**4. The role of nursing education in promoting patient's kidney self-care capacities**

Health education, as a field for knowledge production, assumes a privileged relationship with active citizenship, providing patient/family with the possibility of making informed decisions and acting in collaboration with the health team.

Assuming the empowerment speech as a key element of the care action, which is shaped at the border between the biomedical model and the model of care centred on the patient, Orem's theory of self-care fits in this context. Especially when it is intended to establish partnerships and promote self-care behaviors in the prevention and control of hypertension in patients with CKD through an educational intervention.

According to Orem, the individual is an active subject, but in a situation of illness, his capacity for self-care can be reduced due to his inefficiency in relation to the condition that affects him [39].

In 2013, the World Health Organization (WHO) defined self-care as the ability of individuals, families and the community to promote health, prevent disease and stay healthy. The partnership with healthcare professionals to deal with the disease and disabilities arises when individuals are unable to meet some or all of the needs for self-care, due to a lack of knowledge, disability or perception of their diminished health status.

Nurses act as a resource for the patient, developing helping methods in order to overcome or compensate health-related limitations, leading the patient to undertake actions to regulate their own functioning and development. The intervention is carried out according to a diagnostic and intervention process. It starts with needs assessment, identification of motivation to learn and, in partnership with the patient and/or family, establishment of the goals to be achieved. In this process the nurse can direct, guide, provide support and teach [39].

CKD patients need to undertake a range of complex activities, such as monitoring blood pressure, blood glucose, introducing changes in diet, adhering to therapy, avoiding nephrotoxic substances and practicing physical exercise [40].

It is internationally recognized that disease self-management is now an essential aspect of the health system. The implementation of a disease selfmanagement plan based on negotiated complementary actions, allows the process participants to rediscover the conditions (knowledge and skills) to satisfy their needs. With the aging of population, families assume an increasing importance in the daily management of the disease. Therefore, families and patients are the clients of health professionals and the expression of their interests must be taken into account [41].

There are many difficulties for active participation of individuals in the management of their disease due to lack of knowledge and skills to deal with the disease. Therefore, between unawareness and fears, people's behavior can take two directions: control or ignore the problem. In either cases, nurses have a predominant support role in making people aware of their potential, leading them to develop and put that potential at the service of the disease.

Health education is a strategy to be followed, as it constitutes a teaching, instruction and training tool in order to guide the patient and their families to face a new situation in the management and prevention of the disease.

It is true that CKD patients have the same characteristics as the general population in terms of self-care behaviors in controlling blood pressure, following a healthy diet and regular physical exercise. However, it is no less true that CKD disease, due to its complexity and need for intervention in all of the stages, requires specific intervention and monitoring actions along the path of the disease.

*Self-Management of Blood Pressure Control at Home in Chronic Kidney Disease… DOI: http://dx.doi.org/10.5772/intechopen.96416*

As CKD is an asymptomatic disease, especially in the early stages, it means that patients with CKD, because they are unaware of their situation, do not seek information. It is also a fact that the low perception of susceptibility is associated with low levels of literacy and, consequently, with a reduced perception of the risk of developing the disease [40].

This discouraging picture highlights important gaps regarding the patient's monitoring plan. In this context, innovative and complementary practices are needed to implement an individualized monitoring program based on the patient's real problems, both in hospitals and in primary health care. As a reference, we identify health education projects developed in specialized hospital consultations, or even in the wards, based on information, instruction and training techniques aimed at this population.

The question that arises is: what directions can be pursued to achieve these goals?

Firstly, it is essential to identify and accurately assess self-care behaviors, regarding blood pressure monitoring at home and levels of activation in disease management in its various stages. Secondly, the implementation of an intervention that promotes knowledge, skills and patient activation in the disease management. That is, providing the means to enable patients to make informed decisions, make a self-monitoring and self-assessment of their condition and implement strategies to solve some problems that arise [42].

Indeed, in the context of CKD research, self-management interventions are on the top of the agenda when it comes to preventing disease progression [43]. For example, Havas et al. indicates that chronic kidney patients reported the need to learn how self-manage their disease and to integrate self-management behaviors into their daily lives [44].

In this context, the education process is a fundamental tool. For it to be successful it is important to take into account the motivation, the literacy level, the patient activation in disease management and the patient/health professional relationship [45].

Activation is an interactive process and consists of the patient's ability to actively participate in disease management, to assume an active behavior in favor of a passive attitude. Several factors take action in this process, such as the patient's motivation, beliefs, knowledge and abilities/skills to perform [46].

Activated patients have higher scores for participation in disease self-management, namely blood pressure monitoring, healthy eating habits, physical exercise, smoking cessation, etc., when compared to those who are not [47].

Activation exists in a continuum in which the patient moves between four levels, depending on state of health, self-confidence, motivation to get involved and circumstances of life.

The four levels are:


Along with the concept of patient activation, the concept of perceived efficacy gains relevance in the disease self-management. To the previous ones, demographic characteristics (age, gender, education) and clinical characteristics (cognitive and physical capacity) are added.

Perceived self-efficacy refers to the person's perception of their own ability to perform a certain activity in order to achieve a goal or result. According to Bandura, it is important for people to believe that they are able to successfully develop a certain action, because that will be the guarantee of getting involved and adopting goals for that purpose [49].

Bandura also defines how much effort a person will need and how long it will last when faced with difficulties and negative experiences. There is a tendency to avoid situations that may exceed the limit of the person's capabilities and to deal with those that the person thinks are solvable. The person tends to distance from situations with high levels of demand, offering the most varied justifications [50].

In this way, different scores for perception of self-efficacy can increase or decrease the motivation for action, with higher self-efficacy scores corresponding to better health. Previous research has shown this relationship, in addition to showing that high self-efficacy was associated with positive changes in health behaviors [49].

Several studies in nephrology field have found an association between high levels of perceived self-efficacy and health gains in groups of hemodialysis patients, regarding weight control improvement between dialysis sessions, reducing hospitalizations, amputations and improving quality of life [51].

Taking into account the international scenario, hypertension represents a burden for global disease context. Thus, standardized blood pressure measurement is essential for diagnosis and blood pressure management [36].

Lopez-vargas et al. showed that patients with CKD in the most advanced stages have low levels of knowledge about the associated risk factors, including hypertension and its management. The authors found that 54% of the patients received information on blood pressure monitoring, adherence to therapy and food preparation. They also identified that nurses had the main role of educators in 73% of the necessary studies. The results indicated that of the 54% of the patients involved in disease self-management, 31% had their blood pressure controlled [52].

The interventions that most contributed to the effectiveness of the process were: teaching practical skills, workshops, follow-up patient on a regular basis and negotiating goals to achieve.

Patients involved in blood pressure monitoring at home learn to understand the connection between measuring and controlling blood pressure and more easily adhere to strategies that contribute to controlling blood pressure, specifically diet, exercise and adherence to therapy. This attitude towards the disease shows improvements in health status [53].

For Wanchai & Armer nurses can help the patient to improve their self-care skills [54]. The question is: how to do it?

Returning to Orem's theory, the authors mention that there are three classifications of nursing systems to meet the self-care requisites of the patient: wholly compensatory system, partially compensatory system and the supportive-educative system. Regarding the first system, nurses need to completely replace the individual due to the inability to self-care. In the second system, a patient can meet some self-care requisites but needs a nurse to help meet other needs. In the supportiveeducative system, a patient can meet self-care requisites but needs assistance with decision making, behavior control, or knowledge acquisition skills, so nurses teach, train and support the patient for self-care. Often the patient is unable to perform his activities because he does not have the necessary knowledge to perform them. According to Orem, in some situations, the patient needs the nurse's guidance to

#### *Self-Management of Blood Pressure Control at Home in Chronic Kidney Disease… DOI: http://dx.doi.org/10.5772/intechopen.96416*

carry out the self-care action and in other situations he needs to learn the techniques to be able to perform them.

The authors mention other methods of training the patient for self-care, promoted by nurses, such as coaching, stimulating the patient's participation and establishing of therapeutic relationship.

The authors add the motivational interview as a strategy to motivate the patient to change specific behaviors. They also report that review studies have shown the effectiveness of this method in changing behaviors for healthy lifestyles. Other authors have stated that this type of approach is useful in situations where the patient is less motivated to assume self-care or in situations where the patient not yet prepared to take charge of his illness condition.

In the context of health education, giving educational materials can help the patient in the learning process. However, it is necessary to pay attention to the patient's abilities in terms of reading and comprehension to avoid bad decisions about self-care. The demonstration and training blood pressure measurement in different methods involving the technique of blood pressure measurement at home should be promoted. Additional resources such as videos, access to websites dedicated to this subject or leaflets demonstrating the technique, may be useful in demonstrating blood pressure monitoring at home.

Nurses play an important role in this process, helping the patients to select and understand the best method for themselves [55].

Nurses should inform the patient about the recommended schedule for blood pressure monitoring at home. According to the European Hypertension Society Working Group, blood pressure should be taken twice in the morning and twice in the afternoon [56].

In some experts' opinion, blood pressure self-monitoring over a long period may allow a more accurate assessment of blood pressure stability and increase the patient's commitment to treatment.

Nurses should discuss with patients the importance of blood pressure selfmanagement. Therefore, an important element in this whole process is the communication established between the health professional and the patient. Feedback should be maintained even when the professional is not on duty. The patient should be able to communicate with the healthcare professional via telephone, fax and e-mail. There are also other ways of data communication, namely through stored data in devices, mobile phone applications (smartphone applications) and internet.

Nurses can help the patient to obtain health gains through adequate training in blood pressure measuring methodology and interpreting the values obtained in blood pressure monitoring at home.

To this purpose, nurses should explain and demonstrate the technique to the patient and inform about the recommended devices [57]. The **Table 2** shows the Society of Cardiology and the European Society of Hypertension recommendations regarding blood pressure measurement at home.

Regarding device selection, literature indicates that the recommended devices for HBPM are the automatic oscillometric arm devices. This kind of equipment is more user-friendly and requires less skills when compared to manual devices.

Electronic arm devices for BP measurement, especially those that allow the storage, transmission or printing measuring data, should be preferred for HBPM. It is also crucial that patients make sure that the devices they acquire have been validated according to recommended criteria. The European Society for Hypertension Working Group on Blood Pressure Monitoring has developed a protocol applicable to most BP measuring devices available on the market. The European Society of Hypertension supported the creation of a website where updated lists of validated BP measurement devices are published (www.dableeducational). The British


#### **Table 2.**

*Recommendations for HBPM.*

Hypertension Society (www.bhsoc.org) also publishes information on device validation.

In Herber, et al., it is essential that the patient and family have coping strategies to deal with the disease and complications. The authors highlight the role of regular home visits in establishing a therapeutic relationship. In these visits, nurses can support and teach the patient and family to manage the therapeutic regimen, increase levels of knowledge about the disease and self-care behaviors, as well as guide the resources available in the community [58].

For Coates et al., the management of the disease is challenging, both for the patient and his relatives, as well as for health professionals, as it requires a change

#### *Self-Management of Blood Pressure Control at Home in Chronic Kidney Disease… DOI: http://dx.doi.org/10.5772/intechopen.96416*

in the philosophy of care. The paradigm change demands the active involvement of the patient in decisions and problem solving. In this context, new strategies are required to make the patient responsible for the management of his health [59].

Negotiation is, thus, an important strategy to prevent the patient from adopting a passive attitude and, at the same time, to equip the patient with the necessary skills and abilities for disease management [60].

Advice and support in changing daily routines are essential for the control of HTA [61].

Blood pressure self-monitoring makes patients more aware of their pressure values and leads them to commit themselves more actively in their therapeutic plan.

In summary, self-care is an essential component for chronic disease management and, in the case of CKD, is certainly a sine qua non condition. The evolutionary path of CKD brings with it a growing number of daily self-care activities for the individual, such as deciding what to do, undertaking self-care activities related to disease monitoring and putting a strong increase in the investment of healthy behaviors, including blood pressure control, diet and exercise, among others.

The health gains for the patient consist of increased quality of life, empowerment, success in lifestyle changes due to active role and involvement in disease management. The change in perception of hypertension can encourage the patient to comply with therapy and make the necessary lifestyle changes [62].
