ANSWER
Nursing in hypertension care includes lifestyle change counseling, blood pressure measurement, and acting as a translator for the physician. Changing one’s lifestyle entails self-care for the patient. Given the scarcity of research and guidelines for nurses, a middle-range nursing theory in hypertension care was developed to guide nurses in their practice, improve patient nursing, and design studies to investigate nursing in hypertension care. The patient (attitude and beliefs about health and illness, autonomy, personality and traits, level of perceived vulnerability, hardiness, sense of coherence, locus of control, self-efficacy, and access to social support and network), and nursing concepts are presented (applying theories and models for behavioral change in the consultation and using counseling skills, patient advocacy, empowerment, professional knowledge, and health education, and supporting the patient). The consultation concepts (communication, shared decision-making, concordance, coping, Adherence, and self-care) are then integrated with Orem’s nursing theory. The theory’s clinical and research implications are discussed.
ORDER WITH US AND GET FULL ASSIGNMENT HELP FOR THIS QUESTION AND ANY OTHER ASSIGNMENTS (PLAGIARISM FREE)
Visit: 1. Introduction

Nursing in hypertension care has been shown to include lifestyle change counseling, blood pressure measurement, and acting as a translator for the physician [1]. Hong [2] provides a more detailed description of the nursing interventions. Blood pressure is reduced when a nurse works as part of a team with other healthcare professionals to care for a hypertensive patient [1]. This is due to a change in lifestyle, better medication adherence, and more frequent follow-up visits. In this context, changing one’s lifestyle and taking medications imply performing self-care.

Patients with hypertension during pregnancy or other severe diseases are typically managed in specialized care, whereas adult patients with hypertension are typically contained in primary care. Team-based care is preferable so that patients are met consistently. Aside from the nurse and physician, the team may include a physiotherapist or other professionals. Team members must be aware that not many patients can identify any apparent symptoms associated with hypertension [3]; elevated blood pressure is most often detected when a patient is being treated for another ailment. The discovery may surprise the patients, and being asked to perform self-care to adjust some figures on paper may be perceived as a real challenge. The nurse who sees the patient during primary care clinic visits is assumed to take a health-promotional, holistic, and psychosocial approach to assist the patients in achieving blood pressure control.

Even though nurses worldwide treat hypertensive patients, there are few theoretical guidelines for nurses available. There are general self-care and self-management theories for chronic illnesses, but none for hypertension. A literature review revealed a theoretical framework for studying medication adherence in Chinese immigrants [4]. A study that aimed to determine the effectiveness of a nurse’s caring relationship according to Watson’s Caring Model of blood pressure and quality of life [5], one that evaluated Orem’s nursing self-care theory in hypertensive women (in Portuguese) [6, and another that presented the middle-range idea of Attentively Embracing Story for practice implications with a client who had hypertension [7] were the only papers with theoretical aspects found. Because these theoretical frameworks did not encompass all aspects of nursing in hypertension care, it was determined that a middle-range theory of nursing in hypertension care was required to guide nurses in their practice, develop patient nursing, and design studies to investigate nursing in hypertension care. Previous work has been presented in developing the proposed theory [8, 9].

Visit: 2. Methodology
A middle-range theory will be developed inductively from research and practice [10] and can be combined with existing approaches [11]. Other disciplines’ ideas and practice research can also be integrated. With this context in mind, a middle-range theory of nursing in hypertension care (Figure 1) is proposed, which includes concepts related to the patient, nursing in hypertension care, the encounter between the patient and the nurse, the expected outcomes of this encounter, and the integration of an existing grand theory of nursing.

An external file containing a picture, illustration, or other data.
The object name is IJHY2018-2858253.001.jpg Figure 1 The constructed middle-range theory for nursing management of hypertension patients, with concepts involved in lifestyle counseling and Orem’s self-care deficit theory of nursing applied (shown in italics).

An extensive literature search and review were conducted during the development process of the proposed theory to find concepts that mirrored counseling on lifestyle change and taking medications to assist the patient in self-care. Blood pressure measurement was omitted because it must be done in a standardized manner that is well-defined in hypertension guidelines. In terms of nursing in general, pieces from other disciplines such as medicine, sociology, and psychology fit in well; the databases PubMed, Cinahl, PsycINFO, SocSci, and Eric, as well as the Cochrane Library, were used in the literature search in 2001, 2005, and 2014. (Table 1). The massive output of the initial investigations in 2001 was reduced by a thorough review to determine what might be relevant for nursing in hypertension care. A variety of keywords (both MeSH terms and free text keywords) were used to find all pertinent papers that could provide any new aspects to be taken into account when elucidating what might be of concern for the patient and nurse in hypertension care: Adaptation, attitude, communication, compliance, coping, counseling, educational models, emotions, empowerment, health behavior, health education, health promotion, hypertension, lifestyle, motivation, nurse-patient relation In each database, and the words were used separately as well as combined in the same structured manner. The procedure was documented so the literature search could be repeated or refined.

Table 1 shows the results of searches conducted in various databases over the years. The investigations in 2001 began with the year the database was established.

2001 2005 2014
Database (covering years) (covering years)
The number of relevant discoveries
Database (covering years) (covering years)
The number of relevant findings
Database (covering years) (covering years)
The number of appropriate conclusions
PubMed (1966–2001) (1966–2001)
PubMed has 520 results (2002–2005)
PubMed 15 (2006–2014)
Cinahl 4 (1982–2001)
Cinahl 326 (2002–2005)
Cinahl 11 (2006–2014)
PsycINFO 4 (1967–2001)
298
PsycINFO (2002–2005) (2002–2005)
PsycINFO 15 (2006–2014)
2 Sociology (1986–2001)
SocSci 147 (2002–2005)
3 Social Sciences (2006–2014)
2
Eric (1966–2001) (1966–2001)
0 Eric (2002–2005) (2002–2005)
0 Eric (2006–2014) (2006–2014)
0
Launch in a new window
Reference lists were also used during the review to locate cited original literature. A drawing was made while reviewing the findings from papers, books, and dissertations to get an overview of the relationships between the concepts and the way or order they fit in. The proposed model was gradually constructed, with the images relevant to the patient and nurse arranged to form the model (Figure 1). The background for selecting keywords included several years of nursing studies in hypertension care while obtaining bachelor’s, master’s, and doctoral degrees. Furthermore, my personal experience as a primary care advanced nurse running a nurse-led hypertension clinic was critical. The theory was first presented as part of the author’s thesis framework, and it was decided some years later to rewrite the framework into a paper to be distributed among colleagues for discussion and review. Some of the concepts included are well-defined, but others need to be developed and defined, and they are also not used in research with hypertensive patients. The proposed theory is still in development, and more work is required. Based on these assumptions, the theory is presented.

Go to: 3. Concept Definitions
The paper presents research findings from each concept whenever a study involving hypertensive patients is discovered, regardless of the study’s age. First, patient concepts are presented, followed by nursing concepts in hypertension care. In these consultation concepts, the patient and nurse meet, integrate with Orem’s self-care deficit theory, and finally, the expected outcome (Figure 1).

3.1. Patient-Related Concepts
The concepts presented here are related to the patient’s ability, disposition, and willingness to change their lifestyle and take medications. It is essential to consider factors such as attitude and beliefs about health and illness, autonomy, personality and traits, perceived vulnerability, hardiness, sense of coherence, locus of control, self-efficacy, and access to social support and network.

3.1.1. Health and Sickness Attitudes and Beliefs A value is a personal belief about a particular idea or object’s worth, desirability, goodness, truth, and beauty [13]. An attitude is a psychological tendency expressed by evaluating a separate entity with some degree of favor or disfavor [12]. Because one’s concept of health is linked to one’s belief systems, no patient will follow instructions they do not believe will work or will work towards a goal they do not value. As a result, the patient’s values can be used to decide whether to implement lifestyle changes. Patients have beliefs about whether hypertension is a disease or not, whether the drug is a necessary evil or a help, how the drug should be taken and its effects [14], and their perceptions of the cause of hypertension, symptoms, and treatment beliefs can all influence their self-management [15]. Assessing these attitudes and ideas is an essential first step in developing a patient care plan [16].
3.1.2. Independence Self-government is defined as autonomy; people are autonomous to the extent that they can control their own lives [17]. The hypertensive patient is faced with demands to make lifelong lifestyle changes. As a result, the decision must be made autonomously [18]; otherwise, the maintenance of the new behavior is likely to decrease. It is, therefore, critical for nurses to determine whether the patient is sufficiently autonomous, which means that the patient can understand and retain information relevant to the decision at hand, believe the data, and weigh the information to make a decision.
3.1.3 Personality and Characteristics A personality is a combination of two or more traits [19] that influence our behavior in various situations and when it comes to changing our lifestyle. Extraversion (active, assertive, enthusiastic), agreeableness (appreciative, forgiving, generous), conscientiousness (efficient, organized, responsible), neuroticism (anxious, tense, worrying), and openness are the dimensions of traits (artistic, imaginative, insightful). States or moods are one-of-a-kind occurrences. Older adults over 65 who score high on conscientiousness perceive themselves to have health competence, which is strongly related to health behaviors (exercise, dietary/health information, and relaxation/social Support) [20]. A high conscientiousness score may also promote self-control skills, which can affect treatment adherence [21]. The aggressive pursuit of more and more in less and less time appears to increase blood pressure reactivity to external stressors in people with mild hypertension [22].
Vulnerability 3.1.4 In the nursing literature, vulnerability is defined as an externally evaluated risk (by someone outside the experience) or as an experiential state (as understood by the person herself) [23]. Individuals’ perceived vulnerability is created by their perceptions of themselves, challenges, and resources to overcome such challenges. The level of vulnerability varies depending on the level of environmental Support and personal resources [24]. Vulnerability can cause feelings of not belonging, helplessness, fear, anger, uncertainty, loss of control, isolation, anxiety/worry, and powerlessness, among other things. The likelihood of positive action to change behavior is determined by whether the individual perceives himself as healthy, chronically ill, or suffering from an acute illness [25]. It is concluded that a hypertensive person can be classified as either well or sick chronically, implying that motivation to learn about any aspect of healthcare is based on acceptance of personal responsibility for one’s health. The individual does not feel threatened or vulnerable.
3.1.5. Toughness Hardiness was first introduced as a personality trait with three dimensions: commitment (active participation in one’s life activities), control (belief in one’s ability to influence the course of one’s life events), and challenge (change is standard and growth-producing) [26]. Hardy people are more committed to themselves and their work, see life change as a challenge rather than a threat and maintain a sense of control over their lives rather than powerlessness. People with hypertension and RA are more likely to participate in patient education programs, which have been linked to improved physiological functioning [27].
3.1.6. Sensibility to Coherence A salutogenic model (salute = health, genesis = origin) underpins the theory of sense of coherence [28]. A person who possesses generalized resistance resources such as money, self-strength, cultural stability, and Social Support can manage to make stressors understandable, i.e., have a sense of coherence. Coping strategies or a plan for behavior, Social Support, and cultural factors are also included. A person with a sense of coherence has a long-lasting and deep faith in the world’s predictability and believes there is a high likelihood that things will turn out as well as you can reasonably expect. It does not imply that one is in command, but instead, that one is a participant in the processes that shape one’s fate and daily experience. It makes no difference whether power is in our hands or elsewhere; what matters is that power is located where it is legitimately supposed to be.
3.1.7. Control Point Rotter et al. [29] proposed that generalized expectancies and reinforcement create a sense of locus of control over the events in one’s life, as psychosocial dynamics influence health behavior. A belief in external power is defined as the perception that the effect of reinforcement is not entirely derived from a person’s actions but is the result of luck, chance, or fate, as well as being under the control of powerful others. A belief in internal power occurs when a person believes that his behavior or characteristics caused the event. It has been reported that patients with hypertension who scored high on internal control and adhered to their medication had blood pressure control [30].
3.1.8. Confidence in Oneself Perceived self-efficacy refers to belief in one’s ability to plan and carry out the steps necessary to achieve specific practical goals [31]. People will not try to make things happen if they believe they cannot [32]. Perceived self-efficacy is a consistent predictor of a wide range of behaviors. Efficacy beliefs influence performance both directly and indirectly through intentions. Nonpharmacological treatment for hypertension, Adherence to diet and medication regimens for lipid control, and interventions to improve exercise habits are suggested research areas [33]. The effects of health literacy on self-efficacy and health knowledge are also factors to consider [34].
3.1.9. Social Networking and Support There is no universally accepted definition or conceptualization of social Support; however, Lindsey [35] defines it as the provision of information that leads people to believe they are cared for, loved, esteemed, valued, and a member of a network of communication and mutual obligation. There are four types of social Support: informational (the provision of information that the person can use to cope with personal and environmental problems), appraisal (the transmission of information relevant to self-evaluation), instrumental (the individual’s access to behaviors that directly help in times of need), and emotional (the provision of emotional Support) (requirement of empathy and demonstration of love, trust, and caring). A social network that provides social Support is defined as a group of people with whom the person has formal or informal social connections that can be described by size, density, and complexity. According to research, high social network scores are associated with lower systolic and diastolic blood pressure in both sexes [36]. In China, social Support, education, and the duration of hypertension diagnosis were significant predictors of treatment adherence [37].
Nursing Concepts in Hypertension Care, Section 3.2
The following concepts are essential for nurses to understand when caring for hypertensive patients. They entail applying behavioral change theories and models in consultations and using counseling skills, patient advocacy, empowerment, professional knowledge, health education, and patient Support.

3.2.1 Behavioural Change Theories and Models Several theories and models have been developed to understand better what influences behavior. The health belief model [38] is the most commonly used in behavior change in healthcare. Goal-setting, decision-making, and social learning are all integrated into this model for making decisions based on positive or negative attitudes. Perceived susceptibility and barriers to behavior change are also considered. Other models that nurses can use to help patients change their lifestyles include the transtheoretical model (TTM) or stages of change model (SOC) [39], in which the learner goes through a cycle of pre-contemplation, contemplation, preparation, action, and maintenance of new behavior; the self-regulatory model (SRM) [40], in which motivation for changing lifestyle is dependent on perceived threat; and the protection motivation theory (PMT) [41]. In our research, we discovered that nurses trained in the SOC model might be of assistance when using the model to counsel hypertensive patients [43].
3.2.2 Counseling Ability Counselling is defined as “the process by which one person assists another in clarifying his life situation and deciding on the next steps” (p. 2) [44]. To act, the patient must identify what she needs to do, stop, continue, and accept. Morrison and Burnard [45] define counseling as assisting people in coming to terms with a problem, finding solutions to problems, or helping others. Motivational interviewing (MI) [46] is a goal-oriented patient-centered counseling style for dealing with the coercion of ambivalence about change. This counseling style lets you keep the consultation patient-centered, empathic, and autonomous. Own studies show that after consultation training, nurses fulfilled more aspects of patient-centeredness [47] and were more focused and discussed lifestyle factors with their patients to a greater extent [48]. Effects on patients’ weight parameters, physical activity, perceived stress, and the proportion of patients who achieved blood pressure control have also been demonstrated [49].
Patient Advocacy 3.2.3 An advocate is defined as “one who pleads another’s the cause” (p. 439) [50]. Advocacy is linked to morality, ethics, autonomy, and patient empowerment. According to Gadow [51], advocacy is the philosophical foundation and ideal of nursing. The nurse is uniquely suited for fundamental and existential advocacy instead of simply providing correct and objective information to the patient and being paternalistic. According to Schwartz [52], the advocate should inform the patient and promote informed consent, empower the patient and protect autonomy, protect the patient’s rights and interests, ensure access to available resources, support the patients, and represent the patients’ views/desires rather than just their needs.
3.2.4 Emancipation The word empower means “to authorize, license, impart power, enable, and permit,” and the concept of empowerment can be defined as “in a helping partnership, it is a process of enabling people to choose to take control over and make decisions about their lives” (p. 309) [53]. Rappaport [54] sees empowerment as a vehicle for dealing with life’s problems, and it implies a sense of control over one’s life in personality, cognition, and motivation. The empowerment model of health education aims to increase patient autonomy and freedom of choice [55]. The nurse can help by assessing patients’ psychosocial health and assessing health and health risks. Personal empowerment is promoted by encouraging people to identify their values, needs, goals, and problem-solving resources. The four pillars of empowerment are awareness, freedom, choice, and responsibility. In a study of hypertension care, nurses’ counseling was found to contain empowerment and nurse-centered features, which alternated during the conversations, but nurse-centered features were predominant [56].
3.2.5. Professional Knowledge To perform all of the tasks associated with nursing in hypertension care, the nurse must be up to date on the most recent hypertension treatment guidelines, both pharmacological and nonpharmacological. As the leader of the team [1] that surrounds the patient, the nurse must understand how to value the results of the patient’s blood tests, such as blood lipids, as well as body measurements, such as waist circumference and body mass index. The nurse must also be able to estimate the patient’s risk profile.
3.2.6. Education in Health Health has long been recognized as an essential nursing component. A professional model for teaching in nursing practice has four features: social service ideal (professional characteristics), practice environment (an environment that influences practice), client state (nurse’s perspective on the client), and nursing practice strategies (unique nursing interventions) [57]. This model is applicable in hypertension care nursing because it includes a professional autonomy and spirit that the nurse must master. After all, she frequently manages the clinic on her own. She must also understand man’s physiological and psychosocial states to assess the patient and determine the type of teaching required. This encompasses a comprehensive viewpoint. Individual or group instruction is available. Patients with hypertension were polled on their thoughts on a working booklet used in consultations at nurse-led clinics where the nurses had received counseling training [58]. Some patients claimed to have read the booklet several times, but others claimed to have forgotten to receive it. Individual health education in primary care has been shown to reduce systolic and diastolic blood pressure, BMI, and self-efficacy in medication adherence [59].
3.2.7. Support The patient frequently receives Social Support from family and friends, but the nurse must also support the patient with specific individual lifestyle problems. Support and MI skills may also be required to increase patients’ self-efficacy to change their lifestyles [46]. This could also be expressed as interpersonal transactions involving the expression of positive affect by one person toward another, the affirmation of another’s actions, perceptions, or expressed views, and the provision of symbolic or material assistance to another [35, 60].
Concepts Concerning the Consultation and the Expected Outcome
The patient and the nurse meet during the consultation. Specific concepts related to this meeting and the expected outcome are presented below. The nurse communicates with the patient to reach a shared decision in agreement with the patient regarding the self-care the patient should perform. To be able to perform self-care, the patient employs various coping strategies to adhere to the prescribed treatment.

3.3.1. Interaction Caring is an interpersonal process that fosters the relationship between the nurse and the patient. A conceptual framework for classifying different types of interpersonal intervention between nurse and patient has been developed [45]. The authoritative interventions are prescriptive (to give advice or make suggestions), informative (to provide information), and confronting (to challenge). In contrast, the facilitative interventions are cathartic (to allow emotion to be released), catalytic (to “draw out”), and supportive (to encourage or validate). An interpersonally skilled person can move appropriately and freely between the various categories to guide therapeutic action. All of these interventions are present in MI [46], except for the authoritative type, which is viewed as counterproductive to establishing rapport with the patient. A client-centered approach implies that the client can best decide how to solve his problems in life [61]. All communication skills, such as listening, paraphrasing, challenging, and goal-setting, are also counseling skills [62]. Communication can take place either verbally or nonverbally. Following the nurses’ counseling training, hypertensive patients reported that the nurse listened and guided, and motivated them to make lifestyle changes [58]. Compared to the control group, this group had more informed thoughts about managing their lifestyle.
3.3.2. Consensus and Shared Decision-Making According to the Swedish Health and Medical Services Act [63], care should be provided regarding patients’ autonomy and integrity. In a paper [64], Toop from New Zealand states that a patient-centered approach based on mutual participation has gained increasing Support, and the concept of sustained partnership between patient and clinician has been included in a definition of primary care in the United States. Mutual goal-setting is when a nurse and a patient work together to define a set of patient goals and agree on the goals that must be met. Setting goals is an integral part of problem-solving and the nursing process. According to Charles et al. [65], the shared treatment decision-making model must have four elements: both the physician and the patient are involved in the treatment decision-making process, they share information, they take steps to participate in the decision-making process by expressing treatment preferences, and a treatment decision is made. Although Charles and the contributors focus on physicians’ interactions with patients, the decision-making principles are generally applicable.
The new concept will begin to take shape through the concordance website managed by the RPSGB concordance coordinating group [66]. The historical context was the problem of medication noncompliance and growing knowledge about people’s beliefs about their medication and medicines in general. These beliefs determine whether or not an individual will follow a prescription. The concept can also be applied to other treatment modalities, such as behavior modification. Concordance should be negotiated between equals during the consultation. Concordance implies the approach of bringing patients into a full therapeutic partnership, that a patient’s decision-making preferences may change over time and under different circumstances, and that if the patient has more authority or control in the consultation, the prescriber will have less.
Furthermore, the patient may choose a treatment other than that recommended by the prescriber, which is not a failure but a success of care, and if this occurs, there is no reason to reject the patient. The term concordance is not used in MI, but the idea of the MI spirit means that patients are viewed as valued partners who the counselor wants to assist in making their health decisions [46]. Concordance and shared decision-making do not overlap but rather complement each other.

3.3.3. Adaptation Coping refers to a person’s strategies for dealing with difficult situations and demands deemed taxing or exceeding the person’s resources [67], such as being diagnosed with hypertension. A person can use strategies to handle the stress through acceptance, tolerance, medication, avoidance, and so forth, or plans to change the situation that caused the strain [68]. A vigilant coping strategy is directed to the problem to prevent or control it [67] and could mean information searching or systematic problem-solving. Coping by avoidance could be jogging, relaxation, vacation, hobbies, wishful thinking, eating, drinking, smoking, using drugs or medications, or sleeping. Arora and McHorney [69] used questionnaires to study whether 2472 chronically ill (hypertension, diabetes, congestive heart failure, myocardial infarction, depression) persons preferred an active or passive role in medical decision-making. They found that patients using an operational coping strategy preferred an active role in meetings with health professionals.
3.3.4. Adherence There has been a shift through the years from using the term compliance to Adherence, though many authors still use the word compliance. Compliance has traditional connotations, implying that the practitioner expects the patient to follow the rules for the patient’s good [13] or that the patient is a passive responder to the clinician’s authoritative demands [70]. Noncompliance means that the patient asserts the right to self-responsibility. Adherence can be defined as “the extent to which a person’s behavior (in terms of taking medications, following diets, or executing lifestyle changes) coincides with medical or health advice,” according to Haynes in 1979 [71]. Expectancy of internal control over health and hypertension and knowledge of the treatment regimen are significant determinants of Adherence. Poor Adherence to treatment can also mean that the person has not changed his opinion, has not understood the message entirely, is not convinced about changing behavior to avoid illness, or has not received any help to adopt other habits [72]. The sensitivity of symptoms is generally an indicator of disease and is used as a motivator and guide for treatment. Hypertension is an excellent example of poor sensitivity and, therefore, a lousy motivator for treatment adaptation [40]. Regarding medication adherence, Allen [73] states that the hypertensive patient feels well, and there will be no increase in perceived well-being when medication is taken, which could contribute to noncompliance. The cost of the drug [74], especially among older people [75], is an essential barrier to Adherence.
3.3.5. Self-Care Self-care can be defined as activities initiated or performed by an individual, family, or community to achieve, maintain, or promote maximum health [42]. Within the medical model, self-care has been defined as self-care in illness, compliance with therapeutic regimens, and active participation in rehabilitative activities. Self-care for health promotion requires that “clients have the knowledge and competencies that can be used to maintain and enhance health” (p. 98). (p. 98). A similar definition is used by Levin [76], meaning that self-care is a process where a layperson can effectively take care of their health promotion and prevention and disease detection and treatment. Within nursing, the concept of self-management encompasses not only different coping strategies but also health-promotive actions, interaction with healthcare providers, treatment adherence, monitoring health status, making care decisions, and management of the impact of the illness on health [77].
3.4. Integration with Existing Theory of Nursing
All the defined concepts related to nursing in hypertension care form the basis for nursing interventions, and the nurse assesses the patient’s self-care demands in communicating with the patient to help the patient to change lifestyle, that is, to perform self-care. For that reason, Orem’s self-care deficit theory of nursing [78] is integrated as a natural ingredient in the proposed middle-range approach.

The self-care deficit theory of nursing consists of three parts: theory of self-care, theory of self-care deficit, and theory of nursing systems [78]. Presuppositions for the idea being that people develop and exercise intellectual and practical skills through learning and manage themselves to sustain motivation essential for continuing daily care of themselves. Self-care is an act of persons who have developed the capabilities to take care of themselves in their environmental situations. They have the agency or power to regulate internal and external factors that affect their functioning and development, that is, in the interest of life, health, and well-being. The ability to perform self-care, the self-care agency as a specific power of individuals, differs depending on capabilities and circumstances related to the self-care demands and health disorders. Self-care deficit arises when capabilities for self-care, because of existing limitations, are not equal to meeting some or all of the components of their therapeutic self-care demands. In hypertension care, the self-care deficit could mean that the patient lacks knowledge about or is not motivated to perform lifestyle changes or to start taking medicines. These deficiencies mean that the patient cannot develop appropriate self-care agency.

To meet the patient’s self-care deficit, nurses produce systems of nursing actions and agencies [78]. In hypertension care, these agencies most often are supportive-educative to help the patient to regain his self-care. The supportive-educative system is the only system where a patient’s requirements for help are confined to decision-making, behavior control, and acquiring knowledge and skills. The nursing actions could be of long or short duration.

The concepts related to nursing (theories and models for behavioral change, counseling skills, patient advocacy, empowerment, professional knowledge, health education, and Support) form the nursing system in hypertension care which the nurse brings into the encounter with the patient. The patients, in turn, get certain attitudes and beliefs, a view of health, a need for autonomy, their personality and traits, perceived vulnerability, hardiness, a sense of coherence, locus of control, self-efficacy, and social support and network into the encounter. All these factors affect behavior and, thus, the patients’ habits. The nurse uses appropriate parts of the nursing system to assess the patient’s self-care deficits in the interaction. Shared decision-making should emerge from the exchange in patient-centered communication, with goal-setting in concordance between the patient and the nurse. From the decisions made about performing self-care, the patient has to develop self-care agencies to achieve behavior change through his own coping and with assistance from nursing agencies, that is, the nurse’s interventions. The desired outcome is a changed lifestyle with the goal of Adherence to treatment and maintenance of new behavior. This was demonstrated in our research in measuring hypertensive patients’ exercise of self-care agency [79], where counseling training gave an increase in the patient’s self-care agency scores, which was significantly correlated with increased physical activity and improved satisfaction with information about medication [80], which mirrors Adherence to treatment. From Turkey, it is similarly reported that hypertensive patients’ educational level and social insurance situation affect the measured self-care agency score [81].

Go to:\s4. Clinical and Research Implications
Nursing in hypertension care has been criticized for not being fully professionally performed and not having any structure for the counseling in the consultations [82]. Nurses could have a prominent position in treating hypertensive patients, but to achieve this, the standard of nursing needs to be enhanced. For that reason, a theory can be necessary to give a basis for the nurses to develop guidelines for their practice.

In being patient-centered in their communication, nurses must see the individual patient with their needs. It is then necessary for the nurse to know what factors may affect the patient, factors that might help or be less helpful for the patient to manage to perform essential lifestyle changes or take medicines. A patient may believe that living a healthy lifestyle is not for him because he is genetically predisposed to cardiovascular disease. His attitude is careless, and he believes that paying attention to his weight is pointless. He maintains his stance to maintain his autonomy. Because he is efficient and organized, he gives the impression of being conscientious. In terms of his hypertension, he feels helpless (vulnerable) and thus has a low level of hardiness. He also has a shared sense of coherence because he lacks self-strength and believes that he will be lucky to reach the age of fifty (external locus of control). He would, however, score high on self-efficacy because he strongly believes in his ability to succeed. He also has social Support from his family and a social network, which would be beneficial if he could be motivated to change his way of life. Table 2 demonstrates this. When meeting patients, the experienced nurse presumably gets a sense of the individual patient and can report most of the statements listed in the scenario above. Still, the nurse is unlikely to be able to provide theoretical context and relate to these concepts. A theoretical foundation is required to study and articulate what nursing in hypertension care entails.

Table 2 shows a diagram of how a nurse could apply the proposed theory in hypertension care. All counseling sessions with patients do not have to be conducted similarly. One concept is not used only once; for example, communication and professional knowledge are used throughout the consultation. The treatment mentioned here is a lifestyle change.

The consultation procedure

Theme ideas for the meeting

Concepts concerning the patient

Nursing-related concepts
Developing a rapport with the patient
Communication
Who is this individual?
Personality and characteristics
Counseling abilities
determining the patient’s risk profile and informing the patient of the outcome
Evaluation of the patient’s self-care deficiencies
Professional expertise
What does the patient have to say?
Attitudes and beliefs about health and illness
Coherence sense
Vulnerability perception
Hardiness
The patient has concerns.
Autonomy
Health instruction
Discussion of the benefits and drawbacks of lifestyle changes, with the patient deciding whether or not to make a change.
Concordance and shared decision-making
Control point
Patient representation
Behavioral change theories and models
The patient is ready.
Development of self-care organizations based on coping strategies
Self-efficacy
Networking and Social Support
Empowerment\sSupport
Follow-up
Adherence to a new way of life through self-care
Launch in a new window
to incorporate Orem’s self-care theory is particularly relevant to patient teaching with the development of self-care skills [13, 32], as this is the goal for hypertensive patients, and the theory has widespread acceptance with its application to a wide range of client populations and clinical settings (Whetstone and Reid, 1991). Many hypertensive patients struggle to understand how the figures describing their blood pressure level will affect their lives. Most patients do not exhibit symptoms that are easily linked to the diagnosis. This means that their challenge is more difficult than that of many other patients. It is also a significant challenge for the nurse to assist the patient in comprehending the gravity of the figures and motivating the patient to make the necessary lifestyle changes. As a result, the nurse in hypertension care requires a more detailed and applied theory than Orem’s grand theory alone or even a middle-range explanatory theory of self-management behavior [83].

Nursing intervention studies in hypertension care have revealed that consultation training can provide nurses with a structure for consultations [48] and that nurses can be more patient-centered in their counseling [47]. Behavioral models have also been helpful as a theoretical framework [43]. Other research indicates that integrating behavioral models with counseling techniques, such as in MI [84], benefits healthcare providers of various professions. This gives the provider a structure for the consultation and allows them to be more effective in treating patients. Applying a theory in hypertension care can provide nurses with a deeper understanding of their patients’ challenges and their professional nursing actions.

Further research could focus on applying the theory to clinical settings or the theoretical relationships between the concepts. In clinical settings, it would be interesting to study nurses’ perspectives on using the approach in their practice, as well as hypertensive patients’ perspectives on how they perceive their treatment and their experiences with self-care. Intervention studies could be carried out in which nursing care is based on the theory to see if this affects patient outcomes. The relationships between the concepts, as well as the development of the various ideas, require attention. There are several questions to be answered, such as what the differences between concordance and shared decision-making are, whether it is essential to incorporate levels of hardiness, sense of coherence, and locus of control in theory, and whether it makes a difference to define counseling skills using the word patient-centredness rather than person-centredness. According to Higgins and Moore’s definitions [85], this proposed theory is predictive. That is, it anticipates a specific set of outcomes, containing identified and defined concepts, assumptions that clarify the fundamental underlying truths, and a context within which the theory is placed. Still, it lacks identified relationships between and among the ideas. As a result, perspectives from the world of nurses interested in developing theoretical nursing in hypertension care are precious.

QUESTION
Goal:
Analyze and evaluate a middle range theory. You will select a middle range theory and identify application of nursing theories into clinical practice.
Content Requirements:
Components of the theory
Discuss the major concepts of the theory
Philosophical basis or worldview change, advancing health
Structural aspects of the theory
Discuss the framework of the theory.
Identify an area of your practice where this theory could be applicable
What question does the theory help to answer?
Describe the area of interest in relationship to the theory/theoretical model.
Is it appropriate for the practice setting and is it applicable?
Discuss the strength and weakness of the theory. If there is weakness, discuss what makes it difficult to be used in practice.
Use of theory in clinical practice.
Performing a literature review is essential to completing this section. If there is no literature available about the application of this theory in practice, address reason(s) why based on your findings.
Evaluation of theory
Is this theory used to understand and apply into practice?
What difficulties did you encounter or would anticipate encountering in using this theory?
What would make this theory more usable or applicable to practice?