The Ankle Blood Pressure Study: An Exemplar Project of Mentoring, Leadership, and Collaboration to Promote Nursing Research

The purpose of this presentation is to describe the evolution of a clinical practice question from evidence-based practice project to research study and delineate the roles of all nurses involved, with particular attention to the role of the advanced practice nurse.   Additionally, the presentation will focus on the outcomes of the project, both from a practice perspective as well as a professional development perspective.  Strong leadership by the APN and the commitment to the mentoring process by the team contributed to project success. This project serves as an exemplar for those wanting to increase nurse engagement in research and nursing's influence within organizations.

 In the Magnet® organization where this project took place, advanced practice nurses (APNs) are charged with providing guidance for staff nurses regarding EBP and research.  The APNs at this institution are Master’s prepared nurses who hold the title of Clinical Nurse Specialist (CNS).   Involvement in research activities, including interpretation, translation, evaluation, and conduct of EBP and research, is an essential component of the CNS role as identified by the 2004 National Association of Clinical Nurse Specialists  (NACNS) Statement on Clinical Nurse Specialist Practice and Education (NACNS, 2004). In addition, the American Association of Colleges of Nursing (AACN) Essentials of Master’s Education in Nursing requires that graduates be prepared to lead the healthcare team in the implementation of EBP and serve as role models and mentors for evidence-based decision making in practice (AACN, 2011).

 The project began when a BSN nurse approached the cardiovascular specialty CNS and cardiovascular nurse educator about the use of the ankle as an alternative site for blood pressure (BP) measurement. The BSN nurse relayed that she had observed this practice being done by her colleagues when the arm was not available for use.  She wanted to know if an ankle BP was an acceptable option.  The BSN nurse was encouraged by the CNS to investigate this clinical question by participating in Research Roundtable (Harne-Britner & Schafer, 2009).  Research Roundtable is a collaborative effort, led by a team of CNSs, in which staff nurses and senior baccalaureate nursing students, with the support of academic nurse faculty, investigate clinical questions. Research Roundtable enables nurses to bring clinical questions forward and to work with a group to explore the available evidence and determine if a practice change is warranted or if additional research is needed.  Under the guidance of the CNS, evidence related to this EBP project was examined, and it was determined that there was a lack of evidence to either support or discontinue the use of ankle BPs. The CNS met with the BSN nurse and the cardiovascular nurse educator, who together decided that the next step would be the development of a formal research proposal. To facilitate this work, the CNS recommended that the nurse apply for a Nursing Research Fellowship. With the support from the team, the nurse was granted the Research Fellowship, which provided release time for scholarly work and development of the proposal. The CNS contacted the academic nurse researcher and elicited her support and expertise for the project. In addition, the CNS served as a mentor to the BSN nurse in the writing of the proposal and championed the proposal through the approval processes, which included the Nursing Research Council and the institutional review board. The study was granted approval. Upon initiation of the study, the team was assembled, which included the BSN nurse, CNS, cardiovascular nurse educator, and the academic nurse researcher. Roles were delineated, and the timeline established.

 During initiation of the study the nurse researcher served as a mentor and guide to the team regarding study design, methods, and data analysis. The CNS ensured the integrity of the research process by obtaining institutional review board approval, managing consent procedures, piloting data collection tools, and monitoring the integrity of the data collection process.  The BSN nurse served as the lead data collector and recruited other nurses to the data collection team.  She mentored here peers in the data collection process and shared information about the study with other nurses on the unit and throughout the organization.

 In order to assess BP reading agreement between the arm and the ankle, the team performed a series of 3 readings for each subject and 2 sets of readings were recorded, 1 for the arm and the second for the ankle. The results for all 3 tests and 6 pairings indicate that the readings taken at the arm are significantly different (P < .001) from those taken at the ankle. Four composite mean readings (arm systolic, arm diastolic, ankle systolic, and ankle diastolic) were computed for each subject across his/her 3 measurements. The mean (SD) arm systolic reading was 129.59 (16.13) mm Hg, whereas the mean ankle systolic reading was significantly higher at 153.05 (15.55) mm Hg (P < .001). This was also true for the diastolic readings, with a mean (SD) arm diastolic BP of 72.27 (8.93) mm Hg and mean (SD) ankle diastolic BP of 82.62 (10.66) mm Hg (P < .001). The difference in scores for each subject was also calculated. The mean difference in ankle systolic readings was determined to be 23.49 mm Hg (95% confidence interval [CI], 21.44-25.54) higher than arm reading. For diastolic BP, the mean difference in ankle readings was 9.35 mm Hg (95% CI, 8.23-10.46) higher than arm readings.  Bland-Altman analysis (Bland & Altman, 1995) revealed that there was considerable variation in the difference scores by individual subjects. The SD of the difference in systolic BP was 13.65 mmHg, and for diastolic, it was 7.41 mm Hg; therefore, it is estimated that 95% of patients could have ankle measurements of systolic BP readings that are 50.84 mm Hg above or -3.78mmHg below their arm measurements. For diastolic pressure, the ankle readings could be 24.14 mm Hg above or -5.52 mm Hg below the arm measurements. (For a full description of the study, detailed results, and limitations see Maneval, et, al., 2014).  The data suggest that arm and ankle BP measurements are not comparable, and there was not a predictable relationship between the two measurements. 

 As a result of the study findings the quality of patient care was impacted through the development of a new practice guideline by the CNS for ankle BP measurements and the education of staff nurses. The findings of the study suggest that ankle BP measurements lack agreement, and often overestimate both systolic and diastolic BP, when compared with arm BP measurements; thus, individual differences in variation calls into question the practice of relying on ankle BP measurements in routine clinical practice. The CNS, aware that nurses are faced with a difficult dilemma when attempting to obtain BP measurements when the upper arm is not a viable option, crafted a new practice guideline to address this issue. The guidelines call for obtaining baseline arm and ankle BP measurements upon admission. Then, if ankle measurements become necessary, a comparison is to be made based upon the individual patient’s arm and ankle systolic and diastolic differences. By doing this, the ankle BP measurement is understood in the context of the individual patient’s BP measurements.

 The CNS educated the nurses on the complexity of interpreting BP readings taken at the ankle and the importance of careful consideration of the meaning of the results for the individual patient. The importance of consistency in choice of extremity used and the need for careful charting of the location of each BP measurement was communicated as a crucial component of ankle BP measurement. The CNS worked to modify the electronic medical record so that alternative sites could be documented. The CNS has continued to facilitate the development of organizational policies that require baseline assessment of arm and ankle BP for select patients and the proper documentation of those results.

 The project also enhanced opportunities for mentoring relationships which increased knowledge and confidence of the team in both the EBP process and research process. Mentoring occurred between the nurse researcher and the CNS, the CNS and the BSN nurse, and the BSN nurse and peers.  The CNS also mentored the BSN nurse in the creation of a poster and podium presentation on the study for dissemination at both local and national conferences.

 Additionally, leading the research project elevated the CNS’s visibility and influence within the organization by clearly demonstrating the value of the CNS in the research process and the impact that nursing research has on nursing practice and patient outcomes. Participation by the BSN nurse demonstrated to peers, managers, and administrators the key role bedside nurses have in identifying clinical issues and supporting the research process through active engagement.   As demonstrated by this project, nurses engaged in the EBP process and the conduct of original research influence nursing practice at the bedside, organizational level, and beyond.