Hypertension is a worldwide problem with substantial consequences (Fisher and Curfman, 2018). It is a progressive condition (Jamison, 2006) requiring lifelong management with pharmacological treatments and lifestyle adjustments. However, adopting these lifestyle changes can be notoriously difficult to implement and sustain (Fisher and Curfman, 2018) and non-adherence to chronic medication regimens is extremely common (Abegaz et al, 2017). This is also recognised by the National Institute for Health and Care Excellence (NICE) (2009) which estimates that between 33.3% and 50% of medications are not taken as recommended. Abegaz et al (2017) furthered this by claiming 83.7% of people with uncontrolled hypertension do not take medications as prescribed. However, leaving hypertension untreated or uncontrolled is the single largest cause of cardiovascular disease (Fisher and Curfman, 2018). Therefore, better adherence to medications is associated with better outcomes (World Health Organization, 2003) in terms of reducing the financial burden associated with the disease process on the health service, improving outcomes for patients (Chakrabarti, 2014) and increasing job satisfaction for professionals (McKinnon, 2013). Therefore, at a time when growing numbers of patients are presenting with hypertension, health professionals must adopt a concordant approach from the initial consultation to optimise adherence.
Great emphasis is placed on optimising adherence to medications (NICE, 2009), but the meaning of the term ‘adherence’ is not clear and it is sometimes used interchangeably with compliance and concordance (De Mauri et al, 2022), although they are not synonyms. Compliance is an outdated term alluding to paternalism, obedience and passivity from the patient (Rae, 2021), whereby the patient's behaviour must conform to the health professional's recommendations. Adherence is defined as ‘the extent to which a person's behaviour, taking medication, following a diet and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider’ (Chakrabarti, 2014). This term is preferred over compliance as it is less paternalistic (Rae, 2021), as the patient is included in the decision-making process and has agreed to the treatment plan. While it is not yet widely embraced or used in practice (Fawcett, 2020), concordance is recognised, not as a behaviour (Rae, 2021) but more an approach or method which focuses on the equal partnership between patient and professional (McKinnon, 2013) and enables effective and agreed treatment plans.
NICE last reviewed its guidance on medication adherence in 2019 and did not replace adherence with concordance within this. This supports the theory that adherence is an outcome of good concordance and the two are not synonyms. NICE (2009) guidelines, which are still valid, show evidence of concordant principles to maximise adherence. Integrating the theoretical principles of concordance into this case study demonstrates how the trainee advanced nurse practitioner aimed to individualise patient-centred care and improve health outcomes through optimising adherence.
Patient introduction and assessment
Jane (a pseudonym has been used to protect the patient's anonymity; Nursing and Midwifery Council (NMC) 2018), is a 45-year-old woman who had been referred to the surgery following an attendance at an emergency department. Jane had been role-playing as a patient as part of a teaching session for health professionals when it was noted that her blood pressure was significantly elevated at 170/88 mmHg. She had no other symptoms. Following an initial assessment at the emergency department, Jane was advised to contact her GP surgery for review and follow up. Nazarko (2021) recognised that it is common for individuals with high blood pressure to be asymptomatic, contributing to this being referred to as the ‘silent killer’. Hypertension is generally only detected through opportunistic checking of blood pressure, as seen in Jane's case, which is why adults over the age of 40 years are offered a blood pressure check every 5 years (Bostock-Cox, 2013).
Consultation
Jane presented for a consultation at the surgery. Green (2015) advocates using a model to provide a structured approach to consultations which ensures quality and safety, and improves time management. Young et al (2009) claimed that no single consultation model is perfect, and Diamond-Fox (2021) suggested that, with experience, professionals can combine models to optimise consultation outcomes. Therefore, to effectively consult with Jane and to adapt to her individual personality, different models were intertwined to provide better person-centred care.
The Calgary–Cambridge model is the only consultation model that places emphasis on initiating the session, despite it being recognised that if a consultation gets off to a bad start this can interfere throughout (Young et al, 2009). Being prepared for the consultation is key. Before Jane's consultation, the environment was checked to minimise interruptions, ensuring privacy and dignity (Green, 2015; NMC, 2018), the seating arrangements optimised to aid good body language and communication (Diamond-Fox, 2021) and her records were viewed to give some background information to help set the scene and develop a rapport (Young et al, 2009). Being adequately prepared builds the patient's trust and confidence in the professional (Donnelly and Martin, 2016) but equally viewing patient information can lead to the professional forming preconceived ideas (Donnelly and Martin, 2016). Therefore, care was taken by the trainee advanced nurse practitioner to remain open-minded.
During Jane's consultation, a thorough clinical history was taken (Table 1). History taking is common to all consultation models and involves gathering important information (Diamond-Fox, 2021). History-taking needs to be an effective (Bostock-Cox, 2019), holistic process (Harper and Ajao, 2010) in order to be thorough, safe (Diamond-Fox, 2021) and aid in an accurate diagnosis. The key skill for taking history is listening and observing the patient (Harper and Ajao, 2010). Sir William Osler said:‘listen to the patient as they are telling you the diagnosis’, but Knott and Tidy (2021) suggested that patients are barely given 20 seconds before being interrupted, after which they withdraw and do not offer any new information (Demosthenous, 2017). Using this guidance, Jane was given the ‘golden minute’ allowing her to tell her ‘story’ without being interrupted (Green, 2015). This not only showed respect (Ingram, 2017) but interest in the patient and their concerns.
Table 1. Clinical history
| Component | Findings | |
|---|---|---|
| Presenting complaint | Jane had incidentally had her blood pressure (BP) checked and it was found to be elevated. She was otherwise well with no reported symptoms | |
| Symptom analysis | Onset/duration | Jane had initially had her BP checked the day before during a role-play scenario for health professionals. She had presented to emergency department where her BP had remained elevated |
| Provocation/palliative | Jane reported not feeling stressed but does acknowledge she has a very stressful job. But is now worried about her high BP readings | |
| Quality/quantity | None | |
| Region/radiation | None | |
| Severity | BP elevated but no red flags requiring transport to hospital | |
| Timing | Jane had only become aware of her high blood pressure readings the day before with no previous high blood pressure readings | |
| Associated symptoms | Jane had no associated symptoms. No chest pain, palpitations. No headaches, dizziness, visual disturbances nor retinal haemorrhages. Jane reports a good sleep pattern. No change in mood, no weight loss/gain. No change in appetite | |
| Current health (general enquiry) | Jane reports feeling well. She has just returned to work following a holiday and continues with all her interests and hobbies | |
| Past medical history | Nil to note | |
| Family history | Jane's parents are alive and well. She has two siblings, both are well. No family history of cardiovascular disease | |
| Psychosocial history | Jane lives alone, she is not married and has no children. Jane currently works full-time. She doesn't smoke and doesn't drink alcohol. She reports drinking one or two cups of coffee daily. Jane tries to eat healthily but finds this challenging and she reports a sedentary lifestyle with no regular exercise | |
| Medications | None, including prescribed/over the counter/herbal/recreational | |
| Allergies | None | |
Once Jane shared her story, it was important for the trainee advanced nurse practitioner to guide the questioning (Green 2015). This was achieved using a structured approach to take Jane's history, which optimised efficiency and effectiveness, and ensured that pertinent information was not omitted (Young et al, 2009). Thomas and Monaghan (2014) set out clear headings for this purpose. These included:
- The presenting complaint
- Past medical history
- Drug history
- Allergies
- Social history
- Family history.
McPhillips et al (2021) also emphasised a need for a systemic enquiry of the other body systems to ensure nothing is missed. From taking this history it was discovered that Jane had been feeling well with no associated symptoms or red flags. A blood pressure reading showed that her blood pressure was elevated. Jane had no past medical history or allergies. She was not taking any medications, including prescribed, over the counter, herbal or recreational. Jane confirmed that she did not drink alcohol or smoke. There was no family history to note, which is important to clarify as a genetic link to hypertension could account for 30–50% of cases (Nazarko, 2021). The information gathered was summarised back to Jane, showing good practice (McPhillips et al, 2021), and Jane was able to clarify salient or missing points. Green (2015) suggested that optimising the patient's involvement in this way in the consultation makes her feel listened to which enhances patient satisfaction, develops a therapeutic relationship and demonstrates concordance.
During history taking it is important to explore the patient's ideas, concerns and expectations. Moulton (2007) refers to these as the ‘holy trinity’ and central to upholding person-centredness (Matthys et al, 2009). Giving Jane time to discuss her ideas, concerns and expectations allowed the trainee advanced nurse practitioner to understand that she was concerned about her risk of a stroke and heart attack, and worried about the implications of hypertension on her already stressful job. Using ideas, concerns and expectations helped to understand Jane's experience, attitudes and perceptions, which ultimately will impact on her health behaviours and whether engagement in treatment options is likely (James and Holloway, 2020). Establishing Jane's views demonstrated that she was eager to engage and manage her blood pressure more effectively.
Vincer and Kaufman (2017) demonstrated, through their case study, that a failure to ask their patient's viewpoint at the initial consultation meant a delay in engagement with treatment. They recognised that this delay could have been avoided with the use of additional strategies had ideas, concerns and expectations been implemented. Failure to implement ideas, concerns and expectations is also associated with reattendance or the patient seeking second opinions (Green, 2015) but more positively, when ideas, concerns and expectations is implemented, it can reduce the number of prescriptions while sustaining patient satisfaction (Matthys et al, 2009).
Physical examination
Once a comprehensive history was taken, a physical examination was undertaken to supplement this information (Nuttall and Rutt-Howard, 2016). A physical examination of all the body systems is not required (Diamond-Fox, 2021) as this would be extremely time consuming, but the trainee advanced nurse practitioner needed to carefully select which systems to examine and use good examination technique to yield a correct diagnosis (Knott and Tidy, 2021). With informed consent, clinical observations were recorded along with a full cardiovascular examination. The only abnormality discovered was Jane's blood pressure which was 164/90 mmHg, which could suggest stage 2 hypertension (NICE, 2019; 2022). However, it is the trainee advanced nurse practitioner's role to use a hypothetico-deductive approach to arrive at a diagnosis. This requires synthesising all the information from the history taking and physical examination to formulate differential diagnoses (Green, 2015) from which to confirm or refute before arriving at a final diagnosis (Barratt, 2018).
Differential diagnosis
Hypertension can be triggered by secondary causes such as certain drugs (non-steroidal anti-inflammatory drugs, steroids, decongestants, sodium-containing medications or combined oral contraception), foods (liquorice, alcohol or caffeine; Jamison, 2006), physiological response (pain, anxiety or stress) or pre-eclampsia (Jamison, 2006; Schroeder, 2017). However, Jane had clarified that these were not contributing factors. Other potential differentials which could not be ruled out were the white-coat syndrome, renal disease or hyperthyroidism (Schroeder, 2017). Further tests were required, which included bloods, urine albumin creatinine ratio, electrocardiogram and home blood pressure monitoring, to ensure a correct diagnosis and identify any target organ damage.
Joint decision making
At this point, the trainee advanced nurse practitioner needed to share their knowledge in a meaningful way to enable the patient to participate with and be involved in making decisions about their care (Rostoft et al, 2021). Not all patients wish to be involved in decision making (Hobden, 2006) and this must be respected (NMC, 2018). However, engaging patients in partnership working improves health outcomes (McKinnon, 2013). Explaining the options available requires skill so as not to make the professional seem incompetent and to ensure the patient continues to feel safe (Rostoft et al, 2021).
Information supported by the NICE guidelines was shared with Jane. These guidelines advocated that in order to confirm a diagnosis of hypertension, a clinic blood pressure reading of 140/90 mmHg or higher was required, with either an ambulatory or home blood pressure monitoring result of 135/85 mmHg or higher (NICE, 2019; 2022). However, the results from a new retrospective study suggested that the use of home blood pressure monitoring is failing to detect ‘non-dippers’ or ‘reverse dippers’ (Armitage et al, 2023). These are patients whose blood pressure fails to fall during their nighttime sleep. This places them at greater risk of cardiovascular disease and misdiagnosis if home blood pressure monitors are used, but ambulatory blood pressure monitors are less frequently used in primary care and therefore home blood pressure monitors appear to be the new norm (Armitage et al, 2023).
Having discussed this with Jane she was keen to engage with home blood pressure monitoring in order to confirm the potential diagnosis, as starting a medication without a true diagnosis of hypertension could potentially cause harm (Jamison, 2006). An accurate blood pressure measurement is needed to prevent misdiagnosis and unnecessary therapy (Jamison, 2006) and this is dependent on reliable and calibrated equipment and competency in performing the task (Bostock-Cox, 2013). Therefore, Jane was given education and training to ensure the validity and reliability of her blood pressure readings.
For Jane, this consultation was the ideal time to offer health promotion advice (Green, 2015) as she was particularly worried about her elevated blood pressure. Offering health promotion advice is a way of caring, showing support and empowerment (Ingram, 2017). Therefore, Jane was provided with information on a healthy diet, the reduction of salt intake, weight loss, exercise and continuing to abstain from smoking and alcohol (Williams, 2013). These were all modifiable factors which Jane could implement straight away to reduce her blood pressure.
Safety netting
The final stage and bringing this consultation to a close was based on the fourth stage of Neighbour's (1987) model, which is safety netting. Safety netting identifies appropriate follow up and gives details to the patient on what to do if their condition changes (Weiss, 2019). It is important that the patient knows who to contact and when (Young et al, 2009). Therefore, Jane was advised that, should she develop chest pains, shortness of breath, peripheral oedema, reduced urinary output, headaches, visual disturbances or retinal haemorrhages (Schroeder, 2017), she should present immediately to the emergency department, otherwise she would be reviewed in the surgery in 1 week.
Review
Jane was followed up in a second consultation 1 week later with her home blood pressure readings. The average reading from the previous 6 days was calculated (Bostock-Cox, 2013) and Jane's home blood pressure reading was 158/82 mmHg. This reading ruled out white-coat syndrome as Jane's blood pressure remained elevated outside clinic conditions (white-coat syndrome is defined as a difference of more than 20/10 mmHg between clinic blood pressure readings and the average home blood pressure reading; NICE, 2019; 2022). Subsequently, Jane was diagnosed with stage 2 essential (or primary) hypertension. Stage 2 is defined as a clinic blood pressure of 160/100 mmHg or higher or a home blood pressure of 150/95 mmHg or higher (NICE, 2019; 2022).
A diagnosis of hypertension can be difficult for patients as they obtain a ‘sick label’ despite feeling well (Jamison, 2006). This is recognised as a deterrent for their motivation to initiate drug treatment and lifestyle changes (Williams, 2013), presenting a greater challenge to health professionals, which can be addressed through concordance strategies. However, having taken Jane's bloods, electrocardiogram and urine albumin:creatinine ratio in the first consultation, it was evident that there was no target organ damage and her Qrisk3 score was calculated as 3.4%. These results provided reassurance for Jane, but she was keen to engage and prevent any potential complications.
Agreeing treatment
Concordance is only truly practised when the patient's perspectives are valued, shared and used to inform planning (McKinnon, 2013). The trainee advanced nurse practitioner now needed to use the information gained from the consultations to formulate a co-produced and meaningful treatment plan based on the best available evidence (Diamond-Fox and Bone, 2021). Jane understood the risk associated with high blood pressure and was keen to begin medication as soon as possible. NICE guidelines (2019; 2022) advocate the use of an angiotensin-converting enzyme (ACE) inhibitor or angiotensin-receptor blockers in patients under 55 years of age and not of Black African or African-Caribbean origin. However, ACE inhibitors seem to be used as the first-line treatment for hypertensive patients under the age of 55 years (O'Donovan, 2019).
ACE inhibitors directly affect the renin–angiotensin-aldosterone system which plays a central role in regulation of blood pressure (Porth, 2015). Renin is secreted by the juxtaglomerular cells, in the kidneys' nephrons, when there is a decrease in renal perfusion and stimulation of the sympathetic nervous system (O'Donovan, 2018). Renin then combines with angiotensinogen, a circulating plasma globulin from the liver, to form angiotensin I (Kumar and Clark, 2017). Angiotensin I is inactive but, through ACE, an enzyme present in the endothelium of the lungs, it is transformed into angiotensin II (Kumar and Clark, 2017). Angiotensin II is a vasoconstrictor which increases vascular resistance and in turn blood pressure (Porth, 2015) while also stimulating the adrenal gland to produce aldosterone. Aldosterone reduces sodium excretion in the kidneys, thus increasing water reabsorption and therefore blood volume (Porth, 2015). Using an ACE inhibitor prevents angiotensin II formation, which prevents vasoconstriction and stops reabsorption of sodium and water, thus reducing blood pressure.
When any new medication is being considered, providing education is key. This must include what the medication is for, the importance of taking it, any contraindications or interactions with the current medications being taken by the patient and the potential risk of adverse effects (O'Donovan, 2018). Sharing this information with Jane allowed her to weigh up the pros and cons and make an informed choice leading to the creation of an individualised treatment plan.
Jamison (2006) placed great emphasis on sharing information about adverse effects, because patients with hypertension feel well before commencing medications, but taking medication has the potential to cause side effects which can affect adherence. Therefore, the range of side effects were discussed with Jane. These include a persistent, dry non-productive cough, hypotension, hypersensitivity, angioedema and renal impairment with hyperkalaemia (Hitchings et al, 2019). ACE inhibitors have a range of adverse effects and most resolve when treatment is stopped (Waterfield, 2008).
Following discussion with Jane, she proceeded with taking an ACE inhibitor and was encouraged to report any side effects in order to find another more suitable medication and to prevent her hypertension from going untreated. This information was provided verbally and written which is seen as good practice (Green, 2015). Jane was followed up with fortnightly blood pressure recordings and urea and electrolyte checks and her dose of ramipril was increased fortnightly until her blood pressure was under 140/90 mmHg (NICE, 2019; 2022).
Conclusions
Adherence to medications can be difficult to establish and maintain, especially for patients with long-term conditions. This can be particularly challenging for patients with hypertension because they are generally asymptomatic, yet acquire a sick label and start lifelong medication and lifestyle adjustments to prevent complications. Through adopting a concordant approach in practice, the outcome of adherence can be increased. This case study demonstrates how concordant strategies were implemented throughout the consultation to create a therapeutic patient–professional relationship. This optimised the creation of an individualised treatment plan which the patient engaged with and adhered to.
KEY POINTS
- Hypertension is a growing worldwide problem
- Appropriate clinical assessment, diagnosis and management is key to prevent misdiagnosis
- Long-term conditions are associated with high levels of non-adherence to treatments
- Adopting a concordance approach to practice optimises adherence and promotes positive patient outcomes
CPD reflective questions
- How has this article developed your assessment, diagnosis or management of patients presenting with a high blood pressure?
- What measures can you implement in your practice to enhance a concordant approach?