Effectiveness of Aerobic Exercise on Ambulatory Blood P.docx

Effectiveness of Aerobic Exercise on Ambulatory Blood
Pressure in Hypertensive Patients
Presented by
Chinyere Christiana Pamugo
1
DNP 965: Final Oral Presentation
December 13, 2022
A Direct Practice Improvement Project Presented in Partial
Fulfillment

of the Requirements for the Degree
Doctor of Nursing Practice
2
Investigator’s background
Registered Nurse for XXX years
3
Topic’s background
Many individuals are unaware of the symptoms for
hypertension, which makes it a top priority to educate patients

and their families.
In the United States, over 37 million individuals are affected
(Centers for Disease Control and Prevention [CDC], 2021; Krist
et al., 2021).
The American College of Cardiology and the American Heart
Association guidelines for hypertension management and
definition of HTN defines it as having a blood pressure at or
above 130/80 mmHg (The American College of Cardiology
Foundation and the American Heart Association, 2018). At the
same time, stage 2 HTN is blood pressure at or above
140/90mmHg (CDC., 2021).
4
Topic’s background
Complications of the condition include myocardial infarction,
heart failure, chronic renal disease, and stroke (Ghatage et al.,
2021).
American Heart Association Task Force (AHA) published new
guidelines to help manage the increase of the disease (Wang et
al., 2019).
Purpose statement
The purpose of this quantitative, quasi-experimental project was
to determine if or to what degree the translation of Saco-Ledo et

al.’s research on aerobic exercise would impact ambulatory
blood pressure when compared to current practice among adult
hypertensive patients in a primary care clinic in southwest
Texas over four weeks
6
problem statement
It was not known if or to what degree the translation of Saco-
Ledo et al.’s research on aerobic exercise would impact
ambulatory blood pressure when compared to current practice
among adult hypertensive patients
7
Identified problem
At the clinical site, there were no standardized guidelines for
clinicians to educate hypertensive patients regarding
implementing daily physical activity as a blood pressure
management mechanism.
Collaboration with the medical director and some of the nursing
staff showed an increase of 37.1% in diagnosed HTN patients
within the past six months. The clinic’s findings corresponded

with the health statistics from the Texas Department of State
Health Services (2022), as the county ranks 22 in the States
with diagnosed hypertensive patients
8
Significance of the project
Implementing a recommended evidence-based strategy by the
AHA guideline regarding aerobic exercise
Commodore-Mensah et al. (2018) state that the financial prices
are significant, approximately $131-198 billion annually
This project could help decrease the financial costs associated
with the disease
Hypertensive persons incur an extra $2000 yearly in healthcare
expenditures compared to non-hypertensive persons
(Commodore-Mensah et al., 2018).
9
Clinical question
To what degree does the translation of Saco-Ledo et al.’s
research on aerobic exercise would impact blood pressure when
compared to current practice among adult hypertensive patients
in a primary care clinic in southwest Texas?
The independent variable was the translation of Saco-Ledo et
al.’s research regarding aerobic exercise, and the dependent
variable is blood pressure
10
Theoretical underpinnings

Dorothy Orem’s self-care deficit theory (Orem, 1995).
Kurt Lewin’s change model (Lewin, 1947).
Unfreezing
Change or Movement
Refreezing
Based on the theory, self-care is that patients must engage in to
maintain and improve their quality of health (Orem, 1995).
Utilizing this theory, the nurses do not see their patients as
inactive or receiving health services; instead, they consider
them strong and reliable to participate in daily activities and
decision-making processes (Orem, 1995). Three nursing systems
are defined in Orem’s nursing theory; they include wholly
compensatory, partially compensatory, and supportive-educative
strategies (Khademian et al., 2020).
The chosen change is Lewin’s change model. It was selected
because it is a way to describe the process change versus
guiding the activities that will be conducted.
11
review of the Literature
Prevention of Hypertension
Systolic Blood Pressure Management
Diastolic Blood Pressure Management
Ambulatory Blood Pressure Management
Aerobic Exercise Health Intervention
Pre-Aerobic State
Post-Aerobic State
Ambulatory Blood Pressure Management
Effect of Exercise on Blood Pressure
Health Literacy Level
Self-Efficacy
Lifestyle Modification

12
clinical Question
To what degree does the implementation of American Heart
Association guideline aerobic exercise would impact blood
pressure when compared to current practice among adult
Texas?
The independent variable is the American Heart Association
guideline regarding aerobic exercise, and the dependent variable
is blood pressures.
13
Methodology
Quantitative methodology
Using numerical data
It is objective, systematic, and focused data analysis strategies
(Guetterman & Fetters, 2018).
Data can be replicated (Creswell & Creswell, 2018).
In this project, the project manager will evaluate the AHA

guidelines and its impact on the blood pressures of HTN
patients. The dependent variable will be measured four weeks
before and post project intervention. This methodology is the
most appropriate because other investigators can replicate the
data (Creswell & Creswell, 2018).
A qualitative methodology was not selected because this method
is often thematic and subjective, and findings are produced
using the participants' words verbatim (Creswell & Creswell,
2018). In this project, the project manager will not seek to
understand the participants' behaviors, feelings, or lived
experiences (Creswell & Creswell, 2018
14
Project design
Quasi-experimental design
Determines the effect that the independent variable has on the
dependent variable (Creswell & Creswell, 2018).
Participants are not randomly assigned (Creswell & Creswell,
2018).
Project manager will manipulate the independent variable
For this project, the dependent variable (blood pressure) will be
measured at two different times (once before the intervention
and one after the intervention (Creswell & Creswell, 2018). A
correlational design was not the most appropriate for this
project. It is a non-experimental design where the independent
and dependent variables are measured and assessed for their
correlation relationship (Creswell & Creswell, 2018).

15
Instrumentation
Data source: ABPM log retrieved from the Oscar 2 device
Electronic ABP data retrieved from the electronic medical
record
Before starting the ABP project, it was imperative to ensure that
the device operated as required and was installed correctly on
the patient (Nwankwo et al., 2020).
The electronic ABP data on the device was retrieved from a
computer via a USB cable
16
Data collection
Data collected four weeks pre/post implementation
Oscar 2 device
Participants walked at home three to five times weekly for 20
minutes
They were instructed to continue taking their antihypertensive
medications
Tracked their process in a logbook (Mon, Wed, Fri)
Participants were re-evaluated at the clinic week four
The healthcare providers took the 24-hour ABP measurements at
two-time points: baseline without aerobic exercise in week one
and week four after the workout
In week four, the participants returned to the clinic to retake
their ABP using Oscar 2 device. Participants ambulated around
the clinic for 20 minutes wearing the Oscar 2 device. They were

monitored for their walking, whether it was intense or moderate.
The ABP measurements were taken after a 20-minute rest period
by the staff.
17
Data analysis
Descriptive data (such as age, gender, and ethnicity)
Paired Sample t-Test.
Descriptive data (such as age, gender, and ethnicity) will be
collected via the clinic’s electronic medical records (evaluated
using frequency counts and percentages)
The independent variable is nominal, and the dependent variable
is an interval level variable (Schober & Vetter, 2019). This t-
test examines the mean scores taken from the same participants
(Schober & Vetter, 2019).
The level of statistical significance was set to .05 to indicate
that a p-value of less than .05 will be considered statistically
significant.
18
resultsVariableDescriptive DataMSDAge56.507.92
Table 1
Descriptive Data for Age
Table 2
Descriptive Data for Gender and RaceVariableDescriptive
Datan%Gender Male330.0 Female770.0Race African
American880.0 Hispanic110.0 Caucasian110.0
Note. M = mean; SD =standard deviation
Note. n =count; % = percentage

results
VariablePre
Post
t (9)
pMSDMSDSystolic BP
(mm/Hg)152.6014.42126.1019.936.35.001
Chi-square test results showed a decrease in the mean systolic
BP level from pre (M = 152.60, SD = 14.42) to post (M =
126.10, SD = 19.93), t (9) = 6.35, p = .001. The p-value is less
than .05 which indicates that the decrease in mean systolic BP
was statistically significant. Clinical significance was supported
by the 26.50 mean decline in the systolic mean levels after the
intervention.
Table 3
Paired t-Test Results for Systolic Blood Pressure Levels
results
VariablePre
Post
t (9)
pMSDMSDDiastolic BP (mm/Hg)87.3011.1978.108.452.56.031

Chi-square test results showed a decrease in the mean diastolic
BP level from pre (M = 87.30, SD = 11.19) to post (M = 78.10,
SD = 8.45), t (9) = 2.56, p = .031. The p-value is less than .05
which indicates that the decrease in mean diastolic BP was
statistically significant. Clinical significance was supported by
the 9.20-point mean decline in the systolic mean levels after the
intervention.
Table 4
Paired t-Test Results for Diastolic Blood Pressure Levels
limitations
Small sample size
Limited time frame to conduct project (four-weeks)
Data analysis being conducted by outside statistician
First limitation: Small sample size
Second limitation: Limited time (four-weeks) a longitudinal
project three or more months
Third limitation: Due to the project manager’s limited
knowledge and time in conducting statistical analysis, an
outside statistician not affiliated with the project or manager
will perform the data analysis.
22
discussion
Clinical significance was demonstrated by the 26.50 mean
decline in the systolic mean and 9.20 in the diastolic mean and
9.20 in the diastolic mean levels

Based on the results, the translation of Saco-Ledo et al.’s on
aerobic exercise may improve blood pressure. One
recommendation for future projects is to conduct the project in
other medical settings, such as medical-surgical units, women’s
health, and dialysis patients.
Recommendations
The project findings showed that an educational program in
combination with aerobic exercise about hypertension can result
in systolic and diastolic blood pressure changes
Reproduce the intervention in other healthcare settings
Conduct longitudinal project (one year or longer)
For nurse managers to pay attention to the HTN risk in their
older employees (age 40 and above)
Evaluate the patient’s health stressors that can contribute to
hypertension
references
Centers for Disease Control and Prevention, (2021). Facts about
hypertension in the United States.
https://www.cdc.gov/bloodpressure/facts.htm
Commodore-Mensah, Y., Selvin, E., Aboagye, J., Turkson-
Ocran, R., Li, X., Himmelfarb, C., Ahima, R., & Cooper, L. A.
(2018). Hypertension, overweight/obesity, and diabetes among
immigrants in the United States: An analysis of the 2010–2016
national health interview survey. BMC Public Health, 18(1), 1-
8. https://doi.org/10.1186/s12889-018-5683-3

Creswell, J.W., & Creswell, J. D. (2018). Research design:
Qualitative, quantitative, and mixed methods approaches
(5thed.). Sage Publications.
references
Ghatage, T., Goyal, S., Dhar, A., & Bhat, A. (2021). Novel
therapeutics for the treatment of hypertension and its associated
complications: Peptide- and nonpeptide-based
strategies. Hypertension Research, 44(7), 740-755.
https://doi.org/10.1038/s41440-021-00643-z
Guetterman, T., & Fetters, M. (2018). Two methodological
approaches to the integration of mixed methods and case study
designs: A systematic review. American Behavioral Scientist,
62, 900-918.
https://doi.org/10.1177/0002764218772641
Krist, A., Davidson, K., Mangione, C., Cabana, M.,
Caughey, A., Davis, E., Donahue, K., Doubeni, C., Kubik, M.,
Li, L., Ogedegbe, G., Pbert, L., Silverstein, M., Stevermer, J.,
Tseng, C., & Wong, J. (2021). Screening for hypertension in
adults. JAMA, 325(16), 1650-
1656. https://doi.org/10.1001/jama.2021.4987
references
Lewin, K. (1947). Frontiers in group dynamics: concept,
method, and reality in social science; social equilibria and
social change. Human Relations, 1, 5–41.
https://doi.org/10.1177/001872674700100103

Nwankwo, T., Coleman King, S. M., Ostchega, Y., Zhang, G.,
Loustalot, F., Gillespie, C., & Merritt, R. (2020). Comparison
of 3 devices for 24-hour ambulatory blood pressure monitoring
in a nonclinical environment through a randomized trial.
American Journal of Hypertension, 33(11), 1021-
1029.https://doi.org/10.1093/ajh/hpaa117
Orem, D. E. (1991). Nursing: Concepts of practice (4th ed.).
Mosby.
Schober, P., & Vetter, T. (2019). Descriptive statistics in
medical research. Anesthesia & Analgesia, 129(6), 1445-1447.
https://doi.org/10.1213/ane.0000000000004480
Wang, D., Hatahet, M., Wang, Y., Liang, H., Bazikian, Y., &
Bray, C. (2019). Multivariate analysis of hypertension in
general US adults based on the 2017 ACC/AHA guideline: data
from the national health and nutrition examination survey 1999
to 2016. Blood Pressure, 28(3), 191-198. doi:
10.1080/08037051.2019.1593042
By Chinyere Christiana Pamugo
Grand Canyon University, Phoenix Arizona
Introduction and Problem
Variables
Descriptive Data
Results
Results (cont.)
Clinical Question(s)

Discussion
Project Limitations
Recommendations for Future Projects and Practice
Purpose of the Project
Data Analysis
The project site is a primary care clinic in urban Texas. A
convenience sample of n= 10 adult patients with HTN were
enrolled in the project. Descriptive data were collected for age,
gender, and race.
Table 1 displays the descriptive data for age. The mean age was
56.50 (SD = 7.92) ranging from 43 to 71.
References
The independent variable was the translation of Saco-Ledo et
al.’s research regarding aerobic exercise, and the dependent
variable is ambulatory blood pressure.
.
.
Centers for Disease Control and Prevention (CDC). (2021).
Facts about hypertension in the United States.
https://www.cdc.gov/bloodpressure/facts.htm
Krist, A., Davidson, K., Mangione, C., Cabana, M., Caughey,
A., Davis, E., Donahue, K., Doubeni, C., Kubik, M., Li, L.,
Ogedegbe, G., Pbert, L., Silverstein, M., Stevermer, J., Tseng,

C., & Wong, J. (2021). Screening for hypertension in adults.
Journal of the American Medical Association, 325(16), 1650-
1656. https://doi.org/10.1001/jama.2021.4987
Leedy, P., & Ormrod, J. (2020). Practical research: Planning
and design. Pearson Publications.
Saco-Ledo, G., Valenzuela, P., Ruiz-Hurtado, G., Ruilope, L., &
Lucia, A. (2020). Exercise reduces ambulatory blood pressure in
patients with hypertension: A systematic review and meta-
analysis of randomized controlled trials. Journal of American
Heart Association, 15(9), 1-18. doi: 10.1161/JAHA.120.018487.
Many individuals are unaware of the symptoms for
hypertension, which makes it a top priority to educate patients
and their families.
In the United States, over 37 million individuals are affected
(Centers for Disease Control and Prevention [CDC], 2021; Krist
et al., 2021).
Using the translation of Saco-Ledo et al.’s research on aerobic
exercise would impact ambulatory blood pressures.
At the clinical site, there were no standardized guidelines for
management mechanism
It was not known if or to what degree the translation of Saco-
Ledo et al.’s research on aerobic exercise would impact
among adult hypertensive patients
Chi-square test results showed a decrease in the mean systolic

BP level from pre (M = 152.60, SD = 14.42) to post (M =
126.10, SD = 19.93), t (9) = 6.35, p = .001. The p-value is less
than .05 which indicates that the decrease in mean systolic BP
was statistically significant. Clinical significance was supported
by the 26.50 mean decline in the systolic mean levels after the
intervention. The results are displayed in Table 3.
The results are presented to address the clinical question related
to the impact of the AHA guidelines for aerobic exercise on
systolic and diastolic blood pressure. A paired t-test was
conducted on systolic and diastolic blood pressure at pre-and
post-implementation.. The goal was to reduce ambulatory blood
pressure after the intervention. Results are displayed in
narrative and table format.
to determine if or to what degree the translation of Saco-Ledo et
al.’s research on aerobic exercise would impact ambulatory
Texas over four weeks
To what degree does the translation of Saco-Ledo et al.’s
research on aerobic exercise would impact blood pressure when
compared to current practice among adult hypertensive patients
in a primary care clinic in southwest Texas
Clinical significance was demonstrated by the 26.50 mean
decline in the systolic mean and 9.20 in the diastolic mean and
9.20 in the diastolic mean levels
Based on the results, the translation of Saco-Ledo et al.’s on
aerobic exercise may improve blood pressure. One
recommendation for future projects is to conduct the project in
other medical settings, such as medical-surgical units, women’s
health, and dialysis patients.

The first limitation was the restricted time to conduct the
project (four weeks). A longitudinal project allows one to
evaluate the trends and changes over time (Leedy & Ormrod,
2020).
The second limitation was the small sample size. The primary
problem with a small sample size was interpreting the results,
mainly related to the confidence intervals and p-values (Leedy
& Ormrod, 2020).
The project findings showed that an educational program in
combination with aerobic exercise about hypertension can result
in systolic and diastolic blood pressure changes
Nurse managers to pay attention to the HTN risk in their older
employees (age 40 and above)
hypertension
Descriptive data (such as age, gender, and ethnicity) including
mean and standard deviation for age and frequencies and
percentage for gender and ethnicity.
To examine systolic and diastolic blood pressure at pre- and
post-implementation, paired sample t-tests were conducted in
IBM SPSS version 28 using a level of significance of .05.
Table 1
Descriptive Data for Age
Table 2
Descriptive Data for Gender and Race
Gender and race are displayed in Table 2. There were three
males (30.0%) and females made up 70.0% (n = 7). Race was
80.0% (n = 8) African American, 10.0% (n = 1) Hispanic, and
10.0% (n = 1) Caucasian.

Table 3
Paired t-Test Results for Systolic Blood Pressure Levels
Chi-square test results showed a decrease in the mean diastolic
BP level from pre (M = 87.30, SD = 11.19) to post (M = 78.10,
SD = 8.45), t (9) = 2.56, p = .031. The p-value is less than .05
which indicates that the decrease in mean diastolic BP was
statistically significant. Clinical significance was supported by
the 9.20-point mean decline in the systolic mean levels after the
intervention.
Table 4
Paired t-Test Results for Diastolic Blood Pressure Levels
Note. n =count; % = percentage
TEMPLATE DESIGN © 2008
www.PosterPresentations.com
28
Statistics show that as at the end of 2010, an estimated 31.1% of
adults (1.39 Billion) worldwide had hypertension, with many
people unaware of its symptoms. This makes my projects unique
as it is designed for educating patients and their families. As

indicated above, complications from this health condition may
include myocardial infarction, heart failure, chronic renal
disease, and stroke (Ghatage et al., 2021).
Purpose of Study: My quantitative, quasi-experimental project
determines if or to what degree the translation of Saco-Ledo et
al.’s research on aerobic exercise can impact ambulatory blood
pressure when compared to current practice among adult
Texas over four weeks. The problem came from the fact that at
the clinical site, there was no standardized guidelines for
management mechanism. It created a problem statement that “it
was not known if or to what degree the translation of Saco-Ledo
et al.’s research on aerobic exercise would impact ambulatory
hypertensive patients.”
The significance of this project stems from the fact there is the
need to implement an evidence-based strategy such as the ones
recommended by the AHA guideline regarding aerobic exercise
as well as the recommendation of Commodore-Mensah et al.
(2018), in which it states that spending on prices are significant
and is approximately $131-198 billion annually. This project
potentially helps in decreasing the financial costs associated
with the disease when Dorothy Orem’s self-care deficit theory
(Orem, 1995) and Kurt Lewin’s change model (Lewin, 1947)’s
Unfreezing, Change or Movement and Refreezing are used.
Recommendations: The discovery in this projects proved that an
educational program in combination with aerobic exercise about
hypertension results in systolic and diastolic blood pressure
changes. Other recommendations include:
For nurse managers to pay attention to the HTN risk in their
older employees (age 40 and above)

hypertension
29
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4
Submitted by
A Direct Practice Improvement Project Presented in Partial
Fulfillment
of the Requirements for the Degree
Doctor of Nursing Practice
Grand Canyon University
Phoenix, Arizona
December 7th, 2022

© by Chinyere Christiana Pamugo, 2022
All rights reserved.
GRAND CANYON UNIVERSITY
has been approved
December 7th, 2022
APPROVED:
Dawn Robinson DNP, MSN, RN, LNHA, DPI Project
Chairperson
Khoa Don Nguyen, MD., DPI Project Mentor
ACCEPTED AND SIGNED:
________________________________________
Lisa Smith, Ph.D., RN, CNE
Dean and Professor, College of Nursing and Health Care
Professions
_________________________________________
Date

Abstract
Hypertension is a prevalent disease affecting millions of
individuals in the United States. At the project site, there were
no standardized guidelines for educating hypertensive patients
regarding incorporating exercise (daily physical activity) as a
blood pressure (BP) management mechanism. The purpose of
this quantitative, quasi-experimental project was to determine if
or to what degree the implementation of “the American Heart
Association’s” guideline on aerobic exercise would impact
among adult hypertensive patients in a primary care clinic in
southwest Texas over four weeks. Dorothy Orem’s self-care
deficit theory and Lewin’s change model were the scientific
underpinnings . Data were retrieved from the clinic’s electronic
medical records of adult hypertensive patients. (
n-10) and compared at baseline and four weeks post-
implementation of the American Herat Association’s guideline
on aerobic exercise. A paired-sample
t-test showed a statistically and clinically significant
improvement in the systolic blood pressure (
M=??,
SD=??,
p=??) and diastolic blood pressure (
M=??,
SD=??,
p=??). Based on the results, the American Herat
Association’s guideline on aerobic exercise may improve blood
pressure. One recommendation for future projects is to conduct
the project in other medical settings such as medical-surgical
units, women’s health, and dialysis patients.
Keywords: aerobic exercise, American Heart Association
guideline, Dorothy Orem’s self-care deficit theory,
hypertension, hypertension-related conditions, Kurt Lewin’
change model.

Dedication
I dedicate this project to God, my life's author and finisher.
Irrespective of the unsurmountable challenges and moments of
despair, your mercy, grace, and love lead me through. Without
your divine wisdom, Almighty father, I would not have been
here this day.
To my Beloved families here and abroad, my mum, siblings,
cousins, and spouse Engr. G. O. Pamugo, I achieved this goal
because of your fervent prayers, support, and encouragement
that fortified my strength, endurance, perseverance, and
resilience not to quit to frustrations and fears. Even with my
poor health, I struggled and still made it to this day because you
all held my weak parts as I journeyed and ran the race to
success. Thank you for believing in me and investing in my
success. God bless you all. To my dad-late Chief M.E. Chukwu,
I did accomplish your dreams on me, and I know wherever your
soul is at this time, it is full of joy; rest in peace, daddy, until
we meet again.
To my elder brother in the Lord, Rev. Fr. C. Iwuagwu, words
cannot express the magnitude of gratitude I owe you for your
fatherly and brotherly love, belief in my abilities, countless
hours of encouragement, enormous -uplifts, and renewed
determination. You are a blessing and gift to our family; remain
blessed.
Acknowledgments
The fruitful journey of my Doctor of Nursing program (DNP)
was made possible by the unconditional support of
extraordinary and cherished individuals, such as Dr. Khoa and
Don Nguyen, MD, for serving as my preceptor/mentor
throughout the stages of my direct immersion project. Dr.
Dawn Robinson, my Faculty /Chair, for her unshaken patience,
quick feedback, and radiant positive energy, together with Dr.
Katherine McDermott and faculty in course level review,
reading countless revisions and providing knowledgeably expert

guidance to the end of this course.
To my colleagues, Jeffrey Souza, Tresa Antony, Mercy Daniel,
Lisa Johnson, Marissa Rafael, and Skyler Meyer, thank you for
your unfading support. Countless times, I felt like the world has
collapsed upon me, desperately seeking the way out in the
darkness, lo and behold, your torchlights point through the
doors of escape. I recognized each day we journeyed that the
race was worth it because you all were there pointing your
lights to the proper outlet.
To my supportive friends, Sr. Onyinyechukwu Uba, Ms.
Euphemia, Ms. Amaka, Dr. Bashiru, Calista, Sylvia, Vincent,
and Ogunbayode. Thank you for your support, encouragement,
love, and understanding, especially in moments of desolation,
sequestration, and poor communication from me due to loads of
assignments on my table.
To my preceptees, Vivian, Michael, Adaeze, Jane, Kate, Esther,
Marybeth, Florence, Ebong, Nkele, and others, your
understanding when I transfer my frustrations to you humbled
me most in my relationship with you as a preceptor. Looking
upon the "role model thing" was the driving force that propelled
me to this finishing point. You are more than welcome anytime
for more guidance in the future in your further studies.
I was also working on my post-graduate certification program
in the psychiatric mental health nurse practitioner program, and
this is where I thank Dr. Ghislaine Mogo, my preceptor, for her
tremendous patience and support.
To my spiritual family, the Daughters of Charity of the Most
Precious Blood, God gave me the best opportunity to be among
you. Mother Ofelia Marzocca, see what I have become this day
because of your decisions in the most challenging moments of
my life and humble expression of an arduous journey that would
benefit all. Thank you all, and may God reward us according to
our deeds.
PLS USE THIS STATEMENT TO RESTRUCTURE, PROB

STATEMENT , CLINICAL QUSSTIONE, PUROSE AND
TOPIC
Statement of the Problem
It was not known if or to what degree the implementation “of a
translation of Saco-Ledo et al, aerobic exercise” would impact
among adult hypertensive patients.
Table of Contents
Chapter 1: Introduction to the Project1
Background of the Project2
Problem Statement3
Purpose of the Project4
Clinical Question7
Advancing Scientific Knowledge7
Significance of the Project10
Rationale for the Methodology11
Nature of the Project Design12
Definition of Terms13
Assumptions, Limitations, Delimitations15
Summary and Organization of the Remainder of the Project17
Chapter 2: Literature Review19
Theoretical Foundations22
Review of the Literature25
Prevalence of Hypertension26
Aerobic Exercise Health Intervention31
Effect of Exercise on Blood Pressure34
Summary39
Chapter 3: Methodology41
Statement of the Problem42

Clinical Question43
Project Methodology44
Project Design45
Population and Sample Selection46
Instrumentation and Sources of Data48
Validity49
Reliability49
Data Collection Procedures50
Data Analysis Procedures52
Potential Bias and Mitigation53
Ethical Considerations53
Limitations54
Summary55
Chapter 4: Data Analysis and Results57
Chapter 4 summarizes the collected data and how it was
analyzed. Other chapter segments include the problem
statement, clinical question, and methodology. The results are
presented in narrative form along with figures, tables. The last
section of the chapter provided a preview of Chapter 5 and its
contents.58
Descriptive Data58
Results60
Chapter 5: Summary, Conclusions, and Recommendations64
At the clinical site, the project manager, Medical Director, and
clinic manager collaborated regarding the increased ambulatory
blood pressures noted within the past three months. The
standard of care at the site is through medication management
for their condition. Hence, a unanimous decision was made to
utilize a new strategy, implementing the American Heart
Association's guidelines on aerobic exercise to influence
hypertensive patients.64
Chapter 5 reintroduced the project’s topic and summarized the
project. Other chapter segments included a summary of the
project’s findings and conclusion, theoretical, practical, and
future implications. The last portion of the chapter offered

recommendations for future quality improvement projects and
clinical practices.64
Summary of the Project65
This quality improvement project was conducted utilizing a
quantitative methodology and quasi-experimental design in four
weeks. Chapter 1 presented studies such as Adam and Wright
(2020), Aung and Htay (2021), Krist et al. (2021), and Saco-
Ledo et al. (2020) related to incorporating aerobic exercise to
be included in an individual’s HTN management plan. The
project contributed to the current body of literature, such as
Aung and Htay (2021), Krist et al. (2021), and Saco-Ledo et al.
(2020), regarding aerobic exercise being included in
hypertension management. The impacted population was adults
diagnosed with hypertension in a primary care clinic. The
county’s demographics revealed that roughly 60,000 seniors 65
and older comprise the county’s populace (Data USA, 2019). In
Texas, the incidence of HTN is at 35.1%, which validates
findings from the CDC (2021) and Million Hearts (2021).65
Chapter 2 discussed Orem’s self-care deficit theory and Lewin’s
change model are the theoretical underpinnings for this quality
improvement project. Orem’s self-care theory was chosen
because it focused on the reciprocal relationship between
humans and their environment (Orem, 1995). The theory
highlighted that a human could provide self-care, and the
primary goal of the healthcare provider should assist them in
achieving an optimal level of independence (Orem, 1995). The
nursing theory comprises five constructs: universal self-care
requisites, normalcy, developmental self-care requisites, and
health deviation self-care requisite (Orem, 1995). Implementing
this theory permitted the project manager to guide the clinicians
regarding their responsibilities in providing the patient with a
transparent plan of care. This helped the HTN patients to
sustain an appropriate level of self-care (Orem, 1995).65
Lewin’s change model was selected for this quality
improvement project. It was chosen because it emphasized the
need for change for clinicians and HTN patients impacted by

restraining forces (Lewin, 1947). The change model consists of
three phases: unfreezing, change (movement), and refreezing
(Lewin, 1947). The first phase, unfreezing, began when the
project manager collaborated with the nursing manager, medical
director, and a few nursing staff to detect the increase in
ambulatory blood pressures in HTN patients within the past
three months. The second phase, changing (movement), began
when the project manager educated the staff to use the
implementation of the American Heart Association (AHA)
guidelines related to aerobic exercise. During the phase, the
patients were educated by the staff, clinicians were trained, and
the project was monitored. The last stage, refreezing, began
when the discussion about the AHA guidelines became infused
into the organizational culture and a daily habit in the
healthcare providers' clinical practice (Lewin, 1947).66
The project was implemented once approval was received from
Grand Canyon University IRB and the project site. It was
implemented in four weeks to examine the impact of AHA
guidelines related to aerobic exercise on ambulatory blood
pressures. The project came after collaboration with the medical
director and some nursing staff showed an increase of 37.1% in
diagnosed HTN patients within the past six months. The project
contributed to the current body of literature regarding the
impact of aerobic exercise on decreasing one’s hypertension
(Aung & Htay, 2021; Krist et al., 2021; Saco-Ledo et al., 2020).
Other areas affected by regular aerobic exercise are weight loss,
improved well-being, and decreased symptoms of depression
and anxiety (CDC, 2022).66
Summary of Findings and Conclusion67
Implications69
The nursing field is a discipline that requires research, which
concentrates on issues that affect the nursing practice (Polit &
Beck, 2021). Nursing implications are essential in considering
when to begin a new medication, intervention, or procedure
(Polit & Beck, 2021). Healthcare providers who understand the
potential impact they could have on the clinical practice,

nursing care, and the patient allows them to provide the best
quality care (Polit & Beck, 2021). The implications discussed in
the following sections were developed on the project
findings.69
Theoretical Implications69
Practical Implications71
The third implication is for clinicians to use an interactive
pictorial wheel to improve self-management in HTN patients.
This educational style using pictures can help patients discuss
their personalized approach to managing HTN without feeling
belittled or embarrassed. Furthermore, this method has been
adapted for other diseases such as asthma, heart failure, and
stroke (Gan et al., 2022). This communication style would be
beneficial for individuals with low health literacy levels. The
communication wheel would be based on medication, exercise,
weight management, diet, and complications72
Future Implications72
Recommendations72
Recommendations for Future Projects73
The “next step” in forwarding this project is for the healthcare
providers to deliver patient care using culturally competent care
for this populace. Unfortunately, many of the patients seen at
the clinic are from Black and Brown communities. As
mentioned in Chapter 1, the project site’s demographics show a
high population of Hispanics (36.72%) and Blacks (18.5%).
This confirms the statistics found by the Centers for Disease
Control and Prevention (2022), Hispanics (39%), and Blacks
(56%).74
Recommendations for Practice74
References76
Appendix A91
Grand Canyon University Institutional Review Board Outcome
Letter91
Appendix B92
Saco-Ledo et al.’s Research Article92
Appendix C93

Permission to Use Saco-Ledo et al.’s Research Article93
Appendix D94
American Heart Association Physical Activity Guidelines94
Appendix E95
Permission to Use the American Heart Association Physical
Activity Guidelines95
Chapter 1: Introduction to the Project1
Background of the Project2
Problem Statement3
Purpose of the Project4
Clinical Question6
Advancing Scientific Knowledge7
Significance of the Project9
Rationale for the Methodology10
Nature of the Project Design11
Definition of Terms12
Assumptions, Limitations, Delimitations14
Summary and Organization of the Remainder of the Project16
Chapter 2: Literature Review19
Theoretical Foundations22
Review of the Literature25
Prevalence of Hypertension26
Aerobic Exercise Health Intervention31
Effect of Exercise on Blood Pressure34
Summary39
Chapter 3: Methodology41
Statement of the Problem42
Clinical Question43
Project Methodology44
Project Design45
Population and Sample Selection46
Instrumentation and Sources of Data48
Validity49
Reliability49
Data Collection Procedures50

Potential Bias and Mitigation53
Ethical Considerations53
Limitations54
Summary55
Chapter 4: Data Analysis and Results57
Descriptive Data58
Results60
Summary61
Chapter 5: Summary, Conclusions, and Recommendations63
Summary of the Project64
Summary of Findings and Conclusion66
Implications67
Theoretical Implications67
Practical Implications69
Future Implications70
Recommendations71
Recommendations for Future Projects71
Recommendations for Practice72
References74
Appendix A89
Grand Canyon University Institutional Review Board Outcome
Letter89
Appendix B90
Saco-Ledo et al.’s Research Article90
Appendix C91
Permission to Use Saco-Ledo et al.’s Research Article91
Appendix D92
American Heart Association Physical Activity Guidelines92
Appendix E93
Permission to Use the American Heart Association Physical
Activity Guidelines93
List of Tables
Table1.DescriptiveDataforAge58

Table2.DescriptiveDataforGenderandRace59
Table3.Pairedt-TestResultsforSystolicBloodPressureLevels60
Table4.Pairedt-TestResultsforDiastolicBloodPressureLevels61
Chapter 1: Introduction to the Project
Hypertension (HTN) is a medical condition associated with
higher blood pressure, whereby the arteries that transport blood
become damaged. Despite the availability of treatment
strategies, less than one in five individuals have their blood
pressure under control (Ghatage et al., 2021). Currently, in the
United States (U.S.), the disease poses a significant problem
that affects over half of the adult population (37 million
individuals) (Centers for Disease Control and Prevention
[CDC], 2021; Krist et al., 2021). Complications of the condition
include myocardial infarction, heart failure, chronic renal
disease, and stroke (Ghatage et al., 2021).
The increase in the cases of hypertension prompted the
American Heart Association Task Force (AHA) to publish new
guidelines to help manage the rise in hypertension among
American adults (Wang et al., 2019). One critical change within
the AHA guideline is the improvised reference and definition of
hypertension values. The American College of Cardiology and
the American Heart Association guidelines for hypertension
management and definition of HTN defines it as having blood
pressure at or above 130/80 mmHg (The American College of
Cardiology (2022); American Heart Association, 2022). At the
same time, stage 2 HTN is blood pressure at or above
140/90mmHg (CDC., 2021). Improved blood pressure (BP)
among hypertensive patients has been associated with positive
health outcomes (Severin et al., 2020), and early detection and
control of BP have significantly impacted morbidity and

mortality rates in the healthcare delivery system (CDC, 2021;
Severin et al., 2020).
At the project site, the project manager collaborated with the
Medical Director and clinical manager regarding the increasing
ambulatory blood pressures seen within the past three months.
Although the site provided patients with medication
management for their disease, it was suggested that another
strategy be employed to help reduce blood pressure. The
conversation concluded with the project manager implementing
the American Heart Association's guidelines on aerobic exercise
to influence hypertensive patients.
The project was worth conducting because it helped to increase
HTN patients’ knowledge levels and assist in helping them
change their behaviors to combat this “silent killer” (CDC,
2019). Unfortunately, many individuals are unaware of the
symptoms, which makes the situation dire. This project
promoted decreasing the fifth leading cause of death (CDC,
2019). Other areas the project impacts were one’s improvement
of their quality of life, reducing their chances of stroke,
protecting their kidneys, and decreasing healthcare costs (CDC,
2019).
Chapter 1 introduces the topic of hypertension and the use of
daily physical activity to combat the disease. Other sections of
the chapter include the problem statement, purpose statement,
and clinical question. Other areas of the chapter involve
advancing scientific knowledge related to the theoretical
underpinnings, quantitative methodology, and quasi-
experimental design. The chapter's last segments comprise the
definition of terms, assumptions, limitations, and delimitations
with a preview of Chapter 2.Background of the Project
The prevalence of hypertension among the adult population in
the United States increased rapidly between 1988 to 2010,
accounting for half of all fatalities from stroke, end-stage renal
disease (ESRD), and stroke (Million Hearts, 2021). According

to Muntner et al. (2020) trend analysis, the estimated proportion
of the U.S. adult population suffering from hypertension
between 1999 and 2000 was 31.8 %. The adult population
affected by hypertension increased from 31.8 % in 1999-2000 to
48.5 % in 2007 and 2008 (Muntner et al., 2020). The number of
affected U.S. adults has been on the rise ever since, and
between 2013 and 2014, which was 53.8 % (Muntner et al.,
2020). The percentage dropped slightly from 53.8% to 43.7%
between 2017 and 2018, but the value is still relatively high
(Muntner et al., 2020). This data imply that the American
population is considerably affected by hypertension at an
alarming rate.
The current hypertensive population impacted by ambulatory
blood pressure is 43.7%, according to a recent study by Adams
and Wright (2020). Currently, at the facility, there were no
standardized guidelines for educating hypertensive patients
regarding incorporating exercise (daily physical activity) as a
blood pressure management mechanism. The standard
treatments include medications such as diuretics, angiotensin-
converting enzyme (ACE) inhibitors, angiotensin II receptor
blockers (ARBs), and calcium channel blockers (Mayo Clinic,
2021). After collaborating with the medical director and nursing
staff, the decision was to implement the AHA recommendation
for aerobic exercise to help lower ambulatory blood pressure
among this clinic’s adult hypertensive population.
Problem Statement
It was not known if or to what degree the implementation of the
American Heart Association’s guideline on aerobic exercise
would impact ambulatory blood pressure when compared to
current practice among adult hypertensive patients. At the
clinical site, there are no standardized guidelines for clinicians
to educate hypertensive patients regarding implementing daily
physical activity as a blood pressure management mechanism.
Collaboration with the medical director and some of the nursing
staff showed an increase of 37.1% in diagnosed HTN patients

within the past six months. The clinic’s findings corresponded
with the health statistics from the Texas Department of State
Health Services (2022), as the county ranks 22 in the States
with diagnosed hypertensive patients. The data, in combination
with current literature by the Centers for Disease Prevention
and Control [CDC] (2021), emphasizes that hypertension affects
approximately 45% of American adults.
The project contributes to the current body of literature, such as
Aung and Htay (2021), Krist et al. (2021), and Saco-Ledo et al.
(2020), regarding aerobic exercise being included in
hypertension management. The CDC (2020) states that regular
physical activity is essential for general wellness, weight loss,
and well-being. Other areas impacted are the reduced symptoms
of depression and anxiety (CDC, 2020). The project validates
that using aerobic exercise, as stated by Saco-Ledo et al.
(2020), decreases one’s systolic blood pressure by
approximately 2 to 4 mm Hg in normotensive and 5 to 8 mm Hg
in hypertension adult patients.
Purpose of the Project
to determine if or to what degree the implementation of the
American Heart Association’s guideline on aerobic exercise
would impact ambulatory blood pressure when compared to
current practice among adult hypertensive patients in a primary
care clinic in southwest Texas over four weeks. The
independent variable for the project is the American Heart
Association’s guidelines, and the dependent variable is blood
pressure measurements. Convenience sampling will be used to
choose the participants. The project was conducted within four
weeks using a quasi-experimental design and quantitative
methodology. Six healthcare providers will be educated using
the American Heart Association’s guidelines for aerobic
exercise (walking and blood pressure measurement using Oscar
2 Device) for HTN patients. The primary investigation carried
out the implementation and comparison of data during the

project using ambulatory blood pressure baseline and post-
implementation data. Data were retrieved from the clinic’s
electronic medical record and input into a Microsoft Excel
spreadsheet. An outside statistician not associated with the
primary investigator or project analyzed the data. A paired
sample t-test was used to analyze the statistical significance of
the variables using the Statistical Package for the Social
Sciences (SPSS-28).
The inclusion criteria for the participants were 18 and older,
diagnosed with HTN, current clinic patients, and able to
participate in aerobic activity. The exclusion criteria are
patients with musculoskeletal disabilities, mental disorders, and
individuals with comorbidities that could bias the project
findings. The participants engaged in aerobic exercise for 30
minutes in 24 hours, three days a week, for the four weeks of
the project duration. The outcome post-intervention was a
reduction in ambulatory blood pressure reading of the
recommended BP below 140/80mmHg. The average decrease in
SBP with aerobic exercise is approximately 2 to 4 mm Hg in
normotensive patients and 5 to 8 mm Hg in adult hypertension
patients (Saco-Ledo et al., 2020).
The persons who implemented the intervention were one
physician, two nurse practitioners, two registered nurses, and
one medical assistant. All healthcare providers were educated
regarding “the American Heart Association’s” guideline to
include exercise in HTN patients’ disease management. The use
of Oscar 2 Device for measuring ambulatory blood pressure.
The clinicians demonstrated vibrant understanding via the
teach-back method to the project manager to safeguard all the
participants were taught the same way. The individuals
currently work full-time at the clinic for over one year and have
access to the documentation software.
The project site’s geographic location is in southwest Texas, the
most populous county and the third most populous county in the
United States (U.S. Census Bureau, 2020). The affected
population was patients diagnosed with HTN. The demographics

show a diverse population of White (28.9 %), White-Hispanic
(36.72%), Blacks (18.5%), Asians (6.9 %), and Latinos (8.98.
%) (U.S. Census Bureau, 2020). Many residents over the age of
60 have chronic diseases such as (chronic obstructive
pulmonary disease, heart disease, and diabetes) (UT Health
Science Center at Houston, 2020). The age groups in the county
18 to 34 (20,586), 35 to 54 (46,513), and 55 to 64 reflect the
participants in the project.
The project contributes to the nursing field by offering an
evidence-based strategy and evaluating how aerobic exercises
such as walking improved ambulatory blood pressure. The
project provided vital information that could be shared with
other nursing staff or healthcare providers at other primary care
clinics, minority communities, or populations in similar diverse
populations. The project also preferred an avenue for helping
individuals and families to understand the relationship between
the disease process and its management.
Clinical Question
Saco-Ledo et al. (2020) conducted a systematic review and
meta-analysis. The authors claimed that ambulatory blood
pressure (ABP) better predicts cardiovascular disease and
mortality in adult hypertensive populations. Aerobic exercise
played a significant role in lowering blood pressure, and it was
beneficial in lowering ambulatory blood pressure in HTN
patients. The following clinical question that guided this
quantitative project: To what degree did the implementation of
“the American Heart Association’s” guideline on aerobic
exercise impact ambulatory blood pressure when compared to
current practice among adult hypertensive patients in a primary
care clinic in southwest Texas?
Dr Sewer, I don’t understand what she meant by me
having it in two waysin her comment The independent variable
is “the American Heart Association’s” guideline regarding
aerobic exercise, and the dependent variable is ambulatory

blood pressures.
Advancing Scientific Knowledge
Implementing an aerobic exercise education program to lower
ambulatory blood pressure by following AHA guidelines, the
initiative improved population health outcomes for hypertensive
individuals. Completing this quality improvement project
advanced our understanding of ambulatory blood pressure in
hypertensive patients to reduce or manage ambulatory blood
pressure. The overall goals of aerobic exercise walking in
controlling blood pressure in hypertensive patients were to
decrease morbidity and increase the population's wellness,
happiness and vitality. Physical activities such as walking,
running, swimming, and biking improve symptoms, quality of
life, functional status, and reduces hospitalizations (CDC,
2021).
In clinical practice, management of cardiovascular diseases
entailed resolving cardiovascular etiologies such as coronary
heart disease and related conditions such as diabetes,
preventative care, follow-up monitoring of cardiac status, care
coordination and case management, educating and supporting
patients for self-management, rehabilitation of heart function,
and health promotion, among others (Jiang & Wang, 2021). The
pharmacological treatment of cardiovascular diseases has
improved with the development of new therapies and
understanding its pathophysiology. Despite developing novel
pharmacological interventions for patients with HTN,
congestive heart failure existing treatments have not yielded
significant mortality benefits for HF patients with heart failure
with reduced ejection fraction (HFpEF). Instead, the drug
treatments try to control symptoms, treat comorbidities, and risk
factors that the cause through measures such as aerobic
exercise, diet and weight control, blood pressure self-
monitoring, and low sodium intake, among others (CDC, 2021).
The identified gap is the elevated ambulatory blood pressure
among the hypertensive group based on the available research

(Blumenthal et al., 2018; Saco-Ledo et al., 2020). Educational
programs on aerobic exercise to decrease and manage
ambulatory blood pressure should build on the findings
(Blumenthal et al., 2018). Other factors that influence blood
pressure are the presence of comorbidities and risky behaviors
such as smoking, patients’ education level, caregiver presence,
and in-patient HTN education. As the patients became more
aware of the aerobic exercise in lowering blood pressure
through the educational program, individuals showed less
comorbidities that reduced risk to hypertensive complications
and frequent hospitalizations (Saco-Ledo, 2020). The initiative
filled the gap or need by utilizing the AHA guidelines for
aerobic exercise education programs to lower ambulatory blood
pressure for patients with hypertension.
The selected theoretical framework for this quality improvement
project was Dorothy Orem’s self-care deficit theory. Based on
the theory, patients must engage in self-care to maintain and
improve their quality of health (Orem, 1995). Utilizing this
theory, the nurses did not see their patients as inactive or
receiving health services; instead, they consider them strong
and reliable to participate in daily activities and decision-
making processes (Orem, 1995). Three nursing systems are
defined in Orem’s nursing theory; they include wholly
compensatory, partially compensatory, and supportive-educative
strategies (Khademian et al., 2020). For this project, the focus
is on the last system (supportive educational system). The
clinicians assessed the patient’s readiness to learn something
new but need assistance and guidance. Patients with chronic
illnesses require motivation and the skills to conduct the
behaviors needed to maintain and improve their health
(Khademian et al., 2020). Hence, the patient gained the
capability to learn disease processes and perform activities
independently, overcoming seen and unseen limitations.
Lewin’s change model was chosen to work in combination with
Orem’s self-care deficit theory. It was selected because it was a
way to describe the process change versus guiding the activities

that were conducted. The theory worked well with Orem’s
nursing theory in improving the patient’s self-efficacy and
management of hypertension. Furthermore, this model allowed
the project manager to actively examine the clinic site and
clinicians' change process and progression (Harrison et al.,
2021). The model consisted of three stages: unfreezing,
changing (movement), and refreezing (Lewin, 1947). The first
stage, unfreezing, allowed the project manager, medical
director, and a few nursing staff members to identify the
problem, develop an evidence-based strategy, and consent to
change (Lewin, 1947). The second stage, movement, happened
when the intervention was implemented. The healthcare
providers provided a timeline with a clear plan that were
followed for the project (Lewin, 1947). The last stage,
refreezing, occurred when the intervention became a daily part
the clinical practice and conversation with hypertensive patients
(Lewin, 1947).
Significance of the Project
The significance of the quality improvement project was
implementing a recommended evidence-based strategy by “the
AHA’s guideline” regarding aerobic exercise. Implementing the
project helped decrease the healthcare costs associated with
HTN in the United States. Commodore-Mensah et al. (2018)
state that the financial prices are significant, approximately
$131-198 billion annually. Hypertensive persons incur an extra
$2,000 yearly in healthcare expenditures compared to non-
hypertensive persons (Commodore-Mensah et al., 2018).
Furthermore, HTN is a crucial risk factor in various diseases,
including myocardial infarction, heart failure, stroke, and
chronic renal disease (Commodore-Mensah et al., 2018).
One nursing implication relates to Lewin’s change model in
creating and sustaining change. A multi-systematic approach
must be drawn from the model to support the implementation of
the American Heart Association guidelines regarding aerobic
exercise for hypertensive patients. The model highlighted the

principles relating to people changing from the onset,
discussing their feelings regarding the change, and supporting
the process via communication and collaboration (Harrison et
al., 2021).
The second nursing implication relates to the participants’
management of their disease process (hypertension). The
participants were taught the importance of including aerobic
exercise and walking (30 minutes, three times a week) in their
private daily schedules. The project manager evaluated the
respondents' understanding and receptiveness to new
information and safety measures related to exercising. Rationale
for the Methodology
The quantitative methodology was used to provide information
that uses numerical data (Statistical
Solution
s, 2019). This method best answered the clinical question and
addressing the problem statement for this project because it
allowed an in-depth comparison of the relationship between pre-
and post-intervention results (Guetterman & Fetters, 2018). It
was used because it offered objective, systematic, and focused
data analysis strategies (Guetterman & Fetters, 2018). In this
project, the project manager evaluated “the AHA’s guidelines”
and its impact on the blood pressure of HTN patients. The
dependent variable were measured four weeks before and after
improving the intervention. This methodology was the most
appropriate because other investigators could replicate the data

(Creswell & Creswell, 2018).
A qualitative methodology was considered but deemed
inappropriate for this project. It focused on describing the
characteristics or qualities of a phenomenon (Creswell &
Creswell, 2018). This method is often thematic and subjective,
and findings are produced using the participants' words
verbatim (Creswell & Creswell, 2018). In this project, the
project manager did not seek to understand the participants'
behaviors, feelings, or lived experiences (Creswell & Creswell,
2018). The data was analyzed using a coding method that
explores themes and patterns (Creswell & Creswell, 2018). The
results were presented verbatim in two to three columns using
the respondent's words.
Nature of the Project Design
A quasi-experimental design was used in this quality
improvement project. The rationale behind selecting the project,
as mentioned above, was that it allowed for comparing the
dependent (blood pressure) and independent variables
(implementation strategy aerobic exercise education guideline.
The design was suitable for scrutinizing the project’s variables
and determining the independent variable's effect on the
dependent variable (Creswell & Creswell, 2018). Furthermore,
the design did not allow the participants to be randomly
assigned (Creswell & Creswell, 2018). For this project, the

dependent variable (ambulatory blood pressure) were measured
at two different times (once before the intervention and once
after the intervention (Creswell & Creswell, 2018).
A correlational design was not selected for this quality
improvement project. It was not chosen because it is a non-
experimental design where the variables are measured and
evaluated for their relationship (correlation) (Creswell &
Creswell, 2018). The variables cannot be controlled (Creswell &
Creswell, 2018). Two rationales for not using this type of
design are evaluating the causal statistical relationships between
the variables and not manipulating the independent variable
(Creswell & Creswell, 2018).
The project sample explored was adult patients diagnosed with
HTN. The individuals were 18 or older, spoke English, and were
able to participate in aerobic exercise. The exclusion criteria
include respondents with mental challenges, musculoskeletal
disabilities, and comorbidities that could bias the project
results. The sample size was calculated using G* Power
software, version 3.1.9.2, with an alpha measure of 0.05, an
effect size of 0.5, and a power of 80%. The minimum number of
participants suggested for the project was N=34.
The data collection process was began after receiving the
approval to conduct the project from Grand Canyon University
Institutional Review Board and the clinical site. The data
collection procedures included educating the six healthcare

providers for one hour using the AHA guideline (aerobic
exercise) and slide presentation. The clinicians demonstrated
the procedures via the teach-back methods. All potential
participants were educated regarding the minimal risks and
benefits of partaking in the project. The demographic data was
retrieved from the clinic’s electronic medical records (age,
gender, race, marital status, and education).
Definition of Terms
A quality improvement project must offer the reader an
understanding of the terms, concepts, and variables used (Grand
Canyon University, 2021). New knowledge is critical to
successful solutions (Polit & Beck, 2018). Below are the words
used intermittently throughout the project
Ambulatory Blood Pressure Monitoring (ABPM)
Ambulatory blood pressure monitoring was introduced in the
early 1960s and was used to assess one’s blood pressure in real-
time (Shackelford, 2022). A healthcare provider typically
evaluated the blood pressure during routine activities such as
working, sleeping, or doing chores (Shackelford, 2022).
The American College of Cardiology Foundation
The American College of Cardiology Foundation is a non-profit
medical organization dedicated to improving the lives of
cardiovascular patients (American College of Cardiology,

2022). This was done via continuous quality improvement
monitoring, patient-care strategies, payment innovation, and
professionalism (American College of Cardiology, 2022).
American Heart Association
The American Heart Association was formed in 1924 to
establish scientific research that could offer healthcare
providers and patients methods to treat cardiac disease and
prevention (American Heart Association, 2022).
Aerobic Exercise
Aerobic exercise refers to any activity involving cardiovascular
conditioning and pertains to running, brisk walking, swimming,
or even cycling. This project will apply aerobic exercise to help
hypertensive patients reduce their ambulatory blood pressure
(Seals et al., 2019).
High Blood Pressure
High blood pressure refers to the scenario in which an adult’s
blood pressure is above the optimum level, which is usually at
130/80mmHg for adult patients. When a patient's blood pressure
exceeds the optimum shown above, they are exposed to the risk
of chronic heart failure, stroke, myocardial infarction, and in
extreme circumstances, death (Fuchs & Whelton, 2020).
Hypertensive Patients

Hypertensive patients refer to the patients diagnosed with
hypertension since hypertension has been shown to be a
causative factor for other diseases such as chronic heart failure,
stroke, and even myocardial infarction (Schwingshackl et al.,
2019). Assumptions, Limitations, Delimitations
Grand Canyon University (2021) stated that an assumption is an
indisputable fact. The first assumption was that this quality
improvement project was based on the AHA guideline on
aerobic exercise education program will enhance the self-
efficacy of adult hypertensive patients by helping them keep
their blood pressure at optimum levels. In turn, the AHA
guideline on the aerobic exercise education program
intervention would play a pivotal role in lifestyle improvement
and skill development which were required to encourage
improved health outcomes and adaptive health-related behavior
(Cameron et al., 2018). The second assumption was that all
participants answered the questions honestly. To maintain
honesty from the participants during the project, the project
manager did not influence the participants answers. To maintain
objectivity and reduce the possibility of the data being skewed,
the investigator hired an outside statistician to conduct the data
analysis (Statistical

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