Applied Nursing Research 35 (2017) 106–111

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Applied Nursing Research

journal homepage: www.elsevier.com/locate/apnr

The effect of sustained nursing consulting via telephone (Tele Nursing)

on the quality of life in hypertensive patients☆
Fahimeh Dadgari a, Shirzad Hoseini b,⁎, Shahla Aliyari c, Shirin Masoudi d
a
Faculty of Nursing, AJA University of Medical Sciences, Tehran, Iran
b
Chancellor of Research & Technology, Elite Foundation, AJA University of Medical Sciences, Tehran, Iran
c
Department of Maternal & Newborn Health, Faculty of Nursing, AJA University of Medical Sciences, Tehran, Iran
d
Department of Medical-Surgical, Faculty of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran

a r t i c l e i n f o

Article history:
Received 20 September 2016
Accepted 1 February 2017
Available online xxxx

© 2017 Elsevier Inc. All rights reserved.

1. Introduction 2. Background

Hypertension is considered as one of the most common chronic con-
ditions in the public health with an increasing trend in the developing
countries. Nearly 25% of adults have high blood pressure. Noticeably,
high blood pressure has a negative impact on the quality of life of pa-
tients with high blood pressure because of its high prevalence and
high mortality rate in these patients (Samavat, Hojatzadeh, & Naderi,
2001). Studies have shown that the prevalence of the hypertension is
increasing in all countries, including Iran (Sotodeh asl, Neshat-Dust,
Kalantari, Talebi, & Khosravi, 2010). Over 7.1 million deaths in world-
wide are attributed to hypertension (Erem, 2008). Studies have shown
that hypertension is present in 32.5% of adults in Iran. According to
the worldwide prevalence of hypertension, its complex nature as well
as long-term serious side effects, the control of this disease is one of
the priorities of health care organizations in all countries. In general,
lifestyle modification, including weight loss, exercise, diet, smoking ces-
sation, decreases in salt intake and alcohol consumption, increased die-
tary intake of potassium, calcium and magnesium could be useful in
controlling the hypertension (Lilly, 2003). However, there are more
than one hundred medications effective in the treatment of hyperten-
sion, which are classified into 4 categories, including diuretics, anti-
sympathetic, vasodilators drugs and angiotensin-renin system blockers
(Longo, 2012).
☆ Financial support: This study is funded by AJA University of Medical Sciences (9311).
⁎ Corresponding author at: No. 42, Second Deadlock, Shahid Kobar 1 Alley, Maali Abad
Bridge, Shiraz, Iran.
E-mail address: sh-hoseini@razi.tums.ac.ir (S. Hoseini).
According to the studies, despite the national, regional and interna-
tional corporations, hypertension is still considered as a serious public
health challenge for all countries. At the present, uncontrolled hyper-
tension is recognized as the most common and important risk factor
of public health in various societies (Kearney, Whelton, Reynolds,
Whelton, & Hypertens, 2004). Patient adherence to dietary recommen-
dations is an important part of hypertension treatment which is provid-
ed through the collaboration between healthcare providers and
patients. In this regard, consistent and regular care is very important.
Providing training, development goals and social support can help
patients' adherence to treatment and control the hypertension. So
that, incomplete treatment adherence is a treatment challenge experi-
enced by patients with hypertension and other chronic disease. Gener-
ally, patients with chronic diseases have continuous interactions with
the health care system. On the other hand, it is necessary that patients
receive high-quality medical cares according to evidence-based medi-
cine. Therefore, using a health-care model could be useful for health
care providers (Pare, Janna, & Sicotte, 2007). The development of a
telemedicine program, which is associated with improved availability
of services, decreases overall costs and have resulted in an increasing
trend toward using telemedicine in home care (Hebert, Korabek, &
Scott, 2006). It appears that the electronic management of chronic
diseases could be an effective method in treatment of such diseases.
This is mainly due to providing valid information for patients, enabling
patients, as well as the effect on patients' attitude and behaviors and po-
tential improvement in health status (Pare et al., 2007). Telenursing, a
component of electronic health care projects, is defined as “the use of

http://dx.doi.org/10.1016/j.apnr.2017.02.023
0897-1897/© 2017 Elsevier Inc. All rights reserved.
 F. Dadgari et al. / Applied Nursing Research 35 (2017) 106–111
telemedicine technology and includes a wide range of communication
technologies such as phone, email, internet, and video clips to deliver
nursing care” (Telenursing Inc., 2013). Among these electronic devices,
telephone which is available for the most of the people, is being used in-
creasingly (Black & Hawks, 2005). The health calling system through
which the patients receive weekly or monthly calls from nurses is con-
sidered as a useful method of treatment in chronic disease which results
in an effective treatment outcome, better health status, development of
patients-nurse communication, and overcome the obstacles of time and
distance to provide better nursing cares (Shearer, Cisar, & Greenberg,
2007). One of the advantages of telenursing is the cost-effectiveness of
this method for both patients and health care system. The aim of our re-
search was to scale up patients' self-efficiency and provide an effective
health care approach to promote quality of life through reducing per-
sonal visits, transport costs, waiting time for visit and eradicating the
lack of access to health care providers, in addition to promoting the
quality of health care by enhancing the communication with health
care staff.
3. Methods
3.1. Design
Our study was a clinical trial study conducted on 70 patients with di-
agnosed hypertension (use of anti-hypertensive agents) who were se-
lected randomly from the XXX hospital during 2014. Patients were
selected randomly according to the inclusion criteria by the simple sam-
pling method. Prior to the initiation of the study, all of patients signed an
informed consent. Then, the subjects were assigned randomly into the
case and control groups.
3.2. Questionnaires
Questionnaires used in this study consisted of researchers-designed
questionnaire extracting demographic, family history information and
SF-36 questionnaire for the quality of life. The SF-36 questionnaire
consisted of both physical and mental domains, including physical func-
tioning, role-emotional, role-physical, bodily pain, social functioning,
mental health, vitality, and understanding general health. The scale for
each question was linearly transformed into a 0 to 100 scale. A high
score indicates the better health conditions. The validity and reliability
of this questionnaire were evaluated in Iranian population (Baraz,
Mohammadi, & Broumand, 2008). Montazeri, Goshtasbi, and
Vahdaninia (2005) conducted a study to evaluate the validity of the Ira-
nian version of the SF-36 questionnaire and reported the Cronbach's a
coefficient ranging from 0.77 to 0.90.
3.3. Inclusion & exclusion criteria
The inclusion criteria were as follows: age 18–65 years old, diag-
nosed hypertension with the use of antihypertensive agents, having
systolic and diastolic blood pressure ranging from140 to 180 mm Hg
and from 90 to 110 mm Hg, respectively having ability to communicate
effectively, being able to be contacted by telephone at home, no talking
or hearing disorder, literacy of patients or at least one of their relatives,
patients who required one or more antihypertensive medications, in-
cluding diuretics, ACE inhibitor and calcium channel blockers, no de-
mentia and no mental disorders, having no end-stage renal or liver
disease, cancers or history of heart attacks, strokes, and hemodialysis,
having no nurse or other health care providers in families and relatives.
Patients were excluded if they had lack of willingness to continue the
study, not respond to phone calls more than three times consecutively,
diagnosis of dementia during the study, diagnosis of mental or behav-
ioral disorders during the study, diagnosis of end-stage renal or liver
disease, cancers, heart attacks, strokes, and hemodialysis. In addition,
107
patients who received dialysis or hospitalized for other reasons were
excluded.
3.4. Sample size
The sample size of our study was calculated according to the results
of Chiu study (Chiu & Wong, 2010). Therefore, we estimated the sample
size in each group in order to detect the mean difference of 11.06 be-
tween the two groups with a power of 80% and a standard deviation
of 16 and α = 0.05. We set the target sample size as 35 subjects in
each group accounting for the potential losses to follow-up. During
the study, 5 patients were excluded due to the lack of cooperation and
finally 65 subjects completed this study.
3.5. Respondents and procedure
The subjects were asked to complete the questionnaires by inter-
view and with the help of researcher prior to the intervention. The
weight and height were measured with standard method. The research
assistants were blinded to group assignment, whether the subjects were
from the case or control groups. In the next phase, a standard form was
used to measure patients' knowledge, ability and health behavior to-
ward hypertension. All patient education programs have been devel-
oped based on educational needs and their high-risk health behaviors.
Each educational session was 45 min. One close relative was paired
with each patient. The educational content of each session involved pro-
viding the behavioral goals and action plan for each of them. In the ed-
ucational session, the educator and patients, together, developed the
behavior change goals and action plan for each of them. During this ses-
sion, participants also learned about self-monitoring of blood pressure
at home and received a written pamphlet. To address the questions or
problems, telephone follow-up contacts were scheduled to occur
twice during the first 2-week period and once the during the second
2-week period for each participant. During the intervention, if patients
had any problems and adverse events, they could call the researchers
by telephone at all times. The measurements and questionnaires were
collected in three phases; baseline assessment (first step), after the
8 week intervention period (second step) and one month after the
end of second step, without any intervention in both groups (final step).
3.6. Data analysis
We used SPSS16.0 for Windows (SPSS Inc., Chicago, IL) for all statis-
tical analysis. Descriptive statistics, frequencies, means and standard de-
viations were calculated to explore the included variables. The Student's
t-test, Repeated Measures ANOVA, Multivariate tests and Paired t-test
were used for statistical comparisons.
3.7. Ethics
This study was conducted according to the Helsinki declaration. This
clinical trial study has been registered in www.irct.ir with the code of
IRCT2015062422903N1 and obtained the code of ethics from the ethics
council 9311.
4. Results
In this study, 32 subjects (49.2%) were assigned to the experimental
group and 33 subjects (50.8%) subjects were allocated to the control
group. Of the 70 subjects, 38 subjects (58.5%) were females and 27 sub-
jects (41.5%) were males, including 20 women and 12 men in the exper-
imental group and 18 women and 15 men in the control group. All of the
participants were married. Values of b 0.05 were set as a statistical sig-
nificance. Overall, the distributions of demographic parameters includ-
ing marital status, gender, education level and employment status
were similar between two groups. We observed no statistically
108 F. Dadgari et al. / Applied Nursing Research 35 (2017) 106–111

Table 1 Table 3
Comparison of the quality of life of patients between two groups before and after the Comparison of the quality of life domains of patients between two groups after the
intervention. intervention.

Time Groups QOL dimensions Mean ± SD of total quality t-Test Effect size
of life score
Mean ± SD of total quality of life score
Case Control P-value (d) Evaluation
First step Second step Final step
Total 176.96 ± 8.25 173.47 ± 8.08 0.01 2.13 High
Case 163 ± 13.62 176.96 ± 8.25 179.6 ± 8.63
Mental health 19.56 ± 1.31 18.46 ± 1.81 0.008 1.03 High
Control 167.84 ± 9.96 173.47 ± 8.08 172.03 ± 9.21
General health 15.81 ± 1.44 14.21 ± 2.67 0.004 1.7 High
P-value 0.15 0.01 0.0001
Physical functioning 25 ± 4.16 17.03 ± 4.25 0.0001 0.93 High
Bodily pain 4.18 ± 1.4 6.81 ± 1.57 0.0001 0.75 Moderate
Role-physical 4.56 ± 1.1 6.06 ± 1.04 0.0001 0.72 Moderate
significant differences in all qualitative demographic characteristics Social functioning 6.83 ± 0.71 5.25 ± 1.19 0.001 0.55 Moderate
between cases and controls (P N 0.05). Ages ranged from 37 to 68 Role-emotional 3.55 ± 0.67 5.43 ± 0.66 0.0001 0.96 High
(mean ± SD of age was 58.48 ± 6.73 years). Vitality 15.96 ± 1.3 13.81 ± 1.46 0.0001 1.75 High
The mean of weight and height in the participants were 69.03 ±
11.31 kg (range, 49–106 kg) and 165.65 ± 7.14 cm (range, 150–
185 cm), respectively. There was no statistical difference for age, weight intervention on QOL in the post-intervention period and final phase
and height between two groups according to results of t-test (P N 0.05). (Table 5).
Distributions of basic characteristics such as smoking, a history of family Fig. 1 shows that the telenursing has a significant effect on the total
hypertension, having another diseases, the required number of antihy- score of quality of life in the second and third stages of the intervention.
pertensive agents and other drugs were equal between two Although the score of QOL had an increasing trend in the control group
groups and chi-square test showed no statistical significant differences patients after the intervention, this increase was lower than that in case
(P N 0.05). group patients. Therefore, we observed a decreasing trend in the score
The SF-36 questionnaire was completed for each participant in three of QOL in the final phase. However the effect of intervention on the qual-
points, before and after the intervention and at the final phase. The ity of life score was statistically significant.
mean score of HRQL was not statistically significant difference before
the intervention between two groups, whereas the differences between
4.1. Limitations of the study
two follow-up steps (after the intervention and final phase) compared
to baseline were significant (Table 1).
We acknowledge that there are at least three limitations to this
Our results showed that, of the eight quality of life domains in the SF-
study. The subjects included in the study were in the early stage of
36, there were statistically significant differences in bodily pain; role
being diagnosed with hypertension, and the effect of the intervention
limitations due to physical and emotional health between two groups
adopted in this study needs to be further tested in patients who have
at baseline (Table 2).
a longer history of hypertension and possibly more co-morbidities.
According to data in Table 3, the all domains of quality of life had sta-
Also, the sustained effect of the intervention needs to be established in
tistically significant differences between two groups after the interven-
further studies. This study was confined to one family clinic with a
tion. The G-power software (version 3.1.1) was used to examine the
small sample size and a relatively weak power of 0.5. The generalization
effect size of intervention (telenursing) on the quality of life. Regarding
of the results has its limitations. In addition, we did not have a mecha-
to the effects of telenursing on the scores of the quality of life, our data
nism to validate whether the self-reporting of adherence to a healthy
showed that telenursing has a significant improving effect on the all as-
lifestyle truly reflected the actual practice.
pects of the quality of life. The effect size of the intervention on the emo-
tional health, general health, physical function, role limitations due to
emotional and vitality was reported high, while the intervention repre- 5. Discussion
sented the moderate effect on bodily pain, role limitations due to phys-
ical health and social functioning. The comparison between patients in The main goal of our study was to determine the effect of sustained
the case and control group showed that all domains of the quality of telephone consulting by a nurse on the quality of life of hypertensive pa-
life had significant differences after the intervention (Table 4). tients at the Shiraz Hospital in Iran. The results of our study revealed
Repeated measurement was used to evaluate the effect of that telephone consulting of nurses with patients leads to significant
telenursing on the eight domains of quality of life (QOL) among exper- improving effects on different domains of the quality of life, including
imental period (including at baseline, after the intervention and final physical functioning, role-emotional, role-physical, bodily pain, social
phase) and between groups, which showed the significant effect of functioning, mental health, vitality, and understanding general health.

Table 2 Table 4
Comparison of the quality of life domains of patients between two groups before the Comparison of the quality of life domains of patients between two groups at the final
intervention. phase of the study.

QOL dimensions Mean ± SD of total quality of life score t-Test QOL dimensions Mean ± SD of total quality of life score t-Test

Case Control P-value t Case Control P-value t

Total 163 ± 13.62 167.84 ± 9.96 0.15 0.611 Total 179.06 ± 8.63 172.03 ± 9.21 0.0001 2.321
Mental health 18.78 ± 3.64 19.21 ± 1.6 0.53 2.381 Mental health 19.62 ± 1.33 18.46 ± 1.31 0.001 2.267
General health 15.81 ± 1.85 15.3 ± 1.20 0.2 0.443 General health 15.62 ± 1.43 13.96 ± 2.81 0.004 3.72
Physical functioning 19.4 ± 2.82 19.53 ± 3.99 0.42 2.498 Physical functioning 24.9 ± 4.23 16.56 ± 4.45 0.0001 0.349
Bodily pain 6.78 ± 1.4 5.4 ± 1.72 0.001 0.001 Bodily pain 4.18 ± 1.37 6.5 ± 2.32 0.0001 0.768
Role-physical 4.75 ± 0.87 5.37 ± 1.4 0.03 0.196 Role-physical 4.40 ± 1.22 5.85 ± 0.89 0.0001 3.39
Social functioning 6.71 ± 1.14 6.73 ± 1.12 0.36 0.398 Social functioning 6.76 ± 1.01 6 ± 1.31 0.022 2.396
Role-emotional 4.15 ± 0.88 3.68 ± 0.85 0.03 2.540 Role-emotional 3.85 ± 1.190 5.43 ± 0.66 0.0001 0.454
Vitality 14.78 ± 2.94 15.12 ± 1.26 0.54 3.221 Vitality 15.4 ± 1.38 14.12 ± 1.26 0.0001 1.629
 F. Dadgari et al. / Applied Nursing Research 35 (2017) 106–111 109

Table 5
Comparison of the quality of life scores of patients between two groups using Repeated Measurement test.

QOL dimensions First step Second step Final step Repeated measurement
Mean ± SD Mean ± SD Mean ± SD P-value

Case Control Case Control Case Control

Total 163 ± 13.62 167.84 ± 9.96 176.96 ± 8.25 173.47 ± 8.08 179.06 ± 8.63 172.03 ± 9.21 0.002
Mental health 18.78 ± 3.64 19.21 ± 1.6 19.56 ± 1.31 18.46 ± 1.81 19.62 ± 1.33 18.46 ± 1.31 0.006
General health 15.81 ± 1.85 15.3 ± 1.20 15.81 ± 1.44 14.21 ± 2.67 15.62 ± 1.43 13.96 ± 2.81 0.021
Physical functioning 19.4 ± 2.82 19.53 ± 3.99 25 ± 4.16 17.03 ± 4.25 24.9 ± 4.23 16.56 ± 4.45 0.0001
Bodily pain 6.78 ± 1.4 5.4 ± 1.72 4.18 ± 1.4 6.81 ± 1.57 4.18 ± 1.37 6.5 ± 2.32 0.0001
Role-physical 4.75 ± 0.87 5.37 ± 1.4 4.56 ± 1.1 6.06 ± 1.04 4.40 ± 1.22 5.85 ± 0.89 0.007
Social functioning 6.71 ± 1.14 6.73 ± 1.12 6.83 ± 0.71 5.25 ± 1.19 6.76 ± 1.01 6 ± 1.31 0.031
Role-emotional 4.15 ± 0.88 3.68 ± 0.85 3.55 ± 0.67 5.43 ± 0.66 3.85 ± 1.190 5.43 ± 0.66 0.003
Vitality 14.78 ± 2.94 15.12 ± 1.26 15.96 ± 1.3 13.81 ± 1.46 15.4 ± 1.38 14.12 ± 1.26 0.0001

Rambod, Rfiee, and Hoseini (2008) reported the significant relationship
between quality of life, marriage status, and educational level. It can
therefore be concluded that the adjustment of these confounding fac-
tors, including marriage status and educational at the baseline may
grant sufficient validity to this study. We observed no significant differ-
ences in the quality of life between patients in the case and control
groups prior to the intervention, whereas patients in the case group
had a better quality of life score compared to the controls after the inter-
vention and at the final phase. Among the domains of the quality life
scale, there were significant differences in bodily pain, role limitations
due to physical and emotional health between cases and controls before
the intervention. Therefore, according to the results of Table 6, we used
G Power software (version 3.1.1) to assess the effect size of the inter-
vention on various domains of QOL. The overall effect size was reported
2.13. According to Cohen's criteria, telephone consulting of the nurses
had a significant improving effect on the quality of life in hypertensive
patients. In addition, the reported effect size of the intervention on the
emotional health, general health, physical functioning, role limitations
due to emotional and vitality was high, while the intervention repre-
sented the moderate effect on bodily pain, role limitations due to phys-
ical health and social functioning. In the final phase of the study, all
domains of the quality of life, including physical functioning, role-emo-
tional, role-physical, bodily pain, social functioning, mental health, vital-
ity, and understanding general health presented the significant
differences between cases and controls. Patients who received nurse
consulting had better scores in QOL after the intervention compared
to controls. The result of our study was consistent with the result of
the other study showing that the telephone counseling by nurse has
an improving impact on the QOL of the patients with pacemaker after
the coronary artery bypass surgery (Aliakbari, Khalifehzadeh, & Parvin,
2009, Khakbazan, Goliantehrani, Paighambardoost, & Kazeminejad,
2010, and Sadeghi et al., 2009). However, this is noticeable that these
studies had been performed on patients with pacemaker to improve
the quality of life, while the goal of the current study was to
demonstrate the effect of telenursing on the quality of life in hyperten-
sive patients. Our results were consistent with Aliakbari et al. (2009),
conducted on the sixty patients with pacemaker implantation in two
groups. In addition the routine care, patients in the case group received
4-week educational sessions. They concluded that telenursing counsel-
ing is an available and cost-effective complementary method in the pro-
motion of the quality of life. The telephone follow-up program consisted
of three calls of around 20 minute duration over a four-week period. The
mean scores of the eight domains of the quality of life revealed the sig-
nificant differences between two groups (P b 0.001) (Aliakbari et al.,
2009). In another study, Khakbazan et al. (2010) conducted a study to
assess the influence of the telephone counseling intervention during
post-partum period on the quality of life among 260 women with a nor-
mal vaginal delivery. This study was a randomized clinical trial per-
formed in Razi Hospital in Marand. Women were selected randomly
according to the inclusion criteria and then were divided into two inter-
vention and control groups (n = 130 in each group). In addition to nor-
mal care, patients in the case group received twice telephone counseling
in the first week of the intervention and once per week during the fol-
low up periods. Each of the calls took about 20 min. A 24-hour hotline
was provided to extract data for women. Questionnaires including de-
mographic sheet, postpartum checklist and the SF-36 quality of life
questionnaire were completed on the first and 42nd day after the deliv-
ery for each woman. The authors reported no statistical differences in
the physical and mental scores on the quality of life between two groups
on the first day after the delivery. The results showed that women in the
intervention group had higher physical and mental scores of QOL than
controls. They reported that the physical and mental scores of the life
quality had statistically significant differences on the 42nd day after
the delivery. In addition, the overall score of the quality of life was sig-
nificantly lower in the controls than cases (61.45 vs, 80.17 P b 0.001). Fi-
nally, this study concluded that telephone counseling, as a supportive
program, could help to promote the quality of life in the post delivery
period (Khakbazan et al., 2010). In another study Ajalli and Fallahi
Khoshknab (2015) reported that providing chronic patients with
telenursing cares have led to the increased efficiency in adherence to

Table 6
The effect size of the intervention on various domains of QOL.

QOL dimensions Effect size (d) Evaluation

Mental health 1.03 High

General health 1.7 High
Physical functioning 0.93 High
Bodily pain 0.75 Moderate
Role-physical 0.72 Moderate
Social functioning 0.55 Moderate
Role-emotional 0.96 High
Fig. 1. Comparison of Total Scores of quality of life according to Repeated Measurement
Vitality 1.75 High
test between case and control groups before and after the intervention and at the final
Total 2.13 High
phase of the study.
110 F. Dadgari et al. / Applied Nursing Research 35 (2017) 106–111
the treatment regimen, reduced mortality rates and costs, reduced de-
pression and anxiety, decreased hospitalizations, and improvement of
quality of life in patients (Ajalli & Fallahi Khoshknab, 2015). The results
of this study were consistent with the findings of Sadeghi et al. study.
They conducted a study on patients underwent coronary artery bypass
graft (CABG) to evaluate the influence of continuous care model on
the quality of life of patients. They showed that the physical, mental
and social aspects of the quality of life were better in the case group
than the controls following the intervention (Sadeghi et al., 2009).
Also in another research, Smith and Lesperance (2008) reported that re-
habilitation programs accompanied by training had a significant im-
proving effect on the parameters, including physical activity, general
health, social activity and physical limitation in the cases compared to
the controls. In addition, Harkness et al. (2005) conducted a study to de-
termine the effectiveness of nursing intervention via telephone in pa-
tients following CABG surgery. They revealed that the patients who
had received nursing cares by telephone had better rehabilitation con-
ditions compared to controls with only routine care. In the other studies,
Sabzmakan et al. (2010) and Babaee, Keshawarz, and Hidarnia (2007)
found the similar results on the influence the Health Educational Pro-
gram in the improvement of the quality of life in patients who
underwent heart open surgery. Moreover, the Repeated Measurement
test showed a statistically significant effect of the intervention on all as-
pects of the quality of life, including emotional health, general health,
physical functioning, bodily pain, role limitations due to physical health,
social functioning, role limitations due to emotional, vitality), and the
total score of the quality of life at the end of the intervention and at
the final phase period. Xuejiao, Kam, Wong, and HarWu (2014) con-
ducted a study to develop a nurse-mediated hypertension manage-
ment. A total of 73 recruited subjects were randomly assigned into
two groups. The case group received a home visit and 2–4 telephone fol-
low-ups from the trained community nurses assisted by nursing stu-
dent volunteers. The control group received doctor-led hypertension
management. Data was collected at recruitment and immediately after
the 8-week program. Outcome measures included blood pressure read-
ings, self-care adherence, self-efficacy, quality of life, and patient satis-
faction. Participants from the study group led by nurses had
significant improvement in self-care adherence, patient satisfaction
post-intervention than those from the control group led by doctors.
However, blood pressure readings, quality of life and self-efficacy
showed no statistical significant differences between the two groups.
The findings show that the nurse-led hypertension management ap-
pears to be a promising way to manage hypertensive patients at the
community level, particularly when the healthcare system is well inte-
grated (Xuejiao et al., 2014). In another study Higano et al. (2015) in-
vestigated the effectiveness of using patient participation goal
attainment scaling in a telenursing system for self-management behav-
ior in two Japanese type 2 diabetic patients. The intervention consisted
of using goal attainment scaling to set goals; and efforts toward realizing
these goals were made using a telenursing system that included on-
demand webcam conversations, e-mails and phone calls. Over the
intervention period of 6 months, the patients performed daily self-
monitoring and the nurse provided telenursing support according to
the patients' needs and nursing care requirements. Both patients had
improved self-management behavior and had a positive opinion of the
telenursing system and goal attainment scaling. Finally, they concluded
that incorporating goal attainment scaling into a telenursing system for
type 2 diabetic patients was effective in continuing self-management
behaviors, suggesting that it is effective in providing continued home
nursing care in diabetic patients (Xuejiao et al., 2014). Consistent with
Higano et al. (2015), in a study of diabetic patients in Turkey Tavisanli,
Karadakovan, and Saygil (2013) suggested that videophone technology
can be a useful method in the glycemic control of these patients. Accord-
ing to results of our study, the mean score of the various aspects and
total score of the QOL were higher in the case group than controls. We
concluded that applying the continuous nurse counseling via telephone
promotes quality of life of hypertensive patients. One of the strengths of
this study is the similar demographic variables of the population so that
gender, marital status, education level, age, height, weight, occupation,
family history of hypertension, monotherapy or polytherapy, smoking,
having other diseases, and systolic and diastolic blood pressure were
not significantly different in the test and control groups. Other strengths
of this study are that the patients in both groups received individual
face-to-face comprehensive training. In addition, a thorough review
was conducted as a needs assessment tool for each patient using the
standard form prior to the training which led to individualized training
before consulting. Also, due to the individual nature of training, educa-
tional recommendations were tailored to the needs of each patient;
and planning of self-care objectives for each patient as well as continu-
ous follow-up consultation by phone was carried out based on the
predefined behavioral and operational objectives with the consent of
the patients and according to their physical and mental conditions.
This provided the possibility of promoting behavioral objectives, detect-
ing obstacles, and exploring possible solutions at every call. Moreover,
the dynamic, continuous, targeted and bilateral relationship between
the researcher as a healthcare provider and patient through scheduled
weekly calls, as well as the researcher's role as a bridge between the pa-
tient and physician to transfer questions, ambiguities and problems and
to forward the answers can be also inferred as other advantages of this
study. In addition to all this, the possible contact of the researcher with
the patient at all hours of the day, and his readiness to provide the pa-
tients with self-care advice and guidance within 24 h are noted as an-
other positive point of this study. Among the study limitations and
problems is that some patients did not respond to the phone calls.
And that the outcomes did not report the use of blind observation. In ad-
dition, using the self-report method to assess and to measure the adher-
ence of patients to self-care behaviors, and considering the media
training and the possibility of participating in training classes during
the research; it can't be claimed for sure that their statements are
based on the reality. Given that telenursing, as a tool for health service,
needs people and health system access to the mass media, it should be
noted that the cost-benefit ratio is cost-effective as a whole. Comparing
the results of other studies, one can conclude that using the phone in
telenursing system seems to be reasonable and cost effective due to cov-
ering all classes in the society at a lower cost and with easier accessibil-
ity. In a study the effect of three methods of post discharge care in
reducing the risk of re-hospitalization was compared using remote
home care services. These methods included video conferencing,
telenursing and routine outpatient care. Both remote home care sys-
tems showed significant results compared to routine care. However,
video conferencing, despite having the highest cost, led to better results
than the telephone system. In fact, the telenursing system is as effective
as remote home care services though enjoying a lower cost (Jerant,
Azari, & Nesbitt, 2001). Also, the results of this study indicated that
this type of follow-up counseling can improve the quality of life in dif-
ferent dimensions, including emotional health (mental) public health,
physical functioning, bodily pain, social functioning, and limitations
due to physical, emotional and psychological impairments.
6. Conclusion
Telenursing consultation provides a continuous relationship be-
tween patient and the healthcare system and has positive effects on
all aspects of health services and their outcomes. Telephone counseling
by nurses provides an effective method of sustained service in health
promotion. Easy access is another advantage of this system. It means
that this cost effective service is available for a higher number of pa-
tients. These aspects would be particularly important for subjects who
live far from health institutions or have motor disorders. Finally, we
showed that continuous counseling and providing supportive system
according to the presented protocol in our study is practicable in our
culturally specific society, especially in patients with chronic disease
 F. Dadgari et al. / Applied Nursing Research 35 (2017) 106–111
such as hypertension. According to the important role of nurses in the
promotion of health care system and patient's health, telenursing can
reveal the effective role of nursing in second level of prevention in
chronic disease and decreases the need of rehabilitations and its adverse
outcomes.
Conflict(s) of interest
There is no conflict of interest.
Acknowledgement
XXXX.
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