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Empowering Nurses to Lead Efforts to Reduce Cardiovascular Disease and Stroke Risk

Tools for Global Impact

Commodore-Mensah, Yvonne PhD, MHS, RN, FAHA, FPCNA; Turkson-Ocran, Ruth-Alma PhD, MPH, MSN, RN, FNP-BC; Dennison Himmelfarb, Cheryl R. PhD, RN, ANP, FAHA, FPCNA, FAAN

doi: 10.1097/JCN.0000000000000606
DEPARTMENT: PCNA Progress in Prevention

Yvonne Commodore-Mensah, PhD, MHS, RN, FAHA, FPCNA Assistant Professor, Johns Hopkins School of Nursing, Baltimore, Maryland.

Ruth-Alma Turkson-Ocran, PhD, MPH, MSN, RN, FNP-BC PhD Candidate, Johns Hopkins School of Nursing Baltimore, Maryland.

Cheryl R. Dennison Himmelfarb, PhD, RN, ANP, FAHA, FPCNA, FAAN Sarah E. Allison Endowed Professor, Johns Hopkins School of Nursing, Baltimore, Maryland.

The authors have no funding or conflicts of interest to disclose.

Correspondence Yvonne Commodore-Mensah, PhD, MHS, RN, FAHA, FPCNA Johns Hopkins School of Nursing, 525 N Wolfe St, Rm 419, Baltimore, MD 21205 (

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the United States and globally.1,2 The Global Burden of Disease Study has demonstrated that progress in reducing mortality from noncommunicable diseases such as CVD stalled or reversed between 1990 and 2017.2 Although medications to lower blood pressure and cholesterol are the most cost-effective interventions to reduce the burden of CVD, mortality from CVD has increased globally since 2007.3 Lifestyle modification, however modest, can substantially minimize the risk for CVD and stroke.4 However, adopting and maintaining heart-healthy behaviors such as physical activity and a healthy dietary pattern are challenging for many individuals all over the world. Factors contributing to stalled efforts in reducing the burden of CVD and stroke are complex; they include system-level, provider-level, and patient-level factors.

Tackling this global health problem requires a team-based approach. Healthcare professionals representing different disciplines have critical roles to play in managing risk factors for CVD and stroke. Nurses are well positioned to take on the role of team leaders in managing CVD and stroke risk and have proven their ability to reduce CVD and stroke risk through nurse-led and team-based models for CVD prevention.5–7 Nurses represent the largest segment of the healthcare workforce and play a crucial role in promoting health and well-being. There are approximately 29 million nurses and midwives globally, with almost 4 million nurses in the United States.8 Nurses adhere to treatment guidelines and protocols, reduce hospitalization, improve quality of life, and provide cost-effective services to diverse populations. The role of nurses in reducing CVD risk factors such as hypertension has expanded in the past 5 decades, complementing that of the physician and other members of the interdisciplinary healthcare team.9 Although the scope of practice of nurses varies in the United States and globally, they are skilled health professionals who provide care that is holistic and considers the multiple determinants of health, including social determinants. Nurses are well trusted to provide care across the lifespan and work with diverse communities all over the world.

Mobilizing, investing in, and equipping nurses with appropriate training, resources, and implementation tools are essential strategies in the global agenda to curb the rising burden of CVD and stroke. In addition to involving nurses in high-level policy-making, practice, and research, there is an urgent need to empower nurses with the proven strategies, tools, and resources to lead healthcare teams to prevent, detect, and manage risk for CVD and stroke. Outlined below and in the Table are resources and tools to build capacity among nurses to manage CVD and stroke risk locally and globally.



  • 1. World Health Organization (WHO) HEARTS technical package for cardiovascular disease management in primary care10:

The HEARTS technical package is a resource that provides a strategic approach to improving cardiovascular health globally. It consists of 6 modules in multiple languages, including English, French, Spanish, and Russian. The step-by-step modules provide a framework and implementation guide for managing CVD and stroke risk and require tailoring to each country's unique context. The 5-step approach for implementing HEARTS includes (1) engage stakeholders, (2) select demonstration site, (3) plan implementation, (4) implement and monitor, and (5) evaluate and scale up. Target users for the modules include national, subnational, and primary care provider teams.

  • 2. WHO Package of Essential Noncommunicable (PEN) disease interventions for primary healthcare in low-resource settings11:

The WHO PEN is a resource that provides a collection of prioritized interventions and tools that guide the delivery of quality, cost-effective care for noncommunicable diseases in different settings, including low-resource areas. The WHO PEN facilitates early detection and management of CVD and to prevent the development of adverse events or life-threatening complications. The WHO PEN is available in English for use by healthcare professionals and other members of the primary care team. The WHO PEN includes protocols to aid with detection, diagnoses, and management of CVD, myocardial infarction and stroke risk prediction tools, and guidelines on basic requirements for essential medicines and technologies as well as instruments to assess the impact of the resource. Flow charts are used in the clinical protocols to present evidence-based interventions and a CVD prediction tool to help healthcare professionals identify and classify persons who are at high risk for adverse CVD events. This integrated multifactorial risk approach is cost-effective and improves outcomes.11

  • 3. World Heart Federation (WHF)12:

The The World Heart Federation is a global collaboration representing several entities, including national and intercontinental cardiology scientific societies and foundations; scientific, medical, and professional communities; as well as patients and charitable organizations. It is the only CVD nongovernmental organization in official relations with the WHO, and a member of the Non-Communicable Disease Alliance. It also leads global advocacy efforts for action to prevent, control, and reduce the global burden of CVD. Resources from this organization are available in English.

  • 4. Preventive Cardiovascular Nurses Association (PCNA)13:

The PCNA is a nursing organization that is dedicated to managing CVD and has a mission to promote nurses as leaders in CVD prevention and management across the lifespan. The PCNA serves as a leading voice for CVD prevention and management and supports nurses through professional and patient education, leadership, and advocacy on issues pertaining to CVD. The Global Cardiovascular Nursing Leadership Forum,14 an initiative created by PCNA, seeks to engage, mobilize, and empower an international community of nurse leaders to promote the prevention of CVD and stroke worldwide through research, education, policy, and advocacy.15

There is a pressing need to provide nurses globally with resources and tools to educate patients and populations regarding risk factors for CVD and stroke to prevent premature death and the costly complications of these conditions. In both resource-constrained and abundant settings, nurses can lead healthcare teams to improve access to cost-effective interventions to reduce CVD and stroke risk. Nurses must be deliberately engaged in policy-making regarding prevention efforts and in the global health agenda to reduce morbidity and mortality. Ensuring that nurses' scope of practice reflects the full extent of their training and licensure will improve the ability of healthcare systems to offer the necessary preventive measures to reduce burden and to manage the volume and acuity of patients living with CVD and stroke. However, in many settings, this effort will require rigorous training of nurses and redesigning healthcare systems to empower nurses to practice at levels beyond their current scope of practice.

The NursingNow! Campaign,16 a collaboration between the WHO and International Council of Nursing, is a 3-year effort (2018–2020) that seeks to improve global health by raising the status of nurses worldwide. The 5 core areas of (1) ensuring that nurses and midwives have a more prominent voice in health policy-making, (2) encouraging greater investment in the nursing workforce, (3) recruiting more nurses into leadership positions, (4) conducting research that helps determine where nurses can have the greatest impact, and (5) sharing of best nursing practices are all directly relevant to the fight against CVD and stroke. The WHO has also designated 2020 as the “Year of the Nurse and Midwife” to honor the 200th birth anniversary of Florence Nightingale.17 This commemoration presents governments with a unique opportunity to reimagine nursing in the 21st century and empower them to lead global efforts to avert deaths and disability due to CVD and stroke.

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