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Case Report

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Healthcare provision has over the years evolved from merely being the offering treatment to patients in relation to the clinical presentations of their illnesses to more a dynamic approach. Other factors have seemingly become important considerations to the healthcare being offered as well as how it impacts the patient. Such factors have been particularly critical when handling patients suffering from chronic illnesses.  As a result, there has been a continuous pursuit of how the various gaps in the provision of healthcare may be addressed. The Doctor of Nursing Practice (DNP) practitioners are among those at the center of this pursuit more so given their significant role in the nursing profession. The DNP practitioners though often taking every measure to apply the most applicable intervention to patients, have severally failed to recognize the need to apply middle-range theories and ethical theories in their practice adequately. Essentially there remains a gap in the application of middle range or ethical theories to certain health conditions. One such condition is hypertension among older adults. Although significant strides have been made over the years towards enabling the hypertension patients to manage the condition, the role of middle rage theories and ethical theories has not been effectively considered. Consequently, high death rates and ineffective management of the condition are still prevalent.

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Literature Review

In view of the deficiencies exhibited in the addressing of hypertension among patients, various scholars have sought to study how best these inadequacies may be countered. Their scholarly works have been very insightful in explaining the role of middle range theories and ethical theories in addressing health care deficiencies and particularly with regard to hypertension. They have equally attempted to offer solutions to address the deficiencies associated with hypertension which they all acknowledge is a global health concern.  For instance, according to Khatib et al. (2014), although hypertension is still a top global risk element for mortality, its proper treatment and control are yet to be realized. These authors emphasize the need for hypertension patients to be accorded proper treatment whether in the case of lifestyle changes, medication or a combination of both. They further assert that although such arguments are premised on evidence from established research, their nursing practice reveals how little attention has been accorded to it. Further, they hold the view that implementation may fail due to a failure to overcome the barriers presented by health care providers.  The barriers identified by the authors are, however, considered from both the perspective of health care providers and patients’ perspectives.

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On the contrary, Ausili et al., (2014), assert that patients who suffer from chronic conditions require the implementation of a wide range of behaviors to ensure that patients can maintain their well-being and an equally improved quality of life to minimize associated complications. These behaviors according to the authors are what is termed as the self-care concept (Ausili et al., 2014). The three authors also raise the importance of finding the right tools to enable health professionals to identify the abilities of self-care and consequently provide appropriate care to the patients. Ideally, the authors point out the health caregivers as having a central role in how chronic conditions such as hypertension may be treated and managed.

As for Bonney (2013), he emphasizes on the principle of autonomy and the right of the patient to self-determination when making choices, which is an element of ethical theories. These authors essentially note how the ethical principle demands of healthcare providers to be led by certain moral rules which include respecting the decisions of patients as well as assisting them to arrive at important decisions regarding interventions. Generally, the works of Bonney (2014) emphasize the value of incorporating ethical theories into the provision of healthcare especially when decision making is central to the care being provided.

Description of the Case from a Theoretical Perspective

Mrs. Simpson has been suffering from hypertension for a while now. She is among the many Americans that continue to suffer from hypertension. From the time she developed the condition a few months ago, she has regularly visited her community health facility. Although her condition has over the three months been efficiently managed over, she feels she would have had a better experience at the health facility. In each visit, she is made to feel as though her opinion regarding her condition and treatment have been sidelined from the onset.

Further, she feels deprived of her ability to make decisions, yet she has always been in control of virtually every issue affecting her, especially her health. As an adult of sound mind, she feels obligated to make decisions regarding her life. The hypertension condition has taken a huge toll on her more so in view of the difficulty to control the condition. Issues of lifestyle change have been at the center of her concerns. She feels changing lifestyle is a personal matter which the health professionals have rather ignored in her view. For instance, her diet has had to change significantly in order to help lower blood pressure. Having to forgo her favorite coffee which she would regularly have twice a day as well as having to eat a healthier diet has been challenging. What bothers her the most, however, is how she felt left out in the changing of her diet. Except for the time she needed to provide certain information to the healthcare provider, her involvement was very limited. It was as though the new routine was being forced on her as opposed to taking into consideration her thoughts about the new changes.

Moreover, she feels that not having been given options to choose from went against her right to exercise some sense of independent judgment. Overall, Mrs. Simpson though appreciative of the efforts made by the health professionals at the facility to help her manage her condition, she is desirous of a situation where the caregivers will give a patient autonomy

Summary of the Case

The case of Mrs. Simpson is one of a hypertension patient who although appreciative of the role played by health care providers in treating and managing her condition considers some aspects of the treatment as isolating her opinion. For the past three years since developing the condition, she has struggled to adapt to the new lifestyle changes largely because she feels the changes have been, to a significant extent, been imposed on her. For her, such changes require her to be fully involved as these changes affect her the most. She desires to be allowed to decide on the various aspects regarding her condition as she has always made decisions for herself. As an older adult, she considers herself knowledgeable enough to make certain decisions. She is nonetheless positive that the health facility she attends is capable of incorporating her views and desires while still enabling her to manage her condition in the best way possible.


The healthcare provision for hypertension patients includes offering counseling patients on their lifestyle adjustments as well as blood pressure. For a hypertension patient, the change in lifestyle implies that they perform self-care. The middle range theory is a mechanism that aids the nurses in their practice so as to improve patient care and include further their understanding of patient care. Although every nursing across the globe is at some point involved in the treatment of hypertension, theoretical guidelines are often unavailable or inadequate (Drevenhorn, 2018). Middle range theories as discussed above may be applied to other theories such as ethical theories. In adopting ethical theories principles such as autonomy and beneficence are emphasized. Autonomy is understood as being one’s independence from influence. A patient is autonomous to the extent that they have a form of control over their lives. In the case of a hypertension patient, they are often faced with a dilemma of making lifelong changes to their lifestyle. As such, they ought to be given an opportunity to make such a decision autonomously. Imposing a decision on a patient, therefore, may consequently hamper the patient from maintaining a new form of behavior. Nurses therefore in applying the two categories of theories may be able to note when a patient is adequately autonomous clearly. The awareness of a patient’s autonomy or lack of it, however, is heavily dependent on how these nurses are informed and prepared.

Proposed Solutions

The assertions by Khatib et al., (2014) are indisputably an indication of the grave effect of hypertension which is not only a mortality risk but a health condition whose effective handling is yet to be realized. As such, their arguments for the treatment of patients that is proper can be said to be heavily supported by the current status of hypertension globally and its accompanying intervention. Arguably, these views are rather related to the arguments advanced by Ausili et al., (2014) that the manner in which healthcare providers handle hypertension patients is critical to how these patients manage their condition. As a result, some of the complications that are witnessed and which in some cases lead to death may be said to be a direct consequence of the failure by the health care providers to appropriate handle patients thus efficient self-care. The concept of self-care entails a process in which persons take charge of their health understanding, the promotion of such an understanding and how the understanding may be damaged (Ausili et al., 2014). In essence, such a process is an everyday routine of health activities and practices.

Hypertension as a chronic condition requires the implementation of various elements. Ensuring that the existent gaps in the handling of hypertension patients are minimized, demands not only the understanding of the role of middle-range theories and ethical theories but also applying these theories. Among the viable propositions include having a framework by the DNP practitioners which evaluates the treatment accorded to a hypertension patient in a wholesome way.  Such a framework would essentially form a basis upon which the healthcare providers will offer treatment to patients.

One of the ways that middle range theories may be applied is in the deliberative nursing process theory. Under the theory, there is an emphasis on the relevance of how nurses and patients interact, the process validation and how the nursing process is reliable in realizing positive outcomes for the patients. The theory encompasses five essential stages which can be effective if applied to hypertension patients. The stages are the assessment, diagnosing planning, implementing and evaluation stages. All the five stages are complementary to each other as they are all linked. Essentially each stage paves the way for the next phase. As such, failure to incorporate all the five stages may result in undesirable outcomes for the healthcare. Further, each stage has to be given the sufficient attention and careful consideration on how it will impact the next.

In planning, health professionals get to have an approach prior to addressing a hypertension case. Such planning is intended for preparing the health caregiver on how to approach each patient in helping them manage their condition. As for the assessment phase, the nurse practitioner will be able to assess the relevant factors revolving around a patient’s condition. In the diagnosing stage, the factors considered under assessment will be considered in order to establish a patient’s potential or actual health problems. In the case of a hypertension patient, a risk diagnosis would be vital in revealing whether the patient presents a risk factor that could result in other health conditions. It is particularly important to note that hypertension is a precursor for other health problems such as heart attack and stroke.

The fourth stage which is the implementation is perhaps one of the important stages as it the phase where all the other past stages get to be effected. In an implementation, the healthcare providers will seek to apply the theory to the patient’s condition fully. As for the evaluation stages, the approach taken in the five stages will be analyzed in order to determine its effectiveness or the lack of it. Ideally, through the entire whole five-stage process, focus on the patient’s needs. More importantly, the theory places emphasis on individualized care which is a positive aspect when attending to hypertension patients.

As a middle range theory, the deliberative nursing process, therefore, accords health practitioners the ability to accurate seal the gap created by the disharmony between patients desire to be fully involved in the lifestyle change as it is not only a life to change development but also has the potential of impacting their quality of life. By relying on the process, the patient’s views and those of health care providers will be merged. Ultimately, the objective ought to ensure that the patient’s concerns are addressed conclusively.

As part of the solution to the problem in question, the creation of awareness and placing of emphasis would be helpful in highlighting the need for healthcare providers to align their care to the patient’s perceptions. Even so, a health professional one has a duty to their patient to make them understand the basis for the lifestyle changes and the possible reasons as to why patients feel left out. By doing so, the patient’s perceptions will have a lesser negative impact on the adjustments that they are to make in their everyday lives.

Thus, in applying the middle range theories and the ethical theories, the health professionals will be better placed to have an accurate and elaborate understanding how their handling of these hypertension cases impacts the patients as well as how best they can minimize the existent gap and lead to positive patient perceptions with regards to their experience. Health professions will further be able to measure how much the patients feel involved in the decisions regarding their lifestyle changes. Some of the lifestyles changes include a modification in one’s diet so as to aid in the lowering of the blood pressure. Such an adjustment is often a difficult one. Some of the lifestyles changes include a modification in one’s diet to aid in the lowering of the blood pressure. Such an adjustment is often a difficult one.

Identification of the Instruments for Measuring the Proposed Solutions

The perceptions of a patient regarding their experience during health care are essential to the provision of quality care that is patient-centered.  One of the tools that may be used to measure the effectiveness of the middle range and ethical theories is the Patient-reported experience measures (PREMS). These are questionnaires which measure the perceptions of patients regarding their experience while receiving care. PREMS may be categorized as being either functional or relational. In a relational form of PREMS, the patients’ experience during treatment gets to be identified. As for the functional type, it focuses more on the examination of practical issues such as facilities. In the case in point, the relational form is more convenient. Therefore, as an instrument, PREMS serves as an important tool in evaluating the patients’ experience is valuable in enabling the health professionals to improve or correct on areas not well addressed regarding the patient’s perceptions. PREMS can be particularly useful in the hypertension cases whereby the persons suffering from this condition tend to have differing perceptions with health professionals regarding their care.

The questionnaires to be relied on under the PREMS method may be issued during the regular visits to the health facility where patients will be given an option on whether to go home or give their feedback before leaving the facility. On the other hand, in the era of digitalization, the questionnaires can equally be issued through online platforms. Such an option would make the giving of feedback from the patients more secure and faster.  As an advantage, online filling of the questionnaires will give the patients the freedom to provide honest answers without the fear of stigmatization or bias.  Caution has to be nonetheless given to the form of language to be used and the structure of the questions. Simple language will be an essential consideration as well as the use of open-ended questions to allow the patient to give an elaborate explanation of their experience at the facility. Consequently, a facility will make informed decisions regarding the expectations of the hypertension patients.


From the above discussion that is generated from relevant literature review and discussion, hypertension is a condition that has continued to receive increased attention owing to the prevalence of complications and high mortality rates. While the effective treatment for the condition is not a new concept for health professionals, there are obvious gaps which negatively impact the patient’s self-care in hypertension. Effective reliance on the middle range theories and ethical theories is one way these gaps can be bridged. These theories have in the recent past proven to be effective and as such can potentially address the prevailing inadequacies in the hypertension condition.

1. American Heart Association News. (2018). More than 100 million Americans have high blood pressure, AHA says. Retrieved from https://news.heart.org/more-than-100-million-americans-have-high-blood-pressure-aha-says/

2. Ausili, D., Masotto, M., Dall’Ora, C., Salvini, L., & Di Mauro, S. (2014). A literature review on self-care of chronic illness: definition, assessment and related outcomes. Professioni Infermieristiche, 67(3), 180-189. doi: 10.7429/pi.2014.673180.

3. Bonney, W. (2013). Medical errors: Moral and ethical considerations. Journal of Hospital Administration, 3(2), 80-88. doi: 10.5430/jha.v3n2p80

4. Drevenhorn, E. (2018). A Proposed Middle-Range Theory of Nursing in Hypertension Care. International Journal of Hypertension, 2018, 1-11. doi: 10.1155/2018/2858253

5. Khatib, R., Schwalm, J. D., Yusuf, S., Haynes, R. B., McKee, M., Khan, M., & Nieuwlaat, R. (2014). Patient and healthcare provider barriers to hypertension awareness, treatment and follow up: a systematic review and meta-analysis of qualitative and quantitative studies. PloS One, 9(1), e84238. doi: 10.1371/journal.pone.0084238

6. Kingsley, C., & Patel, S. (2017). Patient-reported outcome measures and patient-reported experience measures. BJA Education, 17(4), 137-144. doi: 10.1093/bjaed/mkw060

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