Aims and objectives: The aim of the research was to identify how the development of concept analyses have influenced practising nurses' understanding of health promotion. More specifically the aim gives rise to the objective of establishing how they translate their understanding into practice.
Background: The acknowledgement that nurses are confused about health promotion has led to attempts to define the term through the production of concept analyses, which aim to clarify the term for nursing education, research, policy and practice.
Design and methods: A qualitative approach, using semi-structured interviews was undertaken with a purposive sample of 21 district nurses, based throughout Wales. Thematic content analysis was used to order, describe and interpret the data.
Results: Generally the respondents gave definitions of health promotion that were confined to the traditional conceptualization of health promotion, comprising actions aimed at changing the behaviour of individuals. These interpretations were translated into practice, where district nurses adopted a mainly reactive and individualistic approach to health promotion.
Conclusions and relevance to clinical practice: The paper concludes that the more contemporary definitions of health promotion that focus on empowerment, community development and socio-political action are yet to reach practising district nurses. Considerable effort is required from educationalists and practitioners if nurses are to include these ‘new paradigm’ approaches to health promotion in their practice.
Health promotion is a prominent term in nursing, with authors, such as Tones (1993), arguing that health promotion is central to the philosophy of nursing. Directives and declarations from professional (SNMAC 1995, RCN 2002) and governmental (NAfW 2000, DoH 2002) organizations that exhort nurses to develop a health promotion focus, are testimony to its envisaged pivotal position in nursing. For example, Liberating the Talents (DoH 2002) identifies the involvement of nurses in public health, health protection and health promotion as one of three core functions for nurses. Furthermore, the Munich Declaration (WHO 2000) recognizes that action needs to be increased to enhance the roles of European nurses and midwives in public health, health promotion and community development.
In Wales, national policy distinguishes a role for community nurses in health promotion. For example, the Welsh national health promotion strategy, Promoting Health and Wellbeing (NAfW 2000) identifies a key role for community nurses in improving the health of the Welsh population. Furthermore, the Welsh NHS Plan Improving Health in Wales (NAfW 2001a) and the consultation document The Future of Primary Care (NAfW 2001b) both establish that health education and promotion fall within the domain of primary health care and community nursing.
There is a dearth of literature which focuses specifically on the health promotion activities of district nurses or indeed, according to Bryans (1998) and Kennedy (2002), on district nursing in its entirety. Therefore, to gain some understanding of such activities, the literature that relates to community nurses in general also needs to be consulted.
Littlewood and Parker (1992) suggested from their survey-based research that community nurses held the conviction that they had a pivotal role in health promotion. More recently, Forbes et al. (2001) undertook a study using a triangulation of methodological approaches to elicit the core skills that are required by community staff nurses. They conclude that health promotion and health education are key skills required by community nurses to fulfil their role effectively. Despite the recency of this study, concerns remain about the representativeness of the findings as, in correspondence with Littlewood and Parker (1992), the sample was obtained from one inner city NHS trust in England and was also relatively small in size (n = 68). Nevertheless, the fact that many other authors (Sourtzi et al. 1996, McDonald et al. 1997, Whitehead 2000) acknowledge the significant role that community nurses have in health promotion, helps to dispel these misgivings.
Sourtzi et al. (1996) used multiple methods to examine the nature and extent of community nurses' health promotion activities. The results highlighted an emphasis by community nurses on individualistic work with a focus on lifestyle advice and ill health prevention. These findings are supported by Whitehead's (2000) literature review, in which he demonstrates that community nurses are mainly involved in the prevention of coronary heart disease through programmes that tend to be epidemiologically based and target driven. Cantrell (1998) used focus group and individual interviews specifically with district nursing sisters in Scotland to explore how they perceived their health education role. The study concentrated on health education rather than health promotion and Cantrell (1998) justified this focus by arguing that the nature of district nursing confines their role to one of health education. Cantrell (1998) found that in practice, district nurses focus on giving health information to individuals rather than on engaging in the wider issues that relate to community-orientated health education.
It is evident from this albeit limited body of literature that health promotion is open to diverse interpretations and community nurses have difficulty in identifying the ideologies that should be pivotal to health promotion practice (Sourtzi et al. 1996, Peckham & Wirrmann 2003). The initial aim of this paper is to explore recent interpretations of the concepts of health promotion and health education.
Two notable concept analyses of health promotion have been published in the nursing literature (Maben & Macleod Clark 1995, Whitehead 2004). Maben and Macleod Clark (1995) identify a number of defining attributes of health promotion, which include health education. Their final definition distinguishes between traditional health promotion, where the focus is health education, lifestyle and behaviour change and new paradigm health promotion, the mainstay of which is empowerment and community development. This conceptualization is closely aligned to Ewles and Simnett's (1999) interpretation of health promotion. They identify five approaches to health promotion, namely the medical, behavioural change, educational, client-centred and societal change approaches. They suggest that the educational approach aims to ensure that well-informed decisions are made, by giving information and ensuring knowledge and understanding. The medical approach to health promotion involves prevention or amelioration of ill health through screening and early diagnosis and the behavioural approach involves the encouragement of individuals to adopt healthier lifestyles. Thus, adopting Maben and Macleod Clark's (1995) stance these approaches harmonize with ‘traditional’ health promotion. It follows that the client-centred and societal change approaches correspond with ‘new paradigm’ health promotion as Ewles and Simnett (1999) distinguish these approaches as the empowerment of clients and undertaking political and social action to engender health-enhancing environments.
Whitehead (2004) argues that health education does not help to define health promotion, but rather is a mature concept, which has boundaries that are distinct from health promotion. Therefore, whereas Maben and Macleod Clark (1995) suggest that health education is one important component of health promotion, Whitehead (2004) offers separate definitions of the concepts health promotion and health education. He argues that, while they are closely related, the terms cannot be used interchangeably. Health education, Whitehead (2004) believes, is an activity that aims to inform individuals about the determinants of health and illness and to motivate people to change their behaviour. Whitehead (2004) points out that health promotion has evolved since Maben and Macleod Clark's (1995) conceptualization to form a more politically orientated configuration, which seeks to transform and empower communities by involving them in activities that influence public health. He argues that it is no longer helpful to distinguish between traditional and new paradigm health promotion, which he asserts are often more appropriately classified within the definition of health education.
Whichever conceptualization of health promotion one chooses to uphold, the question of how health promotion is perceived by practising nurses remains, giving rise to the ensuing research aim.
The research reported here forms the second phase of a two-phase study and builds on the findings of a Delphi study (Irvine 2005). One of the aims of the research was to provide some insight into how district nurses interpret the concept of health promotion and translate it into their practice.
A qualitative approach, using semi-structured interviews, was adopted and between July 2000 and May 2001, 21 district nurses based throughout Wales were interviewed for the study. The sample was selected using purposive sampling, which led to the inclusion of participants from 10 out of a potential 14 NHS trusts (Table 1).
Table 1 Interview inclusion criteria
Ethical approval to undertake the study was gained and permission was granted to recruit and interview district nurses by the nurse executives from each of the participating NHS trusts. The normal convention of ensuring confidentiality was followed and participants who agreed to be interviewed were asked to sign a consent form.
The interview schedule was developed using the findings of the earlier Delphi study and refined following the completion of a pilot study. The schedule focussed on district nurses' interpretation of the concept of health promotion and their translation of the concept into practice. Individual interviews were conducted with 19 out of 21 of the respondents. The remaining two respondents chose to be interviewed together.
Burnard's (1991) sequential process was followed during the analysis process. This approach allows for the interpretation of meaning of data by identifying steps for coding, categorizing data, ensuring rigour and organizing and writing up. An independent researcher read a sample of transcripts, trailed the decision process and scrutinized the identified categories to enhance the truthfulness and consistency of the study (Slevin & Sines 1999/2000).
All 21 of the respondents were female and 20 out of the 21 had either sole or shared responsibility for managing a caseload. The other respondent managed a number of district nursing teams. A profile of the interview respondents can be seen in Table 3.
Table 3 Profile of interview respondents
Six themes emerged through the analysis process. The two themes that relate to the research aims of this paper are examined in the following section.
The district nurses offered a diversity of views of the meaning of the concept health promotion, categorized as follows.
One of the most prominent definitions that emerged from the analysis relates to lifestyle and behaviour change. For example, one respondent remarked:
Looking after the community, looking after their lifestyles and advising them really on their needs and how to change their lifestyle, probably, and how to improve their lifestyle. (1–011)
The category of lifestyle linked closely to that of behaviour change, which featured in some of the district nurses' definitions of health promotion. Although most of the district nurses discussed lifestyle and behaviour change in a positive light, some scepticism about this approach to health promotion was demonstrated, as illustrated in the following statement:
We are very autocratic in trying to get people to live healthy lifestyles. (1–003)
This suggests a lack of comfort with the prevailing biomedically defined framework (Whitehead 2003) that was evident in the submitted definitions.
The respondents often associated education and advice giving with lifestyle and behaviour change and some of the meaning units could be applied to both of these categories. Despite this overlap external homogeneity, where the categories can be seen as distinct and separate (Maynan 2001), is demonstrated.
In general, the distinction between these two categories is concerned with process and outcome, where the process relates to how the intervention operates and the outcome relates to the effect of the intervention (Øvretveit 1998). Advice and education was conceptualized as the process of health promotion and lifestyle and behaviour change centred on the outcome of the activity.
The respondents were able to distinguish between different levels of health promotion. For example, one district nurse pointed out that:
Normally there is three stages, it is divided into sort of primary, which is looking at people who are healthy, and the secondary, where people have got risks, dealing with the risks in their, sort of, life, like smoking. And there's the tertiary approach, sort of carrying on with their lives suffering from illness and getting the best quality health. (1–007)
Some district nurses talked of health promotion in terms of patients taking responsibility for their own health. For other district nurses there appeared to be negative connotations attached to the category. This is demonstrated by one respondent who remarked:
I think health promotion, to me, is healthy people helping themselves and getting the health education message across so they can then take responsibility for their own health. So that, I think, is the crux of health promotion, cause people… often want to take, want to get rid of their responsibilities for themselves and put it on people like us and doctors and then complain like mad if something goes wrong or a certain treatment isn't working. (1–002R2)
Clearly, individuals cannot take full responsibility for their health unless they are aware of all the choices that are available to them and this leads to the next category of offering choices.
In defining health promotion, some district nurses recognized the importance of offering choices to their patients. To illustrate, one of the respondents stated that health promotion involves:
…giving advice to that individual when they are trying to make decisions and choices about their lifestyle relating to health. (1–006)
The ultimate goal of health promotion according to some respondents is achieving optimum health. This is illustrated below:
Health promotion – helping patients, also clients to get the best out of their health as possible, to get the optimum health or best possible health. (1–015)
These accounts are testimony to the fact that there is some conflict of opinion amongst district nurses relating to the definition of health promotion. Opinions vary significantly. They range from the process to the outcome of health promotion and extend from a narrow perspective of maintaining optimum health to a wider view of giving responsibility and offering choices. These definitions influence the role that district nurses fulfil in health promotion.
A range of role-related meaning units emerged through the data analysis, which characterized clearly distinguishable data categories.
The respondents commonly cited a disease-orientated approach to health promotion as one that they most typically use in their practice. In this situation, such an approach is normally directed towards patients whom they are seeing for a particular purpose. When discussing disease-orientated health promotion, the respondents referred to three main elements of this work. Firstly, they talked in terms of specific illnesses, where their role focused on the prevention or the containment of certain conditions. Respondent 20 for example, talked about the prevention of a condition thus:
Most of my caseload is mostly elderly people so we aim at hypothermia and everything to do with keeping warm really of preventing (it)…. (1–020)
The second element of district nurses' disease-orientated health promotion work related to the administration of vaccinations. District nurses are particularly involved in the administration of vaccinations against influenza. Finally, in relation to disease, the respondents discussed their role in screening. Again, this screening tends to be directed towards specific conditions.
In their health promotion work, district nurses do not focus exclusively on specific diseases and this leads to the second category, lifestyle-orientated approaches.
A lifestyle-orientated approach is an important aspect of the respondents' health promotion work. For example one of the interviewees said:
I mean if you are going in to a diabetic even if you are just going in to do a leg ulcer or just a routine wound check, you would check on diet, you would promote healthy eating…. That is mainly what we do you know, try and encourage a nutritional healthy diet. …so I would say you would pick up if somebody was eating what they shouldn't be, or smoking…. (1–013)
If district nurses define health promotion in terms of lifestyle and behaviour change, then they attempt to achieve this either by focussing on the lifestyle or behaviour; or on the disease that such a lifestyle risks causing or exacerbating. One mechanism by which these issues are addressed is through opportunistic work.
Many of the respondents perceive their work in health promotion to be what they class as ‘opportunistic’, where the opportunity to promote somebody's health arises spontaneously. The chance to offer health promotion often transpires during a planned patient contact. This is highlighted by one interviewee, who remarked:
Again, as I said, opportunistically, when we go in about one thing, you can get talking about their lifestyles. (1–008)
The message emanating from these categories is that, on the whole, district nurses' health promotion work is reactive in nature. That is, district nurses tend to respond when a situation arises, rather than actively seeking out opportunities for health promotion. However, this is not always the case and some district nurses talked of a proactive approach to health promotion.
Within this category a clear dimensional continuum was exhibited, with comments displaying positions from the positive, proactive stance through to the negative, reactive stance. It is commendable that some of the respondents were able to give examples of innovative and proactive health promotion work in which they and their teams are involved. Respondent 10 spoke about three ongoing projects, which she had initiated. One of these projects she explained thus:
We set an afternoon a month to visit all of the people within a particular housing complex… (we are) trying to allow it to be client led in terms of whatever issues concern them. Things like hearing aids and audiology, where do you get your batteries from and that sort of thing…. And again we take advantage of things that come periodically like flu vaccine. We give an afternoon aside for that and are able then to push the preventative side of accepting the vaccine rather than going down with the flu. …Quite a few things like that, safety in the home is another thing. Preventing falls, you know the ‘slips, trips and broken hips’ agenda. I have used that you know, because falls is high on the agenda isn't it. (1–010)
However, some of the respondents admitted that they were not involved in any proactive health promotion work.
In terms of proactive health promotion, the respondents appear to hold similar beliefs about the concept, expressing the viewpoint that they saw a proactive approach to health promotion as desirable but not necessarily achievable. Although in the main their proactive role is yet to be developed, the district nurses see that their role in health promotion is evolving.
District nurses believe that their role has changed considerably in recent years and that it is likely to continue changing in the future. Some of the respondents considered this change to their role by using their past and present experience to anticipate the shape that their role is likely to take in the future. This is illustrated by the following passage:
I think it (health promotion) is going to take more of our time in the future. I think it is more evident in the future, that this is the road we should be going down. Not just that we, as district nurses, are looking after the elderly like the Nerys Hughes of district nursing, I think we are going to be looking at a more wide range of people. Our role is expanding if they allow it. (1–011)
To clarify, Nerys Hughes played that part of a district nurse working in Wales in the early 1940s in a television drama, which centred on her role. It was a role that was mentioned in a number of the interviews.
Other respondents were more precise in their predictions about the nature of their role in the future and identified specific initiatives that they could adopt to advance their role in health promotion.
Some of the respondents indicated that health promotion is merely an integral part of the care that they provide for all their patients. This is exhibited in the following quote:
Well all the time as we go to patients really. You cannot identify that this is health promotion. Whatever advice you are giving people is health promotion really…. (1–011)
However, the fact that health promotion is considered in these terms means that the district nurses do not always recognize their role. Unfortunately, it is not only the district nurses who fail to acknowledge this important aspect of their role. District nurses are now required to produce details of their activities in practice, either in the written form or electronically and there is not always the opportunity to identify health promotion as a legitimate district nursing activity. As one respondent pointed out, this was the case for her activity analysis:
I don't think there is even a contact code for health promotion… no there isn't. (1–014)
The overall impression that this oversight conveys, whether it is correct or not, is that district nurses are not heavily involved in health promotion.
It is evident from the study that no single definition of health promotion is held by the district nurses. However, it appears that there is some consensus about the defining attributes of health promotion and the respondents identify common processes and outcomes of the concept.
Accordant with Ewles and Simnett's (1999) account of an educational health promotion approach, district nurses impart health-related information in an effort to influence the knowledge, attitudes and behaviour of their patients. Thus it seems that Cantrell (1998) correctly argued that the district nursing role is limited to health education. They engage in primary health promotion, which focuses on preventative work; secondary health promotion, which is concerned with restoring good health; and tertiary health promotion, which is directed at illness containment. Although Unsworth (2000) indicates that district nurses traditionally have a role in secondary and tertiary health promotion, Ewles and Simnett (1999) suggest that it is often difficult to identify where people fit into the primary, secondary or tertiary framework, because health status is open to interpretation. These uncertainties may explain why limited attention is paid to this conceptualization of health promotion in the literature.
The respondents indicated that adopting these health promotion processes should give rise to specific outcomes; defined by the district nurses in terms of lifestyle and behaviour change, choice and responsibility and optimum health. This opinion accords with the literature, which discloses that behaviour change is the mainstay of district nurses' health promotion and health education activities (Sourtzi et al. 1996, Cantrell 1998). Yet, some authors such as Tones and Tilford (2001) argue that a lifestyle/behaviour change approach to health promotion is at best defective, since, as Whitehead and Russell (2004) contest, changing a client's health-related behaviour is notoriously problematic. Further condemnation of this approach is submitted by Bunton et al. (1991) who maintain that the belief that individual behaviour is the primary determinant of health is misguided, because a number of critical factors such as social–political structures and cultures also influence health. At worst, the lifestyle and behaviour change approach is considered to be unethical (Thomas & Wainwright 1996) because it gives rise to ‘victim-blaming’ where people feel responsible and culpable for any ill health (Nettleton & Bunton 1995). As such, a behaviour change approach is arguably one that should be avoided. However, Whitehead and Russell (2004) point out that behaviour change should not be dismissed, as good patient outcomes can be achieved if careful consideration is given to the underpinning theoretical and practical constructs.
It seems, however, that the district nurses are not wholly conversant with the relevant theoretical constructs, for although the interviewees remarked on the importance of offering choice to patients and promoting self-responsibility, any articulation of the concept of empowerment was absent from their accounts. This omission seems surprising as authors such as Rissell (1994), Jacobs (1996) and Macdonald (1998) advocate that empowerment is fundamental to effective health promotion. The key to empowerment, it is argued is the use of interpersonal skills to enable individuals and groups to use their personal resources to develop healthy lifestyles (Kendall 1998) and to influence the societal and environmental structures that affect their health (Piper & Brown 1998, Beattie 2002). Of course, as Kendall (1998) points out, one interpretation of empowerment embraces the notions of choice and responsibility, which the interviewees alluded to. However, Kendall (1998) and Webster and French (2002) are critical of this approach, which they imply serves to perpetuate the much maligned victim-blaming approach to health promotion.
The respondents identify the ultimate outcome of health promotion as the maintenance of optimum health; however, those who defined health promotion in these terms appeared to have a limited understanding of the concept. They had difficulty providing a definition of the concept and gave little more than what might be described as a layman's perspective of health promotion. This apparent confined grasp of health promotion was, as one might expect, not manifest in the literature where it could be expected that poorly constructed definitions of the concept would be eliminated through the referee process adopted in most journals.
An interesting element of the respondents' definitions of health promotion is the factors that they omitted to consider. They overlooked empowerment and community development and they did not consider health promotion as socio-political action. Rather, their interpretations sit well with Whitehead's (2004) portrayal of health education and Maben and Macleod Clark's (1995) account of traditional health promotion, as Table 2 illustrates.
Table 2 Comparison of definitions of health education and health promotion
One explanation for the confined definitions of health promotion relates to the district nurses' education. As the Audit Commission (1999) points out, district nurses are Registered Nurses who have undertaken additional qualifications. The academic level of this additional qualification however ranges from certificate to degree level. As demonstrated in the respondent profile of Table 3, the majority of the respondents were not educated beyond diploma level and had not received any formal education relating to health promotion.
These circumstances give rise to two particular issues that help to explain district nurses' limited definitions of health promotion. Firstly, most respondents lack a degree level education and this suggests that they are yet to develop the high level cognitive functioning associated with the ability to analyse and synthesize information (Quinn 2000). Therefore they may have difficulty applying the notion of socio-political action to their practice. Secondly, most respondents were not exposed to a curriculum driven, as today, by specialist practice learning outcomes that include health promotion and health education (UKCC 2001). Thus the majority of respondents will have had a limited introduction to these concepts.
The situation revealed in the interviews is in accordance with the work of Thomas and Wainwright (1996) who highlight the lack of health promotion training that district nurses and health visitors receive. Therefore it is of little wonder that the district nurses interviewed in this study have a limited grasp of the concept of health promotion. As one might anticipate, the definitions that district nurses assign to health promotion influence the nature of the role that they fulfil in practice.
In the main the role that district nurses accommodate in their practice conforms to a health education framework. They adopt a medical approach, adhering to processes that are mainly reactive and opportunistic. Any proactive work is preventive in nature and as such is orientated towards diseases and lifestyle.
A similar message is conveyed through the literature, Cantrell (1998) for example suggested that general practitioners and other healthcare professionals do not perceive the value that district nurses have in health education and this is supported by the work of Williams and Sibbald (1999) and McDonald et al. (1997). The research undertaken by both of these teams demonstrates tensions relating to the role that community nurses of different disciplines fulfil, where one group of community nurses feels threatened by the expanding role of nurses from another discipline and are reluctant to relinquish any health promotion activities.
The district nurses are mainly aware of the current limits of their health promotion role but believe that their role is likely to evolve. This sentiment is also expressed in the literature, which shows that the focus of work has shifted from that of fundamental nursing care in the 1980s, to a more proactive role in the 21st century. This should include involvement in health needs assessment and community profiling (Unsworth 2000, Tinson & Hutchinson 2001), advising on the commissioning of health services (Antrobus & Brown 1997, Audit Commission 1999), and the development of new skills to meet the changing demands of patients (Audit Commission 1999, Unsworth 2000). These developments may offer more scope for health promotion.
This study is limited in size and confined to one of the UK countries. Nevertheless, it has produced rich data, highlighting issues that have important implications beyond the regional level.
There was considerable variation in the educational profile and work setting of the sample, which may have effected the respondents' interpretation of health promotion. However, as Kennedy (2002) points out, the variations reflect the profile of district nurses in the UK. The sample was selected to capture the broad-ranging capacity of district nurses in Wales and allow for generalization on conceptual grounds (Miles & Huberman 1994).
This research demonstrates that in Wales, district nurses remain entrenched in practice that aligns with health education or traditional health promotion. Generally, district nurses have not developed their knowledge base beyond educational, medical and behaviour change approaches and consequently they fulfil a role which is lifestyle and disease orientated. Despite Whitehead's (2004) dismissal of traditional and new paradigm health promotion as redundant terms, these are more real to district nurses than his radical interpretation of health promotion as an inherently political activity. Of course, it should be acknowledged that at the time of the interviews Whitehead's (2004) concept analysis would not have been available to the respondents and thus could not have shaped their thinking. However more recent research (Williams et al. 2004) suggests that the health promotion role of district nurses remains at the reactive level.
Clearly, Whitehead's (2004) is a model definition, which is founded mainly on a theoretical discussion of health promotion and, as he acknowledges, draws only on limited nursing research ‘that is credibly linked to health promotion strategies directly impacting socio-politically on communities’ (p. 317). Thus, it could be argued that Whitehead's definition focuses on the ideal rather than the reality of how health promotion is currently effected in nursing practice. Indeed, Whitehead (2003) contends that nurses are aware of their limitations in implementing broad ranging health promotion programmes and his position is confirmed by this research study. However, Brown and McKenna (1999) argue that if the ideal is to be embraced by nursing, then it needs to be used in theory generation, research and education in order to be transmitted into practice. Therefore, rather than discarding Whitehead's (2004) interpretation of health promotion, it is worth considering Brown and McKenna's (1999) position and embracing a construct that moves beyond traditional and new paradigm health promotion to take account of a ‘more politically-orientated empowering health promotion paradigm’ (Whitehead 2004, p. 315).
This research has demonstrated that the definitions that individuals attribute to health promotion are related to the role that they fulfil in practice. So if Whitehead's (2004) interpretation of health promotion is to reach district nursing practice, an obvious starting point is to update current and future district nurses' knowledge of the concept. Innovative approaches to teaching and learning, in diverse educational and practice settings, should help to facilitate this shift in knowledge so that eventually district nurses can embrace a socio-political health promotion role.
I am grateful to Prof. Annette Jinks for her advice and support during this research.
Study design: FI, data analysis: FI; manuscript preparation: FI.
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Key words: concept analysis; district nursing; health education; health promotion; nurses
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