foumal of Advanced Nursing, 1994,20, 828-835

Nursing and health promotion: conceptualconcernsFaith G Delaney SRN BSc(Hons} MSc PGCESenior Lecturer, Faculty of Health and Social Care, Leeds Metropolitan University,Calverley Street, Leeds LSI 3HE, England

Accepted for publication 16 February 1994

DELANEY F G (1994) Journal of Advanced Nursing 20, 828-835Nursmg and health promotion, conceptual concernsThe importance of health promotion to nursmg is now well estahlishedHowever, different interpretations of health promotion exist It is argued thatmany allegations of nursing's inadequacy in this field are misplaced and to alarge extent result from the confused and variahle ways in which the termhealth promotion is used Concepts of health promotion in general areconsidered and compared with usage of the term in nursing literature Thecontribution of nursing to health promotion and health education is discussedand some cmncular issues are raised

INTRODUCTION

The centrahty of health promotion to nursing is well estab-lished and a plethora of publications have provided arationale for, critique of and guidance on its practice (forexample Murray & Zentner 1985, 1989, Pender 1987)However, different interpretations of health promotionexist among various stakeholders These interpretationssuggest different implications for nurses' practical contn-bution to health promotion, m turn posing interestingconsiderations for nurse education

This paper suggests that some allegations of nursing'sinadequacy in this field are misplaced and to a large extentresult from the confused and vanable ways m which theterm health promotion is used m academia and practice— both withm 'specialist' health promotion and nursingThe development of concepts of health promotion m gen-eral v«ll be considered Usage of the term m nursing litera-ture will then be addressed Drawing on empincal studiesthe current contnbution of nursmg to health promotion,and health education, will be discussed and observationson health-based nursing curricula made

CONCEPTUAL BASES OF HEALTHPROMOTION

A range of interpretations of health promotion have beenidentified m vanous studies and contexts (Anderson1984) Some focus on principles, others attempt to specify

goals, others the kinds of activities embraced (WHO 1984,1986) A succinct, specific and precise definition, with theability to discriminate, has not been forthcoming

WHO (1984) descnbe health promotion as

a unifying concept for those who recognise the need for changein the ways and conditions of living a mediating strategybetween people and their environments synthesising personalchoice and social responsibility (my emphasis)

This illustrates the supposedly dual emphasis on life-style and living conditions withm WHO's statements onhealth promotion Many commentators have sought toclanfy or operationahze such vague or all-embracingdescriptions Often these rest on existing distinctionsbetween service goals or activities Tannahill (1985) pro-poses that health promotion embraces three overlappingspheres of health protection, health education and preven-tion Although helpful, this can be challenged m that edu-cation, as a process intended to produce some leanungabout health, can contribute to both 'protective' and 'pre-ventive' activities A further 'operational' definition isoffered by Tones et al (1990) where policy and educationare complementary elements of health promotion whichact S3mibiotically

Both these views can be considered as 'inclusive' (orumbrella, or eclectic) views, that is, the term health pro-motion encompasses a range of component activities con-tnbutmg to health The difficulty with such a definition isthe implication that it includes any health improving

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activity — acute services, social and community care —depending on one's view of health Whether the term ismeant to refer to all or any of the composite activities isvanable and unclear, this determines whether we can con-sider health education to be the same as, different from orsubsumed within health promotion

Critiques of health education

This concem can be illustrated by considenng critiques ofhealth education One of the contributions to the develop-ment of health promotion has been the limitations ofhealth education, technically and philosophically It hasbeen descnbed as ineffective and unethical, 'blaming thevictims' for their health problems (Rodmell & Watt 1986,Crawford 1980) Some cntics advocated social change orradical approaches to rectify this inherent individualism(French & Adams 1986, and see Tones et al 1990, Downieet al 1990) Health promotion for many commentators, isor should he concerned with the conditions, rather thanways of living The 'radical' approach to health educationthus complemented (or was replaced by) health pro-motion, for such comentators

Other variants of health promotion have been identifiedIt has been seen as a manifestation of populism (Ashton &Seymour 1988) but some questioned its grandiose claims(Tones 1985) and saw it as a cynical exercise m high profilemarketing of 'positive health' (Williams 1985) Further,rather than being used to tackle the socio-economic deter-minants of lU-health, the term can be simply used for indi-vidually focused 'preventive' activities One particularexample is the official sanctioning of 'health promotionclinics' in British primary care Denny & Jacob (1990) areamong others (e g Tones 1990) in rightly arguing that thensk factor screening and lifestyle change advice offered insuch clinics rests on health education alone However,their implicit criticism of all health education is not war-ranted for two reasons

Firstly, the debate withm health education/promotionsummarized above suggests that a simple distinction isnot appropriate Different models of health educationreflecting a range of values, goals and approaches havebeen identified (Beattie 1990, Tones & Tilford 1994,Downie et al 1990) and a narrow, victim blaming approachhas been challenged We have also noted vanants on con-cepts of health promotion, again with some interpretationsattracting cnticism (Bunton 1992b) So, simply to suggest'health education bad, health promotion good' is not valid

Secondly, such a distinction provides an example of an'exclusive' view of health promotion that it is a discreteactivity (m this case concerned with changing structuralphenomena) and particuleirly is distinct from health edu-cation Unless health education is health damaging, it issurely illogical to exclude it from heedth promotion'

A third conceptual vanation is provided by Ewles &

Simnett (1992) They subscrit>e to the 'umbrella' view ofhealth promotion setting out a number of composite activi-ties they consider to contribute to better h^th Inaddition, they refer to another descriptor, set out m theOttawa Charter

health promotion is the process of enabling ])eople to increasecontrol over and improve their health

(WHO 1986)

Ewles & Simnett (1992) distinguish between those activi-ties done to and those done for people, the latter fulfillingthe cntena of enablement Thus while apparently holdingan 'inclusive' position, their exclusion rests on the basisof philosophical cntena The example of surgery is offeredas It IS done to the patient, it is excluded This attempt toclarify IS valuable but the judgement as to whether anaction IS enabling is highly contentious

This latter view then straddles the categories presentedabove it is inclusive m one sense but exclusive on thebasis of criteria of principle or value This appears valida range of activities might be legitimately consideredhealth promotion provided they adhere to key principlesHowever, these are many and varied Equity m health,multisectoral collaboration and community participationare often cited (WHO 1984, 1986) Conceptual develop-ments have brought m further ideas which conflate prin-ciple, activity and goal, such as 'reorientation of healthservices' and 'building healthy public policy' as set out inthe Ottawa Charter (WHO 1986)

Further, while notions of enablement, empowermentand participahon have arguably become central pnnciples(Green & Raebum 1988, Tones 1992) they remain conten-tious and difficult to operationahze They imply notionsof individual and collective self-determination Such pnn-ciples might be undermined by 'healthy public policy'(WHO 1986) While a significant goal, involvement of thestate m any health related issue does not necessanly resteasily with notions of enablement or empowerment(Bunton 1992a) Nevertheless, such formulations canguide practice as well as provide a reasonably coherentconceptual basis Whether the principles are peculiar toand therefore descriptive of health promotion will be con-sidered later

Diversity

Due to the diversity of the health promotion field there isno single authontative voice and many commentators andagencies are able to pronouce on health pronaotion Suchpronouncements might legitimately range frnm calls forrestructunng of the global economy, throu^ communitydevelopment to individual support for a behaviourchange Bunton & MacDonald (1992) claim that the manydefinitions ultimately 'all accept that both individual

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(lifestyle) and structural (fiscal/ecological) elements playcntical parts , '

However, m translating such inclusive definibons intopractice, substantial vanations exist such that very differ-ent practices might claim to be health promotion Thenotion of exclusion critena (principles), although conten-tious, IS thus an important constraint and is the author'sprefered conception Health education is mcluded underthe rubnc of health promotion — provided it complieswith critena regarding the educational approach adoptedThis will be explored more thoroughly below, in the con-text of nurses' educational role

In summary, a range of conceptions and categonzationsof health promotion have been identified Here, inclusiveand exclusive types of definitions have been addressedThese are 'ideal types', they are not mutually exclusiveand frequently coexist Ckinfusion arises where health pro-motion IS seen as a combination of activities but practiceof any single one (especially health education) is deniedthe label Such logic would hold that no one could practicehealth promotion unless they operated at all levels, in allcontexts One solution is to impose 'exclusion criteria' andto consider the contnbution of different professional roles— emphasizing its multi-disciplinary and multi-sectoralnature

Problematic issues

Despite apparent consensus demonstrated through the pre-dominance of inclusive views (Whitelaw 1993), severalissues remain problematic for understanding of health pro-motion and therefore for nurse education and practiceThese revolve around

1 the concept of health and assumptions about diseasecausation and preventability implied or explicated incompeting concepts,

2 the perceived relationship between prevention and thepromotion of health/well-being,

3 the relevance and place of the classical notions of pri-mary, secondary and tertiary prevention to and m healthpromotion and subsequent implications for patienteducation,

4 the role and place assigned to health education mdifferent notions of health promotion, and

5 the place assigned to policy and potential for producingpolicy change as a health promotion task

These issues are explored further in revievnng the nurs-ing literature on health promotion Some practical andeducational implications, particularly for nurses' health/patient education, will be noted

HEALTH PROMOTION WITHIN NURSINGLITERATURE

Attention has been given to contrastmg conceptions ofhealth and well-being, for example m relation to self-care(Hartweg 1990) Substantial detail on positive aspects ofhealth status and their assessment and modification is pro-vided m texts on health promotion and nursmg (Pender1987, Murray & Zentner 1989) In many cases it appearsthat nursing commentators use the term m a way whichcontrasts (positive) health promotion with care, cure andrehabilitation

Pender (1987) asserts that health protection is concernedwith preventing illness and includes environmental pro-tective measures and health service mitiatives (andindividual actions) Prevention is described as 'health pro-tecting behaviour' She asserts that different motivationalforces affect health protecting behaviour and health pro-moting behaviour This contrasts with the framework pro-posed by Tannahill (1985) noted earlier For Pender, healthprotection is directed toward 'decreasmg the probabilityof experiencing illness', whereas health promotion 'isdirected toward increasing the level of well-being and self-actualisation' of an individual or group

Pender (1987) goes on to outline a proposed model ofhealth behaviour The model addresses various 'cogmtive-perceptive factors' and notes 'situational' and demo-graphic features as 'modifying factors' Such limitedattention to the latter has been the basis of cnticism ofearly health/illness behaviour models (RUHBC 1988) andsome have developed models which emphasize social andstructural influences (Tones et al 1990)

Hartweg (1990) considers Brubaker's (1983) definitionof health promotion and its prmciple components it isdifferent from disease prevention, health meimtenance,health education and other medical terms, it is d3mamic,directed towards growth and well-being, and thirdly it canonly apply after health stability is achieved This can beconsidered an exclusive definition and contrasts with thenotion that health promotion incorporates other activitiesHartweg, drawmg on Pender's (1987) work, takes issuewith the latter descnptor — that health stability is neces-sary It should cater for people who do not fit idealisticnotions of health or 'high-level wellness'

The potential threat of 'heedthism' from over-emphasizmgthe pursuit of positive heedth has been identified byCrawford (1980) Brubaker's (1983) view also implies thathealth and illness are poles on a smgle continuum, and thishas been challenged by assertions that they constituteseparate (if mterrelated) entities (Pender 1987)

Health maintenance

Hartweg attempts to extend and clanfy the differencebetween health promotion £uid health maintenance but

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acknowledges that there is substantial overlap t>etween therelevant self-care activities Pender (1987) outlines levebof prevention within her distinct 'health protection' cate-gory, thus implying that any patient education of a preven-tive nature is quite different from health promotion Thisthen, IS in confhct with Hartweg's (1990) rejection ofBrubakers' (1983) point, Pender's view of health pro-motion IS also exclusive While Pender provides a wealthof supportive evidence, her subsequent focus is on individ-ual lifestyle, but nsk factors for disease are included (pre-vention) — illustrating the conceptual and practicaldifficulfy m maintaining her abstract distinction t)etweenhealth protection and health promotion

If health promotion is considered m exclusive terms(concerned only with positive health m this case) and isnot seen to incorporate a range of health related activities,it cannot embrace secondary and tertiary prevention, orrelated patient education

Other nursmg commentators hold different conceptionsof health promotion Research and literature m Bntain hasbeen concerned with nurses' role in secondary or tertiaryhealth education For example, MacLeod Clark's work hasfocused on nurse communication m relation to smokingcessation (MacLeod Clark et a7 1990) However, in generalthe terms communication, health education and healthpromotion often appear to be used almost mterchangeably,with no clear rationale for differentiation (Close 1988, Gott& O'Brien 1990a, Latter et al 1992)

Patient education

The use of the term patient education further confuses theissue Wilson Bamett (1988) attempted to differentiatepatient teaching, patient counselling and informationgiving Luker & Caress (1989) assert that patient edu-cation IS

the imparting of information, skills or knowledge by the nurse,with the aim of bringing about demonstrable behavioural or attitu-dinal change in patients

They note that teaching methods can vary While mmordetails in this statement can be challenged — not least theassumption that the nurse is always the patient teacher —It does approximate to the view of the author

Patient teaching and patient leammg are two parts ofthe equation Education descrit)es the whole process —mputs and outcomes The method and style can vary butteachmg is (or should be) concerned with the facilitationof learning (Rankm & DuSy 1983, Close 1988, Noble 1991)

The position held here is that health education includesany education associated with health — including pn-mary, secondary and tertiary patient education — thuscontnbuting to health promotion However, Tones et al'scategorization is useful They note that 'patient education'IS usually condition specific, health education is of a more

general nature In addition 'health promotion pohcies' area third aspect of health promotion mtervention withmhealth care settings and are concerned with changing theimmediate environment and reducing bamers to healthyhving (Tones et ai 1990)

Gott & O'Bnen's (1990a, 1990b) research mto usage inacademic literature and nursmg curricula found use of theterm health promotion to mean health education and com-mumcation The implications, they ai^ue, are that 'victimblaming' occurs in a different guise and that the real causesof lU-health remain This again could he challenged if onesees health education as a potentially empowenng contri-bution to health promotion (Tones 1992)

Gott & O'Bnen also challenge those nurse researcherswho focus only on nurse communication in bringii^ aboutmajor lifestyle changes in patients They note a perceptionthat 'health promotion is only about getting people to do"healthy things"' Even if it were the literature on behav-iour change suggests that longstanding change requiresmore than 'good communication' by a nurse (Gott &O'Brien 1990a)

This criticism can be extended to other commentatorswho assume that improved communication and convic-tion on nurses' part will lead to major improvements mtheir clients' health behaviour (see for example Rowland& Maynard (1989) who argue that nurses need persuadingof their role m alcohol education)

Developments within nursing

In general, it appears that developments within nursmghave been in some respects distinct from the health pro-motion field, which has been influenced by or absorbedpronouncements by the World Health Organization(Europe) Perhaps inevitably, nursing has to a large extentseen health promotion m terms of individual disease pre-vention, or positive well-being, playing down structuralissues or 'conditions of living' The perception that domg'healthy things' is the goal of health promotion could befostered by the emphasis on well-being and self-care innursing commentary (see for example Hartweg 1993)However, there is by no means a simple division

Pender, along with other nurse commentators addressesthe importance of 'socio-political strategies' for healthimprovement Conversely, we have noted that heedth pro-motion commentators vary m the extent to which struc-tural conditions are addressed Furthermore, generallythere appears to be a greater emphasis on 'policy' con-cerned with facihtatmg healthy lifestyles (tobacco andfood policy for example) than on wider public policy(Bunton 1992b, Delaney 1994)

There have, however been repeated calls for a politicaland policy role for nursmg throughout the profession(Salv^e 1985) Kendall (1992) has recently argued thatrather than helping people 'cope' nurses should help

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people 'fight back' against 'the forces which mamtam theirhomeles8ne88, hopelessness and himger' A model for'emancipatory nursmg interventions' is outlmed Denny &Jacob (1990) have advocated a health promotion role forhealth visitors which addresses structural influences onhealth and focuses on communities' perceived needs

Some commentanes conclude that nurses are not yetfulfilling their potential for effecting political change Gottk O'Brien (1990a) challenge some of the rhetoncal state-ments atrout nurses' role m health promotion and mrelation to 'HFA2000' They are sceptical about nurses'abihty to operate at a policy level A number of reasonsmay be suggested for this including concems about legit-imacy, lack of political awareness and general disem-powerment (Gott & O'Bnen 1990b, Chavasse 1992)However, even in the allegedly more limited health edu-cation role, many commentators suggest that nurses do notconduct health education or related activities well eitherTo what extent can this claim be upheld'

NURSES AS HEALTH EDUCATORS INPRACTICE

It IS the contention of this paper that confusion is inevi-table and results at least in part from the differential focusand emphasis m nursmg hterature and 'mainstream' litera-ture and in the conceptual variation and confusion withmthose two areas This also confounds attempts to oper-ationally define the notions for empincal research

Methodologically, it is extremely difficult to assess theextent and quality of nurses health education, let aloneother health promotion work Even direct observation islimited Early empincal work on the paucity and low stan-dard of nurses' health education (such as Syred 1981,MacLeod Clark 1983) is often and repeatedly cited Close(1988) and Noble (1991) note the predommance of non-research based articles on nursing and patient educationNoble (1991) cites Hockey & Zander from 1978

nurses now recognise teaching [is] part of their role but they failto have any specific methods or defined objectives for teaching

Have there really been no improvements' Empincalwork often utilizes small samples but Latter et al (1992)conducted a lai^e national study and Gott & O'Bnen's(1990b) work on health promotion was more wide rangingLatter et al found that senior staff m a majonty of distnctsreported that several categones of health education didtake place m acute settings They do comment on the prob-lems of operationalizing the concept etnd of differentinterpretations of familiar terms, such as informationgiving and patient education The extent, quahty and effectof these clearly cannot be assessed Taped or videorecordings have l)een used m assessing quality of com-munication in one-to-one interaction (MacLeod Clark &

Webb 1985, MacLeod Clark et al 1990) What does 'good'health education look and sound like'

Humanistic education

Empathy, a non-directive approach, open questioning,active listemng and an assessment of client's behe&, needsand concems are pnnciples of humanistic education,wtuch IS considered to be ethical, effective and em-powering At the same time, nurses have (usually) somenormative goal in mmd It is possible, even if undesirable,to produce changes m behaviour without adhenng to suchpnnciples

Gott & O'Bnen (1990b) comment on the mampulativenature of attempts to 'improve commumcation' andFahrenfort (1987) has questioned whether 'emancipatoryeducation' is feasible, desirable and consistent with thegoal of 'patient compliance' So, claims that 'health edu-cation' IS bemg undertaken may be accurate but thateducation may or may not be effective or comply withpnnciples MacLeod Clark's study of smoking cessationsuggests that generally, even where 'success' is demon-strated, nurses tend to resort to prescnptive, standardizedadvise (MacLeod Clark et al 1990)

Vanous reasons have been put forward for poor perform-ance lack of motivation, interest, skills, knowledge, time(Syred 1981, Close 1988, Delaney 1991) and ambivalenceabout the 'role model' notion (Clarke 1991) Noble (1991)asserts that

nurses of the 1990s seem to be more aware of the need for goodpatient education than ever before, but as a result of inadequatepre- and post-registration training they lack the skills required toprovide it

Impact of health-based curricula

Do health-based cumcula seem hkely to make an nnpact'One particular concem is that an emphasis in Project 2000curricula on 'health' appears to focus more on the abstractconceptual issues around definitions of health and theneed for health promotion, without a thorough explorationof practical implications and translation into clmical com-petencies Gott & O'Brien (1990a) support this claim Theyconclude that despite exhortations about heedth pro-motion, general and post-basic cumcula do not fullyaddress the potential range of activities and skillsAlthough there may be some movement toward morehohstic views of health, scant attention is given to thetranslation of general pronouncements mto skills andknowledge

Gott & O'Bnen (1990a) assert that terms like 'enable' and'empower' etre translated m practice into an emphasis oncommunication skills This can result m a mismatchbetween espoused pnnciples and actual t>ehavioiir on the

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part of the nurse Indeed, Bnmi (1990) goes further m hercntical analysis of health based Australian cumculaDespite their new terminology, cumcula reflect conserva-tive and reformist values and thus their ability to producereal change is questioned She suggests that the holistichealth rhetoric actually constitutes a 'healthism' whichretains medical model assumptions of location of andresponsibility for illness This derives from an emphasison wellness and holism which actually mdividualizeshealth and illness and an emphasis on client 'uniqueness'which results in 'abstraction of the client from their socialcontext' Such effects run counter to the WHO principlesof health promotion (WHO 1984)

One might suggest that this is an inevitable result of theover-emphasis on well-being and the promotion of positivehealth identified m nursing health promotion literatureThe emphasis on the nurse as a role model might also beconsidered as a form of healthism, blaming the nurse forunhealthy behaviour m isolation from the social (andoccupational) context of that behaviour (Delaney 1991)

Nurses' perceptions

A number of small unpublished studies of nurses' percep-tions suggest the follovnng tentative conclusions Nursesdo appear to see a legitimate role in patient and carer edu-cation However, nurses of all grades tend to confusehealth education and health promotion In particular,vague ideas that they are different may be held but theoperationalization of the differences — what they maymean in and to practice — is very unclear Or conversely,where clear distinctions are offered, they are not necessar-ily consistently and logically upheld Those schooled inhealth promotion may be able to recite definitions butthere is little evidence to suggest that this is ngorously orreadily related to everyday practice (Richardson 1992,Glossop 1993)

This problem is not peculiar to health promotion Arecent study of project 2000 courses foimd that the theory-practice gap remains (Elkan & Robinson 1993) althoughthe difference was one of emphasis not principle If thisIS the case for nursing m general, perhaps em even widergap should be expected between 'positive' bealth theory(and rhetonc) and practice, which with few exeptionsremains largely concerned with acute and chronic illness,pam and suffenng'

On the other hand, some of the studies reviewed hereand the work of student and practising nurses from a widerange of contexts, illustrates that many have internalizedprinciples and skills relevant to health education and otheraspects of health promotion, albeit those largely related tomdividual or community nursing practice Nurses andhealth visitors are supporting clients m a range of wayswhich appear to comply with nursmg and health pro-motion pnnciples

THE RELATIONSHIP BETWEEN NURSINGAND HEALTH PROMOTION

It IS at this point that a further reason for the conceptualand practical problems arises Nursing, despite healthydebate as to its nature, has adopted a number of corevalues, these might include canng, respect for persons,client-centredness, and a commitment to empowermentThere is clear overlap m some issues of concem and inter-ventions adopted between nursing and health promotionThis does not mean that nursing and health promotion aresynonjTnous nor that one might subsume the other

However, it then becomes difficult to assert that anyaspect of health promotion is distinct from nursmg —indeed, I argue that it is integral to nursing But, it isdifficult to identify distinct 'health promotion' activitiesm nursing practice It is inappropriate to be exclusive andsuggest that nurses are not really promoting health untilthey operate politically, it seems unfair to expect anygroup or individual to operate at all levels m health pro-motion Furthermore, we have noted the many calls forpolitical action for nurses — is this nursing or healthpromotion'

Ironically, the clearest aspect of health promotion thatcan be distinguished within nursing is health education,and even then education/support is mcreasmgly seen as alegitimate nursing role One might argue that fully andtotally compensatory activities are not health promotionbut that depends on whether one adopts inclusive, exclus-ive or pnncipled views of health promotion and whetherthe 'unhealthy' are excluded

General conclusions

Four general conclusions emerge from this accountFirstly, health education is a legitimate and valid part ofnursing work There may well be room for improvementIn particular, there should be an imderstanding of the ethi-cal and practical implications associated with encouragingor supporting personal change, by nurses and those whojudge their health education/promotion competenceNurses can play a role m educating groups, the generalpublic, policy makers and managers, as well as 'patients'

Secondly, as Gott & O'Bnen (1990a) assert, nurses' con-tnbution to health promotion will be dependent on contextand level Some will be active at policy levels, perhapsthe majonty will contnbute most through their education/support of individuals and communities

Thirdly, nursing and health promotion are lntncatelybound up and we need not feel anxious about the blumngof boundaries Ironically, the major potential difficulty liesin professional and institutional domsuns if we can'tclearly define and operationalize 'health promotion' howdo we know who does, teaches, measures and benefitsfrom i f This need not undermine professioned roles and

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remits and should he welcomed Multi-disciplmanty andmtersectoral collaboration are key prmciples of healthpromotion and are sought by the nursmg profession Theexchange of ideas is welcome and should tie fostered

Finally, although the difficulty of doing so has beenaddressed, climcal competencies and skills m health edu-cation and promotion (where appropnate) should be ident-ified £ind specified and addressed alongside the conceptualcontent of holistic, health-onented cumcula

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