Does Patient Education Control Hypertension?Does Patient Education Control Hypertension?A Challenge for ChangeA Challenge for Change

Literature Review Literature Review

Hamad HarthiHamad Harthi

RN BSN MSNRN BSN MSN (ANP) (ANP)

Hemodialysis UnitHemodialysis UnitKing Faisal Specialist Hospital King Faisal Specialist Hospital

and Research Centerand Research Center

Supervisor: Professor Leaan Aitken, Griffith University, Gold Coast, Queensland, Australia

IntroductionIntroduction

Implementing evidence-based change is necessary Implementing evidence-based change is necessary across all areas of healthcare including nursingacross all areas of healthcare including nursing

To implement change it is necessary to consider:To implement change it is necessary to consider:– Clinical needClinical need– Clinical context of careClinical context of care– Quality of the research evidence which will inform practiceQuality of the research evidence which will inform practice– Challenges of implementing the change itselfChallenges of implementing the change itself

This projects considers an evidence-based change This projects considers an evidence-based change relating to hypertension control in community-dwelling relating to hypertension control in community-dwelling adults with existing high blood pressureadults with existing high blood pressure

Project OverviewProject Overview

Identification of the problem to be addressedIdentification of the problem to be addressed

Definition of the clinical questionDefinition of the clinical question

Identification of search terms and inclusion/exclusion Identification of search terms and inclusion/exclusion criteriacriteria

Literature search plus selection of relevant articlesLiterature search plus selection of relevant articles

Critical appraisal of selected articlesCritical appraisal of selected articles

Implementing practice change: processes and practicalities Implementing practice change: processes and practicalities including planning and evaluation of the projectincluding planning and evaluation of the project

ConclusionsConclusions

RationaleRationale

Hypertension constitutes a considerable global Hypertension constitutes a considerable global healthcare burdenhealthcare burden

Worldwide total of 972 million adults with hypertension Worldwide total of 972 million adults with hypertension in 2000in 200011

– No. of affected adults almost 2-fold greater in developing No. of affected adults almost 2-fold greater in developing vsvs developed countries (639 million developed countries (639 million vsvs 333 million) 333 million)

No. of adults with hypertension expected to increase by No. of adults with hypertension expected to increase by ~60% to 1.56 billion by 2025~60% to 1.56 billion by 202511

Evidence suggests there is a lack of understanding of Evidence suggests there is a lack of understanding of hypertension among hypertensive patientshypertension among hypertensive patients22

11Kearney et al. Kearney et al. Lancet Lancet 2005; 365: 2172005; 365: 217––23; 23; 22Oliveira et al. Oliveira et al. J Gen Intern MedJ Gen Intern Med 2005; 20: 219 2005; 20: 219––25.25.

PICOPICO

PPATIENTS: Patients with chronic hypertension on ATIENTS: Patients with chronic hypertension on anti-hypertensive therapy in the community healthcare settinganti-hypertensive therapy in the community healthcare setting

IINTERVENTION: Patient education programme designed NTERVENTION: Patient education programme designed to improve self-care in hypertension management to improve self-care in hypertension management (nurse-led education session plus patient information booklet)(nurse-led education session plus patient information booklet)

CCOMPARISON: Blood pressure regulation in patients OMPARISON: Blood pressure regulation in patients participating in educational programme participating in educational programme vsvs patients receiving patients receiving usual care aloneusual care alone

OOUTCOMES: Reduction in hypertension (two or more UTCOMES: Reduction in hypertension (two or more readings within the normal range) plus improved patient readings within the normal range) plus improved patient self-efficacyself-efficacy

The Clinical QuestionThe Clinical Question

Does patient education reduce the Does patient education reduce the incidence of continued hypertension incidence of continued hypertension

in hypertensive patients?in hypertensive patients?

Literature searchLiterature search

Strategy:Strategy:– Key search terms and limitations identifiedKey search terms and limitations identified

Search terms:Search terms: Hypertension; community health Hypertension; community health interventions; interventions; health education; patient health education; patient education and education and hypertension hypertensionLimitations:Limitations: English language articles published within English language articles published within

the last 15 years the last 15 years

– Searches of electronic databases CINAHL, Searches of electronic databases CINAHL, PROQUEST, MEDLINE and GOOGLE SCHOLAR PROQUEST, MEDLINE and GOOGLE SCHOLAR performedperformed

Total of 5 relevant articles selected for critical Total of 5 relevant articles selected for critical appraisalappraisal

Summary of Selected ArticlesSummary of Selected Articles

ArticleArticle SummarySummary

Alm-Rojer et al. Alm-Rojer et al. Eur J Cardiovasc NursEur J Cardiovasc Nurs 2003; 2003; 3: 3213: 321––3030

Study to investigate factors affecting Study to investigate factors affecting adherence to lifestyle changes and adherence to lifestyle changes and medication in patients with coronary heart medication in patients with coronary heart diseasedisease

Burke et al. Burke et al. Health Edu ResHealth Edu Res 2008; 23(4): 2008; 23(4): 583583––9191

Randomised, controlled trial of an Randomised, controlled trial of an educational intervention (lifestyle change educational intervention (lifestyle change program) for overweight hypertensive program) for overweight hypertensive patients in Australia patients in Australia

Leung et al. Leung et al. J Adv NursJ Adv Nurs 2005; 52(6): 631 2005; 52(6): 631––99 Exploratory study to evaluate a small-group, Exploratory study to evaluate a small-group, nurse-led intervention to improve nurse-led intervention to improve hypertension control and outcomeshypertension control and outcomes

Mohammadi et al. Mohammadi et al. Int J Nurs PracInt J Nurs Prac 2006; 12: 2006; 12: 153153––99

Evaluation of a ‘partnership care model’ for Evaluation of a ‘partnership care model’ for hypertension controlhypertension control

Zernike and Henderson. Zernike and Henderson. J Clin NursJ Clin Nurs 1998; 7: 1998; 7: 3737––4444

Evaluation of the effectiveness of two Evaluation of the effectiveness of two teaching strategies for patients diagnosed teaching strategies for patients diagnosed with hypertensionwith hypertension

Evidence Supporting Implementation of a Evidence Supporting Implementation of a Community-Based Education Program in Community-Based Education Program in

Hypertensive PatientsHypertensive Patients

Community-based education programmes are highly Community-based education programmes are highly effective in addressing specific health needseffective in addressing specific health needs11

Community-based interventions for hypertension are Community-based interventions for hypertension are effective as long as they are appropriate to the context effective as long as they are appropriate to the context and target populationand target population11

Both nurses and patients benefit from small group Both nurses and patients benefit from small group education in hypertension controleducation in hypertension control

A study of lifestyle changes in patients with coronary A study of lifestyle changes in patients with coronary heart disease showed that greater knowledge of their heart disease showed that greater knowledge of their condition is one key to improved self-management and condition is one key to improved self-management and behavioural changebehavioural change22

11Connell et al. Connell et al. Health Soc Care CommunityHealth Soc Care Community 2008; 16: 165 2008; 16: 165––87; 87; 22Alm-Roijer et al. Alm-Roijer et al. Eur J Cardiovasc NursEur J Cardiovasc Nurs 2004; 3: 321 2004; 3: 321––30. 30.

Implementing the Change in Implementing the Change in PracticePractice

Managing the implementation of change is Managing the implementation of change is challenging in healthcare settingschallenging in healthcare settings

Planning is needed to introduce the change and Planning is needed to introduce the change and drive it forwarddrive it forward11

Process-based change managementProcess-based change management1 1

– Focuses on:Focuses on:What do individual healthcare professionals do?What do individual healthcare professionals do?

What are the benefits to patients, staff and the wider What are the benefits to patients, staff and the wider healthcare service?healthcare service?22

11Greasely.Greasely. Technovation Technovation 2006; 26: 95 2006; 26: 95––103; 103; 22Fullan 2004. Fullan 2004. Leading in a Culture of Change: Personal Action Guide Leading in a Culture of Change: Personal Action Guide and Workbookand Workbook, Josse Bass CA., Josse Bass CA.

Process MappingProcess Mapping

Use of a process analysis tool to map:Use of a process analysis tool to map:1,21,2

– Change processChange process– Personnel involved in the changePersonnel involved in the change– Those likely to be affected by the changeThose likely to be affected by the change– Anticipatory actions to support the changeAnticipatory actions to support the change

Tools derived from the business sectorTools derived from the business sector– Sophisticated, largely computer-basedSophisticated, largely computer-based– Nurses may not possess necessary level of Nurses may not possess necessary level of

theoretical and technical expertisetheoretical and technical expertise– May be detrimental to the success of the changeMay be detrimental to the success of the change

11Green. Green. Nursing LeadershipNursing Leadership 2003; 15: 27 2003; 15: 27––30; 30; 22Greasely. Greasely. TechnovationTechnovation 2006; 26: 95 2006; 26: 95––103.103.

Process Mapping of theProcess Mapping of theChange PlanChange Plan

Alternative approach needed:Alternative approach needed:11

– Match process mapping to existing technologies and Match process mapping to existing technologies and capabilities within organisation and its personnelcapabilities within organisation and its personnel

Steps involved in the process:Steps involved in the process:– Development of change planDevelopment of change plan– Recruitment of relevant personnelRecruitment of relevant personnel– Involvement of management and consultationInvolvement of management and consultation– Evaluation of change planEvaluation of change plan

Resources mapped against available provision Resources mapped against available provision and any resource implications presented to and any resource implications presented to managementmanagement

11Greasely. Greasely. TechnovationTechnovation 2006; 26: 95–103. 2006; 26: 95–103.

Implementing Practice Change: Implementing Practice Change: Application of Theory Application of Theory

Lewin’s Field Theory and Change TheoryLewin’s Field Theory and Change Theory1,21,2

– Organisations/departments undergo 3 processes:Organisations/departments undergo 3 processes:Unfreezing:Unfreezing: Old ways of working are broken down in light of Old ways of working are broken down in light of

new knowledge and in response to the new knowledge and in response to the actions actions

of change agentsof change agentsChange:Change: Implementation of the changeImplementation of the changeRefreezing:Refreezing: New ways of working become consolidated into New ways of working become consolidated into

practicepractice

In this change:In this change:– The force destabilising current practice is the presentation of The force destabilising current practice is the presentation of

evidence about improving practiceevidence about improving practice

– Dissemination of the findings of the literature review will start Dissemination of the findings of the literature review will start the unfreezing processthe unfreezing process

Requires the identification of ways to do this and the development Requires the identification of ways to do this and the development of communication toolsof communication tools

11Lewin 1951. Lewin 1951. Field Theory in Social ScienceField Theory in Social Science, Harper Row, London; , Harper Row, London; 22Lewin 1958. Group decision and social change. Lewin 1958. Group decision and social change. In: In: Readings in Social PsychologyReadings in Social Psychology, Maccoby et al. (eds), Holt, Rinehart & Winston, New York., Maccoby et al. (eds), Holt, Rinehart & Winston, New York.

Implementing Practice Change: Implementing Practice Change: Application of Theory (2)Application of Theory (2)

Lewin’s Theory of Force Field AnalysisLewin’s Theory of Force Field Analysis11

– Allows the change leader to identify:Allows the change leader to identify:Driving forces to push the change forwardDriving forces to push the change forward

Resisting forces which get in the way of change happeningResisting forces which get in the way of change happening

In this change:In this change:– Many of the driving and resisting forces will be Many of the driving and resisting forces will be

identified during the initial information phaseidentified during the initial information phaseAllows for interim planning to address these forcesAllows for interim planning to address these forces

Plan will incorporate activities that address the need to Plan will incorporate activities that address the need to increase the power of the driving forces and break down, increase the power of the driving forces and break down, remove or minimise the resisting forcesremove or minimise the resisting forces1,21,2

11Lewin 1951. Lewin 1951. Field Theory in Social ScienceField Theory in Social Science, Harper Row, London, Harper Row, London; ; 22Shanley. Shanley. J Nurs ManJ Nurs Man 2007; 15: 538 2007; 15: 538––46.46.

Implementing Practice Change: Implementing Practice Change: Application of Theory (3)Application of Theory (3)

Ottoway Change CycleOttoway Change Cycle11

– Mimics well-known nursing process by using Mimics well-known nursing process by using assessment, planning, implementation and evaluationassessment, planning, implementation and evaluation

– Structured approach which uses terminology that most Structured approach which uses terminology that most nurses are familiar withnurses are familiar with

May assist with distributive leadership approachMay assist with distributive leadership approach

– Planning stage of the model considers:Planning stage of the model considers:Nature of the changeNature of the change

Personnel involvedPersonnel involved

Other social, organisational and political issues which may Other social, organisational and political issues which may affect the change affect the change

11Grol and Wensin. Grol and Wensin. Med J AustMed J Aust 2004; 180: 57 2004; 180: 57––60..60..

Implementing Practice Change: Implementing Practice Change: LeadershipLeadership

Leaders:Leaders:– Powerful drivers of the change processPowerful drivers of the change process11

– Role modelsRole models22

– Set standardsSet standards3,43,4

– Exert influence over others involved in Exert influence over others involved in the changethe change22

Effective leadership is key for successful Effective leadership is key for successful implementation of this changeimplementation of this change55

11Beinicke & Spencer. Beinicke & Spencer. Int J Leadership Pub ServInt J Leadership Pub Serv 2007; 3: 4 2007; 3: 4––13; 13; 22Buchanan et al. Buchanan et al. Int J Manag RevInt J Manag Rev 2005; 7: 189 2005; 7: 189––205; 205; 33By. By. J Change ManagJ Change Manag 2005; 5: 369 2005; 5: 369––80; 80; 44Hewerd et al. Hewerd et al. Health Prom IntHealth Prom Int 2007; 22: 170-8; 2007; 22: 170-8; 55Bass 1990. Bass 1990. Bass and Stogdill’s Bass and Stogdill’s Handbook of Leadership: Theory, Research and Managerial ApplicationsHandbook of Leadership: Theory, Research and Managerial Applications , Free Press, New York., Free Press, New York.

Implementing Practice Change: Implementing Practice Change: Leadership (2)Leadership (2)

Many leadership theories cite singular leadersMany leadership theories cite singular leaders1,21,2

Harris and Spillane Model of Distributive Harris and Spillane Model of Distributive Leadership:Leadership:33

– Primary change leader identifies and supports several Primary change leader identifies and supports several leaders in the organisationleaders in the organisation

– Considers organisational cultureConsiders organisational cultureSignificant in identifying driving and resisting forcesSignificant in identifying driving and resisting forces4 4

– Supports ‘ownership’ of the change at all levelsSupports ‘ownership’ of the change at all levels5,65,6

– Contributes to staff developmentContributes to staff development7,87,8

11Bass 1990. Bass 1990. Bass and Stogdill’s Handbook of Leadership: Theory, Research and Managerial ApplicationsBass and Stogdill’s Handbook of Leadership: Theory, Research and Managerial Applications , Free Press, New York; , Free Press, New York; 22Burns. Burns. LeadershipLeadership, Harper and Row, New York; , Harper and Row, New York; 33Harris & Spillane. Harris & Spillane. Manag EduManag Edu 2008; 22: 31 2008; 22: 31––4; 4; 44Jackson 2006. Jackson 2006. The Human Face The Human Face of Organisational Change Thesisof Organisational Change Thesis, Southern Cross University, Australia; , Southern Cross University, Australia; 55Carney. Carney. J Nurs ManJ Nurs Man 2000; ?: 265 2000; ?: 265––72; 72; 66Cork. Cork. Nurs StanNurs Stan 2005; 19: 402005; 19: 40––2; 2; 77Day. Day. The Leadership QuarterlyThe Leadership Quarterly 2000; 11: 581 2000; 11: 581––63; 63; 88McPhail. McPhail. J Nurs ManagJ Nurs Manag 1997; 5: 199 1997; 5: 199––205.205.

Leadership Roles in the Leadership Roles in the Change PlanChange Plan

Change leaders will initiate, monitor, develop, evaluate Change leaders will initiate, monitor, develop, evaluate and act as agents for the changeand act as agents for the change1,21,2

One single change agent will initiate the change by:One single change agent will initiate the change by:– Disseminating information about the changeDisseminating information about the change– Providing education sessions for staff involved in the changeProviding education sessions for staff involved in the change– Presenting the change plan and proposed management of the Presenting the change plan and proposed management of the

change to the manager of the practice and the practice boardchange to the manager of the practice and the practice board

Additional change agents will:Additional change agents will:– Implement the change within their client groupsImplement the change within their client groups– Assist in cascading the change to other staff involved in the Assist in cascading the change to other staff involved in the

care of patients with hypertensioncare of patients with hypertension

Use of experienced nursing staff in this role reflects the Use of experienced nursing staff in this role reflects the need for leaders with the status and credibility to make need for leaders with the status and credibility to make them powerful change driversthem powerful change drivers

11Martin 2003. Martin 2003. Leading Change in Health and Social CareLeading Change in Health and Social Care , Routledge, London; , Routledge, London; 22Iverson. Iverson. Int J Hum ResInt J Hum Res 1996; 7: 122 1996; 7: 122––49.49.

Resource Implications of the Resource Implications of the Change PlanChange Plan

Resource implications and the effects on staff Resource implications and the effects on staff workload/morale of any change plan must be workload/morale of any change plan must be consideredconsidered– Resources are limited within most healthcare servicesResources are limited within most healthcare services– Healthcare staff are known to be resistant to change Healthcare staff are known to be resistant to change

because they do not like the destabilisation of existing because they do not like the destabilisation of existing approaches to careapproaches to care11

– A sense that the change may add to workload may A sense that the change may add to workload may affect morale and impact on the success of the affect morale and impact on the success of the programmeprogramme22

Disseminated leadership will reduce burden on Disseminated leadership will reduce burden on individual staff and address the above concernsindividual staff and address the above concerns

11Martin 2003. Martin 2003. Leading Care in Health and Social CareLeading Care in Health and Social Care, Routledge, London; , Routledge, London; 22Yoder-Wise 2007. Yoder-Wise 2007. Leading and Managing Leading and Managing in Nursingin Nursing, Mosby, St. Louis., Mosby, St. Louis.

Project TimelinesProject TimelinesMonthMonth Key ActionsKey Actions

11 Development of an patient-centred community educational model to Development of an patient-centred community educational model to improve hypertension controlimprove hypertension controlPresentation of model to relevant parties to gather feedbackPresentation of model to relevant parties to gather feedback

22 Finalise staff and patient information materialsFinalise staff and patient information materialsImplement pilot education programme in 3 selected patientsImplement pilot education programme in 3 selected patientsAmend intervention according to feedback receivedAmend intervention according to feedback received

33––55 Recruitment and education of change leaders/agentsRecruitment and education of change leaders/agentsPreparation for implementationPreparation for implementation

55 Identification of resisting forces to change and necessary actions to Identification of resisting forces to change and necessary actions to overcome theseovercome theseDevelopment of record-keeping procedures and inclusion criteria for Development of record-keeping procedures and inclusion criteria for interventionintervention

66––88 Recruitment of patientsRecruitment of patientsAgree evaluation plan (quantitative/qualitative)Agree evaluation plan (quantitative/qualitative)

99–11–11 Implementation of interventionImplementation of interventionRegular weekly meetings of all staff to discuss emergent issuesRegular weekly meetings of all staff to discuss emergent issues

1212 First evaluation of interventionFirst evaluation of intervention

1515 Final evaluation of interventionFinal evaluation of intervention

ConclusionsConclusionsResearch highlights the need to improve patient understanding of Research highlights the need to improve patient understanding of hypertension, the symptoms, and the significance of ongoing high blood hypertension, the symptoms, and the significance of ongoing high blood pressure readingspressure readings

Evidence demonstrates the benefits of education programmes in Evidence demonstrates the benefits of education programmes in hypertensive patientshypertensive patients

This educational program would support patients with hypertension to This educational program would support patients with hypertension to reduce blood pressure readings through an increased understanding of reduce blood pressure readings through an increased understanding of their condition and normal their condition and normal vsvs abnormal readings abnormal readings

Potential benefits:Potential benefits:– Improved self-efficacy regarding management of their condition Improved self-efficacy regarding management of their condition – Reduced demand on healthcare servicesReduced demand on healthcare services

A structured approach will be employed which incorporates classic change A structured approach will be employed which incorporates classic change theories to plan, implement and evaluate the changetheories to plan, implement and evaluate the change

A successful program will require effective leadership, based on distributive A successful program will require effective leadership, based on distributive leadership theory, which gives authority and responsibility to multiple leadership theory, which gives authority and responsibility to multiple nursing change agentsnursing change agents

Resource implications appear to be minimalResource implications appear to be minimal

References Alm-Roijer, C., Stagmo, M., Uden, G. & Erhardt, L. (2004) Better knowledge improves adherence to lifestyle changes and medication in patient with coronary heart disease. European Journal of Cardiovascular Nursing, 3, 321-330. Bass, B.M. (1990) Bass and Stogdill's Handbook of Leadership: Theory, Research and Managerial Applications. New York: Free Press. Baulcomb, J.S. (2003) Management of change through force field analysis. Journal of Nursing Management, 11, 275-280. Beech, M (2002) `Leaders or managers: the drive for effective leadership', Nursing Standard, 16 (30), 35-36. Beinecke, R.H. & Spencer, J.(2007) International Leadership Competencies andIssues. The International Journal of Leadership in Public Services.3 (3), 4-13.Bowling, A. (2002) Research Methods in Health: Investigating health and health services (2nd ed.). Maidenhead: Open University Press. Breitmayer, B.J., Ayres, L. & Knafl, K.A. (1993) Triangulation in qualitative research: evaluation of completeness and confirmation purposes. Journal of Nursing Scholarship, 25 (3), 237-243. Buchanan, D., Fitzgerald, L. Ketley,D. et al. (2005) No going back: A review of the literature on sustaining organizational change International Journal of Management Reviews, 7 (3), 189-205.

Burke, V., Beilin, L.J, Cutt, H.E. et al. (2008) Moderators and mediators of behavior change in a lifestyle program for treated hypertensive's: a randomized controlled trial (ADAPT). Health Education Research, 23 (4) 583-591.

Burnes, B. (2004) Kurt Lewin and the planned approach to change: a re-appraisal. Journal of Management Studies 41 (6)

Burns, J.M. (1978) Leadership. New York: Harper and Row. Burns, N. & Grove, S.K. (1999) Understanding Nursing Research.

Philadelphia: WB Saunders. By, R.T. (2005) Organisational change management: A critical review Journal of

Change Management, 5 (4), 369-380. Carney, M. (2000) The management of change: using a model to evaluate the change

process. An innovative approach. Journal of Nursing Management, 265272 Clegg, A. (2000) `Leadership: improving the quality of patient care',

Nursing Standard, 14 (30), 31-32. Cockburn, J. (2004) Adoption of evidence into practice: can change be sustainable.

Medical Journal of Australia, 180 (9), 66-67. Connell, P., Wolfe, C. & McKevitt, C. (2008) Preventing stroke: a narrative review of

community interventions for improving hypertension control in black adults. Health and Social Care in the Community, 16 (2), 165-

187. Corben, V. (1999) Misusing phenomenology in nursing research: identifying theissues Nurse Researcher, 6 (3), 52-66.Cork, A. (2005) `A model for successful change management', Nursing Standard,

19 (25), 40-42.

Dagget, L.M., Harbaugh, B.M. & Collum, L.A. (2005) A worksheet for critiquing quantitative nursing research. Nurse Educator, 30 (6), 255-258.

Day, D.V. (2000) Leadership development: a review in context. The Leadership

Quarterly, 11 (4), 581-683.Denzin, N.K. & Lincoln, Y.S. (2005) The Sage Handbook of Qualitative

Research. London: Sage Publications. Department of Health. (2000) The NHS Plan. London: Department of Health.

DiCenso, A., Guyatt, G. & Ciliska, D. (2005). Evidence based nursing: A guide to clinical practice. Philadelphia: Mosby.

Donovan, S. (2002) Systematic Critique - the Art of Scientific Reading. Biomedical Scientist, Feb 1-2.

Duffy, M.E. (2005) Resources for Critically Appraising Quantitative Research Evidence for Nursing Practice. Clinical Nurse Specialist, 19 (5), 233-235.

Forchuk, C. & Roberts, J. (1993) How to critique qualitative research articles. Canadian Journal of Nursing Research, 25(4), 47-5.

Fullan, M. (2004) Leading in a culture of change: personal action guide and

workbook. : Josse Bass CA.Garside, P. (1998) Organisational context for quality: lessons from the fields of

organisational development and change management. Quality in Health Care, 7 (Suppl) S8-S15.

Greasely, A. (2006) Using process mapping and business process simulation to support a process-based approach to change in a public sector organisation.

Technovation, 26, 95-103.

Green, E. (2003). What should change in nursing practice over the next five minutes. Nursing Leadership, 15 (4), 27-30. Grint, K. (2005) Problems, problems, problems: The social construction of `leadership'. Human Relations, 58 (11), 1467-1494. Grol, R. & Wensin, M. (2004) What drives change? Barriers to and incentives for achieving evidence-based practice. Medical Journal of Australia, 180 (6), 57-60. Gustafson, D.H., Sainfort, F., Eichler,M. et al. (2003) Developing and Testing a Model to Predict Outcomes of Organizational Change Health Services Research, 38 (2), 751-776. Hagerman, Z.J. & Tiffany, C.R. (1994) `Evaluation of two planned change theories', Nursing Management, 25 (4), 57-62. Harris, A. & Spillane, J. (2008) Distributed leadership through the looking glass.Management in Education, 22 (1), 31-34.Hek, G. (2000) Evidence-based practice: finding the evidence. Journal of Community

Nursing 14 (11), 19-22. Heward, S., Hutchins, C. & Keleher, H. (2007) Organizational change-key to capacity building and effective health promotion. Health Promotion International, 22(2), 170-178. Iverson, R.D. (1996) Employee acceptance of organizational change: the role of organizational commitment The International Journal of Human Resource Management, 7 (1), 122-149.

Jackson, C.R.A. (2006) The Human Face of Organisational Change Thesis: Southern Cross University, Australia.

Kearney, P.M. Whelton, B.S., Reynolds, K. et al. (2005) Global burden of hypertension: analysis of worldwide data. The Lancet, 365 (9455), 217-223.

Kitson, A., Harvey, G. & McCormack, B. (2000) Enabling the implementation of evidence based practice: a conceptual framework. Quality in Health Care, 7, 149-158.

Leung, C.M., Ho, G.K.H., Foong, M. et al. (2005) Small-group hypertension health education programme: a process and outcome evaluation. Journal of Advanced

Nursing, 52 (6), 631-639. Lewin, K. (1958) Group decision and social change. In Maccoby, E.E., Newcomb,

T.M. & Hartley, E.L. (eds.) Readings in Social Psychology. New York: Holt, Rinehart and Winston.

Lewin, K. (1951) Field Theory in Social Science. London: Harper Row. Martin, V. (2003) Leading change in Health and Social Care. London:

Routledge. McLaren, S. et al. (2002) Leading opinion and managing change in complex

organisation: findings from the South Thames Evidence-Based Practice project. NT Research, 7 (6), 444-458.

McPhail, G. (1997) Management of change: an essential skill for nursing in the 1990s. Journal of Nursing Management, 5(4), 199-205.

Mohammadi, E., Abedi, H.A., Jalali, F. et al. (2006) Evaluation of `partnership care model' in the control of hypertension. International Journal of Nursing Practice, 12,

153-159. Mulrow, P. J. (1998) Detection and control of hypertension in the population The United

States experience American journal of hypertension, 11 (1), 739-765.

Murphy, L. (2004) Transformational leadership: a cascading chain reaction. Journal of Nursing Management, 13, 128-136.

Neill, J. (2004) Field Theory-Kurt Lewin, available athttp://wilderdom.com/theory/FieldTheory.html (Accessed 8 October 2008).Oliveria, S..A., Chen, R.S., McCarthy, B.D. et al. (2005) Hypertension knowledge,

awareness and attitudes in a hypertensive population. Journal of General and Internal Medicine, 20, 219-225.

Redfern, S. & Christian, S. (2003) Achieving change in health care practice. Journal of Evaluation in Clinical Practice, 9 (2), 225-23 8.

Reigle, J. (1989) Resource allocation decisions in critical care nursing. Nurse Clinics of North America, 24 (4), 1009-15.

Robinson, J. H. (2001) Mastering research critique and statistical interpretation Nurse Educator, 26 (3), 136-141.

Rosswurm, M.A. & Larrabee, J.H. (1999) A model for change to evidence-based practice. Journal of Nursing Scholarship, 31 (4), 317-22.

Russel, C.K. & Gregory, D.M. (2003) Evaluation of qualitative research studies Evidence Based Nursing, 36 (6), available at www.evidencebasednursing.com

(Accessed 15 October 2008. Shanley, C. (2007) Management of change for nurses: lessons from the discipline of

organizational studies. Journal of Nursing Management, 15, 53 8-546. Sheldon, L. & Parker, P (1997) `The power to lead'. Nursing Management, 4

(1), 8-9. Spendlove, M. (2007) Competencies for effective leadership in higher education. International Journal of Educational Management, 21 (5), 407-417

Stetler, C.B., Brunell, M., Giuliano, K.K. et al. (1998) Evidence-based practice and the role of nursing leadership. Journal of Nursing Administration, 28 (7-8), 45-53.

Stockhausen, L. & Conrick, M. (2002) Making sense of research: a guide for critiquing a paper. Contemporary Nurse, 14 (1), 38-48. Tan, C.C. (2006) The theory and practice of change management. Asian Business

and Management, 5, 153-155. Tappen, R.M. (2001) Nursing Leadership and Management: concepts

and practice (4th ed.). Philadelphia: FA Davis Company. Thompson, D. (2000) Design and Analysis of Clinical Nursing Research

Studies London: Routledge. Tortora, G.J. & Grabowski, S.R. (1996). Principles of Anatomy and

Physiology (8`hed.). New York: Harper Collins.Yoder-Wise, P.S. (2007) Leading and Managing in Nursing. St Louis:

Mosby. Zernike, W. & Henderson, A. (1998) Evaluating the effectiveness of two teaching

strategies for patients diagnosed with hypertension. Journal of Clinical Nursing, 7, 37-44.