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Nurses' roles in health promotion practice: an integrative review

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Virpi Kemppainen, Kerttu Tossavainen, Hannele Turunen, Nurses' roles in health promotion practice: an integrative review, Health Promotion International , Volume 28, Issue 4, December 2013, Pages 490–501, https://doi.org/10.1093/heapro/das034

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Nurses play an important role in promoting public health. Traditionally, the focus of health promotion by nurses has been on disease prevention and changing the behaviour of individuals with respect to their health. However, their role as promoters of health is more complex, since they have multi-disciplinary knowledge and experience of health promotion in their nursing practice. This paper presents an integrative review aimed at examining the findings of existing research studies (1998–2011) of health promotion practice by nurses. Systematic computer searches were conducted of the Cochrane databases, Cinahl, PubMed, Web of Science, PsycINFO and Scopus databases, covering the period January 1998 to December 2011. Data were analysed and the results are presented using the concept map method of Novak and Gowin. The review found information on the theoretical basis of health promotion practice by nurses, the range of their expertise, health promotion competencies and the organizational culture associated with health promotion practice. Nurses consider health promotion important but a number of obstacles associated with organizational culture prevent effective delivery.

The role of nurses has included clinical nursing practices, consultation, follow-up treatment, patient education and illness prevention. This has improved the availability of health-care services, reduced symptoms of chronic diseases, increased cost-effectiveness and enhanced customers' experiences of health-care services ( Strömberg et al ., 2003 ; Griffiths et al ., 2007 ). In addition, health promotion by nurses can lead to many positive health outcomes including adherence, quality of life, patients' knowledge of their illness and self-management ( Bosch-Capblanc et al ., 2009 ; Keleher et al ., 2009 ). However, because of the broad field of health promotion, more research is needed to examine the role of health promotion in nursing ( Whitehead, 2011 ).

The concept of health promotion was developed to emphasize the community-based practice of health promotion, community participation and health promotion practice based on social and health policies ( Baisch, 2009 ). However, empirical studies indicate that nurses have adopted an individualistic approach and a behaviour-changing perspective, and it seems that the development of the health promotion concept has not influenced practical health promotion practices by nurses ( Casey, 2007a ; Irvine, 2007 ). On the other hand, there has been much discussion about how to include health promotion in nursing programmes and how to redirect nurse education from being disease-orientated towards a health promotion ideology ( Rush, 1997 ; Whitehead, 2003 ; Mcilfatrick, 2004 ).

The aim of this integrative review was to collate the findings of past research studies (1998–2011) of nurses' health promotion activities. The research questions addressed were: (i) What type of health promotion provides the theoretical basis for nurses' health promotion practice? (ii) What type of health promotion expertise do nurses have? (iii) What type of professional knowledge and skills do nurses undertaking health promotion exhibit? (iv) What factors contribute to nurses' ability to carry out health promotion?

An integrative review was chosen because it allowed the inclusion of studies with diverse methodologies (for example, qualitative and quantitative research) in the same review ( Cooper, 1989 ; Whittemore, 2005 ; Whittemore and Knafl, 2005 ). Integrative reviews have the potential to generate a comprehensive understanding, based on separate research findings, of problems related to health care ( Kirkevold, 1997 ; Whittemore and Knafl, 2005 ). The integrative review was split into the following phases: problem identification, literature search, data evaluation, data analysis and presentation of the results ( Whittemore and Knafl, 2005 ).

Search method

Several different databases were searched to identify relevant published material. Systematic searches of the Cochrane databases, Cinahl, PubMed, Web of Science, PsycINFO and Scopus databases were undertaken 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 studies published during the period 1998–2011 because, prior to 1998, nurses' health promotion practice was mainly linked to health education.

Search result

The original search identified 1141 references: 119 in the Cochrane databases; 227 in Cinah, 345 in PubMed, 128 in the Web of Science, 100 in PsycINFO and 222 in Scopus. After duplicate papers were excluded one researcher (V.K.) read the titles and abstracts of the remaining 412 research papers. No specific evaluation criteria are employed when conducting an integrative review using diverse empirical sources; one approach is to evaluate methodological quality and informational value ( Whittemore and Knafl, 2005 ). All three researchers (V.K., K.T. and H.T.) defined the inclusion criteria together. Studies were included in the integrative review if they met the following criteria: the language had to be English, Swedish or Finnish, as translators for other languages were not available and the papers had to be published in peer-reviewed journals and describe nurses' health promotion roles, knowledge or skills and/or factors that contributed to nurses' ability to implement health promotion in nursing delivered through hospital or primary health-care services. The main exclusion criteria were: the published works were editorials, opinions, discussions or textbooks, or they described health promotion programmes, competencies other than health promotion or nursing curricula, or if the group studied included patients. The included studies were tabulated in chronological order under the following headings: citation, aim of the paper, methodology, size of the sample, measured variables, method of analysis, major results, concepts used as the basis of the study and limitations. Studies included in this review are available in Supplementary data, Table S1 .

Data analysis

Conducting an integrative review that analyses various types of research paper is a major challenge ( Whittemore and Knafl, 2005 ). In this review, the concept map method was adopted for both data analysis and presentation of the results. The use of concept mapping promotes conceptual understanding and provides a strategy for analysing and organizing information and identifying, graphically displaying and linking concepts. The concept map method was applied according to the recommendations of Novak and Gowin [( Novak and Gowin, 1984 ), p. 15–40] and Novak ( Novak, 1993 , 2002 , 2005 ). According to Novak ( Novak, 1993 , 2002 , 2005 ) the process of concept mapping involves six phases: (i) Identify a key question that focuses on a problem, issue or knowledge central to the purpose of the concept map. (ii) Identify concepts through the key question. (iii) Start to construct the concept map by placing the key concepts at the top of the hierarchy. After that, select defining concepts and arrange hierarchially below of the key concepts. (iv) Combine the concepts by cross-links or links between concepts in different segments or domains of the concept map. (v) Give the cross-links a name of a word or two. (vi) To concepts can be added specific examples of events or objectives that clarify the meaning of the concept.

All three researchers (V.K., K.T. and H.T.) were involved in the concept mapping process. The process proceeded as follows: first, one researcher (V.K.) 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 (V.K.) 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 then listing definitions of the concepts down the middle of each page. Other researchers (K.T. and H.T.) verified the first and the second phases of the concept mapping process. Third, one researcher (V.K.) continued the construction of each concept map by combining main concepts and definition concepts using links that were then named. Other researchers (K.T. and H.T.) critically evaluated the concept maps thus produced. Fourth, one researcher (V.K.) selected examples of the main concepts and these were listed on the right side of each page for clarification.

In the end 40 research papers, were included in our integrative review. The research papers were methodologically very diverse: 16 of them included qualitative approaches; 14 were different types of reviews; 8 were quantitative; 1 used concept analysis and 1 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 six between 2010 and 2011.

What type of health promotion provides the theoretical basis for nurses' health promotion practice?

The theoretical basis underlying nurses' health promotion activities was identified in 25 of the research papers ( Benson and Latter, 1998 ; McDonald, 1998 ; Robinson and Hill, 1998 ; Sheilds and Lindsey, 1998 ; Burge and Fair, 2003 ; Hopia et al ., 2004 ; Whitehead, 2004 , 2006a , b , c , 2009 , 2011 ; Berg et al ., 2005 ; Runciman et al ., 2006 ; Casey, 2007a , b ; Folke et al ., 2007 ; Irvine, 2007 ; Piper, 2008 ; Witt and Puntel de Almeida, 2008 ; Chambres and Thompson, 2009 ; Fagerström, 2009 ; Richard et al ., 2010 ; Samarasinghe et al ., 2010 ; Povlsen and Borup, 2011 ). According to these papers the theoretical basis of health promotion reflects the type of practical actions undertaken by nurses to promote the health of patients, families and communities. The research suggests that nurses work from either a holistic and patient-oriented theoretical basis or take a chronic diseases and medical-oriented approach. These theoretical foundations were considered to represent the main concepts of health promotion orientation and public health orientation in this review (Figure  1 ).

Concepts and examples of the theoretical basis of nurses' health promotion activities.

Health promotion orientation

The most common factor influencing the concept of health promotion orientation was individual perspective ( Robinson and Hill, 1998 ; Hopia et al ., 2004 ; Runciman et al ., 2006 ; Casey, 2007a ; Chambres and Thompson, 2009 ; Samarasinghe et al ., 2010 ; Povlsen and Borup, 2011 ). When nurses' health promotion activities were guided by individual perspective nurses' exhibited a holistic approach in their health promotion practice, they concentrated on activities such as helping individuals or families to make health decisions or supporting people in their engagement with health promotion activities ( Hopia et al ., 2004 ; Irvine, 2007 ; Chambres and Thompson, 2009 ; Samarasinghe et al ., 2010 ; Povlsen and Borup, 2011 ). Nurses' strategies for health promotion included giving information to patients and providing health education ( Casey, 2007a ). However, patient participation was mainly limited to personal aspects of care, such as letting patients decide on a menu, when to get out of bed and what clothes they wanted to wear ( Casey, 2007a ).

The second common defining concept of health promotion orientation was empowerment, which was related to collaboration with individuals, groups and communities ( McDonald, 1998 ; Berg et al., 2005 ; Whitehead, 2006a ; Irvine, 2007 ; 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 ).

The third common defining concept of health promotion orientation was social and health policy ( Benson and Latter, 1998 ; Whitehead, 2004 , 2006a , b , 2009 , 2011 ). These studies suggested that nurses' health promotion activities should be based on the recommendations in, for example, the World Health Organization's (WHO) charters and declarations and directives and guidance from professional and governmental organizations. However, the studies examined found that nurses were not familiar with social and health policy documents and that they did not apply them to their nursing practice ( Benson and Latter, 1998 ; Whitehead, 2011 ).

The last defining concept of health promotion orientation was community orientation ( Sheilds and Lindsey, 1998 ; Whitehead, 2004 ; Witt and 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. In addition a health promotion orientation appeared to result in nurses working more closely with members of communities, for example, being involved in voluntary work and implementation of protective and preventive health measures.

Public health orientation

Public health-orientated chronic disease prevention and treatment has traditionally been the theoretical basis of nurses' health promotion activities ( Burge and Fair, 2003 ; Berg et al ., 2005 ; Whitehead, 2006c ; Folke et al ., 2007 ; Casey, 2007b ; Irvine, 2007 ; Chambres and Thompson, 2009 ; Fagerström, 2009 ; Richard et al. , 2010 ). The first defining concept of public health orientation was disease prevention ( Berg et al ., 2005 ; Whitehead, 2006c , Folke et al ., 2007 ; Irvine, 2007 ; Fagerström, 2009 ; Richard et al. , 2010 ). According to these studies, this occurred in health promotion when the focus was on diagnosis, physical health and the relief of the physical symptoms of disease. The second defining concept of public health orientation was the authoritative approach ( Burge and Fair, 2003 ; Casey, 2007b ; Irvine, 2007 ; Chambres and Thompson, 2009 ). This approach emphasizes 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 ; Chambres and Thompson, 2009 ).

What type of health promotion expertise do nurses have?

The expertise of nurses with respect to health promotion was described in 16 research papers ( Robinson and Hill, 1998 ; Whitehead, 2001 , 2006b , 2007 , 2009 , 2011 ; Hopia et al ., 2004 ; Cross, 2005 ; Jerden et al ., 2006 ; Runciman et al ., 2006 ; Kelley and Abraham, 2007 ; Witt and Puntel de Almeida, 2008 ; Fagerström, 2009 ; Parker et al ., 2009 ; Goodman et al ., 2011 ; Whitehead, 2011 ). According to these papers nurses implemented a range of types of health promotion activity and applied different health promotion expertise across a wide range of nursing contexts. Depending on the context nurses are able to make use of a variety of types of expertise in health promotion. Nurses can be classified into: general health promoters, patient-focused health promoters and project management health promoters (Figure  2 ).

Concepts and examples of the types of nurses' expertise as health promoters.

General health promoters

Health promotion by nurses is associated with common universal principles of nursing. The most common health promotion intervention used by nurses is health education ( Robinson and Hill, 1998 ; Whitehead, 2001 , 2007 , 2011 ; Runciman et al ., 2006 ; Witt and Puntel de Almeida, 2008 ; Parker et al ., 2009 ). General health promoters are 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 ( Witt and Puntel de Almeida, 2008 ; Whitehead, 2009 ).

Patient-focused health promoters

There is growing recognition that different patient groups, such as the elderly or families with chronic diseases, have different health promotion needs. In promoting the health of these different groups, nurses can be regarded as patient-focused health promoters ( Hopia et al ., 2004 ; Cross, 2005 ; Jerden et al ., 2006 ; Kelley and Abraham, 2007 ; Goodman et al ., 2011 ). These studies revealed 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

Nurses should be able to plan, implement and evaluate health promotion interventions and projects ( Runciman et al ., 2006 ; Whitehead, 2006b ; Witt and Puntel de Almeida, 2008 ; Fagerström, 2009 ). Projects can facilitate the development of health promotion in nursing practice ( Runciman et al ., 2006 ). Thus, managers of health promotion projects should have advanced clinical skills and take the 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 ( Witt and Puntel de Almeida, 2008 ; Fagerström, 2009 ).

What type of professional knowledge and skills do nurses undertaking health promotion exhibit?

Nurses' knowledge of health promotion and their relevant practical skills were described in 18 research papers ( McDonald, 1998 ; Nacion et al. , 2000 ; Burge and Fair, 2003 ; Whitehead, 2003 ; Hopia et al ., 2004 ; Reeve et al ., 2004 ; Spear, 2004 ; Cross, 2005 ; Irvine, 2005 , 2007 ; Rush et al ., 2005 ; Jerden et al ., 2006 ; Casey, 2007b ; Kelley and Abraham, 2007 ; Piper, 2008 ; Witt and Puntel de Almeida, 2008 ; Wilhelmsson and Lindberg, 2009 ; Goodman et al ., 2011 ). These studies suggested that nurses' health promotion activities consisted of a variety of competencies. We classified these into multidisciplinary knowledge, skill-related competence, competence with respect to attitudes and personal characteristics (Figure  3 ).

Concepts and examples of nurses' health promotion competencies.

Multidisciplinary knowledge

Nurses' health promotion activities were often based on a broad and multidisciplinary knowledge ( Nacion et al ., 2000 ; Burge and Fair, 2003 ; Spear, 2004 ; Irvine, 2005 ; Casey, 2007b ; Witt and Puntel de Almeida, 2008 ; Whitehead, 2009 ). This included a 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 ( Burge and Fair, 2003 ; Spear, 2004 ; Irvine, 2005 ; Runciman et al ., 2006 ; Piper, 2008 ; Witt and Puntel de Almeida, 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 ( Burge and Fair, 2003 ; Irvine, 2005 ).

Skill-related competence

Nurses must possess a variety of health promotion skills; of these, communication skills were considered to be the most important ( McDonald, 1998 ; Nacion et al. , 2000 ; Burge and Fair, 2003 ; Hopia et al ., 2004 ; Irvine, 2005 ; Jerden et al ., 2006 ; Casey, 2007b ). Nurses play a particularly important role when they encourage patients and their families to participate in decision-making related to treatment or to discuss and express their feelings about situations associated with serious illness ( Hopia et al ., 2004 ). Skill-related competence also includes the ability to support behavioural changes in patients and the skill to respond to patients' attitudes and beliefs ( Burge and Fair, 2003 ). In addition, skill-related competence involves teamwork, time management, information gathering and interpretation and the ability to search for information from different data sources ( Irvine, 2005 ; Jerden et al ., 2006 ).

Competence with respect to attitudes

Competence with respect to attitudes emerged as a positive feature of health promotion ( Whitehead, 2003 ; Reeve et al ., 2004 ; Spear, 2004 ; Cross, 2005 ; Irvine, 2005 , 2007 ; Kelley and Abraham, 2007 ; Piper, 2008 ; Wilhelmsson and 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 and Lindberg, 2009 ). In addition, nurses who have personal experience, for example, of having had a baby, have a more positive attitude towards promoting the health of patients in the same situation ( Spear, 2004 ).

Personal characteristics

Traditionally, nurses were perceived to be healthy role models, engaging in healthy activities, not smoking and maintaining an ideal weight Burge and Fair, (2003) ; Reeve et al. , 2004 ; Rush et al ., 2005 ). In addition, personal confidence and flexibility are personal characteristics that nurses working in health promotion are expected to possess ( Burge and Fair, 2003 ; Rush et al ., 2005 ).

What factors contribute to nurses' ability to carry out health promotion?

Thirteen research papers identified features which contributed to nurses' health promotion activities ( Robinson and Hill, 1998 ; Reeve et al ., 2004 ; Jerden et al. , 2006 ; Runciman et al ., 2006 ; Whitehead, 2006b , 2009 , 2011 ; Casey, 2007a , b ; Kelley and Abraham, 2007 ; Wilhelmsson and Lindberg, 2009 ; Beaudet et al ., 2011 ; Goodman et al ., 2011 ). All of the features related to cultural aspects of the organization in which nurses work. We considered that these could be classified as either supportive or discouraging (Figure  4 ).

Concepts and examples of organizational culture associated with health promotion activities.

First, organizational culture consisted of three supportive aspects: hospital managers, culture of health and education. The hospital managers were responsible for whether health promotion was a strategically planned and whether it was considered to be of great importance ( Whitehead, 2006b , 2009 ). In addition, the hospital managers were key individuals in ensuring that health promotion activities did not conflict with other work priorities ( Jerden et al ., 2006 ; Casey, 2007a ; Beaudet et al ., 2011 ). Hospital managers also have an important role in cultivating a culture of health in the work community, for instance by prohibiting smoking during working time ( Casey, 2007a ). Education enhanced nurses' health promotion skills and health promotion projects were catalysts for health promotion in nursing practice ( Goodman et al ., 2011 ). Organizational culture included three discouraging factors. The major one was a lack of resources, including a lack of time, equipment (e.g. computers) and health education material ( Robinson and Hill, 1998 ; Reeve et al ., 2004 ; Runciman et al ., 2006 ; Casey, 2007b ; Kelley and Abraham, 2007 ; Wilhelmsson and Lindberg, 2009 ; Beaudet et al ., 2011 ). In addition, nurses may lack skills to implement health promotion in their working place ( Goodman et al ., 2011 ). Recent studies have also revealed that health promotion activities are still unclear to nurses ( Beaudet et al ., 2011 ; Whitehead, 2011 ).

Several authors have identified a need to clarify the concept of health promotion in nursing ( Goodman et al ., 2011 ; Whitehead, 2011 ). We found the concept map method useful to enhance conceptual understanding of this complex nursing phenomenon. This integrative review was intended to identify the findings of nursing-specific studies of health promotion activities published in the period 1998–2011. We identified 40 relevant English research papers. Most of these studies were published between 2005 and 2009. Combining qualitative and quantitative studies is complex and can introduce bias and error ( Whittemore and Knafl, 2005 ). The data examined herein originated from methodologically diverse research. Therefore, we should be cautious of generalizing our findings. 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 (V.K., K.T. and H.T.) during the research process; this enhanced our understanding and increased scientific rigour ( Jones and Bugge, 2006 ).

We found that health promotion and public health orientation have guided nurses' health promotion activities (e.g. McDonald, 1998 ; Whitehead, 2009 ; Richard et al ., 2010 ; Povlsen and Borup, 2011 ). It was surprising that, even though there has been much public debate and research has emphasized that health policies should guide nurses' health promotion activities worldwide, health policies have little impact on nursing practice (e.g. Benson and Latter, 1998 ; Irvine, 2007 ; Whitehead, 2011 ). 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 (e.g. Whitehead, 2008 ; Witt and Puntel de Almeida, 2008 ; Fagerström, 2009 ; Goodman et al ., 2011 ). The management of health promotion projects is particularly important, although only three studies ( Whitehead, 2006b ; Witt and Puntel de Almeida, 2008 ; Fagerström, 2009 ) described the type of expertise possessed by such managers. We found that there has been great interest in nurses' health promotion competencies (e.g. Irvine, 2005 , 2007 ; Witt and Puntel de Almeida, 2008 ; Wilhelmsson and Lindberg, 2009 ). A number of studies found that nurses' health promotion activities were based on multidisciplinary knowledge (e.g. Burge and Fair, 2003 ; Irvine, 2005 ; Whitehead, 2009 ). Interestingly, knowing about the trends that will influence the population's health in the future, such as multiculturalism, new technologies and ecological changes, were not identified as nurses' health promotion competencies. Unexpectedly for us the competencies associated with attitudes were not emphasized as one of the most important competencies even though nurses should be advocates of good health. We also 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. Burge and Fair, 2003 ; Reeve et al. , 2004 ; Rush et al. , 2005 ). Nurses are aware of the importance of health promotion, but organizational culture with respect to health promotion can either support or discourage them from implementing it (e.g. Reeve et al ., 2004 ; Casey, 2007a , b ; Goodman et al ., 2011 ; Whitehead, 2011 ). Managers in health-care organizations should appreciate the value of health promotion activities and ensure adequate resources for their implementation (e.g. Casey, 2007b ; Beaudet et al ., 2011 ).

According to much of the health promotion research, it appears that nurses have not yet demonstrated a clear and obvious political role in implementing health promotion activities. Instead, nurses can be considered general health promoters, with their health promotion activities based on sound knowledge and giving information to patients. Nursing is an appropriate profession in which to implement health promotion, but several barriers associated with organizational culture have a marked effect on delivery. Therefore, more research is needed to determine how to support nurses in implementing health promotion in their roles in a variety of health-care services.

V.K. was responsible for the computer-based data searches and the data analysis via the concept map method. K.T. and H.T. verified that the data searches were made properly. K.T. and H.T. verified that the concept mapping process proceeded properly and made critical appraisals in every phase of the research process. V.K. was responsible for the drafting of the manuscript. K.T. and H.T. made critical revisions to the paper for important intellectual contents, conceptualization, support in theorizing the findings and provided material support. K.T. and H.T. supervised the study.

This research received a specific grant from The Finnish Foundation for Nurse Education and The Finnish Nurses Association.

Virpi Kemppainen would like to acknowledge the support from the University of Eastern Finland, Department of Nursing Science.

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Effective approaches to health promotion in nursing practice, adele phillips senior lecturer in health promotion and public health, school of allied and public health professions, faculty of health and wellbeing, canterbury christ church university, canterbury, kent, england.

• To recognise the role of individuals’ lifestyles, the environment, healthcare organisations and biology in the prevention of illness and the maintenance of population health

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• To count towards revalidation as part of your 35 hours of CPD, or you may wish to write a reflective account (UK readers)

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This article defines the concept of health promotion and explains why it is essential for nurses to embed health promotion aims and values in their practice. It discusses how health promotion contributes to the improvement and maintenance of population health and contemporary public health agendas in the UK and worldwide. Using several practical activities, this article aims to encourage nurses to identify their own approach to promoting health in their professional role, consider how they can implement ‘Making Every Contact Count’ with the patients they care for, and enhance the overall effectiveness of their practice.

Nursing Standard . doi: 10.7748/ns.2019.e11312

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

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None declared

Phillips A (2019) Effective approaches to health promotion in nursing practice. Nursing Standard. doi: 10.7748/ns.2019.e11312

Accepted 19 November 2018

Published online: 04 March 2019

behaviour change - health inequalities - health literacy - health promotion - lifestyles - patient education - patient empowerment - patients - public health - wellbeing

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An assessment of nurses’ participation in Health Promotion: a knowledge, perception, and practice perspective

Herbert melariri.

1 Eastern Cape Department of Health, Port Elizabeth Provincial Hospital, Port Elizabeth, South Africa

2 School of Life and Health Sciences, University of Roehampton, London

TOLU ANDREA OSOBA

Margaret (maggie) williams.

3 Centre for Community Technology, School of Information Technology, Faculty of Engineering, Nelson Mandela University, Port Elizabeth, South Africa

PAULA MELARIRI

4 Department of Environmental Health, Nelson Mandela University, Summerstrand, Port Elizabeth, South Africa

Health promotion (HP) at the population level serves to improve health inequalities, enhance the quality of life, and ensures the provision of healthcare and related services. Nurses at all levels are charged with the task of ensuring that patients receive HP services. However, their competence in addressing this challenge needs further exploration. This study assessed the influence of HP knowledge and perceptions in nurses’ HP practice.

The study was conducted using a self-administered questionnaire among 184 nurses randomly sampled from a tertiary hospital. Questions bordered on respondents’ demographics, knowledge, perception, and practice of HP. Responses were retrieved and analysed using IBM SPSS Statistics, Version 26.0. Armonk, NY: IBM Corp, 2019.

Analysis showed a statistically significant relationship between participants demographics and possessing adequate knowledge to provide HP services. Statistically significant relationships were found amongst the following variables: ‘A holistic knowledge of disease pathology and processes are vital for effective care of patients’ and ‘education of patients on medication’ p = 0.001, ‘awareness of importance of educating patients about their condition’ and ‘patients encouraged to engage in healthy lifestyle’ p < 0.001.

Data showed that nurses’ knowledge regarding HP had a strong influence on their perception of HP. Their perception of HP in turn strongly influenced their practice of the same. Therefore, rigorous efforts must be made by governmental agencies, and organizations involved in healthcare worker training and nursing accreditation, to ensure the HP curriculum is well incorporated in nursing undergraduate training and sustained in service.

Introduction

Health Promotion involves a variety of approaches aimed at preserving the wellbeing and quality of life of people by addressing the fundamental causes of certain diseases as opposed to purely focusing on biomedical care [ 1 ]. Previously, health was seen as the very opposite of illness and diseases. With the Ottawa charter for HP in 1986, the World Health Organization effected a major change to the global view of health, not as a goal but a means to a full life [ 2 ]. As a result, HP emerged as a prime and essential activity for contemporary society with diverse initiatives and interventions designed by the World Health Organization aimed at translating the numerous concepts of HP towards practical reality [ 3 ]. Amongst the initiatives are the health-promoting hospitals (HPH) [ 4 ], health-promoting schools [ 5 ], health promotion in the sustainable development goals (SDGs) [ 6 ] and workplace-related HP [ 7 ]. These programmes have thrived due to the beneficial health outcomes emanating from them.

Today more than ever, nurses play a crucial role in HP. In addition to routine consultations and clinical duties, nurses are also involved in check-up care, patients education as well as disease prevention (DP) services [ 8 ]. In addition, nurses meaningfully contribute to several beneficial health outcomes such as educating patients on how prescribed medication works, therapeutic compliance [ 9 ], quality of life [ 8 ], and overall patient support and empowerment. To further uncover the importance of the nursing role in health promotion, Whitehead explored the current position of nursing concerning its practice, associated concept, and policy [ 10 ]. The questions raised included how much nurses know about HP and their views towards the subject of HP. Literature confirms that nurses utilize a range of expertise in delivering HP which may be generalized, patient-centered, or project management-related HP [ 8 ].

Despite the vital role nurses play in promoting population health, the prevalence of several preventable diseases continue to pose a major public health concern. In 2017, about 60% of patients presenting at all hospital emergency departments in the United States presented with preventable chronic conditions amounting to $8.3 billion in costs [ 11 ]. Relating to hospitalization, patients with chronic preventable diseases feature more frequently and stayed longer in hospital [ 12 ]. Similarly, in 2017 in India, more than 9.5 million deaths and nearly half a billion disability-adjusted life-years (DALY) were recorded [ 13 ]. Of the recorded deaths, more than 33% were considered to be preventable [ 13 ]. Within the low- and middle-income countries (LMIC), the adverse impact of the global burden of non-communicable disease (NCD) remains dire [ 14 ]. Despite widespread access to information regarding adjustable lifestyle behaviours, such knowledge does not necessarily translate to lifestyle changes [ 15 ].

South Africa is faced with a quadruple burden of disease comprising a mélange of four colliding epidemics [ 16 ]. These include communicable diseases such as HIV/AIDS and TB; maternal and child mortality; NCDs such as hypertension and cardiovascular diseases, diabetes, cancer, mental illnesses, and chronic lung diseases like asthma (mainly related to preventable lifestyle behaviour); as well as trauma and injury [ 16 ]. The quadruple burden of disease has led to the country’s adoption, in February 2013, of the 17-year visionary health plan for 2030 referred to as the national development plan (NDP) [ 16 ].

Nurses working at the various levels of healthcare delivery have a significant responsibility in HP, DP, and wellness. Due to the nursing profession’s ability to navigate the entire healthcare system worldwide, plus their role as patients’ advocates, nurses are in a position to achieve the comprehensive goal of universal health coverage (UHC) through HP. However, some reports have questioned nurses effectiveness in the discipline and practice of HP. In this study, we assessed the health promotion knowledge, perceptions, and practice of nurses in a South African tertiary hospital.

DESIGN, SAMPLE, AND RESPONDENTS

A descriptive cross-sectional design was used for this study. The population comprised of registered nurses working in a tertiary hospital in the Eastern Cape province of South Africa. The respondents were randomly selected from the overall population. Student nurses, and nurses on exchange training programs from different countries and auxiliary nurses were excluded from the study.

DATA COLLECTION

Data were collected using a self-administered structured questionnaire. Retrieved information was anonymised and only the principal researcher had access to the data. The questionnaire was adapted from a previous study [ 17 ] which had similar objectives. The questionnaire was administered over a three-month time frame between February and April 2017. Using a 95% confidence interval and a 5% error margin, a sample size of 184 was calculated. Data collection was stopped when the target sample size was achieved. Data collection was carried out by the principal investigator and a trained fieldworker.

SURVEY INSTRUMENT

The questionnaire (supplementary file 1) comprised of 22 closed-ended questions divided into four sections. Section A comprised of seven questions focused on demographics including sex, age group, registration status as a nurse, and duration of registration as a nurse. Section B (questions 8-9) elicited information on knowledge; Section C (questions 10-15) concentrated on nurses’ perceptions towards health promotion, while section D (questions 16-22) centered on nurses’ practice of health promotion.

DATA ANALYSIS

Data was analyzed using IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp, 2019. Simple descriptive analysis was conducted on all four sections (demographics, knowledge, perception, and practice) for which data were retrieved. Bivariate analysis was conducted to establish the relationship between demographics and knowledge, perception, and practice. A similar analysis was conducted to assess the relationship between perception and practice, knowledge, and practice, as well as knowledge and perceptions.

The study protocol received ethics approval from both the University of Roehampton, London, and the Research Ethics Committee (Human) (REC-H) of the Nelson Mandela University (NMU), Ref: H16-HEA-NUR-EXT-003. Every respondent signed an informed, written consent form prior to participation. The study comprised of a survey of non-vulnerable adults, and there was no potential for coercion of respondents, distress, loss of work time, or damage to professional reputation.

BASELINE CHARACTERISTICS

A total of 184 nurses responded to the questionnaire. Female nurses comprised 82.6% (n = 152), while males comprised 7.6% (n = 14) of the respondents. Genders for 9.8% (n = 18) were not specified. Most nurses, 72% (n = 133) were 40 years or above. Of the respondents, 35.9% (n = 66) have been registered for 10 years or less as nurses. Analysis on each variable is relative to the total responses Received: that variable. A descriptive summary of the variables has been presented in Tables I-IV .

Knowledge, perception and practice of health promotion.

Relationship between responses on health promotion perception and practices by nurses

SA: Strongly Agree; A: Agree; N: Neutral; DA: Disagree; SDA: Strongly disagree.

Relationship between Knowledge and Practice

Relationship between nurses’ knowledge and Perception regarding HP

KNOWLEDGE, PERCEPTION AND PRACTICE OF HEALTH PROMOTION

Of the participating 184 nurses, 56.0% (n = 103) agreed to having adequate knowledge regarding the conditions patients present within their units and their ability to provide health promotion services. A total of 63.6% (n = 117) respondents strongly held the perception that health education and counselling from nurses could enhance patients’ health, while 51.6% (n = 95) encourage their patients to observe fitness assessments and health screening. A descriptive summary of the respondents has been presented ( Tab. I ).

BIVARIATE ANALYSIS OF RELATIONSHIPS AMONG OUTCOMES

Results show that at a 5% significance level, there is a significant association between the professional registration duration of a nurse and them having adequate knowledge to provide HP services regarding the conditions patients present with in their unit (p = 0.015). Similarly, the demographic variable ‘age range’ has a statistically significant relationship with the perception that the hospital is an ideal place for HP to occur (p = 0.006). No statistical association was identified between nurses’ demography and practice.

In a comparative assessment of nurses’ perceptions and their HP practices as outcome variables, 21 variables were statistically significant ( Tab. II ). Of the 21 emerging factors, four emerged between the perception that a holistic knowledge of disease processes is a pre-requisite for patient care when compared with HP practice; four from the perception that a hospital is an ideal place for HP when compared with practices; four factors were observed from the perception that patients who engage in an unhealthy lifestyle will not benefit from HP when compared with HP practice; two from the perception that health education and counselling from nurses could enhance patients’ health when compared with HP practice; and seven factors from the perception that patients do not want health education from nurses when compared with HP practice. No statistically significant factor emerged from the perception that health promotion is a waste of time when compared with HP practice.

Comparison of the relationship between Knowledge and Practice yielded 11 statistically significant relationships ( Tab. III ). A breakdown of the 11 factors shows that nurses having adequate knowledge necessary for HP provision and practice had six significant factors, while the relationship between nurses being aware of the importance of providing health education (HE) to patients with HP practice produced five statistically significant relationships. The results showed that there were significant associations between ‘having adequate knowledge regarding the conditions patients present with in this unit to provide HP services’ and educating patients about their disease condition’, p < 0.001; ‘awareness of the importance of educating patients about their condition’and ‘patients encouraged to engage in healthy lifestyle’ p < 0.001.

Table IV shows the relationship between nurses’ knowledge and perception towards HP. The analysis showed nine significant associations emerging including: ‘having adequate knowledge regarding the conditions patients present with in this unit to provide HP services’ and ‘HE, advise and counseling from nurses could positively enhance patients health’, p < 0.001; ‘awareness of the important of educating patients about their condition’ and ‘patients do not want HE from nurses’, p < 0.001.

This study provides an assessment of nurses’ views regarding their knowledge, perception, and practice towards health promotion in a South African tertiary hospital. The data analysis revealed that nurses agreed to having adequate knowledge regarding their patients’ disease condition to provide adequate health promotion; that hospital is an ideal place to provide health promotion; and that they do encourage their patients to engage in the healthiest lifestyle they can attain. They therefore deserve a strong support system to enable them to sustain and improve their role in HP.

Findings from this study show that the duration of registration as a nurse was associated with adequate knowledge, indicating that experience adds to the nurses know-how and expertise [ 18 ]. Lartey et al. reported on the wealth of knowledge and wisdom associated with experienced nurses as being critical in the provision of high quality care to patients and their family [ 19 ]. Though this benefit of experience and adequate knowledge resulting from experience could be generalized in some cases, it is mostly discipline-specific. For example, it has been observed that nurses without exposure to health promotion and health literacy, regardless of their nursing experience, lack requisite knowledge in these disciplines [ 20 ].

The present study revealed the influence of nurses HP perception on their practice of HP. For example, the nurses who had the perception that holistic knowledge of disease pathology and processes are vital for effective care of patients were more inclined to educate their patients about adherence to medication, the importance of check-ups, and engagement in a healthy lifestyle. In a similar study by Al-Noumani et al., (2019), the authors demonstrated that adherence to medication was greater among those that believed in the importance of medication [ 21 ]. In the study of Ojong, Nsemo and Aji, (2020) conducted in Nigeria, it was observed that despite good knowledge and perception towards routine check-ups, there was still a poor practice of check-up care [ 22 ], which is an essential component of HP. The finding of good check-up practice in the current study may be related to the study context, in our case, a public tertiary hospital in South Africa where the public healthcare is solely funded by the state [ 23 , 24 ], and free transport services to and from hospitals are provided to indigent patients living in the rural areas [ 25 ]. A major fact regarding perception is its ability to become reality and guide people’s behavior [ 26 ]. In this study, the perception of the respondents is that holistic knowledge of disease pathology is a prerequisite for HP provision. This perception was formed based on their formal training and lived experience from practice. Furthermore, this study identified the perception “hospital is an ideal place for HP” as being associated with nurses using their smart devices to access supportive information during practice in order to educate patients about medication and the importance of regular check-ups. Evidence abounds regarding the efficacy of the HP effectiveness of nurses linked to organizational culture [ 8 ] as demonstrated in hospital settings [ 15 ]. Educating patients within healthcare institutions is a fundamental aspect of healthcare delivery. The educational roles of nurses therefore serve as a determinant in shared decision-making between nurses and patients regarding treatment adherence, improving the patients degree of satisfaction with service provision, and enhanced care.

Credible sources have been noted to be key players in the dissemination of public health messages amongst various groups [ 27 ]. Nurses occupy such a position among patients and are well suited to provide HP. Our results corroborate with the findings of Timmers et al., (2020) which demonstrated that educating patients at the point of care using prompt medical information accessed via smartphones and similar devices does enhance treatment compliance, satisfaction, and improves the eventual health outcome [ 28 ]. Although our study did not show a significant relationship between ‘hospital is an ideal place for HP’ and ‘educating patients about their disease condition’, the study of Nikitara et al., (2019) did indicate that nurses who are actively involved in educating patients with diabetes mellitus empower the patients to optimise management of their disease condition [ 29 ]. The reason for our finding of non association between hospital is an ideal place for HP and education of patient concerning their health condition could be related to the nurses lack of knowledge about specific disease entities [ 29 ].

The influence of knowledge among nurses correlated positively with regards to their HP practice in this study. It was noted that there was a statistically significant relationship between the provision of necessary guidance regarding diet and lifestyle to patients and adequate knowledge regarding the medical condition of the patients. Sufficient knowledge [ 30 , 31 ] is required in order for nurses to guide patients about smoking cessation, diet, and physical activity. However, in some hospital settings, nurses argue that it is the responsibility of specialists, such as dieticians, to provide dietary counselling to patients [ 30 ]. Despite this contention, enhancing the knowledge of nurses has proven to be a cost-effective strategy towards addressing the ever-increasing cost of healthcare [ 32 ]. In addition, optimum training and knowledge empowerment can embolden nurses to fully discharge their HP roles [ 32 ], including adequately guiding their patients on matters relating to necessary and health inducing diet and lifestyle changes.

This study was aimed at assessing the influence of HP knowledge and perceptions in the practice of HP amongst nurses working in a tertiary hospital. The data revealed that nurses’ HP knowledge played a key role in influencing their perception of, and eventual, HP practices. Health promotion is an important public health discipline necessary, and essential, for the achievement of universal health coverage. Nurses, due to their expertise and being regularly in touch with patients, especially those with chronic non-communicable diseases, occupy a distincitve place both in leadership and provision of HP services to their patients. A rigorous educational programme is required, in both undergraduate training and in the form of in-service training, to ensure that their knowledge of HP is updated. Future research is encouraged to interrogate the possibility of nurses achieving and sustaining a model that can bring about a realistic reform in HP.

Acknowledgements

The authors would like to acknowledge the Eastern Cape Department of Health, South Africa for granting access and space for this study, and the registered nurses that participated. No funding was received for this study from any funding agency.

Figures and tables

Conflict of interest statement

The authors declare no conflict of interest.

Authors’ contributions

Conceptualization: HM; Methodology: HM, TAO, MW, PM; Software: HM, PM; Validation: HM, TAO, MW, PM; Formal analysis: PM, HM; Investigation: HM; Data Curation: HM, PM; Writing - Original Draft: HM; Writing - Review & Editing: HM, TAO, MW, PM; Visualization: HM, TAO, MW, PM; Supervision: TAO, MW.

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-nurse student companion-, nurses role in health promotion essay.

Health promotion is a fundamental factor in the well-being of everyone. It is the "procedure of enabling people to have control of and develop their health" (WHO, 1986). It is important for individuals to take responsibility for their health by eating healthy and staying active but nurses are a vital ingredient in promoting wellness and a healthy lifestyle.Some do not know the best way to stay fit and rely on nurses for guidance. This discussion will reveal the different roles by a nurse in promoting health in various work environments.

Nurses Role in Health Promotion for Patients

Nurses' role in health promotion has a high rate of success since they work in various settings and interact with people from different cadres. They look after patients in healthcare facilities, patient homes and within the community. Most of the time, they perform a diagnosis and give the instructions to care givers hence they are the people to spend more time with the patients. Nurses therefore play a “key role in promoting patient health” (Irvine, 2005). The long hours they spend providing care enables them to understand other life aspects by patients in addition to the ailment they are recovering from to determine if their lifestyle is healthy. They are also able to follow up if a patient is following the instructions and advice on improving the quality of life.

Nurses interact widely with patients at different places getting an environment to educate and discuss the health status than the physicians who only meet with a patient in hospitals and clinics. It is the reason behind the argument that nurses have a potentially critical role in promoting patients’ health (Irvine, 2005). A good example is that it is the responsibility of nurses to provide continuity of care to a patient after a hospital discharge. Usually a community nurse will follow up on the progress of recovery. It will include educating the patients on how to live a healthier life and prevent diseases. For patients who are under the care of their families, a nurse also becomes an agent of healthy promotion to other people in the home. The ultimate point is that nurses can reach everyone.

Nurses Role in Health Promotion in Communities

To strengthen communities and to create a supportive environment are some of the pillars for supporting the initiative by world health organization (WHO) for having "health for all."

In every community, there is a nurse, but it is not usual to have doctors in the smaller neighborhoods. The proximity of nurses to members of the community enables them to be educators, advocates, and coordinators of promotion of health including lifestyle changes. (Blais& Hayes, 2011). Usually, it is upon nurses to educate their patients about the benefits of observing a healthy lifestyle including the essential habits that people neglect such as exercising, taking a balanced diet, exercising and getting an adequate amount of sleep.

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A nurse can coordinate a healthy plan with patients to substitute unhealthy choices with wholesome and beneficial alternatives. For instance, nurses are essential in creating a healthy meal plan and regimen for exercising to help obese persons in reducing their weight.

Another critical role that nurses play in promoting health is to encourage members of the community to attend regular screenings and early detection diagnostic tests (Blais& Hayes, 2011). The motivation helps in early detection of terminal illnesses such as cancer before reaching life threatening level.

Nurses Role in Health Promotion By Immunization

Immunization is a critical element and cost effective way of promoting preventive care. According to WHO, vaccination prevents up to three million deaths per year. Nurses play an essential role in advancing the health of children by administering an immunization.

"When functioning in a health promotion model" (Rankin 2005), each contact that nurse have with patients or their families is an opportunity to educate their patients or families. They advise parents on the excellent ways of taking care of their kids and coordinate childhood immunization programs in their respective areas. Also, they administer recommended immunization such as Hepatitis B vaccinations to adults, offer advice and administer travel vaccines.

As health care gravitates more from treatment to prevention of infections, nurses have a significant role in health promotion for patients, communities, and immunization for preventive purpose. With a range of ways to promote healthy living and preventing disease, nurses should be proactive in providing education on eliminating risk factors.

NursingWritingServices.com is a reputable online platform that provides top-notch nursing writing services to students and professionals in the healthcare industry. The website is dedicated to offering high-quality academic and professional writing services to meet the unique needs of individuals seeking nursing-related help.

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Health Promotion Model by Nola Pender Essay

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Introduction

Purpose of theory, explanation of the theory, concepts of the theory, practical application, health promotion model and research, health promotion model and education, reference list.

Nola Pender established the Health Promotion Model in 1962. According to Peterson and Bredow (2013), Nola’s model is an example of a middle-range theory. Middle-range theories “fill gaps between grand nursing theories and nursing practices” (Peterson & Bredow, 2013, p. 32). Nola established the theory to create a link between nursing studies and practices. The Health Promotion Model’s scope is narrow.

Consequently, it is possible to apply the theory in both research and practice. The theory focuses on behavioral standards of the lifestyle that affect one’s health. Chinn and Kramer (2011) posit that the insight of health is naturally recognized as the target of nursing. People realize their capacities through close interactions with nursing. Nola’s model offers a mutual relation worldview. The model’s multidimensional facts include spiritual, cultural, biopsychosocial, and environmental attributes. The theory is “holistic, and it sees individuals as the sum of individual parts interacting with their environment” (Pender, Murdaugh & Parsons, 2011, p. 47).

Pender came up with the Health Promotion Model to help nurses to identify the main factors that contribute to health behavior (Pender, Murdaugh & Parsons, 2011). In return, the nurses would come up with counseling programs aimed at advocating healthy ways of life.

The Health Promotion Model originated from two social theories, which are “The Bandura’s social cognitive theory and Fishbein’s expectancy-value theory” (Pender, Murdaugh & Parsons, 2011, p. 47). Fishbein’s expectancy-value theory holds that individuals are likely to invest their energy and resources in the activities that they believe will result in constructive outcomes. On the other hand, Bandura’s social cognitive theory alleges that self-worthiness encourages people to change their behavior. The nursing theoretical framework consists of four meta paradigms, which are personality, health, surroundings, and nursing (Chinn & Kramer, 2011). All these standards are incorporated in Pender’s model, and they are transposable. There is the interaction between personality, health, surroundings, and nursing when people start moving away from sickness and persistent disease en route for wellness and vigor. People are related to their surroundings, wellbeing, and nursing. Pender alleges that personal health is inseparable from the community health and that people are mutually dependent with the entirety of the universe. In other words, the theory holds that it is difficult for one to be well in the midst of an unhealthy world.

Pender’s approach pays attention to three areas, which are “Individual characteristics and experiences, behavior-specific cognitions and affect, and behavior outcomes” (May & Rew, 2012, p. 116).

According to Pender’s theory, every person has exclusive personal traits and skills, which influence their actions. In other words, past occurrences contribute to present and future knowledge. May and Rew allege, “The set of variables for behavior explicit knowledge and effect have important motivational significance” (2012, p. 116). The variables can be altered through nursing feats. Health endorsing action is the desired behavioral result, and which marks the climax of the Health Promotion Model. These variables should help to improve health, boost functional aptitude, and enhance the value of life throughout the development stages.

The Health Promotion Model is based on four fundamental concepts, which are person, the environment, nursing, and health. A person is “a biopsychosocial organism that is partially shaped by the environment but also seeks to create a climate in which inherent and acquired human potential can be fully expressed” (Butts & Rich, 2011, p. 57). Consequently, there is a mutual relationship between an individual and the surroundings. The theory posits that personal qualities and life experience play a greater role in shaping one’s health behavior. Pender believed that individuals have exclusive personal traits and knowledge that influence successive actions. These qualities, coupled with the environment, affect one’s behavior.

The environment as the second concept of the Health Promotion Model refers to the physical, cultural, and social background in which an individual grows (Butts & Rich, 2011). In many cases, people adopt certain behaviors based on upbringing. Hence, the theory claims that an individual can alter his or her environment to come up with a constructive framework of signs and catalysts for health-enhancing actions. Nursing is the third key concept of the Health Promotion Model. The model treats nursing as a collaboration between individuals, relatives, and society to nurture an appropriate atmosphere for the demonstration of the best possible fitness and high-level health. As mentioned earlier, personal health depends on the interaction between a person and his or her environment. The environment comprises of relatives and society at large. Pender’s model defines health as the realization of intrinsic and gained human capacity through objective-oriented behavior, proficient self-care, and mutual relationship with others (May & Rew, 2010). The model argues that health can only be achieved by making regular adjustments of personal behavior to suit the environment.

Pender’s Health Promotion Model is applied in daily life, particularly in the nursing environment. The model helps the nurses to relate personal traits with treatment procedures. Pender alleged that Health Promotion Model intends to help nurses to understand the key factors that contribute to health behavior as a foundation for behavioral counseling (Pender, Murdaugh & Parsons, 2011). Health Promotion Model is used in patient teaching. The model assumes that health practitioners can influence patients’ ways of life. Presently, Pender’s model is used in helping individuals suffering from cancer. The model supposes that personal behavior and actions contribute to a healthy or unhealthy life (Pender, Murdaugh & Parsons, 2011). Therefore, medical practitioners have used the model to initiate exercise as one of the measures to help breast cancer survivors. Besides, nurses have come up with a physical activity plan based on the Health Promotion Model. The program seeks to understand the patient’s past behavior, social and cultural environment, and personal influences to help in determining the right treatment.

Health Promotion Model is used in treating adults suffering from broken bones and fractures. Through Pender’s model, the nurses understand that adults’ past active lifestyle is likely to affect their recovery process. Consequently, the nurses come up with a treatment procedure that embraces the patient’s normal lifestyle (Pender, Murdaugh & Parsons, 2011). The nurses believe that patients can quickly recover if they use a treatment plan that does not alter their normal life. Moreover, nurses use the Health Promotion Model to help patients to understand how lifestyle may affect their recovery. In response, the patients strive to change their lifestyle as a way to assume full control of their wellbeing.

Rebecca Syx gives a case study of how the Health Promotion Model was used to treat a patient suffering from broken hip and blood pressure in her Orthopedic Nursing Journal (Pender, Murdaugh & Parsons, 2011). According to the article, nurses used Pender’s model to create a treatment plan that was related to the patient’s lifestyle. They incorporated the patient’s daily routine into the treatment plan to lure the patient into collaborating. Based on the Health Promotion Model, the nurses knew very well that factors like past routine and personal factors would affect the patient’s supposed benefits and hurdles to health endorsement. Consequently, they enlightened the patient on the importance of changing his lifestyle as a way to facilitate his healing process. Eventually, the patient was able to cope with the problem.

Pender’s Health Promotion Model is widely used in research. Present studies support the experimental worth of Pender’s Health Promotion Model. May and Rew allege, “Health Promotion Model has been used as a framework to gain information about cultural beliefs and values, and to demonstrate a need for culturally diverse health promotion programs” (2012, p. 117). The model has helped researchers to assess the current health promotion programs. What’s more, scholars have used Pender’s model to carry out descriptive studies aimed at explaining the present methods of preventing diabetes. In Taiwan, the Health Promotion Model has been used to research the sex disparity linked to physical activities. The model was preferred because it brings together the numerous elements that influence physical activity.

One of the studies that were conducted using the Health Promotion Model was the research conducted by Kerr, Lusk, and Ronis in 2002. The study sought to explain the rationale behind the use of hearing protection gadgets among Mexican American workers (May & Rew, 2010). The researchers used the model to verify the correlation between the use of hearing protection gadgets and cognitive-perceptual issues.

Health Promotion Model is used in varied fields. They include education, medical, and research fields. In education, the Health Promotion Model is used to create programs used in nursing education. The model has been used to educate nurses about the variables that affect health behavior (Butts & Rich, 2011). In return, nurses can create treatment plans that relate to these variables, therefore, helping patients to recover. Health Promotion Model amalgamates research findings from psychology, nursing, and public health. Thus, the model is used to train nurses on human health behavior. It equips the nurses with vast knowledge about psychological, social, and cultural variables that affect personal health. Hence, the nurses are left in a better position to deal with these variables. Apart from creating nursing education programs, the Health Promotion Model can be used to educate the public on ways to address health challenges like overweight. The model can be used to enlighten the parents on their role in curbing overweight among the school-going children. The repercussions of overweight are both communal and psychological. Therefore, the model can be used to teach the public about the social and psychological measures that can be used to address the challenges caused by overweight.

The Health Promotion Model is crucial in promoting a healthy lifestyle. The model helps medical practitioners to identify personal behavior and environmental factors that hamper a healthy way of life. One of the primary objectives of the design was to establish a link between nursing studies and practices. Indeed, the model has been used in numerous nursing education programs. Today, the model is used to train nurses on how to deal with behavioral variables that affect health behavior. What’s more, Pender’s model has been used to treat cancer survivors and adults recovering from broken bones. In research, the Health Promotion Model has helped the scholars to examine the existing health promotion programs. Moreover, the model has been used to study sex disparity linked to physical activities.

Butts, J. & Rich, K. (2011). Philosophies and theories for advanced nursing practice . Sudbury, MA: Jones and Bartlett Publishers.

Chinn, P. & Kramer, M. (2011). Integrated theory and knowledge development in nursing . St. Louis, MO: Elsevier.

May, K. & Rew, L. (2012). Mexican American youths’ and mothers’ explanatory models of diabetes prevention. Journal for Specialist in Pediatric Nursing, 15 (1), 6-15.

Pender, N., Murdaugh, C. & Parsons, M. (2011). Health promotion in nursing practice . Ohio: Ohio State University Press.

Peterson, S. & Bredow, T. (2013). Middle range theories: Application to nursing research . Philadelphia: Lippincott Williams & Wilkins.

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[Health promotion and prevention in nursing homes in the context of the German Prevention Act]

Affiliations.

• 1 Medizinische Fakultät, Institut für Gesundheits- und Pflegewissenschaft, Martin-Luther-Universität Halle-Wittenberg, Magdeburger Straße 8, 06112, Halle (Saale), Deutschland. [email protected].
• 2 Medizinische Fakultät & Uniklinik Köln, Institut für Pflegewissenschaft, Universität zu Köln, Köln, Deutschland.
• PMID: 37074449
• DOI: 10.1007/s00103-023-03690-8

Abstract in English, German

The German Prevention Act obliges the nursing care insurance funds to provide health-promoting interventions and preventive offers in nursing homes. These interventions should clearly differ from activating nursing care and be of proven effectiveness and cost-effectiveness.The present opinion article critically appraises the evidence base of the interventions belonging to the pre-defined preventive areas "nutrition," "physical activity," "cognitive resources," "psychosocial health," and "prevention of elder abuse." The interventions' underlying evidence is weak or even missing. It is unclear whether the interventions contribute to the intended strengthening of the health-promoting potential of care facilities and meet the goal of improving the health situation and resources of the care-dependent people. On the other hand, there are areas of prevention, which are not covered, but have great potential for improving the life situation of those in need of care, for example, in the context of person-centered care and a caring nursing culture.

Das Präventionsgesetz (PrävG) verpflichtet die Pflegekassen zur Einführung gesundheitsfördernder und präventiver Angebote in Pflegeheimen. Diese sollen sich von der aktivierenden Pflege unterscheiden sowie wirksam und kostenwirksam sein.In dem vorliegenden Diskussionsbeitrag wird die wissenschaftliche Fundierung von Maßnahmen der definierten Handlungsfelder „Ernährung“, „körperliche Aktivität“, „kognitive Ressourcen“, „psychosoziale Gesundheit“ und „Prävention von Gewalt“ kritisch hinterfragt. Die den Interventionen der Handlungsfelder zugrunde liegende Evidenz ist größtenteils unzulänglich oder nicht vorhanden. Es ist unklar, ob die Maßnahmen zur intendierten Stärkung der gesundheitsfördernden Potenziale von Pflegeeinrichtungen beitragen und dem Ziel dienen, die gesundheitliche Situation und die Ressourcen der Pflegebedürftigen zu verbessern. Demgegenüber drängen sich Präventionsbereiche auf, die in den Handlungsfeldern nicht abgebildet sind, aber ein großes Potenzial für die Verbesserung der Lebenssituation der Pflegebedürftigen haben, so unter anderem im Kontext einer personzentrierten Pflege und einer fürsorglichen Pflegekultur.

Keywords: Effectiveness; Health promotion; Nursing homes; Older age; Prevention.

© 2023. Springer-Verlag GmbH Deutschland, ein Teil von Springer Nature.

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Knowledge at Wharton Podcast

What does your writing style say about you, july 23, 2024 • 15 min listen.

Wharton’s Jonah Berger explains how writing style can predict future success.

Listen to the podcast.

Wharton marketing professor Jonah Berger discusses his published study, “ Topography of Thought ,” which was co-authored with Olivier Toubia , business professor at Columbia Business School. The paper examines how someone’s writing style can be indicative of their future success, and where generative AI might come into the picture.

Read an edited transcript below.

Studying How Successful People Think

Angie Basiouny: Give us an overview of this paper by way of explaining your title. What is topography of thought?

Jonah Berger: I don’t have to tell you that we all use language all the time. We write emails, make presentations, and submit job applications. We use language all the time. And language, in some sense, is a fingerprint. It reveals or reflects things about the people who produce it. You can predict how extraverted someone is, for example, based on the words they use.

But beyond the individual words people use, might the pattern of ideas they put out there, the way they organize their ideas, reveal something interesting about them and their likelihood of future success?”

I think it’s important to talk about what I mean about the pattern of ideas. When someone talks about something, they can cover a small amount of ground or a large amount of ground. If you ask someone about their work history, for example, they can talk about a variety of things they’ve done or a smaller set of things they’ve done. They can cover a lot of ground or a little bit of ground.

If you want to use an analogy here, you can almost think about going for a run. Someone can go for a run and go all the way around the city, or they can go for the same number of miles, but just go around the block a number of times. In both cases, they did the same distance, but they covered more ground in one than the other. So, one way we express ideas is the amount of ground we cover. We cover more ground with our ideas, or less. We can talk about more ideas, more topics, more themes, more things that are disparate from one another, or things that are related to one another.

But it’s not just that. It’s also the speed with which we move between adjoining ideas. Imagine a movie. It can cover more or less ground across the course of the movie, but it can also move faster or slower between ideas. If a movie has one scene, for example, that’s at the beginning of a wedding, if the next scene is the later part in a wedding, that’s related to the first part. Different things may happen, but it’s pretty closely related. But if you jump from a wedding to an action scene, that would be really different sorts of ideas. They’re not very related. They’re moving further across those two points.

We wondered if these two ideas, how much ground someone covers, and how quickly they move between ideas, might tell us something about their likelihood of future success.

Basiouny: You’re not talking about the length of the piece of writing. You’re not talking about whether it’s a 500-word essay or 1,000-word essay. It’s really about how they use that space to move through their ideas. Correct?

Berger: Yes, great point. It’s not about the length. It’s about the ground covered. Are they covering a lot of ground in their hundred or thousand words, whatever it is? Or are they covering less ground? Someone talking about their vacation could share 1,000 words, but they could use those words to talk just about the food they ate, or also to talk about the sights they saw and the places they visited.  The former would cover less ground while the latter would cover more.

Basiouny: How did you go about studying this?

Berger: The same ideas can be applied to any type of content, but here we looked at college applications. In other work we’ve looked at online reviews, and in related work we looked at books, movies, and TV shows.

We took 40,000 college application essays from a variety of folks who were applying to school, and we looked at what they wrote and the topography of thought of what they wrote — how much ground they covered in that essay. Again, similar length, but how much ground they covered, and how quickly they moved between ideas. And we looked at their future success. How well did they do in school? What was their GPA once they got there? We were interested in seeing whether, not just the individual words they use, but the way they express ideas might that reveal something or predict how likely they are to be successful in the future.

The Essay Writing Style That’s Linked to Greater Success

Basiouny: What did you find?

Berger: We found two very important things. First, covering more ground, that notion of covering a broad range of things in the same amount of length, was linked to greater success. But doing so while moving rather slowly, was also important.

Think about the numbers arrayed on a circular clock. You could cover a lot of ground by moving in a circle, (e.g., going from 12 to 1 to 2 to 3 to 4) or by traversing the same ground but going from like 12 to 6 to 1 to 7 to 3 to 11. You’ve covered the same amount of ground, but you’ve taken a much longer route between each individual point.

What we found is that folks who are successful in school are able to blend these two things that might seem mutually exclusive. It might seem like covering a lot of ground requires moving really quickly between points to get there. But folks that end up doing well in school figure out a way to cover that ground really efficiently. They’re able to do so by moving slowly between these points, and they don’t have to take a lot of big jumps along the way.

Basiouny: In this paper, you controlled for some socioeconomic factors. Can you talk about that a little bit?

Berger: Yes, so someone could wonder, “OK, so you’ve found that people did well in school, and you’re using writing as a way to indicate how they think. But does it indicate something else?” Maybe it’s just that people who do better on the SAT also have higher grades and also tend to write a certain way. Maybe it’s that people who have parents who are more educated tend to write a certain way and also do better in school. Or maybe people who have parents who are more educated can afford to pay for an essay consultant who helps them write a certain way and also helps them do better in school.

So, we controlled for a variety of different things. We controlled for what they wrote about. Maybe certain types of people tend to write about certain types of things, rather than other types of things. Maybe it’s not about how they write, it’s about what they wrote about — the topics or themes they discussed. No, it wasn’t that.

Maybe it’s parents’ education. No, we controlled for that. Maybe it’s SAT scores. No, we can control for that. What this suggests is that the topography of thought goes beyond things related to just socioeconomic factors or family background. It’s not just that people who might have had wealthier families, for example, tend to write a certain way or have application consultants and do better in school because they get tutoring. No, it really suggests that writing reveals something about the way we think, which can reveal or predict our likelihood of being successful in the future.

Implications Beyond College Essay Writing

Basiouny: There are other critical forms of writing that we do every day in business, like cover letters, resumes, a press release, communications to the C-suite. Can you take this research and translate it into a business context?

Berger: What I find fascinating about these ideas is yes, we looked at the case of college application essays, but it doesn’t have to be only about application essays. These same ideas should apply more broadly to a variety of contexts, whether it’s a cover letter that someone writes, whether it’s an online review that someone puts together, whether it’s the emails they write at the office — all these things provide insight into who people are and what they’re likely to do in the future. I think on a previous episode that you had me on, I talked about a paper I loved recently, where they can tell whether someone is going to default on the loan or not by the language they use in their application. Similarly, you can predict whether someone is going to get promoted or fired or leave a job for a better opportunity elsewhere based on the language they use in their email.

Most of this work that I just mentioned is using individual words, but I think what our work suggests beyond the individual words someone used, you can get insight into who they are, how they think, and how well they’re going to do in the future, based on the pattern of ideas that they have or their topography of thought.

Basiouny: As a manager, it gives you an indication of how they might move through their physical work or their knowledge work, right?

Berger: Yes, one thing we’re looking at right now is, as people learn more, does that change the way their topography of thought looks? Obviously, as we gain more knowledge in a given domain, we may talk differently. We may think about ideas differently. One thought we have is, “Hey, if people who are able to cover a lot of ground really efficiently by moving slowly between points, how did they get there? Are they naturally that way?” Probably not. They may have gained more knowledge along the way that allows them to represent their ideas differently.

One thing we’re doing right now is looking at online forums where people write multiple reviews over time. Someone, for example, might write hundreds of wine reviews over the years. They’ve learned more about wine years later. We’re looking at how do they represent ideas differently as they gain knowledge? And that may help us understand why people who represent ideas certain ways end up doing better.

Humans Still Write Better than ChatGPT and Gen AI — For Now

Basiouny: ChatGPT and artificial intelligence have entered the conversation. People have access to these free tools that can help them perfect their cover letters and written business communication. How does this change things? We can’t really tell how good someone’s topography of thought is if they have an AI-assisted piece of writing. What do we do?

Berger: Yes, so I’d say a couple of things. I agree with much of what you said, except one word. I’m not sure they allow you to “perfect” your writing. At least at the moment. What they do is allow you to write something pretty good quickly and easily. You give it a prompt, and it produces content that’s pretty interesting, does a pretty good job of doing something that might have been difficult for you to do.

And to a degree it uses your own content somehow. Like you could say, “Take my CV and use it to put together a cover letter based on my past experiences.” So that is based on you, and someone else’s might look different, to the degree that their CV is different, but I wouldn’t say it necessarily perfects anything. At least at the moment.

Certainly, tools like ChatGPT and others have made the production of content much easier, and I can imagine a time down the road where we do use them for many tasks, rather than writing ourselves. But I still think there is a lot to be understood about how language reflects the people that produce it and how to write more effective content, based on understanding what makes language impactful.

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