Title: Health promotion and health education practice: nurses' perceptions
Aim: This paper is a report of a study to explore nurses' perceptions of health promotion and health education practice in a Chinese provincial hospital.
Background: Health promotion and health education practices are based on universal constructs. Therefore, such practices should share common principles. To date, most nursing-related studies have been conducted in Europe or in North America.
Method: A Husserlian phenomenological approach was adopted. Interviews were conducted in 2006 with a sample of eight nursing students and eight senior nurses. The interviews were audio-recorded and transcribed from Mandarin to English. Data analysis adhered to the framework developed by Giorgi.
Results: Reported health education and health promotion-related practices showed results similar to those reported in Europe and North America. Hospital-based nurses were often aware of what health promotion is, but did not have the scope or opportunity to implement it in practice. Instead, they were likely to conduct more limited forms of health education. Actual understanding of health promotion and health education constructs was high with most participants, underpinned by active clinical-based educational support. Some participants were able to conduct broader health promotion activities on a voluntary basis in their own communities.
Conclusion: Health education and health promotion are universal health-related constructs. Thus, there is an expectation that all nurses will implement these in a similar fashion. Where possible, hospital-based nurses should strive to improve their health education practices and further embrace wider perspectives of health promotion practice.
Health promotion and health education practices are based on universal constructs. Therefore, wherever they are conducted and experienced, they should share common principles between healthcare professionals and their setting. To date, most nursing-related studies in this area have focused on either the European or North American context. This study, instead, presents a unique insight into health promotion and health education practices in mainland China.
The differences and relationships between the paradigms of health promotion and health education have been explored in-depth elsewhere (see, e.g. Whitehead 2004, Rush et al. 2005, Runciman et al. 2006, Casey 2007, Irvine 2007). Essentially, authors agree that health education practice is traditionally grounded in disease-oriented behavioural models designed to prevent, reduce or react to an individual's risk of illness. Health promotion, on the other hand, is viewed as a much broader process, which encompasses community and population-based health, public health, primary health care, health policy and social equity, but which may contain elements of health education.
Wide-reaching international legislation and recommendations have, for many years, called for the explicit inclusion and application of health promotion in nursing and all health professional practice [Department of Health and Human Services 1991, Department of Health 1997, 1998, National Health Service Executive 1998, World Health Organisation (WHO) 2000]. Subsequently, a number of studies that measure and contrast the nature and extent of health promotion and health education activity in clinical practice, especially in hospital settings have been published (Latter et al. 1993, McBride 1994, Davis 1995, Callaghan et al. 1997, Haddock & Burrows 1997, Norton 1998, Chan & Wong 2000, Wainwright et al. 2000, Whiting 2001, Reeve et al. 2004, Cross 2005, Irvine 2005, Casey 2007). A similar level of scrutiny has occurred in nursing education (Mitchinson 1995, Ward 1997, Clark & Maben 1998, Liimatainen et al. 2001, Whitehead 2002, Sjögrén et al. 2003).
Older and more recent China-based studies reflect a growing interest in studying health promotion and health education as it relates to nursing practice (Haughey et al. 1992, Callaghan et al. 1997, Chan & Wong 2000, Hui 2002, Kwong & Kwan 2007). Being all Hong Kong-based, however, these studies may not be representative of Mainland China. This said, recent developments in mainland China have witnessed a growing interest in health promotion at a national, political level. This is illustrated in the release of two government-sponsored health promotion documents. These documents, The Chinese Development Programme for Nursing Business – 2005–2010 and A Schemed Nationwide Work Plan for Health Education and Health Promotion – 2005–2010, were released in 2005 by The Ministry of Health of China (National Development and Reform Commission). Both support claims for a national health promotion strategy based on social and community health development, and are intended to promote and initiate an effective national public health strategy. The first document specifically outlines the role and function of nurses in achieving this. Against this background, we explored the perceptions of health promotion and health education of nurses in a large Mainland Chinese hospital.
The aim of this study was to explore nurse's perceptions of health promotion and health education practice in a Mainland Chinese provincial hospital.
A Husserlian phenomenological approach was adopted (Husserl 1965), based on the work of Giorgi (1985, 1997, 2000).
A purposive sample of eight nursing students and eight senior staff nurses at a large hospital in the Shandong Province of China was selected. All participants were either currently or had recently been enrolled in pre- or post-registration education programmes with a health promotion component. The students were selected from a hospital-based nursing education centre, while the staff nurses were working on the wards of the same hospital. All were interviewed in these respective settings. The students' age range was 19–22 years and that of the nurses was 30–34 years. The average years of qualification for the nurse sample, was 11 years. All participants were female.
In-depth interviews were conducted in Mandarin Chinese in 2006 by a senior nurse and a nurse educator working at the hospital. In keeping with the Husserlian approach, interviewers attempted to put aside all personal presuppositions, assumptions and biases to obtain pure descriptions of participants' perceptions of health education and health promotion. The interviews lasted 50–120 minutes. An interview guide was used to promote a degree of consistency between interviews while, at the same time, accessing participants' perceptions. The data were digitally recorded in MP3 format and then directly e-mailed to the researchers. The data were translated from Mandarin Chinese into English and then transcribed verbatim.
The study was approved by the Shandong Provincial Hospital Ethics Committee. In China, at the time when the study was conducted, there was no requirement for written consent to be obtained. Participants were informed of the health education and health promotion nature of the study and how and where the interviews would take place. Willingness to participate was taken as consent and all participants were informed that they could withdraw from the study at any time without explanation.
Giorgi's framework was used to analyse the data. In accordance with the Husserlian (1965) approach, the researchers attempted to bracket their own perceptions and attitudes. The steps of the analysis were:
Where (NS) is used against the following participant statements, this indicates a nursing student, while (SN) indicates senior nurse. A different number was allocated each participant. Six essential themes were identified in the data and are presented here.
Most of the participants viewed the education (health education) that they offered their clients as inextricably linked to the client's level of health. This manifested at both reactive and preventative levels. The offered information generally related to exercise, nutrition and mental health-based health constructs. General preintervention, postintervention and discharge advice, relating to illness, condition, or procedure also emerged as health education. Most participants were clear as to what health education was and how it manifested itself in their practice:
My health education is disseminating health knowledge to the patient and includes lifestyle-advice such as nutrition. (SN1)
The main part of my health education is offering health care knowledge to patients about their disease while they are in hospital and preparing them to manage this when they leave. (SN2)
After an operation, I instruct patients how to recover through education on exercising, quitting smoking and abstaining from alcohol. (NS2)
I help inform patients on their disease, their diet and treatment so that they can better understand their disease and pay more attention to real life situations and change their health-related activities. (NS8)
Health education is very important. It helps me to gain better nursing skills. The key to it is to help you communicate better with patients and help them recover more quickly. (NS1)
The participants also noted when they thought that health education advice was best delivered and to who. Generally, it was stated that educational level, gender and age of clients were the main factors for perceived success of health education information:
Giving health education to the younger person is better and easier. The young person generally values their health more nowadays. For older people, they worry more about the cost. (NS1)
The lower the literacy of the patient, the less knowledge they take on. This is especially with aged patients and those that live in villages. Youth's and middle-aged people accept new knowledge easier. (NS2)
Nurse's personality and knowledge are related to how effective health education is. (SN4)
I find that mothers are more likely than fathers to accept health advice – but it does depend on the mood of the patient. (SN5)
The patient's cognitive skills and their ability to accept health education is important. For those, with poor acceptance ability, we need to persevere and persist. (NS8)
Cultural background influences the patient. The higher the cultural background, the better health education they receive. Occupation affects this as well. For example, the businessman and farmers think that disease should be cured by medicine – not by changing their behaviour. (NS7)
Both Diploma students and qualified participants stated how they attempted to practise health education on the basis of what they had been formally taught, or as part of practical supervision:
In the endocrine section, nurse teachers teach us health education once per week. (NS6)
I learnt about health education as part of my second-year study in College. (NS7)
I first heard about health education in 2000. It was as a result of a project to carry out systematic and holistic care in our hospital. Now we offer all aspects of a health guide to our patients. (SN3)
Health education is taught in theory in our College as a general introduction to the foundational nursing sciences. (NS2)
The earliest time that I recall health education was during my praxis. I think that the concept has matured since then. (SN7)
However, the participants often felt that what was taught or demonstrated was difficult to both teach and apply:
Teachers often feel too tired and the shortness of nursing staff does not help. (NS1)
We have limited time and energy for health education. Most of our time is related to treatment and basic nursing care. Lack of knowledge, stress and lack of study-time don't help. Often, when I try to give health education to patients I don't finish as I have to attend to other treatments. (SN6)
We do not get enough annual leave to help us recover and promote more health education. We need 20 days annually – where we get less than 10 days now. This would also give us more time to study. (SN5)
We have a narrow range of knowledge and little experience of health education. This might improve if there was more opportunity to dialogue between nurse leaders and ordinary nurses. (NS4)
The participants demonstrated a good understanding of health promotion as an extended activity from their hospital-based health education activities. They showed that their own activities could support their client's health in a wider capacity, once they returned to their normal social environment. This was especially so with involving the family, as well as the client, in health education interventions. The participants also acknowledged the need for determining levels of community-based support, beyond the walls of the hospital and aligning this to the notion of continuing and ‘seamless’ services:
I regularly carry out health education with my patients, which includes the reason for their disease, how to prevent further symptoms, and management of medications. This is not just to the patient – but for the family members as well. This makes it more helpful and involving the family makes the health effect better. (SN7)
On our paediatric surgical unit, it is necessary to closely involve both patient and family [parents and grand-parents]. They need lots of health information with discharge advice on on-going management of their condition and the importance of continuing follow-up care. (SN5)
When I give health advice to patients, I also try to involve their friends and family. This is mainly to advise on how to pay attention to lifestyle issues and to rectify any unhealthy habits in their social lives. The future for health education is to carry advice to family and friends on disease prevention. (NS7)
One of the clearest themes to emerge from this study was the participant's knowledge of health promotion constructs and practices. While most acknowledged that their hospital-based practices did not include health promotion interventions (instead they regularly practiced health education), they were able to articulate how they could or were applied when working in different fields, i.e. community-based practice:
Health promotion activity belongs to health education. Health promotion is a series of activities that promote overall human health. This relates to the social environment at a national level – not just at the individual level. For example, this includes environmental protection, the management of pollution and community exercise programmes. (SN6)
Health promotion is about improving the level of health of all people throughout their lives. (NS6)
Health education includes influencing the community-based environment of the patient. I think that health promotion is about advocating for people to live good and healthy lifestyles that then promote healthy communities overall. (NS4)
Some participants, however, confused the contexts of health education and health promotion. They suggested that health education was something broader than health promotion:
I think that health promotion is to promote health using health education. (SN1)
Health education includes health promotion. The meaning of health education is wider. (NS2)
As long as there is health education, there is health promotion. (SN2)
A good understanding and awareness of community-based services and interventions was revealed in the data:
I think that health promotion is about promoting good public health through community activities which promote health propaganda and health knowledge dissemination -such as Diabetes Day, health publicity leaflets, health propaganda and regular public health reports. (SN3)
I think that it is important to give more health education information via the use of media. (SN2)
Health promotion includes social community services organized by neighbourhood committees. For example, community medical treatment, vaccinations and health propaganda. I do volunteer work, organized by the Bureau of Health Office, whereby I teach health in the Spring City Square. (SN6)
Health promotion is deeper than health education. It is about promoting the whole of society to take part in and pay attention to all people's health. It is about paying attention to the social economy of communities throughout China. (SN8)
I don't do it – but I wish that I could attend community work to strengthen my sense of social responsibility. (SN1)
In an ideal situation, we would go to remote places in need and promote universal health knowledge. I attend organized charity activities, where we issue health propaganda material – especially for National Health Days. (SN3)
A theme emerged around the intention of policy and political process as a determinant of the participant's client's health status:
There are lots of health activities that I am interested in at our hospital. Our nursing department has recently finished restructuring the management system, the nursing process structure, and nursing regulations [standards]. (SN2)
The hospital could adopt a policy of training personnel for health promotion exclusively through multi-media. (NS1)
There should be more policy that supports care for disabled and sick people in society. I volunteer to visit welfare agencies and orphanages to help local children. (SN2)
A policy of sending our academic Chairs to go into the community and instruct people would be useful. (NS8)
There were several limitations with this study. With the translation of interview transcripts from one language to another, there was a risk that some points could have been misinterpreted, misrepresented or lost. Trustworthiness of the data and findings, however, was facilitated by the passing back and forth of transcripts and analysed data between the researchers and participants, for verification and validation. The use of a ‘loose’ open-question interview guide may not fit fully with a phenomenological approach. However, Wimpenny and Gass (2000) contend that such an approach may be the most appropriate where areas of nursing are yet ill-defined. This was the case for our study. The interview guide was neither rigidly adhered to nor used in any specific order. Instead, it was used to assist the natural flow of the interviews. The initial question, used for all interviews, was ‘How do you feel about your health promotion and health education practice?’ With all questions, prompts were included to elicit how participants felt about the issues discussed. They were also offered the opportunity to expand on their answers.
Our findings are comparable with reports in the national and international literature. Five previous Chinese researchers explored issues of health promotion and health education practice in China. They were, however, all Hong Kong-based, which may not represent the situation in Mainland China (Haughey et al. 1992, Callaghan et al. 1997, Chan & Wong 2000, Hui 2002, Kwong & Kwan 2007). The Haughey et al. (1992), Callaghan et al. (1997) and Hui (2002) studies were more concerned with nurses' personal health-related activities, beliefs and lifestyles, rather than the practical application of health promotion and health education. Kwong and Kwan (2007) claimed to be reporting on health promotion but, instead, dealt with health education and behavioural change. The Chan and Wong (2000) findings most closely matched our own. Areas of similarity are that the Chan and Wong study showed a positive attitude of nurses to health education and health promotion constructs, with nurses seeing a role for these. They also reported that health education and health promotion should be a visible and active part of nurse education, and that many nurses were reluctant to adopt a health promotion role due to lack of knowledge and education.
Many of our findings are similar to those of other international literature on the health promotion and health education perceptions and practices of nursing staff (Wainwright et al. 2000, Liimatainen et al. 2001, Whiting 2001, Whitehead 2002, Sjögrén et al. 2003, Reeve et al. 2004, Cross 2005, Irvine 2005, Casey 2007). The main similarities are:
One difference between our findings and those of other comparable international studies, however, is the degree to which participants conceptualized health education and health promotion as different (except in a few cases). It appears that effective education and clinical supervision supported this. Another difference is that the participants positioned acute hospital services as working alongside community health service provision. Lu et al.'s (2007) report of a recent Mainland China survey supports this. They reported an increase in job satisfaction of Chinese nurses, and saw this as a direct result of the replacement of traditional disease-centred hospital-based nursing models by a greater emphasis on primary care provision. Chan and Wong (2000) found that nurses agreed that they should be health advocates, taking a leading role in the local community. The difference between the participants in that study and those in ours, however, is the extent to which they actually engaged at this interface. In our study, there were many examples where participants actively engaged in community service at policy and practical levels, but this was mainly in a voluntary capacity. We assumed that this was influenced by the cultural norms concerning close communities and extended family roles in China. In line with other similar international health strategies (i.e. Department of Health and Human Services 1991, Department of Health 1998, WHO 2000), our findings suggest that nurses in Mainland China are also embracing national strategies for community-based population health initiatives (The Ministry of Health of China 2005a, 2005b).
Our findings highlight the value of good educational promotion of health-related concepts, but also emphasize the need for effective support and resourcing of the practical implementation of health promotion and health education in acute care settings. They also highlight the role of nurses in facilitating and supporting voluntary community-based health promotion.
This research is supported by the Department of Science & Technology 2007RKA268 Science Project, Shandong, China.
DW and YW were responsible for the study conception and design and DW, YW, JW, JZ, ZS and CX were responsible for the drafting of the manuscript. JW, JZ, YW and DW performed the data collection and data analysis. DW and YW obtained funding. DW and YW made critical revisions to the paper.
Callaghan P., Fun M.K. & Yee F.C. (1997) Hong Kong nurses' health-related behaviours: implications for nurses' role in health promotion. Journal of Advanced Nursing 25, 1276–1282. Ovid Full Text Bibliographic Links [Context Link]
Casey D. (2007) Findings from non-participant observational data concerning health promoting nursing practice in the acute hospital setting focusing on generalist non-specialist hospital-based nurses. Journal of Clinical Nursing 16, 580–592. [Context Link]
Chan F.Y.S. & Wong K.C. (2000) Health promotion in hospitals: the attitudes of health care professionals. The Hong Kong Nursing Journal 36, 7–15. [Context Link]
Clark J.M. & Maben J. (1998) Health promotion: perceptions of Project 2000 educated nurses. Health Education Research 13, 185–196. [Context Link]
Cross R. (2005) Accident and Emergency nurses' attitudes towards health promotion. Journal of Advanced Nursing 51, 474–483. Ovid Full Text Bibliographic Links [Context Link]
Davis S.M. (1995) An investigation into nurses' understanding of health education and health promotion within a neuro-rehabilitation setting. Journal of Advanced Nursing 21, 951–959. Ovid Full Text Bibliographic Links [Context Link]
Department of Health (1997) The New NHS: Modern, Dependable. The Stationery Office, London. [Context Link]
Department of Health (1998) Our Healthier Nation: A Contract for Health. The Stationery Office, London. [Context Link]
Department of Health and Human Services (1991) Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: DHSS, Publication no. [PHS] 91–50213. [Context Link]
Giorgi A. (1985) Phenomenology and Psychological Research. Duquense University Press, Pittsberg, PA, USA. [Context Link]
Giorgi A. (1997) The theory, practice, and evaluation of the phenomenological method as a qualitative research procedure. Journal of Phenomenological Psychology 28, 235–260. [Context Link]
Giorgi A. (2000) Concerning the application of phenomenology to caring research. Scandanavian Journal of Caring Sciences 141, 11–15. [Context Link]
Haddock J. & Burrows C. (1997) The role of the nurse in health promotion: an evaluation of a smoking cessation programme in surgical pre-admission clinics. Journal of Advanced Nursing 26, 1098–1110. Ovid Full Text Bibliographic Links [Context Link]
Haughey B.P., Mathewson-Kuhn M.A., Dittmar S.D. & Yow-Wu B. (1992) Health care practices of critical care nurses. Heart and Lung: The Journal of Critical Care 21, 203–208. [Context Link]
Hui W.-H.C. (2002) The health-promoting lifestyles of undergraduate nurses in Hong Kong. Journal of Professional Nursing 18, 101–111. Bibliographic Links [Context Link]
Husserl E. (1965) Phenomenology and the Crises of Philosophy (translated by Quentin Lauer), Harper & Row, New York. [Context Link]
Irvine F. (2005) Exploring district nursing competencies in health promotion: the use of the Delphi technique. Journal of Clinical Nursing 14, 965–975. Ovid Full Text Bibliographic Links [Context Link]
Irvine F. (2007) Examining the correspondence of theoretical and real interpretations of health promotion. Journal of Clinical Nursing 16, 593–602. [Context Link]
Kwong E.W-y. & Kwan A.Y-h. (2007) Participation in health-promoting behaviour: influences on community-dwelling older Chinese people. Journal of Advanced Nursing 57, 522–534. [Context Link]
Latter S., Maben J., Clark M.J. & Wilson-Barnett J. (1993) Perceptions and practice of health education and health promotion in acute ward settings. Nursing Times 89(21), 51–4. Bibliographic Links [Context Link]
Liimatainen L., Poskiparta M., Sjögrén A., Kettunen T. & Karhila P. (2001) Investigating student nurses' constructions of health promotion in nursing education. Health Education Research 16, 33–48. Bibliographic Links [Context Link]
Lu H., While A.E. & Barriball K.L. (2007) Job satisfaction and its related factors: a questionnaire survey of hospital nurses in Mainland China. International Journal of Nursing Studies 44, 547–588. [Context Link]
McBride A. (1994) Health promotion in hospitals: the attitudes, beliefs and practices of hospital nurses. Journal of Advanced Nursing 20, 92–100. Bibliographic Links [Context Link]
Mitchinson S. (1995) A review of the health promotion and health beliefs of traditional and Project 2000 student nurses. Journal of Advanced Nursing 21, 356–363. Ovid Full Text Bibliographic Links [Context Link]
National Health Service Executive (1998) A Consultation on a Strategy for Nursing, Midwifery and Health Visiting. London: Health Service Circular 1998/045. [Context Link]
Norton L. (1998) Health promotion and health education: what role should the nurse adopt in practice? Journal of Advanced Nursing 28, 1269–1275. Ovid Full Text Bibliographic Links [Context Link]
Reeve K., Byrd T. & Quill B.E. (2004) Health promotion attitudes and practices of Texas nurse practitioners. Journal of the American Academy of Nurse Practitioners 16, 125–133. [Context Link]
Runciman P., Watson H., McIntosh J. & Tolson D. (2006) Community nurse's health promotion work with older people. Journal of Advanced Nursing 55, 46–57. Ovid Full Text Bibliographic Links [Context Link]
Rush K.L., Kee C.C. & Rice M. (2005) Nurses as imperfect role models for health promotion. Western Journal of Nursing Research 27, 166–183. Bibliographic Links [Context Link]
Sjögrén A., Poskiparta M., Liimatainen L. & Kettunen T. (2003) Teachers' views on curriculum development in health promotion in two Finnish polytechnics. Nurse Education Today 23, 112–122. [Context Link]
The Ministry of Health of China (2005a) The Chinese Development Programme for Nursing Business - 2005~2010. The Ministry of Health of China, Beijing. [Context Link]
The Ministry of Health of China (2005b) A Schemed Nationwide Work Plan for Health Education and Health Promotion – 2005~2010. The Ministry of Health of China, Beijing. [Context Link]
Wainwright P., Thomas J. & Jones M. (2000) Health promotion and the role of the school nurse: a systematic review. Journal of Advanced Nursing 32, 1083–1091. Ovid Full Text Bibliographic Links [Context Link]
Ward M. (1997) Student nurses' perceptions of health promotion: a study. Nursing Standard 11(24), 34–40. Ovid Full Text Bibliographic Links [Context Link]
Whitehead D. (2002) The health promotional role of a pre-registration student cohort in the UK: a grounded-theory study. Nurse Education in Practice 2, 197–207. [Context Link]
Whitehead D. (2004) Health promotion and health education: advancing the concepts. Journal of Advanced Nursing 47, 311–320. Ovid Full Text Bibliographic Links [Context Link]
Whiting L. (2001) Health promotion: the views of children's nurses. Paediatric Nursing 13, 27–31. Bibliographic Links [Context Link]
Wimpenny P. & Gass J. (2000) Interviewing in phenomenology and grounded theory: is there a difference? Journal of Advanced Nursing 31, 1485–1492. Ovid Full Text Bibliographic Links [Context Link]
World Health Organisation (2000) Munich Declaration. Nurses and Midwives. A Force for Health. The 2nd WHO Ministerial Conference on Nursing & Midwifery in Europe. WHO, Munich. [Context Link]
Keywords: China; Giorgi; health education; health promotion; interviews; nursing practice; phenomenology
Copyright (c) 2000-2007 Ovid Technologies, Inc.Version: OvidSP_UI01.01.
No comments:
Post a Comment