Aim: To identify nurses' beliefs about health promotion and its delivery in routine care of people aged over 65 years.
Background: Regardless of age, health promotion interventions can enhance health and, in general, older people are motivated to take such preventive action. The National Service Framework for Older People sets the promotion of healthy living as a standard for UK National Health Service Trusts. However, the delivery of health promotion is ‘haphazard’; patients aged over 65 years rarely report receiving health promotion, and reports from nurses suggest they are unsure how to deliver effective health promotion.
Method: A theory-based survey of all nurses working in a department specializing in the care of people aged over 65 years, 41% of questionnaires were returned.
Results: The majority of nurses identified examples of health promotion and 88% judged health promotion to be effective and worthwhile. Three quarters of the sample viewed health promotion as part of their role and most of the respondents were confident in their ability to provide health promotion. However, the respondents also reported that health promotion was not appropriate for all their patients and considered it an increasingly difficult task as people got older. Organizational barriers to the routine provision of health promotion were identified.
Conclusion: Nurses working on wards for people aged over 65 years are mostly positive about integrating health promotion into their everyday work. However, for health promotion to be routinely implemented, all nursing staff need to feel confident in undertaking the task and believe it is worthwhile. Health promotion needs to be awarded greater importance by hospital management to ensure that it does not conflict with other work priorities. Until this happens the provision of health promotion in hospitals will remain sporadic and lack conviction.
Relevance to clinical practice: With an increasing older population nurses need to be confident and proficient at implementing health promotion to patients aged over 65 years. This survey demonstrates that nurses need more training and support to achieve this.
The growing proportion of older people in the UK population will, in the absence of preventive healthcare, increase the prevalence of chronic health problems and health services demand (Department of Health, DOH 2000). Traditionally, health promotion in the UK has been situated in primary care and seen as the responsibility of public health professionals. There has been little research into how routine practice in the NHS can include health promotion for patients aged over 65 years, this is particularly true of nurses working in hospitals. This may need to change. In a government-sponsored review of the UK National Health Service (NHS), Wanless (2004) described the NHS as a ‘National Sickness Service’. This observation echoes worldwide concerns that health-care services are reactive rather than proactive (World Health Organisation, WHO 1997). Wanless (2004, p. 10) argued that, ‘our health services must evolve from dealing with acute problems through more effective control of chronic conditions to promoting the maintenance of good health’. Wanless (2002) calls for people to take active responsibility for their health and, for this to be achieved, easy access to high quality health promotion advice has to be available. This has been recognized in government documents, for example, standard eight of The National Service Framework for Older People (NSFOP) (DoH 2001) has the aim to, ‘extend the healthy life expectancy of older people’ (p. 107) and underlines the need to provide equal access for older people to health promotion activities.
The issue today is not whether health promotion should be provided for people aged over 65 years but how effective health promotion can be incorporated into their routine care.
Nurses constitute the largest workforce in the NHS, with more than 386 000 full-time qualified nurses and nearly 300 000 HCAs (DoH 2003). The DoH (2000) has highlighted how people have close contact with nurses at key points in their lives, creating significant opportunities for delivering health promoting interventions and, since 1983, the professional bodies governing nurses in the UK have stated that health promotion, while challenging, is a fundamental part of the nurse role (United Kingdom Central Council 1983). Consequently, nurses, midwives and health visitors have a crucial role in promoting health and preventing illness. However, Macleod Clark and Maben (1998) observed that the potential for nurses to deliver health promotion was not being realized in acute ward settings and nurses, involved in health promotion for older patients, have reported a lack of effective health education strategies (Burbank et al. 2000).
Despite the call for health promotion to be implemented into routine nursing care there has been little investigation into how it can be successfully incorporated and how nurses perceive this role.
There are numerous definitions of health promotion (McBride 1994) and the most commonly used is that, ‘health promotion is the process of enabling people to increase control over and to improve their health’ (WHO, 1986). Seedhouse (2004) argues that this definition is vague and lacks precision creating an, ‘illusion of shared meaning’, whereby practitioners assume they hold a collective understanding of the term health promotion. (Seedhouse 2004) argues this is not the case and that the practice of health promotion is based on ambiguity and value judgements. This ambiguity may contribute towards the contradictory findings that are apparent in the literature examining nurses' beliefs about health promotion.
Nurses report ambivalent beliefs towards health promotion. McBride (1994) found that 95% of nurses recognized the need for the routine delivery of health promotion, 93% thought they were ideally placed to give health education and 84% believed they should be actively helping patients to stop negative health behaviours, such as smoking and overeating. However, McBride (1994) also found that 20% of hospital nurses thought that patients found health promotion boring and linked the concept of health promotion ‘preaching’. Similarly, Williams and MacIntosh (1996) found that some nurses thought health promotion could induce worry and was too detailed for some patients. These latter beliefs are especially prevalent among nurses providing care for people aged over 65 years (Pursey & Luker 1995, Young 1996).
The role of health educator may conflict with other roles nurses adopt. Taking on the role of patient advocate conceptualizes nurses as patient defenders who, first and foremost, respect patients' decisions. In this role nurses support the health and well-being of the patient, as defined by the patient, not by the healtHCAre system (Robinson & Hill 1998).
McBride (1994, p. 93) describes the provision and routine application of health promotion throughout hospitals in the NHS as of a ‘haphazard nature’. The reactive culture of acute services has led to an implicit understanding by hospital nurses that health promotion is the responsibility of primary care or specialist nurses (Robinson & Hill 1998).
Kok (1993) proposes that, if health promotion is to be effectively integrated in an organization, it has to be congruent with the underlying economic, socio-cultural and philosophical value system. Without a coherent health promotion policy nursing staff may not see health promotion as an important part of their daily practice. Health promotion has been described by nurses as an ‘extra’ that can be provided if there is time (McBride 1994, Macleod Clark & Maben 1998). In one survey of hospital nurses, 68% reported that they did not have enough time to include health promotion in their work (McBride 1994). The so-called ‘rush culture’ of hospitals reinforces the belief by hospital workers that acute settings are not an appropriate setting for health promotion; ‘nurses don't see health promotion as core work with it taking second place to work that is more concretely measurable’ (English National Board of Nurses 2000).
The majority of nurses report feeling confident about delivering health promotion and in their ability to modify patients' behaviours (Fridinger et al. 1991). Burbank et al. (2000) discuss the role of the nurse in assisting patients to modify behaviours and comment how this can be a difficult and frustrating task for nurses who are not aware of effective behavioural change strategies. Berland et al. (1995) found only 42% of hospital nurses were happy with their health promotion skills.
To investigate the beliefs of a group of nurses who specialize in the care of people aged over 65 years, towards the routine implementation of health promotion, we applied the Theory of Planned Behaviour (TPB). TPB (Ajzen 1991) is the most widely applied model of the cognitive antecedents of action (Ajzen 2001). The model (Fig. 1) suggests the most proximal determinants of behaviour are perceived behavioural control (PBC) and the intention to engage in that behaviour. Intentions are supported by PBC, attitudes (i.e. evaluations of the behaviour) and subjective norms (i.e. beliefs about others' approval of the behaviour). PBC refers to the person's appraisal of their ability to perform the behaviour and is similar to Bandura's construct of self-efficacy (Ajzen 1988, Bandura 1997, 2000). PBC enhances intention because people are more likely to intend to do things they think they can accomplish. PBC may also have a direct impact on behaviour because it reflects actual control and because greater confidence leads to enhanced effort and perseverance during performance (Bandura 1997, 2000) (see Ajzen 1991 and Conner & Sparks 2004 for detailed discussions of the TPB). Thus, according to the TPB, nurses' intentions to routinely implement health promotion and their subsequent behaviour will be dependent on a combination of these cognitions.
Figure 1 The theory of planned behaviour.
There have been few applications of the TPB to health promotion practice and very few studies examining the psychological prerequisites of health promotion among hospital nurses. McCarty et al. (2001) employed the TPB to explore nurses' attitudes towards providing smoking cessation advice and found nurses had positive attitudes towards providing advice. Berland et al. (1995), Chan and Wong (2000) and McBride (1994) explored the attitudes of nurses towards health promotion on acute adult wards and concluded that, while nurses are keen to include health promotion in their practice, barriers such as lack of knowledge, heavy workloads and lack of management support hinder routine implementation.
No studies investigating the beliefs and cognitions of healtHCAre assistants (HCA) towards health promotion were found. As the role of the HCA expands (Murray 2001) it is realistic to think that HCAs could be involved in the delivery of health promotion. HCAs have reported that advising patients is part of their job, especially when the qualified nurses did not have the time to do so (Workman 1996).
The present study used a survey to explore and map the cognitive antecedents (as proposed by the TPB) of health promotion practice among qualified nurses and HCAs working in a hospital with people aged over 65 years.
The study had three aims; firstly, to identify qualified nurses and HCAs' beliefs about health promotion, including their understanding of the term ‘health promotion’ and perceptions of the effectiveness of health promotion, particularly in relation to people aged over 65 years. Secondly, to identify qualified nurses and HCAs' perceptions of the normative context in which health promotion occurs, including their view of their roles as health promoters. Thirdly, to identify qualified nurses and HCAs' control beliefs by assessing their confidence in providing health promotion and identifying perceived barriers to the routine provision of health promotion.
All the qualified nurses and the HCAs employed in the Department of Medicine for the Elderly (DOME) of a medium-sized district general hospital in the UK were sent a questionnaire in January 2002. This method had the advantage of reaching a large number of healthcare workers without undue disruption to work of the ward. Attempts at organizing individual interviews or focus groups were unsuccessful.
A pilot questionnaire was shown to all the ward managers for comments. The questionnaire was found to be acceptable and no changes were made. All the qualified nurses and the HCAs working in the department were sent an anonymized questionnaire through the internal hospital postal system. A reminder letter and another copy of the questionnaire were sent one month later, with an apology to those who had already replied. In total 72 questionnaires were returned, a response rate of 41%. Although this is a somewhat disappointing response rate, it is not an unusual response rate for this population. For example, Williams and MacIntosh (1996) obtained a 48% response rate, Berland et al. (1995) 57% and Fridinger et al. (1991) a 26% response rate.
Table 1 shows the number of respondents and their nursing grades; the representation of grades was reflective of the department except for the under representation of the HCAs. Six respondents did not provide data on their nursing grade.
Table 1 Nursing grade of respondents
The respondents (N = 67) had specialized in nursing people aged over 65 years for a mean of 10·49 years (SD = 8·14), ranging from five months to 28 years. Just over half (55%, (N = 37) had spent over 10 years in the speciality and 45% (N = 30) under 10 years. There were no differences in the time spent working with people aged over 65 years between the nursing grades. Twenty-two respondents (31%) reported some training in health promotion, 18 of the qualified nurses reported some training and four of the HCAs.
As the survey was anonymous, details of the nurses and the HCAs who did not reply could not be established.
The questionnaire included both open-ended questions and questions with fixed response options. In populations where the relevant beliefs affecting intentions and the subsequent behaviour (here the routine delivery of health promotion by hospital nurses) are undetermined. Ajzen (2002) recommends using a series of open-ended questions designed to elicit accessible beliefs to construct a list of the most commonly held beliefs in the research population.
The questionnaire was presented in three main sections corresponding to the cognitive antecedents of motivation specified by the TPB, namely, (1) beliefs about, and evaluations of, health promotion; (2) perceived normative context for health promotion practice and (3) perceived ability to provide health promotion in routine practice.
Understanding of health promotion was explored using two open-ended questions, ‘What is your definition of health promotion?’ and, ‘What is the main aim of health promotion?’
Beliefs about the outcomes of health promotion were assessed using three questions. Firstly, respondents were asked to give an example of health promotion in hospital and then to comment on the effectiveness of health promotion (‘How effective do you think health promotion is?’). Finally, respondents were asked ‘How cost-effective do you think health promotion is?’ Perceived effectiveness and cost effectiveness were measured on a seven-point scale labelled ‘1 = extremely ineffective to 7 = extremely effective’.
Beliefs about the routine implementation of health promotion were assessed by asking; ‘Should patients have the choice to decide whether to receive health promotion advice? Please give a brief reason why or why not.’
Beliefs about the provision for people aged over 65 years were assessed by three open questions; (1) ‘What is the main aim of health promotion for people aged over 65 years?’, (2) ‘What do you think about routinely providing health promotion for people aged 65–75 years?’ and (3)‘What do you think about routinely providing health promotion for people aged over 75 years?’.
Respondents were asked to comment on health promotion as part of the nursing role using an open-ended question: ‘Do you consider health promotion to be part of your role as a nurse?’.
The appropriateness of hospitals as a setting for the delivery of health promotion was explored using two open-ended questions: ‘Do you think acute hospitals are an appropriate place for health promotion?’ and ‘Please give your reasons why or why not’.
Perceived ability to provide health promotion was measured by the question: ‘How would you rate your ability to provide health promotion?’ on a seven-point scale labelled ‘extremely good to extremely bad’. Respondents were also asked what could be done to improve the way they provide health promotion (‘What do you think could be done to improve the way you provide health promotion for patients?’) and how they would feel about being asked to provide routine health promotion (‘How would you feel if you were asked to implement a health promotion intervention for people aged over 65 years as part of your routine work?’).
Routine provision of health promotion was assessed by one question, ‘Do you routinely provide health promotion for your patients?’ on a five-point semantic scale labelled ‘always, most of the time, sometimes, hardly ever and never’.
The survey was approved by the West Sussex Local Research Committee. The questionnaire was accompanied by an information sheet with details about the survey and contact numbers for nurses or HCAs wanting more information.
Open-ended questions were analysed using thematic analysis (Morse & Field 1996). A bottom-up approach was employed to ensure that all themes were captured. The first author and a research assistant who was a qualified and practising nurse independently generated initial coding categories to describe responses for each open-ended question. These codes were compared for each question and disagreements were resolved through discussion. This resulted in an agreed coding category list for each question. For example, for the question (‘What do you think could be done to improve the way you provide health promotion for patients?’) these included responses such as, ‘more time’ and ‘available materials’. Categories were then grouped into over-arching themes. For example, the two categories identified above were amalgamated into the theme ‘resource restraints’. Once a set of themes had been agreed the two coders independently allocated each response to a theme. There was a very high level of agreement and discrepancies were resolved through discussion.
Questions measured with a likert scale were analysed using means and standard deviations. Chi-squared tests were used to compare variables analysed as proportions. Mann–Whitney tests were conducted to compare the responses of qualified and unqualified nurses.
For the majority of the results, the responses from the qualified nurses and the HCAs were not different in their content and they will be reported together as a total sample. Any results that are significantly different between the two groups will be reported separately.
Three themes were used to summarize the dominant definitions of health promotion, these were included in 109 responses provided by 67 respondents (see Table 2).
Table 2 Definitions of health promotion
In general, health promotion was seen as education about the benefits of a healthier lifestyle and about behaviours which have the potential to enhance health with 81% of responses being included in two ‘education-based’ themes. All the nursing grades contributed to each definition, although higher grade nurses were significantly more likely to define health promotion as the dissemination of techniques to change behaviour and empower people, that is, 10% of HCAs, 20% of the junior nurses but 45% of the senior nurses ([chi]2 = 5·83, d.f. = 2, P = 0·05). Of course, these numbers are small and inferences based on this result should be treated with caution.
Seventy-six per cent of respondents (n = 55) generated 70 descriptions of the main aims of health promotion (see Table 3) which were grouped into five themes, three of which accounted for 83% of responses, that is, to improve the quality of life and preserve health, to prevent disease and to educate and provide information. A further 13% of responses were categorized as concerning empowerment of the recipients of health promotion.
Table 3 The main aims of health promotion
Sixty-one examples of health promotion were recorded by 50 respondents. Eight themes emerged and are listed in Table 4. Thirty per cent of these referred to promotion of healthy eating, 26% to smoking cessation, 8% to exercise promotion and 13% provided an example of a particular health promotion technique, e.g. providing leaflets.
Table 4 Examples of health promotion
Fifty respondents commented on the effectiveness of health promotion with 88% (n = 44) judging it to be effective. Thirty-nine per cent (n = 16) justified the effectiveness of health promotion with reference to the rationale of their chosen example, e.g. ‘smoking causes cancer, stopping smoking stops cancer deaths’. Thirty-four per cent (n = 14) considered health promotion to be effective because it raised awareness of a disease, for example, ‘people can be unaware of the problems of not taking medication regularly’. Twenty-two per cent (n = 9) perceived effectiveness as providing support and tips, for example, ‘it can get through the information and helps support a person with a problem’. Lastly, 5% (n = 2) considered health promotion to be effective because it empowered people, for example, ‘it gives control’. Six respondents (12%) were more critical and did not consider health promotion to be effective, reporting effectiveness to be dependent on the individual and the relevance of the information, for example, ‘often the information is not used properly’.
respondents' (n = 58) mean rating of the effectiveness of health promotion was 4·95 (SD = 1·1) and of cost effectiveness, 5·07 (SD = 1·0) on a seven-point response scale. Overall, respondents perceived health promotion as both effective and cost-effective, indicating positive attitudes towards health promotion.
Fifty-seven per cent of respondents (n = 41) thought patients should not have the choice to decide whether they should receive health promotion, believing knowledge to be necessary for patients to take responsibility for their behaviour and, subsequently, to make informed decisions about their health. In addition, 54% (n = 22) of these 41 respondents stated that, ultimately, advice can be ignored and it is the patient's choice to follow the advice. By contrast, 21% of respondents (n = 15) thought patients should have a choice about receiving health promotion. Two-thirds of these (10 of the 15) viewed health promotion as ‘health fascism’, and the remaining five respondents thought that, given limited NHS resources, money could be better spent. Twenty-two per cent (n = 16) of respondents did not reply to this question.
When asked directly about the importance of providing routine provision of health promotion for people aged over 65 years, 75% of respondents (n = 54) acknowledged this was an important area of practice. Although more nurses thought health promotion was harder to implement in people aged over 75 years than in people between the ages of 65 and 75 years. Only 4% (n = 2) of the nurses (n = 54) that responded to the question thought it would be a difficult task with people aged between 65 and 75 years compared with 15% (n = 8) when considering people aged over 75 years.
Three quarters of respondents (n = 54) acknowledged that health promotion was part of their nursing role, 22% (n = 16) did not respond to this question (four were HCAs) and only two nurses (3%), who were both HCAs, stated that it was not part of their role. Seventy-four per cent (n = 40) of the 54 respondents who considered health promotion was part of their role gave more detailed replies; 35% of the 40 noted that health promotion was an integral part of nursing care, 25% (n = 10) considered teaching as part of the nursing role and, equally, 25% (n = 10) considered their role to prevent further illness. Fifteen per cent (n = 6) did consider health promotion as part of their role but thought that specialists are better suited to provide health promotion.
Hospitals were perceived as an appropriate place for health promotion by 63% (n = 46) of respondents. More than one reason was given by seven respondents to this question. The main reasons being that health promotion is part of holistic nursing care (65%, n = 30), that it is a nurse's duty to share their knowledge on health (35%, n = 16) and that health promotion helps prevent readmission (15%, n = 7). However, 15% (n = 11) of respondents did not consider hospital an appropriate place for health promotion. Reasons included ‘patients are too ill’ and, ‘it is too late’. In addition, 10 of these 11 believed that health promotion was of low importance, for example, ‘there are more important things’ and ‘there is not enough time’. Fifteen respondents did not reply to this question.
Respondents (n = 58) had a mean score of 4·82 (SD = 0·72) on a seven-point response scale) when rating their ability to provide health promotion. This indicates a fairly high degree of perceived self-competence. No differences were found between grades but a significant association was found between the respondent's self-reported ability to perform health promotion and how often they reported providing health promotion (rs = 0·22, P = 0·04).
Seventy per cent (n = 51) of respondents answered the question asking how they would feel about implementing routine health promotion with people aged over 65 years; 39% (n = 20) of these were positive, stating that they would implement a health promotion as part of their routine work. Four per cent (n = 2) stated they would not be happy to do so because they were stressed enough already and the remaining 57% (n = 29) respondents stated they would be happy routinely to implement an intervention on the conditions; they had more time (n = 13), were given more information on health promotion (n = 5), had appropriate training (n = 5), did not have to do additional paperwork (n = 2) and knew that there was evidence supporting the effectiveness of the health promotion (n = 2).
Finally, factors identified as potentially facilitating the routine delivery of health promotion were the availability of appropriate materials and resources, the provision of education and training, more time and evidence to demonstrate health promotion works.
Table 5 summarizes the respondents' commonly held beliefs about routinely providing health promotion. Figure 2 illustrates how often respondents' (n = 58) provided health promotion. Overall qualified nurses provide health promotion significantly more often than the HCAs (U = 200, P = 0·02).
Figure 2 The routine provision of health promotion.
Table 5 The respondents' commonly held beliefs about the routine delivery of health promotion in hospitals
Among a group of experienced qualified nurses and HCAs who have specialized in working with people aged over 65 years for an average of 10 years, we found that the routine delivery of health promotion was low with only 17% of qualified nurses and none of the HCAs reporting always providing health promotion to their patients and with only 35% of the qualified nurses and 26% of the HCAs delivering health promotion most of the time.
Nonetheless, we found positive beliefs about routine delivery of health promotion with 75% of the respondents regarding health promotion as part of their role and 63% regarding hospital as an appropriate setting for health promotion. Moreover, 88% regarded health promotion to be effective and fairly high ratings were observed for the general effectiveness and cost effectiveness of health promotion. In general, the respondents also felt confident about their ability to deliver health promotion but only a minority (39%) were willing to introduce health promotion into everyday practice. The majority of respondents identified organizational barriers that would have to be tackled before this would be a realistic possibility. Overall, these results suggest that hospital nurses and HCAs caring for older patients are able and willing to play a greater role in health promotion. However, the findings also highlight challenges that will need to be overcome before this can be achieved.
The majority of the respondents defined health promotion and its aims in the narrower terms of health education focusing the dissemination of information and disease prevention. This is consistent with previous research (Macleod Clark & Maben 1998, Whitehead 2001). The higher grade nurses in the department were more likely to define health promotion as empowerment and were more confident and likely to routinely provide health promotion, perhaps suggesting as Bandura (1977) would predict, that higher perceived ability increases the likelihood of performing a behaviour. This indicates that greater training and experience facilitate understanding and implementation of health promotion.
Although 20% of the sample saw health promotion as ‘health fascism’ the majority viewed health promotion as part of the nurse's role. Nurses considered health promotion to be effective and cost effective and could see the benefits and importance of health promotion programmes (e.g. in relation to cancer screening or prescribing prophylactic medication). This corresponds to reports that health promotion has been well received and seen as useful and interesting by doctors (Cohen et al. 1985, Dietrich et al. 1990). Yet, as in this study, the effect on everyday practice has been minimal or moderate at best (see also Cohen et al. 1985, Dietrich et al. 1990).
It is possible that greater insight into health promotion and having the same understanding of the term (see Seedhouse 2004), and construing health promotion as empowerment may help distance it from ‘preaching’ and ‘health fascism’. Thereby, facilitating nurses to fulfil their role as teachers while helping patients to remain autonomous and make their own informed decisions.
When asked about health promotion for people aged over 65 years, respondents were supportive although they also reported concerns about effectiveness in changing behaviour in this population and the ease of delivery, particularly with patients aged over 75 years. This suggests that, if standard eight of the UK National Service Framework for Older People is to be implemented, further education may be required in relation to the effectiveness of health promotion in reducing disability and health-care service usage amongst older people (see, e.g. Fries 2000, Leveille et al. 2000, Khaw et al. 2001).
Robinson and Hill (1998) identified the hospital ‘crisis’ culture as a barrier to health promotion implementation and nurses in this study endorsed this view. The majority of the respondents in this study felt competent to deliver health promotion but also believed that they could only implement health promotion on a routine basis if it had a higher priority, they had more time, more information on health promotion and appropriate training. Williams and MacIntosh (1996) found that nurses forgot to implement a health promotion intervention. This may be due to conflicting goal priorities in everyday nursing practice. Studies using prompts, such as stickers on patient notes, have been effective in reminding practitioners to implement health promotion interventions (Evans et al. 1996, Grady et al. 1997). However, Carney et al. (1992) question whether such prompts could be integrated into routine practice and have demonstrated that tackling organizational issues and removing environmental obstacles is more productive. Thus, integrating health promotion into routine practice is likely to require additional resources both to provide training and to free staff time from other work tasks.
HCAs defined health promotion more negatively (as preaching) and reported delivering it less often. If a person does not feel confident to perform a task they will be less likely to persevere or award a task the same level of importance as an action that can be achieved more easily (Bandura 1977). Therefore, additional training will be especially important if HCAs are to deliver health promotion. Hills (1998) has rightly argued for the development of the knowledge attitudes and skills and that will enable nurses to be empowering in relation to patients' health behaviours.
It is interesting that we did not find more differences between the qualified nurses and HCAs. This could be a result of the under-representation of HCAs, it could be the HCAs who responded were interested and knowledgeable about health promotion and felt able to answer the questionnaire. There may well have been marked differences between the qualified nurse and HCAs had more replied.
Our use of one hospital and our response rate caution against generalization, although our findings echo the results of previous research (e.g. McBride 1994). The length and type of questions in the questionnaire may have deterred some potential respondents because the topics explored demanded answers to be recorded in some detail. The sample could over represent nurses who are interested in health promotion and were more inclined to answer the questionnaire, so responses may be more positive than if all department nurses returned this questionnaire. Social desirability effects may also have prompted more positive answers although anonymizing the questionnaires and a covering letter asking for honest answers aimed to reduce these effects.
This study has profiled the key beliefs about health promotion held by hospital nurses who work with people aged over 65 years and identified barriers to integration of health promotion into routine nursing. There is a clear indication that most nurses in this setting are willing to integrate health promotion into their everyday work but also anticipate barriers to achieving this.
In conclusion, nurses have generally positive attitudes towards the delivery of health promotion but need further training, resources and management support to ensure health promotion is routinely delivered in the care of older patients.
In an increasing ageing population, health promotion is the key to ensuring health and social services can provide a sustainable service, it makes sense to delay or better still prevent disease, disability and dependence. Nurses in all settings and with all patient groups should be confident and proficient at implementing routine health promotion. In this study, hospital nurses' responses (nurses specializing in the care of people aged over 65 years) indicate that this is not be the case, and that nurses need further training, resources and management support.
Study design: KK; data analysis: CA and manuscript preparation: KK, CA.
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Key words: attitudes; beliefs; health promotion; hospital nurses; older people; Theory of Planned Behaviour
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