Nurses play an important role in promoting public health. Traditionally, the focus of health promotion by nurses has been on disease prevention and changing the behaviour of individuals with respect to their health. However, their role as promoters of health is more complex, since they have multi-disciplinary knowledge and experience of health promotion in their nursing practice. This paper presents an integrative review aimed at examining the findings of existing research studies (1998–2011) of health promotion practice by nurses. Systematic computer searches were conducted of the Cochrane databases, Cinahl, PubMed, Web of Science, PsycINFO and Scopus databases, covering the period January 1998 to December 2011. Data were analysed and the results are presented using the concept map method of Novak and Gowin. The review found information on the theoretical basis of health promotion practice by nurses, the range of their expertise, health promotion competencies and the organizational culture associated with health promotion practice. Nurses consider health promotion important but a number of obstacles associated with organizational culture prevent effective delivery.
health care, nursing, competencies, health
The role of nurses has included clinical nursing practices, consultation, follow-up treatment, patient education and illness prevention. This has improved the availability of health-care services, reduced symptoms of chronic diseases, increased cost-effectiveness and enhanced customers' experiences of health-care services (Strömberg et al., 2003; Griffiths et al., 2007). In addition, health promotion by nurses can lead to many positive health outcomes including adherence, quality of life, patients' knowledge of their illness and self-management (Bosch-Capblanc et al., 2009; Keleher et al., 2009). However, because of the broad field of health promotion, more research is needed to examine the role of health promotion in nursing (Whitehead, 2011).
The concept of health promotion was developed to emphasize the community-based practice of health promotion, community participation and health promotion practice based on social and health policies (Baisch, 2009). However, empirical studies indicate that nurses have adopted an individualistic approach and a behaviour-changing perspective, and it seems that the development of the health promotion concept has not influenced practical health promotion practices by nurses (Casey, 2007a; Irvine, 2007). On the other hand, there has been much discussion about how to include health promotion in nursing programmes and how to redirect nurse education from being disease-orientated towards a health promotion ideology (Rush, 1997; Whitehead, 2003; Mcilfatrick, 2004).
The aim of this integrative review was to collate the findings of past research studies (1998–2011) of nurses' health promotion activities. The research questions addressed were: (i) What type of health promotion provides the theoretical basis for nurses' health promotion practice? (ii) What type of health promotion expertise do nurses have? (iii) What type of professional knowledge and skills do nurses undertaking health promotion exhibit? (iv) What factors contribute to nurses' ability to carry out health promotion?
An integrative review was chosen because it allowed the inclusion of studies with diverse methodologies (for example, qualitative and quantitative research) in the same review (Cooper, 1989; Whittemore, 2005; Whittemore and Knafl, 2005). Integrative reviews have the potential to generate a comprehensive understanding, based on separate research findings, of problems related to health care (Kirkevold, 1997; Whittemore and Knafl, 2005). The integrative review was split into the following phases: problem identification, literature search, data evaluation, data analysis and presentation of the results (Whittemore and Knafl, 2005).
Several different databases were searched to identify relevant published material. Systematic searches of the Cochrane databases, Cinahl, PubMed, Web of Science, PsycINFO and Scopus databases were undertaken using the search string ‘nurs* AND professional competence* OR clinical competence* OR professional skill* OR professional knowledg* OR clinical skill* OR clinical knowledg* AND health promotion OR preventive health care OR preventive healthcare’. The searches were limited to studies published during the period 1998–2011 because, prior to 1998, nurses' health promotion practice was mainly linked to health education.
The original search identified 1141 references: 119 in the Cochrane databases; 227 in Cinah, 345 in PubMed, 128 in the Web of Science, 100 in PsycINFO and 222 in Scopus. After duplicate papers were excluded one researcher (V.K.) read the titles and abstracts of the remaining 412 research papers. No specific evaluation criteria are employed when conducting an integrative review using diverse empirical sources; one approach is to evaluate methodological quality and informational value (Whittemore and Knafl, 2005). All three researchers (V.K., K.T. and H.T.) defined the inclusion criteria together. Studies were included in the integrative review if they met the following criteria: the language had to be English, Swedish or Finnish, as translators for other languages were not available and the papers had to be published in peer-reviewed journals and describe nurses' health promotion roles, knowledge or skills and/or factors that contributed to nurses' ability to implement health promotion in nursing delivered through hospital or primary health-care services. The main exclusion criteria were: the published works were editorials, opinions, discussions or textbooks, or they described health promotion programmes, competencies other than health promotion or nursing curricula, or if the group studied included patients. The included studies were tabulated in chronological order under the following headings: citation, aim of the paper, methodology, size of the sample, measured variables, method of analysis, major results, concepts used as the basis of the study and limitations. Studies included in this review are available in Supplementary data, Table S1.
Conducting an integrative review that analyses various types of research paper is a major challenge (Whittemore and Knafl, 2005). In this review, the concept map method was adopted for both data analysis and presentation of the results. The use of concept mapping promotes conceptual understanding and provides a strategy for analysing and organizing information and identifying, graphically displaying and linking concepts. The concept map method was applied according to the recommendations of Novak and Gowin [(Novak and Gowin, 1984), p. 15–40] and Novak (Novak, 1993, 2002, 2005). According to Novak (Novak, 1993, 2002, 2005) the process of concept mapping involves six phases: (i) Identify a key question that focuses on a problem, issue or knowledge central to the purpose of the concept map. (ii) Identify concepts through the key question. (iii) Start to construct the concept map by placing the key concepts at the top of the hierarchy. After that, select defining concepts and arrange hierarchially below of the key concepts. (iv) Combine the concepts by cross-links or links between concepts in different segments or domains of the concept map. (v) Give the cross-links a name of a word or two. (vi) To concepts can be added specific examples of events or objectives that clarify the meaning of the concept.
All three researchers (V.K., K.T. and H.T.) were involved in the concept mapping process. The process proceeded as follows: first, one researcher (V.K.) read studies that met the inclusion criteria and the concepts were identified through the four research questions upon which the review is based. Second, one researcher (V.K.) began to construct four concept maps hierarchically. This was achieved by putting the key concepts on the top of the left side of a page then listing definitions of the concepts down the middle of each page. Other researchers (K.T. and H.T.) verified the first and the second phases of the concept mapping process. Third, one researcher (V.K.) continued the construction of each concept map by combining main concepts and definition concepts using links that were then named. Other researchers (K.T. and H.T.) critically evaluated the concept maps thus produced. Fourth, one researcher (V.K.) selected examples of the main concepts and these were listed on the right side of each page for clarification.
In the end 40 research papers, were included in our integrative review. The research papers were methodologically very diverse: 16 of them included qualitative approaches; 14 were different types of reviews; 8 were quantitative; 1 used concept analysis and 1 was a mixed-method study. Twelve empirical studies were conducted in hospitals and fourteen in primary health-care settings. Eleven studies were published in the period 1998–2004, twenty-two between 2005 and 2009 six between 2010 and 2011.
What type of health promotion provides the theoretical basis for nurses' health promotion practice?
The theoretical basis underlying nurses' health promotion activities was identified in 25 of the research papers (Benson and Latter, 1998; McDonald, 1998; Robinson and Hill, 1998; Sheilds and Lindsey, 1998; Burge and Fair, 2003; Hopia et al., 2004; Whitehead, 2004, 2006a,b,c, 2009, 2011; Berg et al., 2005; Runciman et al., 2006; Casey, 2007a,b; Folke et al., 2007; Irvine, 2007; Piper, 2008; Witt and Puntel de Almeida, 2008; Chambres and Thompson, 2009; Fagerström, 2009; Richard et al., 2010; Samarasinghe et al., 2010; Povlsen and Borup, 2011). According to these papers the theoretical basis of health promotion reflects the type of practical actions undertaken by nurses to promote the health of patients, families and communities. The research suggests that nurses work from either a holistic and patient-oriented theoretical basis or take a chronic diseases and medical-oriented approach. These theoretical foundations were considered to represent the main concepts of health promotion orientation and public health orientation in this review (Figure 1).
Health promotion orientation
The most common factor influencing the concept of health promotion orientation was individual perspective (Robinson and Hill, 1998; Hopia et al., 2004; Runciman et al., 2006; Casey, 2007a; Chambres and Thompson, 2009; Samarasinghe et al., 2010; Povlsen and Borup, 2011). When nurses' health promotion activities were guided by individual perspective nurses' exhibited a holistic approach in their health promotion practice, they concentrated on activities such as helping individuals or families to make health decisions or supporting people in their engagement with health promotion activities (Hopia et al., 2004; Irvine, 2007; Chambres and Thompson, 2009; Samarasinghe et al., 2010; Povlsen and Borup, 2011). Nurses' strategies for health promotion included giving information to patients and providing health education (Casey, 2007a). However, patient participation was mainly limited to personal aspects of care, such as letting patients decide on a menu, when to get out of bed and what clothes they wanted to wear (Casey, 2007a).
The second common defining concept of health promotion orientation was empowerment, which was related to collaboration with individuals, groups and communities (McDonald, 1998; Berg et al., 2005; Whitehead, 2006a; Irvine, 2007; Piper, 2008; Richard et al., 2010; Samarasinghe et al., 2010). Such orientation was described in these studies in terms of nurse–patient communication and patient, group and community participation. Although these studies found empowerment to be one of the most important theoretical bases for health promotion activities by nurses, empowerment was not embedded in nurses' health promotion activities (Irvine, 2007).
The third common defining concept of health promotion orientation was social and health policy (Benson and Latter, 1998; Whitehead, 2004, 2006a,b, 2009, 2011). These studies suggested that nurses' health promotion activities should be based on the recommendations in, for example, the World Health Organization's (WHO) charters and declarations and directives and guidance from professional and governmental organizations. However, the studies examined found that nurses were not familiar with social and health policy documents and that they did not apply them to their nursing practice (Benson and Latter, 1998; Whitehead, 2011).
The last defining concept of health promotion orientation was community orientation (Sheilds and Lindsey, 1998; Whitehead, 2004; Witt and Puntel de Almeida, 2008). These papers revealed that nurses had knowledge of community-orientated health promotion: they were expected to use health surveillance strategies, work collaboratively with other professionals and groups and respect and interact with different cultures. In addition a health promotion orientation appeared to result in nurses working more closely with members of communities, for example, being involved in voluntary work and implementation of protective and preventive health measures.
Public health orientation
Public health-orientated chronic disease prevention and treatment has traditionally been the theoretical basis of nurses' health promotion activities (Burge and Fair, 2003; Berg et al., 2005; Whitehead, 2006c; Folke et al., 2007; Casey, 2007b; Irvine, 2007; Chambres and Thompson, 2009; Fagerström, 2009; Richard et al., 2010). The first defining concept of public health orientation was disease prevention (Berg et al., 2005; Whitehead, 2006c, Folke et al., 2007; Irvine, 2007; Fagerström, 2009; Richard et al., 2010). According to these studies, this occurred in health promotion when the focus was on diagnosis, physical health and the relief of the physical symptoms of disease. The second defining concept of public health orientation was the authoritative approach (Burge and Fair, 2003; Casey, 2007b; Irvine, 2007; Chambres and Thompson, 2009). This approach emphasizes the need for nurses to give information to patients. In addition, the authoritative approach suggests that health promotion activities should aim to change patients' behaviour (Irvine, 2007; Chambres and Thompson, 2009).
What type of health promotion expertise do nurses have?
The expertise of nurses with respect to health promotion was described in 16 research papers (Robinson and Hill, 1998; Whitehead, 2001, 2006b, 2007, 2009, 2011; Hopia et al., 2004; Cross, 2005; Jerden et al., 2006; Runciman et al., 2006; Kelley and Abraham, 2007; Witt and Puntel de Almeida, 2008; Fagerström, 2009; Parker et al., 2009; Goodman et al., 2011; Whitehead, 2011). According to these papers nurses implemented a range of types of health promotion activity and applied different health promotion expertise across a wide range of nursing contexts. Depending on the context nurses are able to make use of a variety of types of expertise in health promotion. Nurses can be classified into: general health promoters, patient-focused health promoters and project management health promoters (Figure 2).
General health promoters
Health promotion by nurses is associated with common universal principles of nursing. The most common health promotion intervention used by nurses is health education (Robinson and Hill, 1998; Whitehead, 2001, 2007, 2011; Runciman et al., 2006; Witt and Puntel de Almeida, 2008; Parker et al., 2009). General health promoters are expected to have knowledge of health promotion, effective health promotion actions, national health and social care policies and to have the ability to apply these to their nursing practice (Witt and Puntel de Almeida, 2008
Nurses Role in Health Promotion
Health promotion is one of the important aspects which the World Health Organization or WHO addresses in every meeting. Though it is not possible to completely define this term to perfection, the WHO attempts to revise the definition every time to cover all aspects of health promotion.
According to the Bangkok Charter of WHO (2005), health promotion is be defined as “the process of enabling people to increase control over their health and its determinants, and thereby improve their health.” This definition has been modified from the previous definition as per Ottawa Charter (WHO, 1998) which states that “health promotion is the process of enabling people to increase control over, and to improve their health.”
The responsibility of health promotion vests not only with the government and health authorities, but also with the health professionals like nurses and physicians. This essay explores the role of nurses at all levels of health promotion.
Levels of health promotion and the role of nurses
Nurses play an important role in the health promotion of an individual due to their direct contact and proximity with the patients. The 3 basic roles of a nurse are that of a practitioner, leader and researcher.
As a practitioner, the nurse attends to all the medical needs of the patient and as a leader she takes decisions which relate to, influence and facilitate the actions of others with an aim to achieve a particular goal. As a researcher, the nurse aims to implement studies to determine the actual effects of nursing care and to work towards further improvement in nursing care (Nettina, 2006).
The steps in the nursing process are assessment, nursing diagnosis, planning, implementation and evaluation (Baillie, 2005; Nettina, 2006). Assessment is the systematic collection of data which are markers of the health status of the individual and help in identifying any health related problems.
Nursing diagnosis is the actual identification of the disease process which needs to be dealt with. Planning is a process of setting health related goals that are aimed to resolve the potential health problems identified by means of nursing diagnosis. Implementation is the means of delivering the plan to achieve the set goals. Evaluation is determination of patient’s response to the interventions made towards the achievement of goal (Nettina, 2006).
There are basically 3 levels of health promotion. They are primary level, secondary level and tertiary level. Majority of people receive primary health care. According to WHO, “Primary health care seeks to extend the first level of the health system from sick care to the development of health.
It seeks to protect and treat the problems at an early stage. Primary health care services involve continuity of care, health promotion and education, integration of prevention with sick care, a concern for population as well as individual health, community involvement and the use of appropriate technology.”
The approach to primary health care is characterized by “holistic understanding of health as wellbeing, rather than the absence of disease” (WHO, 2005). An extension to primary health care is community health services which provide acute care, care of the elderly, drug and alcohol-related services, services for those who are sexually assaulted and also mental health services (PHC Connect, 2006).
Nurses involved in the primary health care work collaboratively and autonomously to improve, promote and restore health. Primary health care nurses play an important role in health promotion, population health, prevention of diseases, care of wellness, first point of contact care and disease management across the lifespan (Ministry of Health, 2005).
People who cannot be dealt with in a primary care center are referred to secondary health care. Secondary health care involves a consultant or a specialist in a hospital or a clinic setting with suitable equipment with certain technology like X-rays and laboratory tests (WHO, 2005). In secondary care centers, nurses play an important role in the history taking and assessment of the patients. They collaborate with the consultant and the diagnostic services to enhance health promotion.
People who need health care beyond secondary care are managed in tertiary care centers which are mainly institutions like teaching hospitals or superspeciality hospitals which house many specialist and superspecialists and have advanced technology for adequate investigations and tests (WHO, 2005). In tertiary health care set up, nurses provide health promotion by working in collaboration with physicians and other health professionals (Kotzer, 2005).
Nurses play an important role in the health promotion of people at all levels of health care. Nurses are not only involved in the initial assessment and history taking of the patients but also in coordination with specialists, diagnostics and other health professionals.
Nurses also have an important role in decision making and organization of the treatment plans of the patient. Due to their crucial role, health promotion becomes impossible without the involvement of nurses.
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