The Role of the Nurse in Health Promotion

University Degree Subjects allied to Medicine

Edward Bracher 0917308 09b (Masters)

The Role of the Nurse in Promoting Health

Introduction

Over the last few decades the promotion of a healthy lifestyle has attracted a huge amount of attention. Health has obviously been a well discussed issue politically and culturally (Bunton et al., 1995). This paper offers a history of the development of the idea of promoting health in order to properly understand what is meant by the term. The role of the nurse in health promotion is explored with specific reference to a patient undergoing bowel surgery. In order to do this a health promotion model is chosen by critically comparing two different models, and a health promotion strategy for the patient is developed using this model.

For the purpose of this paper The World Health Organisation (WHO) definition of health will be used. WHO describe health as not just about ones physical condition or absence of disease but encompasses a persons mental and emotional state, their social and societal position and their spiritual and sexual condition (WHO, 2010a).

Health Promotion

Health promotion is a phrase that can be used on a global, national or individual scale. Its exact meanings and the action taken to promote health can be different at different levels. For example a government will promote health in a very different way to a nation or community than a nurse will promote health to an individual or family on a hospital ward.

It was not until the end of the 70’s that the term health promotion became popular, however in under 10 years it became a powerful factor on the formation of national policy (Parish, 1995). The WHO defines health promotion as a process of empowerment. That is giving people the power to take control of and improve their own health. It does not just involve intervention in the behaviour of individuals but must include societal and environmental considerations (WHO, 2010b)”. The development of this definition by WHO will now be explored.

In 1977 the WHO started its Health for All (HFA) Campaign, this concept was introduced at the 1978 International Conference on Primary Healthcare where the Declaration of Alma-Ata was signed (WHO, 2003). This declaration noted that good health and the ability to participate in the planning of one's own healthcare was a fundamental right of all people. It also stated that the difference between the health of those in developed and developing countries, specifically the poor nutritional status of those in developing countries, was unacceptable and that it was the responsibility of all governments to cooperate and address this issue. The declaration suggests that primary healthcare is the key to achieving these goals and that primary healthcare is not just limited to the health sector but requires the coordinated efforts of the agricultural, food, industrial, educational and housing sectors. (International Conference on Primary Health Care, 1978). At the same time the Health Education Council in the UK was realising that previous approaches to improving the health of the nation were not adequate to noticeably improve the nation's health (Health Education Council, 1983). By 1985 HFA had 38 targets set for countries in the WHO European region. The UK signed this agreement and so agreed towards the HFA ideal.

This new awareness in the political arena led to a series of 7 global conferences on health promotion hosted by the WHO over the next 2 decades in order to achieve the targets set down in the 1985 HFA agreement. This started with the 1986 Ottawa Charter for Health Promotion (WHO, 1986) and ended with the 7th Global Conference on Health Promotion in 2009 (WHO, 2009a). These conferences first built upon the declaration at Alma-Ata and subsequently built upon each other.

They aimed to set down strategies on how to improve the health of the world. These strategies involved promoting the idea that health is the responsibility of all and that those writing health policy should be accountable for the health of those it affects. They also argue that our health is intrinsically linked to our environment and therefore a sociological approach to health is required and not just a clinical one and that in order to promote health we should create healthy working and living environments and educate the population on how to look after their own health. They build upon the idea that it is not just the health sector that is responsible for improving health but also that of social and economic sectors, non-governmental and voluntary organisations, local authorities, industry and the media (WHO, 1986, 1988, 1991, 1997, 2000, 2005, 2009a, 2009b).

The trend that can be seen through the history of the WHO conferences is that health promotion is about raising the quality of living and working environments and improving health education. This, alongside high quality healthcare, creates choices for individuals and communities about their health and empowers people to raise their health status. It is interesting to note that the role of the nurse in promoting health is not directly mentioned in the WHO health promotion conferences.

Models of Health Promotion

Tannahill’s Seven Domains of Health Promotion (1996)

Tannahill’s seven domains contains seven aspects of health promotion formed from combinations of three main activity groups.

Disease prevention applies to any measures that directly prevent disease, immunization is a good example. Health education activities involve educating people about maintaining their own health. An example of this could be teaching a diabetic to self administer their insulin. Health protection represents legal or legislative measures to protect health from negative influences. Legislation for food hygiene in restaurants is an example. The three main spheres then overlap forming combined forms of health promotion. Disease prevention and health education combine to form preventative health education. This is education aimed at preventing the onset or spread of disease. Educating on the use of effective contraception to combat sexually transmitted infections could be fitted into this category. A combination of health education and health protection is named education for health protection. This domain characterises activities that educate with an aim to increase awareness of health promotion. Preventative health protection is when disease prevention and health protection activities merge. This includes policy aimed at reducing the incidence of disease. A combination of all three main domains is named health education for preventative health protection. Educating policy makers on the benefits of providing a service for the prevention of a disease is an example.

Beatties Model of Health Promotion (1991)

Adapted from Beattie’s model of health promotion (Beattie, 1991).

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Beatties Model of Health Promotion (1991)

Adapted from Beattie’s model of health promotion (Beattie, 1991).

Beattie’s model of health promotion places health promotion activities on a dual axis (see diagram below). One axis represents an authoritative or negotiated approach. The second represents health promotion to an individual or to a collective. The authoritative verses negotiated axis represents the method used to promote health. It can be either “authoritative”, meaning the activity relies on decisions being made for those that are affected by said activity. Alternatively the method could be “Negotiated”, meaning to undertake action with the input of those affected by said action. The individual versus collective axis represents who the health promotion activity is aimed at. The individual side represents individuals or small isolated groups of people. Collectives are communities of people or groups of people with a similar health status or health concerns (Beattie, 1991).

A comparison of the models

Both models are attempts at mapping out different ways of approaching the topic of promoting health. Beattie’s model distinguishes between health promotion activities that are targeted at individuals or groups whereas Tannahill does not make this distinction. Tannahill, however, breaks down the types of activity into more detail than Beattie. Beattie’s authoritative versus negotiated concept is a very simple and easy to understand way to visualise different activities. Essentially Beattie is saying that either you tell people what to do, relying on a superior knowledge of what is best, or you attempt to work with those whose health you are trying to promote by using their own knowledge and experience of their specific circumstances to guide you. Tannahill has made a different approach. The spheres break down all health promotion activities into three main categories but at the same time allow activities to cross over into two or all three of the spheres. This is far more specific than Beattie’s very generalized approach. Is could be argued that this complexity is unnecessary. Although Tannahill’s model is better at classifying different activities into groups it does not offer advice on how to approach different targets. Beattie’s model, although arguably very limited in this context, goes some way towards doing this. In the opinion of this author some of the combined spheres in Tannahill’s model are very difficult to visualise mentally when visiting the model for the first time especially the central portion of the diagram which combines all three spheres.

Health Promotion for a Client with a Stoma

Client X has undergone an ileostomy to form a stoma. Details of Client X’s medical history and the reasons for performing the surgery are in appendix 1. How the surgery is performed is explained in appendix 2.

A stoma is hole on a person's body created by a surgeon which allows faeces (ileostomies and colostomies) or urine (urostomies) to be expelled. They are created for a wide range of reasons but it is beyond the scope of this assignment to cover them all. They are, however, only created when there is no or little other alternative and when an illness is going to deteriorate without the surgery (White, 1997).

Having a stoma is a huge change for any person. Needless to stay having moving a person's anus to their abdomen can cause them a wide range of problems and it is the job of a nurse to help them learn to manage and cope with their new stoma. This help is a form of health promotion, and in order for a person to return to health promptly a health promotion strategy must be put in place. For any health promotion strategy to be successful it must be well planned, implicated and then evaluated (Whitehead, 2003). This author will design a health promotion strategy for client X using Beattie’s model of health promotion as a starting point. Implicating this strategy will not be possible as this is a theoretical piece of work; however ways that the strategy could be evaluated after use will be discussed later. This model was selected for its relative simplicity and the ease at which it can be understood.

Potential Negative Influences on the Health of Client X

Personal image problems are not uncommon with this kind of surgery (Brown and Jacqueline, 2005). Client X now excretes faecal waste from a hole in his abdomen and has to wear a special pouch to collect it, which will be referred to here as a stoma appliance. These appliances, although designed to be discrete, are still different from anything anyone else normally has to wear. Client X is still young and is soon to be married. It can be assumed he has an active sex life and personal image issues could cause problems with sex. The surgery can also cause temporary damage to the blood vessels and nerves involved with sexual sensation in men and women (White, 1997). It is important that clients know that this is temporary and that they and their partner become comfortable with the stoma (Dansac Ltd, 2009). A stoma has to be cared for; appliances need to be changed when full and the surrounding skin kept healthy due to damage caused by the caustic nature of the contents of the ileum (White, 1997). Due to the wide range of different appliances available Client X will have to be educated on the right ones for him and then on how to use them properly to prevent leakage. During the changing process odour can be an issue, again linking back to personal image problems Client X will face. Wind movements can be less easily controlled from a stoma compared to the anus so embarrassing sounds could be another personal image problem. Less obvious psychological personal image issues could arise. Clients with stomas may get feelings of inadequacy and feel that they are no longer a complete person or they may worry that it looks repulsive and other people may notice it under their clothes. All of these points will need to be assessed. There are more issues that arise when considering how Client X will cope with day to day life and continue with activities and hobbies that he was used to (Simmons, 2007). Client X played football, he has a lot of friends and enjoys going out. Client X also has a young child and a second on the way who may not understand the stoma. The emotional health of the whole family unit must be considered since Mandle says that one family member can affect the health of others (Mandle, 2002). Client X’s diet is going to have to change. The colon is the primary area for water re-absorption from the stool. Its removal means waste from an ileostomy will be looser and more watery than usual so fluid and salt intake will have to increase. Chewing thoroughly to aid digestion and avoiding foods that cause you flatulence or foul odour will be advisable (Dansac Ltd, 2009). Worries about entering social situations, going back to work or travelling and the stoma appliance leaking or coming off are serious problems. Many stoma clients report a decrease in leisure activities, a reduction in the frequency of seeing friends and an increase in marital problems (Sprangers et al., 1995, Vironen et al., 2006). Again good education in stoma care and the continued support of healthcare professionals will be crucial. It may be helpful to design coping strategies and discuss worse case scenarios to help ease worries (White, 1997). Much of the bad feeling with a stoma may stem from a fear of the unknown so meeting other people who deal with a stoma could help.

Abraido-Lanza et al have suggested that patients suffering with chronic diseases adapt to a new lifestyle more easily if they accept their diagnosis (Abraido-Lanza et al., 2004). Assuming we can compare living with a stoma to living with a chronic disease then it is safe to say that a successful health promotion strategy should begin to be implemented before surgery even takes place. Client X is obviously an individual. It is going to require his co-operation and willingness to help himself in order for any health promotion strategy to be successful. The strategy will therefore fit into the “personal counselling for health section of Beattie’s model of health promotion. According to Beattie any activities involved are going to involve the client and health care professionals actively working together. Activities should be educational, teaching Client X about his condition and explaining why surgery is necessary. Client X should also be taught about what to expect from life with a stoma and how to cope with his appliances so that the shock of the reality is less severe. Giesse-Davis suggests that people with positive supportive relationships adapt better than those that do not. If his family is well educated and supports him then Client X will adapt quicker and his health will improve faster (Giesse-Davis et al., 2000). Familiarizing his fiancé with the change in his appearance could also have a positive influence their sexual activities. His young child could also be made familiar with the appliances so that she finds it easier to cope once her father has to wear them. Much of this education can be done at stoma clinics. These would be run by specialist stoma nurses that have a wealth of knowledge and experience helping clients with similar conditions. It would also help to meet clients who are about to face the same or similar surgery and clients who have undergone it already so that they can share their problems and successes. Before surgery, a stoma nurse should also discuss with Client X where the most convenient and comfortable place on his abdomen for the stoma is. This will take into account the kind of clothes worn, where the skin naturally folds and the practicality of that placement from the surgeons point of view.

Post surgery continual support is paramount. It is important that Client X does not start to feel neglected as it may be very difficult for him to cope alone. Nurses on his ward or a stoma nurse should begin education on how to use stoma appliances. Once he is discharged there will almost certainly be issues that need to be resolved. It must be made clear that support in the form of a community nurse network is available. Information leaflets covering where to get extra stoma supplies, hints and tips on sex and relationships, diet planning and things to consider whilst travelling are available for nurses to give to patients (Dansac Ltd, 2009). As a nurse you must be certain that your patient is capable of caring for them self. A patient who is not is likely to be a failed discharge.

Evaluation is an important stage of any health promotion strategy. Clinical governance should come into play here. The health promoter should be accountable for their actions and should be able to prove that their interventions were of benefit to Client X. (Whitehead, 2003) explains that both the process and the outcome should be evaluated. It is therefore recommended that Client X attend a series of follow up appointments with a stoma nurse to review how he is coping and resolve any issues. This should be an ongoing process that lasts until Client X is totally happy with his situation and able to live a full, happy, productive and healthy life. This evaluates the outcome. The process could be evaluated by using a questionnaire style audit tool, filled out by Client X, which asks him to reflect on his experience.

Conclusion

Health promotion is a huge concept encompassing a plethora of activities. The idea of promoting health has been debated for over 40 years. The average ward nurse is not involved in writing national policy or legislation Since nursing interactions on the whole involve individuals and small groups and not populations a nurses approach must be different (Latter, 1998). This health promotion strategy has shown that nurses are applicators of educational health promotion.

Using Tannahill's seven domains of health promotion (Downie et al., 1996), assuming this model comprehensively covers all types of health promotion activity and considering the distinction between individuals and collectives offered in Beattie's model of health promotion (Beattie, 1991), it can be shown that nurses have are involved with most types of health promotion activity. It has already been shown that nurses play a large part in educating individual patients about their health. Nurses also educate communities or groups of people. Examples of this include members of the Student Nurse Organisation increasing awareness of the need to donate blood at Salem Community College (Bournias, 2008), research nurses publishing evidence based papers on best nursing practice or nurse educators who train student nurses. Nurses regularly carry out activities that fit into the disease prevention domain. Tasks as simple as turning patients with reduced mobility to reduce the chances of pressure sores are forms of disease prevention to individuals as is the reduction of disability or complications caused by a chronic disease by implementing rehabilitation (USPSTF, 2010), even if this means a nurse referring a patient in their care to another member of the multi disciplinary team. Health protection involves legal and legislative activities which are less within the direct control of most nurses. It is possible however for nurses to influence local hospital policy and even national law by providing research and educating the right people about their working experiences. These are only a few examples of nursing activities which cover most of Tannahill's three main domains and there are countless others that will overlap to cover the other combined domains.

WHO defines health promotion as a form of empowerment (WHO, 2010b) giving people control over their own health. While this is a undoubtedly a large part of health promotion the activities described in this paper suggest that the role of the nurse in health promotion goes further than this and the author proposes the following definition. The role of the nurse in health promotion includes any activity carried out by a nurse or nurses which has a positive influence over the health, as defined by the WHO (WHO, 2010a), of an individual, group of individuals or community.

References

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Appendix 1 – Client History

Client X is a 31 year old male. He was described by one physiotherapist as being “Supremely fit”. Client X has a fiancé and young child and is currently trying for a second. He regularly plays football and goes out with friends. Client X has suffered from severe ulcerative colitis since 2006 but other than a broken foot and injured knee from sports he has no significant other medical history.

Ulcerative colitis is a form of inflammatory bowel disease. The exact causes of this condition are currently unknown but there is a genetic link and an inappropriate immune response is involved. The condition affects the colon and causes a steady loss of epithelium characterised by extensive ulceration. Bleeding, electrolyte imbalances and an increased chance of cancer are typical (Nowak, 2004).

For almost four years client X was able to control the condition with medication and prevent degeneration however towards the end of 2009 he visited his GP looking “washed out, pale and unwell”. He reported frequency of bowel movements, 7-9 a day, accompanied by a lot of blood in the stool which was loose and watery. Fainting was also reported including one episode which involved a fall down the stairs. The current medication was no longer working and the condition had deteriorated. Since alterative medications for this condition can cause fertility problems in men they were not suitable. It was at this point that surgery was offered as a solution and he was counselled by a colorectal nurse to help make his decision.

Surgery took place early in 2010. A colectomy and ileostomy was performed. After surgery antibiotics are prescribed to reduce the chances of post surgical infection and food and drink is given as tolerated. Recovery was fast with the patient being discharged after a week.

Appendix 2 - Colectomy and ileostomy

This involves removal of the colon leaving only the rectal stump in place. The ileum is then brought to the surface to create a stoma. The rectal stump can survive alone for up to four years and is left to leave the potential for the ileum to be reconnected to the rectum at a later date. The surgery is complex and takes a long time. First the colonectomy is performed. The colon is mobilised, this means it has to be separated from the surrounding fatty supportive tissue called the mesentery and disconnected from the blood supply by cutting and sealing the appropriate colic arteries. Next the colon is cut at the sigmoid section, leaving the rectum in place, and at the end where the colon joins the ileum, it is then removed. The ileostomy is then performed, the ileum is brought to the skin surface at a point designated by a stoma nurse prior to surgery and stitched into place. This new opening on the surface is called a stoma and is where the client’s bowels will now empty.

The Role of the Nurse in Health Promotion

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