Digital Repository Masters Theses Spring 2026 Enhancing Certified Nursing Assistant Instructor Confidence in Underserved Communities Savanna Searle Weber State University Follow this and additional works at: https://dc.weber.edu/collection/wsudoctoral Searle, S. 2026. Enhancing Certified Nursing Assistant Instructor Confidence in Underserved Communities. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/WSUDoctoral This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. WSU REPOSITORY MSN/DNP Enhancing Certified Nursing Assistant Instructor Confidence in Underserved Communities Project Title by Savanna Searle Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, UT 4/19/2026 Date Savanna Searle, RN, MSN Student 4/19/2026 Student Name, Credentials (electronic signature) Date Anne Kendrick, DNP, RN, CNE 4/25/2026 MSN Project Faculty Date (electronic signature) Anne Kendrick, DNP, RN, CNE 4/25/2026 Anne Kendrick Date (electronic signature) DNP, RN, CNE MSN Program Director Note: The program director must submit this form and paper. 1 Enhancing Certified Nursing Assistant Instructor Confidence in Underserved Communities Savanna Searle Annie Taylor Dee School of Nursing Weber State University Anne Kendrick MSN Project 4/25/2026 2 Abstract Purpose/Aims: This project evaluates the impact of implementing evidence-based educational strategies for certified nursing assistant (CNA) instructors in underserved communities. The aims are to strengthen instructor confidence in teaching, standardize blood pressure education, and integrate social determinants of health. Rationale/Background: Hypertension management in underserved populations is often affected by language barriers, limited health literacy, and socioeconomic challenges. CNA instructors prepare frontline caregivers responsible for routine blood pressure monitoring and patient education. Improving instructor confidence and standardizing teaching practices may enhance care quality and promote health equity. Methods: The initiative introduces training focused on accurate blood pressure measurement, health literacy strategies, and awareness of social determinants of health. Content includes a standardized blood pressure checklist, scenario-based skills practice, and multilingual education materials. Pre- and post-intervention surveys will assess instructor confidence and knowledge. Results: Anticipated outcomes include increased instructor confidence, improved teaching consistency, and enhanced patient education strategies to support hypertension management and reduce health disparities in underserved communities. The approach can be adapted across CNA training programs. Conclusions: The project addresses inconsistent hypertension and health literacy education among CNA instructors in underserved communities by using the Iowa model to implement standardized training to reduce disparities and improve patient outcomes. Keywords: social determinants of health, health disparities, health equity, hypertension, health literacy 3 Enhancing Certified Nursing Assistant Instructor Confidence in Underserved Communities Certified Nursing Assistant (CNA) instructors play a vital role in preparing students with the foundational competencies necessary to deliver safe and compassionate care. Traditional CNA education emphasizes assisting patients with activities of daily living, including bathing, dressing, eating, toileting, and mobility, as well as instruction in communication, infection prevention, vital sign monitoring, and patient safety principles (Utah Nursing Assistant Registry, 2024). However, current trends in healthcare highlight the need to expand this education to encompass an understanding of social determinants of health (SDOH), not only to enhance patient care but also to support CNAs in maintaining their own health. Given the physically and emotionally demanding nature of their work, CNAs often face personal and professional challenges related to socioeconomic status and educational background. By incorporating education on SDOH into CNA training, instructors can help students identify how these factors influence both their patients’ and their own health outcomes. The Healthy People 2030 framework outlines five domains of SDOH: economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, and social and community context (U.S. Department of Health and Human Services, 2022). Integrating these concepts into CNA education enables students to recognize health disparities, utilize available resources, and develop effective strategies to care for themselves and others. Bridging this gap through standardized, evidence-based education can enhance instructor confidence and strengthen the overall quality of CNA training, highlighting the project’s significance for both educators and students. Statement of Problem 4 High blood pressure, a leading global cause of preventable deaths, is strongly influenced by SDOH, which contribute to disparities in hypertension control and cardiovascular outcomes (Chaturvedi et al., 2023). Within a CNA program in the Western United States, there is a lack of standardized, evidence-based education for instructors to teach students blood pressure monitoring and health literacy effectively. The educational gap lies in the limited awareness among CNAs regarding how SDOH contribute to their own elevated risk of hypertension. As frontline caregivers who routinely monitor patients’ blood pressure and provide basic health education, this lack of understanding not only affects their personal well-being but also influences the quality of care delivered to underserved populations (Alghamdi et al., 2024). King et al. (2022) used the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study, which identified four vulnerabilities associated with developing hypertension, including low educational attainment, low annual household income, living in a high-poverty zip code, and lacking health insurance. These findings highlight the need for standardized education that equips instructors to address clinical skills and SDOH-related barriers in CNA students. Given these findings, this project aims to strengthen CNA instructor confidence and standardize hypertension education. The goal is to implement a standardized, evidence-based blood pressure protocol that CNA students can use to manage their own blood pressure, along with resources for managing hypertension. Educational attainment, closely linked to socioeconomic status, significantly influences lifestyle behaviors, including nutrition and physical activity. Evidence from previous research suggests that hypertension incidence declines with increasing education levels, underscoring the importance of teaching CNAs how to access available resources (Alghamdi et al., 2024). By enhancing the instructor’s confidence, the project can improve the consistency and quality of health education provided to CNA students, leading to better blood pressure control and reducing disparities in hypertension management. 5 Health literacy skills are another critical factor influencing health outcomes. Health literacy refers to the knowledge and competencies that enable individuals to access, understand, appraise, and utilize information and services to promote and maintain good health and wellbeing (Shahid et al., 2022). Individuals with inadequate health literacy often struggle to understand prescription labels, participate in health decisions, follow medical recommendations, and attend follow-up appointments. These limitations are associated with poor self-care behaviors, receiving fewer preventative measures, and an increased mortality rate. Significance of the Project Studies have found that hypertension is most prevalent among individuals with a high school education or less, which has important implications for CNA training. CNAs enter the workforce with limited formal education, typically holding a high school diploma and a certificate of completion for their training program. This may limit their exposure to health literacy, including an understanding of risk factors such as SDOH and hypertension management (Alghamdi et al., 2024). Equipping CNAs with education on hypertension and self-care management can enhance their ability to manage their own health, advocate for recognizing SDOHs, reduce health disparities, and lead to better patient outcomes (Gleason et al., 2023). This project is essential for improving hypertension management in underserved communities by empowering the CNA instructors to recognize SDOH and contribute to equitable care. Alghamdi et al. (2024) highlighted the impact of socio-demographic and occupational factors on hypertension prevalence, underscoring the need for targeted interventions to prevent and manage the condition among healthcare workers. CNA instructors play a crucial role in preparing students to deliver safe care; however, current training often lacks standardized education on the SDOH and hypertension management, 6 which are essential for both patient and caregiver well-being. This project addresses that gap by equipping instructors with evidence-based tools to teach blood pressure monitoring and health literacy, ultimately improving health outcomes and reducing disparities in underserved communities. Review of the Literature This literature review was conducted to synthesize current research and identify best practices that enhance instructor confidence and instructional effectiveness. The MSN Project PICOT question: (P) In CNA course instructors teaching in underserved communities, (I) how does implementing evidence-based strategies and education programs, (C) compared to standard practice (O) affect their confidence in providing health education (T) over six months? In this section, the project framework, search strategies, and synthesis of the literature will be further discussed. Framework The Iowa Model of evidence-based practice, which promotes quality care, provides a structured framework for implementing evidence-based interventions in healthcare and educational settings. It emphasizes problem identification, synthesis of research evidence, pilot testing, and integration into practice (Bell, 2022). For this project, focused on enhancing CNA instructor confidence in underserved communities, the Iowa Model ensures that the intervention is both evidence-driven and sustainable. The model's recurring steps support continuous evaluation and adaptation, aligning well with the project's six-month timeframe. According to Dusin et al. (2023), the steps include first, question development; second, searches, appraisals, and literature synthesis; third, if lacking research, perform research; fourth, develop, enact, and appraise a pilot solution; and fifth, if successful, implement this throughout the organization. If 7 unsuccessful, restart the process. Users must have prior knowledge and relevant skills to assess the evidence. This framework can empower CNA instructors, nursing educators, and program coordinators to implement evidence-based teaching strategies—such as active learning, culturally responsive instruction, and hypertension management examples—with confidence and consistency. By embedding health literacy and SDOH into the curriculum and aligning with the Iowa Model, the project promotes lasting improvements in patient education and health outcomes, particularly in underserved communities (Cullen et al., 2022). Strengths and Limitations The Iowa Model incorporates multiple feedback loops that enable continuous analysis, evaluation, and refinement based on process and outcome data, as well as members’ expertise. These loops are essential for adapting evidence to specific practice settings, tailoring care to individual patient needs and preferences, and supporting the integration of evidence-based practices across diverse healthcare systems and environments (Melnyk & Fineout-Overholt, 2023). The Iowa Model is a practical and proven framework for evidence-based practice. It helps nurses lead quality and value improvements in healthcare. Its global use, long-term success, and free implementation resources show its effectiveness and lasting value. One limitation is that the model does not provide a framework for data collection methods. A list of appraisal tools and steps to synthesize the evidence may also be beneficial and could further improve this model. Cullen et al. (2022) conducted a study aimed at updating implementation science and improving the Iowa Implementation for Sustainability Frameworks for clinicians at all skill levels. However, most survey participants were highly educated, so their feedback may not accurately represent the experiences of beginner users. 8 Search Strategies A literature search was conducted to identify current evidence using Google Scholar, Weber State University’s Steward Library’s OneSearch, and Advanced Search (which spans multiple databases). Only articles published from 2020 to 2025 were included in this literature review to ensure the information is current. The research included the keywords health disparities, inequities, cardiovascular disease, hypertension, guidelines, prevention, health literacy survey, social determinants of health, blood pressure, and CNA education. Synthesis of the Literature Three themes were identified in the literature: a) SDOH affect cardiovascular disease and hypertension, b) health literacy affects healthcare, disease prevention, and health promotion, and c) people with low education have lower health literacy skills. These themes are explained in more detail in the following information. SDOH Affects Cardiovascular Disease and Hypertension Despite existing clinical guidelines, uncontrolled blood pressure remains a significant cause of preventable death, particularly among disadvantaged groups (Chaturvedi et al., 2023). A review highlighted how SDOH significantly impacted hypertension and cardiovascular disease through interconnected behavioral, biological, and psychological factors. Creating environments that support healthy behaviors—such as access to nutritious food, safe spaces for exercise, tobacco control, transportation, and digital tools—can promote equitable blood pressure control, reduce cardiovascular disease, and advance public health goals like the Healthy People 2030 (U.S. Department of Health and Human Services, 2022). The U.S. Surgeon General issued a call to action to control hypertension to address the declining rates of blood pressure control among Americans, from 53.8% in 2013–2014 to 43.7% 9 in 2017–2018 (U.S. Department of Health and Human Services, 2020). The report emphasized the serious health and economic impacts of uncontrolled hypertension and urged efforts to prioritize blood pressure control. Hypertension and related cardiovascular outcomes disproportionately affect racial and ethnic minorities and low-income populations, whose health has improved more slowly or worsened compared to higher-income and White groups (Colvin et al., 2022). The COVID-19 pandemic further highlighted how social and economic inequalities worsen health risks for marginalized communities. The call to action aims to eliminate hypertension disparities driven by social conditions and to promote health equity through targeted interventions that address the SDOH (U.S. Department of Health and Human Services, 2020). Lastly, a study found significant racial and ethnic disparities in hypertension management, with Black and Hispanic patients less likely to achieve blood pressure control compared to White patients (Hussain et al., 2022). These disparities stem from multiple factors, including differences in healthcare access, insurance coverage, socioeconomic status, patient– provider communication, and medication adherence. These variations in hypertension management reflect more profound health inequities that may increase the risk of stroke, heart attack, and kidney disease among affected populations. Health Literacy Affects Healthcare, Disease Prevention, and Health Promotion Current literature suggests that health literacy directly affects healthcare, disease prevention, and health promotion. Tavousi (2022) found that people with low health literacy often experience poorer health outcomes, limited knowledge about disease prevention, and lower participation in preventive care. They may struggle to understand or follow medical instructions, leading to poor treatment adherence, communication difficulties with healthcare providers, more 10 frequent hospitalizations, higher healthcare costs, increased illness and death rates, and reduced ability to manage their own health. Greene et al. (2024) found that from 2018 to 2023, the Self-Measured Blood Pressure program focused on health equity, addressing how racism and social barriers affect patient care. It partnered with five Massachusetts health centers, mainly serving low-income, uninsured, and Black or Hispanic/Latino patients who face significant barriers to managing blood pressure. The program requires key strategies to improve blood pressure control among high-risk patients. It was found that using a racial equity framework to implement Self-Measured Blood Pressure programs helps healthcare providers design care that effectively reaches marginalized patients who might otherwise be left out. The flexible, patient-centered approach at the five federally qualified health centers shows that equitable delivery of this evidence-based intervention is achievable. Chu-Ko et al. (2021) found in their study that adolescents struggle most with evaluating health information, a key part of health literacy. While studies show mixed results on how media health literacy affects teens' efforts to seek health information, King et al. (2022) found a clear correlation between higher education and better health knowledge and behaviors. This underscores the importance of the work needed in promoting health literacy. Education not only leads to better job opportunities and higher income but also to easier access to healthcare and healthier lifestyle choices, such as regular exercise, checkups, and avoidance of smoking and drinking. Lower Education Leads to Lower Health Literacy Skills The research shows that hypertension and uncontrolled blood pressure are more common among U.S. adults with low socioeconomic status, contributing to higher rates of illness and 11 death (Zacher, 2023). According to the study, education plays a significant role; 47% of adults with a high school education or less have hypertension, compared to 38.5% of those with a college degree. These disparities likely stem from unequal access to social, economic, and health-related resources, as well as early-life conditions such as childhood health and socioeconomic status. According to Colvin et al. (2022), studies show that individuals with lower education levels are more likely to develop hypertension. For example, U.S. women with only a high school education or some college education are more likely to have hypertension than those with college degrees. Similarly, older adults with less education have a higher risk of developing hypertension. Another study suggests that patients with low health literacy are more likely to revisit the emergency department, even after accounting for factors such as age, sex, and comorbidities (Shahid et al., 2022). The research found that those with both low health literacy and lower education were more likely to return than those with high health literacy and higher education. This suggests that the interaction between education and health literacy significantly influences hospital revisits. The findings highlight that both education and health literacy play a key role in patients' healthcare utilization and outcomes. Summary of Literature Review Findings and Application to the Project The literature review reveals that uncontrolled hypertension remains a significant public health issue, especially among underserved populations, due to the influence of SDOH such as access to care, education, and economic stability. Health literacy plays a crucial role in managing hypertension, with lower literacy levels associated with poorer outcomes, higher healthcare costs, and increased hospital admissions. Education is a key factor, as individuals with higher 12 levels of education tend to have better health knowledge, healthier behaviors, and greater access to resources. Programs like the SMBP initiative demonstrate that equity-focused, patientcentered approaches—such as community outreach, social support, and culturally responsive care—can effectively improve blood pressure control in marginalized communities (Greene, et al., 2024). These findings support the proposed solution by emphasizing the need to integrate health literacy education, active learning, and SDOH awareness into CNA training to enhance teaching effectiveness and promote equitable health outcomes. Project Plan and Implementation This MSN project will implement an evidence-based educational intervention specifically designed to prepare CNA instructors to teach CNAs how to support patients in managing blood pressure, navigating health information, and addressing SDOH in underserved communities, to improve patient outcomes. The emphasis of implementation is not on direct patient education, but on strengthening instructor capacity to equip CNAs with the knowledge, skills, and confidence needed to promote safe blood pressure monitoring, patient understanding, and resource connection at the point of care. Guided by the Iowa Model, the project focuses on standardizing how instructors teach CNAs to: (a) accurately measure and interpret blood pressure, (b) communicate health information in a manner appropriate for patients with limited health literacy, and (c) recognize SDOH-related barriers—such as language, access to care, and socioeconomic constraints—that affect patients’ ability to manage hypertension. Implementation includes instructor-focused training modules, a standardized blood pressure protocol checklist, multilingual patient education tools, and skills-based competency labs that model how CNAs can support patients during routine care activities. 13 The intervention is delivered exclusively to CNA instructors within a CNA program in the Western United States. Through pre- and post-confidence surveys, hands-on skills validation, and structured teaching tools, instructors can be prepared to consistently train CNAs to apply these concepts when assisting patients, rather than relying on informal or inconsistent instruction. By strengthening instructor confidence and standardizing instructional practices, the project aims to improve CNA readiness to support patient blood pressure management, enhance patient understanding, and reduce health disparities influenced by SDOH. Plan and Implementation Process The project will be carried out in a step-by-step process to ensure consistency and align with evidence‑based practice (Dusin et al., 2023). It will begin with a baseline survey of CNA instructors’ current knowledge, confidence, and teaching practices related to blood pressure monitoring, health literacy, and SDOH. This assessment will guide the development and customization of the training modules. Following the assessment, instructors will participate in a structured educational program that includes interactive learning strategies and hands‑on skills practice. The project will conclude with a post-survey to measure changes in instructor confidence and identify opportunities for ongoing improvement. All instructors will be invited to participate, and participation will be voluntary, recognizing their valuable role in this initiative. A baseline survey will be administered to all participating CNA instructors to evaluate their confidence in teaching blood pressure monitoring, knowledge of hypertension guidelines, understanding of SDOH and their impact on patient outcomes, comfort with teaching health literacy concepts, and familiarity with evidence‑based blood pressure protocols. The survey will include Likert-scale items to measure self-efficacy and open-ended questions to identify barriers 14 and training needs. Findings from this assessment will guide improvements to the training modules and ensure the education is tailored to the instructors’ specific needs. Based on the baseline survey results, a series of standardized training modules will be developed that incorporate the American Heart Association (AHA) guidelines for accurate blood pressure measurement techniques, common errors, stages of hypertension, health literacy and teach-back best practices, SDOH education emphasizing how socioeconomic factors influence hypertension, and culturally responsive approaches. These modules will be designed to strengthen instructor confidence and promote consistent, evidence-based teaching practices across the program. A blood pressure protocol checklist will be created to guide instructors in teaching and evaluating students. The checklist will outline pre-measurement requirements (rest period, positioning, and cuff selection), step-by-step measurement techniques, documentation expectations, troubleshooting common errors, and key patient education points. This checklist will be used during the skills lab and embedded into the CNA curriculum to ensure long‑term consistency in instructional practices. Instructors will participate in a structured, scenario-based skills lab designed to strengthen their ability to teach CNAs how to support patients in blood pressure management, health literacy, and SDOH-related needs. The lab will model how instructors should instruct CNA students during routine patient care activities in underserved settings. During the lab, instructors will rotate through standardized teaching stations that simulate common patient scenarios, including patients with limited English proficiency, low health literacy, or financial barriers to medication adherence. At each station, instructors will practice demonstrating and teaching CNAs how to measure blood pressure correctly, explain results in plain language, 15 assess patient understanding using teach-back techniques, and identify SDOH barriers that interfere with hypertension control. The purpose of the skills lab is not simply to improve instructors’ own technical skills, but to ensure they can consistently and confidently teach CNAs how to integrate accurate blood pressure monitoring, effective patient communication, and SDOH-informed care into daily patient interactions. This approach supports equitable hypertension management and prepares CNAs to better serve patients in underserved communities. To address language barriers identified in the literature, the project will develop or adapt patient‑education materials in multiple languages. These materials will include information on the basics of hypertension, SMBP, lifestyle modification strategies, and local community resources. Providing materials in various languages will enhance instructors’ ability to teach diverse student populations effectively. Following completion of the training and skills lab, instructors will complete a post‑confidence survey identical to the baseline assessment. Comparing pre- and post-survey results will help determine changes in instructor confidence, improvements in knowledge, the perceived usefulness of the training, and areas requiring additional support. Additional feedback will be collected to identify the strengths of education and opportunities for improvement (Melnyk & Fineout-Overholt, 2023). To maintain long-term effectiveness, the project will integrate the training modules into annual instructor development sessions, embed the blood pressure protocol checklist into the CNA curriculum, maintain ongoing access to education materials in multiple languages, and establish a continuous feedback loop for quality improvement. These strategies will support 16 lasting improvements in instructor confidence and the overall quality of health education delivered within the CNA program. Interdisciplinary Team The healthcare professionals involved in this project include the CNA program manager, program coordinator, CNA instructors, and CNA students. Each team member will help strengthen instructional quality, support standardized teaching practices, and ultimately improve health outcomes for CNA students and the underserved communities they will serve. Program Manager. The program manager will oversee project operations and coordinate communication among team members. They will organize timelines, schedule training sessions, and ensure that all educational components are developed and delivered on time. They will also help secure the necessary resources, such as skills lab equipment, training space, and translation services. Program Coordinator. The program coordinator will contribute their nursing expertise and curriculum development skills. They will help create lesson plans, refine teaching materials, and ensure the modules follow best practices and are accessible to instructors with different levels of experience. Their role will support integrating the training into the existing CNA curriculum. CNA Instructors. CNA instructors will be the primary participants in the project. They will complete pre- and post-surveys, participate in the training modules, and participate in the skills lab to practice standardized blood pressure measurement, health literacy strategies, and SDOH-focused teaching. Their feedback will be essential for improving the training and addressing implementation challenges. As frontline educators, their increased confidence and competence will directly enhance the quality of instruction provided to CNA students. 17 CNA Students. Although CNA students will not directly participate, they will benefit from improved teaching practices and standardized instruction on SMBP skills, such as correctly using home cuffs and having the patient demonstrate how they take their blood pressure at home. Their ability to measure blood pressure accurately, recognize SDOH barriers, and communicate effectively with patients will grow as their instructors become more confident and skilled. These improvements will ultimately support better patient outcomes in the communities they serve. Description and Development of Project Deliverables Six deliverables will be used to implement this MSN project. The six deliverables include: a) a PowerPoint train-the-trainer presentation, b) a pre-survey to evaluate CNA instructors’ confidence and knowledge, c) standardized learning modules, d) a blood pressure checklist and patient education, e) a Spanish version of the blood pressure checklist and patient education, and f) a post-survey to evaluate CNA instructors’ confidence and knowledge. Overall, this project uses an evidence-based approach to strengthen CNA instructors’ confidence, knowledge, and teaching practices related to blood pressure monitoring, health literacy, and SDOH. Through targeted assessment, standardized training, and hands-on skills practice, the project promotes consistent, high-quality instruction that can be sustained within the CNA curriculum. By enhancing instructor preparedness, the project ultimately aims to improve CNA student competence and support better patient outcomes, particularly in underserved communities. PowerPoint Train the Trainer Presentation. The first deliverable is a PowerPoint presentation (see Appendix A) designed to explain the importance of this project to CNA instructors and to introduce an initiative to strengthen instructor preparation in blood pressure monitoring, health literacy, and SDOH. CNA programs traditionally emphasize basic caregiving 18 skills; however, the literature shows that uncontrolled hypertension in underserved communities is largely driven by broader contextual factors, including low health literacy, limited education, poverty, and unequal access to healthcare (Chaturvedi et al., 2023; King et al., 2022; U.S. Department of Health and Human Services, 2020). Low health literacy significantly impairs patients’ ability to understand blood pressure readings, follow treatment recommendations, and engage in preventive care, leading to worse health outcomes and higher mortality rates (Shahid et al., 2022; Tavousi et al., 2020). Additionally, individuals with lower levels of education experience higher rates of hypertension and reduced access to health resources, further contributing to health disparities (Zacher, 2023; Colvin et al., 2022). The PowerPoint presentation uses this evidence to demonstrate why CNA instructors must be prepared to teach not only accurate blood pressure measurement, but also effective communication strategies and SDOH-informed care to support equitable hypertension management in underserved communities. Pre-Survey for CNA Instructors. The second deliverable is a pre-survey (see Appendix B) to evaluate the CNA instructors’ confidence in teaching blood pressure monitoring, knowledge of hypertension guidelines, understanding of SDOH and their impact on patient outcomes, comfort with teaching health literacy concepts, and familiarity with evidence‑based blood pressure protocols. It will allow them to discuss the barriers that they currently face when teaching blood pressure monitoring and health literacy, which can be further incorporated into the learning modules, the blood pressure checklist, and patient education. The literature reviewed in this project highlights that instructor confidence and knowledge directly influence the quality and consistency of health education delivered to students (Cullen et al., 2022; Melnyk & Fineout-Overholt, 2023). In addition, health literacy 19 research shows that providers who feel more confident in communication and education strategies are more likely to use patient-centered approaches that improve understanding and adherence (Shahid et al., 2022; Tavousi et al., 2020). Blood Pressure Checklist and Patient Education. The standardized blood pressure checklist and patient education tool (see Appendix C) was developed in response to evidence from the literature demonstrating that inaccurate blood pressure measurement and inconsistent education contribute significantly to poor hypertension control, particularly in underserved populations. Studies have shown that blood pressure is frequently mismeasured in both clinical and home settings, leading to misdiagnosis and inappropriate treatment (Clapham et al., 2024; Elias & Goodell, 2021). In addition, lack of standardized education has been identified as a major contributor to disparities in blood pressure management (Chaturvedi et al., 2023; Colvin et al., 2022). The checklist is designed to support CNA instructors in teaching CNAs to perform accurate, evidence-based blood pressure measurements and to provide patient-centered education. It includes standardized steps for positioning, cuff selection, rest periods, and measurement technique, as recommended by the AHA and international hypertension guidelines (Unger et al., 2020; American Heart Association, 2024). In addition to technical skills, the checklist includes patient education prompts, such as explaining results in plain language and reinforcing lifestyle and follow-up recommendations. This directly supports the project goal of reducing educational variation and improving hypertension management through standardized CNA instruction. Spanish Version of Blood Pressure Checklist and Patient Education. The Spanish version of the blood pressure checklist and patient education materials (see Appendix D) was 20 developed to address language barriers identified in the literature as a major contributor to hypertension disparities in underserved populations. Research consistently shows that racial and ethnic minorities, particularly Hispanic and Latino patients, experience lower rates of blood pressure control due in part to limited English proficiency, reduced access to health information, and communication barriers with healthcare providers (Hussain et al., 2022; Colvin et al., 2022). Studies reviewed in this project emphasize that culturally and linguistically appropriate education improves patient understanding, treatment adherence, and engagement in care (Greene et al., 2024). The equity-focused SMBP program described by Greene et al. (2024) demonstrated that providing culturally responsive and language-appropriate resources significantly improved hypertension management in underserved clinics. Integrating multilingual materials aligns with the project’s SDOH framework by reducing language-based inequities and promoting more equitable hypertension education. Post-Survey for CNA Instructors. The post-survey (see Appendix E) was developed to evaluate changes in CNA instructors’ confidence, knowledge, and readiness to teach blood pressure management, health literacy, and SDOH after completing the training intervention. To demonstrate program effectiveness, plans are included for follow-up to track whether instructor improvements lead to better hypertension control and health literacy in the community over time, supporting continuous quality improvement (Dusin et al., 2023). The post-survey mirrors the baseline assessment and measures instructors’ confidence in teaching blood pressure measurement, explaining results clearly, supporting patients with low health literacy, and addressing SDOH-related barriers. By comparing pre- and post-survey data, the project can determine whether the training and tools increased instructor self-efficacy and preparedness. The post-survey included two additional questions. The first asks what additional 21 support/resources would help the instructors feel more confident in teaching the topics and the second asks what improvements would the instructors recommend for future training sessions. These questions allow the CNA instructors to provide input on improving the training. This evaluation supports continuous quality improvement and provides evidence of the CNA instructors’ ability to prepare CNAs to support patients in underserved communities. Timeline The timeline (see Appendix F) for this project is six months to allow sufficient time for baseline assessment, instructor training, skills development, and evaluation. During month one, administrative approvals will be obtained, the CNA instructors will be invited to participate, and the baseline will be administered to assess current confidence, knowledge, and teaching practices related to blood pressure, health literacy, and SDOH. The data will guide the final refinement of the training modules, blood pressure checklist, and multi-language patient education materials. Months two and three will focus on developing and delivering the standardized training modules. CNA instructors will participate in evidence-based instruction on accurate blood pressure measurement, health-literacy-sensitive communication, and identification of SDOH barriers that affect hypertension management. During this time, instructors will also receive the blood pressure protocol checklist and Spanish-language materials and will be trained on integrating these tools into CNA instruction. Month four will be dedicated to the instructor skills lab. Instructors will rotate through simulated teaching stations that model real-world patient scenarios in underserved communities. They will practice teaching CNAs how to measure blood pressure correctly, explain results in plain language, and use the teach-back technique to assess patient understanding (Talevski, et., al, 2021) and address SDOH-related barriers using standardized tools. Month five will focus on 22 implementation into instructional practice. CNA instructors will begin using the checklist, patient education materials, and standardized teaching strategies with their CNA students. Ongoing feedback will be collected to identify any barriers or needed adjustments. Month six will include administering the post-confidence survey, collecting instructor feedback, and comparing pre- and post-survey results to evaluate changes in instructor confidence, knowledge, and readiness to teach blood pressure management, health literacy, and SDOH. Findings will be used to guide sustainability and recommendations for ongoing faculty development. This project will implement a structured, evidence-based educational program to strengthen CNA instructors’ ability to teach CNAs how to support patient blood pressure management, health literacy, and SDOH in underserved communities. Through standardized training, skills-based learning, and multilingual teaching tools, instructors will be equipped to deliver consistent, equitable, and effective hypertension education. The goal is to improve CNA preparedness and promote better health outcomes for underserved patients. Project Evaluation Evaluating the effectiveness of this project requires a combination of formative and summative assessment methods to measure changes in CNA instructor confidence, knowledge, and instructional consistency. The evaluation plan aligns with the Iowa Model's emphasis on continuous feedback, iterative improvement, and outcome measurement. Formative evaluation will occur throughout the development and implementation phases to guide improvements and ensure it meets instructor needs. The baseline pre-intervention survey is a structured instrument designed to assess CNA instructors' readiness and capacity to teach evidence-based hypertension education. The survey 23 will measure instructor confidence in teaching blood pressure measurement, knowledge of current AHA blood pressure guidelines, understanding of SDOH and their impact on hypertension, comfort with teaching health literacy concepts, and current instructional practices. To capture these domains, the survey includes Likert-scale self-efficacy items and one openended question to identify perceived barriers and professional development needs. A validated instrument was created to specifically assess teaching confidence in hypertension instruction and in evidence-based educational practices (Hoegen et al., 2021). This baseline data will serve as a reference point for measuring progress and guiding targeted improvements. During the training sessions, ongoing feedback will be used to support learning and improve instruction. This will include live questions or polls to check understanding, as well as brief reflections on how explicit and useful the material is. This feedback allows trainers to adjust the content, pace, or examples as needed to better meet the instructor's needs, ensuring the training remains responsive and effective. During the skills lab, instructors will receive formative feedback to support skill development and teaching effectiveness. This will include observation feedback from project facilitators, peer feedback during teaching demonstrations, and the use of the Blood Pressure Protocol Checklist to identify gaps in technique or clarity of instruction. These strategies help instructors refine their clinical skills and teaching approaches before the summative evaluation. The summative evaluation will demonstrate the project's success and inspire confidence in the training's effectiveness. Instructors will complete a standardized skills assessment using the Blood Pressure Protocol Checklist to evaluate the accuracy of blood pressure measurement, the ability to explain results in plain language, the use of the teach-back method, and the identification of SDOH 24 barriers in simulated scenarios. These scores will be compared to baseline performance to determine improvement following the intervention. To assess whether instructors are applying the standardized protocol in their teaching, structured observations of instructors teaching CNA students will be conducted, student practice checklists will be reviewed for alignment with the protocol, and instructional materials used after implementation will be audited. These measures ensure that the intervention results in consistent and sustained instructional change. A brief post-training evaluation will measure instructor satisfaction with the training modules, perceived relevance to underserved communities, confidence in long-term application, and suggestions for improvement. This qualitative feedback will support ongoing program refinement. Three to six months after implementation, instructors will complete a follow-up postsurvey assessing continued use, and program leadership will review whether the checklist and training modules have been integrated into the routine curriculum. The post-survey includes the same questions as the pre-survey, plus two additional qualitative questions about any additional support needed or improvements recommended. Additional feedback on barriers to sustainability will be collected to evaluate whether the project has achieved lasting impact. Ethical Considerations The project demonstrates social responsibility by addressing health inequities that affect people with limited education, low income, and poor access to care, groups commonly served by CNA programs in underserved communities. By improving instructors’ ability to teach blood pressure management, health literacy, and SDOH, the project supports more equitable care and helps reduce hypertension disparities. Protecting privacy and cultural respect is central to the project. All surveys and skills-lab evaluations will be collected anonymously, and only aggregated results will be reported 25 (McGonigle & Mastrian, 2025). No real patient information will be used; all scenarios will be simulated. The project also follows the Centers for Disease Control Health Equity Guiding Principles for Inclusive Communication (2021) by using culturally responsive teaching, multilingual materials, diverse patient scenarios, and resources designed for different literacy levels. These strategies support fairness, accessibility, and inclusion for both instructors and CNA students. Several ethical issues may arise. Instructors may feel pressured to participate, so participation is voluntary. They may also worry about being judged, so the project will emphasize that the goal is to evaluate the training, not individual performance, and all assessments will be supportive and formative. To protect confidentiality, surveys will be anonymous, and results will be reported only in summary form. To reduce bias, standardized evidence-based tools will be used, along with faculty oversight and consistent evaluation methods (Melnyk & Fineout-Overholt, 2023). Overall, the project reflects beneficence by strengthening instruction and improving CNA education, justice by providing equitable and culturally appropriate resources, and respect for persons by protecting privacy, choice, and dignity. These ethical principles guide the project toward responsible and equitable improvements in CNA instructor training. Discussion This MSN project addresses hypertension in underserved communities by strengthening CNA instructor confidence in teaching evidence-based blood pressure monitoring, health literacy, and SDOH. Evidence-based ways to share this project include presenting the findings in a poster session for nursing faculty and peers, distributing the standardized training materials and blood pressure checklists to CNA programs, and incorporating the content into instructor 26 continuing education. The project is significant to the advancement of nursing practice because it expands the role of nursing education beyond technical skill training to include health literacy, equity-focused communication, and SDOH-informed care, competencies essential to reducing hypertension disparities and improving population health. By empowering instructors with standardized tools, culturally responsive teaching strategies, and multilingual patient education resources, the project promotes consistent, high-quality instruction that directly influences CNA preparedness and patient outcomes. Key implications include improved instructional consistency, increased instructor selfefficacy, and greater capacity to support patients with limited health literacy and socioeconomic barriers. To support long-term success, the training modules and blood pressure checklist should be incorporated into CNA instructor orientation, expanded to other CNA programs, and further studied to determine how they affect CNA practice and patient blood pressure over time. Evidence-Based Solutions for Dissemination Project findings will be shared in several ways to maximize impact. The project coordinator will present the PowerPoint training materials to CNA instructors using evidence from literature to support improvements in how blood pressure, health literacy, and SDOH are taught. Results from the pre- and post-confidence surveys will be summarized and shared with program leadership and instructors to show changes in confidence and instructional readiness. In addition, the project coordinator will virtually present a poster on the MSN project to faculty and peers at Weber State University’s Annie Taylor Dee School of Nursing to raise awareness and support evidence-based CNA education. Significance to the Advancement of Nursing Practice 27 This project supports nursing practice by improving frontline caregivers' preparedness to support patients with high blood pressure, especially in underserved communities. Uncontrolled hypertension remains one of the leading causes of heart disease and stroke, and it affects people with limited income, education, and access to care at much higher rates (Chaturvedi et al., 2023; Colvin et al., 2022; Zhuang et al., 2025). CNAs are often the ones taking blood pressure readings, noticing changes in patient condition, and reinforcing health education during routine care, so gaps in their training can affect patient outcomes. Studies show that poor blood pressure technique and low health literacy are linked to missed diagnoses, poor follow-up, and difficulty managing chronic disease (Clapham et al., 2024; Shahid et al., 2022). By equipping CNA instructors with clear, evidence‑based tools and training in blood pressure measurement, communication, and SDOH, this project can ensure CNAs are better prepared to support patients in meaningful and effective ways. In doing so, it reinforces nursing’s role in prevention, education, and health equity—key drivers of improved long‑term patient outcomes. Implications The project identified several strengths and challenges related to its implementation. It offers several strengths, including its structured, evidence‑based design, standardized instructional tools, and multilingual patient education. The Iowa Model further enhances the project by providing “multiple feedback loops that enable continuous analysis, evaluation, and refinement,” which supports long‑term sustainability and improvement (Cullen et al., 2022). In addition, the skills lab, blood pressure protocol checklist, and patient education help promote consistency and equity across instructional practices (Duff et al., 2021). At the same time, a few limitations have been identified—such as differences in instructors’ experience levels, hesitation around adopting new teaching expectations, and the 28 Iowa Model’s noted gap in outlining specific data‑collection methods. Practical barriers like limited time, increased workload, or concerns about being evaluated may also arise. Challenges can be eased by keeping participation voluntary, integrating the training into existing continuing‑education activities, and offering streamlined, user-friendly tools. Maintaining open communication, encouraging instructor input, and adjusting based on survey results and skills‑lab feedback will help reduce barriers and strengthen the project’s overall success. Recommendations Several recommendations can strengthen the project and further improve patient outcomes. Updating the training modules in response to instructor feedback will help keep the content relevant, and broadening the skills‑lab scenarios to identify the types of challenges commonly seen in underserved settings may boost instructor confidence. Because the Iowa Model “does not provide a framework for data collection methods,” creating more precise guidance for how outcomes will be measured would enhance consistency and strengthen evaluation efforts (Cullen et al., 2022). Incorporating the training into continuing education and regularly updating materials as AHA guidelines evolve will also help ensure the project remains sustainable over time. The goal is to pilot the project in additional CNA programs or compare it with programs that continue to use standard instruction to better understand its broader impact. The gaps that require further investigation include how instructors’ SDOH shape their teaching, the long‑term effects of instructor training on CNA student performance, and whether standardized health‑literacy instruction improves hypertension outcomes in underserved communities (Alghamdi et al., 2024; Greene et al., 2024). Exploring these areas would help build a stronger evidence base and guide future improvements to CNA education. Conclusions 29 The project focuses on the lack of standardized, evidence‑based hypertension and health literacy education among CNA instructors in underserved communities. This gap leads to inconsistent teaching and missed opportunities to address disparities in blood pressure control. The literature makes clear that SDOH plays a significant role in shaping hypertension risk, with factors such as low income, limited education, and restricted access to care contributing to higher rates of uncontrolled blood pressure (Chaturvedi et al., 2023; Alghamdi et al., 2024). Health literacy also emerged as a central issue; individuals with limited literacy skills often have difficulty understanding medical information, adhering to treatment plans, and engaging in preventive care, thereby increasing their risk of poor outcomes and higher healthcare use (Shahid et al., 2022). Education level further compounds these challenges, as hypertension is more common among adults with a high school education or less (Zacher, 2023). These findings highlight the importance of preparing CNA instructors to deliver accurate blood pressure instruction, health‑literacy support, and SDOH guidance with confidence. In response, the project uses the Iowa Model to guide baseline assessments, develop evidence‑based training modules, create a standardized blood pressure protocol checklist, and implement a scenario-based skills lab that addresses common challenges in underserved settings. Incorporating multilingual patient education materials further supports equitable education. These strategies aim to strengthen instructor confidence and promote more consistent education for CNA students, with the broader goal of improving long‑term health outcomes in communities disproportionately affected by hypertension and limited access to care (Greene et al., 2024). 30 References Alghamdi, R. S. I., Alqarni, A. H. A., Eralfan, A. A. A., Asiri, S. M. A., Abdullah, S. K., Nursing, E. N. A. A., Al-Otaibi, B. A. H., Asiri, N. Z. H., Alharthy, T. F. M. A., & Alruwaili, J.G., (2024). The frequency of hypertension and contributing variables among hospital staff. 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Less than 1 year 1-3 years 4-6 years 7-10 years More than 10 years 3= Undecided 2=Disagree 1=Strongly Disagree Use the scale to answer the following questions: 5= Strongly Agree 4= Agree I feel confident teaching students how to accurately measure blood pressure. 5 4 3 2 1 I am knowledgeable about current AHA blood pressure measurement guidelines. 5 4 3 2 1 I can identify common errors students make when measuring blood pressure. 5 4 3 2 1 I can teach students how to troubleshoot inaccurate blood pressure readings. 5 4 3 2 1 I feel confident teaching students how to communicate health information clearly. 5 4 3 2 1 I can teach strategies to support patients with low health literacy. 43 5 4 3 2 1 I understand how social determinants of health influences hypertension and patient outcomes. 5 4 3 2 1 I feel comfortable teaching CNA students about social determinants of health. 5 4 3 2 1 I feel confident teaching students from diverse cultural backgrounds. 5 4 3 2 1 I can effectively use multilingual patient-education materials. 5 4 3 2 1 I feel prepared to deliver standardized, evidence-based education on hypertension. 5 4 3 2 1 I feel comfortable implementing the blood pressure protocol checklist. 5 4 3 2 1 I feel confident supporting CNA students in developing skills that promote health equity. 5 4 3 2 1 What barriers do you currently face when teaching blood pressure monitoring or health literacy? 44 Appendix C 45 46 Appendix D 47 48 Appendix E CNA Instructor Confidence Post-Survey Blood Pressure, Health Literacy & Social Determinants of Health Date__________________ What is your role in the CNA program? CNA Instructor Program Coordinator Program Manager Other _____________ How long have you been teaching CNA students? Less than 1 year 1-3 years 4-6 years 7-10 years More than 10 years 3= Undecided 2=Disagree 1=Strongly Disagree Use the scale to answer the following questions: 5= Strongly Agree 4= Agree I feel confident teaching students how to accurately measure blood pressure. 5 4 3 2 1 I am knowledgeable about current AHA blood pressure measurement guidelines. 5 4 3 2 1 I can identify common errors students make when measuring blood pressure. 5 4 3 2 1 I can teach students how to troubleshoot inaccurate blood pressure readings. 5 4 3 2 1 I feel confident teaching students how to communicate health information clearly. 5 4 3 2 1 I can teach strategies to support patients with low health literacy. 49 5 4 3 2 1 I understand how social determinants of health influences hypertension and patient outcomes. 5 4 3 2 1 I feel comfortable teaching CNA students about social determinants of health. 5 4 3 2 1 I feel confident teaching students from diverse cultural backgrounds. 5 4 3 2 1 I can effectively use multilingual patient-education materials. 5 4 3 2 1 I feel prepared to deliver standardized, evidence-based education on hypertension. 5 4 3 2 1 I feel comfortable implementing the blood pressure protocol checklist. 5 4 3 2 1 I feel confident supporting CNA students in developing skills that promote health equity. 5 4 3 2 1 What barriers do you currently face when teaching blood pressure monitoring or health literacy? 50 What additional support/resources would help you feel more confident in teaching these topics? What improvements would you recommend for future training sessions? 51 Appendix F Timeline Project Timeline Program manager reviews plan and Week 1 deliverables Instructor presentation and preWeek 1 survey Begin training session modules Skills lab training and feedback Complete post-training surveys Analyze post-survey results and revises curriculum Finalize revised materials for long-term use Week 1 Week 2 Week 6 Week 10-13 Week 15 Week 16-20 Week 24