1. Discuss the nursing implications of the findings of the researc

1. Discuss the nursing implications of the findings of the
research. Consider the following questions:
· Were the results statistically significant, if reported?
· What is the clinical significance of the findings?
· What are the risks vs. benefits to practice of the findings?
· Are the findings feasible to implement?
Work 57 (2017) 259–268
DOI:10.3233/WOR-172551
IOS Press
259
“I’ve never been able to stay in a job”:
A qualitative study of Veterans’
experiences of maintaining employment
Molly Harroda,∗ , Erin M. Millerb, Jennifer Henrya and Kara
Zivina,b,c,d
a VA Center for Clinical Management Research, VA Ann Arbor
Health Care System, Ann Arbor, MI, USA
bDepartment of Psychiatry, University of Michigan Medical
School, Ann Arbor, MI, USA
cDepartment of Health Management and Policy, University of
Michigan School of Public Health,
Ann Arbor, MI, USA
dInstitute for Social Research, University of Michigan, Ann
Arbor, MI, USA
Received 5 February 2016
Accepted 4 December 2016

Abstract.
BACKGROUND: Ensuring Veteran employment needs are met
is a top priority for the Department of Veteran Affairs
and the United States government. However, Veterans,
especially those with mental health disorders, continue to
encounter
difficulties when employed. While many employment related
programs offer numerous services aimed at helping Veterans
gain employment, their ability to maintain long-term
employment remains unknown.
OBJECTIVE: The objective of this study was to understand
factors that affect the ability of Veterans with mental health
disorders to maintain long-term employment.
METHODS: An exploratory, qualitative study design consisting
of semi-structured interviews with 10 Veterans was per-
formed. Inductive thematic analysis was performed to identify
salient themes.
RESULTS: We found that participants’ symptoms manifested
themselves within the workplace affecting their ability to
maintain employment, participants felt as if they had been
demoted from what they did in the military, and they felt unable
to relate to civilian co-workers. Strategies that helped some
transition into the civilian workforce were also identified.
CONCLUSIONS: A better understanding of the difficulties
some Veterans face when trying to maintain employment is
needed. Our findings suggest that increasing awareness of
existing programs and ensuring that services provide resources
and skills that help Veterans maintain long-term employment is
critical.
Keywords: Long-term employment, mental health, reintegration
1. Introduction
Within the United States there are approximately

5.5 million Veterans who served during the Gulf War
era (from August 1990 until present) [1]. These Vet-
erans are younger, more likely to be of working age
(18–55), and looking to secure civilian employment.
∗ Address for correspondence: Molly Harrod, HSR&D (152)
P.O. Box 130170 Ann Arbor, MI 48113-0170, USA. Tel.: +1
734
845 3600; Fax: +1 734 222 7503; E-mail: [email protected]
Ensuring that Veteran employment needs are met is
a top priority for the Department of Veteran Affairs
(VA) and the United States government. Several poli-
cies and programs have been developed at Federal,
state, and local levels to help Veterans obtain employ-
ment including the American Jobs Act, the Veterans
Opportunity to Work to Hire Heroes Act, and the
Veterans Job Corps, among others [2–4].
These programs offer a wide range of services
from providing web portals that connect Veterans
1051-9815/17/$35.00 © 2017 – IOS Press and the authors. All
rights reserved
mailto:[email protected]
260 M. Harrod et al. / Veterans’ experiences of employment
with employment opportunities in their community to
providing more personalized services such as match-
ing military skills with civilian occupations, career
counseling, resume writing, job retraining and edu-
cation [2]. However, despite robust programming,
several studies have identified difficulties Veterans
may encounter when employed especially those Vet-

erans with mental health disorders. For example,
Sayer et al. [5] surveyed Iraq-Afghanistan combat
Veterans and found that nearly 35% had difficulty
completing tasks, potentially affecting their work
productivity, and nearly 25% experienced job loss.
Additionally, Veterans with post-traumatic stress dis-
order (PTSD) tended to miss more work days, were
unhappy with their employment, and had difficulty
getting along with their co-workers when compared
to non-Veterans [6, 7].
While many employment related programs for Vet-
erans (with and without mental health disorders)
offer numerous services aimed at helping them gain
employment, it remains unclear how many offer ser-
vices related to maintaining employment. In fact, a
study by Burnett-Zeigler et al. [8] found that Veterans
with mental health disorders may have more difficulty
maintaining their employment rather than obtain-
ing employment. Studies have also noted the need
for research and information on reintegration experi-
ences and on-going needs, including those related to
employment of Veterans [4, 9].
Considering that studies [4, 10–13] have found that
unemployment can impede successful reintegration,
it is crucial to not only offer employment support to
Veterans, but to identify gaps in services to main-
tain employment. Therefore, the aim of this study
was to understand factors that may affect the ability
of Veterans with mental health disorders to maintain
long-term employment.
2. Methods
2.1. Study design, sampling and recruitment

We conducted an exploratory qualitative study
to better understand the general employment expe-
riences of Veterans with mental health disorders,
and their ability to maintain long-term employment
specifically. We chose a purposive sampling approach
which enables a “detailed exploration and under-
standing of the central themes” (p. 78) of interest
[14]. Thus, Veterans from one VA primary care clinic
were mailed a survey exploring employment related
issues and mental health status [15]. Inclusion criteria
for the survey consisted of patients who had a recent
primary care visit with planned follow-up and were
between the ages of 18 and 55 (ages most associated
with employment). Based on 287 survey responses,
32 respondents who screened positive for depression
and/or anxiety and indicated that they were experi-
encing unemployment, under-employment (workers
who are overqualified for the job they perform or
workers who are working part-time but prefer to work
full-time), or considered themselves to be insecurely
employed were eligible for the interview portion of
the study. All 32 survey respondents were contacted
by phone by the study’s project manager, explained
the purpose of the study, and offered a phone or
in-person interview. If they agreed to participate,
they were mailed a letter describing the study and
the informed consent form. Informed consent was
obtained prior to the interview. Of the 32 eligible,
10 survey respondents agreed to participate in semi-
structured interviews (October 2014-February 2015).
Each participant received a $25 gift card as a token
of appreciation. The local VA medical center Insti-
tutional Review Board approved all aspects of this
study.

2.2. Data collection and analysis
Semi-structured interviews focused on employ-
ment, mental health, and reintegration (Appendix A).
The questions were developed to be open-ended and
explore if and how Veterans were able to maintain
employment. Each interview lasted, on average, 48
minutes (30–89 minutes), was audio-recorded and
transcribed. Transcripts were analyzed using an iter-
ative [16], inductive thematic analysis approach [17].
Prior to coding, all transcripts were read by the first
author (MH) and principal investigator (KZ) to better
understand the data set as a whole. Then, each tran-
script was re-read resulting in codes being created,
defined, and applied. As coding progressed and addi-
tional codes emerged, previously coded transcripts
were revisited to ensure new codes were applied
to all transcripts. All codes, definitions, and criteria
were documented in a codebook. Once initial cod-
ing was complete, pattern coding, in which codes are
reanalyzed and grouped into categories based on sim-
ilarities and relationships, was performed to develop
themes [18]. NVivo 10® software was used to man-
age the data and check for consistent application of
codes. This process led to the development of themes
discussed below.
M. Harrod et al. / Veterans’ experiences of employment 261
3. Results
In order to contextualize participants’ employment
experiences, they were asked about their military his-

tory including employment experiences while in the
military and since discharge (see Table 1). All of the
participants were Gulf War era Veterans. Although
post-traumatic stress disorder (PTSD) was not a
criterion for participation in an interview nor did
we ask specifically about this diagnosis, 5 out of
the 10 participants stated they had been diagnosed
with PTSD in conjunction with depression and/or
anxiety either while they were still active duty or
post-discharge.
What follows are three salient themes regard-
ing the difficulties participants faced in maintaining
employment. These themes reflect their experiences
of how their mental health symptoms, especially
those resulting from PTSD, manifested within the
work environment, their feelings of demotion from
what they did in the military to their civilian employ-
ment, and their feelings of being unable relate
to civilian co-workers, all of which affected their
abilities to maintain employment. We also include
strategies that have helped some of the participants
make the transition into the civilian workforce (see
Table 2).
Table 1
Veteran demographics
Gender
Male 8
Female 2
Marital status
Single 0
Married 5
Divorced/Separated 4

In a relationship 1
Education
High school or less 3
Some college 2
Bachelor’s or more 5
Military Branch
Army 5
Marines 2
National Guard 2
Navy 1
Years in Military
1–5 years 2
6–10 years 4
11–15 years 2
16+ years 2
Employment status at time of interview
Full-time 2
Part-time 3
In school 2
Unemployed 3
3.1. Symptom manifestation
How PTSD affected some of the participants’ abil-
ity to maintain employment came up organically in
the interviews. They told vivid stories of how their
PTSD symptoms, especially flashbacks which are
common PTSD symptoms [19], manifested while
they were at work. These unexpected events often left
participants struggling with how to react in a civilian
context when reminded of their wartime experience.
For example:

“I took a month off after deployment and then I
went back [to substitute teaching] and I was at
[named] High School and as it turns out, their
bell for passing between hours was a lot like the
incoming fire alarm in Iraq and every time I heard
that I would freeze up and at one point I had to say,
‘You know I can’t do this, can I go home?’ and
they knew that I had just come home and they
were like, ‘Yeah, we’re okay with that,’ . . . and
Table 2
Themes with definitions
Theme/Sub-theme Definition
Symptom manifestation Symptoms of PTSD
PTSD effect in
workplace
Stories about how Veterans’
symptoms of PTSD affected their
ability to function in the
workplace.
Triggers Veterans not knowing what would
cause a flashback.
Effect on social
interactions
Talk of how PTSD and its symptoms
impacted Veterans abilities to
interact with co-workers.

Feelings of demotion Civilian work did not compare to the
level of importance of Veteran
military careers.
Non-utilization of
military skills
Military skills are context dependent
and may be underutilized.
Inability to relate Difficulties relating to civilian
co-workers
Work ethics Sense that work ethic did not match
those of civilians.
Unappreciated Feeling a lack of respect or lack of
appreciation from co-workers for
their military service.
Lack of camaraderie Lacking a connection to co-workers.
Finding their way Coping mechanisms or strategies
Veterans developed themselves to
maintain employment.
Supportive co-workers Support and understanding from
co-workers, especially supervisors.
Independent work Work that allowed the Veteran to
work independently and control
own environment.
Change in career Change in career that is more
conducive to current needs.

after that, you know, I just avoided that school
for a little while of course as you can imagine.”
(Identification (ID) #200189)
Compounding these feelings was the uncertainty
of what might trigger a flashback. One participant
spoke of not knowing what his triggers were and
therefore, had difficulty controlling how he felt in
certain situations.
“ . . . [the] hardest part is I don’t know my triggers
for my PTSD. I do know when it hits, it hits,
you know, the anxiety goes up and stuff like that
and the anger just comes right to the top.” (ID
#200219)
These types of reactions occasionally affected their
interactions with co-workers. In an attempt to control
a situation, some of the participants stated that they
would often fall back on how they communicated
and interacted with their fellow soldiers, assuming
this was the way to get work done. They described
how the approach to work is significantly different
in the civilian context and they would often be per-
ceived as being “aggressive” or “harassing” towards
co-workers.
“I get mad at people and talk to them with a really
authoritative voice that was really powerful and
some people didn’t know how to take that. They
thought I was being harassing when I was just
telling them to clean the spider webs off a dis-

play for the third time . . . But that’s just the way
I’m used to communicating in the military, you
know?” (ID #200700)
Whether it was the unexpected events or the
inability to control one’s environment, many of the
participants either quit their jobs or were fired. Their
military experiences, especially for those with PTSD,
seemed to affect how they were able, or not, to adjust
to their work environments.
3.2. Feelings of demotion
While in the military, the participants stated
that they had received copious amounts of training
and education. Some had top level security clear-
ance in highly classified jobs, and others spoke
of being responsible for leading troops in com-
bat missions. However, once they returned to the
civilian workforce, participants stated they felt as
though they had been demoted. They felt their civil-
ian work was demeaning and they were not able
to use the skills they had acquired while in the
military.
“I mean it’s just, it wasn’t fun, it’s pretty demean-
ing and you go from being a platoon sergeant
to . . . filling a [expletive] vending machine and
you’re getting paid, you know, $10 an hour, so
yeah, it was pretty demeaning.” (ID #200848)
While many of the programs offered to Veterans
focus on translating skills acquired in the military
into a civilian context for securing employment we
found that, for some of the participants, it was the

context in which those skills were to be applied that
was the issue. For example, one participant, who had
been a military police officer, knew that because of
his PTSD, he was no longer capable of performing
these functions.
“I don’t have the mentality and I know I don’t.
I get easily aggravated and I’m smart enough to
know to not put myself into a situation where I
have a gun . . . ” (ID #200463)
Feeling demoted and/or that their skills were not
being utilized led some of the participants to seek out
new employment. However, this resulted in many of
them cycling through several jobs in an attempt to
find a work environment they felt utilized their skills
and knowledge. The two participants who returned
to school did so in an attempt to obtain not only bet-
ter employment but positions that were equivalent to
their military experiences. However, both wondered
if they would be able to adjust to the work environ-
ment, especially the social interactions that are often
required, in a way that would be successful.
3.3. Inability to relate
Many of the participants spoke about the difficul-
ties they had relating to civilian co-workers. Reasons
included differing work ethics, feeling a lack of
respect for their military service and skills, and a lack
of camaraderie/loyalty.
“. . . so many times I shake my head in different
places I’ve worked and thought, ‘Man, you can
tell these guys weren’t in the military.’ I guess [the
military] just raised my expectations of . . . work

ethics or respect to other people.” (ID #200016)
Some participants disassociated themselves from
their work and were more comfortable not develop-
ing work relationships. By keeping these two worlds
separate, some participants felt that they were better
able to control their work environments.
“I try not to let my personal life interfere with my
professional life. I’ve learned over time, when I
go to work, I leave home at home and when I go
home, I leave work at work . . . That’s just the way
I’ve wired myself to deal with [problems].” (ID
#200219)
However, participants recognized that their inabil-
ity to cultivate work relationships put them at a
disadvantage for work-related opportunities and pro-
motions.
“I just sort of stick to myself when it comes to
co-workers . . . I think if I was a little bit more
outspoken, I probably would get a little bit further
but it’s really hard to [do that].” (ID #200848)
Inability to relate to co-workers affected partic-
ipants work relationships, sometimes in significant
ways, and many of them felt that it prevented them
from advancing in their careers.
3.4. Finding their way

One goal of the interviews was to try to discern
what types of employment services participants had
engaged in both during and after discharge. Half of
the participants stated they had attended the Tran-
sition Assistance Program/Transition Goals Plans
Success (TAPS) program during their discharge pro-
cess. TAPS is focused on offering services meant to
ensure that the separating service member is career
ready when they transition out of the military [2].
Although this program became mandatory in 2012,
the participants who had gone through the program
found it to be only moderately helpful. They stated
that it was too much information at once, they were
focused on going home rather than what they were
going to do for employment, and they did not know
how to apply the strategies they were taught once
discharged. For example, one focus of the TAPS
program is help with resume writing, including trans-
lating military skills into a civilian context, but one
participant stated:
“. . . that’s what the class [resume writing] was
and then they say, ‘Oh, just go on the computer
and put your resume on the computer.’ But if I
don’t know how to explain military life to civilian
life, they’re not helping me.” (ID #200145)
When asked if they had used any VA employment
support programs since discharge, 9 out of the 10
participants said they had not. A few had met with
a Veteran representative at the state unemployment
office, but did not find this resource helpful. Most
had heard of Veteran job fairs, but for the two who
had attended these, they found them to be unhelpful
in terms of actually securing a job.

“. . . it was a lot of people just handing out busi-
ness cards . . . There really wasn’t much to it, like
a lot of it was just information I could’ve already
received online.” (ID #200189)
Although use of employment services was almost
non-existent among participants, some of them were
able to manage their work environments in a way that
supported their transition back into the work force.
They spoke of having employers that understood their
circumstances and offered support and a willingness
to work with them in times of distress. This often
required the participant talking with their employer
about what they were going through and the difficul-
ties they were having reintegrating back into the work
environment.
“I talked to my boss . . . I said, ‘I won’t be able
to take it, I’ll explode and I’ll get up and walk
out’ . . . and we kind of [talked our] way through
it and he got me to smile . . . he’s a good guy like
that.” (ID #200016)
Not all participants were comfortable speaking to
their employers about their struggles. Instead, they
found jobs in areas that allowed them to work on their
own. For example, one participant found that working
in a job that offered him more independence and less
day-to-day direct contact with co-workers provided
him the time and space he needed to respond to stress
in a more measured and controlled way.
“I think what has helped me is my independence
from somebody being constantly on me . . . [it’s]
given me more reason to stand back and it’s that

time and space that allowed me to react within
reason and not immediately, you know, force back
when something upsets me.” (ID #200848)
Another participant stated that he found a change
in career was needed. He found solace in a factory
job that provided an environment that was stable and
predictable.
“Like people are puzzled like, ‘Why did you
leave the professional world for that? You went
to school for how many years and now you’re just
a factory worker?’ But I’m like you know what?
I’ve never been happier with the job. I mean its
menial labor, but it pays well, I get along with
everybody, there’s no stress so and I’m actually up
for promotion, and I’ve only been there a month,
so it works.” (ID #200189)
Even though these participants found ways of rein-
tegrating back into the civilian workforce, almost all
had done so without help from a Veteran employ-
ment program. Although they had been able to obtain
employment, they were not able to maintain their
employment, changing jobs frequently or leaving
the job market altogether. When asked what they
thought would be most helpful in terms of employ-
ment services, participants stated knowing what was
available, what they were eligible for, and where
they could find information would be most useful.
Some also stated that support for changing careers

was needed given that many had changed jobs and
others were still trying to figure out where they fit in
the employment sector.
4. Discussion
Although understanding the difficulties Veterans
face when trying to obtain employment is impor-
tant, we found that understanding their struggles
with maintaining employment is crucial. Many of the
existing programs were developed with the idea that
Veterans reenter and remain in the workforce. How-
ever, all of our participants were no longer employed
in the job they had immediately following discharge.
Several of them had cycled through multiple jobs and
3 remained unemployed.
Resnick and Rosenheck [20] note that because
symptoms of PTSD are difficult to control, those with
PTSD may withdraw to environments that are known
and predictable. Participants in our study described
how PTSD symptoms or triggers manifested them-
selves within the workplace and ultimately impacted
their ability to perform at their jobs. As a result, some
remained unemployed while others chose to return to
school or change careers. We also found that some of
the participants felt they had been demoted from the
jobs they performed in the military to what they were
doing in civilian employment. Feelings of demotion
came from not applying the skills they had obtained
while in the military and how they felt they were
treated within the workplace, especially during their
interactions with co-workers.
Difficulty relating to co-workers was a common
theme among the participants. Inability to relate often

prevented many of the participants from developing
work relationships, sometimes resulting in negative
consequences such as placing them at a disadvan-
tage for work-related opportunities and promotions.
While a few of the Veterans we spoke with were able
to find employment within predictable environments
or adapt their work environments to make work more
manageable, they had cycled through several jobs
before reaching stable employment. They were not
aware of any programs that could have helped them
through this process.
4.1. Implications for practice
Our findings support prior research that concluded
that employment services need to address obtain-
ing employment and effective functioning within the
work environment, especially when mental health
symptoms are present [21]. Programs that currently
do not include counseling on how to identify PTSD
triggers and coping strategies to mitigate symptoms
should consider adding these to their programs. In
addition, employer education should include infor-
mation on Veteran mental health disorders including
depression, anxiety, and PTSD and how the work
environment could be optimized to lessen the burden
of these illnesses.
A great deal of attention has been paid to the need
for skill matching between military experience and
civilian job requirements. As noted above, one of the
main goals of the TAPS program [2] is to translate
military skills prior to discharge so that Veterans are
prepared to enter the civilian workforce. However,
we found that it may also be necessary to consider
the contexts in which they are applying those skills.

Assessment of Veteran job skills, or the tasks they
can perform, may be insufficient to determine their
ability to adjust to a different context. Determining
the type of environment a Veteran is comfortable
in may help identify jobs that are a better match,
potentially making long-term employment more
feasible.
Similar to other recommendations, employment
service programs should include counseling on how
to build and maintain relationships within the work-
place for both Veterans and their civilian co-workers.
In addition, developing a network of Veterans who
have been successful in these pursuits could pro-
vide support for newly employed Veterans looking
for guidance and mentorship [22].
And finally, because most of the Veterans we
spoke with were not aware of any employment pro-
grams that could help them maintain employment,
employment services should be structured as on-
going support programs that are designed not only
to help Veterans find initial employment, but also to
help them adapt to their workplace and, if unsuccess-
ful, provide additional support so that a change in
career is possible.
4.2. Limitations
A limitation of this study was the low number of
Veterans who participated. Therefore, it is difficult to
discern how applicable our findings are to the Veteran

population as a whole and may, in fact be limited to
the Veteran participants in this study. However, we
feel that the use of an exploratory design, purposive
sampling strategy, and thematic analysis approach
mitigates this limitation in that it presents a richer
understanding of the difficulties some Veterans
face while trying to maintain employment. Another
limitation was that very few of the participants
had used a Veteran-related employment service
program since discharge. Therefore, it is necessary
to talk with Veterans who have participated in
employment-related programs in order to determine
how these programs currently provide resources
directed at maintaining employment and understand
their experiences. And finally, we did not include
interviews with staff who administer employment
programs, including career counseling. Understand-
ing their experiences working with Veterans and the
resources required to provide on-going support for
maintaining employment is critical.
5. Conclusion
Our study provides insight into how some Veterans
have experienced employment however, additional
research is needed on those who have been able
to maintain their employment and the skills they
employ to do so. Although there has been a tendency
to focus on Veteran unemployment rates, a better
understanding of the difficulties some Veterans face
when trying to maintain employment is also needed.
Current employment programs tend to prioritize job
obtainment. Our findings suggest that increasing the
awareness of existing programs and ensuring that
these services provide resources and skills that help
Veterans maintain long-term employment is critical.

Acknowledgments
The authors wish to extend a heartfelt thanks
to the participants in this study for sharing their
time, thoughts, and experiences. The authors alone
are responsible for the writing, content and views
expressed in this paper and do not necessarily repre-
sent the views of the Department of Veterans Affairs.
Conflict of interest
The authors report no conflicts of interest.
References
[1] U.S. Census Bureau. Profile America Facts for Features:
CB15-FF.23. [cited 2015 July 30]. Available from: (http://
www.census.gov/content/dam/Census/newsroom/facts-
for-features/2015/cb15-ff23 veterans day 2015.pdf).
[2] Collins B, Dilger RJ, Dortch C, Kapp L, Lowry S, Perl L.
Employment for Veterans: Trends and programs. Congres-
sional Research Service, Washington DC; 2014.
[3] West M, Kregel J. Employment services and supports
available to veterans with disabilities through the U.S.
Department of Veterans Affairs and other Federal agencies
(No. 8092). Mathematica Policy Research; 2014.
[4] Yosick T, Bates M, Moore M, Crowe C, Phillips J, Davison
J.
A review of post-deployment reintegration: Evidence, chal-
lenges, and strategies for program development. Defense
Center of Excellence: For Psychological Health and Trau-
matic Brain Injury; 2012.

[5] Sayer NA, Noorbaloochi S, Frazier P, Carlson K, Gravely
A, Murdoch M. Reintegration problems and treatment
interests among Iraq and Afghanistan combat veterans
receiving VA medical care. Psychiatric Services 2010;61(6):
589-97.
[6] Hoge CW, Terhakopian A, Castro CA, Messer SC, Engel
CC. Association of posttraumatic stress disorder with
somatic symptoms, health care visits, and absenteeism
among Iraq war veterans. The American Journal Psychiatry
2007;164(1):150-3.
[7] Pietrzak RH, Goldstein MB, Malley JC, Johnson DC, South-
wick SM. Subsyndromal posttraumatic stress disorder is
associated with health and psychosocial difficulties in vet-
erans of Operations Enduring Freedom and Iraqi Freedom.
Depression and Anxiety 2009;26(8):739-44.
[8] Burnett-Zeigler I, Valenstein M, Ilgen M, Blow AJ, Gorman
LA, Zivin K. Civilian employment among recently return-
ing Afghanistan and Iraq National Guard veterans. Military
Medicine 2011;176(6):639-46.
[9] Kleykamp M. Unemployment, earnings and enrollment
among post 9/11 veterans. Social Science Research
2013;42(3):836-51.
[10] Adler DA, Possemato K, Mavandadi S, Lerner D, Chang H,
Klaus J, Tew JD, Barrett D, Ingram E, Oslin DW. Psychi-
atric status and work performance of veterans of Operations
Enduring Freedom and Iraqi Freedom. Psychiatric Services
2011;62(1):39-46.
http://www.census.gov/content/dam/Census/newsroom/facts-for-
features/2015/cb15-ff23_veterans_day_2015.pdf

http://www.census.gov/content/dam/Census/newsroom/facts-for-
features/2015/cb15-ff23_veterans_day_2015.pdf
[11] Chicas J, Maiden P, Oh H, Wilcox S, Young D. From war
to
the workplace: Helping Veterans transition to civilian work
settings. Policy Brief. Los Angeles, CA: USC Center for
Innovation and Research on Veterans and Military Families.
2012.
[12] Interian A, Kline A, Callahan L, Losonczy M. Readjust-
ment stressors and early mental health treatment seeking by
returning National Guard soldiers with PTSD. Psychiatric
Services 2012;63(9):855-61.
[13] Wilcox SL, Oh H, Redmond SA, Chicas J, Hassan AM,
Lee PJ, Ell K. A scope of the problem: Post-deployment
reintegration challenges in a National Guard unit. Work
2015;50(1):73-83.
[14] Ritchie J, Lewis J. (Eds.) Qualitative research practice: A
guide for social science students and researchers. London;
Sage; 2013.
[15] Zivin K, Yosef M, Levine DS, Abraham KM, Miller EM,
Henry J, Nelson CB, Pfeiffer PN, Sripada RK, Harrod M,
Valenstein M. Employment status, employment function-
ing, and barriers to employment among VA primary care
patients. Journal of Affective Disorders 2016;193:194-202.
[16] Dey I. Qualitative data analysis: A user friendly guide for
social scientists., New York, NY: Routledge; 2003.

[17] Braun V, Clarke V. Using thematic analysis in psychology.
Qualitative Research in Psychology 2006;3(2):77-101.
[18] Saldaña J. The coding manual for qualitative researchers.
London: SAGE; 2013.
[19] PTSD: National Center for PTSD. [cited 2015 July
10]. Available from: (http://www.ptsd.va.gov/public/PTSD-
overview/basics/symptoms of ptsd.asp).
[20] Resnick SG, Rosenheck RA. Posttraumatic stress disor-
der and employment in veterans participating in Veterans
Health Administration Compensated Work Therapy. Jour-
nal of Rehabilitation Research & Development 2008;45(3):
427-35.
[21] Erbes CR, Kaler ME, Schult T, Polusny MA, Arbisi
PA. Mental health diagnosis and occupational function-
ing in National Guard/Reserve veterans returning from
Iraq. Journal of Rehabilitation Research & Development
2011;48(10):1159-70.
[22] Little R, Alenkin N. Overcoming barriers to employment
for
veterans: Current trends and practical approaches. Policy
Brief. Los Angeles, CA: USC Center for Innovation and
Research on Veterans and Military Families. 2011.
http://www.ptsd.va.gov/public/PTSD-
overview/basics/symptoms_of_ptsd.asp
Appendix A. Veteran Employment Interview
Guide

Interviewee Background
• Please start by telling me a little about yourself?
◦ Tell us about your living situation, (e.g,
partner, children)
� Has this changed since you have been
home?
• Can you tell me a little about your military expe-
riences?
◦ In which branch of the military did you
serve?
◦ Why did you join the military?
◦ What were your duties?
� Did these duties change over the course
of your enlistment?
◦ What types of skills, training or education
did you receive in the military?
◦ Deployments?
◦ How long have you been home?
◦ From what base were you discharged?
◦ Can you describe for me the discharge pro-
cess?
� What were you most concerned about?
� Prior to discharge, did you receive any
job-related information?

Employment Experiences
• Since discharge (or last ten years if discharge
was longer), can you tell us about your job his-
tory?
◦ How many jobs have you had?
◦ Where did you work?
◦ How did you hear/find out about the job?
◦ Did you have to interview for it?
� If yes, what was that like?
◦ What were your duties?
◦ How long did you work there?
◦ Reason for leaving?
◦ What did you like/dislike about the job?
• Tell us about your most recent job.
◦ Where do you work?
◦ How did you hear/find out about the job?
◦ Did you have to interview for it?
� If yes, what was that like?
◦ What are your duties?
◦ How long have you worked here?
◦ What do you like/dislike about your job?
◦ Is it something you want to continue doing?
• What have the challenges been for you at work?
• What has been helpful to you in feeling comfort-
able at work?
• What has been helpful to you in succeeding at
work?
• What types of support, if any, do you have at

work?
Reintegration and Mental Health Issues
• Can you tell us how your return to civilian life
has gone?
• Have you experienced emotional issues or prob-
lems since your return?
◦ If so, what types of issues or problems have
come up? Do you know why?
◦ Are these new issues or problems you have
experienced for some time?
◦ How have these emotional issues or prob-
lems affected your functioning at work and
other parts of your life?
Treatment Seeking and Experience
• Do you know what options are available for
addressing employment problems and issues?
• Do you know where help might be offered?
• Have you talked to a professional for an employ-
ment related issue?
◦ Have you ever used an employment
agency?
◦ If yes:
� Where did you go? What were the rea-

sons you chose this agency?
� What was your experience in getting
employment services?
• What help did they provide?
• What advice did you receive?
� What did you like?
� What do you think could be better?
� What might make it difficult for you to
continue using employment services?
� How do your family and friends feel
about you going to employment services?
◦ If no, but interviewee expresses need:
� What prevents you from using these
types of services?
� Do you know if the VA or another Veteran
organization offers any type of employ-
ment service?
� What have you heard about these differ-
ent services?
◦ If no and not interested:
� How do you get employment related
information now?

� Why would you not be interested in using
the VA or another Veteran organization
for employment support?
◦ Have you had a Veteran friend who has used
employment services? Tell me about that.
◦ Where did he/she go? How has that affected
you?
Assessment of comfort with possible future
intervention
• What concerns/issues would you most like to get
help with?
• Tell me your feelings about attending classes to
improve your comfort and skill in interacting
with people.
• What would be the most useful focus of employ-
ment services for you?
• What would increase the likelihood of partici-
pating in services?
• What barriers do you see to using employment
services?
• What interpersonal situations have been difficult
for you when seeking work or on the job?
• When you imagine going to a job interview, what
thoughts run through your mind?
• When you get nervous during a job interview,

what do you worry about?
• When you have to talk to the boss, what might
you think about?
Future Plans and Goals
• What are your plans regarding employment at
this point?
◦ Future schooling or training?
• What would be your dream job?
◦ Do you see yourself ever having that type
of job?
◦ What would it take for you to get that job?
• What do you think the VA needs to do help
Veterans with employment?
Copyright of Work is the property of IOS Press and its content
may not be copied or emailed
to multiple sites or posted to a listserv without the copyright
holder's express written
permission. However, users may print, download, or email
articles for individual use.
International Journal of Caring Sciences
January-April 2021 Volume 14 | Issue 1| Page 392

www.internationaljournalofcaringsciences.org
Original Article
Effect of Nursing Intervention on Knowledge and Practice of
Salt and Diet
Modification among Hypertensive Patients in a General
Hospital
South-West Nigeria
Ajiboye, Rachael Oluwafunmilayo
Senior Nurse Tutor, School of Nursing, Lagos State College of
Nursing, Midwifery and Public Health,
Igando, Lagos, Nigeria
Okafor, Ngozi Antonia
Senior Lecturer, Department of Nursing, Babcock University,
Ilishan-Remo, Ogun State, Nigeria
Olajide, Tayo Emmanuel
Lecturer II, Department of Nursing, Babcock University,
Ilishan-Remo, Ogun State, Nigeria
Emmanuel Olayemi Tosin
Principal Nurse Tutor, School of Nursing, Lagos State College
of Nursing, Midwifery and Public Health,
Igando, Lagos, Nigeria. [email protected]
Correspondence: Ajiboye, Rachael Oluwafunmilayo School of
Nursing, Lagos State College of Nursing,
Midwifery and Public Health, Igando, Lagos, Nigeria. E-
mail:[email protected]

Abstract
Background: Hypertension is the most common non-
communicable disease and the leading cause of
cardiovascular disease in the world. Current management of
hypertension stressed the importance of salt and
diet modifications. Unfortunately, many hypertensive patients
do not have proper knowledge of this, which
results to inadequate practice. Therefore, there is need to
develop strategies that will help to improve knowledge
and practice of salt and diet modifications among hypertensive.
Objective: To determine the effect of nursing intervention on
knowledge and practice of salt and diet
modifications among hypertensive patients.
Materials and Methods: A quasi experimental design was
conducted using purposive sampling to select the
sample size of 38 participants. A researcher-developed
questionnaire derived from the literature review and
Hypertension Self-Care Activity Level Effects (H-SCALE)
adapted from Warren-Find low and Seymour (2011)
was used to measure knowledge and practice of salt and diet
modification among the participants. Data gathered
from participants were expressed using tables and percentages
while research questions were answered with
descriptive statistics of mean and standard deviation through
statistical package for the social science software
version 21.
Results: the study revealed that higher percentage of the
participants (81.6%) had poor of knowledge of salt and
diet modification pre-intervention, also 92.1% of the
participants reported poor practice before intervention.
Intervention was given to the participants and results showed a
positive change in knowledge and practice of salt
and diet practice post-intervention.
Conclusion: regular training should be given to hypertensive
patients by nurses to improve their knowledge and

practice of salt and diet modification for effective blood
pressure control.
Keywords: Hypertension, Knowledge, Practice, Salt and Diet
modification, Nigeria
Introduction
The burden of hypertension and other non-
communicable diseases is rapidly increasing and
this poses a serious threat to the economic
development of many nations. Hypertension is a
global public health challenge due to its high
prevalence and the associated risk of stroke and
cardiovascular diseases in adults.
Globally, hypertension is implicated to be
responsible for 7.1 million deaths and about
12.8% of the total annual deaths (World Health
Organization (WHO), 2018). Africa, among
other WHO regions was rated highest with
increased prevalence of high blood pressure,
estimated at 46% from age 25 years and above in

which Nigeria contributes significantly to this
increase (Okwuonu, Emmanuel, & Ojimadu
2014; Ekwunife, Udeogaranya, & Nwatu, 2018;
WHO, 2018). This is so in spite of the
availability to safe and potent drugs for
hypertension and existence of clear treatment
guidelines, hypertension is still grossly not
controlled in a large proportion of patients
worldwide.
Current national recommendations for the
prevention and treatment of high blood pressure
emphasized non-pharmacological therapy, also
termed "lifestyle modification" which includes
salt and diet modification. However, there is a
dearth of information on the knowledge and
practice of salt and diet modification among
hypertensive patients attending Nigeria’s health
institutions (Abubakar et. al, 2017). Hence, poor
knowledge of salt and diet modifications, and
inability to practice these were one of the
identified patient- related barriers to hypertension
control (Tesema et.al, 2016). This gap may also
be attributed to the type of information or
training programmes given to patients on salt and
diet modification.
Therefore, this study might help to improve the
knowledge of hypertensive patients on salt and
diet modification which in turn may affect its
practice thus reducing the death burden,
complications and economic cost of poorly
controlled hypertension among patients and in
the society.
Objective

The aim of the study was to determine the effect
of nursing intervention on knowledge and
practice of lifestyle modification among
hypertensive patients. The following research
questions were expected to be answered:
1. What is the pre-intervention knowledge
and practice of salt and diet modification among
hypertensive patients?
2. What is the post-intervention knowledge
and practice of salt and diet modification among
hypertensive patients?
Methods
It is a quasi-experimental study, which adopted
one pre-test-post-test design, conducted between
February and September 2019, at a secondary
health facility (General Hospital), South-west,
Nigeria. The study was carried out among
hypertensive patients attending medical out-
patients department (MOPD) in the general
hospital. The hospital was purposively selected
being the only secondary health facility located
in one of the densely populated communities in a
major commercial city of South-west, Nigeria.
Sample size and sampling procedure: Sample
size was calculated using Taro Yamane method
of sample size determination, n = calculated
sample size, Population size (N) = 42 based on
daily clinic attendance of hypertensive patients,
and margin of error = 0.05 with a confidence
level of 95% given a sample size of 38

participants. Inclusion criteria were male and
female patients who were ≥18 years of age,
diagnosed to be hypertensive and attending
medical out-patients department (MOPD),
available and willing to participate in the study,
who could communicate either in English or
Pidgin English. Exclusion criteria were other
patients at MOPD who were not diagnosed to be
hypertensive, or with any co-morbidity that could
interfere with participation in the training, and
have attended previous educational programme
on salt and diet modification. Participants were
selected based on the inclusion criteria using
purposive sampling.
Data collection tools and procedures: Data
were gathered using researcher-developed
questionnaire derived from the literature review
with the opinions of experts in the field to assess
participants’ knowledge of salt and diet practice
and modified Hypertension Self-Care Activity
Level Effects (H-SCALE) developed by Warren-
Findlow and Seymour (2011) to assess practice
of salt and diet modification among the
participants.The questionnaire consists of three
parts. The first part includes the demographic
characteristics of the participants with eight (8)
items; the second part assessed the participants’
knowledge of salt and diet modification. The
knowledge of salt and diet modification
questions includes twelve (12) items with
maximum and minimum scores of 12 and 0
respectively. Participants’ knowledge scores of
9-12 points indicate high knowledge, 6-8 points
indicate moderate knowledge and scores <6
points indicate poor knowledge. The third part

assessed the practice of salt and diet modification
among the participants with seven items which
were used to assess practices related to eating a
healthy diet, avoiding salt while cooking and
eating, and avoiding foods high in salt content.
Responses were coded ranged from never (1) to
always (3). Responses were summed up creating
a range of scores from three (3) to twenty one
(21). Scores of eleven (11) and above indicates
that participants followed the low-salt diet and
was considered as having good low salt diet
practice while score <11 indicate poor salt diet
practice. The psychometric properties of the
instrument was checked by experts in the field
using face and content validity criteria, the
reliability of the instrument was determined
using split-half method and the Cronbach’s alpha
reliability coefficient on knowledge of salt and
diet modification was 0.78, while salt and diet
practice was 0.72 which showed high reliability
of the instrument. The method of data collection
involved three phases:
Phase 1: this involved meeting with the
consultant and nurses in charge of MOPD of the
General Hospital to explain the purpose of the

study and its benefits, and to seek their co-
operation for the success of the study. This took
place during the first week of the study. In the
second week of the study, the researcher with
two research assistants visited the MOPD to
listen to health talk given to the patients by the
nurses and other health personnel, gaps were
identified which was used to modify the training
modules. The participants were met to discuss
the purpose, course and potential benefits of the
study. Interested participants were enrolled for
the study after obtaining their consent. Further
selection of the participants continued in the third
and fourth week. A pre-test instrument
(questionnaire) was given to the selected
participants to complete during the selection. No
external interference was allowed during data
collection, researcher and research assistants
stayed with the participants throughout the
period of completing the questionnaire after
which they were thoroughly checked for
completeness before retrieval from the
participants.The results from this phase were also
used to modify the training module for better
intervention. Reminder for the training
programme was given through phone calls, text
messages and visits on the clinic- days prior to
the training.
Phase 2: A developed intervention package was
implemented based on feedback obtained from
pre-intervention knowledge and practice score
with learning modules which was used for the
educational training of hypertensive patients on
salt and diet modification. The intervention

package had two modules of learning which was
delivered for two hours weekly for two weeks.
Different instructional methods were utilized to
deliver the programme including lectures, group
discussion, questions and answers, chats/pictures
and educational hand out. Follow-up through
phone calls and text messages was done every
week after intervention to ensure adequate
practice before the post-intervention test.
Phase 3: A post-test was given one month post-
intervention with the same instruments used
during the pre-test. Data collected were coded
and processed using statistical package for social
science (SPSS), version 21. Frequency table was
constructed and data were expressed on it. The
research questions were answered using
descriptive statistics of mean and standard
deviation.
Ethical Consideration: The ethics committee of
the researcher’s institution approved the study
with approval reference BUHREC102/19 dated
27th February, 2019 and written permission of the
State Health Service Commission was also
obtained to conduct the study. Participants were
informed about the purpose of the study and their
consents both verbal and written were taken
before the study commences. Participation was
voluntary and participants have the right to
withdraw at any stage of the study.
Results
The socio-demographic data reveals that greater
number of the participants was females (68.4%)

possibly, because females tend to pay more
attention to their health and engaged more in
physical and emotion stress than their male
counterparts. Majority, (44.7%) participants were
between the ages of 46 to 60 years, also many of
the participants (28.9%) have primary education
and 42.1% were self-employed. This could also
be related to the fact that the study was carried
out in one of the largest commercial city in
South-west Nigeria and research facility was
located in one of the densely populated
communities in the state which often require
constant subsidized health care services (Table 2)
Table 1: Intervention programme module about salt and diet
modification
Goals Learning content
At the end of the module, the
participants will:
Have a background knowledge of
hypertension
Know and identify the risk factors of

hypertension
Understand the contribution of salt and
diet modification to blood pressure
control.
Describe salt intake reduction and the
recommended quantity of salt intake
for blood pressure control.
Week One
Background knowledge of hypertension
Hypertension is the leading cause of heart and blood vessels
diseases
worldwide.
About 7.1 million deaths worldwide (~12.8% of total deaths)
are
estimated to be caused to hypertension.
Africa has the highest numbers of people with hypertension.
In Nigeria, hypertension is graded as number one of all terrible
diseases
among the people.
It affects both men and women, rich and poor people in rural
and urban
communities.
Hypertension is also called high blood pressure. Blood pressure
is the
measurement of force against the walls of your arteries when
your heart
pumps blood through your body. It has two numbers; the top

number is
called systolic blood pressure while the bottom number is
diastolic
pressure.
Your blood pressure is normal when these numbers are lower
than
120/80mmHg most of the time. Whenever these numbers are
120/80mmHg or higher most of the time but below
140/90mmHg is
called pre-hypertension. Any time the number is 140/90mmHg
or higher
most of the time is hypertension.
The risk factors of hypertension
These are situations that can make one to have hypertension.
Those situations that you can control
Unhealthy (bad) diet
Too much of salt intake
Overweight or obese
Sedentary lifestyle (lack of physical activity)
Tobacco usage
Excessive alcohol usage
Stress
Lack of sleep
Those situations that you can control
Age
Race
Family History

The contribution of salt and diet modification to blood pr essure
control.
Salt restriction: when you take not more than 2.4 g of sodium
per day it
reduces your blood pressure by 2-8 mmHg.
Adopt DASH eating plan: when you eat a diet rich in fruits,
vegetables,
and low fat dairy products with a reduced content of saturated
(solid
fats) and total fat it reduces your blood pressure by 8–14
mmHg.
Salt intake reduction and recommended quantity of salt intake
for blood
pressure control.
Ways to reduce your salt intake:
Salt intake should be reduced to less than 2,400 milligrams
(mg) a day (1
teaspoon).
Aim for less than 1,500 mg a day (not more than ½ teaspoon),
if

possible.
Do not add extra salt at the table.
Remove or reduce the amount of salt used in cooking and
baking.
Reducing salt to less than 2,400mg (1 teaspoon) can reduce
your blood
pressure to 2-8 mm Hg.
At the end of the module, the
participants will:
Adopting Dietary Approaches to Stop
Hypertension eating plan (DASH diet)
that lowered blood pressure
Components of Dash eating plan
Examples of daily and weekly servings
that meet DASH eating plan targets for
a 2,000 to 2,100-calorie-a-day diet.
Examples of food items that make up
the DASH eating plan.
Week Two
Adopting Dietary Approaches to Stop Hypertension eating plan
(DASH

diet) that lowered blood pressure
Food is an essential measure in prevention and treatment of
hypertension.
DASH diet is a simple and complete eating plan that helps
produce a
heart-healthy eating style for life.
It requires no special foods but provides daily and weekly
nutritional
goals.
Studies have shown that the DASH diet can lower blood
pressure within
2 weeks.
Adopting DASH eating plan can produce blood pressure
lowering
effects of 8-14mmHg, comparable to drug monotherapy.
Components of Dash eating plan
The plan recommends
eating vegetables, fruits, and whole grains
fat-free or low-fat dairy products
limiting foods that are high in saturated fat,
Avoiding /limiting sugar-sweetened beverages and sweets
Examples of daily and weekly servings that meet DASH eating
plan
targets for a 2,000 to 2,100-calorie-a-day diet
Food Group Daily Servings
Grains 6–8
Meats, poultry, and fish 6 or less
Vegetables 4–5
Fruit 4–5
Low-fat or fat-free dairy products 2–3
Fats and oils 2–3
Sodium (salt) 2,300 mg*

Weekly Servings
Nuts, seeds, dry beans, and peas 4–5
Sweets 5 or less.
Examples of food items that make up the DASH eating plan.
1. Rich in potassium, calcium, magnesium (fruits and
vegetables).
Examples: Avocado, Bananas, Carrots, Beans, orange, Pears
(fresh),
Peanuts, Spinach, Tomatoes, Skimmed Milk, Pawpaw, Oysters,
Soy
milk, Tofu.
2. Low in saturated and trans- fat or low-fat dairy products :
Examples: fish, yogurt, mayonnaise, unsalted nuts and seeds
such as
almonds, peanuts, walnuts, vegetable oils: canola, olive, peanut,
sunflower, corn, soybean, cottonseed.
3. Good source of fibre and protein
Examples: Whole grains, Whole wheat bread, Brown rice, oats,
barley,
wheat , White beans, kidney beans, northern beans.
4. Avoid food high in saturated diet
Example:
Meat: fatty/red meats, processed meats like hot dogs, organ
meat
Full-fat dairy products: whole milk, whole-milk products and

2% milk
Tropical oils: coconut oil, palm oil or palm kernel oil.
Fats: Margarines, cocoa butter, vegetables cooked in excessive
amounts
of sauce and butter, fried foods.
Snacks and Sugar: chocolate, ice cream, cakes, candy (sweet),
butter
rolls, egg breads, and commercial doughnuts.
Table 2: Socio-demographic data of the participants n=38
Variable Experimental (n=38)
Age (years) Freq. (%)
18-30 years 2 (5.3)
31-45 years 3 (7.9)
46-60 years 17 (44.7)
>60 years 16 (42.1)
Total 38 (100.0)
Gender
Male 12 (31.6)
Female 26 (68.4)
Total 38 (100.0)

Educational Level
No formal education 11 (28.9)
Primary education 11 (28.9)
Secondary education 5 (13.2)
Tertiary education 11 (28.9)
Total 38 (100.0)
Occupation
Employed 8 (21.1)
Retired 10 (26.3)
Self employed 16 (42.1)
House keeper 4 (10.5)
Total 38 (100.0)
Duration of Hypertension
1-5 years 16 (42.1)
6-10 years 21 (55.3)
>10 years 1 (2.6)
Total 38 (100.0)

Table 3: Summary of responses on knowledge and practice of
salt and diet modification
pre-intervention
Knowledge Level n=38
Poor knowledge
(0-5 points)
Moderate knowledge
(6-8 points)
Good knowledge
(9-12 points)
Total
Pre-
intervention
31 (81.6%) 7 (18.4%) 0 (0.00%) 38 (100%)
Practice Level n=38
Poor practice (0-10

points)
Good practice (11-21
points)
Total
Pre-
intervention
35 (92.1) 3 (7.9) 38 (100%)
Table 4: Comparing pre - and post-intervention knowledge and
practice of salt and diet
modification.
Knowledge and Practice Level n=38
Knowledge of salt
and diet
modification n=38
Poor knowledge
(0-5 points)
Moderate
knowledge (6-8
points)
Good
knowledge (9-12
points)

Total
Pre-intervention 31 (81.6%) 7 (18.4%) 0 (0.00%) 38 (100%)
Post-intervention 1 (2.6%) 0 (0.0%) 37 (97.4%) 38 (100.0%)
Practice of Salt and
Diet Modification
Poor practice (0-10
points)
Good practice (11-
21 points)
Total
Pre-intervention 35 (92.1) 3 (7.9) 38 (100%)
Post-intervention 4 (10.5) 34 (89.5) 38 (100%)
Table 3 summarily shows participants responses
on knowledge and practice of salt and diet
modification pre-intervention. 81.6% of the
participants had poor knowledge of salt and diet
modification, 18.4% had moderate knowledge
level and none of the participants had high
knowledge level (0.00%) of salt and diet
modification. Participants also demonstrated
poor practice of salt and diet modification as
92.1% of the participants reported poor practice,
while only 7.9% of the participants reported
good practice of salt and diet modification before

intervention. However, Table 4 reveals a positive
change in the participants’ level of knowledge
and practice of salt and diet modification after
intervention. Only 2.6% of the participants
demonstrated poor level of knowledge of salt and
diet modification post intervention as against
81.6% before intervention. While 97.4%
demonstrated high knowledge level post-
intervention training as opposed to none (0.00%)
before intervention. When comparing pre and
post intervention practice of salt and diet
modification, the practice of diet and salt
restriction was good (≥11) from 7.9% pre-
intervention to 89.5% post intervention. While
poor practice level (≤10) was reduced to 10.5%
from 92.1% after intervention.
Discussion
The study revealed that the pre-intervention
knowledge of participants about salt and diet
modification was poor (81.6%). This finding
corroborates the findings of a study done in India
in 2011 and South Ethiopia (2017) that majority
of the respondents have poor knowledge of salt
and diet modification (Subramanian et. al 2011;
Buda et.al, 2017). The finding is also in
agreement with Okwuonu, Emmanuel, and
Ojimadu (2014) that most hypertensive patients

are not fully aware of the impact of unsaturated
oil, reduction in diary food, whole grains,
consumption of fruits and vegetables in the
control of blood pressure and salt reduction The
study also showed poor practice of salt and diet
modification (92.1%) among the participants
before intervention. This finding was a bit higher
compare with a similar study done in China that
about 70% of the participants had poor adherence
to modification practices (Lu, et. al, 2017). This
may be attributed to poor knowledge of salt and
diet modification which in turn affects its
practice among the participants. This agreed
with Babu, (2015) who said that the desired
changing level in patients’ attitude toward
modification was not achieved due to insufficient
information in relation to effect of salt and diet
modification on blood pressure control given by
the health care professionals. Hence, an intense
effort should be made by health care givers for
effective improvement.
According to the findings of the study, poor
modification as demonstrated by the participants
may affect effective blood pressure control
which may be attributed to poor health seeking
behavior on the part of patients or inadequate
information provided by the health personnel.
This is particularly supported by a group of
researchers who posited that targeted health

education strategies are obviously necessary to
enhance the knowledge level of hypertensive as
this will help to prevent adverse effect of poor
blood pressure control, and that health care
givers are needed to provide appropriate cost-
effective programmes on management of
hypertension with a lot of reinforcement and
motivation for effective practices (Gnanaselvam
et. al, 2016). In addition, patients need to be
taught the basic underlying principles behind
every part of their care for them to be motivated
and adopt any change of behavior. Therefore,
patient education should be strengthened on the
use of salt and different type of diets that are
suitable for prevention and effective control of
blood pressure (Okwuonu, Emmanuel, and
Ojimadu, 2014); Tesema et.al, 2016).
The study findings revealed a notable
improvement on knowledge and practice of salt
and diet modification after the intervention
training programme as shown by post-
intervention test score. This shows that
intervention programme was very effective as the
participants gained more insight salt and diet
modification in relation to blood pressure
control. This agreed with Babu (2015) that when
a structured instructional module is used to
divulge facts on salt and diet modification among
hypertensive patients this will in turn affect their
practice and thus lowered blood pressure.
The findings validate the report of a randomized
controlled clinical trial which states that increase
in knowledge about the role of lifestyle in the

occurrence of high blood pressure would cause
people to start modifying their lifestyles and
enhance their preventive behaviours (Jafari et.al,
2016). This was proven with the result of a meta-
analysis of 37 randomized controlled trials by
Aburto et. al, (2013) who demonstrates the
strong and consistent relationship that has been
observed between dietary sodium and blood
pressure that reduced sodium intake reduces
blood pressure in both non-acutely ill adults and
children. The largest controlled feeding study of
potassium supplementation effects on blood
pressure was conducted among Chinese adults by
Gu et. al (2013) the study demonstrated a
significant reduction in blood pressures that was
reproducible after an average of 4.5 years. Even
more encouraging are the results of magnesium
supplements decreasing systolic and diastolic
blood pressure 3 to 4 mmHg and 2 to 3 mmHg,
respectively, with greater dose-dependent effects
at supplementations >370 mg/day (Kupetsky-
Rincon & Uitto, 2012). In subgroup analyses
involving five trials conducted among
hypertensive, fiber intake significantly reduced
both systolic and diastolic blood pressure by 5.95
and 4.20 mmHg, respectively (Bazzano et.al,
2015). Buda et al. (2017) added that irrespective
of other treatments options, if all hypertensive
patients are given needed information and
support required in controlling blood pressure it
will assist in achieving and maintaining salt and
diet practices. Hence, educational programs are
essential in increasing knowledge, improving
self-management, and controlling dietary habits
that are detrimental to effective blood pressure
control (Beigi et. al, 2014)

Conclusion and Recommendation: The study
helped to validate that a nurse-led intervention
programme has significant effect in improving
knowledge and practice salt and diet
modification among hypertensive patients.
Therefore, it is recommended that nurses should
ensure adequate provision of such programme in
a continuous and intermittent way with accurate
information while providing care for these
patients.
Limitation of the Study: There are other
variables that are effective in control of blood
pressure which were not included in the study
such as measurement of patients’ clinical
parameters like cholesterol level and
triglycerides due to financial constraints. Another
important limitation was follow-up time, hence,
future studies should be conducted given enough
time for follow-up.
Acknowledgements: The researchers show their
appreciation management of the health facility
used as well the State Health Service
Commission for permission to use their facility
for the study. Appreciation also goes to all
participants that took part in the study.

References
Abubakar, S., Muhammad, L. U., Ahmed, A., &Idris,
F. (2017). Knowledge, attitude, and adherence to
non-pharmacological therapy among patients with
hypertension and diabetes attending the
hypertension and diabetes clinics at tertiary
hospitals in Kano, Nigeria. Sahel Medical
Journal20(3), 102-108. Retrieved from
www.smjonline.org DOI: 10.4103/1118-
8561.223170
Aburto, A., Nancy, J., Ziolkovska, A., Hooper, L.,
Paul, E., Cappuccio, F. P., Meerpohl, J. J. (2013).
Effect of lower sodium intake on health:
Systematic review and meta-analyses.
BMJ , 346 doi: https://doi.org/10.1136/bmj.f1326.
Babu, A.(Eds.). ( 2015). Effectiveness of structured
teaching program on knowledge of hypertensive
patients regarding dash diet at selected community
area, Bangalore. Karnataka, India: Rajiv Gandhi
University of Health Science.
Bazzano, L. A., Green T., Harrison T. N., &
Reynolds K. (2015). Dietary approaches to
prevent hypertension. Curr Hypertens Rep,15(6),
694–702.
Beigi, M. A., Zibaeenezhad, M. J., Aghasadeghi, K.,
Jokar, A., Shekarforoush, S., & Khazraei,H.
(2014). The effect of educational programs on
hypertension management. International
Cardiovasc Res J,8(3), 94–98.

Buda, E. S., Hanfore, L. K., Fite, R. O., & Buda, A.S.
(2017). Lifestyle modification practice And
associated factors among diagnosed hypertensive
patients in selected hospitals, South Ethiopia.
Clinical Hypertension, 23(26).
Ekwunife, O. I., Udeogaranya, P. O., &Nwatu, I. L.
(2018). Prevalence, awareness, treatment and
control of hypertension in a Nigerian population.
Scientific Research Publishing Inc. 2(7), 731-735.
Gnanaselvam, K., Ilankoon, P., Arulanandem, K., &
Joseph, J. (2016). Assessment of knowledgeon
hypertension, its consequences and management
practices among hypertensive patients: A
descriptive study. Journal of the Postgraduate
Institute of Medicine,3(30), 1-11
Gu, D., Zhao, Q., Chen, J., Chen, J. C., Huang, J.,
Bazzano, L. A. ,… He, J. (2013). Reproducibility
of blood pressure responses to dietary sodium and
potassium interventions: The general salt study.
Hypertension, 62(3), 499-505.
Jafari, F., Shahriari M., Sabouhi F., Farsani A. K.,
&Babadi M. E. (2016). Effects of a lifestyle
modification program on knowledge, attitude and
practice of hypertensive patients with angioplasty:
A randomized controlled clinical trial. Int J
Community Based Nurs and Midwifery, 4(4),
286–296.
Kupetsky-Rincon, E. A.,&Uitto J. (2012).
Magnesium: Novel applications in cardiovascular
disease—A review of the literature. Ann

NutrMetab, 61(2), 102–10.
Lu, J., Lu, Y., Wang, X., Li, X., Linderman, G. C.,
Wu, C., Jiang, L. (2017). Prevalence, awareness,
treatment, and control of hypertension in China:
Data from 1.7 million adults in a population-based
screening study (China peace million persons
project). Lancet, 390, 2549.
Okwuonu, C.G, Emmanuel, C.I, &Ojimadu, N.E.
(2014).Perception and practice of lifestyle
modification in the management of hypertension
among hypertensive in South-east Nigeria.
International Journal of Medicine and Biomedical
Research, 3(2), 121-131
Subramanian, H., Soudarssanane, M. B.,
Jayalakshmy, R., Thiruselvakumar, D.,
Navasakthi, D., Sahai, A., &Saptharishi, L. G.
(2011). Non-pharmacological interventions in
hypertension: A community-based cross-over
randomized controlled trial. Indian Journal of
Community Med., 36(3), 191–196.
Tesema, S., Disasa, B., Kebamo, S., &Kadi, E.
(2016). Knowledge, attitude and practice
regarding lifestyle modification of hypertensive
patients at Jimma university specialized hospital,
Ethiopia. Primary Health Care Open Access
Journal, 6(218), 1-4.
Warren-Findlow, J.& Seymour, R. B. (2011).
Prevalence rates of hypertension self-care
activities among African Americans. Joint
National Medical Association, 103(6), 503–512.

World Health Organization (2018) Global health
observatory data: Raised blood pressure Situation
and trends. Retrieved
fromhttp://www.who.int/chp/ncd_global_status_re
port/en
Copyright of International Journal of Caring Sciences is the
property of International Journal
of Caring Sciences and its content may not be copied or emailed
to multiple sites or posted to
a listserv without the copyright holder's express written
permission. However, users may
print, download, or email articles for individual use.

1. Discuss the nursing implications of the findings of the researc

Recommended

Recommended

More Related Content

Similar to 1. Discuss the nursing implications of the findings of the researc

Similar to 1. Discuss the nursing implications of the findings of the researc (20)

More from AbbyWhyte974

More from AbbyWhyte974 (20)

Recently uploaded

Recently uploaded (20)

1. Discuss the nursing implications of the findings of the researc