health!promotion!in!primaryhealthcare! · vii!! acknowledgements! i want to extend! my sincere...

Health Promotion in Primary Health Care Registered Nurses’ Appointments

VIRPI MAIJALA

Health Promotion in Primary Health Care Registered Nurses’ Appointments

To be presented by permission of the Faculty of Health Sciences, University of Eastern Finland for public examination in Mediteknia, Auditorium MD100, Kuopio,

on Friday, May 27th 2016, at 12 noon

Publications of the University of Eastern Finland Dissertations in Health Sciences

Number 349

Department of Nursing Science, Faculty of Health Sciences,

University of Eastern Finland Kuopio 2016

III

A-‐‑Print Oy

Tampere, 2016

Series Editors: Professor Tomi Laitinen, M.D., Ph.D.

Institute of Clinical Medicine, Clinical Physiology and Nuclear Medicine Faculty of Health Sciences

Professor Hannele Turunen, Ph.D. Department of Nursing Science

Faculty of Health Sciences

Professor Kai Kaarniranta, M.D., Ph.D. Institute of Clinical Medicine, Ophthalmology


Associate Professor (Tenure Track) Tarja Malm, Ph.D. A.I. Virtanen Institute for Molecular Sciences


Lecturer Veli-‐‑Pekka Ranta, Ph.D. (pharmacy) School of Pharmacy


Distributor: University of Eastern Finland

Kuopio Campus Library P.O.Box 1627

FI-‐‑70211 Kuopio, Finland http://www.uef.fi/kirjasto

ISBN (print): 978-‐‑952-‐‑61-‐‑2104-‐‑8 ISBN (PDF): 978-‐‑952-‐‑61-‐‑2105-‐‑5

ISSN (print): 1798-‐‑5706 ISSN (PDF): 1798-‐‑5714 ISSN-‐‑L: 1798-‐‑5706

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Author’s address: Department of Nursing Science University of Eastern Finland KUOPIO FINLAND

Supervisors: Professor Kerttu Tossavainen, Ph.D.

Department of Nursing Science University of Eastern Finland KUOPIO FINLAND Professor Hannele Turunen, Ph.D. Department of Nursing Science University of Eastern Finland KUOPIO FINLAND

Reviewers: Professor Tarja Kettunen, Ph.D. Department of Health Sciences University of Jyväskylä JYVÄSKYLÄ FINLAND

Adjunct professor Tuovi Hakulinen, Ph.D. National Institute for Health and Welfare HELSINKI FINLAND

Opponent: Professor Riitta Suhonen, Ph.D.

Department of Nursing Science University of Turku TURKU FINLAND

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Maijala, Virpi Health Promotion in Primary Health Care Registered Nurses’ Appointments University of Eastern Finland, Faculty of Health Sciences Publications of the University of Eastern Finland. Dissertations in Health Sciences. 349. 2016. 54 p. ISBN (print): 978-‐‑952-‐‑61-‐‑2104-‐‑8 ISBN (pdf): 978-‐‑952-‐‑61-‐‑2105-‐‑5 ISSN (print): 1798-‐‑5706 ISSN (pdf): 1798-‐‑5714 ISSN-‐‑L: 1798-‐‑5706 ABSTRACT Nurses play increasingly important roles in health promotion practices (HPPs) in primary health care (PHC) settings. This study aimed to: (1) synthesize the findings of past research studies (1998-‐‑2011) of health promotion in nursing and (2) identify and reach a consensus among municipal primary health care participants on the types that registered nurses’ (RNs’) appointments represent in the implementation of HPPs, the required case management competencies in RNs’ appointments in HPPs, and the elements required for success in implementation of HPPs delivered in RNs’ appointments in primary health care in Eastern Finland. The study included an integrative review (n=40) and a two-‐‑stage modified Delphi study. In round 1, semi-‐‑structured interviews were conducted among the participants (n=42, 100%) in eleven health centres in 2009. In round 2, a questionnaire survey was conducted in the same health centres in 2011 in Eastern Finland. The questionnaire was answered by 64% of those surveyed (n=56). Content analysis, concept mapping method and statistical analysis were used to analyse the data. The findings of the integrative review indicated the theoretical foundations to be health promotion orientation (based on individual perspective, empowerment, social and health policy and community orientation) or public health orientation (based on disease prevention and authoritative approach). The integrative review revealed that nurses represented different types of expertise in health promotion which were: general health promoter, patient-‐‑focused health promoter and manager of health promotion projects. The integrative review indicated health promotion competencies for nurses to consist of multidisciplinary knowledge, skill-‐‑related competence and competence with respect to attitudes. The findings of the integrative review revealed supportive factors and obstacles associated with organisational culture that influenced effective delivery of health promotion. In the Delphi study, consensus was reached on four types that RNs’ appointments represented in the implementation of HPPs: client-‐‑oriented health promoter, developer of health promotion practices, member of multi-‐‑professional teams of health promotion, and the type who showed interest towards health policy. Furthermore, a consensus was reached on the required case management competencies in HPPs for RNs’ appointments to include various abilities to work independently and collaboratively with different sectors. Finally, a consensus was reached on the required elements for the success of HPPs delivered in RNs’ appointments. These were health-‐‑promoting organisational culture, nurses’ professional growth and development, client’s approach to being healthy, and health policy. Health promotion orientation based on the holistic approach to the promotion of patients’ health seemed to guide HPPs in RNs’ appointments in PHC. RNs represented various types in the implementation of HPPs. They were found to need broad competencies of health promotion knowledge and skills. A health-‐‑promoting organisational culture emerged as significant in the implementation of the HPPs. These findings can be utilised for the development of health promotion in municipalities, primary health care and RNs’ appointments as well as when drawing up educational standards and competence requirements for health promotion. National Library of Medicine Classification: WA 590 Medical Subject Headings: Health Promotion; Nurse'ʹs Role; Professional Competence; Primary Health Care

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Maijala, Virpi Terveyden edistäminen perusterveydenhuollon sairaanhoitajien vastaanotoilla Itä-‐‑Suomen yliopisto, terveystieteiden tiedekunta Publications of the University of Eastern Finland. Dissertations in Health Sciences. 349. 2016. 54 s. ISBN (print): 978-‐‑952-‐‑61-‐‑2104-‐‑8 ISBN (pdf): 978-‐‑952-‐‑61-‐‑2105-‐‑5 ISSN (print): 1798-‐‑5706 ISSN (pdf): 1798-‐‑5714 ISSN-‐‑L: 1798-‐‑5706 TIIVISTELMÄ Sairaanhoitajilla on yhä tärkeämpi rooli terveyden edistämisen käytännössä perusterveydenhuollossa. Tämän tutkimuksen tavoitteena oli: (1) yhdistää aikaisemmat tutkimustulokset (1998–2011) terveyden edistämisestä hoitotyössä sekä (2) tunnistaa ja saavuttaa kunnallisen perusterveydenhuollon osallistujien yksimielisyys tyypeistä, joita sairaanhoitajien vastaanotot edustavat terveyden edistämisen käytäntöjen toteuttamisessa, vaadittavista asiakasvastaavatoiminnan osaamisalueista sairaanhoitajien vastaanotoilla terveyden edistämisen käytännössä ja tarvittavista perusedellytyksistä terveyden edistämisen käytännön toteuttamiselle sairaanhoitajavastaanotoilla perusterveydenhuollossa Itä-‐‑Suomessa. Tutkimus sisälsi integroidun katsauksen (n=40) ja kaksivaiheiden mukaillun Delphi-‐‑tutkimuksen. Ensimmäisellä kierroksella puolistrukturoidut haastattelut toteutettiin kaikkien osallistujien (n=42) keskuudessa 11 terveyskeskuksessa vuoden 2009 aikana. Toisella kierroksella kyselytutkimus toteutettiin samoissa terveyskeskuksissa vuoden 2011 aikana Itä-‐‑Suomessa. Kyselyyn vastasi 64 % tutkituista (n=56). Aineiston analysointiin käytettiin sisällön analyysiä, käsitekarttamenetelmää ja tilastollisia analyysejä. Integroidun katsauksen tulokset osoittivat terveyden edistämisen teoreettisen perustan olevan joko terveyden edistämiseen suuntautuminen (pohjautuen yksilölähtöisyyteen, voimavaralähtöisyyteen, sosiaali-‐‑ ja terveyspolitiikkaan ja yhteisölähtöisyyteen) tai kansanterveyteen suuntautuminen (pohjautuen sairauksien ennaltaehkäisyyn ja auktoritatiivinen lähestymistapaan). Integroitu katsaus paljasti sairaanhoitajien edustavan terveyden edistämisessä asiantuntijuuksia, joita olivat seuraavat: yleinen terveyden edistäjä, potilaskeskeinen terveyden edistäjä ja terveyden edistämisen projektien johtaja. Integroidun katsauksen tuloksista ilmeni sairaanhoitajien terveyden edistämisen osaamisalueiden koostuvan monitieteisestä tietoperustasta, taidollisesta osaamisesta, asenteellisesta osaamisesta ja persoonallisista ominaisuuksista. Integroidun katsauksen tuloksissa tuli ilmi tukevia ja estäviä tekijöitä, jotka liittyivät organisaatiokulttuuriin ja jotka vaikuttivat tehokkaaseen terveyden edistämisen toteuttamiseen. Delphi-‐‑tutkimuksessa saavutettiin yksimielisyys neljästä terveyden edistäjä tyypistä, joita sairaanhoitajien vastaanotot edustivat toteuttaessaan terveyden edistämisen käytäntöjä: asiakaslähtöinen terveyden edistäjä, terveyden edistämisen käytäntöjen kehittäjä, terveyden edistämisen moniammatillisten tiimien jäsen sekä tyyppi, joka ilmaisi kiinnostusta terveyspolitiikkaa kohtaan. Lisäksi saavutettiin yksimielisyys sairaanhoitajien vastaanotoilla vaadittavista asiakasvastaavatoiminnan osaamisalueista, jotka sisälsivät erilaisia kykyjä työskennellä itsenäisesti ja yhteistyössä eri sektoreiden kanssa. Lopuksi saavutettiin yksimielisyys vaadittavista perusedellytyksistä terveyden edistämisen käytännön onnistumiselle sairaanhoitajien vastaanotolla toteutettuna. Näitä olivat terveyttä edistävä organisaatiokulttuuri, sairaanhoitajan terveysorientaatio ja kehittyminen, asiakkaiden lähestymistapa terveenä olemiseen sekä terveyspolitiikka. Terveyden edistämiseen suuntautuminen, joka pohjautui kokonaisvaltaiseen lähestymistapaan edistää potilaiden terveyttä, näytti ohjaavan terveyden edistämisen käytäntöä perusterveydenhuolloin sairaanhoitajien vastaanotoilla. Sairaanhoitajat edustivat erilaisia tyyppejä toteuttaessaan terveyden edistämisen käytäntöjä. He tarvitsevat monipuolista tiedollista ja taidollista terveyden edistämisen osaamista. Terveyttä edistävä organisaatiokulttuuri paljastui merkittävimmäksi terveyden edistämisen käytännön toteutumisen kannalta. Näitä tuloksia voidaan hyödyntää kehitettäessä terveyden edistämistä kunnissa, perusterveydenhuollossa ja sairaanhoitajien vastaanotoilla sekä luotaessa koulutuksellisia standardeja ja pätevyysvaatimuksia terveyden edistämiselle.

Luokitus: WA 590 Yleinen suomalainen asiasanasto: terveyden edistäminen; hoitotyö; perusterveydenhuolto; osaaminen

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Acknowledgements

I want to extend my sincere thanks to everyone who has contributed to my study, supported me through this process and helped make it happen. This study focused on health promotion in RNs’ appointments in the primary health care setting in Eastern Finland and was carried out at the Department of Nursing Science in the University of Eastern Finland. I express my deepest acknowledgements to my principal supervisor, Professor Kerttu Tossavainen, Ph.D., for her expertise, guidance and support throughout the study. I am also very grateful to my second supervisor, Professor Hannele Turunen, Ph.D., for her valuable advice and positive encouragement throughout my dissertation. I warmly thank the participants of this study. The visits to primary health care centres included in this study were one of the most memorable experiences during this study process. It was empowering to share your views related to my research topic. I warmly thank the official reviewers, Tarja Kettunen, Ph.D., and Tuovi Hakulinen, Ph.D., for their valuable questions and comments. I also want to express my warmest thanks to Professor Riitta Suhonen, Ph.D., for accepting the request to act as my opponent. I want to deeply thank my close friend Kaisa Haatainen for many interesting discussions and for her support during this study. Your friendship has been the bridge over trouble wather. Additionally, I warmly thank my colleagues Hilkka Majasaari and Hanna-‐‑Leena Melender for their respectful and encouraging comments during the study process. I warmly thank Anna Vuolteenaho for proofreading of my dissertation. I would like to thank my work organisation, Seinäjoki University of Applied Sciences, for providing time and flexible working conditions and showing an interest toward my thesis. My loving thanks belong to my family and the people closest to me who have helped and supported me in many ways during these years. I am grateful for all the support and understanding to my parents Pekka and Kyllikki Kemppainen. You have always encouraged me to make my dreams come true. I am also grateful to my sister Marjut and her husband Jarkko for all the support they have given me during these years. I also want to say my loving thanks to my dear husband Jaakko. Your positive support and understanding towards my thesis have been invaluable. Thank you for teaching me patience! I also warmly thank Pekka and Marja Maijala for all the encouragement and positive comments during these last couple of years. I am grateful to organisations that have financially supported this study: a specific grants from The Finnish Foundation for Nurse Education, The Finnish Nurses Association, Kuopio University Hospital, The Finnish Association of Nursing Research, and Seinäjoki University of Applied Sciences. In Tampere, Ratinanranta 2015 Virpi Maijala

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List of the original publications

This dissertation is based on the following original publications:

I Kemppainen V, Tossavainen K and Turunen H. Nurses’ roles in health promotion: an integrative review. Health Promotion International 28(4): 490-‐‑501, 2013.

II Maijala V, Tossavainen K, and Turunen H. Primary health care registered nurses’ types in implementation of health promotion practices. Primary Health Care Research & Development, doi: 10.1017/S1463423615000547 2015.

III Maijala V, Tossavainen K, and Turunen H. Identifying nurse practitioners’ required case management competencies in health promotion practice in municipal public primary health care. A two-‐‑stage modified Delphi study. Journal of Clinical Nursing 24(17-‐‑18): 2554-‐‑2561, 2015.

IV Maijala V, Tossavainen K, and Turunen H. Health promotion practices delivered by primary health care nurses: elements for success in Finland. Applied Nursing Research 30: 45-‐‑51, 2016.

The publications were adapted with the permission of the copyright owners.

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Contents

1 INTRODUCTION .............................................................................. 1

2 FRAMEWORK FOR HEALTH PROMOTION IN PRIMARY HEALTH CARE…………. ..................................................................... 3 2.1 Health policy basis for health promotion ...................................... 3 2.2 Health promotion, health promotion practices and primary health care ................................................................................. 4 2.3 Health promotion practices delivered in nursing ........................ 5

2.3.1 Registered nurses in health promotion practices ............. 5 2.3.2 Health promotion competencies in nursing ...................... 7 2.3.3 Case management competencies in nursing ..................... 9 2.3.4 Summary of knowledge basis of the study ....................... 10

3 AIMS OF THE STUDY AND STUDY QUESTIONS .................. 12 4 METHODS AND DATA ................................................................... 13 4.1 Integrative review (Original publication I) .................................. 13

4.1.1 The integrative review method and data ........................... 14 4.1.2 Data analysis .......................................................................... 16

4.2 Two-‐‑stage modified Delphi study (Original publication II-‐‑IV) 16 4.2.1 The Delphi method ............................................................... 16 4.2.2 Participants of the study ....................................................... 17 4.2.3 Qualitative data collection ................................................... 18 4.2.4 Qualitative data analysis ...................................................... 19 4.2.5 Quantitative data collection and analysis .......................... 21

5 FINDINGS ........................................................................................... 22 5.1 Theoretical basis for health promotion in nursing (Original publications I-‐‑III) ................................................................... 22 5.2 Registered nurse types as health promoters (Original publications (I-‐‑II) ................................................................... 23 5.3 Required competencies for registered nurses in health promotion practices (Original publications (I-‐‑III) ............. 25 5.4 Elements influencing the implementation of health promotion practices in nursing (Original publications I-‐‑IV) 27 5.5 Summary of the study findings ...................................................... 30 5.6 Ethical considerations of the study ................................................ 32

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6 DISCUSSION ...................................................................................... 33 6.1 Discussion of the findings ............................................................... 33 6.1.1 Health promotion orientation as theoretical framework ... 33 6.1.2 Registered nurse types in implementation of health promotion practices in primary health care ...................................................... 34 6.1.3 Competencies of health promotion for registered nurses'ʹ appointments in health promotion practices in primary health care 35 6.1.4 Elements required for success of implementation of health promotion practices in primary health care registered nurses'ʹ appointments ........................................................................ 36 6.2 Trustworthiness of the study ........................................................... 39

6.2.1 Integrative review .................................................................. 39 6.2.2 Two-‐‑stage modified Delphi study ...................................... 39

7 CONCLUSIONS .................................................................................. 41 8 REFERENCES ...................................................................................... 44 APPENDICES

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Abbreviations

CM Case management

CompHP Core competencies framework for health promotion

EU European Union

HPPs Health promotion practices

ICN The International Council of Nurses

NP Nurse practitioner

PHC Primary health care

RN Registered nurse

SOTE Sosiaali-‐‑ ja terveydenhuollon palvelurakenneuudistus

WHO World Health Organisation

1 Introduction

Facing the challenge of ageing populations and a rising prevalence of chronic conditions, health promotion is an essential strategy for the reduction of population health disparities in primary health care (PHC) in Finland (The Health Care Act 1326/2010). To meet the growing needs of health promotion practices (HPPs) of populations, nurses have been recognised to have a growing role in health-‐‑promotive care (Burgess et al. 2011, Sangster-‐‑Gormley et al. 2011, Lowe et al. 2012). This study targets registered nurses’ (RNs’) appointments in HPPs in PHC. Health promotion has evolved towards the achievement of health equity, health as a human right and political priority by taking actions based on the social determinants of health (World Health Organisation 2013). The HPPs are actions based on commitment to values such as respect for health as a human right, ensuring that health promotion actions are beneficial, and seeking the best available evidence needed to implement effective policies and programmes that influence public health (WHO 2013). As public health has become a key issue for governments in many countries, for example in the European Union (EU), there has been concern about population health disparities related to life expectancy. Therefore, the EU’s health strategy “Together for Health” and the EU Framework Programme for Research and Innovation (2014) emphasises promoting health, preventing diseases and fostering supportive environments for healthy lifestyles, taking into account the ‘health in all policies’ principle (European Union 2014). In Finland, we are attempting to be prepared for the health needs of the population, and the renewed health care law (The Health Care Act 1326/2010) emphasises national health promotion and a reduction in disparities in the health of its people. PHC is provided by local authorities and covers public health services, health promotion, and any related provision of health counselling and health checks (The Health Care Act 1326/2010, National Institute for Health and Welfare 2013). Recently, social welfare and health care services have been under development. It is suggested that in the future, health services are arranged close to the clients, and a health promotion approach should guide the development of health in PHC settings (The Health Care Act 1326/2010, Ministry of Social Affairs and Health 2015). However, health promotion is particularly challenging in Eastern Finnish provinces (Northern Karelia, Northern Savo and Kainuu), where around 20% of the population is older than 65 and long-‐‑term conditions, such as mental health problems, obesity, smoking and alcohol consumption, are more common than elsewhere in Finland (Organisation for Economic Co-‐‑operation and Development 2012, Eurostat 2014a; 2014b). Nurses in advanced practices have become a significant feature in improving health-‐‑promotive care in PHC settings (Donald et al. 2013). In the Finnish context, RNs are authorised by the National Supervisory Authority for Welfare and Health (Valvira) and they are able to receive clients supported by doctor’s consultation or in collaboration with a doctor in specialised care and primary health care settings (Delamaire & Lafortune 2010, National Institute for Health and Welfare 2013).

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In clinical nursing science, there has recently been a lot of interest towards nurses in advanced practices, for example, their scope of practice and competencies in nursing (e.g. Duffield et al. 2009, Jokiniemi et al. 2012, Gardner et al. 2013, Sastre-‐‑Fullana et al. 2014). This study examines HPPs delivered in nursing as there is a need to clarify the nature of health-‐‑promotive care (Goodman et al. 2011, Keleher & Parker 2013). Nurses have been found to provide primary prevention such as educating, teaching and counselling on healthy nutrition, as well as secondary prevention, such as screening blood pressure (Berry 2009, Gardner et al. 2010, Jarl et al. 2014, Leach & Burton Shepherd 2015). In Finland, nurses have previously been found to engage in tertiary preventive care and follow-‐‑up of clients with chronic conditions within many special areas such as cardiovascular diseases, diabetes, chronic pain, and mental health care (Fagerström 2009). Nevertheless, both experience and research have found several issues that challenge HPPs delivered by nurses. For example, nurses’ capacity to implement HPPs is affected by organisational factors such as positive health culture including wellness planning, workplace milieu, development of organisation members and appreciation on the part of health care organisation managers towards health promotion (Barrett et al. 2007, Johansson et al. 2010). On the other hand, health promotion training has been found to increase nurses’ motivation to implement these activities into nursing (Brobeck et al. 2013), as well as their own health and well-‐‑being (Roelen et al. 2013). Moreover, clients’ commitment to healthy lifestyle, their motivation for self care, and community resources, such as availability of preventive services, have also been found to enhance the success of health promotion (Badertscher et al. 2012, Findholt et al. 2013). This dissertation summarises the findings of four original publications (I-‐‑IV). Firstly, findings of previous research regarding health promotion in nursing (Original publication I) were synthesised. Secondly, a consensus was identified and reached among municipal primary health care participants for types that RNs’ appointments represent in implementation of HPPs, the required case management (CM) competencies in HPPs for RNs’ appointments, and the elements influencing successful implementation of HPPs delivered in RNs’ appointments in PHC in Eastern Finland.

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2 Framework for Health Promotion in Primary Health

Care 2.1 HEALTH POLICY BASIS FOR HEALTH PROMOTION

Health promotion and prevention is an essential strategy for reducing health disparities of populations. The World Health Organisation (WHO) has for decades guided a strategic programming of health promotion based on following Milestones, such as: Advocacy and enabling (WHO 1986), healthy public policy (WHO 1988), supportive environments for health (WHO 1991), collaboration, increasing capacity and empowerment (WHO 1997), bridging the equity gap (WHO 2000), and Health in All Policies (WHO 2013). In the EU, there has been concern about population health disparities related to life expectancy, which is strongly influenced by factors such as employment, income, level of education and ethnicity. A recent survey revealed that Europe has the highest rates of alcohol consumption and tobacco smoking in the world (WHO 2015). Additionally, population in the EU region is ageing, with the proportion of those 65 years or older increasing from 18.2% at the start of 2013 to 28.1% by the year 2050, while the proportion of working-‐‑age population will decrease from 66.2% to 56.9% (Eurostat 2014b). Therefore, EU’s health policy attention has increasingly focused on the quality of life. Healthy life years provide a measure of the number of years that a person may be expected to live in a healthy condition (defined by the absence of limitations in functioning/disability). EU’s health strategy "ʺTogether for Health"ʺ and the EU Framework Programme for Research and Innovation (2014) highlight promoting health, preventing diseases and fostering supportive environments for healthy lifestyles, taking into account the 'ʹhealth in all policies'ʹ principle (European Union 2014). It emphasises actions concentrating on protecting people from health threats and diseases, promotion of healthy lifestyle choices, workplace health and safety, and taking into account the 'ʹhealth in all policies'ʹ principle (European Union 2014). In Finland, the roots of health policy go back to the 1970s when the first public health law entered into force. Today, in line with the EU’s health strategy, the government guides and supports health promotion by means of legislation, action programmes and recommendations (National Institute for Health and Welfare, 2013). The goal is to promote the welfare and health of the population as a whole. Health care legislation emphasises the importance of maintaining and improving the health and quality of life of the whole population, preventing illnesses and health problems, as well as the reduction of health inequalities between population groups (The Health Care Act 1326/2010). Health care services have been the subject of great changes throughout the 2000s. The goal of the on-‐‑going social welfare and health care reform known as “SOTE” is to improve the availability of health services and curb the rise of social and health care costs. The proposed SOTE draft law suggests that the structure of social welfare and health care services will be financed by the government while services will be managed by community-‐‑based autonomous regions. According to the Government Programme (2015) there will be five to fifteen social welfare and health care or SOTE areas.

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2.2 HEALTH PROMOTION, HEALTH PROMOTION PRACTICES AND PRIMARY HEALTH CARE Health promotion Health promotion is advocated by the WHO in various settings by recognising that people live in complex social, cultural economic and political environments worldwide (WHO 1986). The Ottawa Charter for health promotion describes health as “a resource for everyday life” and health promotion as a social and political process that enables individuals “to increase control over determinants of health in order to achieve health and quality of life” (WHO 1986). Since then a definition of health promotion has been developed to emphasise empowerment of communities, community-‐‑based practice of health promotion, community participation and health promotion practice based on social and health policies (Baisch 2009). The focus has moved from individual behaviour towards a wide range of social and environmental interventions (WHO 2012). In this study, health promotion is defined as “the process of enabling people to increase control over and to improve their health” and achievement of health equity, health as a human right and political priority, and taking into account that health and health promotion are defined by factors outside the health care sector and as part of public health thinking (WHO 1986, 2013, Van den Broucke 2013). Additionally, health promotion highlights a holistic view of health that focuses on respect, a collective approach and the common good of the whole population instead of individual health only (Baisch 2009, Povlsen & Borup 2011). Health promotion practices Health promotion practices (HPPs) are guided by ethical values that are defined by the Ottawa Charter (WHO 1986). Additionally, HPPs in nursing should be based on the recommendations in, for example, the World Health Organisation’s (WHO) charters and declarations, and on directives and guidance from professional and governmental organisations. The theoretical basis that guided nurses’ HPPs included empowerment that was related to collaboration with individuals, groups and communities (Irvine, 2007, Piper 2008, Richard et al. 2010). Furthermore, a holistic approach as theoretical basis concentrated on activities such as helping individuals or families to make health decisions or supporting people in their engagement with health promotion activities (Chambers & Thompson 2009, Samarasinghe et al. 2010, Povlsen & Borop 2011). HPPs are involved in primary prevention aimed to reduce risk factors before initial occurrence of disease; secondary prevention allows early detection and treatment of existing diseases, while tertiary prevention decreases the consequences of a disease once established (WHO 2005). In this study, HPPs are defined as actions that are based on empowerment and a holistic approach including collaboration with individuals, groups and communities (Baisch 2009, Povlsen & Borop 2011). Additionally, HPPs are based on commitment to values such as respect for health as a human right, ensuring that health promotion actions are beneficial and cause no harm, as well as seeking the best available evidence needed to implement effective policies and programmes that influence public health (WHO 2013).

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Primary health care Primary health care (PHC) is identified as the first level of contact of individuals, families, and communities with the national health care system, bringing health care as close as possible to where people live and work, constituting the first elements of a continuing health care process (WHO 1978). Public health is a key vision in primary health care; according to the Finnish Constitution, in Finland, public authorities must offer all citizens adequate social, medical and health services and promote the health of the population. Today, the Finnish social and welfare system is founded on government-‐‑subsidised services, and health care services are divided into primary health care and specialised medical care. In the on-‐‑going development work of health services, the proposed SOTE areas will provide the services in their area or may use private or third sector service providers (Ministry of Social Affairs and Health 2015). Finland has approximately 160 primary health centres which are operated by local authorities in municipalities. These health centres are responsible for providing health promotion in communities (National Institute for Health and Welfare 2013). In this study, primary health care is defined by characteristics including accessibility, availability and affordability of services as a first point of contact with care and health promotion (WHO 2012). This study was conducted in health centres that represent citizens’ first point of contact with primary health care services and are responsible for health promotion practices and preventive health care services such as health checks, screening and follow-‐‑up (National Institute for Health and Welfare 2013). 2.3 HEALTH PROMOTION PRACTICES DELIVERED IN NURSING 2.3.1 Registered nurses in health promotion practices In Finland, registered nurses (RNs) are educated in a Bachelor degree programme of 3.5 years (210 ECTS), and training is offered at Universities of Applied Sciences. During the first three years (180 ECTS), nursing students are required to achieve minimum qualifications based on the Professional Qualifications Directive (EU/55/2013), while during the last six months (30 ECTS) they expand and deepen their professional knowledge and skills. The RN is a protected title based on legislation (e.g. Degree on Health Care Professionals 554/1994, Act on Health Care Professionals 559/1994), and they are authorised by the National Supervisory Authority for Welfare and Health (Valvira). The Universities of Applied Sciences are responsible for educating health care professionals to meet the changing needs of population health, development of social welfare and health care services, and health policy (University of Applied Sciences Act 932/2014, Health Care Act 1326/2010, Ministry of Social Affairs and Health 2012, 2015). The RNs can develop their knowledge and skills through additional education that is offered in three steps: 1) specialising in nursing (30 to 60 ECTS, with training offered at Universities of Applied Sciences), 2) Master’s degree (210+90/300 ECTS, with training offered at Universities and at Universities of Applied Sciences), and 3) doctorate level of education, with training offered at Universities (Ministry of Social Affairs and Health 2012).

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Internationally, RNs’ expanding roles in health care have lead to development of nurses’ advanced practices that were first established as nurse practitioners (NP) in the United States more than 50 years ago to facilitate the delivery of primary health care services in community settings (Gardner et al. 2010). Since then, nurses’ advanced practice roles have been implemented in many countries in a variety of nursing settings (e.g. Burgess et al. 2011, Lowe et al. 2012, Donald et al. 2013). Nurses’ advanced practices have been found to provide a set of services that might otherwise be performed by doctors; for example, being the first contact for people with minor illness, providing routine follow-‐‑up of patients with chronic conditions, prescribing drugs or ordering diagnostic tests (Delamaire & Lafortune 2010). The International Council of Nurses (ICN) has defined advanced practices as roles of registered nurses (RNs) who have acquired expert knowledge base, complex decision-‐‑making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice (ICN 2014). Furthermore, these nurses have been described as follows: they are RNs with additional education and training in nursing areas such as cardiovascular nursing or diabetes preventive care, who have professional autonomy, treat clients in acute and primary care settings, and who have abilities to apply interventions such as disease prevention and health education and counselling in nursing (e.g. Canadian Nurses Association 2009, Lindblad et al. 2010, Royal College of Nursing 2012, American Association of Nurse Practitioners 2013, Nursing and Midwifery Board of Australia 2013, Irish Practice Nurses Association 2014). They have also been found to deliver HPPs such as counselling on healthy nutrition and health education to prevent disease processes, as well as secondary prevention, by doing examinations such as screening blood pressure to prevent disease complications (Berry 2009, Jarl et al. 2014; Leach & Burton Shepherd 2015). However, this development has also led to a situation where educational and competency requirements, and the scope of practice vary greatly in different countries (Delamaire & Lafortune 2010, Sastre-‐‑Fullana et al. 2014). A summary of definitions for nurses’ advanced practices in different countries is given in Appendix 1. (See Appendix 1). For the target group of this dissertation, primary health care RNs’ appointments (the term “RNs’ appointments” is used later), the following terms have been used in this study: “RNs who receive clients” in (Original publications II and IV) and “nurse practitioner” in (Original publication III). In Finland, RNs’ advanced practices were introduced in the 2000s and have been described according to local and organisational-‐‑based guidelines both in primary health care and specialised care (Delamaire & Lafortune 2010). In early 2010, the government proposed legislation to allow RNs to prescribe a limited number of drugs (1089/2010). RNs’ appointments are located in health centres, they have professional autonomy, they receive clients supported by doctor’s consultation or in collaboration with a doctor, and have abilities to apply interventions, such as disease prevention and health education and counselling, for different client groups (Fagerström 2009, Delamaire & Lafortune 2010). Their scope of practice has the same characteristics as NPs in many countries (see Appendix 1). On the other hand, RNs’ appointments share similarities with case managers whose work is based on a client-‐‑centred model to support clients’ self-‐‑care by education and counselling as well as coordinating the care of chronically ill patients and community-‐‑based health promotion work (Wilson et al. 2012). Although there are no national education programmes or protected titles for RNs’ appointments in Finland, they are recommended to have at least five years’ working

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experience in PHC and additional education (30 ECTS) in nursing. (Muurinen & Mäntyranta 2011). 2.3.2 Health promotion competencies in nursing As a result of the development of holistic health promotion orientation, a broader view of health and community-‐‑based participation calls for nurses to have multidisciplinary knowledge, skills and attitudes of health promotion (Battel-‐‑Kirk et al. 2009). The concept of competence in nursing has been defined by several authors. One of the first definitions was given by Gonczi (1994) who described competence as follows: as task-‐‑based or behaviourist, as general attributes such as knowledge, skills, values and attributes, which are needed for intelligent performance. Traditionally, nurses’ health promotion competencies are described as consisting of themes related to knowledge, skills, and attitudes (Irvine 2005). Core competencies of health promotion in nursing are identified and defined according to the challenges of public health, such as health-‐‑related needs of the ageing population (Battel-‐‑Kirk et al. 2009). In PHC, nurses were suggested to have competencies of health promotion such as health promotion interventions, applying health education knowledge in nursing, and coordinating health educational actions in the health unit (Witt & Puntel de Almeida 2008). In this study, Health promotion competencies are defined as knowledge and skills according to CompHP project by Dempsey et al. (2011) and Speller et al. (2012). In CompHP project core competencies framework for health promotion were defined as follows: 1) assessment (e.g. knowledge of assessment methods and skills to assess health); 2) planning (e.g. knowledge of effectiveness of current health promotion planning models and skills to use those models); 3) implementation (e.g. knowledge of theory and practice of programme implementation and skills to use participatory implementation processes); 4) evaluation of research (e.g. knowledge of different qualitative and quantitative models of evaluation and skills to use research methods); 5) communication (e.g. knowledge of application of information technology and skills to verbal and non-‐‑verbal communication); 6) advocate for health (e.g. knowledge of determinants of health and skills to use advocacy techniques); 7) collaborative working (e.g. knowledge of negotiation, teamwork and network and skills to work collaboratively with groups and communities); 8) leadership (e.g. knowledge of effective leadership and skills to motivate individuals and groups); and 6) enable change (e.g. knowledge of health promotion approaches and skills to work with individuals and groups). A summary of definition of health promotion competencies in this study is presented in Table 1. (See Table 1).

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Table 1. Summary of definition of health promotion competencies in this study Health promotion Description of the contents Examples for knowledge and skills competency of the competency (Speller et al. 2012) areas in nursing (Dempsey et al. 2011) Assessment Conduct assessment of needs and assets Knowledge of assessment

in partnership with stakeholders, in the methods/processes and evidence- context of the political, economic, social, based health promotion actions. cultural, environmental, behavioural and Skills to health assessment, biological determinants that promote skills to apply qualitative and or compromise health. quantitative research methods.

Planning Develop measurable health promotion Knowledge of effectiveness of

goals and objectives based on current health promotion planning assessment of needs and assets in models and theories. partnership with stakeholders. Skills to use of health promotion planning models and project tools.

Implementation Implement effective and efficient, Knowledge of theory and practice

culturally sensitive, and ethical health of programme implementation and promotion action in partnership understanding cultural diversity. with stakeholders. Skills to use of participatory implementation processes

Evaluation and research Use appropriate evaluation and Knowledge of different models of

research methods in partnership with evaluation (qualitative/ stakeholders to determine the reach, quantitative). Skills to use impact and effectiveness of research methods and tools as well health promotion action. as write research reports.

Communication Communicate health promotion action Knowledge of application of

effectively, using appropriate techniques information technology and health and technologies for diverse audiences. literacy. Skills to verbal/nonverbal

communication and use of information technology.

Advocate for health Advocate with/on behalf of individuals, Knowledge of determinants of

communities and organisations to health, techniques of advocacy, improve health and well-being and build knowledge of strategies and capacity for health promotion action. policies. Skills to use the advocacy techniques, ability to facilitate community development.

Collaborative Work collaboratively across disciplines, Knowledge of negotiation, working sectors and partners to enhance teamwork and networking. the impact and sustainability of Skills to work collaboratively

the health promotion actions. with groups and communities.

Leadership Contribute to the development of Knowledge of theory of effective the shared vision and strategic direction leadership and strategic for health promotion action. development. Skills to motivate

individuals and groups. Enable change Enable individuals, groups, communities Knowledge of health promotion

and organisations to build capacity for approaches, behavioural change health promotion action to improve techniques and interventions. health and reduce health inequities. Skills to work with individuals and groups as well as ability for

collaborative working.

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2.3.3 Case management competencies in nursing In order to ensure positive patient outcomes case management (CM) has been found to play a key role in client-‐‑centred care in nursing (Owen 2011). CM was established in social work in the early 1980s and has later been increasingly used in healthcare (Gray & White 2012). It is based on the assumption that patients with complex health problems and high-‐‑cost medical conditions need assistance in using the health care system effectively and appropriately (Finkelman 2011, Gray & White 2012). CM is used and defined in many different settings of nursing. For example, the Case Management Society of America (CMSA 2015) defines case management as “a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality cost-‐‑effective outcomes”. In Finland, CM has been applied in various client groups with long-‐‑term conditions, such as diabetes and cardiovascular diseases (Muurinen & Mäntyranta 2011), and nurses have coordinated care of these client groups in collaboration with general practitioners and other health care professionals (Kanste 2010). In this study, CM is defined through case management competencies in nursing, applying the definition by Finkelman (2011, p. 34-‐‑41), who has described these as follows: 1) Providing patient-‐‑centred care (e.g. respecting patients’ different values, preventing diseases and promoting healthy lifestyle) 2) Critical thinking (e.g. outcome-‐‑focused thinking that requires careful identification of key health needs); 3) Evidence-‐‑based practice (e.g. integrating best research with clinical expertise); 4) Collaboration (e.g. teamwork skills to work together with all health care professionals involved in a client’s care); 5) Coordination (e.g. recognition of client’s individual health needs and the resources that are available to meet these needs); 6) Communication (e.g. the ability to transmit information on different levels, such as from individual to individual, in small and larger teams as well as between health care organisations); 7) Negotiation (e.g. the ability to communicate when people or organisations disagree or have opposite views about a problem or solution); 8) Leadership (e.g. the ability to ensure that their work role and responsibilities are recognised in their organisation), 9) Delegation (is important in care coordination, and nurses need to be familiar with the process of delegation); 10) Evaluation (e.g. the ability to assess individual health needs as well as evaluate and give feedback on outcomes of client’s health promotive care); and 11) Entrepreneurship (e.g. awareness of changes in health care environment and willingness to communicate and find opportunities to new roles for nurses). A summary of the definition of case management competencies used in this study is presented in Figure 1. (See Figure 1). As nurses have become a significant part in improving health-‐‑promotive care in PHC, several issues have emerged that influence the delivery of HPPs in nursing. In this study, these supportive aspects of HPPs in nursing are defined through three factors: 1) Organisational factors such as positive health culture including wellness planning, workplace milieu, organisation member development and health care organisation’s managers’ appreciation toward health promotion affect nurses’ capacity to implement health promotion practices (Barrett et al. 2007, Johansson et al. 2010). 2) Training of health promotion has been found to increase nurses’ motivation to implement these activities into nursing (Brobeck et al. 2013) as well as nurses’ own health and well-‐‑being (Roelen et al. 2013). 3) Client’s commitment to healthy lifestyle, their motivation for self-‐‑care as well as community resources, such as availability of preventive services, have been found to

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enhance the success of health promotion (Badertscher et al. 2012, El-‐‑Mallakh et al. 2012, Findholt et al. 2013, Geense et al. 2013). 2.3.4 Summary of the knowledge basis of the study Health promotion involves not only actions directed at strengthening the skills and capabilities of individuals; it has also developed to emphasise the community-‐‑based practice of health promotion, community participation and health promotion practice based on social and health policies. The literature indicated that health promotion in nursing is guided by health policy, international and national laws, recommendations and programmes. The theoretical basis for nurses’ health promotion is based on empowerment and a holistic approach including collaboration with individuals, groups and communities. Additionally, the goals of health promotion were achievement of health equity, health as a human right and political priority by taking actions based on the social determinants of health. In the primary health care setting, which is people’s first point of contact with health services, nurses are required to have a variety of competencies, such as multidisciplinary knowledge, skills and attitudes of health promotion. Nurses included in their work various HPPs: primary prevention, e.g. counselling on a healthy lifestyle, secondary prevention, e.g. providing examinations to prevent diseases processes and educating clients to maximize their health, and tertiary prevention, e.g. delivering follow-‐‑up programmes for clients with chronic conditions. There are a variety of aspects related to organisational health culture, training of health promotion, and clients’ commitment to healthy behaviour that influence the implementation of HPPs in nursing. A summary of the knowledge basis in this study is presented in Figure 1.

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Figure 1. Summary of the knowledge basis of the study

Health promotion competencies Enable change Advocate for health Mediate through partnership Communication Leadership Assessment Planning Implementation Evaluation and research

Case management competencies Patient-‐‑centred care Critical thinking Evidence-‐‑based practice Collaboration Coordination Communication Negotiation Leadership Evaluation Entrepreneurship

Health policy framework

Health promotion

Registered nurses (RNs)

Supportive aspects in HPPs

WHO guidelines (e.g. 1986, 1988, 1997, 2000, 2013)

Included

Is defined

Primary health care

Who deliver

As the process of enabling people to increase control over and to improve their health (WHO 1986).

Is defined

Health promotion practices (HPPs) Where

RNs need

Primary prevention e.g. counselling and teaching on healthy nutrition for different client groups (Berry 2009, Gardner et al. 2010).

Secondary prevention e.g. doing different kinds of examinations (e.g. screening blood pressure) to prevent disease complications (Jarl et al. 2014, Leach & Burton Shepherd 2015). Tertiary prevention e.g. delivering follow-‐‑up programmes for clients with chronic conditions such as cardiovascular diseases, diabetes, chronic pain, and mental health care (Fagerström 2009).

Such as

Characteristics include accessibility, availability and affordability of services as a first point of contact for care and health promotion (WHO 2012).

Including

Organisational aspects such as health care leaders’ appreciation toward HP (e.g. Johansson et al. 2010)

Continuing education and training of health promotion (e.g. Brobek et al. 2013)

Client’s commitment to health promotion activities (e.g. Badertscher et al. 2012, Geense et al. 2013).

-‐‑ EU’s Health strategy ”Together for Health” -‐‑ The EU Framework Programme for Research and Innovation 2014

-‐‑ The New Health Care Act 2010 -‐‑ SOTE reform (Government publications 2015)

Community-‐‑based practice of health promotion, community participation and health promotion practice based on social and health policies (Baisch, 2009). Achievement of health equity, health as a human right and political priority (WHO 2013). Taking into account that health and health promotion are defined by factors outside the health care sector and as part of public health thinking (WHO 2013).

Influence in implementation of HPPs

That guides

Where work

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3 Aims of the Study and Study Questions

This dissertation comprises the findings and summaries of the four original publications and provides a consensus among municipal primary health care participants (RNs, directors of nursing, senior physicians and health promotion officers, and local councillors) for health promotion practices (HPPs) delivered in registered nurses’ (RNs’) appointments in primary health care (PHC) setting in Eastern Finland.

The aims and the study questions were as follows:

1. The aim of the integrative review was to synthesise the findings of previous research studies (1998-‐‑2011) of nurses’ health promotion activities. The research questions addressed were:

1.1 What kind of health promotion provides the theoretical basis for nurses’ health promotion practice? 1.2 What kind of health promotion expertise do nurses have? 1.3 What kind of professional knowledge and skills do nurses undertaking health promotion exhibit? 1.4 What factors contribute to nurses’ ability to carry out health promotion? (Original publication I).

2. The aims of the two-‐‑stage modified Delphi study were to identify and reach a consensus among municipal primary health care participants in Eastern Finland on:

2.1 The types that primary health care RNs’ appointments represent in implementation of HPPs (Original publications II). 2.2 The required case management competencies for primary health care RNs’ appointments in HPPs (Original publications III). 2.3 The elements influencing successful implementation of HPPs delivered in primary health care RNs’ appointments (Original publications IV).

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4 Methods and Data

The study design for this study consisted of an integrative review and two-‐‑stage modified Delphi study. Qualitative study was conducted with semi-‐‑structured interviews and quantitative study was executed with a questionnaire. The study was reported by the author as four original publications (I-‐‑IV). Figure 2 presents the study design of the study.

Figure 2. Study design of the study

Integrative review Time of study 2010-‐‑2012 Included 40 recearch papers (Original publication I)

Delphi round 1 Time of study 2009 Qualitative study Semi-‐‑structured interviews among municipal primary health care participants (n = 42)

Developing semi-‐‑structured interview themes

Developing questionnaire

Delphi round 2 Time of study 2011 Quantitative study Questionnaire was completed by 56 municipal primary health care participants

Reporting the results of the two-‐‑stage modified Delphi study Time of study 2012-‐‑2015 (Original publications II, III, IV)

Pre-‐‑test of interview themes (n = 8)

Pre-‐‑test of questionnaire (n = 5)

Initial literature review of health promotion in nursing Time of study 2008-‐‑2009

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4.1 INTEGRATIVE REVIEW (ORIGINAL PUBLICATION I)

4.1.1 The integrative review method and data

In the last decade, the use of integrative review method has increased in nursing science; this is associated with the increasing requirements for integration of knowledge from diverse methodological approaches and providing results that benefit nursing care (Watson & Smith 2002). Integrative reviews have the potential to generate a comprehensive understanding, based on separate research findings, of problems related to healthcare (Kirkevold 1997). Whittemore and Knafl (2005) have suggested that integrative reviews enable a diverse range of primary research methods to be included and can offer a clarification for unclear nursing phenomena. In this study, the integrative review was chosen because it allowed the inclusion of studies with diverse methodologies (e.g. qualitative and quantitative research) in the same review. The integrative review proceeded with the following phases: problem identification, literature search, data evaluation, data analysis and presentation of results (Whittemore 2005, Whittemore & Knafl 2005). Systematic searches were conducted in the databases Cinahl, PubMed, Web of Science, PsycINFO and Scopus using the search string “nurs* AND professional competence* OR clinical competence* OR professional skill* OR professional knowledg* OR clinical skill* OR clinical knowledg* AND health promotion OR preventive health care OR preventive healthcare”. The searches were limited to peer-‐‑reviewed studies published during the period 1998–2011 because prior to 1998, nurses’ health promotion practice was mainly linked to health education. The systematic searches are presented in Table 2.

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Table 2. Systematic searches in the integrative review Database MeSH terms Search results Cochrane nurs* and (professional competence* 119

OR clinical competence* OR professional skill* OR professional knowledg* OR clinical skill* OR clinical knowledg*) and (health promotion OR preventive health care OR preventive healthcare) NOT student*

CINAHL nurs* and (professional competence* 227


PubMed (nurse” OR nursing) AND 345 ("professional competence" OR "clinical competence" OR "professional skills" OR "professional knowledge" OR "clinical skills" OR "clinical knowledge") AND ("health promotion" OR "preventive health care" OR "preventive healthcare") NOT student”

Web of (nurse” OR nursing) AND 128 Science ("professional competence" OR

"clinical competence" OR "professional skills" OR "professional knowledge" OR "clinical skills" OR "clinical knowledge") AND ("health promotion" OR "preventive health care" OR "preventive healthcare") NOT student”

PsycINFO nurs* and (professional competence* 100


Scopus (nurse” OR nursing) AND 222 (~ Embase) ("professional competence" OR

"clinical competence" OR "professional skills" OR "professional knowledge" OR "clinical skills" OR "clinical knowledge") AND ("health promotion" OR "preventive health care" OR "preventive healthcare") NOT student

The original search identified 1,141 references, and after duplicate references were excluded, titles and abstracts of the remaining 412 papers were read by author. Critical appraisal was conducted by evaluating methodological quality and informational value (Whittemore & Knafl 2005). Papers were included in the review if they met the following criteria: they had to be published in peer-‐‑reviewed journals and describe nurses’ health promotion roles, knowledge, skills, attitudes and factors that contributed to nurses’ opportunities to implement health promotion into nursing. Additionally, the papers had to be in English, Swedish or Finnish, as translators for other languages were not available.

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4.1.2 Data analysis In the integrative review, the concept map method was adopted for both data analysis and presentation of results. The use of concept mapping enhances conceptual understanding, and the concept map method was applied according to the recommendations of Novak and Gowin (1984 p. 15-‐‑40) and Novak (1993, 2002, 2005). The concept mapping process included six phases as follows: 1) Identifying a key question that focuses on a problem, issue or knowledge central to the purpose of the concept map. 2) Identifying concepts through the key question. 3) Starting to construct the concept map by placing the key concepts at the top of the hierarchy. After that, selecting defining concepts and arranging them hierarchically below the key concepts. 4) Combining the concepts by cross-‐‑links or links between concepts in different segments or domains of the concept map. 5) Giving the cross-‐‑links a name of a word or two. 6) Specific examples of events or objectives that clarify the meaning of the concept can be added to the concepts. In this study, the concept mapping process proceeded as follows: first, one researcher read studies that met the inclusion criteria and the concepts were identified through the four research questions upon which the review is based. Second, one researcher began to construct four concept maps hierarchically. This was achieved by putting the key concepts on the top of the left side of a page and then listing definitions of the concepts down the middle of each page. Supervising researchers verified the first and the second phases of the concept mapping process. Third, one researcher continued the construction of each concept map by combining main concepts and definition concepts using links that were then named. Supervising researchers critically evaluated the concept maps thus produced. Fourth, one researcher selected examples of the main concepts and these were listed on the right side of each page for clarification.

4.2 TWO-STAGE MODIFIED DELPHI STUDY (ORIGINAL PUBLICATIONS II-‐‑IV)

4.2.1 The Delphi method

While the integrative review was in progress, planning started for conducting a two-‐‑stage modified Delphi study. The Delphi method is a group facilitation technique designed to transform individual opinions into group consensus, and it includes two or more rounds of data collection (McKenna 1994, Keeney et al. 2001). The Delphi technique is useful when there is a lack of knowledge and a need to achieve a consensus from geographically dispersed experts (Keeney et al. 2001). There is wide variation in the number of participants, which can vary according to the scope of the problem and the resources available (Williams & Webb 1994). The Delphi technique does not call for the participants to be representative samples for statistical purposes; it focuses on the qualities of the participants rather than their number (Powell 2003). There is no one recognised guideline on an appropriate level of consensus (Keeney et al. 2006). When the goal of the Delphi study is to achieve consensus, a commonly accepted method for determining consensus is to attribute a percentage value to the level of agreement, which has ranged from 51% to 100% (McKenna 1994, Williams & Webb 1994).

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In a recent Delphi study consensus level was set at 70% (Melnyk et al. 2014). On the other hand, Keeney et al. (2006) suggested 75% as the minimal level, but there is no obvious scientific rationale for this. As researchers are suggested to decide on the level of consensus before commencement of the study, the consensus level was set at 51% (or over) ‘completely agree’ in the scale among participants.

4.2.2 Participants of the study In Delphi round one, an information letter about the study was sent to all 34 municipal health centres in Eastern Finland. Eleven of the recipients responded and volunteered to participate in this study. They were from four health centres in Northern Karelia, four in Northern Savo and three in Kainuu. Participants are suggested to be interested in the topic, credible within their field, and willing to participate throughout the study (Keeney et al. 2001). In both Delphi rounds, the inclusion criteria for municipal primary health care participants (later referred to as “participants”) (RNs’ appointments, directors of nursing, senior physicians and health promotion officers, and local councillors) were that they had been employed for five years or longer in primary health care and they had to have experience of either working autonomously in RNs’ appointment or experience of working as part of a pair or team working with RNs’ appointment. Additionally, they had to be interested in the research topic and willing to be involved throughout the Delphi survey. The possible 39 participants were suggested and named by directors of nursing at the primary health centres (matrons and head nurses). To ensure that the local councillors who were involved in municipal decision-‐‑making were familiar with the research topic one inclusion criterion was that they must have a nursing education background. There were three local councillors who met the inclusion criteria. The researcher asked potential participants for consent to be involved in the study; 42 agreed to participate (100% response rate) including: 18 RNs (43%), 14 directors of nursing (33%), four senior physicians (10%), three health promotion officers (7%), and three local councillors (7%). It emerged that RNs who took part in this study received client groups related to adults and elderly. Demographics of the participants in Delphi round one are presented in Table 3.

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Table 3.Demographics of participants in Delphi round one Participants interviewed (n=42) n % ____________________________________________________________________________ Male 3 (7) Female 39 (93) Registered nurses’ (RNs’) appointments (who received client groups related to adults and elderly) 18 (43) Educational background

- RN and public health nurse (PHN) 5 - RN and additional education in

cardiovascular preventive care 4 - RN and additional education in

diabetes preventive care 3 - RN and 1 year of studies for PHN 2 - RN, PHN and additional education in

diabetes preventive care 2 - RN, PHN and additional education in

diabetes and cardiovascular preventive care 1 - RN and additional education in wound care 1

Directors of nursing 14 (33) Matrons

Educational background - RN and Master’s degree 4 - RN and Postgraduate academic degree (Ph.D.) 2

Head nurses Educational background - RN and Master’s degree 5 - RN and Master student 2 - RN, PHN and Master’s degree 1

Senior physicians 4 (10) Educational background - Medical Doctor (M.D.) 2 - Licentiate of Medicine (L.M.) 2

Health promotion officers 3 (7) Educational background - Master’s degree 2 - Postgraduate academic degree (Ph.D.) 1

Local councillors 3 (7) Educational background - RN 2 - MNSc and senior lecturer of nursing 1

________________________________________________________________________________ RN = registered nurse: Bachelor degree programme 3.5 years, 210 ECTS, training is offered at Universities of Applied Sciences. PHN = public health nurse: Bachelor degree programme 4 years, based on RN 210 ECTS and additional public health nursing studies 30 ECTS, training is offered at Universities of Applied Sciences. Master’s degree = 300 ECTS, training is offered at Universities. Ph.D. = Postgraduate academic degree, 300+30 to 60 ECTS and dissertation, training is offered at Universities L.M. = Licentiate of Medicine, 360 ECTS, training is offered at Universities M.D. = Medical Doctor, 360+30 to 60 ECTS, training is offered at Universities

4.2.3 Qualitative data collection

In Delphi round one, qualitative data were collected via semi-‐‑structured interviews from primary health care participants (n = 42) between April and July of 2009. The first round of the classical Delphi is usually unstructured (Keeney et al. 2001). However, it is acceptable to modify this classical technique by giving participants some pre-‐‑existing information when the proposed Delphi study follows from generated literature or previous research (Keeney

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et al. 2006). Questions and pre-‐‑existing information (examples below the questions) used in the semi-‐‑structured interviews were constructed based on the literature (see Appendix 2). Focused questions were developed as follows: the first theme was health policy framework that guided health promotion in RNs’ appointments. The second theme was required multidimensional knowledge, skills and attitude towards health promotion for RNs’ appointments. The third theme was independent and collaborative work, development of HPPs and their political involvement. The fourth theme was factors that influence implementation of HPPs in RNs’ appointments in PHC. The semi-‐‑structured interview questions were pre-‐‑tested with eight RNs in PHC who were not involved in the research. In the beginning of the interviews, the participants (n = 42) were informed both orally and in written form and they gave written consent to participate voluntarily in this study. The participants responded to the semi-‐‑structured interview themes based on their expertise and experience. The interviews took from 32 minutes to 2 hours 47 minutes. They were conducted in a similar manner, performed in the participants’ work places, tape-‐‑recorded, and transcribed.

4.2.4 Qualitative data analysis In Delphi round one, the aim was to identify the major themes in the research topic, and content analysis technique is a commonly applied method (Powell 2003). In this study, the content analysis was applied according to Graneheim and Lundman (2004) (in Original publication II) and according to Weber (1990) (in Original publication III). Additionally, for qualitative data analysis, the concept map method was applied according to Novak (1993, 2002) (in original publication IV). In original publication II, content analysis began by reading through all the transcribed interviews and identifying meaningful units such as common words, sentences and phrases (Graneheim & Lundman 2004) related to types that RNs’ appointments represented in HPPs. Meaningful units were sorted into subcategories and main categories (see Appendix 3). First, meaningful units that identified RNs to work independently indicated three dimensions in the implementation of HPPs. Those were sorted into subcategories: providing health promotion actions independently, assessing the urgency of preventive care, and advocacy. The main category for this RN type was considered to indicate a client-‐‑orientated health promoter. Second, meaningful units that identified RNs to do collaboration, teamwork or pair work demonstrated two dimensions in the implementation of HPPs; these were sorted into the subcategories collaboration with other health care professionals and involvement in networks. The main category for this RN type was considered to represent a member of multi-‐‑professional teams of health promotion. Third, meaningful units that indicated RNs to develop their work demonstrated four dimensions in the implementation of HPPs, and these were sorted into the following subcategories: evidence-‐‑based practice, planning, implementing, and coordinating. The main category for this RN type was considered to demonstrate the main category of developer of health promotion practices. Finally, meaningful units that identified a dimension of RNs having contacts with municipal decision-‐‑making were considered to represent the main category of a type with

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interest in health policy. It seemed that the interview themes were appropriate, and no other themes came up. In original publication III, the content analysis began by reading through all transcribed interviews and identifying common words, sentences and phrases that described case management competencies for RNs’ appointments (Weber 1990). These were classified into 8 categories that were developed based on the literature on the case management competencies in nursing (Finkelman 2011, p. 34), as follows: 120 on the skills of providing individual or family education; 98 on the ability to perform patient-‐‑ or client-‐‑centred care; 92 on the ability to implement evidence-‐‑based knowledge; 45 on communication skills; 43 on critical thinking, clinical reasoning, and judgment; 23 on the ability to document; 16 on knowledge of community resources; 15 on the ability to evaluate; and 12 on ethical issues. The analysis proceeded so that health promotion competencies based on literature (Irvine 2005, AHPA 2009, Speller et al. 2012) were identified (see Appendix 4). In original publication IV, for qualitative data analysis and presentation of results, the concept map method was applied according to Novak (1993, 2002) (see Appendix 5). The concept mapping proceeded as follows: first, a researcher read through all the transcribed interviews regarding elements needed for success of HPPs delivered in RNs’ appointments. The key concepts and defining concepts were identified in the interview material. Second, the same researcher began to construct the concept map hierarchically. This goal was achieved by placing the key concepts on the top left-‐‑hand side of a page and then listing definitions of those concepts down the middle of the page. Two supervising researchers verified the first and second phases of the concept-‐‑mapping process. Third, one researcher continued the construction of the concept map by combining the key concepts and definition concepts using links that were then named. The supervising researchers then critically evaluated the concept map. Fourth, the researcher selected examples from participants’ interviews and listed these on the right-‐‑hand side of each page for clarification. Finally, when presenting the results in Original publication IV, consensus percentages of the participants were added to the concept maps. (See Figures I, II, III in original publication IV). Based on the information of qualitative data, Delphi round one ended with the development of a questionnaire for a quantitative survey in round two (see Appendices 3-‐‑5). The questionnaire (“kyselylomake”) included an information letter about the study, three questions regarding background information of the participants, and four parts (“Osio I-‐‑IV”) regarding the research topic. The statements in the questionnaire were drawn up as follows: I) guiding premises for HPPs in RN’s appointments, II) required competencies in HPPs for RNs’ appointments, III) types and dimensions that RNs’ appointments represented in implementation of HPPs, and IV) elements required for the success of HPPs delivered in RNs’ appointments in PHC. The statements were scored on a five-‐‑point Likert scale: 1 (completely agree), 2 (partially agree), 3 (partially disagree), 4 (strongly disagree) and 5 (neither agree nor disagree). The questionnaire was pre-‐‑tested with five primary health care RNs who were not involved in the research. The questionnaire included statements regarding premises that guided HPPs in RN’s appointments (“Osio I”). However, results of this part were excluded from this dissertation because consensus was not reached among the participants. Additionally, the questionnaire included statements related to general health promoter (“Osio III, yleinen terveydenedistäjätyyppi”). Results of these statements were also excluded from this

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dissertation because the findings described features that all nurses in different nursing contexts should have as general health promoters. The questionnaire is available on request from the author as supplemental material.

4.2.5 Quantitative data collection and analysis In Delphi round two, the aim was to reach a consensus among participants for those identified types that RNs’ appointments represented in implementation of HPPs, required case management competencies in HPPs for RNs’ appointments, and elements required for the success of HPPs delivered in RNs’ appointments in Eastern Finland. Data from the second Delphi round data were collected in January and March of 2011. The questionnaire was sent to a larger group than in round one, 87 individuals, including participants from round one, and also directors of nursing, RNs’ appointments, and senior physicians in the same 11 primary health care centres who had not participated in the first Delphi round. Demographics of the participants in Delphi round two are presented in Table 4. Table 4. Demographics of participants in Delphi round two Participants (n = 56) who completed the questionnaire n % Male 6 (11) Female 50 (89) RNs’ appointments 31 (56) Directors of nursing 14 (25) Senior physicians 5 (9) Health promotion officers 3 (5) Local councillors 3 (5) After two follow-‐‑ups, round two had a response rate of 64%; 56 participants returned the questionnaire including 31 (56%) RNs’ appointments, 14 (25%) directors of nursing, five (9%) senior physicians, three (5%) health promotion officers and three (5%) local councillors. The data from Delphi round two were analysed with the Statistical Package for the Social Sciences (SPSS® v19.0; IBM Corporation, Somers, NY, USA), and descriptive statistics (frequencies and percentages) for each statement were used to report responses and the consensus among the participants in this study.

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5 Findings

The findings of this dissertation comprised the findings of the integrative review (Original publication I) and the two-‐‑stage modified Delphi study (Original publications II-‐‑IV). Selected papers in the integrative review In the end, 40 research papers were included in the integrative review. The included studies were tabulated in chronological order under the following headings: citation, aim of the paper, methodology, major results, concepts used as the basis of the study and limitations. A summary of the studies included in the review is presented in Appendix 6 (see Appendix 6). The research papers were methodologically very diverse: sixteen of them included qualitative approaches; fourteen were different types of reviews; eight were quantitative; one used concept analysis and one was a mixed-‐‑method study. Twelve empirical studies were conducted in hospitals and fourteen in primary health care settings. Eleven studies were published in the period 1998–2004, twenty-‐‑two between 2005 and 2009, and six between 2010 and 2011 (see Appendix 6).

5.1 THEORETICAL BASIS FOR HEALTH PROMOTION IN NURSING (ORIGINAL PUBLICATIONS I-‐‑III)

The integrative review revealed that the theoretical basis of health promotion reflected actions undertaken by nurses to promote the health of individuals, families and communities (e.g. Whitehead 2009, Richard et al. 2010, Povlsen & Borup 2011). These theoretical foundations were considered to represent the main concepts of health promotion orientation and public health orientation in the review (see Figure 1 in Original publication I). Health promotion orientation was based on individual perspective (e.g. Chambers & Thompson 2009, Samarasinghe et al. 2010, Povlsen & Borop, 2011). When nurses’ health promotion activities were guided by an individual perspective nurses exhibited a holistic approach in their health promotion, they concentrated on activities such as helping individuals or families to make health decisions or supporting people in their engagement with health promotion activities (e.g. Hopia et al. 2004, Irvine, 2007, Samarasinghe et al. 2010, Povlsen & Borop 2011). Nurses gave information to patients and provided health education (Casey 2007a). Furthermore, health promotion orientation was based on empowerment, which was related to collaboration with individuals, groups and communities (e.g. Piper 2008, Richard et al. 2010, Samarasinghe et al. 2010). Such orientation was described in these studies in terms of nurse-‐‑patient communication and patient, group and community participation. Although these studies found empowerment to be one of the most important theoretical bases for health promotion activities by nurses, empowerment was not embedded in nurses’ health promotion activities (Irvine, 2007). Health promotion orientation was also guided by social and health policy (e.g. Whitehead, 2004, 2006a, 2006b, 2009, 2011). These studies suggested that nurses’ health promotion activities should be based on the recommendations in, for example, WHO’s charters and

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declarations and directives and guidance from professional and governmental organisations. However, the studies examined found that nurses were not familiar with social and health policy documents and did not apply them to their nursing practice (Benson & Latter, 1998, Whitehead, 2011). Finally, health promotion orientation was found to be based on community orientation (e.g. Witt & Puntel de Almeida 2008). These papers revealed that nurses had knowledge of community orientated health promotion: they were expected to use health surveillance strategies, work collaboratively with other professionals and groups and respect and interact with different cultures. Public health orientation based on chronic disease prevention has traditionally been the theoretical basis for health promotion in nursing (e.g. Burge & Fair 2003, Berg et al. 2005, Casey 2007b, Richard et al. 2010). According to the studies above, public health orientation appeared in nursing in that nurses concentrated on diagnosis, physical health and the relief of the physical symptoms of disease. Public health orientation also included the authoritative approach (e.g. Casey 2007b, Chambers & Thompson, 2009). This approach emphasises the need for nurses to give information to patients. In addition, the authoritative approach suggests that health promotion activities should aim to change patients’ behaviour (Irvine 2007, Chambers & Thompson, 2009).

5.2 REGISTERED NURSE TYPES AS HEALTH PROMOTERS (ORIGINAL PUBLICATIONS I-‐‑II)

The results of the review showed that nurses have a variety of types of expertise, some working as general health promoters, some as patient-‐‑focused health promoters, and some as managers of health promotion projects (see Figure 2 in Original publication I). General health promoters associated with common universal principles of nursing. General health promoters were expected to have knowledge of health promotion, effective health promotion actions, national health and social care policies and to have the ability to apply these into their nursing practice. The most common health promotion intervention used by nurses is health education (e.g. Whitehead 2001, 2007, 2011, Runciman et al. 2006, Witt & Puntel de Almeida 2008, Parker et al. 2009). Patient-‐‑focused health promoters worked with different patient groups, such as the elderly or families with chronic diseases; these nurses can be regarded as patient-‐‑focused health promoters (e.g. Jerden et al. 2006 & Kelley & Abraham 2007, Goodman et al. 2011). These studies indicated that when health promotion for patient groups who need high levels of care and treatment is required, nurses must have the ability to include health promotion activities in their daily nursing practice. Managers of health promotion projects were suggested to have advanced clinical skills and take responsibility in supervising and leading research and development actions in nursing as well as having the ability to co-‐‑ordinate educational and developmental interventions in health care units and communities (e.g. Runciman et al. 2006, Whitehead 2006b, Witt and Puntel de Almeida, 2008, Fagerström, 2009). Furthermore, the two-‐‑stage modified Delphi study identified and reached a consensus among participants on four types of service provider with twelve dimensions that RNs’ appointments represented in HPPs in PHC in Eastern Finland (Original publication II). First, this study found a consensus among participants for client-‐‑orientated health promoter who demonstrated four dimensions in the implementation of HPPs: providing health

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promotion practice independently reached a consensus level of 89.3%. The dimension included HPPs such as providing health checks, screening, weight control, and follow-‐‑up for various client groups. Providing health education independently reached a consensus level of 87.5% among the participants. The dimensions indicated RNs to deliver HPPs such as counselling on health risks, smoking cessation, and providing health education related to healthy lifestyle to individuals and various client groups as well as assessing the urgency of preventive care (e.g. ordering diagnostic tests). Being an advocate in health promotion reached a consensus level of 82.1% in this study. The dimensions indicated RNs to encourage clients and their families to commit to self-‐‑care activities. Second, in this study, consensus was reached on the developer of health promotion practices who also expressed four dimensions in the implementation of HPPs: the dimension of developing health promotion practices based on current research evidence in their own unit reached a consensus level of 85.7% among the participants. The dimension of planning health promotion practices regarding the health needs of the population in Eastern Finland (e.g. health needs related to ageing) reached a consensus level of 82.1% among the participants. The dimension of implementing national health promotion strategies into practice reached a consensus level of 73.2% in this study. The last dimension for developers of health promotion practices indicated that they coordinated health promotion practices in their own units (e.g. organised activities of peer-‐‑support groups); this reached a consensus level of 71.4% in this study. Third, a consensus was reached on the member of multi-‐‑professional teams of health promotion who represented three dimensions in the implementation of HPPs: the dimension of working in collaboration with doctors in health promotion practice reached a consensus level of 82.1% among the participants. The dimension of being involved in networks of health promotion reached a consensus level of 78.6%, while the dimension of collaboration with other health care professionals on health promotion (e.g. dietician) reached a consensus level of 69.6% among the participants. Finally, a consensus among the participants was reached on type who showed interest towards health policy. Its only dimension, having contacts with municipal decision-‐‑making, reached a consensus level of 55.4% in this study. A summary of consensus in the two-‐‑stage modified Delphi study is shown in Table 5.

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Table 5. Consensus on types that RNs’ appointments represented in implementation of HPPs RN types and Level of consensus* dimensions in HPPs n % Client-orientated health promoter To provide health promotion practices independently 50 (89.3) To provide health education independently 49 (87.5) To assess the urgency of preventive care 49 (87.5) To be advocates in health promotion 46 (82.1) Developer of health promotion practices To develop their own health promotion practices 48 (85.7) based on current research evidence To plan development of health promotion 46 (82.1) practices in their own unit To implement national health promotion strategies 41 (73.2) into practice To coordinate health promotion practices in their 40 (71.4) own unit Member of multi-professional teams of health promotion To work in collaboration with doctors 46 (82.1) in health promotion practices To be involved in networks of health promotion 44 (78.6) To work in collaboration with other health care 39 (69.6) professionals of health promotion A type who had interest toward health policy Having contacts with municipal decision-making 31 (55.4) ____________________________________________________________________________ *) Completely agree responses. Scale included 1 (completely agree), 2 (partially agree), 3 (partially disagree), 4 (strongly disagree), and 5 (neither agree nor disagree).

5.3 REQUIRED COMPETENCIES FOR REGISTERED NURSES IN HEALTH PROMOTION PRACTICES (ORIGINAL PUBLICATIONS I AND III) The integrative review found that there has been great interest in nurses’ health promotion competencies (see Figure 3 in Original publication I). A number of studies found that nurses’ health promotion activities were based on multidisciplinary knowledge that included knowledge of: health in different age groups, epidemiology and disease processes, and health promotion theories. In addition, nurses need to have the ability to apply this knowledge to their health promotion activities (e.g. Burke & Fair 2003, Irvine, 2005; Runciman et al., 2006, Piper 2008). Nurses were also expected to be aware of economic, social and cultural issues, social and health policies and their influence on lifestyle and health behaviour (Burke & Fair 2003, Irvine, 2005). Nurses must possess a variety of health promotion skills; skill-‐‑related competence included communication skills, which were considered to be the most important (e.g. Hopia et al. 2004, Irvine 2005, Jerden et al. 2006, Casey 2007b). Competence with respect to attitudes emerged as a positive feature of health promotion (e.g. Spear 2004, Irvine 2005, 2007, Piper 2008, Wilhelmsson & Lindberg 2009). Effective health promotion practice requires nurses to adopt a proactive stance and act as an advocate. An affirmative and egalitarian attitude towards patients and their families, as well as the desire to promote their health and well-‐‑being, are important attitudes with respect to health promotion activities (Irvine 2005, 2007, Wilhelmsson & Lindberg 2009). Furthermore, the integrative review found that nurses’ individual health-‐‑related beliefs and lifestyles are important personal characteristics in health promotion and that nurses are expected to be healthy role models (e.g. Burke & Fair 2003, Rush et al. 2005).

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Additionally, the two-‐‑stage modified Delphi study identified among the participants of this study 18 required case management competencies in HPPs for RNs’ appointments in PHC in Eastern Finland. A total of 14 of those reached consensus levels 75.0% or higher, three of those reached consensus levels between 66.1% and 73.2%, while one competence did not reach consensus among the participants (see Table 6 and Table 3 in Original publication III). The results indicated that RNs’ appointments were considered to need various abilities, and the highest levels of consensus was reached on the ability to discuss unhealthy lifestyle issues with patients (100%), to treat all patients equally (92.9%), and to create a confidential nursing relationship with the patient (91.1%). Furthermore, high levels of consensus (94.6%) were reached on need to have a holistic approach to the health promotion of patients as well as need to have knowledge about common public health problems. The participants also considered that RNs’ appointments require skills to communicate with various patient groups, which reached a consensus level of 92.9%. A summary of consensus in the two-‐‑stage modified Delphi study is presented in Table 6. Table 6. Consensus on required case management competencies in HPPs for RNs’ appointments Case management competencies Level of consensus* in HPPs n % RNs need the ability to discuss unhealthy lifestyle issues with patients 56 (100) to treat all patients equally 52 (92.9) to create a confidential nursing relationship with the patient 51 (91.1) to evaluate patients’ individual health promotion needs 48 (85.7) to provide face-to-face health education 47 (83.9) to provide health education to various groups 45 (80.4) to search for information from various databases 44 (78.6) to consider the patient’s knowledge related to health 43 (76.8) to provide web-based health education 42 (75.0) to document health promotion issues in patient records 41 (73.2) to apply current research results in HPP 41 (73.2) to make decisions independently 37 (66.1) RNs need to have a holistic approach towards health promotion of patients 54 (96.4) knowledge about common public health problems 53 (94.6) knowledge about how to prevent diseases 50 (89.3) knowledge about health services available in their 46 (82.1) own community RNs need skills to communicate with 52 (92.9) various patient groups RNs need to be interested in municipal 25 (44.6) decision-making ____________________________________________________________________________ *Completely agree responses. Scale included 1 (completely agree), 2 (partially agree), 3 (partially disagree), 4 (strongly disagree) and 5 (neither agree nor disagree)

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5.4 ELEMENTS INFLUENCING THE IMPLEMENTATION OF HEALTH PROMOTION PRACTICES IN NURSING (ORIGINAL PUBLICATIONS I AND IV) The integrative review revealed nurses to be aware of the importance of health promotion, but organisational culture with respect to health promotion can either support or discourage them from implementing it (e.g. Casey 2007a, 2007b, Goodman et al. 2011, Whitehead 2011, Beaudet et al. 2011). Managers in health care organisations should appreciate the value of health promotion activities and ensure adequate resources for their implementation (see Figure 4 in Original publication I). Organisational culture consisted of three supportive factors: hospital managers, culture of health and education. The hospital managers were responsible for whether health promotion was strategically planned and whether it was considered to be of great importance (Whitehead 2006, 2009). It emerged that the hospital managers were key individuals in ensuring that health promotion activities did not conflict with other work priorities (e.g. Jerden et al. 2006, Casey 2007a, Beaudet et al. 2011). Education enhanced nurses’ health promotion skills, and health promotion projects seemed to be catalysts for health promotion in nursing practice (Goodman et al. 2011). Moreover, organisational culture included three discouraging factors. The major one was lack of resources, including lack of time, equipment (e.g. computers) and health education material (e.g. Runciman et al. 2006, Casey 2007b, Kelley & Abraham 2007, Beaudet et al. 2011). It appeared that nurses may lack skills to implement health promotion in nursing (Goodman et al. 2011), or health promotion activities may still be unclear to nurses (Beaudet et al. 2011, Whitehead 2011). Furthermore, using the two-‐‑stage modified Delphi method, this study identified among participants 17 elements needed for the success of HPP delivered in RNs’ appointments in PHC in Eastern Finland. Among the participants, a consensus level of 51% (or over) was reached for fifteen of the identified elements required for success while no consensus was reached for two of them. First, seven of the elements required for the success of HPPs were found related to primary health care organisation; they were considered to represent the key concept of health-‐‑promoting organisational culture (see Figure 1 in Original publication IV). The highest levels of consensus were reached for organisations’ respectful attitude towards health (89.3%) and having sufficient resources for HPPs (83.9%) among the participants. According to the results of this study, primary health care leaders’ appreciation of health promotion reached a consensus level of 80.4%. Organisations’ action plan for health promotion reached a consensus level of 71.4% in this study. HPPs as part of quality management systems reached a consensus level of 64.3%, and a clear management system of health promotion reached a consensus level of 60.7% among the participants of this study. The final identified element related to health promoting organisation culture was development projects for health promotion; however, it did not reach a consensus in this study (level of agreement: 48.2%). Second, this study found two of the elements required for the success of HPPs related to nurses’ professional growth and nurses’ work well-‐‑being that were considered to demonstrate the key concept of nurses’ health orientation and development (see Figure 2 in Original publication IV). Consensus levels of 71.4% and 71.4% were reached in the systematic documentation of HPPs in clients’ electronic health records and the opportunity

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for continuing education in health promotion. No consensus (level of agreement: 28.6%) was reached among participants regarding having contacts with public health researchers as an identified element required for the success of HPP, whereas the opportunity to consult a colleague (another RN) showed a consensus level of 82.1%. In this study, the requirements for RNs’ own health behaviour reached a consensus level of 64.3%, and the opportunity to receive supervision for a challenging client a consensus level of 57.1%. Third, two of the elements required for the success of the HPPs were found related to clients in primary health care; these were considered to indicate the key concept of clients’ approach to being healthy (see Figure 3 in Original publication IV). The requirement for the availability of health promotion practices (e.g. living a short distance from preventive services) reached a consensus level of 75.0% among the participants and client’s commitment to self-‐‑care a consensus level of 69.6%. Fourth, two of the elements required for the success of HPPs were found related to political decision-‐‑making; these were considered to demonstrate the key concept of health policy (see Figure 3 in Original publication IV). The requirement for municipal decision-‐‑making on public health promotion (e.g., to build sports centres and offer cheaper exercise choices) had a consensus level of 69.6% in this study while national legislation on public health promotion (e.g., tighter tobacco and alcohol laws) had a consensus level of 57.1%. A summary of consensus in the two-‐‑stage modified Delphi study is presented in Figure 3.

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Figure 3. Consensus on elements required for the success of HPP delivered in RNs’ appointments in primary health care

Health-‐‑promoting organisational

culture

Nurse’s health orientation

and development

Client’s approach to being healthy

Health policy

Organisations’ respectful attitude towards health (89.3%)

Sufficient resources (83.9%)

Primary health care leaders’ appreciation toward health promotion (80.4%)

Action plan (71.4%)

Quality management systems (64.3%)

Management of health promotion (60.7%)

Development projects of health promotion (48.2%)

Included

Nurse’s work well-‐‑being

Included

Nurse’s professional growth

Systematic documentation (71.4%)

Continuing education and training (71.4%)

Having contacts with researchers (28.6%)

Opportunity to consult other RNs (82.1%)

Own health behaviour (64.3%)

Supervision (57.1%)

Included

Availability of health promotion activities (75.0%)

Commitment to self-‐‑care (69.6%)

Municipal desicion-‐‑making (69.6%)

Included

National legislation (57.1%)

Consisted of

Consisted of

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5.5. SUMMARY OF THE STUDY FINDINGS In summary, the integrative review found that nurses’ theoretical foundations in health promotion were either health promotion orientation based on individual perspective, empowerment, social-‐‑ and health policy and community orientation, or public health orientation based on disease prevention and an authoritative approach. Furthermore, the integrative review showed that nurses have a variety of types of expertise, some working as general health promoters, some as patient-‐‑focused health promoters, and some as managers of health promotion projects. A consensus among the participants in the two-‐‑stage modified Delphi study found four types of service provider that RNs’ appointments represented in the implementation of HPPs in PHC: the client-‐‑oriented health promoter, the developer of health promotion practices, the member of multi-‐‑professional teams of health promotion, and the type who showed interest towards health policy in the implementation of HPPs. The integrative review found that nurses’ health promotion activities were based on multidisciplinary knowledge, skill-‐‑related competence and competence with respect to attitudes. Moreover, the integrative review revealed that nurses’ individual health-‐‑related beliefs and lifestyles are important personal characteristics in health promotion and that nurses are expected to be healthy role models. A consensus among the participants in the two-‐‑stage modified Delphi study was found on a total of 18 required case management competencies in HPPs for RNs’ appointments in PHC. In 17 of these competencies (e.g. various abilities to work independently in HPP and having knowledge and skills of health promotion) a consensus level of 51% (or over) was reached among the participants. The integrative review found that nurses considered health promotion to be important but a number of supportive factors and obstacles associated with organisational culture influenced its effective delivery. A consensus was reached among participants on 15 elements required for the success of HPPs delivered in RNs’ appointments in PHC. A total of six elements were related to health-‐‑promoting organisational culture, three elements to nurses’ professional growth, and three elements to nurse’s work well-‐‑being. Additionally, two elements were related to clients’ approach to being healthy, and two elements were related to health policy. A summary of the findings of this study (Original publications I-‐‑IV) is also presented in Figure 4.

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Health promotion orientation based on individual perspective, empowerment, social-‐‑ and health policy, and community orientation (I)

Public health orientation based on disease prevention and authoritative approach (I)

General health promoter

Patient-‐‑focused health promoter

Manager of health promotion projects

Theoretical basis for health promotion in nursing

Eexpertise as health promoters (I)

Service providers in implementation HPPs (II)

Client-‐‑orientated health promoter

Developer of health promotion practices

Member of multi-‐‑professional teams of health promotion

Type who showed interest towards health policy

Health promotion competencies in nursing (I)

Required case management competencies in HPPs (III)

Skill-‐‑related competence -‐‑ Collaboration -‐‑ Communication -‐‑ Assessment

Competence with respect to attitudes -‐‑ Proactive stance -‐‑ Advocate

Multidisciplinary knowledge -‐‑ Knowledge (e.g. health and its determinants -‐‑ Ability to implement (e.g. health promotion theories) -‐‑ Being aware of (e.g. cultural aspects of health)

Personal characteristics -‐‑ Healthy role model

Need ablities to -‐‑ discuss unhealthy lifestyle issues -‐‑ provide face-‐‑to-‐‑ face, group and web-‐‑based health education -‐‑ search for information -‐‑ consider patients’ knowledge related to health -‐‑ to evaluate health promotion needs individually -‐‑ apply current research in HPPs -‐‑ documentation of health promotion -‐‑ make decisions independently -‐‑ treat all patients equally -‐‑ create a confidential nursing relationship

Need to have knowledge about -‐‑ public health problems -‐‑ disease prevention -‐‑ health services in own community

Need skills to communicate with various groups

Supportive

Factors regarding organisational culture (I)

Discouraging

Elements required for success of HPPs (IV)

Figure 4. Summary of the findings in this study (I) = Original publication I, (II) = Original publication II, (III) = Original publication III, (IV) = Original publication IV RNs = Registered nurses, HPPs = Health promotion practices, PHC = Primary health care

Nurse’s health orientation

and development

Health-‐‑promoting

organisational culture


Health policy

Need to have A holistic approach to the health promotion of patients

Based on papers

Based on papers

Based on papers

Based on papers

Based on consensus

Based on consensus

Based on consensus

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5.6 ETHICAL CONSIDERATIONS OF THE STUDY The same ethical considerations as for any survey also guide Delphi studies (Keeney et al. 2001). However, due to the features of the Delphi technique, with two or more data collection rounds, Keeney et al. (2001) emphasise that the researcher is not allowed to force participants to respond to questionnaires. In order for research to be ethically accepted, the Finnish Advisory Board on Research Integrity (2012) guideline for responsible conduct of research has been applied in this study. In accordance with the above guideline, the necessary research permits have been acquired and a preliminary ethical review that is required for certain fields before research has been conducted. In the beginning, this study was approved by the hospital district research ethics committee (Statement number 120/2008). Before conducting the empirical study, an information letter about the study was sent to all 34 municipal health centres in eastern Finland. The information letter included a summary of the research plan, purposes of the study, sources of funding, description of research methods, information on publishing the results, and a description of the benefits and potential disadvantages for those who participate in this research. Eleven of the recipients responded and the directors of health centres gave their consent to voluntary participation in this research. One point of view of research ethical principles are the methods applied in the research process (Finnish Advisory Board on Research Integrity 2012). In this study, two-‐‑stage modified Delphi technique was applied and ensuring the anonymity of the participants was one key ethical principle through the research process. According to Goodman (1987), anonymity provides equal opportunities for each participant to present their ideas and knowledge related to the research topic. Additionally, anonymity facilitates participants to be open and truthful about their views and opinions (Keeney et al. 2001). Therefore, in order to ensure anonymity of the participants, demographic information of the participants did not present information that might reveal the identity of individual participant, and the results of this study were reported as a group consensus. According to the Finnish Advisory Board on Research Integrity (2012), when publishing the results of a study, researchers should respect the work of other researchers by citing the references appropriately, and clearly separate their own results from those of others. This ethical principle guided the integrative review (Original publication I) which reported clearly the results from studies by other researchers and the findings of the integrative review. In addition, the researcher followed the ethical principle which is mentioned above in all research articles of this study (Original publications II-‐‑IV) by citing the references carefully and appropriately. In addition, when publishing the research results, the ethical principle is that they are communicated in an open and responsible fashion (Finnish Advisory Board on Research Integrity 2012). The researcher of this study has attempted to maintain openness and honesty towards empirical data by, for example, keeping a research diary, writing memos throughout the research process, and returning to the original data in unclear situations to make sure that the results of this study are consistent with the empirical data.

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6 Discussion

6.1 DISCUSSION OF THE FINDINGS This study aimed to collate the findings of nursing-‐‑specific studies of health promotion activities published in the period 1998–2011 and to identify and reach a consensus among municipal primary health care participants on types of service provider that RNs’ appointments represent in HPPs, the required case management competencies for RNs’ appointments in HPPs, and the elements needed for the success of HPPs delivered in RNs’ appointments in PHC in Eastern Finland. The findings are presented in detail in (Original publications I -‐‑ IV). 6.1.1 Health promotion orientation as theoretical framework Theoretical frameworks that guided nurses’ health promotion in nursing were either health promotion orientation or public health orientation. According to the findings of the integrative review, health promotion orientation was based on individual perspective, empowerment, social-‐‑ and health policy and community orientation. When nurses’ health promotion activities were guided by individual perspective nurses provided health education, supported individuals and families to make health decisions and encouraged people in their engagement with health promotion activities (e.g. Hopia et al. 2004, Casey 2007a, Irvine, 2007, Samarasinghe et al. 2010). Furthermore, the integrative review revealed that health promotion orientation included nurses’ health promotion activities guided by empowerment that was related to collaboration and communication with patients, different patient groups and communities (e.g. Piper 2008, Richard et al. 2010, Samarasinghe et al. 2010). Additionally, the findings of the integrative review indicated health promotion orientation to include nurses’ health promotion activities guided by social and health policy, including WHO’s charters and declarations, directives of government organisations and declarations of professional organisations (e.g. Whitehead 2009, 2011). Interestingly, findings of the two-‐‑stage modified Delphi study reached a consensus among participants for health policy (including municipal decision-‐‑making and national legislation related to tighter tobacco and alcohol laws) as element required for the success of HPPs delivered in RNs’ appointments in PHC. This finding may perhaps be considered to express the growing requirements in many countries to control health care costs and population health inequalities. Therefore, for example, the EU’s health strategy (European Union, 2014) emphasises that governments’ health policy and local community policies play a key role in areas such as regional and environmental policy, tobacco taxation, and the regulation of pharmaceuticals and food production. On the other hand, the findings of this study strengthen the goal of the “SOTE” reform of improving the availability of health services in a way that health services must be

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provided close to the clients, and that health promotive-‐‑care services should be at the core of PHC (Ministry of Social Affairs and Health 2015). The findings of the integrative review suggested public health orientation based on chronic disease prevention and authoritative approach as theoretical basis as for health promotion in nursing (e.g. Burge & Fair 2003, Berg et al. 2005, Casey 2007b, Richard et al. 2010). The public health orientation appeared in nursing in that nurses concentrated on diagnosis, physical health and the relief of the physical symptoms of disease. Public health orientation also included an authoritative approach (e.g. Casey, 2007b, Chambers & Thompson, 2009). This approach emphasises the need for nurses to give information to patients. In addition, the authoritative approach suggests that health promotion activities should aim to change patients’ behaviour (Irvine, 2007, Chambers & Thompson, 2009). Surprisingly, public health orientation did not emerge clearly as a finding in the two-‐‑stage modified Delphi study. 6.1.2 Registered nurse types in implementation of health promotion practices in primary health care The findings of the integrative review revealed that nurses applied different health promotion expertise across a wide range of nursing contexts. Depending on the context, nurses used of a variety of types of expertise in health promotion. Some of them were found to represent a type of general health promoters who were expected to have knowledge of health promotion, effective health promotion actions, national health and social care policies and to have the ability to apply these to their nursing practice (e.g. Runciman et al. 2006, Witt & Puntel de Almeida 2008, Parker et al. 2009). Others were found to typify patient-‐‑focused health promoters who worked with different patient groups and who must have the ability to include health promotion activities in their daily nursing practice (e.g. Jerden et al. 2006 & Kelley & Abraham 2007, Goodman et al. 2011). Furthermore, in the two-‐‑stage modified Delphi study, a consensus was reached among the participants for the type of client-‐‑orientated health promoter that indicated that RNs’ appointments deliver various HPPs by providing education and counselling to diverse client groups in PHC. Additionally, they informed their clients about health risks and provided various measurements in order to prevent public health problems. This study confirmed that promoting public health requires activating health-‐‑enhancing communication practices, and that RNs can be active in the implementation of health-‐‑promotive care in PHC (Keleher & Parker 2013, Sun 2014, Roden et al. 2015). On the other hand, this finding is significant since previously, nurses were considered to execute tertiary preventive care and the follow-‐‑up of patients with chronic conditions in Finland (Fagerström 2009). The integrative review showed a type of managers of health promotion projects who were able to plan, implement and evaluate health promotion interventions and with skills to assume responsibility in supervising and leading research and development actions in nursing as well as having the ability to co-‐‑ordinate educational and developmental interventions in health care units and communities (e.g. Runciman et al. 2006, Witt and Puntel de Almeida 2008, Fagerström, 2009). Furthermore, in the two-‐‑stage modified Delphi study a consensus of the participants was reached for the type of developer of health promotion practices who developed their own HPPs based on current research evidence. This result can be considered to confirm the increased requirements for evidence-‐‑based

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practice in the implementation of research evidence of health promotion that is needed for high-‐‑risk clients to improve and maintain their health (Juneau et al. 2011). On the other hand, the developers of health promotion practices can be considered to express capability to develop their skills and knowledge long after they have left formal education (O’Connell et al. 2014). Interestingly, a consensus of two-‐‑stage modified Delphi study also indicated that the developers of health promotion practices planned health-‐‑promotive activities related to clients’ health needs. This included actions such as planning, pre-‐‑testing and implementing, for example, health promotion practices for clients based on new information technologies. Therefore, based on the findings of this study, RNs’ appointments may be considered to play a key role in the future when it is important to develop new forms (e.g. services in wheels) of health services (National Institute for Health and Welfare 2013, Government publications 2015). Moreover, in the two-‐‑stage modified Delphi study a consensus was reached among the participants on the type of member of multi-‐‑professional teams of health promotion. They worked in collaboration with doctors and were involved in networks of health promotion. Based on these findings, we may say that RNs’ appointments demonstrate capabilities to work collaboratively (O’Connel et al. 2014), and they can have an active role to work in partnership and collaboration (Keleher & Parker 2013). On the other hand, nurses have also been found to struggle with understanding how to collaborate in the practical nursing setting (Moore & Prentice 2013). Therefore, it is important to strengthen nurses’ skills to collaborate with others. Nurses who work with multi-‐‑disciplinary health professionals have been found to have better understanding of health promotion and to develop their health promotion knowledge and practices (Roden & Jarvis 2012). Finally, this study found a consensus on a type that demonstrated an interest toward health policy by having contacts with municipal decision-‐‑making in primary health care. There has been much public debate, substantiated by research, that nurses do not demonstrate a clear and notable wider health policy or political role in formulating and implementing health promotion agendas (Whitehead, 2011). In summary, this study identified and clear consensus was reached on four types that RNs’ appointments (who received client groups related to adults and elderly) represented in the implementation of HPPs in PHC in Eastern Finland: i) Client-‐‑orientated health promoter who provides health-‐‑promotive activities such as health checks or counselling on health risks for different client groups, ii) Developer of health promotion practices who, for example, plans development of HPPs in their own unit; iii) Member of multi-‐‑professional teams who, for example, is involved in networks of health promotion, and iiii) a type with an interest in political decision-‐‑making by having contacts with political decision-‐‑makers in their municipalities. This typology is valuable because it clarifies RNs’ appointments scope of practice in health promotion in the PHC setting. In Finland, we have a tradition of health-‐‑promotive activities delivered by public health nurses who have worked for decades in various nursing contexts such as child and maternity clinics, school and student health care, as well as occupational health. Their health-‐‑promotive activities are based on legislation (The New Health Care Act 1326/2010, Government degree 338/2011).

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6.1.3 Competencies of health promotion for registered nurses’ appointments in health promotion practices in primary health care The integrative review revealed that there has been great interest towards health promotion competencies and an emphasis on multidisciplinary knowledge, including knowledge on issues such as health in different age groups, epidemiology and disease processes, and health promotion theories. In addition, nurses need to have the ability to apply this knowledge into their health promotion activities (e.g. Irvine 2005, 2007, Witt & Puntel de Almeida 2008, Wilhelmsson & Lindberg 2009). Nurses were also expected to be aware of economic, social and cultural issues, social and health policies and their influence on lifestyle and health behaviour (Burke & Fair 2003, Irvine, 2005). Furthermore, the two-‐‑stage modified Delphi study reached a consensus among participants that RNs’ appointments were required to have knowledge about common public health problems (94.6%), knowledge about how to prevent diseases (89.3%), knowledge of available health services in their own community (82.1%), ability to search for information from different databases (78.6%), and ability to apply current research result in HPPs 73.2%. These findings strengthen previous recommendations and studies indicating that multidisciplinary knowledge of health promotion, including knowledge about public health issues and, additionally, importance of implementation of evidence-‐‑based practice are the basic foundation for HPPs in nursing (AHPA 2009, Dempsey et al. 2011, Speller et al. 2012, Melnyk et al. 2014). The two-‐‑stage modified Delphi study reached a consensus among participants on the requirement that RNs’ appointments must a holistic approach to the health promotion of patients as case management competence in HPPs in PHC. Similarly, studies have found that a holistic perspective that encompasses nursing actions appropriate for the individual patient, including helping people to make good health decisions and become engaged in changing their unhealthy lifestyles, is the main health promotion approach in nursing (Povlsen & Borup 2011, Runciman 2013, O’Connell et al. 2014). However, interestingly, finding a holistic approach to the health promotion of patients in the Delphi study did not include the health promotion competency area of leadership recommended by Dempsey et al. (2011) and Speller et al. (2012). In order to respond to the challenges faced by primary health care in Eastern Finland leaders are forced to strengthen HPPs delivered in RNs’ appointments and support, for example, continuing education of health promotion for RNs who work in public primary health care. The findings of the integrative review showed that nurses must possess a variety of health promotion skills; of these, communication skills were considered to be the most important (e.g. Burke & Fair 2003, Hopia et al. 2004, Irvine 2005, Jerden et al. 2006, Casey 2007b). This skill-‐‑related competence also includes the ability to support behavioural changes in patients (Burke & Fair 2003), teamwork, time management, information gathering and interpretation and the ability to search for information from different data sources (Irvine, 2005, Jerden et al. 2006). Furthermore, among the participants of the two-‐‑stage modified Delphi study RNs’ appointments were considered to require skills to communicate with various patient groups (92.9%). This result confirmed that RNs who work with vulnerable groups, such as elderly persons, need strong communication skills and equal interaction with patients in HPPs (Goodman et al. 2011, Runciman 2013, Sun 2014). Additionally,

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recommendations according to Dempsey et al. (2011) and Speller et al. (2012) have a broader definition for communication skills in HPPs, i.e., to understand and apply information technologies for diverse audiences, skills in verbal and nonverbal communication and knowledge of health literacy. Interestingly, the results of the Delphi study did not confirm this broader view of communication skills in health promotion practices in primary health care. According to the integrative review, the most common health promotion intervention used by nurses is health education for individuals (e.g. Runciman et al. 2006, Witt & Puntel de Almeida, 2008, Parker et al. 2009, Whitehead 2011). Health education has been found to be a major primary health-‐‑promotive care activity in nursing (Gardner et al. 2010, Chang et al. 2012, Hessler & Siegrist 2012), whereas in the two-‐‑stage modified Delphi study, a consensus among the participants was reached on the required case management competencies in HPPs for RNs’ appointments to include various health education methods, both for individuals and different client groups, as well as providing web-‐‑based health education. These findings of the Delphi study may perhaps be considered to be related to the health promotion competency of advocate for health which according to Dempsey et al. (2011) and Speller et al. (2012) demonstrated the use of advocacy techniques with individuals and communities to improve health and well-‐‑being. However, interestingly, despite the fact that multiculturalism and ecological changes will influence population health in the future, they were not identified as required case management competencies in HPPs for RNs’ appointments in PHC. 6.1.4 Elements required for success of implementation of health promotion practices in primary health care RNs’ appointments It emerged in the integrative review that nurses valued health promotion practices; however, there were factors related to organisational culture that either supported or discouraged nurses from implementing health promotion practices in nursing (e.g. Reeve et al. 2004, Casey 2007a, 2007b, Goodman et al. 2011, Whitehead 2011). Therefore, managers in health care organisations play a key role and they should appreciate the value of health promotion activities and ensure adequate resources for their implementation (e.g. Casey 2007b, Beaudet et al. 2011). Furthermore, in the two-‐‑stage modified Delphi study a consensus among participants was reached on a health-‐‑promoting organisational culture that included sufficient resources for health promotion, primary health care leaders’ appreciation, an action plan for health promotion, and quality management systems for health promotion as significant required elements for the success of HPP delivered in RNs’ appointments in PHC in Eastern Finland. A systematic and appreciative approach on all levels of leadership of health promotion provides direction, defining a vision and strategy for health promotion (Johansson et al. 2010, Beaudet et al. 2011, Fagerström & Glasberg 2011; Wisur-‐‑Hokkanen et al. 2015). On the other hand, a positive organisational health promotion culture has also been found to play a major role in creating opportunities for nurses to implement HPPs in nursing (Johansson et al. 2010). Therefore, it is important to develop collaboration between RNs’ appointments and directors of nursing which may provide a framework for the establishment of a collegial and supportive working relationship in HPPs in PHC setting.

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It appeared in the integrative review that nurses’ individual health-‐‑related beliefs and lifestyles were important personal characteristics in health promotion and that nurses are expected to be healthy role models (e.g. Burke & Fair 2003, Reeve 2004, Rush et al. 2005). On the other hand, in the two-‐‑stage modified Delphi study a consensus among participants was reached on nurse’s health orientation and development as required elements for the success of HPPs delivered in RNs’ appointments in PHC. Nurse’s professional growth included systematic documentation and continuing education and training. The use of electronic health records and systematic documentation of health promotion in clients’ health records have been found to enhance individual health-‐‑promotive care and preventive care coordination (Narcisse et al. 2013). Based on this study finding, it seemed that systematic documentation can be considered to be associated with nurse’s professional growth and consequently, to be an element for the success of HPPs. Moreover, this study confirmed that continuing education and health promotion training are significant for nurses’ professional development as they can improve motivation for the implementation of health promotion practices (Brobeck et al. 2013). Furthermore, in the two-‐‑stage modified Delphi study, a consensus among the participants was reached on nurse’s work well-‐‑being which included the opportunity to consult other RNs, own health behaviour, and supervision. Hence, this study supports the pervious research which found that nurses are expected to engage in healthy activities, as fatigue and long-‐‑term conditions among nurses can reduce the quality of their nursing care (Roelen et al., 2013). Due to this fact and based on the findings of this study, we may consider that health promotion interventions for RNs’ appointments should be ones with a holistic wellness approach and fostered in their workplaces (McElligott et al. 2009). Interestingly, the findings of the integrative review did not reveal issues regarding client’s commitment and responsibility in health promotion. However, a consensus among participants in the two-‐‑stage modified Delphi study was reached on clients’ approach to being healthy as a required element for the success of HPP delivered in RNs’ appointments in PHC. Clients’ approach to being healthy incorporated the availability of health promotion activities and commitment to self-‐‑care, confirming previous research by Thomas et al. (2014), who suggested that clients should be considered as co-‐‑producers of the implementation of healthy lifestyle promotion in primary health care. This means taking into account clients’ individual approach to how to be healthy and managing being healthy. As previously mentioned, the findings of the integrative review indicated that social and health policy, for example, WHO’s charters (e.g. Whitehead 2009, 2011) guide nurses’ health promotion activities. Interestingly, the findings of the two-‐‑stage modified Delphi study reached a consensus among participants on health policy (including municipal decision-‐‑making and national legislation related to tighter tobacco and alcohol laws) as an element required for the success of HPPs delivered in RNs’ appointments in PHC. Recently, health promotion has become a priority in many countries, and controlling health care costs is now considered a key issue in terms of economic stability and social growth. For example, the EU’s health strategy emphasises that governments’ health policy and local community policies play a key role in areas such as regional and environmental policy, tobacco taxation, and the regulation of pharmaceuticals and food production (European Union 2014). In Finland, according to the EU’s health policy, several tools to improve health promotion on municipality level have been introduced, such as the TEAviisari, an online service that depicts municipalities'ʹ activity in promoting their inhabitants'ʹ health.

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The service supports the planning and management of municipal and regional health promotion. (National Institute for Health and Welfare 2015a). Additionally, the Health Care Act (1326/2010) requires that local authorities engage in Health and Welfare Impact Assessment, which means that municipalities and joint municipal boards are required to perform an assessment of the impact of the decisions and solutions on the health and welfare of the population and to take the impact into account in the said decisions and solutions (National Institute for Health and Welfare 2015b).

6.2 TRUSTWORTHINESS OF THE STUDY

6.2.1 Integrative review

The aim of the integrative review was to collate the findings of previous studies (1998–2011) of nurses’ health promotion activities (Original publication I). Combining qualitative and quantitative studies is complex and can introduce bias and error (Whittemore & Knafl, 2005). Methodological rigor should permeate all stages of an integrative review, and according to Ganong (1987) and Morilla-‐‑Herrera et al. (2013) the following suggested procedures should be developed in a critical manner: clear definition of the questions or issue of the review, conducting searches using methodological filters and the use of search terms such as MeSH terms is suggested, description of the criteria of the studies should be included in the review, and the characteristics of the articles analysed should be defined and described. The data examined herein originated from methodologically diverse research. The included criteria were clearly described and the included studies were tabulated in chronological order under the following headings: citation, aim of the paper, methodology, major results, concepts used as the basis of the study and limitations. A summary of the studies included in the review was presented in Appendix 6 (see Appendix 6). Most of the studies were qualitative, but a broad range of health promotion activities undertaken by nurses was described. The concept map method was used to analyse the data; the results of this review are reported both as text and concept maps. Concept maps are rarely used as a data analysis tool and therefore we employed researcher triangulation, so that the researcher of this dissertation was responsible for data collection, analysis, and presenting results, while the concept mapping research process was critically evaluated by the supervisors. This enhanced the researcher’s understanding and increased scientific rigour (Jones & Bugge 2006).

6.2.2 Two-‐‑stage modified Delphi study

The aims of the two-‐‑stage modified Delphi study were to identify and reach a consensus among participants on the following: 1. Types that primary health care RNs’ appointments represent in implementation of HPPs (Original publications II), 2. The required case management competencies for primary health care RNs’ appointments in HPPs (Original

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publications III), and 3. The elements influencing successful implementation of HPPs delivered in primary health care RNs’ appointments (Original publications IV). As pointed out by Murphy et al. (1998), the Delphi technique should not be viewed as a hard scientific method for creating new knowledge, but rather as a process for making the best use of available information or the collective wisdom of participants. In this study, key issues to ensure the credibility of the Delphi findings were addressing the research problems clearly, describing the inclusion criteria of participants as well as procedures of data collection, defining level of consensus, and implementation of the findings (Fink et al. 1991). Keeney et al. (2001) note that results of the Delphi study should be regarded as any qualitative research results. Therefore, the results of this study should be generalised with caution. Although the data were collected from one geographical area seven and five years ago the findings of this study are still relevant in the Finnish context. Today, primary health care is citizens’ first point of contact with health care services, RNs deliver a variety of health promotion practices for diverse client groups, and the goal is to maintain and improve health as well as prevent illnesses of the population (National Institute for Health and Welfare, 2013; Government publications 2015). According to Keeney et al. (2001) a heterogeneous group of participants from diverse backgrounds and knowledge improves the content validity of a Delphi study. Therefore, the participants of this study were representative of a large geographical area and they had various of backgrounds in primary health care. The response rate was 100% in round one and 64% in round two, and the high response among the participants increases the validity of our study (Keeney et al. 2006). Although there is no universal standard for the proportion of participant agreement that equates with consensus, in recent Delphi studies (e.g. McIlrath et al., 2010, Melnyk et al. 2014) the level of consensus has been set at 70% (or over) agreement for the items on the survey. In this two-‐‑stage modified Delphi study the consensus level was set at 51% (or over) agreement. However, if we consider consensus levels of 70% (or over), in this Delphi study levels of consensus that high were reached on: 16 out of 18 required case management competencies for RNs’ appointments in HPP (see Table 2); 10 out of 12 dimensions of types of service provider (see Table 3); and eight out of 17 elements required for success of HPPs delivered in RNs’ appointments (see Figure3). Moreover, a pilot survey was conducted for the semi-‐‑structured interview and questionnaire, which improved the feasibility and reliability of the results (McIlrath et al., 2010). To increase the trustworthiness of the study the characteristics of participants in Delphi rounds, data collection, analysis process and results were carefully described, allowing the reader to consider the relevance of the findings (Graneheim & Lundman, 2004).

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7 Conclusions

The findings of the integrative review and the two-‐‑stage modified Delphi study shed light on the multifaceted field of HPPs delivered in nursing. These study findings portray RNs’ appointment types in the implementation of HPPs, the required case management competencies in HPPs for RNs’ appointments, and the elements required for the success of HPPs delivered in RNs’ appointments in PHC in Eastern Finland. The findings of the integrative review and the two-‐‑stage modified Delphi study were synthesised for RNs’ appointments in PHC: health promotion orientation as theoretical framework, RN types in implementation of HPPs, and elements required for the success of implementation of HPPs in primary health care RNs’ appointments. The findings of this study offer a basis for a frame for educational organisations to develop curricula for continuing education of health promotion for RNs. Furthermore, these study findings can also be used as a basis and frame for municipal decision-‐‑makers and primary health care leaders in the development of health-‐‑promotive services as well as HPPs in RNs’ appointments in primary health care.

Based on the study findings the following conclusions are drawn: 1. The integrative review revealed the multidimensional theoretical basis to be health promotion orientation (based on individual perspective, empowerment, social and health policy and community orientation) and public health orientation (based on disease prevention and authoritative approach), while the two-‐‑stage modified Delphi study demonstrated that primary health care RNs’ appointment need to have a holistic approach to the patients’ health. Therefore, when developing curricula for continuing education of health promotion, it seems that RNs’ awareness and understanding need to be strengthened within a wide theoretical framework (including social and health policy) that guides health promotion in nursing. 2. This study revealed that nurses embody different types of health promoters in nursing. General health promoter and client-‐‑orientated health promoter can be considered to represent the most common health promoter types in nursing. Furthermore, this study indicated that RNs include the types managers of health promotion projects, the developer of health promotion practices, the member of multi-‐‑professional teams of health promotion, and the type showing an interest towards health policy. In Finland, because of the SOTE draft law, health services are under major reform; this typology might therefore be helpful for municipal decision-‐‑makers and primary health care leaders in the development of health-‐‑promotive services in RNs’ appointments in primary health care.

3. The integrative review showed that there has been a great deal of interest toward nurses’ health promotion competencies. The two-‐‑stage modified Delphi study suggested the

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required case management competencies in HPPs for primary health care RNs’ appointments to include various abilities to work independently, having a broad knowledge basis of health promotion, and abilities to work collaboratively with different sectors. These findings might be helpful for educators when they develop nursing curricula regarding the competencies of health promotion at different levels of nursing education.

4. With respect to health promotion, the integrative review revealed that organisational culture can either support or discourage nurses when it comes to implementing health promotion in nursing. Furthermore, the two-‐‑stage modified Delphi study suggested that a health-‐‑promoting organisational culture with strategic and respectful leadership of health promotion is significant in the implementation of the health promotion practices delivered in RNs’ appointments. This finding might be valuable for primary health care leaders in the development of management practices of health promotion in PHC settings.

5. The integrative review indicated that nurses’ individual health-‐‑related beliefs and lifestyles were important personal characteristics in health promotion. Additionally, the two-‐‑stage modified Delphi study indicated nurse’s health orientation and development as required elements for the success of HPPs delivered in RNs’ appointments in PHC. RNs’ professional growth and work well-‐‑being seemed to be a significant element for the success of HPPs. This knowledge might be valuable for primary health care leaders and directors of nursing to provide opportunities for continuing education of health promotion as well as development of wellness programmes for RNs.

6. The two-‐‑stage modified Delphi study revealed clients’ approach to being healthy to be incorporated in the availability of health-‐‑promotion activities and commitment to self-‐‑care. Clients can be seen as co-‐‑producers of the implementation of healthy lifestyle promotion in the PHC setting. This knowledge might be valuable in developing, together with other health care professionals, HPPs that support clients’ self-‐‑care.

7. The integrative review revealed that health promotion orientation including nurses’ health promotion activities should be guided by social and health policy. Furthermore, the two-‐‑stage modified Delphi study indicated health policy (including municipal decision-‐‑making and national legislation) as an element required for the success of HPPs delivered in RNs’ appointments in PHC. It seems that health policies on national and local community level play key roles in public health. This knowledge might be useful for municipal decision-‐‑makers in terms of strengthening health promotion in municipalities.

Suggestions for further research • To examine nursing directors’ and primary health care leaders’ competencies regarding

the management of health promotion. • To test the required case management competencies in health promotion for RNs in

other contexts of nursing. • To study the types of health promoters that RNs represent in other nursing contexts. • To conduct an action research with a continuing education programme of health

promotion for RNs and examine how their knowledge and skills develop through the programme.

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Appendices

Appendix 1 Examples of definitions and scope of practice for nurse practitioners in different countries

Appendix 2 Semi-‐‑structured interview themes in Delphi round one

Appendix 3 Example for data analysis related to types that RNs appointments represent in implementation of HPPs in Delphi round 1 and example for development of a questionnaire in Delphi round 2

Appendix 4 Example for data analysis related to required case management competencies for NPs in HPPs in Delphi round 1 and example for development of a questionnaire in Delphi round 2

Appendix 5 Example for data analysis related to elements for success of

HPPs delivered in RNs’ appointments in Delphi round 1 and example for development of a questionnaire in Delphi round 2

Appendix 6 Summary of studies included in the integrative review

Appendix 1

Examples of definitions and scope of practice for nurse practitioners in different countries Country, since and Role definition and Scope of practice citation educational requirements Canada (since 1967) RNs with additional education They work with individuals, Canadian Nurses preparation and experience communities and diverse Association (2009). who possess and demonstrate populations based on principles the competencies to autonomously of primary health care. Their diagnose, order and interpret scope of practice include health diagnostic tests and prescribe promotion, disease prevention and pharmaceuticals. illness management. Education: A graduate degree in

nursing. Sweden (since 2005) The role has been under Scope of practice verifies. They Lindblad, Hallman, Gillsjo, evaluation and experimentation in have been primarily worked in Lindblad & Fagerström general practice (primary health care). general practice (primary health (2010). A lack of clear definition. care). Education: A Master level. United Kingdom The role in primary health care: They have a wide range of skills, (since 1983) To provide complete episodes of care a broad knowledge base and ability Royal College of for patients of any age and with a variety to deliver specific aspects of care. Nursing (2012). of health needs and health problems They promote public health and such as acute and long-term conditions. well-being. Their expertise and Education: A Master level is clinical judgement are demonstrated recommended. of depth of knowledge. United States Their role is assess patients, order, They diagnose and treat patients (since 1960) interpret diagnostic tests, make both primary and acute care. American Association diagnoses, and initiate and manage Providing initial and on-going care of Nurse Practitioners treatments plans including prescribing including comprehensive histories, (2013). medication. perform physical examinations and Education: A master or doctoral level. health assessment and screening activities. Australia They have the capability to provide Their scope of practice in built on (since 1991) high levels of clinically focused nursing platform of the registered nurse Nursing and Midwifery care in a variety of nursing contexts. (RN), and must meet the Boarding of Australia They care people and communities regulatory and professional (2013). with problems of varying complexity. requirements including the Education: A Master level National competency standards for RNs, Code of ethics and Code of professional conduct. Ireland RNs or midwives working in They carry out e.g. screening, (since 1990s) general practice who provide health promotion, weight Irish Practice Nurses professional holistic health care management, smoking Association (2014). within his/her scope of nursing and cessation, women’s and men’s midwifery practice. health, immunisations, wound Education: RN and additional management, counselling, education regarding their role management of chronic conditions and context in nursing. such as asthma and diabetes. Finland Lack of national definitions of Scope of practice verifies. In PHC (since 2000s) nurse practitioner and advanced nurse RNs’ may have independent Act on Health Care practitioner. The roles of NP and APN appointment supported by doctor’s Professionals (559/1994) have been defined according to local consultation or collaboration with a Decree on Health Care and organisational-based guidelines doctor. Professionals (564/1994) both in primary health care and Muurinen & Mäntyranta specialized care. (2011) Education: RNs, who were authorised by Professional qualifications The National Supervisory Authority for Directive (EY/55/2013) Welfare and Health (Valvira). Local

authorities order additional education and training. Additional education (30ects) or master’s degree is commonly recommended.

Appendix 2

Semi-‐‑structured interview themes in Delphi round one

Dear participant, You have consented to participate voluntarily in this research and you were given information orally and in written form at the beginning of the study. Semi-‐‑structured interviews will take approximately an hour and researcher will come to your work place. All interviews will be tape-‐‑recorded and all responses will be remain anonymously. After interviews the research will continue as a survey. Here are semi-‐‑structured interview themes which you can explore beforehand Interview themes:

1. What kind of premises guide health promotion practices in RN’s appointments in primary health care? (Those can be, for example, health policy, national guidelines for health promotion or legislation).

2. What are the types that RNs’ appointments represent in implementation of health promotion practices in primary health care? (Those can be related to independent work of health promotion, patient-‐‑focused care, development of health promotion or participation in political decision-‐‑making)

3. What kind of competencies RNs’ appointments need in health promotion practice in primary health care? (Those can be, for example, abilities, knowledge, or attitude towards health promotion).

4. What are the factors that influence in implementation of health promotion practices delivered in RNs’s appointment in primary health care? (Those can be, for example, organisational, personal characteristics or factors related to clients)

Appendix 3 (1 / 2)

Example for data analysis related to types that RNs represent in implementation of HPPs in Delphi round 1 and example for development of a questionnaire in Delphi round 2

Main category Subcategory Examples from interviews in round 1 Statements in a questionnaire in round 2 Scale included: 1 (completely agree), 2 (partially agree), 3 (partially disagree), 4 (strongly disagree), and 5 (neither agree nor disagree).

Client-‐‑orientated health promoter

Independent work in health promotion practice

‘RNs (who receive the clients) work independently in health promotion practice. For example, they provide health checks for different client groups in our health centre.’ (Director of nursing)

‘Majority of my independent work includes health education and counselling about health risks.’ (Nurse)

RNs who received the clients provide health promotion practices independently (e.g. health checks for different client groups such as diabetics and clients with cardiovascular diseases)

RNs who received the clients provide health education independently (e.g. counselling about different health risks)

Assessment the urgency of preventive care

‘Our everyday work includes assessment the urgency of preventive care… and we can order diagnostic tests.’ (Nurse)

RNs who received the clients assess the urgency of preventive care (e.g. ordering diagnostic tests)

Being advocate ’RN (who receive the clients) should consider that every contact with client can support client’s self-‐‑care…RNs should see themselves as advocates of health.’ (Health promotion officer)

RNs who received the clients are advocates in health promotion (e.g. encouraging self-‐‑care activities)

A developer of health promotion practices

Evidence based-‐‑practice

‘information changes so quickly. We need to read and utilize current research in health promotion practices.’ (Nurse)

RNs who received the clients developer their own health promotion practices based on current research evidence

Planning ‘…nurses are familiar with the health needs of their clients…In our health centre nurses develop their health promotion practices regarding the health needs of the ageing population in our community…for example, distances are long in our municipality and therefore it is important to develop electronic services.’ (Director of nursing)

RNs who received the clients plan a development of health promotion practices in their own unit (e.g. the health needs of older people)

A developer of health promotion practices

Implementing ‘RNs (who receive the clients) should be aware of national health promotion strategies, for example the Health 2015 programme and implement those strategies into health promotion.’ (Health promotion officer)

RNs who received the clients implement national health promotion strategies into practice (e.g. Health 2015 strategy)

Coordinating ‘In our health centre, RNs (who receive the clients) arrange and coordinate different peer-‐‑support groups, for example, peer-‐‑support groups for overweight patients and tobacco cessation.’ (Nurse)

RNs who received the clients coordinate health promotion practices in their own unit (e.g. organising activities of peer-‐‑support groups)

To be continue

Appendix 3 (2 / 2)

Main category Subcategory Examples from interviews in round 1 Statements in a questionnaire in round 2 Scale included: 1 (completely agree), 2 (partially agree), 3 (partially disagree), 4 (strongly disagree), and 5 (neither agree nor disagree).

Member of multi-‐‑professional teams of health promotion

Collaboration ‘I do work collaboratively with a doctor in health promotion practice…it means that we consider together what is the best for the client.’ (Nurse)

‘ …working together with other health care professionals is very important…for example, I think it is important to work together with dietician.’ (Director of nursing)

RNs who received the clients work collaboration with doctors’ in health promotion practices

RNs who received the clients work collaboration with other health care professionals of health promotion (e.g. dietician)

Networking ’Primary health care RNs should be active and be involve in networks of health promotion.’ (Health promotion officer)

RNs who received the clients are involved in networks of health promotion

A type who have interest toward health policy

‘It is only positive if RN who receives the clients has contacts with municipal decision-‐‑makers.’ (Local councillor)

RNs who received the clients have contacts with municipal decision-‐‑making

Appendix 4 (1 / 2)

Example for data analysis related to required case management competencies for NPs in HPPs in Delphi round 1 and example for development of a questionnaire in Delphi round 2 Categories (Finkelman 2011)

Examples for meaningful units from interviews

Identified competencies of health promotion in round 1 (Irvine 2005, AHPA 2009, Speller et al. 2012)

Statements in a questionnaire in round 2 Scale included: 1 (completely agree), 2 (partially agree), 3 (partially disagree), 4 (strongly disagree), and 5 (neither agree nor disagree).

Individual or family education

“NP must be able to discuss unhealthy issues such as tobacco or overweight with patients.” (Director of nursing)

”Skill to give health counselling is the most important skill for NP…NP must be able to give health counselling to various of patients.” (Nurse)

” NPs must be able to give group counselling… for example I’m responsible for an overweight control group in our health centre.” (Nurse)

” We give more and more health education via Internet.” (Nurse)

Ability to discuss unhealthy lifestyle

Skills to face-‐‑to face health education

Skills to group health education

Web-‐‑based health education

NPs need the ability to discuss unhealthy lifestyle issues with patients

NPs need the ability to provide face-‐‑to-‐‑face health education

NPs need the ability to provide health education to various groups

NPs need the ability to provide web-‐‑based health education

Patient-‐‑ or client-‐‑centred care

” … NP must have a holistic orientation in her health promotion practices… It is not enough to take into account only diseases.” (Nurse)

” NP need to achieve patient’s confidence.” (Nurse)

Holistic approach of health promotion

Ability to create confidential relationship

NPs need to have a holistic approach to the health promotion of patients

NPs need the ability to create a confidential nursing relationship with the patient

Evidence-‐‑based practice

” NP must have good knowledge of common public problems.” (Health promotion officer)

“NP need to know how to prevent diseases.” (Nurse)

”NP must have good skills to search information from different databases.” (Nurse)

”… NPs need to apply current research results in their work.” (Director of nursing)

Knowledge about public health problems

Knowledge about disease prevention

Skills to search for information

Ability to apply current research

NPs need to have knowledge about common public problems

NPs need to have knowledge about how to prevent diseases

NPs need the ability to search for information from various databases

NPs need the ability to apply current research results in health promotion practices

Communication ” NPs need skills to communicate with various of patients… from children to elderly.” (Nurse)

Ability to communicate NPs need skills to communicate with various patient groups

To be continue

Appendix 4 (2 / 2)

Categories (Finkelman 2011)

Examples for meaningful units from interviews

Identified competencies of health promotion in round 1 (Irvine 2005, AHPA 2009, Speller et al. 2012)

Statements in a questionnaire in round 2 Scale included: 1 (completely agree), 2 (partially agree), 3 (partially disagree), 4 (strongly disagree), and 5 (neither agree nor disagree).

Critical thinking, clinical reasoning, and judgment

”… Nowadays, patients read a lot of health information from Internet…NPs need to take into account patient’s knowledge… It is very challenging.” (Nurse)

”NP work is very independent and they need to make decisions by themselves.” (Senior physician)

”… It is good if the NP is interested in municipal decision-‐‑making.” (Local councillor)

Evaluation skills

Decision-‐‑making skills

To be interested in municipal decision-‐‑making

NPs need the ability to consider the patient’s knowledge related to health

NPs need the ability to make decisions independently

NPs need to be interested in municipal decision-‐‑making

Documentation ” … documentation of health promotion issues to patient’s record is important.” (Director of nursing)

Documentation skills NPs need the ability to document health promotion issues in patient records

Knowledge of community resources

”NP must be aware of other health services in our community… such as activities of different voluntary organisations.” (Nurse)

Awareness of community resources

NPs need knowledge of available health services in their own community

Assessment ”… NPs need skills to assess patient’s individual health promotion needs.” (Health promotion officer)

Assessment skills NPs need the ability to evaluate patients’ individual health promotion needs

Ethical issues ”… in this work ethics is important… NP must be able to treat all patients equally.” (Nurse)

Ethical skills NPs need the ability to treat all patients equally

Appendix 5 (1 / 3)

Example for data analysis related to elements for success of HPPs delivered in RNs’ appointments in Delphi round 1 and example for development of a questionnaire in Delphi round 2 Key concepts Defining

concepts Examples from interviews in round 1 Statements in a questionnaire in

round 2 Scale included: 1 (completely agree), 2 (partially agree), 3 (partially disagree), 4 (strongly disagree), and 5 (neither agree nor disagree).

Health promoting organisation culture

Organisations’ respective attitude toward health

’We don’t only threat diseases but we also try to prevent diseases.’ (Senior physician) ’ It is important that we are no smoking health centre.’(Director of nursing)

Organisations’ respective attitude toward health improve an implementation of health promotion practice

Recourses for health promotion

’It is important to have enough time for each client.’ (Nurse)

’It is good that we have own timetable. It allows us to reserve more time for those clients who need health counselling.’(Nurse)

Sufficient resources for health promotion practices (such as time) support an implementation of health promotion

Primary health care leaders’ appreciation

’Primary health care leaders appreciation toward health promotion is important…I try to add recourses for health promotion actions whenever it is possible.’ (Director of nursing)

Primary health care leaders’ appreciation toward health promotion improve an implementation of health promotion practices

Action plan ’We have a clear and updated action plan for health promotion in our health centre...and nurses are familiar with that action plan.’ (Director of nursing)

Organisations’ action plans for health promotion supports an implementation of health promotion practices

Quality management systems

’Health promotion is an important component in our health centre’s quality management system.’ (Health promotion officer)

Health promotion practices as a part of quality management systems improve an implementation of health promotion practices

Management of health promotion

’We have defined responsibilities for each health care professional in our health centre.’ (Senior physician)

A clear management of health promotion support an implementation of health promotion practices

Development projects of health promotion

’National health promotion projects are very good… Those allows networking…we can share ideas regarding health promotion practices.’ (Nurse)

Development projects of health promotion improve an implementation of health promotion practices

To be continue

Appendix 5 (2 / 3)

Key concepts Defining concepts

Examples from interviews in round 1 Statements in a questionnaire in round 2 Scale included: 1 (completely agree), 2 (partially agree), 3 (partially disagree), 4 (strongly disagree), and 5 (neither agree nor disagree).

Nurse’s health orientation and development

Nurse’s professional growth

Systematic documentation

’Systematic documentation of health promotion practices in the client’s electronic health records is important. It helps all of us who are involved in client’s care to know his/her individual goals and needs for health promotion.’ (Nurse)

Implementation of health promotion practices improve systematic documentation of health promotion practices in the client’s electronic health records

Continuing education and training

(Theoretical studies and training for health promotion methods)

‘We have good opportunities for continuing theoretical education in health promotion…for example, open university offers courses related to health promotion.’(Nurse)

‘We had training for motivational interview last year…I have applied for my clients and it really works!’ (Nurse)

Implementation of health promotion practices support an opportunity for continuing education in health promotion (Such as theoretical studies and training of health promotion methods)

Having contacts with researchers

‘It is important to have contact with researchers of public health. It is the quickest way to hear what is going on and current results regarding to public health.’ (Nurse)

Implementation of health promotion practices enhance contacts with researchers of public health

Nurse’s work well-‐‑being

Opportunity to consult other RN

’It is important for my own well-‐‑being at work that I can ask another nurse for advice.’ (Nurse)

Implementation of health promotion practices improve opportunities to consult a colleague (another RN who receives the clients)

Own health behaviour

’A nurse who receives clients must have good health…you can’t promote other’s health if your own well-‐‑being is not good.’ (Nurse)

’ If a nurse who receives clients is very overweight, I think she is not very believable health counsellor.’ (Senior physician)

Implementation of health promotion practices improve RN’s own health behaviour

Supervision ’We have an opportunity to get supervision in challenging client case. For example, clients with substance abuse or mental health problems are challenging.’ (Nurse)

Implementation of health promotion practices improve opportunities to receive supervising on challenging clients cases

To be continue

Appendix 5 (3 / 3)

Key concepts Defining concepts

Examples from interviews in round 1 Statements in a questionnaire in round 2 Scale included: 1 (completely agree), 2 (partially agree), 3 (partially disagree), 4 (strongly disagree), and 5 (neither agree nor disagree).


Availability of health promotion activities

‘In our city, all health centres organize peer-‐‑support groups for weight control and tobacco cessation. The clients are free to choose in which group they want to participate.’ (Director of nursing)

‘Short distances for preventive services increases a number of clients in those services.’ (Nurse)

Implementation of health promotion practices support availability of health promotion practices (e.g. short distance from preventive services)

Commitment to self-‐‑care

‘I feel that I have succeed if the client provides self-‐‑care activities in their everyday life. ‘(Nurse)

‘My work is easy if the client is motivated to self-‐‑care.’ (Nurse)

Implementation of health promotion practices support client’s commitment to self-‐‑care

Health policy Municipality’s decision-‐‑making

‘Population is poor in this neighbourhood.. Therefore, it is important that municipality has a sport centre, where all residents can exercise at low rates.’(Local councillor)

Implementation of health promotion practices enable municipality’s decision making on public health promotion (e.g. to build sports centres and offer cheaper choices to exercise)

National legislation

‘I think that national legislation on public health is a key issue in health promotion of population….the legislation is the only way to force municipalities to organize preventive services for residents.’ (Senior physician)

Implementation of health promotion practices improve national legislation on public health promotion (e.g. tighter tobacco and alcohol laws)

Appendix 6 (1 / 9)

Summary of studies included in the integrative review

Citation Aim of the paper Methodology Major results Concepts used as the basis

Limitations of the study

Benson, A. & Latter, S. (1998) Implementing health promoting nursing: the integration of interpersonal skills and health promotion. Journal of Advanced Nursing, 27, 100-‐‑107.

The paper outlines the meaning of health promotion and distinguishes between a traditional and a new paradigm of health promotion.

Literature review

A new paradigm of health promotion, with recurring questions and four issues identified: the philosophical shift, incongruence between espoused theory and theory in use, conflict or congruence with political ideology, and the role of the nurse and the patient.

Theoretical basis Health promotion orientation Social and health policy

Not reported

McDonald, E. (1998) The role of Project 2000 educated nurses in health promotion within the hospital setting. Nurse Education Today, 18, 213-‐‑220.

The study is concerned with the role of Project 2000-‐‑educated nurses in health promotion within a hospital setting.

Qualitative study Individual interviews

Nurses had a wide ranging understanding of health promotion including aspects of health promotion such as negotiation, collaboration and empowerment. The value of clinical placements in facilitating the development of skills for health promotion was established.

Health promotion competencies Skill-‐‑related competence Collaboration Theoretical basis Health promotion orientation Empowerment

Small sample size

Robinson, S. and Hill, Y. (1998) The health promoting nurse. Journal of Clinical Nursing, 7, 232-‐‑238.

This paper is an attempt to demonstrate clearly ‘who’ the health promoting nurse is,‘what’ she/he does, ‘how’ she/he works and ‘where’ she/he works.

Literature review

This paper suggests that (i) the dominance of an individualistic philosophy of nursing, (ii) nurses’ own perceptions of their role and (iii) the hospital community divide are all obstacles to health promotion being well integrated into nursing practice.

Theoretical basis Health promotion orientation Individual perspective Types of expertise General health promoters Organisational culture Discouraging Hospital managers

Not reported

Sheilds, L. E. and Lindsey, A. E. (1998) Community health promotion nursing practice. Advances in Nursing Science, 20, 23-‐‑36.

To explore how the meanings of community can influence community nursing practice.

Literature review

Community health promotion nursing practice encompasses the four components of listening and critical reflection; participatory dialogue and critical questioning; pattern emergence and recogni-‐‑tion; and movement to action.

Theoretical basis Health promotion orientation Community orientation

Not reported

Nacion, K.W., Norr, K.F, Burnett, G.M. and Boyd, C.B. (2000) Validating the safety of nurse-‐‑health advocate services. Public Health Nursing, 17, 32-‐‑42. K.F,

To examine trained maternal-‐‑child health advocates (MCHAs) who, supervised by professional nurses, conducted maternal-‐‑child home visits involving health promotion and problem identification.

Quantitative study

The nurses identified significantly more women’s health problems (p=0.01) and women’s health care deficits (p = 0.02) than the MCHAs. The nurses referred significantly more women for parental support (p=0.00) and for socioeconomic problems (p = 0.00). The nurses were also significantly (p = 0.00) more likely to refer for emotional/ interpersonal problems than the MCHAs.

Health promotion competencies Skill-‐‑related competence Assessment Multi-‐‑disciplinary knowledge Knowledge

The sample was small and selected

Whitehead, D. (2001) Health education, behavioural change and social psychology: nursing’s contribution to health promotion? Journal of Advanced Nursing, 34, 822-‐‑832.

To review the processes that underpin the modification of client’s health-‐‑related behaviour and to contextualise the differences between health-‐‑education and health promotion .

A selective review of relevant literature

Nurses believe themselves to be health promoters, the likelihood is that they are, in fact, traditional health educators.

Types of expertise General health promoters

Not reported

To be continue

Appendix 6 (2 / 9)



Burke, L.E. and Fair, J.(2003) Promoting prevention. Skill sets and attributes of health care providers who deliver behavioural interventions. Journal of Cardiovascular Nursing, 18, 256-‐‑266.

To outline the skills and attributes considered essential for a health care provider to promote behavioural change and risk reduction in cardiovascular disease prevention.

Literature review

Skill set and attributes were: expertise and knowledge, communication skills, relationship-‐‑building skills, assessment of behaviour change, skills in using behavioural strategies, and skill in considering the patient’s attitudes, beliefs and environment. Attributes of the health care provider were: personal confidence, flexibility, acting as a role model, interview and group process skills, and technology and resource use skills.

Health promotion competencies Multidisciplinary knowledge Knowledge Skill-‐‑related competence Communication Collaboration Assessment Personal characteristics Healthy role model Theoretical basis Public health orientation Authoritative approach

Not reported

Whitehead, D. (2003) Health promotion and health education viewed as symbiotic paradigms: bridging the theory and practice gap between them. Journal of Clinical Nursing, 12, 796-‐‑805.

To present arguments and stances that help to diffuse or avoid the stated paradigm conflict, as a basis for the reform of health education and promotion in nursing.

Literature review

Nurses can move away from restrictive health practices if they approach any change in a realistic, gradual and sustained manner. Health education activities must be voluntary, and must respect the autonomy of the client.

Health promotion competencies Competence with respect to attitudes Advocate

Not reported

Hopia, H., Paavilainen, E. and Åstedt-‐‑Kurki, P. (2004) Promoting health for families of children with chronic conditions. Journal of Advanced Nursing, 48, 575-‐‑583.

To describe how nurses in a paediatric unit promote the health of families of children with chronic conditions during the children’s hospitalisation.

Qualitative study. Group interviews and observing nursing actions.

Systematic family nursing was intended to promote the health of the whole family, drawing on its individual situation. Selective family nursing was based on factors related to the family or nurse’s action. Situation-‐‑specific family nursing was based on getting to know families, gathering information and identifying their needs.

Health promotion competencies Skill-‐‑related competence Communication Collaboration Assessment Theoretical basis Health promotion orientation Individual perspective Types of expertise Patient-‐‑focused health promoters

The sample represented the staff of two paediatric wards in Southern Finland.

Reeve, K., Byrd, T. and Quill, B. E. (2004) Health promotion attitudes and practices of Texas nurse practitioners. Journal of the American Academy of Nurse Practitioners, 16, 125-‐‑133.

To understand and describe the health promotion attitudes and practices of nurse practitioners (NPs) in Texas.

Quantitative study. Questionnaire

Most of the NPs (75%) had a positive attitude towards health promotion. 92% stated that they served as a role model by engaging in a regular activity, not smoking, and maintaining an ideal weight. The most significant barrier to the provision of health promotion, identified by 56.9% of NPs was lack of time.

Health promotion competencies Competence with respect to attitudes Proactive stance Personal characteristics Healthy role model Organisational culture Discouraging Lack of recourses

Selected sample

To be continue

Appendix 6 (3 / 9)



Spear, H. J. (2004) Nurses ‘attitudes, knowledge, and beliefs related to the promotion of breastfeeding among women who bear children during adolescence. Journal of Pediatric Nursing, 19, 176-‐‑183.

To examine attributes, knowledge, and beliefs of maternal-‐‑child nurses related to the promotion of breastfeeding among adolescent mothers.

Quantitative study

The mean attitude score of the postpartum group (n = 25) was significantly lower than delivery nurses (n = 34):15.12 vs.16.38 (t [57],2.73, p <.01) and higher than the mean score of the intensive care nurses group (n = 20): 15.12 vs.13.65, (t [43] 3.40, p <.01). Significant differences in mean knowledge scores were found between the intensive care nursery nurses (n =20) who had a mean knowledge score of 8.0 compared to the mean scores of their labour and delivery (n = 34): 9.5 (t[52], 3.03, p < .05) and public health (n = 23): 9.7 (t[41], 3.06, p < .05) counterparts.

Health promotion competencies Competence with respect to attitudes Proactive stance Multidisciplinary knowledge Knowledge

Selected sample. The instrument was not formally tested for reliability and validity.

Whitehead, D. (2004) Health promotion and health education: advancing the concepts. Journal of Advanced Nursing, 47, 311-‐‑320.

To provide an up-‐‑to-‐‑date analysis of health promotion and health education to serve as a conceptual and operational foundation for clinicians and researchers.

A concept analysis

Socio-‐‑political and community action models of health promotion have overtaken individualistic and behaviourally-‐‑related forms of health promotion.

Theoretical basis Health promotion orientation Social and health policy Community orientation

Not reported

Berg, G.V., Hedelin, B. and Sarvimäki, A. (2005) A holistic approach to the promotion of older hospital patients’ health. International Nursing Review, 52, 73-‐‑80.

To describe how nurses interpreted health promotion related to older patients in a hospital medical ward.

Qualitative study. Observation

Two main perspectives were identified. 1) The biomedical view based on natural science and centred on an expert led approach to human health. The nurses’ interpretation of health promotion was influenced by an acknowledged focus on diagnosis, treatment and the physical aspects of health. 2) The holistic-‐‑orientated view based on an approach to care through empowerment, equality, collaboration and participation.

Theoretical basis Public health orientation Disease prevention Theoretical basis Health promotion orientation Empowerment

Small sample size

Cross, R. (2005) Accident and emergency nurses'ʹ attitudes towards health promotion. Journal of Advanced Nursing, 51, 474-‐‑483

This paper presents a study exploring accident and emergency nurses'ʹ attitudes towards health promotion.

Quantitative study. Q methodology: 33-‐‑item Q-‐‑sorts questionnaire and nurses wrote personal definitions of health promotion.

Three different views of health promotion. The most widely held opinion was a positive view of health promotion and the nurses'ʹ role in health promotion in accident and emergency environments.

Health promotion competencies Competence with respect to attitudes Proactive stance Types of expertise Patient-‐‑focused health promoters

Attitudes are difficult to measure.

To be continue

Appendix 6 (4 / 9)

Citation Aim of the paper

Methodology Major results Concepts used as the basis


Irvine, F. (2005) Exploring district nursing competencies in health promotion: the use of Delphi technique. Journal of Clinical Nursing, 14, 965-‐‑975.

To establish a consensus view among primary health care professionals about the competencies that district nurses need in order to fulfil an effective role in health promotion.

Quantitative Delphi study of Three-‐‑round questionnaire via e-‐‑mail. The 1st round elicited a response rate of 86% the 2nd round 87.5% and the 3rd round 78.9%

The categories for health promotion competencies identified were knowledge, attitude and skill-‐‑related competence. An awareness of the factors that affect health mean 4.4 and SD 0.54. An awareness of economic, social and cultural aspects mean 4.5 and SD 0.54. A knowledge and understanding of health mean4.5 and SD 0.54. A proactive stance mean 4.4 and SD0.6. A commitment to health promotion mean4.6 and SD 0.54. Skill-‐‑related competence mean scores of 4.5-‐‑ 4.6 and SD of 0.5.

Health promotion competencies Multidisciplinary knowledge Knowledge Ability to implement Perception Skill-‐‑related competence Communication Assessment Competence with respect to attitudes Proactive stance Advocate

The Delphi panel was gathered only from Wales

Rush, KL., Kee, CC. and Rice, M. (2005) Nurses as imperfect role models for health promotion. Western Journal of Nursing research, 27, 166-‐‑183.

To identify ways in which nurses describe themselves as health-‐‑promoting role models

Qualitative study. Focus groups and individual interviews.

Nurses defined themselves as role models of health promotion according to the meaning they gave the term, their perceptions of societal expectations, and their self-‐‑constructed personal and professional domains.

Health promotion competencies Personal characteristics Healthy role model

Not reported

Jerden, L., Hillervik, C., Hansson, A. C., Flacking, R. and Weinehall, L. (2006) Experiences of Swedish community health nurses working with health promotion and a patient-‐‑held health record. Scandinavian Journal of Caring Sciences, 20, 448-‐‑454.

To describe Swedish community health nurses'ʹ experiences in working with health promotion and a patient-‐‑held records as an integrated tool in their health-‐‑promotion work.

Qualitative study. Interviews

Nurses'ʹ work were grouped into: (i) working alone and as part of a team; (ii) nurse-‐‑related and patient-‐‑related interests; and (iii) patient'ʹs responsibility and shared responsibility between patient and nurse. The organisation in the primary healthcare centres was important for the community health nurses'ʹ ability to work with health promotion and the patient-‐‑held record.

Health promotion competencies Skill-‐‑related competence Collaboration Communication Types of expertise Patient-‐‑focused health promoters Organisational culture Supportive Hospital managers

Not reported

Runciman, P., Watson, H., McIntosh, J. and Tolson, D. (2006) Community nurses’ health promotion work with older people. Journal on Advanced Nursing, 55, 46-‐‑57.

To describe community nurses’ health promotion work with older people.

Mixed-‐‑method study. Questionnaire and telephone interviews.

Findings confirmed the wide scope of health promotion. Many health promotion activities were not recognized. Over 70% of respondents identified traditional health promotion approaches. Indicators of empower-‐‑ment were identified by50% Only 14% had evaluated their own health promotion work.

Types of expertise General health promoters Theoretical basis Health promotion orientation Individual perspective

Low response rate 35%

To be continue

Appendix 6 (5 / 9)



Whitehead, D. (2006a) The health promoting prison (HPP) and its imperative for nursing. International Journal of Nursing Studies, 43, 123-‐‑131.

An extensive review of the available prison-‐‑related health literature.

Literature review

The review recommended building sustainable group capacity into prison-‐‑based health care, though developing social interaction, cohesion, participation and political action.

Theoretical basis Health promotion orientation Social and health policy Empowerment

Not reported

Whitehead, D. (2006b) Workplace health promotion: the role and responsibility of health care managers. Journal of Nursing Management, 14, 59-‐‑68.

To review the available workplace-‐‑related health literature providing a basis for critical discussion and recommendations for health care managers.

Literature review

The findings suggest that health care managers in all health care service settings should aim to initiate and promote radical health promotion reform as set out in the WHO settings-‐‑based movement.

Theoretical basis Health promotion orientation Social and health policy Organisational culture Supportive Hospital managers

Not reported

Whitehead, D. (2006c) Health promotion in the practice setting: findings from a review of clinical issues. Worldviews on Evidence-‐‑Based Nursing, 3, 165-‐‑184.

To identify from the nursing literature what is reported on with respect to health promotion activity.

Literature review

Nursing-‐‑related health practice is firmly located in reactive-‐‑overall health-‐‑ and disease risk specific preventative. Many nursing health promotion strategies are out-‐‑of-‐‑step with wider health promotion agendas and communities.

Theoretical basis Public health orientation Disease prevention

Not reported

Casey, D.(2007a) Findings from non-‐‑participant observational data concerning health promoting nursing practice in the acute hospital setting focusing on generalist nurses. Journal of Clinical Nursing, 16, 580-‐‑592.

To report on hospital-‐‑based nurses’ health promotion activities in acute settings.

Qualitative study. Observation and semi-‐‑ structured interviews.

Nurses’ strategies in health promotion were prescriptive and individualistic. The main strategy was to give information. Patient participation was limited to personal aspects of care. Ward managers were key individuals in creating a culture of health promotion.

Theoretical basis Health promotion orientation Individual perspective Empowerment Health promotion competencies Competence with respect to attitudes Advocate Theoretical basis Public health orientation Authoritative approach Organisational culture Supportive Culture of health

Small sample size

Casey, D. (2007b) Using action research to change health-‐‑promoting practice. Nursing and Health Sciences, 9, 5-‐‑13.

To examine hospital-‐‑based nurses’ health promotion activities in acute settings.

Qualitative study. Semi-‐‑ structured interviews.

There were three main themes: implementing new practices, barriers to changing practice and factors that facilitate the change in practice. Most nurses were aware of health promotion and were able to incorporate the skills learnt and instigated a change in practice.

Health promotion competencies Multidisciplinary knowledge Implementation Perception Organisational culture Discouraging Lack of recourses Lack of skills

Small sample size

To be continued

Appendix 6 (6 / 9)


Methodology Major results Concepts used as the basis Limitations of the study

Flocke, S. A., Crabtree, B. F. and Stange, K. C. (2007) Clinician reflection on promotion of healthy behaviours in primary health care. Health Policy, 84, 277-‐‑283.

To simulate primary health care physicians and nurses to reflect on their activities in order to generate insights into the opportunities for changing health behaviour.

Qualitative study. Eight self-‐‑reflective questions. Authors’ triangulation.

Opportunities for change in the health behaviour of the population included patient education material such as web-‐‑based information. In the future, the authors envision the development of network-‐‑based clinics.

Theoretical basis Public health orientation Disease prevention

Selected sample and data was collected five years before reporting.

Irvine, F. (2007) Examining the correspondence of theoretical and real interpretations of health promotion. Journal of Clinical Nursing, 16, 593-‐‑602.

To identify how the development of concept analysis has influenced nurses’ under-‐‑standing of health promotion.

Qualitative study. Semi-‐‑ structured interviews.

Definitions of health promotion were confined to traditional conceptualising of health promotion, comprising actions that aimed at changing the behaviour of individuals. Definitions of empowerment, community development and socio-‐‑political action were not achieved in nursing practice.

Theoretical basis Public health orientation Disease prevention Authoritative approach Theoretical basis Health promotion orientation Empowerment

Small and selected sample

Kelley, K. and Abraham, C. (2007) Health promotion for people aged over 65 years in hospitals: nurses’ perceptions about their role. Journal of Clinical Nursing, 16, 569-‐‑579.

To identify nurses’ beliefs about health promotion and its delivery in the routine care of people aged over 65 years.

Quantitative study. Question-‐‑naire

88% of nurses believed that health promotion was effective. 60% of nurses viewed health promotion as a part of their role. 57% would be happy to incorporate health promotion into their work, if they had more time, more information on health promotion and had received appropriate training.

Health promotion competencies Competence with respect to attitudes Proactive stance Organisational culture Discouraging Lack of recourses

Small and selected sample. Low response rate 41%

Whitehead, D. (2007) Reviewing health promotion in nursing education. Nurse Education Today, 27, 225-‐‑237.

To evaluate the literature and identify the nature, provision and position of health promotion in nursing curricula.

A literature review

Health promotion has, in many cases, gone unheeded in nursing education. Educational delivery of broader elements of health promotion is limited in comparison to the traditional constructs of health education.


Not reported

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Appendix 6 (7 / 9)


Methodology Major results Concepts used as the basis


Piper, S. (2008) A qualitative study exploring the relationship between nursing and health promotion language, theory and practice. Nurse Education Today, 28, 186-‐‑193.

To explore the identity and meaning that nurses confer on health promotion and health education.

Qualitative study. Focus group interviews and critical incidents.

The role of nurses as informers was central to the findings. Health promotion was about giving information to patients. Empowerment included helping patients to understand their predicament. Advocacy was identified as collective empowerment.

Health promotion competencies Competence with respect to attitudes Advocate Theoretical basis Health promotion orientation Empowerment

Small sample size

Witt,R. R. and Puntel de Almeida, M.C. (2008) Identification of nurses’ competencies in primary health care through a Delphi study in Southern Brazil. Public Health Nursing, 25, 336-‐‑343.

To identify and analyse the general and specific competencies of nurses in primary health care in Brazil.

Quantitative Delphi study. Three-‐‑round questionnaire via e-‐‑mail.

Health promotion is a specific competence for nurses: taking part in health promotion activities 78%, applying health education knowledge 85%, and co-‐‑ordinating educational actions in the health unit 75%. Health promotion considered to be a general competence for nurses. The consensus of the specialist panel was that nurses apply their health education knowledge to health promotion.

Health promotion competencies Multi-‐‑disciplinary Knowledge Types of expertise General health promoters.

Data were collected in one country, Brazil.

Chambres, D. and Thompson, S. (2009) Empowerment and its application in health promotion in acute care settings: nurses’ perceptions, Journal of Advanced Nursing, 65, 130-‐‑138.

To identify how nurses use the concept of empowerment when engaging in health promotion activities in an acute care.

Qualitative study. Using six vignettes for data collection.

The type I nurse health promotion practitioner employs discourse and is likely to think reflexively. They had a holistic approach towards health promotion practice. The type II nurse health promotion practitioner adopted a more biomedical approach to health promotion. They emphasised individual behaviour.

Theoretical basis Health promotion orientation Individual perspective Theoretical basis Public health orientation Authoritative approach

Small and purposive sample

Fagerström, L. (2009) Developing the scope of practice and education for advanced practice nurses in Finland. International Nursing Review, 56, 269-‐‑272.

To describe the need for APNs in Finland and the develop-‐‑ment process of a Master’s programme in health promotion.

Qualitative study. Open-‐‑ended questions for nurse managers and nine focus interviews for clinical nurse specialists.

The expanded role of APNs included advanced clinical skills and responsibility for disease prevention and health promotion, education, supervision, leadership, research and development.

Theoretical basis Public health orientation Disease prevention Types of expertise Managers of health promotion projects

The study was limited to one region in Finland

Parker, R. M., Keleher, H., Francis, K. and Abdulwadud, O. (2009) Practice nursing in Australia: a review of education and career pathways. BioMed Central Nursing, 8, 1-‐‑6.

To examine measures in place to ensure Australia has a capable, efficient and effective primary care nursing workforce to address current and emerging health needs.

Systematic review

Health promotion was identified for nursing in general practice. Health promotion consisted of prevention, health education and counselling.


Not reported

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Appendix 6 (8 / 9)

Citation Aim of the paper Methodology Major results Concepts used as bases


Wilhelmsson, S and Lindberg, M. (2009) Health promotion: Facilitators and barriers perceived by district nurses. International Journal of Nursing Practice, 15, 156-‐‑163.

To investigate district nurses'ʹ (DN) opinions regarding facilitators and barriers in their work with health promotion.

Qualitative study. Interviews

The DNs stated that nursing was the right profession through which to deliver health promotion, and that it was an important task that was undertaken by no one else. The focus was not on health promotion; the time DNs could spend on health promotion was limited, and instead they had to perform elementary medical tasks.

Health promotion competencies Competence with respect to attitudes Proactive stance Organisational culture Discouraging Lack of recourses

Purposeful sampling

Whitehead, D. (2009) Reconciling the differences between health promotion in nursing and ‘general’ health promotion. International Journal of Nursing Studies, 46, 865-‐‑874.

To draw upon an extensive range of both nursing-‐‑ specific and general health promotion literature.

Literature review

The findings recommended: Clarifying what health promotion and health education are to nursing, adopting effective health promotion frameworks, process and research strategies, bridging health promotion theory and practice, health promotion as a political process and setting-‐‑based health promotion.

Theoretical basis Health promotion orientation Social and health policy Organisational culture Supportive Hospital managers

Not reported

Richard, L., et al. (2010) Health promotion and disease prevention among nurses working in local public health organizations in Montreal, Quebec. Public Health Nursing, 27, 450-‐‑458.

The study investigates conceptuali-‐‑ sations of disease prevention and health promotion (DPHP) among nurses from local public health organizations in Montreal.

Qualitative study. Semi-‐‑ structured interviews

Disease prevention was defined using the terms “harm reduction” and “prevention.” Health promotion was defined as large-‐‑scale health education oriented toward the attainment of positive results, such as health and well-‐‑being. Almost completely absent from participants’ discourse were central notions such as empowerment and health determinants, including socio-‐‑environmental dimensions of health.

Theoretical basis Public health orientation Disease prevention Theoretical basis Health promotion orientation Empowerment

Because of the qualitative study methodology, the results are not generalisable

Samarasinghe, K., Fridlund, B. and Arvidsson B. (2010) Primary health care nurses’ promotion of involuntary migrant families’ health. International Nursing review, 57, 224-‐‑231.

To describe the promotion of health in involuntary migrant families in cultural transition as conceptualized by Swedish primary health care nurses.

Qualitative study. Phenomeno-‐‑graphic approach. Interviews

Three different categories of the PHCNs’ health promotion were found: 1) an ethnocentric approach promoting physical health of the individual, 2) empathic approach promoting mental health of the individual in a family context and 3) a holistic approach empowering the family to function well in everyday life.

Theoretical basis Health promotion orientation Individual perspective Empowerment

Participants were chosen.

Beaudet, N., Richard, L., Gendron, S., and Boisvert, N. (2011) Advancing population-‐‑based health promotion and prevention practice in community-‐‑health nursing. Advances in Nursing Science, 34, E1-‐‑E12.

To examine organisational and professional constraints on the integration of the population-‐‑based health-‐‑promotion and prevention (PB-‐‑HPP) approach into contemporary nursing practice.

Qualitative study. Semi-‐‑ structured interviews

Three classes of factors emerged as key conditions for change: contextual and historical, training and professional development and work-‐‑organisation factors. In addition, nurses reported that their health promotion mandates were often vague.

Organisational culture Supportive Education Hospital managers Discouraging Unclear definition

Purposeful sampling strategy Participants of the study were from four institutions Data were collected 2006-‐‑2007and reporting 2011.

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Appendix 6 (9 / 9)



Goodman, C., Davies, S. L., Dinan, S., See, T. S. and Iliffe, S. (2011) Activity promotion for community-‐‑dwelling older people: a survey for contribution of primary care nurses. British Journal of Community Nursing, 16, 12-‐‑17.

To discover the current level of nurse-‐‑led involvement in activity promotion for older people in primary care and explore the knowledge and attitudes of primary care nurses about health benefits of activity promotion for older people.

Quantitative study. Semi-‐‑ structured question-‐‑naire.

There were organisational and individual constraints on their ability to be involved in the aspect of health promotion work themselves, or to refer older people to local activity promotion schemes.

Types of expertise Patient-‐‑focused health promoters Organisational culture Discouraging Lack of skills

Not reported

Povlsen, L. and Borup, I. K. (2011) Holism in nursing and health promotion: distinct or related perspectives? -‐‑ A literature review. Scandinavian Journal of Caring Sciences, 25, 798-‐‑805.

To explore how the term holism was defined and/or described in Nordic articles with a health-‐‑promotion approach, and how holism aspects were related to nursing and health promotion, and to the other key principles of the Ottawa Charter.

Literature review

A holistic and individual patient perspective could be extracted from most articles. No great but several minor differences were identified in the way holism aspects were related to nursing and health promotion respectively.

Theoretical basis Health promotion orientation Individual perspective

Not reported

Whitehead, D. (2011) Health promotion in nursing: a Derridean discourse analysis. Health Promotion International, 26, 117-‐‑127.

To identify the current position of health promotion in nursing as it relates to its practice, theory and policy and, where possible as a secondary aim, compare and contrast this with the health promotion position of other health professional groups.

Literature review

Strong themes to emerge were that nursing has yet to contextualise and differentiate health promotion and health education and the specific role and function of nursing clearly. Also evident was the view that nursing-‐‑related clinical practice is yet to reflect the theory and language of ‘general’ health promotion universally. Furthermore, nursing has not yet demonstrated a clear and notable wider health policy/political role in formulating and implementing health promotion agendas.

Types of expertise General health promoters Organisational culture Discouraging Unclear definition

Not reported

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