Article Critique

DNP-prepared nurses and DNP graduates are always expected to extrapolate and apply
research results and then integrate them into EBP (evidence-based practice). This involves
considering the implications of research findings to practice, knowledge, and theory.
Implications of research outcomes are the meanings of the findings for the field of nursing
knowledge and practice. As with generalizations or extrapolations, implications for practice are
summative – including both present study and associated literature in the same field of evidence.
According to Gray & Grove (2020), implications for practice are always centered, partly, on
whether or not treatment outcomes or interventions are different in the perspective of the study
results. For practice, these implications are often retrieved from the research findings, inferential
or descriptive, instead of general codes/principles of nursing practice. More than often, the
strength of the study findings depends on the methodology and study designed researchers select
to examine the variables in question or their desired correlation. Each specific design comes with
its “own” unique set of setbacks and benefits in terms of the validity and reliability of the study
outcomes and, thus, the ability to extrapolate and apply research implications to nursing practice.
Therefore, this summary seeks to critique Yeom’s (2021) article titled “Causal Beliefs
About Hypertension and Self-care Behavior” by providing a brief overview before highlighting
the strengths, weaknesses, and potential changes to address the setbacks. The weaknesses and
strengths part will consider sampling, design, data collection, statistical analyses,
outcomes/results, and study discussion. The final part will examine the implications of the study
to nursing practice.

Summary

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I. Overview of the Study
Hypertension is one of the primary causes of cardiovascular disease worldwide, with the
World Health Organization in 2016 linking roughly 31 percent of the globe’s mortality to
cardiovascular disease. Hypertension is a chronic condition that needs persistent self-care to
lower mortality and morbidity from related cardiovascular complications and symptoms. Despite
the efforts to control the morbidity of heart diseases, uncontrolled hypertension or high blood
pressure (HBP) continue to wreak havoc, contributing significantly to the high incidences and
prevalence of cerebrocardiovascular conditions. This has prompted stakeholders, industry
players, and researchers to look for novel ways to address hypertension through self-care
interventions.
One such strategy has focused on understanding patients’ causal perspectives and beliefs
about high blood pressure. Despite evidence suggesting a possibility of this approach providing
long-lasting solutions to persistent hypertension and a lack of compliance and willingness to
initiative self-care among patients diagnosed with high blood pressure, very little research has
been conducted to establish the true potential of this intervention. Therefore, in this study, Yeom
(2021) explores the internal structure influencing the causal beliefs about HBP or hypertension in
Korean patients and how these causal beliefs determine the patient’s self-care intentions and
subsequent medication compliance.
The study employed a cross-sectional design utilizing a convenience sample of145
participants diagnosed with HBP/hypertension from several sites in two southeastern towns in
South Korea, including the cardiovascular outpatient region at a college health facility, local
clinics, and community health clinics. All respondents recruited were required to meet the
following criteria: (a) medically diagnosed with HBP/hypertension by a physician; (b) lived with

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hypertension for a minimum of six months six diagnosis; (c) no clinical history of heart attack,
stroke, or any cardiovascular complication; (d) not hospitalized for surgery for the past six
months; (e) and aged 18 and above. Participants also needed to be of sound mind, respond to
questions, and not be diagnosed with any cognitive impairment or psychological problems by
healthcare providers. Causal beliefs or perceptions about high blood pressure were examined
using an adjusted IPQR (Illness Perception Questionnaire-Revised) tool. A factor analysis using
SPSS 22.0 software extracted the internal framework of causal perceptions/beliefs among
participants. Subsequently, logistical regression and multiple linear regression analyses were
deployed to test the impact of causal perceptions/beliefs on medication compliance and self-care
intention.
The study causal beliefs about high blood pressure (hypertension) were organized into
four themes: habitual, risk, fate-related, and psychological factors. Linking hypertension causes
to fate-related attributes (e.g., accidents and fate) and risk factors (e.g., alcohol and smoking)
were a critical predictor of poor medication compliance and low self-care intention, respectively.
II. Strengths of the Study
The use of the convenience sampling technique is the first strength of the study.
Convenience sampling means that the researchers only selected an appropriate “population” or
“sample” to partake in the study – those genuinely being hypertensive, sound mind, and of age.
This increased the chances of getting logical and reliable outcomes. Each of the seven inclusion
criteria, in one or the other, eliminated any possibility of recruiting unsuitable participants. For
example, the idea that all participants needed to have been medically diagnosed with
HBP/hypertension by a physician was critical in ensuring that only valid hypertensive
participants were recruited. Besides, ensuring that those diagnosed had lived with hypertension

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for a minimum of six months eliminated any potential of recruiting participants who were
erroneously misdiagnosed for hypertension or those who recovered within that period.
Furthermore, excluding patients with a clinical history of heart attack, stroke, or any
cardiovascular complication was necessary to guarantee that no other underlying hypertension
co-morbidity was responsible for the elevated blood pressure. Allowing such respondents to take
part in the research can potentially dent the validity of the results. For example, evidence
suggests that elevated blood pressure is a common symptom after an acute stroke, including both
hemorrhagic and ischemic types (Lattanzi, Silvestrini, & Provinciali, 2013). Therefore, it is
necessary to phase out such individuals. Also, recruiting patients above 18 years and those not
diagnosed with any cognitive impairment or psychological problems by healthcare providers
were necessary to guarantee that everyone could answer questions appropriately and soundly
without consenting to other third parties.
The second strength of the study was its use of valid or approved questionnaire-based
tools to collect specific causal beliefs, behavioral hypertension management, and health-related
and sociodemographic information. For instance, data related to individual perceptions about
high blood pressure, such as causal beliefs, were collected using an adjusted IPQ-R tool. The
study even adjusted the original IPQ-R model to suit the specific characteristics of hypertension,
just as recommended by Moss-Morris et al., who developed the model in 2002. The study tailors
the IPQ-R tool to consider Korea’s unique perceptions and views about high blood pressure.
Furthermore, items with a more general or broader meaning were twisted to attain a more precise
goal. For instance, the “my own behavior” item was changed to a “lack of physical activity.” This
is primarily because several aspects like social activity, exercise, and diet determine behavior.

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Another reason is that researchers have previously found a strong correlation between
hypertension and physical activity among patients in Korea (Shin, Keller, & Sim, 2018).
Finally, the study’s strength stems from applying SPSS 22.0 factor analysis to extract the
internal framework of causal perceptions/beliefs among participants. Factor analysis ensures that
researchers can identify categories of inter-related variables and examine how they relate to one
another. The technique can also help expose underlying construct dimensions that might not be
clear from the direct analysis. Descriptive statistics (such as histogram, kurtosis, skewness,
frequency, standard deviation, and mean) were estimated to test for the accuracy of
homoscedasticity, normality, outliers, missing values, and data entry. Subsequently, logistical
and multiple linear regression analyses were deployed to scree for the impact of causal
perceptions/beliefs on medication compliance and self-care intention. Pearson’s correlation
coefficient, ANOVA, and t-test also played an integral role in assessing the variances in causal
beliefs based on sociodemographic factors.
III. Weaknesses of the Study
Although the study was generally reliable and valid because of statistical analytic
methods and authentic data collection tools, it still had its flaws. For example, the decision to use
convenience sampling affected the ability to produce expected outcomes or results that can be
generalized or extrapolated to the overall population (in this case, Korean hypertensive patients).
This can negatively affect the implications of the research outcomes to nursing practice (Etikan,
2016). The second weakness stems from the use of self-administered questionnaires as the
primary method of data collection. Self-administered questionnaires pose a potential risk in that
respondents can choose to overstate their opinions because of social desirability bias (Gray &
Grove, 2020). Furthermore, the cross-sectional study design is more difficult to establish the

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causality relationship between behavioral characteristics and causal beliefs. Another concern
about the generalizability of the outcome was using a purely limited scale and validated to the
Korean hypertensive patients and the region’s general population. This makes it difficult to
generalize the findings to the global population.
IV. Proposed Changes to Address the Weaknesses
Several adjustments can be made to address the weaknesses above. For instance,
replacing convenience sampling with random sampling can help address the problem of results
generalizability. Random sampling means that each sample (participant) has an equal
chance/probability of being selected. The concern about generalizability can also be addressed
by recruiting participants globally instead of just restricted the sample population to South
Korea. According to Yeom (2021), longitudinal research targeting diverse global participants
using a worldwide validated scale can guarantee that the outcomes can be extrapolated to both
Korean and global populations. The longitudinal design will address the problems posed by the
cross-sectional study design. Finally, self-administered questionnaires can be substituted with
structured questionnaires to address the problem of response bias. According to Adhabi &
Anozie (2017), structured questionnaires will ensure that all respondents are asked a similar set
of standardized questions (open or closed).
V. Implications of the Study to Nursing Practice
This research categorized patients’ causal beliefs about HBP/hypertension in Korea into
four thematic dimensions: habitual, risk, fate-related, and psychological factors. Associating the
cause of high blood pressure to psychological factors was responsible for a majority of the
patients’ perceptions/beliefs. The research also showed that patients’ perceptions about
hypertension might be irrelevant or consistent with medical facts. Also, their causal discernments

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or perceptions are linked to sociodemographic elements, such as education, gender, and age.
Notably, all the causal beliefs connecting hypertension to fate-related and risk factors were
critical predictors of patients’ medication compliance and intention to participate in self-care,
respectively. These results suggest that nurses must keenly observe patients with causal
perceptions about supernatural powers and those that participate in risky behaviors like alcohol
intake and smoking to understand more latent misconstructions and lack of awareness about the
hypertension causes.

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References

Adhabi, E. A., & Anozie, C. B. (2017). Literature review for the type of interview in qualitative
research. International Journal of Education, 9(3), 86. doi:10.5296/ije.v9i3.11483
Etikan, I. (2016). Comparison of convenience sampling and purposive sampling. American
Journal of Theoretical and Applied Statistics, 5(1), 1. doi: 10.11648/j.ajtas.20160501.11
Gray, J. R., & Grove, S. K. (2020). Burns and Grove’s the practice of nursing research:
Appraisal, synthesis, and generation of evidence (9 th ed.). Elsevier.
Lattanzi, S., Silvestrini, M., & Provinciali, L. (2013). Elevated blood pressure in the acute phase
of stroke and the role of angiotensin receptor blockers. International Journal of
Hypertension, 941783. doi: 10.1155/2013/941783
Shin, C. N., Keller, C., & Sim, J. (2018). Cultural factors relevant to Korean Americans in health
research: A systematic review. Journal of Community Health, 43(2), 421–432.
http://dx.doi.org/10.1007/s10900-017-0418-4
World Health Organization. (2016). Hearts: Technical package for cardiovascular disease
management in primary health care. Retrieved from https://www.who.int/cardiovascular
diseases/hearts/Hearts package.pdf
Yeom, H. (2021). Causal beliefs about hypertension and self-care behavior in Korean patients.
Collegian, 28, 48-56. https://doi.org/10.1016/j.colegn.2020.04.007