toronto: Elsevier, p.39.

167

Reuter, L. & Ogilvie, L. (2011). Primary health care: Challenges and

opportunities for the nursing profession, (p.186-208). In J. Ross-Kerr & M.
Wood. (Eds.). Canadian nursing: Issues & perspectives. (5th ed.). Toronto:
Elsevier.
172

and public administration of hospital and medical services.168 It was the Epp
Report that identified challenges to health such as, reducing inequities, increasing
prevention, and enhancing coping. Strategies to improve health included:
fostering public participation, strengthening community services and coordinating
healthy public policy. 169
Cardiac awareness, risk reduction, nutrition awareness of lower salt intake,
smoking cessation, 'Participaction' programs and Healthy Living became the
focus for nursing for teaching and development of patient teaching materials. The
internet began to influence consumer awareness and alternative therapies.
'Smoking causes Cancer' was published from the Surgeon General's Report.170
In the previous years, the Royal Commission on the Status of Women in
Canada (1967-1970) had brought attention to the need for equal opportunity for
women in society and for removing the inequalities in a system that inadequately
remunerated women. By the late 1980s nurses had gained significant experience
in collective bargaining.171 Collective bargaining improved nursing workloads,
increased wages nearly 30%, addressed overtime and improved working
environments.172

168 Ibid.,
169

p. 189.

Ibid.

170 Phillips,

1999, Ibid.

171

Ross Kerr, J. (2011). Emergence of nursing unions as a social force in Canada,

(p. 301-323). In J. Ross-Kerr & M. Wood. (Eds.). Canadian nursing: Issues &
perspectives. (5th ed.). Toronto: Elsevier.
172 Archibald,

T. (2004). Collective bargaining by nurses in Canadian health care:

Assessing recent trends and emerging claims. Health Law Journal, 11, 77-198.
173

Since the 1980's, in the United States, strategies to improve health and
Healthy People Initiatives had been undertaken. Certain key national health
objectives which were founded on the integration of medical care with
preventative services, health promotion, and education; integration of personal
and community healthcare; and increased access to integrated services were
undertaken in 10-year plans.
In the United States health care costs were a national issue in the 1980's.
In 1976, there were approximately 174 health maintenance organizations.
Medicate was still reimbursing for any and all hospital services provided. The
federal contribution to hospital care rose from 13% to 41%. In 1983, in an
attempt to decrease hospital costs, Congress passed the diagnosis-related group
(DRG) system for reimbursement. DRGs were started to provide payment for
hospital services based on the patient" s admitting diagnosis and to reduce the
overall cost. Hospitals would be reimbursed one amount based on the patient's
diagnosis not on hospital charges. This made hospitals increase efficiency and
more closely manage services including length of stay, lab and radiographic
testing and diagnostic procedures. Case management became a new area of
171
specialization for nursing.
As a concern for higher health care costs, the use of ambulatory services
increased. Nurse practitioners increased in popularity as cost effective providers
of primary and preventative health care. More nurses moved from the hospital
setting into the community to practice in programs such as hospice and home

173 Cherry,

B. & Jacob, S. (2002). Ibid.

174

health. Outpatient surgery services started and provided a quick and efficient site
for day surgeries. Costs were reduced as fewer staff were required, fewer supplies
were used and facility costs were decreased. Nurses were particularly interested
in working in these outpatient facilities because they afforded a chance to work
only during the day, with no weekend assignments.174
Nursing Education
Nurse practitioner courses began to develop as a perceived need in
university nursing programs in the 1980s. Student demand increased for these
programs in Canada.175 Many transfer of duties from medicine to nursing
responsibilities were also occurring, with some overlap of duties. Often Canadian
nurses were seeking certification from programs in the United States. The
Canadian Nurses Association developed a policy statement relating to
credentialing in nursing to develop certification in nursing specialties. 176 By
1986, certification exams by the Canadian Nurses Association Testing Services
(CNATS) were in place. Master's programs continued to grow in numbers. Even
in this decade, there was a change in enrollment that could be seen, in 1975 there
203 students registered in Master's programs in Canadian universities versus 524
students in 1985.177

174 Stanhope,

M. & Lancaster, J. (2000). Community and public health nursing.

St. Louis: Mosby.
175

Ross- Kerr, J. (2011). Credentialing in nursing, (p.374-387). In J. Ross-Kerr

& M. Wood. (Eds.). Canadian nursing: Issues & perspectives. (5th ed.). Toronto:
Elsevier.
175 Ibid.
177

Ibid., p.399.
175

In the United States in the 1970's the complexity of health care increased
and the need for qualified nurse educators, administrators and clinicians and the
increasing number of baccalaureate prepared nurses, stimulated the federal
government to provide support for the development of a master of science in
nursing degree and other types of programs. In 1977, most nurse administrators
were diploma graduates (46%) and only 28% had a masters or doctoral degrees.
Efforts from nurse leaders resulted in federal funding for nursing program
development. Grants allowed many RNs to return to school to earn baccalaureate
degrees and advanced degrees to prepare for positions in education,
administration, practice and research. 178
Masters degree nursing programs proliferated with the emphasis on the
preparation of clinical nurse specialists and nurse practitioners. In 1982, there
were 111 accredited masters degree programs. Having a MN was becoming an
important credential for leadership positions. Two types of doctoral programs
were starting to emerge, the PhD or academic doctorate with emphasis on nursing
research, and the DNS or professional doctorate with emphasis on nursing
practice. 179
Blood Pressure Recommendations
In 1977, the Ontario Council of Health developed the first set of guidelines
for hypertension management in Canada. This was literally the beginning of the
movement that started the prevention, detection, treatment and control of high

178 Cherry,
179

B. & Jacob, S. (2002). Ibid., p.87.

Phillips, 1999, Ibid.

176

blood pressure in Canada. Prior to 1977, a multifaceted approach to high blood

pressure care did not exist. The Canadian Cardiovascular Society and the
Canadian Heart Foundation adapted these guidelines further to be national
recommendations. In 1978, a group of hypertension experts and clinical scientists
formed the Canadian Hypertension Society (CHS). The CHS task force started a
series of consensus conferences which resulted in a 1984 publication - The Report
of the Canadian Hypertension Society's Consensus Conference on the
Management of Mild Hypertension.180
Overall Synopsis 1976-1985
In total, 31 articles were identified through a systematic hand search and
paging of all articles published in the CN during the period of 1976-1985 (Table
1). The majority of articles published between 1976 and 1985 in the CN during
this time period were written by nurses (30/31, 96.8%). Within this group of
nurses who published, nearly half were staff nurses (11/30, 36.7%), followed by
nursing instructors and unit supervisors with baccalaureate degrees (9/30, 30.0%),
masters prepared nurses working in a variety of roles (6/30, 20.0%), and several
nurse run teams (4/30, 13.3%). That is, the team of healthcare professionals was
led by a nurse. One published article was written by a nurse practitioner, the first
to be seen in this topic area.
In total, 36 journal articles were identified through a similar systematic
hand search and paging of all articles published in the AJN during the period of

180 Logan,

A. (1984). Report of the Canadian Hypertension Society's consensus

conference on the management of mild hypertension. Canadian Medical
Association Journal, 131, 1053-1057.
177

1976 and 1985 (Table 1). The majority of articles published between 1976 and
1985 in the AJN during this time period were written by nurses as the primary
author (34/36, 94.4%). Of the nurses who published, half were nurses with a
masters degree working primarily as nursing instructors, clinical nurse specialists,
professors and hypertension practitioners (17/34, 50.0%). These nurses had
advanced nursing knowledge and experience working in the area of hypertension
management and operated as clinical nurse specialists and as nurse practitioners.
This was followed by staff nurses with a baccalaureate degree (13/34, 38.2%) and
nurse/physician teams (4/34, 11.8%). Two physicians wrote articles on this topic
area (2/36, 5.6%) in the AJN between 1976 and 1985 (Table 2). Only one
physician wrote an article on this topic area (1/31, 3.2%) in the CN between 1976
and 1985 (Table 2).
Staff nurses were writing most of the articles for the CN, similar to the
period of 1945 and 1955. In the AJN, half of nurses writing for the journal were
master's prepared. A difference is seen in the education level of the nurses who
were writing for each journal. With regards to the AJN, physicians dominated the
publications up until 1965 whereby then nurses with a master's degree who were
practicing as nursing professors and instructors gradually became significant
writers. Physicians are rarely publishing in both nursing journals. It would be my
impression that nursing programs were placing more emphasis on nursing
research and clinical practice and expanding nursing knowledge, thus increasing
the likelihood that nurses became writers.

178

Canadian Nurse
Of the articles identified during the initial identifying term search, the
discussion of BP measurement and management, technological trends and the
nursing role in hypertension in the CN was a primary and central topic of
discussion only within seven articles (7/31, 22.6%) written between 1976 and
1985 in the CN (Appendix A). 181 Still no research study articles concerning blood
pressure were being published in the CN. Less emphasis was spent this decade on
the pathophysiology of hypertensive cases but more on the evaluation of
hypertension and the taking of accurate blood pressure measures (Appendix A).
Of the articles retained, one article reviewed the pathophysiology of
hypertension and the physical examination of the patient.182 The physical
examination of the patient was a responsibility shared, but not equally, by nurse
and physician. It appeared that gender helped to define the different roles in this
work. Instruction in nursing textbooks on the examination of the patient
encouraged, "applying empathy and kindness to this work". The nurse was
advised, for example that when, "shaking down the mercury in a thermometer,

181

These articles are: Jessop, P. (1976). Over and over. The Canadian Nurse,
76(10), 20-23; Goerzen, J. & Abbott, S. D. (1976). Blood pressure measurement:
Guidelines to accuracy. The Canadian Nurse, 76(10), 24-25; Hartley, B. (1979).
Hypertensive disorders in pregnancy. The Canadian Nurse, 79(1), 42-50; Haslam,
P.(1979). Hypertension: Antihypertensives and how they work. The Canadian
Nurse, 79(4), 26-31; McCulley, M. (1979). Hypertension: Questions and answers.
The Canadian Nurse, 79(4), 24-25; Milne, B. & Logan, A. (1979). Hypertension:
Management in industry- an expanded role for nurses. The Canadian Nurse,
75(4), 21-23.; Hilton, A. (1982). Does diabetic control really make a difference?
The Canadian Nurse, 52(10), 49-52.
182 Jessop,

P. (1976). Ibid.
179

avoid any motion near the patient," or, in taking a pulse or blood pressure, "be
sure the hands are warm and dry for the patient's comfort".183 One formal context
for the physician's recognition of the patient's experience was when it directly
influenced results. Physicians gave advice that specified when measuring the
blood pressure, "the patient should be completely relaxed and his attention
diverted since nervousness or exertion will tend to raise the systolic pressure". 184
Sandelowski makes note that a traditionally feminine skill like empathy could
help to distinguish the work of physicians and nurses185.
One article discussed accurate recording and measurement of blood
pressure.

186

It is noted that more nurses with degrees higher than a baccalaureate

in nursing are writing for nurses and sharing their knowledge and expertise. This
"how-to" article was written by Goertzen, a Master of Medical Science student
studying hypertension at the University of Calgary, and Abbott a staff nurse with
183 Reeder,
184

1978, Ibid.p.243.

Ibid.

185 Sandelowski,

M. (2000). Ibid.
It was the introduction to Dr. Barbara Bates' textbook for medical students
entitled, A guide to physical examination and history taking that changed the two
different styles and the two different procedures that had been followed, one for
the nurse and one for the doctor:
"The practitioner must be aware of their patient's feelings. His demeanor should
demonstrate self confidence, patience, courtesy, consideration and gentleness. All
procedures should be explained
At times it may be necessary to cause the
patient some discomfort or pain in order to assess his condition accurately. The
practitioner must be willing and able to do this, too, without undue anxiety or
guilt and with matter-of fact dispatch". Bates set side-by-side what had been two
different styles and sometimes even two different sets of procedures in the
physical examination, one for the nurse and one for the doctor. There was an
insistence for the importance of both empathy and authority.
186 Goerzen,

J. & Abbott, S. D. (1976). Ibid.

180

extensive cardiovascular nursing experience and coordinator of the Foothill's

Hospital hypertension clinic in Calgary, Alberta. The article is practical and is
presented as a 'recipe card' offering step-by step knowledge regarding patient
position, cuff size, BP recording, equipment maintenance and Korotkoff sounds.
The references used were written by American physicians, who today are gurus of
hypertension management and epidemiology- Dr. Norman Kaplan and Dr. Arthur
Clifton Guyton.187 Although, the article was written 36 years ago, many of the
bullet points are still seen in the current yearly CHEP recommendations with
regards to the patient environment and cuff size (Table 3). The greatest change
noted between then and now was that in 1976, a stethoscope and a
sphygmomanometer were normally used, in contrast with today where automatic
devices are used to assess blood pressure.

187 Ibid.

181

Table 3. Comparison Chart of BP Taking Recommendations from 1976 and

2012
Patient
Environment

1976188

2012IS9
Quiet with the least stress
possible

DO

Wait 10-15 minutes if patient

has smoked

Read and carefully

follow the instructions
provided with the
device
Relax in a comfortable
chair with back support
for 5 minutes
Sit quietly without
talking or distractions
(e.g. TV)

DON'T

Cuff Size

188 Ibid.,

It is important the cuff is the

proper size.
If the cuff is too small (i.e. if
cuff width does not equal 2/3
of arm diameter or if the
compression bag (bladder is
too small to encircle the arm
adequately) then, a false
reading as great as 60/30 can
occur

Measure if stressed,
cold, in pain or if your
bowel or bladder are
uncomfortable
Measure within 1 hour
of heavy physical
activity
Measure within 30
minutes of smoking or
drinking coffee

EQUIPMENT

Buy a validated device

Look for the correct
logo or go to
www.hypertenion.ca
for a list of validated
devices available in
Canada
Blood pressure cuffs
come in different sizes.
Your arm
circumference should
be measured mid-way
between the elbow and
shoulder. The wrong
cuff size will give
incorrect readings.

p.24.

189 Hypertension

Canada (2012). 2012 Canadian Hypertension Education

Program: Part 1 recommendations for hypertension diagnosis assessment and
follow-up. Retrieved March 18, 2012, from http://www.hvpertension.ca/cheprecommendations
182

As stated earlier the emergence of recommendation committees and the

Hypertension Task Force guidelines for blood pressure management occurred in
1977 190 Qne

t^e nursesj

Mary McCulley from the University of Toronto was a

member of the task force from 1975-1977. She had worked as a nurse practitioner
at St. George Health Centre in Toronto and was likely the first nurse to start
writing about the role a nurse played in the work-up of the hypertensive patient.191
She stated,
There is now sufficient experience both in Ontario and elsewhere to
confirm that specially trained and appropriately supervised nurses can
carry out the clinical assessment of the hypertensive patient. The task
forces recommended a pared-down work-up on the basis of the data from
previous studies which showed that curable hypertension is rare. 192
She goes on further to state the role nurses could assume in the drug treatment of
hypertension.
The task forces recommended a step-care regimen which can be managed
by specially trained, appropriately supervised nurses in primary care
setting and pointed out that little evaluation of the usefulness of treating
hypertension at the worksite or in other non-traditional settings has been
carried out and priority should be given to such studies.193
In 2008, thirty years later, this was the approach taken in a randomized
control study that was completed by a nurse practitioner and pharmacy group,
entitled, 'A randomized trial of the effect of community pharmacist and nurse care
on improving blood pressure management in patients with diabetes mellitus:

190 McCulley,
191

Ibid.

192 Ibid.,
193

M. (1979). Ibid.

p. 25.

Ibid., p.25.

183

SCRfP-HTN\194 This study aimed to determine the efficacy of a communitybased multidisciplinary intervention on BP control in patients with diabetes
mellitus. A total of 227 eligible patients were randomized whereby the
intervention group had an adjusted mean (SE) greater reduction in systolic BP at 6
months of 5.6 (2.1) mm Hg compared with controls (P = .008). In the subgroup of
patients with a systolic BP greater than 160 mm Hg at baseline, BP was reduced
by an adjusted mean (SE)of 24.1 (1.9) mm Hg more in intervention patients than
in controls (P < .001). Even in patients who had diabetes and hypertension that
were relatively well controlled, a pharmacist and nurse team-based intervention
resulted in a statistically significant and clinically important improvement in BP.
195

Two newer topic articles which have not been seen in the CN literature on
this topic emerged on: 1) blood pressure control in patients with diabetes and, 2)
recognizing and monitoring the development of hypertensive disorders in women
who are pregnant.196 Milne and Logan recognized that screening programs for
hypertension were important for detection of high blood pressure. These authors
suggested that nurses working in business and industry have an expanded longterm nursing role to play in helping patients manage blood pressure at the

194

McLean, D., McAlister, F. A., Johnson, J. A., King, K. M., Makowsky, M. J.,
Jones, C.A., & Tsuyuki, R. T. (2008). A randomized trial of the effect of
community pharmacist and nurse care on improving blood pressure management
in patients with diabetes mellitus: SCRIP-HTN. Archives of Internal Medicine,
168(21), 2355-2361. This article forms part of this dissertation.
195 Ibid.
196 Hilton,

A. (1982).Ibid.; Hartley, B. (1979). Ibid.

184

worksite.197 Thirty-three years later, CHEP 2012, has recognized that certain
populations, such as males between the ages 25-40 years are not aware of their
blood pressure readings and are less controlled. Typically, this identified group
does not regularly follow-up with healthcare visits. Having on-site nurses to
manage hypertension at a worksite would have advantages specifically to this
untargeted group for blood pressure control.

i go

American Journal of Nursing

Of the articles identified during the initial identifying term search, the
discussion of BP measurement and management, technological trends and the
nursing role in hypertension in the United States was a primary and central topic
of discussion within 27 articles (27/36, 75%) written between 1976 and 1985 in
the AJN (Appendix A).799 The majority of articles during this time frame in the

197

Milne, B. & Logan, A. (1979). Ibid.

198 Hypertension

Canada (2012). 2012 Canadian Hypertension Education

Program: Part 1 recommendations for hypertension diagnosis assessment and
follow-up. Retrieved March 18, 2012, from http://www.hypertension.ca/cheprecommendations
199 These

articles are: Long, M. L., Winslow, E. H., Scheuhing, M. A., &

Callahan, J. A. (1976). Hypertension: What patients need to know? American
Journal of Nursing, 76(5), 765-770; Corns, R. H. (1976). Maintenance of blood
pressure equipment. American Journal of Nursing, 76(5), 776-777; Lancour, J.
(1976). How to avoid pitfalls in measuring blood pressure. American Journal of
Nursing, 76(5), 773-775; Greenfield, D., Grant, R., & Lieberman, E. (1976).
Children can have high blood pressure, too. American Journal of Nursing, 76(5),
770-772; Robinson, A. M. (1976). Detection and control of hypertension:
Challenge to all nurses. American Journal of Nursing, 76(5), 778-780; Woods, S.
L. (1976). Monitoring pulmonary artery pressures. American Journal of Nursing,
76(11), 1765-1771; Mitchell, E. S. (1977). Protocol for teaching hypertensive
patients. American Journal of Nursing, 77(5), 808-809; Foster, S., & Kousch, D.
C. (1978). Promoting patient adherence. American Journal of Nursing, 78(5),
829-832; Smith, R. N. (1978). Invasive pressure monitoring. American Journal of
Nursing, 78(9), 1514-1521; Giblin, E. (1978). Controlling high blood pressure.
185

American Journal of Nursing, 75(5), 824; Ward, G. W., Bandy, P., & Fink, J. W.
(1978). Treating and counseling the hypertensive patient. American Journal of
Nursing, 78(5), 824-828; Hill, M. (1979). Helping the hypertensive patient control
sodium intake. American Journal of Nursing, 79(5), 906-909; Weiner, E. E.
(1980). Nurse management of hypertension. American Journal of Nursing, 80(6),
1129; Moser, M. (1980). Hypertension: How therapy works. American Journal of
Nursing, 80(5), 937-941; Hill, M. N. (1980). Hypertension: What can go wrong
when you measure blood pressure. American Journal of Nursing, 80(5), 942;
Marcinek, M. B. (1980). Hypertension: What it does to the body. American
Journal of Nursing, 80(5), 928-936; Flynn, J. B., & Moore, P. V. (1981). Coinoperated sphygmomanometer. American Journal of Nursing, 81(3), 533-534;
Lowther, N. B., & Carter, V. D. (1981). How to increase compliance in
hypertensives. American Journal of Nursing, 81(5), 963; Willis, S. E. (1982).
Hypertension in pregnancy: Pathophysiology. American Journal of Nursing,
82(5), 792-797; Willis, S. E., & Sharp, E. S. (1982). Hypertension in pregnancy:
Prenatal detection and management. American Journal of Nursing, 2(5), 798808; Kelley, M. (1982). Maternal position and blood pressure during pregnancy
and delivery. American Journal of Nursing, 82(5), 809-812; Kelley, M., &
Mongiello, R. (1982). Hypertension in pregnancy: Labor, delivery and
postpartum. American Journal of Nursing, 82(5), 813-822; Doyle, J. E. (1982).
Treating renovascular hypertension: Bypass graft surgery. American Journal of
Nursing, 82(10), 1559-1562; Doyle, J. E., & Sequeira, J. C. (1982). Treating
renovascular hypertension renal artery dilation. American Journal of Nursing,
52(10), 1563-1564; Rossi, L. P., & Antman, E. M. (1983). Calcium channel
blockers: New treatment. American Journal of Nursing, 83(3), 382-387;
Dickerson, J. (1983). The pill: A closer look. American Journal of Nursing,
55(10), 1392-1398; Hollace, S., Mittleman, R. & Mittleman, B. (1984). Cocaine.
American Journal of Nursing, 84(9), 1092-1095; Birdsall, C., Pizzo, C., & Muller,
B. (1985). What are orthostatic BP changes? American Journal of Nursing,
55(10), 1062.; Schoof, C. S. (1980). Hypertension common questions patients
ask. American Journal of Nursing, 80(5), 926-921.

186

AJN had a focus on the treatment and management of hypertension. Treatment is

shown to be multifaceted, that is one's chosen lifestyle can play a part in lowering
blood pressure. Dietary measures such as lowering sodium are now being
published in the literature in the AJN.200 There are discussions starting in the AJN
regarding who is best to manage the hypertensive patient. Research study articles
were not identified in this journal to date.
The majority of articles this decade in the AJN focused on factors that
contribute to inaccurate blood pressure readings including discussion surrounding
equipment, technique, clinician error and the patient preparation.201 It is
interesting to note, even 30 years ago, there was recognition that accurate blood
pressure readings were thefirst line in making decisions about blood pressure
treatment. Lancour suggested ways of augmenting Korotkoff sounds.
Raise the person's arm before cuff inflation, to permit venous blood to
drain from the forearm. Inflate the cuff rapidly to prevent venous trapping
and congestion. Inflate the cuff to above systolic level, then ask the patient
to open and close his hand rapidly eight to ten times. This dilates the
vessels in the forearm, increases their blood holding capacity and thus
lowers pressure in the forearm. Deflate the cuff completely, Do not stop
deflation between systolic and diastolic pressures and then re-inflate to
take another systolic reading. This causes the forearm to fill with blood
and affects the intensity and changes in sound.202
These practices today have gone to the way side as automatic blood pressure
monitors are replacing previous sphygmomanometry. These digital monitors are
electronic, easy to operate, and practical in noisy environments. They measure

200 Hill,

M. (1979). Ibid.

201

Flynn, J. & Moore, P. (1981). Ibid; Birdsall, C., Pizzo, C.& Muller, B. (1985).
Ibid; Lancour, J. (1976). Ibid; Hill, M. (1980). Ibid; Corns, R. (1976). Ibid.
202

Lancour, J. (1976). Ibid., p. 775.

187

mean arterial pressure (MAP) and use oscillometric detection to calculate systolic
and diastolic values. In this sense, they do not actually measure the blood
pressure, but rather derive the readings. Digital oscillometric monitors are also
confronted with "special conditions" for which they are not designed to be used:
arteriosclerosis; arrhythmia; preeclampsia; pulsus altemans; and pulsus
paradoxus.
The importance today is making sure the right cuff size is used with these
monitors. An upper-arm blood pressure monitor will come with a cuff that needs
to be wrapped around the arm. If one uses a cuff that is the wrong size, blood
pressure readings will not be correct.
Lancour makes reference to the Korotkoff sounds,.. ..A Russian physician
who, in 1905, first described the sounds heard during sphygmomanometry. He
divided them into three phases. They were later divided into five phases.203
Blood pressure readings today are no longer
recorded in phases, i.e., 152/94/82. Today, measuring at the same time of day on
the same arm and body position including taking multiple readings and averaging
them are important points to document. With the change to automatic cuffs there
is no longer the need to remove mercury, remove dust and mercury oxide, or to
check meniscus readings on manometers.204 Calibration of digital cuffs is
suggested yearly by the American Heart Association. 205

203 Ibid.,

p. 774.

204 Corns,

R. (1976). Ibid.

205 American

Heart Association. (2012). Retrieved April 5, 2012, from

http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/SymptomsDia
188

Several articles of this decade emphasized that therapy is important and

that nurses need to provide extensive counselling and teaching to help patients
adhere to the treatment plan and to give patients a sense of progress. The Task
Force on Nursing in High Blood Pressure Control enters the literature, suggesting
that nurses need to be accountable to the hypertensive population and screen
patients' blood pressures.206 Authors Giblin and Weiner suggested nurses can play
a major role in controlling high blood pressure by detecting and evaluating a
patient's response to therapy. There were also discussions about the benefits to
patients of nurse-managed clinics that had been established as hypertension
control programs.

907

Rossi and Antman discussed calcium channel blockers as a

complement to therapy. Moser presented an overview of contemporary therapy.

Other adjunct therapies such as oral contraceptives and cocaine which increase
blood pressure were also appearing in the literature.208
There was also literature during this time period in the AJN that suggested
nurses needed to have a firm understanding of pathophysiological processes
underlying hypertension and drug therapy in order to give comprehensive care
and counsel patients.209 Monitoring through follow-up nurse appointments to

gnosisMonitoringofHighBloodPressure/How-to-Monitor-and-Record-YourBlood-Pressure_UCM_303323_Article.jsp
206 Robinson,
207

1976, Ibid.

Giblin, E. (1978). Ibid.; Weiner, E. (1980). Ibid.

208 Rossi,

L. & Antman, E. (1983). Ibid.; Moser, 1980, Ibid.; Hollace, Mittleman

& Mittleman, 1984; Dickerson, 1983, Ibid.
209

Marcinek, M. (1980). Ibid.

189

maintain long term blood pressure control was also discussed. There was also the
first mention about teaching patients to measure their own blood pressure.210
Starting in this decade in the AJN, like in the CN, additional topic areas
and populations were being introduced in the literature for nurses whereby
hypertension had been seen to have an effect. These included five articles on
children and hypertension, focusing on pregnancy-induced hypertension and the
importance of prenatal visits with blood pressure screening.211 High blood
pressure results in many maternal and fetal consequences, which can be prevented
by health care initiated by the nurse educating pregnant woman about proper
positioning both prenatally and during labor and delivery.
Other articles focusing on the management of secondary causes of
hypertension and invasive pressure monitoring were seen this decade.212 In 5 to 10
percent of high blood pressure cases, the high blood pressure is caused by a pre
existing problem. This type of high blood pressure is called secondary
hypertension because another problem was present first. Factors leading to
secondary hypertension include: kidney abnormality, including a tumor on the
adrenal gland, which is located on top of the kidneys; a structural abnormality of
the aorta (the large blood vessel leaving the heart) that has existed since birth, or
210 Ward,

G., Bandy, P. & Fink, J. (1978). Ibid.; Lowther, N. & Carter,V. (1981).
Ibid.; Schoof, C. (1980). Ibid.; Foster, S. & Kousch, D. (1978). Ibid.; Mitchell, E.
(1977). Ibid.; Long, M., Winslow, E., Sheuhing, M. & Callahan, J. (1976). Ibid.
211

Greenfield, D., Grant, R. & Lieberman, E. (1976). Ibid.; Willis, S. & Sharp, E.
(1982). Ibid.; Willis, S. (1982). Ibid.; Kelley, M. (1982). Ibid.; Kelley, M. &
Mongiello, R. (1982). Ibid.
212 Smith,

R. (1978). Ibid; Woods, S. (1976). Ibid; Doyle, J. (1982). Ibid; Doyle, J.

& Sequeira, J. (1982). Ibid.
190

narrowing of certain arteries. Invasive pressure monitoring measures blood

pressure directly and involves a catheter being placed in a blood vessel and the
use of a transducer and amplifier to display the pressure on a monitor. The direct
method of arterial blood pressure measurement was used by surgeons during
amputation of limbs. This was first reported by a French surgeon, Jean Faivre,
from Lyons. In 1856, he measured the "arterial pressure while performing
amputations using a U-shaped glass tube filled with mercury". 213This type of
measurement is still being used in intensive care units with critically ill patients
and provides information more accurately and quickly than indirect methods,
especially in hypotensive episodes.

One article identified during this decade in the AJN that still today, 30
years later, has not been fully addressed was the values for pediatric blood
pressure monitoring.214 The Canadian Hypertension Education Program
recommendations still today does not address this population within their
guidelines. We recognize that age, body size and the degree of sexual maturation
determines blood pressure levels in adolescence. Heavier and more sexually
mature teenagers tend to have higher blood pressure. Teenagers who are obese
and have high blood pressure may develop thicker arteries by age 30. Fatty

213

Naqvi, N. & Blaufox, M.D (1998). Ibid. (p.54).

214 Greenfield,

D., Grant, R. & Lieberman, E. (1976). Ibid.

191

buildups in artery walls can lead to a variety of health problems including heart
disease and stroke.

91 S

In summary, there was an overall increase of primary and central articles

in both journals over this decade. More articles were published in this topic area
in the AJN during this time frame of 1976 and 1985. The AJN published articles
focused on the topic as a central feature. The articles in the AJN were longer in
page numbers, with a focus on building clinical skills such as completing accurate
blood pressure measurement, and were written with more detail than the two
articles found in the CN. Within the CN the articles covered similar topics in a
less detailed fashion than in the AJN. The CN had more information with regards
to screening programs by nurses and community follow-up, whereas AJN was
targeting the acute management of hypertension including indepth knowledge of
drug therapy.

1986-1995
In 1986, the Canadian dollar hit an all-time low of 70.2 U.S. cents on
international money markets. In 1988, Ben Johnson won the 100 metres race in
the Olympics exciting all Canadians. The cheers faded quickly after drug screens
showed the Toronto athlete had tested positive for steroids. He was stripped of the
gold medal and his actions led to an inquiry into drugs and sport not only in
Canada but also around the world. The Supreme Court struck down existing

215 American

Heart Association. (2012). Retrieved April 5, 2012, from

http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/UnderstandYo
urRiskforHighBloodPressure/High-Blood-Pressure-inChildren_UCM_301868_Article.jsp
192

legislation against abortion as unconstitutional. In 1989, one-dollar bills were

replaced by the one-dollar coin, popularly called the "loonie." Audrey
McLaughlin was elected first woman leader of the federal New Democratic Party
(NDP) and replaced Ed Broadbent as head of the NDP, becoming the first women
to lead a national party in Canada and North America. After a federal election
fought over the issue of free trade, the free-trade agreement between Canada and
the United States came into effect, gradually ending controls on trade and
investment between the two countries. In 1991, the GST (Good and Services
Tax) was introduced by Brian Mulroney's Conservative government. The seven
percent tax paid at the cash register replaced the 13.5 percent federal
manufacturer's tax.
In 1992, Dr. Roberta Bondar becomes the first Canadian woman in space,
aboard the U.S. space shuttle Discovery. Although the players were all
American, the Toronto Blue Jays become the first Canadian team to win baseball's
World Series. In 1993, common-law union was recognized. Effective for the 1993
and subsequent tax years, common-law unions began to be considered the
equivalent of a legal marriage for tax purposes. The measure was a response to
court challenges that had argued that the tax system discriminated against legally
married couples in favor of common-law ones. Kim Campbell became the first
female prime minister of Canada. She was also the first woman to lead the federal
Progressive Conservative Party. In 1994, the North America Free Trade
Agreement (NAFTA) came into effect, linking Canada, the United States, and
216 Canada

history (2010). Retrieved March 6, 2012, from

http://www.canadahistorv.com/sections/timelines/timeline.htm
193

Mexico in a new economic partnership. In 1995, Donovan Bailey became "the

world's fastest man" when he broke the record for the 100-metre race.217
Meanwhile, in the United States, in 1986, space shuttle Challenger
exploded after the launch at Florida, killing seven aboard. The Oprah Winfrey
Show hit national television. In 1987, US Supreme Court ruled Rotary Clubs
must admit women. In 1988, ninety-eight percent of U.S. households had at least
one television set. Compact discs outsold vinyl records for the first time. George
H.W. Bush won the election of 1988 and presided over the fall of the Berlin Wall
and the disintegration of the communist regimes, ending the Cold War. In 1989,
the ruptured tanker Exxon Valdez sent 11 million gallons of crude oil into
Alaska's Prince William Sound.218 By 1990, 99 percent of U.S. households have
at least one radio, with the average owning five. The Simpsons debuts on Fox and
became an instant hit.
In 1991, Bush organized a broad coalition that forced out the invader Iraq
from Kuwait in the Persian Gulf War. The internet age was exploding, by 1991; a
text-based web browser is made available to the public whereby, within a few
years, millions of people became regular users of the World Wide Web. The smart
board (or the interactive white board) was introduced by SMART Technologies.
Johnny Carson hosted The Tonight Show for the last time. He had ruled late-night
television for 20 years.219

2,7 Ibid.
218 United

States history 1986-1995. (n.d.). Retrieved May 5, 2012, from

http://www.infoplease.com/ipa

219 Ibid.

194

The election of 1992 brought Bill Clinton to the White House. The Gulf
War was waged in the Middle East, by a U.N.-authorized coalition force from
thirty-four nations, led by the U.S. and United Kingdom, against Iraq. In 1999,
along with the rest of the world, the U.S. prepares for the possible effects of the
Y2K bug in computers, which was feared to cause computers to become
inoperable and wreak havoc.220
Healthcare Organization
In Canada, the Ottawa Charter for Health Promotion is the name of an
international agreement signed at the First International Conference on Health
Promotion, organized by the World Health Organization (WHO) and held in
Ottawa, Canada, in November 1986. It launched a series of actions among
international organizations, national governments and local communities to
achieve the goal of "Health For All" by the year 2000 and beyond through better
health promotion.221 The conference was primarily a response to growing
expectations for a new public health movement around the world. Discussions
focused on the needs of industrialized countries, but took into account similar
concerns in all other regions. It built on the progress made through the
Declaration on Primary Health Care at Alma Ata, the World Health
Organization's Targets for Health for All document, and a recent debate at the
World Health Assembly on intersectoral action for health. The nursing profession
was seen as being a key player to attaining health for all. Nurses in Canada,

220 Ibid.
221 World

Health Organization. (1986). The Ottawa Charter for Health Promotion.

Adopted on 21 November 1986 .
195

incorporated primary health care as being "fundamental to nursing's role in

enhancing health".222 Nurses have been actively involved in many efforts to
bring about primary health care reform.
There was much effort during the 1990s on debt and deficit management
which resulted in cuts to health care spending, and a led to a "renewed
commitment to ensuring access to illness care services". The National Forum on
Health in 1997 discussed public concerns about the impact of financial constraints
on health care spending and reported a public perception that health care was
deteriorating in Canada.223
In the United States, health department budgets were being decreased, and
this affected public health programs. A study entitled, The Future of Public
Health, done by the Institute of Medicine had warned that public health needed to
be brought back to its once traditional role and purpose.224 The health of the
nation was a growing concern in the 1990s, which lead to the Healthy People
2000 Initiative: National Health Promotion and Disease Prevention Objectives
being published in 1991 by the U.S. Department of Health and Human Services as
a nationwide effort to help communities look at strategies to address lifestyle
patterns, behaviours and habits. As many of the diseases that were preventable

222 Reuter,

223 Ibid.

L. & Ogilvie, L. (2011). Ibid. p. 199.

p. 190.

224 Stanhope,

M. & Lancaster, J. (2000). Ibid.

196

were characterizing mortality at this time in the United States.225 The AIDS
epidemic had a major impact on infection control. Stopping recapping needles,
wearing latex gloves and using isolation precautions were more prominent
procedures that raised awareness and debate with health care workers. Health
care workers were mandated to use preventive measures in the form of "Routine
Precautions" whereby, all contact with blood and any type of body fluid was
considered potentially infectious.226
Blood Pressure Recommendations
In Canada, during this time period, the Heart Health Initiative included:
Canadian Heart Health Surveys (CHHS) in every province from 1989 to 1992 to
determine the prevalence of high blood pressure, awareness of diagnosis,
treatment and control. This survey was the impetus for pilot programs at
community levels with the potential to prevent and control hypertension. The
Canadian Task Force on the Periodic Health Examination published guidelines on
screening and treatment of high blood pressure among adults and seniors by.
Hypertension was being recognized as a major public health issue in Canada.227
In the United States, data from the Third National Health and Nutrition
Examination Survey (NHANES III) in the United States (1988-1994) stated: 50%
of the American population had optimal blood pressure (<120/80 mmHg)
225 US

Department of Health and Human Services, Public Health Service. (1991).

Healthy people 2000: National health promotion and disease prevention
objectives. Washington, DC: USDHHS.
226 Cherry,

B. & Jacob, S. (2002). Ibid. p.22.

E., Colburn, H., Maclean, D. & Sinclair, G. (1986).
Federal/Provincial Working Group. The prevention and control of high blood
pressure in Canada. Minister of Health and Welfare. 1-82. Ottawa: ON.
227 Macleod,

197

compared to 43% of the people in Canada; 25% of people with hypertension

were under control in the US compared to 13% in Canada; and while about half
of the people with diabetes were between 18 and 74 years were hypertensive
(140/90 mmHg) in both countries, in the US 36% were under control (< 140/90
mrnHg) and only 9% in Canada despite frequent interactions with healthcare. 228
Nursing Education
In Canada, large increases occurred with many new master's programs
and increases in the size of existing programs. By 1993, total enrollment in
mater's programs had reached 904. Demand was increasing. 229 The first funded
doctoral program in nursing was established at the University of Alberta in 1991.
Other doctoral programs in nursing developed shortly thereafter at the University
of British Columbia (1991), University of Toronto (1993), McGill University
(1993) and McMaster (1994). The doctoral student numbers increased as doctoral
programs became established. In 1991, only eight students were enrolled across
the country. By 1995, 62 nursing doctoral students were enrolled across
Canada.230
In the United States, during the late 1980's, many nursing scholars thought
nursing research should have more of a focus on the "substantive information

228 Joffre,

M., Hamet, P., MacLean, D., L'ltalien, G. & Fodor, G. (2001).

Distribution of blood pressure and hypertension in Canada and the United States.
Perspectives of Cardiology, 14, 1099-1105.
229 Wood,

M. & Ross-Kerr, J. (2011). The growth of graduate education in

nursing in Canada, (p. 388-409). In J. Ross-Kerr & M. Wood. (Eds.). Canadian
nursing: Issues & perspectives. (5th ed.). Toronto: Elsevier.
230 Ibid.,

p. 403.
198

required to guide practice, rather than on philosophic and methodological

dilemmas of scientific inquiry".

The National Institutes of Health brought

more federal monies and resources for nursing research and training and created
the National Center for Nursing Research.
Overall Synopsis 1986-1995
In total, six journal articles were identified through a systematic hand
search and paging of all articles published in the CN during the period of 1986
and 1995 (Table 1). It was interesting to note, during the years 1987, 1988, 1989,
1993 and 1995, no published articles were found in the CN that addressed the area
of blood pressure measurement and management.
All six articles published between 1986 and 1995 in the CN were written
by nurses (6/6, 100%). Within this group of nurses, the majority were staff nurses
with a baccalaureate degree (3/6, 50.0%), followed by a professor and a nurse
midwife with a masters degree (2/6, 33.3%), and a diploma prepared nurse (1/6,
16.7%) (Table 2). Most of the authors were nurses working in specialty areas
such as Heart Function Clinic, Sleep Labs, and as nurse professors. Articles were
not plentiful on this topic during this time period.
In total, 14 journal articles were identified through a systematic hand
search and paging of all articles published in the AJN during the period of 1986
and 1995 (Table 1). During 1987 and 1995, no articles were published in the
AJN that addressed the area of blood pressure measurement and management.

231

Hinshaw, A. (1999). Nursing research and the explosion of knowledge, (p.88110). In T. Schorr & M. Kennedy. (Eds)s One hundred years of American
nursing. New York: Lippincott.
199

All of the articles published between 1986 and 1995 in the AJN were
written by nurses (14/14, 100%). Within this group of nurses who published, the
majority were written by masters prepared nurses (9/14, 64.3%) who were
employed as lecturers in nursing, nurse educators, clinical nurse specialists and
hypertension clinicians. This was followed by nurse-led physician teams whereby
the nurses were hypertension research coordinators or staff educators (3/14,
21.4%) and staff nurses holding a baccalaureate degree (2/14, 14.3%) (Table 2).
Within this group of articles, 14 percent of the articles were now being written by
nurses holding a PhD in nursing.
It was apparent that there was a different level of education of the nurses
who were writing for the two journals. The nurses publishing in the AJN had
higher degrees in nursing and preparation. The CN and the AJN had moved away
from regular bedside nurses publishing in this field to nurses with more
specialized knowledge in the area. Nurse led physician teams in the United States
were more common. Over twice as many articles were published in AJN as
compared to the CN during the period of 1986 and 1995.
Canadian Nurse
None of the six articles written between 1986 and 1995 had blood pressure
management as the main area of focus (Appendix A). The topic was only
addressed as a secondary topic. That is, the articles mentioned a BP reading
within a vital sign reading or the word 'hypertension' but not in the context that it
was a central theme within the published article.

200

American Journal of Nursing

Of the articles identified during the initial identifying term search, the
discussion of BP measurement and management, technological trends and the
nursing role in hypertension in the United States was a primary and central topic
of discussion in ten articles (10/14, 71.4%) written between 1986 and 1995 in the
AJN (Appendix A).232 Only one research study, that was poorly constructed,
concerning blood pressure was published.233

Monitoring and recording an accurate blood pressure without error was a

discussion in three of the articles. Practice had progressed and advanced to
having individuals routinely check their blood pressure at home with a home

232

These articles are: Nash, C. (1992). Clinical savvy. How do you test a digital
sphygmomanometer? American Journal of Nursing, 92(1), 66-70; Van Buskirk,
M. & Gradman, A. (1993). Monitoring blood pressure in ambulatory patients.
American Journal of Nursing, 95(6), 44-47; Hill, M. & Grim, C. (1991). How to
take a precise blood pressure. American Journal of Nursing, 91(2), 38-42;
Birdsall, C., Pizzo, C., & Muller, B. (1985). What are orthostatic BP changes?
American Journal of Nursing, 85(10), 1062; Trottier, D. & Kochar, M. (1992).
Hypertension - high cholesterol: A dangerous synergy. American Journal of
Nursing, 92(11), 40-43; Trottier, D. & Kochar, M. (1993). Managing isolated
systolic hypertension. American Journal of Nursing, 95(10), 51-53; Nash, C. &
Jansen, P. (1994). When your surgical patient has hypertension. American Journal
of Nursing, 94(12), 39-45; McCormac, M. (1990). Managing hemorrhagic shock.
American Journal of Nursing, 90(8), 22-27; Brengman, S. & Burns, M. (1988).
Hypertensive crisis in L & D drugs to get the mother's BP out of the danger zone.
American Journal of Nursing, 88(3), 325A-328L; Bristoll, S., Fadden, T.,
Fehring, R., Rohde, L., Smith, P. & Wohlitz, B. (1989). The mythical danger of
rapid urinary drainage. American Journal of Nursing, 89(3), 344-345.
233 Bristoll,

S., Fadden, T., Fehring, R., Rohde, L., Smith, P. & Wohlitz, B.
(1989). Ibid.

201

blood pressure device. Timing of when to take blood pressures was emerging in
the literature. Ambulatory blood pressure monitoring was starting to be discussed
in the literature.234 All three articles although published twenty years ago would
still be very relevant for nurses today.
Van Buskirk, a masters prepared registered nurse and critical care staff
educator, and Gradman, a physician who was heading a division of cardiology,
introduced ambulatory blood pressure monitoring, they suggested that monitoring
a blood pressure automatically over the course of a patient's day could eliminate
variability problems and other factors associated with isolated clinical readings,
and would be a valuable diagnostic tool.
Single blood pressure readings used for primary screenings, produce a
large number of false-positive diagnoses. This is at least partially due to
operator error and substandard screening environments.) Secondary
screenings, therefore, may be more accurate if ambulatory monitoring is
used.
Because it's automatic, ambulatory monitoring eliminates several sources
of human error, including too-rapid deflation (greater than 2mmHg/sec.),
improper placement of the manometer (higher or lower than eye level),
and inability to hear heart sounds in a noisy environment. When used for
extended assessment, it may prevent inappropriate antihypertensive
therapy and help control adverse reactions to long term antihypertensive
use, proving cost-effective in the long run.235
Ambulatory blood pressure monitoring (ABPM) involves the patient
wearing a portable blood pressure monitor for a 24-hour period to measure and
record blood pressure at regular intervals. ABPM should also be considered when
an office-based increase in blood pressure (i.e., white coat hypertension) is

234

Nash, C. (1992). Ibid.; Van Buskirk, M. & Gradman, A. (1993). Ibid.; Hill, M.
& Grim, C. (1991). Ibid.
235 Van

Buskirk, M. & Gradman, A. (1993). Ibid. p.47.

202

suspected in patients. According to the 2012 recommendations of CHEP, an

average daytime ABPM of 135/85 mmHg is considered to be the equivalent of an
office based measurement of 140/90 mmHg. While ABPM is usually lower
during the nighttime, a decrease in nocturnal blood pressure of less than 10% is
associated with increased risk of cardiovascular events.236
Much evidence suggests that office-measured sphygmomanometer-based
blood pressures are not as reliable as ABPM in terms of predicting cardiovascular
events such as myocardial infarction, congestive heart failure, stroke, transient
ischemic attacks as well as other target organ damage such as ventricular
hypertrophy.237 Despite its proven clinical utility, and CHEP recommendations
endorsing its use in diagnosing hypertension, ABPM is difficult to obtain as it is
not available in all communities.
Nash, a hypertension nurse clinician at the Mayo Clinic in Rochester,
discussed how
blood pressure can be measured in one of two ways: either by ausculating the
first and fifth Korotkoff sounds or by monitoring oscillations (pulsations) in the
brachial artery. The article was informative and shared user-friendly information
about how a blood pressure device would signal an error, when a blood pressure
236

Hypertension Canada. (2012). 2012 Canadian Hypertension Education

Program Recommendations: Accurate blood pressure measurement. Retrieved
May 5, 2012, from http://www.hypertension.ca/accurate-measurement-of-bloodpressure
237 Beckett,

L. & Godwin, M. (2005). The BpTRU automatic blood pressure

monitor compared to 24 hour ambulatory blood pressure monitoring in the
assessment of blood pressure in patients with hypertension. British Medical
College of Cardiovascular Disorders, 5(18), 1-19.
203

device failed to take a blood pressure, or how often should a blood pressure
device be checked.238
Hill, a doctorate prepared associate professor of nursing at Johns Hopkins
University, and Grim, a master's prepared assistant professor provided a picture
of a patient having their blood pressure taken and is entitled, "What's Wrong with
the Picture?" The authors used humor and techniques that are opposite to
standard procedures of blood pressure measurement to teach nurses about fine
tuning blood pressure measurement techniques to minimize the influence of
factors that can corrupt blood pressure readings.239
Nurses have played an important role in the detection and diagnosis of
hypertension. Often it is the nurse who is responsible for obtaining, recording and
reporting a patient's blood pressure. The role also extends to education of their
patients, which includes sharing blood pressure results with the patient and other
members of the healthcare team.
Regular blood pressure checks are the means to assessing the need for
antihypertensive treatment and to monitor a patient's vascular risk.240 Nurses
work with patients in a wide range of settings and are in a key position to
facilitate early detection of elevated blood pressure. It is interesting these
published authors began discussing this very same topic to nurses twenty years
238 Nash,
239 Hill,

C. (1992). Ibid.

M. & Grim, C. (1991). Ibid. p.39.

240 Pickering,

T., Hall, J., Appel, L., Falkener, B., Graves, J. & Hill, M. (2005).
Recommendations for blood pressure measurement in humans and experimental
animals part 1: Blood pressure measurement in humans. Hypertension, 45(1),
142-161.
204

ago. CHEP 2012 had recommendations that still discuss the importance of taking
a precise and accurate blood pressure.
Several other articles included discussion of more specific disorders
surrounding blood pressure and its influence on cardiovascular disease such as:
orthostatic BP changes, isolated systolic hypertension, and high cholesterol.241
The articles published in this decade were relating to specific types of
hypertension and the combination effects of having hypertension and other risk
factors.
Trottier, a registered nurse and hypertension research coordinator, with
Kochar, a physician and chief of hypertension, discussed managing isolated
systolic hypertension. Common belief then and still heard about today was,
For a long time many experts on hypertension believed that an increase in
systolic blood pressure was a normal part of aging. In fact, some adhered to
the rule of thumb that, "100 mmHg plus the patient's age" is a tolerable
systolic blood pressure in an older patient. Treatment for hypertension was
based on the diastolic reading primarily, and isolated systolic hypertension
was not treated.242
The Systolic Hypertension in the Elderly Program (SHEP 1991) study
results called this belief into question. The SHEP study, was a randomized,
double-blind, placebo-controlled trial. The main results of the SHEP study
showed treatment of isolated systolic hypertension (ISH) (i.e., patients with SBP
above 160 mm Hg, but diastolic blood pressure - DBP - less than 90 mm Hg)
resulted in significant reduction of all strokes, fatal and nonfatal, by 36%. Along

241 Birdsall,C

Pizzo, C. & Muller, B. (1986). Ibid., Trottier, D. & Kochar, S.

(1992, 1993). Ibid.

242 Trottier,

D. & Kochar, S. (1993). Ibid, p.51.

205

with this reduction in stroke was seen a 71% reduction in fatal and nonfatal MI, a
reduction in all coronary heart disease of 27%, all cardiovascular disease of 32%,
and total mortality of 13%. In addition, transient ischemic attacks and episodes of
congestive heart failure were also reduced. In this study, antihypertensive drug
treatment reduced the incidence of both hemorrhagic and ischemic (including
lacunar) strokes. Reduction in stroke incidence occurred when specific systolic
blood pressure goals were attained.

'}A"l

Trottier and Kochar stated that the goal of treatment for ISH is to reduce
systolic blood pressure below 160 mmHg for those with a baseline systolic
pressure above 180, and to bring it down at least 21 mmHg for those with a
baseline systolic pressure of 160 to 179.244 According to CHEP 2012
Recommendations those targets are still too high. Lower blood pressure to
<140/90 mmHg and in people with diabetes to <130/80 mmHg using a
combination of lifestyle modifications and medication. Treat to target (<140/90
mmHg; <130/80 mmHg in people with diabetes or chronic kidney disease). CHEP
blood pressure targets reflect current best evidence to optimally reduce
cardiovascular disease. Failure to achieve blood pressure targets results in higher
cardiovascular risk, while lowering blood pressure substantially below a target is
of undetermined benefit/harm. People with known cardiovascular disease,

243 SHEP

Cooperative Research Group. (1991). Prevention of stroke by

antihypertensive drug treatment in older persons with isolated systolic
hypertension. Final results of the Systolic Hypertension in the Elderly Program.
Journal of American Medical Association, 265(4), 3255-3264.
244 Trottier,

D. & Kochar, S. (1993). Ibid.

206

diabetes or chronic kidney disease are at high cardiovascular risk and have the
greatest reduction in cardiovascular events by achieving blood pressure targets.
1. Antihypertensive therapy should be prescribed for average diastolic blood
pressures of 100 mmHg or higher (Grade A), or average systolic blood
pressures of 160 mmHg or higher (Grade A) in patients without
macro vascular target organ damage or other cardiovascular risk factors.
2. Antihypertensive therapy should be strongly considered if diastolic blood
pressure readings average 90 mmHg or higher in the presence of
macrovascular target organ damage or other independent cardiovascular
risk factors (Grade A).
3. Antihypertensive therapy should be strongly considered if systolic blood
pressure readings average 140 mmHg or higher in the presence of
macrovascular target organ damage (Grade C for 140 mmHg to 160
mmHg; Grade A for higher than 160 mmHg).
4. Antihypertensive therapy should be considered in all patients meeting the
above indications regardless of age (Grade B). Caution should be
exercised in elderly patients who are frail.245
Trottier and Kochar identified that hypertension and hypercholesterolemia do
often coexist. Each condition contributes separately to coronary heart disease.
high blood pressure by damaging arterial walls, cholesterol by
forming atherosclerotic plaque, but together they have a greater than
additive effect. One of the foremost challenges of the hypertensionhypercholesterolemia combination is the calculated risk of drug treatment.
Nondrug treatment is the foundation for managing hypertension and
the primary approach for treating high cholesterol. Moreover, the lifestyle
changes recommended to combat hypertension also reduce blood
cholesterol levels.246

Unhealthy levels of total cholesterol, triglycerides, and low density

lipoprotein (LDL) are generally associated with higher measured hypertension.
Data from the Canadian Health Measures Survey from 2007 to 2009 show that
245 Hypertension

Canada. (2012). 2012 Canadian Hypertension Education

Program Recommendations: Accurate blood pressure measurement. Retrieved
May 5, 2012, from http://www.hypertension.ca/hvpertension-without-compellingindications
246 Trottier,

D. & Kochar, S. (1992). Ibid. p.40.

207

41% of Canadian adults had a high total cholesterol level: 27% among those from
20 to 39 years of age; 47% among people from 40 to 59; and 54% of those aged
60 to 79.247
According to CHEP 2012, the overall cardiovascular risk of patients with
hypertension should be assessed. Therefore, global cardiovascular risk should be
assessed. Multifactorial risk assessment models can be used to predict more
accurately an individual's global cardiovascular risk and to use antihypertensive
therapy more efficiently. It is also warranted to consider informing patients of
their global risk to improve the effectiveness of risk factor modification and using
analogies that describe comparative risk such as "Cardiovascular Age", "Vascular
Age" or "Heart Age" to inform patients of their risk status.248
Two articles focused on the acute clinical management of blood pressure
during hemorrhagic shock and when a patient is going for surgery.249 These
articles discussed what systolic blood pressure readings indicate in relation to
blood loss. Postoperative hypertension may indicate pain or vital organ damage.
Assessment strategies are reviewed as were physical findings such as volume
overload, hypothermia, hypoventilation and bladder distension.

247 Touyz,

R. (2006) Highlights and summary for the 2006 Canadian

Hypertension Education Program recommendations. Canadian Journal of
Cardiology, 27(3), 565-571.
248 Hypertension

Canada. (2012). 2012 Canadian Hypertension Education

Program Recommendations: Accurate blood pressure measurement. Retrieved
May 5, 2012, from
http://www.hvpertension.ca/images/2012 CHEPFullRecommendations EN HCP
1009.pdf
249 Nash,

C. & Jansen, P. (1994). Ibid.; McCormac, M. (1990). Ibid.

208

Fewer labour and delivery articles were being seen in comparison to the
previous decade.250 There was one article on this topic where hypertensive crisis
was reviewed and treatments were discussed dependent on the underlying
pathology for the acute hypertensive episode. The goal always being that the
woman's blood pressure must be reduced to prevent permanent damage to her
vascular system. Issues surrounding dropping the maternal blood pressure can
reduce uteroplacental blood pressure flow, which can lead to hypoxia.
A research article describing urinary drainage and how threshold clamping
affects blood pressure was published.251 The question being asked was if there
was danger of suddenly emptying a distended bladderhemorrhage, syncope,
sepsis and shock. The authors investigated how complete urinary drainage and
threshold clamping affect the blood pressure, pulse and blood loss of patients
catheterized for urinary retention. They found that complete bladder drainage
produced no evidence of subsequent changes in blood pressure and heart rate.
Nurses during this decade were expected to be many things and to
function in a variety of settings- caregivers, researchers, seekers of knowledge and
thinkers grounded in scientific and logical thought. Nurses were in new roles due
to the scientific and technical advances and increased scope of responsibilities had
increased.252

250 Brengman,

S. & Burns, M .(1988). Ibid.

251

Bristoll,S., Fadden, T., Fehring, R., Rohde, L., Smith, P. & Wohlitz, B. (1989).
Ibid.
252 Grippando,

G. & Mitchell, P. (1989). Ibid.

209

1996-2000
In 1996, Canadian astronaut Marc Garneau made his second trip into
space. In 1997, the Confederation Bridge opened for business, linking BordenCarleton, Prince Edward Island, and Cape Jourimain, New Brunswick. The 12.9
kilometer bridge cost $1 billion. In 1988, the most destructive and disruptive ice
storm in Canadian history dropped close to one hundred millimetres of freezing
rain in some areas of central and eastern Canada, affecting nearly 20 percent of
Canada's population, mainly in Montreal and Ottawa. In 1999, Wayne Gretzky
played his last game in a Canadian arena at the Corel Centre, in Nakata, Ontario.
After twenty years in the National Hockey League with Edmonton Oilers, Los
Angeles Kings, St. Louis Blues, and New York Rangers, the Great One
announced his retirement. His final game in the NHL was three days later at
Madison Square Garden in New York.253
In the 1995, a bombing of a federal office building in Oklahoma City
killed 168 people in the United States. President Clinton sent first 8,000 of
20,000 U.S. troops to Bosnia for a 12-month peacekeeping mission. In 1999,
President Clinton released a federal budget plan. It was the first balanced budget
since 1969. The United States launched missile attacks on targets in Sudan and
Afghanistan following terrorist attacks on U.S. embassies in Kenya and Tanzania.
U.S. and Britain launched air strikes against weapons sites in Iraq. A school
shooting at Columbine High School in Littleton, Colorado, leaves 14 students

253 Canada

history (2010). Retrieved May 05, 2012, from

http://www.canadahistorv.com/sections/timelines/timeline.htm
210

(including the 2 shooters) and 1 teacher dead and 23 others wounded. The United
States and China sign historic trade agreement.254
Healthcare Organization
In Canada, there was a focus on deficit reduction in the 1990s which in
turn meant a cut to health care spending. The National Forum on Health in 1997
aired public perceptions on fiscal constraints on health care spending and reported
that the public believed health care was deteriorating in Canada. The Romanow
Commission on the Future of Health Care in Canada, 2002, suggested that there
was a "strong public commitment to publicly funded health care."255
As in the United States, primary health care was the only way to sustain publicly
funded health care and to meet the increased challenges of access to health
services. In 1997, monies from the federal government from the Health
Transition Fund were received to support innovation for a more integrated system
of health care. By 2000, primary health care reform was a priority for the renewal
of Canada's health care system. The Primary Health Care Transition Fund was
given to provinces to improve the delivery of primary health care over the next
four years.256
In the United States, chemical and radioactive exposure became an added
risk and a major issue for concern for healthcare workers. Increasing costs of
Medicaid and Medicare started political action for reform. Findings from a

254 United

States history 1950-1999 (n.d.). Retrieved May 18, 2012, from

http://w w w.infoplease.com/ipa/A0903597.html#ixzz1vKvF1TuZ
255 Reuter, L. & Ogilvie, L. (2011). Ibid. p. 190.
256

Ibid. p. 191.

211

federal commission which evaluated the American health system found that: 15%
of the gross national product was related to healthcare expenditures; the US spent
more than twice as much as any other industrialized nation on healthcare services;
and Americans were living longer which meant more money needed to be spent
down the line. 257 Too much health care spending was occurring, thus the health
care system moved toward managed care in an attempt to control health care
expenditures. The focus of care moved toward more preventative and primary
care, using outpatient and home settings when possible, and limiting expensive
hospitalizations. Downsizing of hospital staff occurred with an increase use of
unlicensed assistant personnel to provide care in hospitals. There was more
demand for community nurses and nurse practitioners to provide primary care
services.
Nursing Education
In Canada, demand for masters programs was increasing. By 1995, total
enrollment was 860, and by 2000 there were 1,491 students enrolled in master's
programs in Canada. Nurse practitioner programs would become the next added
influence to master programs in Canada. By the year 2000, enrollment in doctoral
programs in nursing had reached 151. Although there were increasing numbers of

257

Kalisch, P. & Kalisch, P. (1995). The advance of American nursing.

Philadelphia: Lippincott.
258 Omermann,

M. (1997). Professional nursing practice. Stamford: Appleton

and Lange.
212

graduates with a Ph.D. in Nursing, it was still insufficient to meet the growing
need for faculty members and researchers.
In the United States, there was a large growth of nursing research during
the 1990s. The National Center for Nursing Research joined the National
Institutes of Health promoted the interdisciplinary possibilities for collaborative
research. Research programs focused more on health promotion across the life
span.260
During the late 1990s, the state licensure authorities and national
nongovernmental certifying bodies came together in a partnership. The certifying
bodies were needing new ways to determine the continuous competence of nurse
practitioners. Credentialing bodies engaged in active public information
campaigns to inform consumers about health care choices. 261
Hypertension Recommendations
In 1999, the Canadian Hypertension Society and the Coalition with Health
Canada and the Heart and Stroke Foundation of Canada produced
recommendations on prevention and control of hypertension through lifestyle
modification using an evidence-based grading scheme.

Much discussion

occurred during this time between Canada's hypertension control rate and that in
259 Wood,

M. & Ross-Kerr, J. (2011). Ibid, p.401.

260 Hinshaw,

A. (1999). Ibid.

261

Styles, M. (1999). The new way of credentialing. In T. Schorr and M.

Kennedy (Eds). One hundred years of American nursing. New York:
Lippincott.
262 Campbell,

N., Burgess, E., Choi,B., Taylor,G., Wilson, E. & Cleroux, J. (1999).

Ibid.
213

the United States and how to deal with it. Health Canada developed a National
High Blood Pressure and Prevention and Control Strategy that had the following
health goals:
1) to reduce the prevalence of uncontrolled high blood pressure in Canada,
2) to reduce the incidence of high blood pressure among Canadians,
3) to reduce the proportion of Canadians who were unaware of their high blood
pressure, and
4) to reduce the prevalence of uncontrolled high blood pressure among those who
have been diagnosed with it.263
This working group was renamed to what is still known today as the
Canadian Hypertension Education Program (CHEP) in 2003. During this time, its
focus was primary care physicians. During the period of 1995-2000 in Canada,
hypertension was poorly controlled. The Canadian hypertension management
recommendations had become more comprehensive and evidence-based, with
increasing (but short-lived) attempts to implement them through multiple formats;
on their own they were not truly influencing clinical practice.264 Several key
messages were starting to be emphasized. There was a lack of awareness of the
diagnosis of hypertension that resulted by the Canadian Heart Health Survey. This

263 Health

Canada and the Canadian Coalition for High Blood Pressure Prevention
and Control. National High Blood Pressure Prevention and Control Strategy,
Report of the Expert Working Group. January 31, 1999.
264 McAlister,

F., Campbell, N., Zarnke, K Levine, M., & Graham, I. (2001). The
management of hypertension in Canada: A review of current guidelines, their
shortcomings and implication for the future. Canadian Medical Association
Journal, 164: 517-522.
214

became the first message main message of CHEP to healthcare professionals, that
is, assess blood pressure in all visits.
Overall Synopsis 1996-2000
In total, two journal articles were identified through a systematic hand
search and paging of all articles published in the CN during the last five year
period reviewed from 1996 and 2000 (Table 1). During the years 1996, 1998 and
2000, no published articles were found in the CN that addressed the area of blood
pressure measurement and management.
The two articles were published between 1996 and 2000 in the CN.
Within this small group of nurses who published, one was written by a nurse and
physician team working in a hypertension clinic (1/2, 50.0%) and the second was
written by a physician working in the area of women's cardiovascular health (1/2,
50.0%) (Table 2).
In total, ten journal articles were identified through a similar systematic
hand search and paging of all articles published in the AJN during this five year
period of 1996 and 2000 (Table 1).
All of the articles published in between 1995 and 1997 in the AJN were
written by nurses (10/10, 100%). Within this group of nurses who published, the
majority were by masters prepared nurses (6/10, 60.0%) employed as staff
educators, nurse instructors and nurse practitioners. This was followed by an
even split of articles written by two nurse-physician teams (2/10, 20.0%) and two
masters prepared nurses (2/10, 20.0%) (Table 2).

215

Nurses who were masters prepared dominated the writing and publishing
in the AJN. Doctoral students (2/10, 20.0%) were now starting to write and be
published in the AJN which was a new trend.
Canadian Nurse
Of the articles identified during the initial identifying term search, the
discussion of BP measurement and management, technological trends and the
nursing role in hypertension in Canada was a primary and central topic of
discussion only within one of the two articles identified written between 1996 and
2000 in the CN (Appendix A).265
Dubois and Wilson discussed Losartan, a new medication and its
medication class; the angiotensin II antagonists. The nurse's role regarding
medication teaching and patient assessment was emphasized in the article. The
authors stated "nurses are an important source of drug information. Along with
medication teaching, nurses must know the effects, side effects and interactions of
their patients' medications. This also includes keeping current on the latest
advances in drug therapy."

Recognizing that one of authors Wilson, was a

member of CHEP, the message from the author was that drug therapy for
hypertension has changed dramatically over the years. The nurses' role was
becoming increasingly challenging and complex. It was important to remind
patients that hypertension medications have a slow, gradual blood pressure

265 This

article was: Dubois, M. & Wilson, T. (1997). Losartan: A new

antihypertensive drug. The Canadian Nurse, 97(6), 31-34.
266

Ibid. p.31.
216

lowering effect with the maximum effect seen about six weeks after starting
therapy.
Most people with hypertension require lifestyle changes and
antihypertensive drug combinations to achieve recommended blood pressure
targets. Diuretics are nearly always required to treat hypertension especially when
'resistant'. Many people with
diabetes or chronic kidney disease require three or more antihypertensive drugs
including diuretics to achieve blood pressure targets. Regular follow-up and
titration of therapy is required to achieve blood pressure targets.
American Journal of Nursing
Of the articles identified during the initial identifying term search, the
discussion of BP measurement and management, technological trends and the
nursing role in hypertension in the United States was a primary and central topic
of discussion within seven published articles (7/10, 70.0%) written between 1996
and 2000 in the AJN (Appendix A).267 None were research articles.
Within the AJN, case studies were being used again as they had been in the
1950s to discuss and illustrate different clinical presentations such as clinical

267 These

articles were: Lilley, L. L., & Guanci, R. (1996). Revisiting digoxin

toxicity. American Journal of Nursing, 96(8), 14; O'Hanlon-Nichols, T. (1997).
The adult cardiovascular system. American Journal of Nursing, 97(12), 34-40;
Cramer, C. (1997). Hypertensive crisis from drug-food interaction. American
Journal of Nursing, 97(5), 32-34; Barbarito, C. (1998). Hypertension-induced
epistaxis. American Journal of Nursing, 98(2), 48-50; Kozuh, J. L. (2000).
NSAIDs & antihypertensives: An unhappy union. American Journal of Nursing,
700(6), 40-43; Karch, A., & Karch, F. (2000). When a blood pressure isn't routine.
American Journal of Nursing, 100(3), 23-25; and Little, C. (2000). Renovascular
hypertension. American Journal of Nursing, 100(2), 46-51.
217

scenarios surrounding taking an accurate blood pressure, the cardiovascular

system, hypertensive crisis and hypertension-induced epistaxis.268 Secondary
causes of hypertension such as renovascular issues continued to be discussed in
the literature.269
New classes of medications for hypertensive therapy (angiotensin II
antagonists) and other medication interactions were described.270 Specifically,
Kozuh, a cardiology nurse practitioner, discussed the concomitant, nonsteroidal
anti-inflammatory drugs (NSAIDs) with antihypertensive agents, suggesting it
was not a safe combination. NSAIDS elevate blood pressure in the normotensive
population and antagonize the effects of many antihypertensive medications. She
stated that any blood pressure elevation in a patient with hypertension enhances
the risk of cardiovascular and cerebrovascular complications. Kozuh suggested
nurses should review complete lists of patients' medications and screen for
NSAIDs. She recommended nurses should advise their patients who have both
hypertension and a condition requiring NSAID therapy to always alert their
prescribing practitioner to both conditions, so that a safe and effective
combination can be chosen.271

268 Karch,

A. & Karch, F.( 2000). Ibid.; O'Hanlon-Nichols, T. (1997), Ibid.;

Cramer, C. (1997). Ibid.; Barbarito, C. (1998). Ibid.
269 Little,

C. (2000). Ibid.

270 Kozuh,
271

J. ( 2004). Ibid.; Lilley, L. & Guanci, R. (1996). Ibid.

Kozuh, J. ( 2004). Ibid.

218

Educating patients about the nature and characteristics of hypertension,

their medications, their probability of taking medications for life, and meaning of
blood pressure reading allows patients to make informed decisions and choices
about modifications to their medication regimens. 272 Increased understanding
and education can help clarify misconceptions, which is often a common barrier
to adherence. Patients need to be informed, motivated and skilled in the use of
cognitive and behavioural self regulation strategies if they are to cope well with
the treatment-related demands imposed by their illness. 273
During this five year period (1996-2000) there again was a continued
decline in the number of total articles published with BP as a central topic. This
was seen in both the CN and the AJN. In comparison, the AJN published an article
in 1996 by Lilley regarding angiotensin II antagonists as a new class of drug
therapy for hypertension. In Canada, Dubois and Wilson in 1997, published a
similar article. The articles in the AJN continue to have a more indepth profile
and length compared to the CN. Typically, the CN articles have a greater focus on
teaching and counselling of patients and follow-up, whereas the AJN publishes
more on clinically acute hypertensive issues. Interestingly, neither nursing
research, nor research studies were published in either journal during this period
of evaluation.

272 Johnson,

M. (2002). The medication-taking questionnaire for measuring

patterned behavior adherence. Communicating Nursing Research, 35 (1), 65-70.
273 Roter,

D., Hall, J., Merisca, R., Nordstrom, G., Cretin, D. & Svarstad, B.
(1998). Effectiveness of interventions to improve patient compliance. A meta
analysis. Medical Care, 36(8), 1138-1161.
219

Conclusion
In summary, a total of 88 primary cuticles were identified out of 365 (183
CN and 165 AJN) which identified blood pressure measurement and management
as a central topic (Figure 1 and Table 1).
The published articles addressed a variety of topics and issues, some
articles addressing more than one central issue (Appendix A). The following
describes raw totals as many articles were represented in several categories. Only
thirteen articles were identified that discussed an aspect of blood pressure
measurement and management as a central topic in the CN literature during the
period of 1945 and 2000. Most of the articles in the CN defined as centrally
addressing the topic of blood pressure measurement and management discussed
pathology, blood pressure recording devices, diagnosing hypertension and the
nursing care of the patient with hypertension.
Fifty - four percent (7/13) of the primary articles in the CN in this
historical review discussed the pathology of hypertension relating to the nature,
the progress and the causes of high blood pressure. Fifty- four percent (7/13) of
all the central articles in the CN examined blood pressure recording devices.
Forty-six percent (6/13) of all the central articles in the CN focused on providing
nursing care to a hypertensive patient and drug therapy. Thirty-eight percent
(5/13) of all the central articles in the CN discussed the procedure regarding
diagnosing hypertension. The remainder of all the central articles in the CN
reviewed diet therapy and how it related to hypertension, multidisciplinary

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teaching and recommended instructions regarding blood pressure management,

and screening for high blood pressure.
With regards to the AJN literature 75 articles were identified that discussed
an aspect of blood pressure measurement and management as a central topic.
Most of the articles in the AJN defined as centrally addressing the topic of blood
pressure measurement and management discussed pathology, blood pressure
recording devices, diagnosing hypertension, drug therapy and the nursing care of
the hypertensive patient.
Sixty -eight percent (51/75) of all the central articles in the AJN discussed
the procedure regarding diagnosing hypertension. Sixty percent (45/75) of all the
central articles in the AJN described the pathology of hypertension relating to the
nature, the progress, and cause of high blood pressure and nursing care of a
patient diagnosed with high blood pressure. Fifty- seven percent (43/75) of all the
central articles in the AJN examined blood pressure recording devices. Thirtynine percent (29/75) of all the central articles in the AJN reviewed drug therapy
and medications for the treatment of hypertension. The remainder of the articles
focused on diet therapy surrounding blood pressure lowering, multidisciplinary
teaching and screening for high blood pressure.
The article topic trends were not noted among the breakdown of decades
in the CN. This most likely was due to having thirteen primary articles being
written within a 55 year period. Most of the articles surrounding hypertension
were written between 1976 and 1982. The article topic trends were noted among
the breakdown of decades in the AJN. Journal articles were not being written that

221

had a central theme of hypertension during the period from 1945 and 1955.
During the period of 1956 and 1975 central topics focused on hypertension as a
risk factor for coronary artery disease, specific disease entities that depicted high
blood pressure such as renal stenosis, periarteritis nodosa and nephrectomy, and
discussions surrounding monitoring and measuring blood pressure. During the
period of 1976 and 1985, the articles had a primary focus of blood pressure
monitoring in critical care areas, for example, during invasive pressure
monitoring, renal dilatation and during bypass surgery. Other articles focused on
controlling blood pressures with medications and accurate blood pressure
measurement. During the period of 1986 and 1995 the trend in article topic
became blood pressure management in labor and delivery and accurate
measurement of blood pressure. The period of 1996 and 2000 focused more on
drug therapy for hypertension and patient teaching.
Overall, through the 55 year period of historical evaluation articles of both
the CN and the AJN discussed mechanisms involved in the regulation of blood
pressure. The pathophysiological mechanisms associated with hypertension were
identified. The clinical manifestations and complications of hypertension, and
strategies for the prevention of hypertension were described. The care of
hypertension, including drug and diet therapy was also examined. Nursing
management of the patient with hypertension, emphasizing patient teaching and
touching on the clinical manifestations and collaborative care of a hypertensive
crisis was also examined. Only one nursing research article in the AJN was
presented that was relevant to the topic during the fifty-five year period that was

222

examined. None were published in the CN. It is likely that two other American
journals, Nursing Research and Nursing Outlook published more nursing research
and were the primary venue for these types of publications.
1945-1955
After WW n, there was a burst of prosperity and progress in North
America. Nursing was enhanced with an explosion of knowledge and technology.
New innovations in healthcare meant nurses were performing many more tasks
formerly done by physicians. Nurses were measuring the blood pressure on a
regular basis and recording the numbers. In this review, the Canadian literature
articles focused on defining hypertension, the nurse's role in the treatment of
hypertension, and the public health nurse's role in caring for a patient with
hypertension. The American literature in this review also focused on the
treatment and nursing care of the hypertensive patient. Other articles in this
decade, focused on taking a blood pressure as being part of a physical exam.
Management of hypertension was described surgically whereby surgeons
conducted sympathectomies to interrupt the sympathetic nervous pathways to the
vascular bed to control blood pressure. This procedure is rarely done today for
hypertension. It would appear from the treatment options described in the
literature, elevated blood pressures were not being diagnosed early but later in the
disease process. Across both borders, the articles at this time were primarily
written for nurses by physicians, therefore, the nursing role in blood pressure
management was in its early definition.

223

1956-1965
Postwar society and healthcare was filled with more technological
improvements. Homes had labour-saving devices and hospitals had more
antibiotics to choose from and other scientific advancements. Health insurance
programs were developing across both borders and more hospitals were being
built. There was a need for nurses. Physicians continued to introduce new
technologies but when the volume of treatments became too many or too
burdensome, nurses absorbed the fallout and became proficient and primary users
of these skills and tasks. By 1954, blood pressure became a standard skill
acquired of all nurses in Canada. In this review, the Canadian literature articles
focused on hypotension and a holistic approach to lowering emotional tension to
decrease blood pressure numbers. The American literature in this review had a
more predominant focus on how to take an accurate blood pressure using a
stethoscope and sphygmomanometer and how to correct common errors of taking
a blood pressure that would reflect on accuracy. Electronical devices were being
introduced as part of patient care. Nurses were being expected to operate these
devices and machines. Other treatment options beyond the sympathectomy
appeared in the literature, such as the effect of weight loss on blood pressure and
the use of vasopressors. The American literature had many articles this decade
that discussed alternative disease processes that had an effect on the blood
pressure. The nurses' role in the management of pressure appears to be
expanding due to the technological explosion of new electronical devices and the
need to be technologically savvy. The nurses' role was expanding from manually

224

taking and recording a blood pressure reading. Nurses were interpreting the
recorded numbers and became educators to their patients, bringing a holistic
psychosocial approach in nonpharmacological treatment to hypertension. Nurses
have taken over the writing and teaching of other nurses across both borders.
1966-1975
In the Western world, social progressive values that began in the 1960s,
such as increasing political awareness and political and economic liberty of
women, continued to grow. The hippie culture, which started in the latter half of
the 1960s, waned by the early 1970s and faded towards the middle part of the
decade, involved opposition to the Vietnam War, opposition to nuclear weapons,
the advocacy of world peace, and hostility to the authority of government and big
business. The environmentalist movement began to increase dramatically in this
period. There was a continued explosion of knowledge and new techniques that
dominated health care. More specialized care and specialized training of nurses
was occurring. In this review, the articles had a focus on nurses knowing the
pathophysiology of heart disease and good physical assessment skills. Treatment
of hypertension by nurses focused on risk factor management and lifestyle
modification. Nurses were now educating patients, and taking a qualitative view
of their patient's experience of having hypertension. Nurses have identified that
knowing a patient's perspective will influence a patients teaching and learning
needs. The articles were moving away from describing and identifying high
blood pressure and moving towards nurses being more involved in the treatment

225

and prevention of hypertension from a holistic perspective. The articles were

written by nurses with higher levels of education, i.e., master prepared nurses.
1976-1985
The early 1980s were marked by a severe global economic recession that
affected much of the developed world. Drugs became a serious problem in the
'80s. Cocaine was popular among celebrities and the young, sophisticated
"yuppies", while crack, a cheaper and more potent offshoot of the drug, turned the
inner cities into war zones. Personal computers experienced explosive growth in
the '80s, going from being a toy for electronics to a full-fledged industry. National
safety campaigns raised awareness of seat belt usage to save lives in car accidents.
Similar efforts arose to push child safety seats and bike helmet usage. Rejection
of smoking based on health concerns increased throughout the western world.
Health care shifted from an acute focus to a health promotion focus. In this
decade, review articles focused on blood pressure screening and early detection of
hypertension. Guidelines and recommendations were being first published for
hypertension management in Canada. Hypertension nurses were noted to be on
Hypertension Task Forces for the management of hypertension. Nurses were
being informed about automatic blood pressure device usage, how to calibrated
digital machines and measure for appropriate blood pressure cuff size. A new
topic focus was having nurses play a role in evaluating a patient's response to
hypertensive therapy. Nurse-managed clinics and nurses with specialized training
in hypertension were starting to be discussed in the literature. Other articles
focused on pregnancy-induced hypertension and invasive pressure monitoring in

226

intensive care units. The nurse's role in the management of hypertension was
becoming broader and independent from the physician, in the sense thatnurses
were specializing in hypertension managed care and evaluating patient's therapy
and goals.
1986-1995
The 1990s is often considered the true dawn of the information age.
Institutions, companies, and organizations were prosperous during the 1990s.
Sustainable growth and environmental protection became serious issues for
governments and the international community. Youth culture/generation X in the
1990s responded to this by embracing both environmentalism and
entrepreneurship. Within hypertension, surveys were being conducted on both
sides of the border to determine the prevalence of high blood pressure, and
awareness of diagnosis, treatment and control. There was publication of
guidelines on screening and treatment of high blood pressure for adults.
Hypertension was being recognized as a major public health issue. Hypertension
specialty and research organization developed evidence-based recommendations
for the management of hypertension. Pilot programs at the community level were
being developed out of the Heart Health Initiatives, with the focus of preventing
and controlling hypertension. The primary articles during this decade for nursing
focused again on fine tuning technique to minimize corrupt blood pressure
readings. Reiteration of possible sources of error when taking blood pressure was
emphasized in the nursing literature. Automated blood pressure monitoring was
being introduced as an alternative to office measurement of blood pressure.

227

Isolated systolic hypertension was being defined alongside treatment goals. More
articles focused on managing cardiac risk factors and conditions that coexisted
such as hypertension and hyperlipidemia. During this decade there were fewer
articles in the nursing literature focusing on acute hypertensive situations, such as
hypertensive crisis in labour and delivery and hemorrhagic shock. Nurses were
taking on a greater educating role with their patients about how to manage their
hypertension. Hypertension was poorly controlled in the 1990s, and although
recommendations were becoming more inclusive, it was noted that a more
comprehensive approach to hypertension prevention and control was still
required.
1995-2000
The number of people with hypertension continued to rise as prevention at
the population level was not as effective as anticipated, therefore leaving high
blood pressure to be inevitable with advancing age. More needs to be done.
There is still a need for health promotion to improve the health and quality of life
of those with hypertension. A significant amount of the current literature for
nurses during this decade identified ways to modify risk factors and focus on a
healthy lifestyle as important for healthy blood pressure. Similar themes in the
articles focused on nurses teaching patients' to prevent blood pressure from rising
and how to lower high blood pressure, and on the need to monitor patients who
are on drug therapies.

228

Standardized Practice Presented in CN and AJN

The majority of articles written in the two journals reviewed stated blood
pressure measures as standard and objective measurements such as 120/80
mmHg, although it had been documented to mean very different things to
different practitioners. For most of the years 1965 to 1975, the diastolic
measurement for example of 80 mmHg could mean either the fourth Korotkoff
(muffling) sound or the fifth (disappearance) sound. Much depended on the
training and experience of the nurse. It was not until after the 1970s when blood
pressure measurement had become a routine nursing task that a standard
definition of diastolic BP was settled.274 The U.S. Bureau of Standards at the
request of the U.S. military set the standards for the construction and calibration
of blood pressure cuffs. Physicians at this time showed no interest in
standardizing a practice that was already used and controlled by them.275
At about the same time, the life insurance industry began to recognize that
death occurred at an earlier age in people with higher blood pressure levels than in
those with lower blood pressure levels. It was insurance companies that called for
a standard definition of diastolic blood pressure for their medical examiners. It
was from this actuarial data from the insurance companies that showed as blood
pressure rises so do mortality rates. This rise is gradual until the level of 140/90
mmHg when the increase in mortality rates becomes steeper. Therefore, the use
of 140/90 mmHg as a cut off number became a standard or recommendation for
274 Crenner,

1998, Ibid.

275 Ibid.

229

blood pressures to fall below. Many of the primary articles regarding

hypertension in the nursing journals at this time focused on efforts directed
towards the treatment of hypertension and the education of the patient with high
blood pressure. Physicians wrote articles surrounding sympathectomy and nurses
started to write articles related to diet.
Toward the late 1980s, Ph.D. nurses appeared in the journal articles
writing as primary authors on topics regarding the outcomes of uncontrolled and
untreated hypertension. Towards the late 1990s, more multidisciplinary team
work and studies appeared in the two journals discussing organ complications,
primarily atherosclerosis. By the year 1995, the discussions in the journals turned
to a focus on hypertensive therapy. Patients who were treated for severe
hypertension experienced fewer cardiovascular complications. Drug therapy
could reduce the number of strokes and prevent the development of more serious
disease. Nursing literature in the late 1990s started to discuss important findings
surrounding the diagnosis of early development of left ventricular hypertrophy in
those with hypertension who remained untreated. A plethora of antihypertensive
medications appeared to be discussed in the literature of both journals across the
1990s, all producing a reduction in blood pressure levels. It was also in the 1990s
that the use of guidelines and recommendations started to be seen in the literature
to aid the clinician. In the United States, the Joint National Committee on
Detection, Evaluation and Treatment of High Blood Pressure and in Canada the
Canadian Hypertension Education Program published several sets of guidelines
that would be referenced in articles suggesting strategies for treatment of

230

hypertension. During the later years of the 1990s, the articles had more emphasis
on patient involvement in treatment regimens, quality of life concerns and control
of other risk factors for cardiovascular disease. Environmental factors appeared
to be also starting to be described across the two countries, relating most recently
to obesity and salt intake.
Nursing Roles Presented in the CN and AJN
It appears through the literature of the CN and AJN, registered nurses have
been ideally positioned to deliver effective patient and public education about
hypertension. In almost every care setting, nurses have participated in efforts to
control high blood pressure. Nurses in the last 55 years have shown and
developed the knowledge, skills and caring as well as the breadth and diversity to
contribute to patient care management of hypertension. Nurses were often the
critical conduit of high-quality information within their families, neighborhoods
and communities.
Hypertension was just as prevalent 40 to 50 years ago as it is today, but it
was not recognized, diagnosed or treated. It is not so long ago that an accepted
'normal' blood pressure was 100 mmHg plus a person's age. Thus, a blood
pressure of 160/90 mmHg was perfectly acceptable for the average 60 year old.
Moreover, 190/100 mmHg was also acceptable for the 90 year old.
The positive changes that occurred over the last 55 years can be attributed
primarily to significant improvements in the process through which high blood
pressure was managed, but also some health promotion and disease prevention
231

initiatives that took hold. Prior to 2000 there was not a widely disseminated clear
message available to nurses about what was critically important for the treatment
of hypertension. With regards to surveillance, no standardized process was in
place for nurses to identify gaps in treatment or to assess the impacts of nursing
strategies to reduce hypertension. Regarding sodium, most of the public and
health literature and research on sodium was derived directly or indirectly by the
food/salt industry. Public awareness campaign on hypertension showed little
impact. There was little standardized up-to-date non-commercial public and
patient information on hypertension that was widely disseminated or available for
nurses to use to educate patients.
Nurses have devoted much attention and effort to help to reduce the
impact of this important condition that is largely preventable or, in the vast
majority of patients, responsive to treatment. Historically, nurses have focused on
preventing hypertension, detecting it earlier and treating it effectively. In the two
journals reviewed prevention became and an increasingly important topic from
1976 onward. The CN core messages had a greater focus on using lifestyle to
prevent and control hypertension. Nurses have recognized hypertension as an
important risk factor for cardiovascular mortality and morbidity. Questions that
have existed throughout this critical review of the literature still exist today and
are still currently debated. They include:
1. What values determine a normal blood pressure reading?
2. What is the best way to measure blood pressure accurately?

232

Auscultation to measure blood pressure was accepted widely as a skilled

practice for physicians prior to 1945. Many physicians emphasized the subjective
elements of auscultation to measure blood pressure. Korotkoff's report from 1905
had proposed the simple method of listening for the appearance and disappearance
of pulse sounds to mark maximal and minimal pressure. Physicians then divided
the changing sounds heard in the artery into five "Korotokoff phases". Clinically,
this began the reporting of systolic and diastolic pressures. Nursing journal
articles in both Canada and the United States at this time were primarily written
by physicians, mostly all being surgeons. Less than twenty percent were written
by either nursing students or unit head nurses. Topics of interest were case
studies and procedural type cases, such as, thyroidectomy, anthrax, and Addison's
disease. Blood pressure was written as a given value with little description as to if
it was a good measure or even what it meant clinically. It was just a recorded
measure.
Limitations of the Study
This review only looked at two journals, The Canadian Nurse and The
American Journal of Nursing. As with other topics, other venues, were also likely
used to publish on the topic of hypertension. Therefore, one cannot be certain that
this was a complete review of all blood pressure measurement articles from 1945
to 2000.

233

Significance of the Study

To a nurse entering the medical wards of a hospital for the first time,
measuring blood pressure appears to be a simple, routine procedure. Yet how this
practice evolved within nursing has not been examined in detail. This review of
the articles published in the CN and AJN is significant in that it provides a
snapshot about what was written about blood pressure in these two journals.
During this period of fifty years measurement of blood pressure by nurses became
the norm.
Although the number of articles centrally focused on blood pressure was
relatively small, as previously discussed, it provided a chronological overview of
publication trends that showed how the roles of nursed evolved during those
years. The articles examined were also reflective of developments related to
blood pressure measurement and practices related to the prevention and
management of blood pressure. Interesting to note, although a search for articles
relating to the topic of diabetes and hypertension was conducted, there was little
to be gathered associated to this topic.
Although not a central focus of this project the information gathered about
who wrote the articles in both journals mirrored developments in nursing
education. As was seen in the early decades that were studied, physicians were
often the authors of most articles. While the gradual shift towards articles being
authored by nurses in the following decades reflected the development of both
undergraduate and graduate education in nursing.

234

In closing, it was clearly apparent that significant aspects of the content of

the articles reviewed is still of value which shows that what we often see as
current or novel wisdom, may in fact have been seen before by our precursor.
This is worth remembering as it keeps us grounded in front of what we see as new
developments.
Therefore, the nursing literature on blood pressure measurement from
1945 to 2000 was reviewed to provide a historic perspective on blood pressure
measurement and management. Hypertension began to be recognized as a
common chronic condition and an effect of aging. During the 1950s and 1960s
the development of research and the provision of higher education in nursing and
other health disciplines contributed to recognizing that hypertension is a
significant health problem and to search for research-based treatment methods.
The nursing literature on blood pressure from 1945 and 2000 was reviewed to
provide a holistic perspective on clinical care nursing patterns before the current
surge in interest in this common chronic condition.
Nursing history can help remind us that nursing is an art as well as a
science. The intent of this undertaking was to hopefully, facilitate
metamorphosis and add to the body of nursing knowledge by moving nursing
forward in nursing practice, research and education in the future.
Now looking into the future, more needs to be done to treat and control
hypertension. One of the most important challenges remains and is that is theprevention of hypertension. Although hypertension is preventable, it is estimated

235

that the condition will develop in 90% of Canadians.276 These are important
challenges for nurses to embrace, as much can be done to improve health through
prevention and control of hypertension. This in turn can save billions of
healthcare dollars and improve the health and quality of life for all.

276 Vasan,

Beiser & Seshadri, 2002, Ibid.

236

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251

Appendix A. Primary Articles Central Topic Description by Decade and Journal

Primary Article Author

Year of
Publication

Disease
Process

Petursson

1950

Sigmundson &
Einarson2
Beamish &
Adamson3

1950

htn

1950

htn

Smithwick &
Kinsey4
Fedder5

1947

htn

1948

htn

Ellis"

1948

Other

Pathology

Case
Study

Diagnostic/
Procedure/
Equipment

BP Device/
BP
Recordings

Surgery

Nrsg
Care

Drug
Therapy

Diet

Teaching

Screening

Q&A

19451955
CN (3)
public
health

vascular
sympathetic

sympathecto
my
causes of HD

AJN(7)

1
>y

Petursson, S. (1950). Public health nurse's role with the hypertensive. The Canadian Nurse, 46(6), 458-460.
Sigmundson, M., & Einarson, C. (1950). Nursing the hypertensive. The Canadian Nurse, 46(6), 455-458.

Beamish, R. E., Adamson, J. D., & Griffin, D. L. (1950). Hypertension. The Canadian Nurse, 46(6), 449-453.

Smithwick, R. H., & Kinsey, D. (1947). Surgical treatment of hypertension. American Journal of Nursing, 47(3), 153-155.

Fedder, H. (1948). Nursing the patient with sympathectomy for hypertension. American Journal of Nursing, 48(10), 643-646.

Ellis, L. B. (1948). Underlying causes of heart disease. American Journal of Nursing, 48(11), 697-698.

252

Con't
Educ

Takayoshi
Christensen8

1953
1953

Primary Article Author

Year of
Publication

Jay9

1953

Freis & Lodge10

1954

Disease
Process

htn

portal htn

portal htn

Other

Pathology

Surgery

Nrsg
Care

physical
exam
treatment/nrs

Case
Study

Diagnostic/
Procedure/
Equipment

BP Device/
BP
Recordings

Diet

Teaching

Screening

Q&A

Con't
Educ

Drag
Therapy

19561965
CN( 2)

Schweisheimer" 1956
1963
Frances12

hypoten

htn

X
X

AJN
(15)

Davidson'3

7 Takayoshi,
o

1957

CV disease
diet

M. (1953). Nursing care of patients with portal hypertension. American Journal of Nursing, 55(10), 1208-1209.

Christensen, S. P. (1953). Portal hypertension. American Journal of Nursing, 55(10), 1206-1207.

Jay, A. N. (1953). What is a routine physical examination? American Journal of Nursing, 53(3), 320-321.

10 Freis,

E. D., & Lodge, M. P. (1954). Treatment and nursing care of hypertension. American Journal of Nursing, 54(11), 1336-1339.

11

Schweisheimer, W. (1956). Hypotension. The Canadian Nurse, 52(1), 53-54.

12

Frances, M. (1963). Hypertensive heart disease. The Canadian Nurse, 59(5), 443-445.

13 Davidson,

S. (1957). Diet and cardiovascular disease. American Journal of Nursing, 57(2), 194-196.

253

14

Knowles &
Goff14
Raney15

1957

periarteritis
nodosa

1957

minor
concussion

Connolly16

1958

BP

Primary Article Author

Year of
Publication

Ansell"
Bean, Krahn,
Anderson &
Yoshida18
Blodi19
Dean20

1958
1963

Diagnostic/
Procedure/
Equipment

BP Device/
BP
Recordings

measurement
sounds
Disease
Process

Other

Palholog}1

nephrectomy

BP

Case
Study

X
X

Surgery

Nrsg
Care

Drug
Therapy

Die!

Teaching

Screening

Q&A

Con'r
Educ

monitoring

glaucoma
measuring

A. F. (1958). Hear that beat! American Journal of Nursing, 58(5), 688-689.

Ansell, J. S. (1958). Nephrectomy and nephrostomy. American Journal of Nursing, 58(10), 1394-1396.
Bean, M. A., Krahn, F. A., Anderson, B. L., & Yoshida, M. T. (1963). Monitoring patients through electronics. American Journal of
Nursing, 63(4), 65-69.

19 Blodi,
20

R. B. (1957). The minor concussion. American Journal of Nursing, 57(11), 1444-1445.

16Connolly,

18

Knowles, H. C., JR., & Goff, A. B. (1957). Periarteritis nodosa. American Journal of Nursing, 57(3), 344-346.

15 Raney,

17

1963
1963

F. C. (1963). Glaucoma. American Journal of Nursing, 63(3), 78-83.

Dean, V. (1963). Measuring venous blood pressure. American Journal of Nursing, (55(10), 70-72.

254

CV BP
measurement

Eggleston21
Thomas &
Holiday22
Callow23

1963
1964

Kelly &
Gensini24

1964

2ndary htn

renal
arteriography

Primary Article Author

Year or
Publication

Disease
Process

Other

Pathology

George25

1965

Malcolm26

1965

Malcolm27

1965

electronic VS
monitoring
BP
measurement
IVICU

2ndary htn

1964

Renal artery
stenosis
sympathetom

21

Case
Study

BP Device/
BP
Recordings

X
X

Surgery

Nrsg
Care

Drug
Therapy

Diet

Teaching

Screening

Q&A

Eggleston, J. M. (1963). It's all in the approach. American Journal of Nursing, 63(11), 112.

22

Thomas, J., & Holiday, E. (1964). Detecting secondary hypertension. American Journal of Nursing, 64(2), 94-96.

23 Callow,

A. D. (1964). A surgeon talks about hypertension. American Journal of Nursing, 64(12), 74-78.

24

Kelly, A. E., & Gensini, G. G. (1964). Renal arteriography. American Journal of Nursing, 64(2), 97-99.

25

George, J. H. (1965). Electronic monitoring of vital signs. American Journal of Nursing, 65(2), 68-71.

26

Malcolm, B. (1965). Correcting common errors in blood pressure measurement. American Journal of Nursing, (55(10), 133-166.

27

Malcolm, B. (1965). Intravenous infusion of vasopressors. American Journal of Nursing, 65(11), 129-152.

255

Con't
Educ

Diagnostic/
Procedure/
Equipment

Vasopressors
19661975
CN (0)

No Articles
AJN
(9)

Rawlings28

1966

Stamler, Hall,
Mojonnier,
Berkson,
Levinson,
Lindberg,
Andelman,
Miller &
Burkey29

1966

Primary Article Author

Year of
Publication

Avery30
Aagaard31

heart
disease

heart attack
prevention

Disease
Proccss

Other

Pathology

1966

2ndary htn

1973

htn

Renal artery
stenosis
treatment

Case
Study

Diagnostic/
Procedure/
Equipment

BP Device/
BP
Recordings

Surgery

Nrsg
Care

Drug
Therapy

Diet

Teaching

Screening

Q&A

Con't
Educ

28

Rawlings, M. S. (1966). Heart disease today. American Journal of Nursing, 66(2), 303-307.

29

Stamler, J., Hall, Y., Mojonnier, L., Berkson, D. M., Levinson, M., Lindberg, H. A.,... & Burkey, F. (1966). Coronary proneness
and approaches to preventing heart attacks. American Journal of Nursing, 66(8), 1788-1793.

30

Avery, D. (1966). Hypertension secondary to renal artery stenosis. American Journal of Nursing, 66(12), 2685-2687.

31

Aagaard, G. N. (1973). Treatment of hypertension. American Journal of Nursing, 73(4), 620-623.

256

Griffith &
Madero32
Conte, Brandzel
& Whitehead33
Finnerty34
*3 C
Federspiel

1973

htn

pt learning
needs

1974

htn

pt learning
needs

1974
1962

htn

drug therapy

renin &
BP

Jessop36
Goerzen &
Abbott37

1976
1976

htn

Primary Article Author

Year of
Publication

Disease
Process

Diet

Teaching

Screening

X
X

19761985
CN(7)

32 Griffith,
33 Conte,

htn

Other

Pathology

Case
Study

Diagnostic/
Procedure/

BP Device/
BP

Surgery

Nrsg
Care

Drug
Therapy

Q&A

E. W., & Madero, B. (1973). Primary hypertension patients' learning needs. American Journal of Nursing, 73(4), 624-627.

A., Brandzel, M., & Whitehead, S. (1974). Group work with hypertensive patients. American Journal of Nursing, 74(5),

910-912.
34 Finnerty,
35

Federspiel, B. (1975). Renin and blood pressure. American Journal of Nursing, 75(9), 1462-1464.

36 Jessop,
37

F., JR. (1974). Aggressive drug therapy in accelerated hypertension. American Journal of Nursing, 74(12), 2176-2180.

P. (1976). Over and over. The Canadian Nurse, 7(5(10), 20-23.

Goerzen, J., & Abbott, S. D. (1976). Blood pressure measurement: Guidelines to accuracy. The Canadian Nurse, 76(10), 24-25.

257

Con'l
Educ

Equipment

Hartley38

1979

Haslam39
McCulley40
Milne &
Logan41
Hilton47

1979
1979
1979

Recordings

htn
disorders
htn

pregnancy

meds

htn

guidelines

htn

occupational
health

1982

htn

diabetes

1976

htn

teaching

1976

htn

equipment

X
X

AJN
(27)

Long, Winslow,
Sheuhing &
Callahan43
Corns44
38

-3Q

41

Hartley, B. (1979). Hypertensive disorders in pregnancy. The Canadian Nurse, 79(1), 42-50.
Haslam, P. (1979). Hypertension: Antihypertensives and how they work. The Canadian Nurse, 79(4), 26-31.

40 McCulley,

M. (1979). Hypertension: Questions and answers. The Canadian Nurse, 79(4), 24-25.

Milne, B., & Logan, A. (1979). Hypertension: Management in industy - An expanded role for nurses. The Canadian Nurse, 79(4),
21-23.

42 Hilton,

A. (1982). Does diabetic control really make a difference? The Canadian Nurse, 82(10), 49-52.

43 Long,

M. L., Winslow, E. H., Scheuhing, M. A., & Callahan, J. A. (1976). Hypertension: What patients need to know? American
Journal of Nursing, 76(5), 765-770.

258

X
X

Lancour45

1976

htn

BP
measurement

Primary Article Author

Year of
Publication

Disease
Process

Other

Pathology

Greenfield,
Grant &
Lieberman46
Robinson47

1976

htn

children

1976

htn

Woods4*

1976

Mitchell49
Foster &
Kousch50

1977
1978

htn

detection &
control
pulmonary
arterial
wedge
pressure ICU
teaching

htn

adherence

44 Corns,

Diagnostic/
Procedure/
Equipment

BP Device/
BP
Recordings

Surgery

Case
Study

Nrsg
Care

Drug
Therapy

Diet

Teaching

Screening

Q&A

R. H. (1976). Maintenance of blood pressure equipment. American Journal of Nursing, 76(5), 776-777.

45 Lancour,

J. (1976). How to avoid pitfalls in measuring blood pressure. American Journal of Nursing, 76(5), 773-775.

46 Greenfield,

D., Grant, R., & Lieberman, E. (1976). Children can have high blood pressure, too. American Journal of Nursing, 76(5),

770-772.
47 Robinson,

A. M. (1976). Detection and control of hypertension: Challenge to all nurses. American Journal of Nursing, 76(5), 778-

780.
48

Woods, S. L. (1976). Monitoring pulmonary artery pressures. American Journal of Nursing, 76(11), 1765-1771.

49 Mitchell,
50 Foster,

Con't
Educ

E. S. (1977). Protocol for teaching hypertensive patients. American Journal of Nursing, 77(5), 808-809.

S., & Kousch, D. C. (1978). Promoting patient adherence. American Journal of Nursing, 78(5), 829-832.

259

51

Smith51

1978

Giblin"

1978

htn

Primary Article Author

Year of
Publication

Ward, Bandy &

Fink53
Hill54
Weiner55
Moser56
Hill57

pulmonary
arterial
wedge
pressure 1CU
control

Disease
Process

Other

Pathology

1978

htn

teaching
adherence

1979
1980
1980
1982

htn

sodium

htn

control

htn

drug therapy

htn

BP
measurement

Case
Study

Nrsg
Care

Drug
Therapy

Diet

Teaching

Screening

Q&A

Diagnostic/
Procedure/
Equipment

BP Device/
BP
Recordincs

X
X

Surgery

Smith, R. N. (1978). Invasive pressure monitoring. American Journal of Nursing, 78( 9), 1514-1521.
Gibin, E. (1978). Controlling high blood pressure. American Journal of Nursing, 78(5), 824.

53 Ward,

G. W., Bandy, P., & Fink, J. W. (1978). Treating and counseling the hypertensive patient. American Journal of Nursing,
78(5), 824-828.

54

'

Hill, M. (1979). Helping the hypertensive patient control sodium intake. American Journal of Nursing, 79(5), 906-909.

55 Weiner,
56 Moser,

57

E. E. (1980). Nurse management of hypertension. American Journal of Nursing, 80(6), 1129.

M. (1980). Hypertension: How therapy works. American Journal of Nursing, 80(5), 937-941.

Hill, M. N. (1980). Hypertension: What can go wrong when you measure blood pressure. American Journal of Nursing, 80(5), 942.

260

Con't
Educ

Marcinek58

1980

htn

Schoof59
Flynn &
Moore60
Lowther &
Carter61

1980
1981

htn

pathophysiol
ogy
Q&A

htn

measurement

1981

htn

adherence

Primary Article Author

Year of
Publication

Disease
Process

Other

Pathology

Willis62

1982

htn

pregnancy

Willis & Sharp" 1982

Kelley64
1982

htn

pregnancy

htn

pregnancy

58 Marcinek,
59 Schoof,

X
X

X
X

Case
Study

Diagnostic/
Procedure/
Equipment

BP Device/
BP
Recordings

Surgery

Nrsg
Care

Drug
Therapy

Diet

Teaching

Screening

Q&A

M. B. (1980). Hypertension: What it does to the body. American Journal of Nursing, 80(5), 928-936.

C. S. (1980). Hypertension common questions patients ask. American Journal of Nursing, 80(5), 926-927.

Flynn, J. B., & Moore, P. V. (1981). Coin-operated sphygmomanometer. American Journal of Nursing, 81(3), 533-534.

61

Lowther, N. B., & Carter, V. D. (1981). How to increase compliance in hypertensives. American Journal of Nursing, 81(5), 963.
t

Willis, S. E. (1982). Hypertension in pregnancy: Pathophysiology. American Journal of Nursing, 82(5), 792-797.

63 Willis,

S. E., & Sharp, E. S. (1982). Hypertension in pregnancy: Prenatal detection and management. American Journal of Nursing,
82(5), 798-808.

64

X
X

60

c*\

Con't
Educ

Kelley, M. (1982). Maternal position and blood pressure during pregnancy and delivery. American Journal of Nursing, 82(5), 809812.

261

Kelley &
Mongiello65
Doyle66

1982

Doyle &
Sequeira67
Rossi &
Antman68
Dickerson69

1982

hln

1982

1983

htn

1983

Primary Article Author

Year of
Publication

Hollace,
Mittleman &
Mittleman70
Birdsall"

1984
1984

Disease
Process

htn

pregnancy

bypass graft
surgery
renal artery
dilation

drug therapy
Ca Channel
blockers
contraceptive
pill

Other

Pathology

cocaine

recordings

X
Case
Study

Diagnostic/
Procedure/
Equipment

BP Device/
BP
Recordincs

Surgery

Nrsg
Care

Drug
Therapy

Diet

Teaching

Screening

Q& A

65 Kelley,

M., & Mongiello, R. (1982). Hypertension in pregnancy: Labor, delivery and postpartum. American Journal of Nursing,
82(5), 813-822.

66

Doyle, J. E. (1982). Treating renovascular hypertension: Bypass graft surgery. American Journal of Nursing, 82(10), 1559-1562.

67 Doyle,

J. E., & Sequeira, J. C. (1982). Treating renovascular hypertension renal artery dilation. American Journal of Nursing,
82(10), 1563-1564.

jO

Rossi, L. P., & Antman, E. M. (1983). Calcium channel blockers: New treatment. American Journal of Nursing, 83(3), 382-387.

69 Dickerson,
70 Hollace,

J. (1983). The pill: A closer look. American Journal of Nursing, 83(10), 1392-1398.

S., Mittleman, R. & Mittleman, B. (1984). Cocaine. American Journal of Nursing, 84(9), 1092-1095.

262

Con't
Educ

19861995
CN (0)

No Articles
AJN
(10)

71

Birdsall, Pizzo
& Muller72
Brengman &
Burns73
McCormac74

1986

htn

orthostatic
change

1988

htn

pregnancy

1990
1991

htn

1992

htn

hemorrhagic
stroke
BP
measurement
risk factors

Hill & Grim75

Trottier &
Kochar76

Birdsall, C. (1984). How accurate are your blood pressures? American Journal of Nursing, 84(11), 1414.

72 Birdsall,

C., Pizzo, C., & Muller, B. (1985). What are orthostatic BP changes? American Journal of Nursing, 85(10), 1062.

73

Brengman, S. L., & Burns, M. K. (1988). Hypertensive crisis in L & D drugs to get the mother's BP out of the danger zone.
American Journal of Nursing, 88(3), 325A-328L.

74

McCormac, M. (1990). Managing hemorrhagic shock. American Journal of Nursing, 90(8), 22-27.

75Hill,
76

M. N., & Grim, C. M. (1991). How to take a precise blood pressure. American Journal of Nursing, 91(2), 38-42.

Trottier, D. J., & Kochar, M. S. (1992). Hypertension - high cholesterol: A dangerous synergy. American Journal of Nursing,
92(11), 40-43.

263

Primary Article Author

Year of
Publication

Disease
Process

Other

Nash77

1992

htn

1993
Trottier &
Kochar78
Van Buskirk & 1993
Gradman79
Nash & Jensen80 1994

htn

automated
measurement
isolated
systolic htn

Dubois &
Wilson81
Lilley &

htn

BP
monitoring

htn

surgery
patient

1997

htn

medication
losartan ARB

1996

htn

medication

Pathology

Case
Study

Diagnostic/
Procedure/
Equipment

BP Device/
BP
Recordings

Surgery

Nrsg
Care

Drug
Therapy

Diet

Teaching

Screening

Q&A

19952000
CN (1)
X

AJN
(7)

77

70

Nash, C. A. (1992). Clinical savvy. How do you test a digital sphygmomanometer? American Journal of Nursing, 92(1), 66-70.
Trottier, D. J., & Kochar, M. S. (1993). Managing isolated systolic hypertension. American Journal of Nursing, 93(10), 51-53.

79

Van Buskirk, M. C., & Gradman, A. H. (1993). Monitoring blood pressure in ambulatory patients. American Journal of Nursing,
93(6), 44-47.

80

Nash, C. A., & Jansen, P. L. (1994). When your surgical patient has hypertension. American Journal of Nursing, 94(12), 39-45.

81

Dubois, M. &Wilson, T. (1997). Losartan: A new antihypertensive drug. The Canadian Nurse, 97(6), 31-34.

264

Con't
Educ

Guanci82
Year of
Publication

O'HanlonNichols83
Cramer84
Barbarito85
Kozuh86

1997

Karch &
Karch87
Little88

82

ARB

Primary Article Author

Disease
Process

Other

Pathology

Case
Study

Diagnostic/
Procedure/
Equipment

BP Device/
BP
Recordincs

CV system

1997
1998
2000

htn

htn crisis

htn

epistaxis

htn

2000

htn

medications
NSAIDS
antihtn meds
special case

2000

htn

renovascular

Surgery

Nrsg
Care

Drag
Therapy

Diet

Teaching

Con't
Educ

T. (1997). The adult cardiovascular system. American Journal of Nursing, 97(12), 34-40.

84

Cramer, C. (1997). Hypertensive crisis from drug-food interaction. American Journal of Nursing, 97(5), 32.

85

Barbarito, C. (1998). Hypertension-induced epistaxis. American Journal of Nursing, 98(2), 48.

86

Kozuh, J. L. (2000). NSAIDs & antihypertensives: An unhappy union. American Journal of Nursing, 100(6), 40-43.

87

Karch, A., & Karch, F. (2000). When a blood pressure isn't routine. American Journal of Nursing, 100(3), 23.

88

Little, C. (2000). Renovascular hypertension. American Journal of Nursing, 100(2), 46-51.

265

Q&A

Lilley, L. L., & Guanci, R. (1996). Revisiting digoxin toxicity. American Journal of Nursing, 96(8), 14,

83 O'Hanlon-Nichols,

Screening

CHAPTER 7
CONCLUSION
In 2006-07 in Canada, nearly 6 million people or 1 in 5 adults were
diagnosed with hypertension.1 Numbers are expected to rise because, according to
the Canadian Hypertension Education Program (CHEP), programs have been
ineffective with prevention at a population level. High blood pressure over time
causes atherosclerosis, which is the main risk for premature death before the age
of 65 years.2 Billions of healthcare dollars have continued to be spent to treat
hypertension and the diseases directly caused by it, such as, stroke, dementia and
kidney failure. Despite the dollars being spent, these diseases are the leading
causes of premature death. Since hypertension is highly preventable, this does not
need to be the case.
More needs to be done. There are many avenues to improve and maintain
vascular health which are predicted to save healthcare dollars and improve the
health and quality of life of people in Canada and in the world. A healthy lifestyle
-5

is cornerstone, as it may prevent blood pressure from increasing and lowers high

Public Health Agency of Canada 2010. Report from the Canadian Chronic
Disease Surveillance System: Hypertension in Canada, 2010. Retrieved from:
http://www.phac-aspc.gc.ca/cd-mc/cvd-mcv/ccdss-snsmc-2010/index-eng.php
1 Canadian

Hypertension Recommendations Working Group. (2002). 2001

Canadian hypertension recommendations. What has changed? Canadian Family
Physician, 48, 1662-1664.
3 Whelton,

P., He, J., & Appel, L. (2002). Primary prevention of hypertension:

Clinical and public health advisory from the The National High Blood Pressure
Education Program. Journal of American Medical Association, 288, 1882-1888.
266

blood pressure.4 Being able to follow and achieve a healthy lifestyle comes with
many challenges for many people. Circumstances, including element whereby
individuals have little or no control within their lives and their environments play
a negative part on people's health, including blood pressure.
My journey with this dissertation was to explore avenues of possibility, a
place of action to offer at least at the research level if not to implement a future
intervention plan of action for those adults with hypertension, and those with
hypertension and diabetes. Recognizing that blood pressure can be measured and
that high blood pressure is treatable there are still 1 in 3 people with hypertension
that is uncontrolled; and 1 in 5 people with high blood pressure who are not aware
of their condition.
More specifically, adults with diagnosed diabetes in 2006-07 were
diagnosed with hypertension 3 times more often than those without diabetes.5
Adults with diagnosed hypertension were diagnosed with diabetes 6 times more
often than those without hypertension.6 Twenty three percent of adults diagnosed
with hypertension also had diabetes in 2006-07.7 Diabetes increases the
cardiovascular risk, and unfortunately, few people with hypertension and diabetes

4 Elmer,

P.J., Obarzanke, E., & Vollmer, V.M.(2006). Effects of comprehensive

lifestyle modification on diet, weight, physical fitness, and blood pressure control:
18 month results of a randomized trial. Annuals of Internal Medicine, 144, 485495.
5 Public Health Agency of Canada 2010. Ibid.
6

Ibid.

Ibid.
267

have both conditions treated adequately, despite the recognition that tighter
control of both is required.8 There is no doubt that an unhealthy lifestyle of
people in most developed societies contributes to a high incidence of
hypertension, diabetes and cardiovascular disease.
How the Papers are Connected Together
The manuscripts in this dissertation are connected and bridge into each
other. The first manuscript 1) addresses from a systematic review of the literature
the significant risk of hypertension for those with diabetes. Much of the health
risk associated with diabetes is due to coexistent hypertension. The key
suggestion for moving forward was that a novel multidisciplinary approach
needed to be developed and tested. The second manuscript 2) identifies
pharmacists as one of the possible members of the healthcare team who could, in
collaboration with other health professionals, play a role in identifying, screening
and management of individuals with hypertension. The third manuscript 3)
describes the design of a unique program of community pharmacist and nurse
intervention, within a multidisciplinary team, to improve the management of BP
in patients with diabetes with manuscript 4) reporting the findings of SCRJP-HTN
the randomized controlled trial which enrolled patients with diabetes and a BP of
>130/80 mm Hg to determine the efficacy of a community-based
multidisciplinary screening and intervention program on BP control in patients

Lonati, C. Morganti, A. & Comarella, L. (2008). Prevalence of type 2 diabetes

among patients with hypertension under the care of 30 Italian clinics of
hypertension: Results of the (Iper)tensione and (dia)bete study. Journal of
Hypertension, 26, 1801-1808.
268

with diabetes. The final manuscript 5) provides a 55 year historic perspective and
understanding the role nurses have played in blood pressure measurement and
management, with reflection retrospectively on the healthcare organization and
nursing education of that time period.
Main Conclusions
Chapter 2:
McLean, D.L., Simpson, S.H., McAlister, F.A., & Tsuyuki, R.T. (2006).
Treatment and blood pressure control in 47,964 people with diabetes and
hypertension: A systematic review of observational studies. Canadian Journal of
Cardiology, 22, 855-860.
Many patients with diabetes also have hypertension, greatly increasing
their risk for cardiovascular disease. A total of 44 studies were systematically
reviewed from 1990-2004 (77,649 subjects with diabetes, 47,964 (62%) of whom
also had hypertension) and included. While 83% (range 32% to 100%) of those
with hypertension received drug therapy, only 12% (range 6% to 30%) had their
blood pressure controlled to < 130/85 mm Hg. While blood pressure control rates
differed by definition of control (those studies with the least stringent definition
for BP control, < 160/90 mm Hg, reported mean control rates of 37%), blood
pressure treatment rates and control rates did not differ appreciably between
countries or health care settings. Therefore, less than 1 in 8 people with diabetes
and hypertension have adequately controlled blood pressure (controlled to
recommended levels <130/80 mmHg), with remarkable uniformity across studies
conducted in a variety of settings. There is an urgent need for multidisciplinary
community-based approaches to manage these high-risk patients. Overall, these

269

results demonstrate the failure of our healthcare system to adequately address the
significant risk of hypertension for those with diabetes.
Chapter 3:
McLean, D.L., Bungard, TJ., Hui, C., & Tsuyuki, R.T. (2006). Community
pharmacists practices in hypertension management. Canadian Pharmacy
Journal, 139, 38-44.
A cross-sectional, observational study of pharmacists' practices using
unannounced standardized patients (SPs) with hypertension using a random
stratified sample of 101 community pharmacies in Edmonton was completed in
effect to determine the current practices of community pharmacists in the
management of hypertension. The pharmacists took reasonable steps to determine
the accuracy of the BP measurement, explain the diagnosis of hypertension and
refer to a physician. Major deficiencies in medical history taking and assessment
of target BP were observed. Main findings included:
Knowledge of Current BP Target Values: Of the 101 community pharmacists
who were visited by the SPs, 69% offered a general BP target value to the SPs
(<120/80), with 7% stating the correct target BP value for this scenario (<140/90).
Only 14% requested enough patient history to properly determine target BP.
Review of Patient Medical History: Few pharmacists questioned the SPs medical
history (7%), their medication profile (16%), a family history of CVD (19%),
previous elevated BP readings (20%), or a previous diagnosis of hypertension
(22%).

270

Accuracy/Confirmation of BP Reading: 53% of pharmacists inquired about the

conditions under which the BP was taken; 39% of pharmacists offered to re-take
BP.
Education/Lifestyle Measures: Pharmacists discussed: how hypertension is
diagnosed (76%), what hypertension was (46%), how to take a BP properly
(46%), the impact of lifestyle measures on BP (60%), and, gave supplemental
educational materials (29%).
Referral: 83% of pharmacists advised the SPs to make an appointment to see a
physician.
Chapter 4:
McLean , D.L., McAlister, F.A., Johnson, J.A., King, K.M., Jones, C.A., &
Tsuyuki, R.T. (2006). Improving blood pressure management in patients with
diabetes: The design of the SCRJP-HTN Study. Canadian Pharmacy Journal,
139, 26-29.
When this paper was published, SCRJP-HTN was an ongoing,
randomized, multicentre trial that evaluated a unique program of community
pharmacist and nurse intervention, within a multidisciplinary team, to improve the
management of BP in patients with diabetes. The start of the trial was May 2005.
The paper provided a brief summary of the design of the trial including: methods,
inclusion and exclusion criteria, patient recruitment strategies, randomization, and
outcome measures are outlined in the paper. The authors recognize that treatment
and control of hypertension is a major public health problem and a key goal of the
Canadian Hypertension Society, now currently referred to as the Canadian
Hypertension Education Program (CHEP).

271

Chapter 5:
McLean , D.L., McAlister, F.A., Johnson, J.A., King, K.M., Jones, C.A., &
Tsuyuki, R.T. (2008). A randomized trial of the effect of community pharmacist
and nurse care on improving blood pressure management in patients with diabetes
mellitus: Study of Cardiovascular Risk Intervention (SCRIP-//77V). Archives of
Internal Medicine, 168, 2355-2361.

The main findings were to determine the efficacy of a community-based

multidisciplinary screening and intervention program on BP control in patients
with diabetes. SCRW-HTN was a randomized controlled trial that enrolled
patients with diabetes and a BP of >130/80 mm Hg using the BPTru device on 2
consecutive visits 2 weeks apart. Intervention patients received care from a nurse
and pharmacist team which included: a BP wallet card with recorded BP
measures, cardiovascular risk reduction education/counselling, a hypertension
education pamphlet, referral to their primary care physician for further
assessment/management, and provision to their primary care physicians of one
page evidence summaries reinforcing the guideline recommendations for the
treatment of hypertension in individuals with diabetes, endorsed by local opinion
leaders. Control arm patients received a BP wallet card, a pamphlet on diabetes,
general diabetes advice and usual care by their physician with no follow-up visits.
The primary outcome measure was the difference in change in systolic BP
between the two groups at 6 months. A total of 227 patients were enrolled, mean
(SD) age was 65 (12.1) years, 60% were male and mean baseline BP was 141.2
(13.9) / 77.3 (8.9) mm Hg. The intervention group had a 5.6 (2.1 standard error)
mm Hg greater reduction in systolic BP at 6 months compared to control
(p=0.008). In the subgroup of 22 patients with systolic BP>160 mm Hg at
272

baseline, BP was reduced by 25.3 (9.2 standard error) mm Hg more in

intervention patients than in controls (p = 0.0136). At 6 months, 33% of control
patients achieved target BP, compared to 47% of intervention patients (p=0.042).
Patients with diabetes and hypertension, who received an intervention based nurse
and pharmacist team care that included opinion leader endorsed evidence
summaries for primary care physicians resulted in a clinically significant
improvement in BP.
Chapter 6:
(Unpublished manuscript) A historical review of elected nursing literature on
blood pressure measurement between 1945 and 2000.
A thorough review and historical critique of writings about blood pressure
taking and management in selected nursing literature (The Canadian Nurse and
The American Journal of Nursing) from 1945 to 2000 was conducted. This
review sheds light on the role(s) played by nurses in blood pressure measurement
and management and provides insight that can be useful in shaping future
directions in respect to nursing practice, nursing research and nursing education.
The purpose of this historical research project was to undertake a beginning study
of the history of blood pressure measurement in nursing. Findings throughout the
55 years reviewed were definitely linked to the organization of healthcare and
mirrored nursing education of the day. Registered nurses were typically the
disseminators of the information about hypertension, especially lifestyle
management options to patients and their families. Nurses were seen as being
focused on preventing hypertension, detecting and screening blood pressures
earlier and following up on treatments. Interestingly, questions surrounding, 1)
273

what values determine a normal blood pressure reading, and 2) what was the best
way to measure blood pressure accurately were seen in the literature 55 years ago
are still currently being debated in the nursing literature today.
Future Nursing Implications
Cumulatively, these papers add to the body of nursing knowledge. They
clearly provide avenues for furthering nursing practice and nursing research, and
consequently to further contribute to the development of nursing knowledge.
Hypertension is a common risk factor for premature disability and death.9 It is a
leading cause of stroke, congestive heart failure, and other cardiovascular
diseases. Stroke deaths parallel the prevalence of hypertension. Many people with
hypertension are unaware of their condition, and those that are aware are often
untreated or undertreated.10 Hypertension is a global issue and has led the World
Health Organization to declare that suboptimal blood pressure is the leading risk
for death in women and the second leading risk for death in men in developed
countries.11

Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. (2005).

Global burden of hypertension: analysis of worldwide data. Lancet, 365, 217-223.
10 Wolf-Maier,

K., Cooper, R.S., Banegas, J.R., Giampaoli, S., Hense, H.W.,

Joffres, M., Kastarinen, M., Poulter, N., Primatesta, P., Rodriguez-Artalejo, F.,
Stegmayr, B., Thamm, M., Tuomilehto, J., Vanuzzo, D., & Vescio, .F. (2003).
Hypertension prevalence and blood pressure levels in 6 European countries,
Canada, and the United States. Journal of American Medical Association, 289,
2363-2369.
11

World Health Organization. The World Health Report 2002. Geneva,

Switzerland: World Health Organization.
274

Canada had nearly 6 million people diagnosed with hypertension in 200607.12 The number is expected to rise as prevention at the population level has
largely been ineffective, therefore, leaving high blood pressure to be almost
inevitable with advancing age. Healthcare systems across Canada are spending
dollars to treat hypertension and the diseases directly attributed to it (stroke, heart
disease, dementia and kidney disease). Almost half of all people in Canada over
age 60 are taking drugs to control blood pressure. Antihypertensive drugs cost
millions and each subsequent year medication costs rise. Approximately one half
of all direct medical costs of cardiovascular disease are due to hypertension and it
related diseases. Despite the investment, these diseases are the leading causes of
premature death. This should not be the case, as hypertension is highly
preventable. Nurses can play a key role!
Nurses have an important role to play in the detection and diagnosis of
hypertension. Routinely, they are responsible for obtaining, recording and
reporting a patient's blood pressure. They also share blood pressure results with
the patient and other members of the healthcare team. Nurses need to take every
appropriate opportunity to assess the blood pressure in order to help facilitate
early detection of hypertension.
Nurses must also use correct technique, appropriate cuff size and
calibrated equipment when assessing a patient's blood pressure. Utilizing a cuff
that is too small leads to a significant overestimate of the blood pressure. When

12

Public Health Agency of Canada 2010. Ibid.

275

the cuff is correctly sized, it should encircle 80-100% of the arm. Regular
calibration is important in order to achieve accurate blood pressure readings.
Nursing Practice Recommendations
The increasing rates of hypertension parallels growing older, overweight
and a sedentary Canadian population. The lifetime risk of hypertension is 90%.13
Despite, established recommendations for prevention and treatment, most
Canadians either are unaware they have high blood pressure or do not receive
treatment to established blood pressure targets. Healthy lifestyles are at the heart
of healthy blood pressure. A healthy lifestyle can prevent blood pressure from
rising and can lower high blood pressure. Consistent with the observations and
findings from our manuscripts 4 and 5 (chapters 5 and 6) our research suggests
that despite evidence that lowering blood pressure lowers the risk of
cardiovascular events and death, the management of hypertension remains
suboptimal. In particular and specific to clinical practice recommendations, our
research suggests there is an inconsistent application of the clinical practice
guidelines, specifically in Canada the Canadian Hypertension Education Program
recommendations to nurses and other health care professionals.
Clinical practice guidelines are one means to close gaps between evidence
and usual practice. The format of these guidelines and the application of the
guidelines to specific work environments are crucial to their success. It has been
recognized in the literature that clinicians and health care professionals

13 Vasan,

R., Beiser, A., Seshadri ,S., Larson, M., Kannel, W. & D'Agostino, R.B.
(2002).Ibid.
276

"consistently identified endorsement by a respected colleague or organization and

the user-friendliness of a guideline as the most import factors in determining
acceptability, with short and concise formats being favored."14 Current guidelines
have many shortcomings, such as the failure to address clinically relevant issues,
format issues, lack of implementations strategies, and failure to include patientclinician values, which in turn, limit their impact in the clinical area.15
It would be recommended that the guidelines or information not be only
distributed, such as through a publication in a journal, but instead, the guidelines
also need to be 'implemented' into practice which would involve overcoming
specific barriers to change. Specific implementation strategies are important as
we recognize that often practice is unlikely to change by traditional continuing
education seminars, conferences, and mailings of guidelines.16
The Canadian Hypertension Education Program (CHEP) guidelines have
been aware of these shortcomings discussed above and most recent versions and
knowledge translation programs through CHEP take into account these
shortcomings. For example, educational sessions about the guidelines are often
held with local opinion leaders or face -to-face educators in different venues
across the country in major centres.
14

Hayward, R., Guyatt, G., Moore, K., McKibbon, K., & Carter, A. (1997).
Canadian physicians' attitudes about and preferences regarding clinical practice
guidelines. Canadian Medical Association Journal, 156 (12), 1715-1723.
15 Cabana,

M., Rand, C., Powe, N., Wu, A., Wilson, M.,& Abboud, P. (1999).
Why don't physicians follow clinical practice guidelines? A framework for
improvement. Journal of American Medical Association. 282, 1458-1465.
16 Oxman,

A., Thomson, M., Davis, D., Haynes, R. (1995). No magic bullets: A

systematic review of 102 trials of interventions to improve professional practice.
Canadian Medical Association Journal, 753(10), 1423-1431.
277

Current clinical practice regarding management of hypertension needs to

be changed to improve knowledge, awareness, and impact on lifestyle choices that
impact hypertension. Future strategies must include health professionals, such as
nurses to be armed with proper educational tools and supports to change
hypertension behavior among those high risk patients.
A collaborative practice model within an interdisciplinary team should
encourage hypertension care and promote the nurses' role in hypertension
management. Nurses, nurse practitioners, physicians, pharmacists, dieticians, and
other health care professionals are often important and trusted contacts, with a key
role in informing people about high blood pressure and its risks and treatment.
Any member of the health care team can proceed with the identification of
patients who are at risk for high blood pressure. By simply ascertaining a patient's
blood pressure reading and history in relation to medical, family, and general
health, they can provide crucial health promotional information. Nurses and nurse
practitioners all have important roles and focus on high blood pressure detection,
patient assessment with the development of a collaborative treatment plan,
promotion of adherence and ongoing follow-up. Although it is beyond the scope
of this chapter to discuss the long holistic tradition found in the discipline of
nursing, it is important to state that it gives a unique flavor to the care provided by
nurses in hypertension management. In addition, nurses and nurse practitioners
along with pharmacists and physicians have a role in monitoring medication
treatment and can respond to any reported side effects or difficulty with regard to
medication use.

278

Nurses are an influential workforce group within health care and therefore
they can have a substantial impact by utilizing their health promotion role.
However, the interdisciplinary team has an important contribution to make
regarding hypertension care through collaborative preventative health education
strategies and health promotion programs. An interdisciplinary approach to
hypertension management should improve patient assessment and outcome. In
particular it could play a critical role in supporting a number of preventative
measures and lifestyle modifications, as well identifying and treating those at risk
of coronary heart disease.
Nursing Research Recommendations
The Canadian Hypertension Education Program (CHEP) focus is to reduce
the burden of cardiovascular disease in Canada through hypertension
management. In Canada, specifically in Ontario, rates of hypertension have
improved but at least 30% of Ontarians IB years of age or older were still either
uncontrolled or not identified.17 Consistent with the observations and findings
from our manuscripts 1, 2 and 4 (chapters 2, 3 and 5) it would be beneficial for
nurses to acknowledge the existing care gap in the management of hypertension
and encourage primary health care professionals to further integrate and
coordinate their efforts with the ultimate goal of decreasing the burden of
cardiovascular disease. Given the prevalence of hypertension and the large patient
care demands already placed on family physicians, one solution for the screening
17

Leenen, F.H., Dumais, J., Mclnnis, N.H., Turton, P., Stratychuk, L, & Nemeth,
K., (2008). Results of the Ontario survey on the prevalence and control of
hypertension. Canadian Medical Association Journal, 178( 11):1441-1449.
279

and care of patients with hypertension is to take full advantage of the special
knowledge, skills, and abilities of other members of the health care team,
specifically nurses and nurse practitioners, but including other health care
professionals.
Therefore, research projects that accent the collaboration of various health
care professionals can increase clarity regarding the role of each professional
group in the management of patients with hypertension. Given the
multidisciplinary nature of CHEP, it is important to explore interdisciplinary
collaboration and how it could be further enhanced. Currently, there is little data
to demonstrate if or how collaborative care affects patient outcomes; however, it
seems intuitive that hypertension control will be enhanced if all team members'
special skill sets are used to the fullest. The family physician has traditionally
been central to the coordination of care for the patient. The changing scope of
practice for nurses, nurse practitioners, and pharmacists, however, is encouraging
their greater involvement in chronic disease management and care of patients. The
combination of increasing numbers of patients with hypertension together with
the demands on family physicians suggests that collaboration is needed. Although
interdisciplinary teams (such as primary care networks or family health teams)
either exist or are being created to incorporate other health professionals into
primary health care, this idea is still underdeveloped and only affects a few
patients with hypertension. Instead, much of the care is still happening at the
traditional family practice level where the infrastructure and financial resources to
facilitate routine interdisciplinary care are not available.

280

Collaborative care can improve care by sharing responsibility, with the

common goal of improving hypertension management in Canada. In doing so, the
goal would be to identify gaps in our current knowledge, which in turn would lead
to further research. The encouragement of interdisciplinary collaboration will
encourage further research aimed at determining whether such collaboration
results enhances outcomes for patients with hypertension. Recognizing there are
overlapping roles among physicians, nurses, and pharmacists; each group has a
unique skill set which can contribute to better patient management. Questions
remain in how best this can be put to work to benefit patient outcomes with
regards to hypertension management.

The 2012 CHEP guidelines promote empowering patients to be more

involved in their own self-management. Successfully achieving this requires the
combined efforts of all primary health care providers. Communication among
team members will be important, so that treatment goals are clearly understood,
aligned, and reinforced by all team members. Working together and maximizing
the benefits of a collaborative, multidisciplinary approach to hypertension
management would lead to better patient outcomes.

Recommendations for Continuing Education

Nurses have contributed to the success that blood pressure can be
objectively measured. Nurses working with adults with hypertension need to
have ongoing professional development and continuing education with formalized
workplace orientations to keep abreast of knowledge and skills regarding

281

hypertension management. It is essential that nurses receive continual education

specifically on hypertension prevention and treatment.
Recognizing that almost 1 in 3 people with hypertension have
uncontrolled blood pressure. There is evidence that healthcare professionals,
nurses amongst them, are still misdiagnosing and not detecting those with
hypertension, as 1 in 5 people with high blood pressure are not aware of their
condition.
Therefore, patients with hypertension need regular follow up from nurses
who are knowledgeable and skilled about hypertension and its management. This
is consistent with the observations and our findings from manuscripts 2 and 4
(chapters 3 and 5) where our research identified that nurses (and other health care
professionals) do not always follow hypertension management guidelines and that
current nursing practice patterns represent a barrier to the treatment and control of
hypertension.
Continuing education ought to be a two-fold approach including selfdirected initiatives, which could include reading and persona] research and
structured in-service education programs. Professional organizations locally and
nationally can play a critical role in hypertension education delivery. In hospital
educators and nurse practitioners could perhaps consider developing and
providing in-service study days on hypertension. A coordinated national
multidisciplinary approach is suggested by the Canadian Hypertension Education

282

Program. A multidisciplinary approach is widely advocated in international

literature to promote further collaborative practice.
More specifically in Canada, the Canadian Hypertension Education
Program (CHEP) was formed in 1999 and was developed because of the low rate
of treatment of individuals who were aware of having hypertension. CHEP was
an effort to improve the treatment and control of hypertension in Canada by
healthcare professionals.18 This program annually updates evidence-based
hypertension management recommendations and has a knowledge translation
program to help healthcare professionals to adopt and implement these
recommendations.
The CHEP is a program run by volunteers that is specifically designed to
influence the clinical practice provided by healthcare professionals. CHEP is
unique in that they have annually updated recommendations that involve most
national clinical hypertension specialists in Canada19 Annual updated educational
tools are available online and through an expanding dissemination program.20
Workshop-based educational sessions are held in most major cities by local and
national opinion leaders. Many of the sessions are based on programs that directly

18 Campbell,

N.C., Nagpal, S., & Drouin, D. (2001). Heart and Stroke Foundation
of Canada. Implementing hypertension recommendations. Canadian Journal of
Cardiology, 17, 851-856.
19 McAlister, F.A. The Canadian Hypertension Education Program-a unique
Canadian initiative. (2006). Canadian Journal of Cardiology, 22, 559-564.
20 Drouin,

D., Campbell, N.R.,& Kaczorowski, J.(2006). Implementation of

recommendations on hypertension: The Canadian Hypertension Education
Program. Canadian Journal of Cardiology, 22, 595-598.
283

use CHEP educational material or programs endorsed by CHEP. "Train-thetrainer" sessions have also been used. CHEP published periodic updates in >22
clinical journals per year since 1999.21 The summaries have emphasized a limited
(5-6) number of key learning points. Many different learning tools (posters,
DVDs, applications for iphones, summaries, 1-page handouts, pocket cards, text
books, and power point slide sets) have been made to meet the individualized
needs of different clinicians. They are currently available at Hypertension Canada
(http://www.hypertension.ca). The use of multiple strategies has been shown to be
more effective than any one single strategy.
Nurses are responsible to ensure that they have the knowledge, skill and
judgment necessary to provide safe and effective hypertension care. It would be
important for nurses to make efforts to attend continuing education opportunities
in their areas to keep abreast of current recommendations. The programs should
be delivered by trained providers/volunteers from the "train-the trainer" programs.
They should be offered in settings that are convenient, including workplaces,
where incentives should be developed to help create and maintain these education
programs, ie., telemedicine. Outpatient clinics, such as nurses in cardiology and
medicine clinics need to be aware of current guidelines and serve as resources to
staff nurses. The Canadian Nurse is received by all registered nurses working in
Canada and could publish annual updates and summaries in the journal.
However, to date, The Canadian Nurse has not been willing to publish these
materials and nurses have not received updates and information for two years.

21

Ibid.
284

Other options would include the CNA 'nurseone' website, provincial nursing
association websites and dispensing information to all nursing programs in
Canada. Nurses need to be aware of CHEP so that they can go online to the
website, download the application for electronic devices, or to become involved
and volunteer with CHEP.
Limitations
These series of papers have a few limitations that need to be taken into account
when interpreting the results. A limitation is the generalization of these results.
Each study sample was site and country specific, with a limited sample size. The
fifth a final historical study was limited to only two specific journals. However
the novelty of the findings will be of interest to practitioners in this area and could
be further strengthened by study replication. Despite the impressive recent
improvements in blood pressure control rates in Canada, significant gaps are still
evident between what is achievable in blood pressure control under clinical trial
settings and what is achieved in general populations. More effective efforts - both
population-based and patient-based - need to be identified to close that gap.
In Conclusion
This dissertation contributes to the knowledge base of nursing
professionals involved with the awareness, treatment and control of hypertension.
Utilizing a multidisciplinary approach to hypertension management to deliver care
and consistent methods of treatment delivery is key to facilitating positive patient
outcomes. I believe the reflection and critical analysis of selected nursing
285

literature during the period of 1945-2000 has shed light on past technological
trends and the past nursing role in hypertension with regards to nurses and blood
pressure measurement and management. This in fact, gives reference to today's
practice of nurses and nurse practitioners and their approach to blood pressure
management.
I hope that registered nurses and nurse practitioners will acknowledge the
findings and increase their awareness of their practices pertaining to hypertension
management. Finally, I am confident that other researchers can use the study
outcomes within this dissertation to entice further inquiry to increase the potential,
both currently and in the future, to facilitate positive patient outcomes in the
management of hypertension.

286

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