role of nurse in health promotion essay

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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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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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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.

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Blog: A nurse’s role in promoting health and preventing ill health (from the bedside to the bingo hall)

Published on 31 May 2019

Read the latest blog from Sue West, Senior Nursing Education Adviser

As a nurse you have contact with people every day, and must make every interaction you have count. Each conversation or encounter with someone is a vital opportunity to help them improve their own health and wellbeing.

For some of us, this might mean providing motivational advice about the importance of staying well to someone with alcoholic liver disease. For others, it might mean helping an older person to exercise in a nursing home, or engaging with school children about healthy eating options.

It’s also about role modelling and providing the information, understanding and potential tools for individuals to make choices about their lifestyles.

However we do it, by improving public knowledge about health and empowering people to make positive choices for themselves, nurses can play their part to transform communities.

‘Promoting health and preventing ill health’ is so important that it’s one of the seven ‘platforms’ in our latest future nurse standards, which were published in May 2018. They’re the standards that every nurse must meet in order to join (and remain on) our register. So including this platform makes it clear that public health is every nurse’s responsibility.

The platform details what newly registered nurses need to know in this area. It includes:

• understanding the principles of health promotion, protection and improvement
• inequalities in health outcomes
• importance of early years and childhood experiences on the impact of life choices
• the determinants of health, illness and wellbeing in a global context. 

The proficiencies also focus on the power of communication and the need to help people make the most of their personal strengths and expertise to help them make informed choices about their care.

When I was at the recent Chief Nursing Officer for Wales 2019 Showcase Conference, I heard about many innovative nurse-led approaches in this area. These included holding health clinics not just in the general practice, but in the local barbers, betting shops and bingo hall. There is lots of great work happening in this area and no shortage of creativity – it’s important we keep sharing this best practice.

At the conference we also heard about the A Healthier Wales 5 year plan, which focuses on encouraging good health and wellbeing throughout life.

As you’d expect for such a key topic, all four countries of the United Kingdom have individual public health strategies with very similar objectives to our ‘future nurse’ standards. These cover:

• health improvement – enabling people and communities to improve their health and wellbeing by addressing the wider determinants of health
• health protection – preventing and responding to contagious or infectious diseases and environmental hazards, and promoting resilience to future risks
• health and care services – maximising the quality of health and care services for the population.

These strategies are very helpful resources for all of us. In Public Health England’s recently launched All Our Health strategy, you’ll find a wealth of evidence-based information about health improvement and illness prevention. They’ve even included tips on having brief conversations, health coaching and motivational interviewing.

These resources have been made even more user friendly with the launch of the new All Our Health e-learning sessions .

Our actions, large or small, can help people, communities and even whole populations to improve their health and wellbeing. Hopefully these resources will help, because wherever we work and in whatever role, we all want to deliver better, safer care.

Other recent news…

05.07.21 blog: #futurecommunitynurse: making the most of this opportunity.

Published on 05 July 2021

Our Chief Executive and Registrar, Andrea Sutcliffe, explains why your involvement in our consultation on draft standards for community and public health nursin

• Andrea Sutcliffe's blog

02.06.21 Blog: What we’re doing to improve how we regulate, for the benefit of the people we serve

Published on 02 June 2021

In her latest blog, Andrea Sutcliffe, our Chief Executive and Registrar, explains what we’re doing to improve how we regulate, for the benefit of the people we

13.05.21 Blog: Better, safer regulation for the public

Published on 13 May 2021

Our Executive Director of Strategy and Insight, Matthew McClelland, explains why the Government's proposed changes to our legislative framework will allow us to

• Last updated: 31/05/2019

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Advancing Healthcare through Comprehensive Health Promotion

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The Evolution of Health Promotion

The economic imperative of health promotion.

Shifting Focus: From Treatment to Prevention

The multi-dimensional role of nurses in health promotion, the three levels of health promotion, optimizing opportunities for health promotion.

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National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington (DC): National Academies Press (US); 2021 May 11.

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity.

• Hardcopy Version at National Academies Press

5 The Role of Nurses in Improving Health Equity

Being a nurse … in 2020 must mean being aware of social injustices and the systemic racism that exist in much of nursing … and having a personal and professional responsibility to challenge and help end them. —Calvin Moorley, RN, and colleagues, “Dismantling Structural Racism: Nursing Must Not Be Caught on the Wrong Side of History”

Health equity is achieved when everyone has a fair and just opportunity to be as healthy as possible. Nurses are well positioned to play a major role in addressing the underlying causes of poor health by understanding and recognizing the wide range of factors that influence how well and long people live, helping to create individual- and community-targeted solutions, and facilitating and working with interdisciplinary and multisector teams and partners to implement those solutions. Nurses have the potential to reshape the landscape of health equity over the next decade by expanding their roles, working in new settings and in new ways, and markedly expanding efforts to partner with communities and other sectors. But for the United States to make substantial progress in achieving health equity, it will need to devote resources and attention to the conditions that affect people’s health and make expanded investments in building nurse capacity. And nursing schools will need to shift education, training, and mindsets to support nurses’ new and expanded roles.

When this study was envisioned in 2019, it was clear that the future of nursing would look different by 2030; however, no one could predict how rapidly and dramatically circumstances would shift before the end of 2020. Over the coming decade, the nursing profession will continue to be shaped by the pressing health, social, and ethical challenges facing the nation today. Having illuminated many of the health and social inequities affecting communities across the nation, the COVID-19 pandemic, along with other health crises, such as the opioid epidemic ( Abellanoza et al., 2018 ), presents an opportunity to take a critical look at the nursing profession, and society at large, and work collaboratively to enable all individuals to have a fair and just opportunity for health and well-being, reflecting the concept of “social mission” described by Mullan (2017 , p. 122) as “making health not only better but fairer.” This chapter examines health equity and the role of nursing in its advancement in the United States.

As stated previously, health equity is defined as “the state in which everyone has the opportunity to attain full health potential and no one is disadvantaged from achieving this potential because of social position or any other socially defined circumstance” ( NASEM, 2017a , p. 32). While access to equitable health care, discussed in Chapter 4 , is an important part of achieving health equity, it is not sufficient. Health is affected by a wide range of other factors, including housing, transportation, nutrition, physical activity, education, income, laws and policies, and discrimination. Chapter 2 presents the Social Determinants of Health and Social Needs Model of Castrucci and Auerbach (2019) , in which upstream factors represent the social determinants of health (SDOH) that affect individuals and communities in a broad and, today, inequitable way. Low educational status and opportunity, income disparities, discrimination, and social marginalization are examples of upstream factors that impede good health outcomes. Midstream factors comprise social needs, or the individual factors that may affect a person’s health, such as homelessness, food insecurity, and trauma. Finally, downstream factors include disease treatment and chronic disease management.

Much of the focus on the education and training of nurses and the public perception of their role is on the treatment and management of disease. This chapter shifts that focus to nurses’ role in addressing SDOH and social needs, including their potential future roles and responsibilities in this regard, and describes existing exemplars. First, the chapter provides a brief overview of nurses’ role in addressing health equity. Next, it describes opportunities for nurses to improve health equity through four approaches: addressing social needs in clinical settings, addressing social needs and SDOH in the community, working across disciplines and sectors to meet multiple needs, and advocating for policy change. The chapter then details the opportunities and barriers associated with each of these approaches.

NURSES’ ROLE IN ADDRESSING HEALTH EQUITY

As described in Chapter 1 , the history of nursing is grounded in social justice and community health advocacy ( Donley and Flaherty, 2002 ; Pittman, 2019 ; Rafferty, 2015 ; Tyson et al., 2018 ), and as noted in Chapter 2 , the Code of Ethics for Nurses with Interpretive Statements, reiterated by American Nurses Association (ANA) President Ernest J. Grant in a public statement, “obligates nurses to be allies and to advocate and speak up against racism, discrimination, and injustice” ( ANA, 2020 ).

Addressing social needs across the health system can improve health equity from the individual to the system level. The report Integrating Social Care into the Delivery of Health Care identifies activities in five complementary areas that can facilitate the integration of social care into health care: adjustment, assistance, alignment, advocacy, and awareness ( NASEM, 2019 ) (see Figure 5-1 and Table 5-1 ). In the area of awareness, for example, clinical nurses in a hospital setting can identify the fall risks their patients might face upon discharge and the assets they can incorporate into their lives to improve their health. In the area of adjustment, telehealth and/or home health and home visiting nurses can alter clinical care to reduce the risk of falls by, for example, helping patients to adjust risks in their homes and learn to navigate their environment. And these activities can continue to the high level of system change through advocacy for health policies aimed at altering community infrastructure to help prevent falls.

Areas of activity that strengthen integration of social care into health care. SOURCE: NASEM, 2019.

Definitions of Areas of Activities That Strengthen Integration of Social Care into Health Care.

In short, improving population health entails challenging and changing the factors and institutions that give rise to health inequity through interventions and reforms that influence the institutions, social systems, and public policies that drive health ( Lantz, 2019 ). It is important to note, however, that there are shortcomings in how evaluations of health equity interventions are carried out (see Box 5-1 ).

Shortcomings of Evaluations of Health Equity Interventions.

• ADDRESSING SOCIAL NEEDS IN CLINICAL SETTINGS

Although the provision of clinical care is a downstream determinant of health, the clinical setting presents an opportunity for nurses to address midstream determinants, or social needs, as well. Screening for social needs and making referrals to social services is becoming more commonplace in clinical settings as part of efforts to provide holistic care ( Gottlieb et al., 2016 ; Makelarski et al., 2017 ; Thomas-Henkel and Schulman, 2017 ). Nurses may conduct screenings; review their results; create care plans based on social needs as indicated by those results; refer patients to appropriate professionals and social services; and coordinate care by interfacing with social workers, community health workers, and social services providers. Although the importance of screening people for social needs has led more providers to take on this role, it has yet to become a universal practice ( CMS, 2020 ; NASEM, 2016 ), as most physician practices and hospitals do not perform screenings for the five key domains of social need 1 : food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence ( CMS, 2020 ; Fraze et al., 2019 ). As trusted professionals that spend significant time with patients and families, nurses are well equipped to conduct these screenings ( AHA, 2019 ). Federally qualified health centers (FQHCs)—community-based health centers that receive funds from the Health Resources and Services Administration’s (HRSA’s) Health Center Program—often screen for social needs.

In many clinical settings, however, challenges arise with screening for social needs. Individuals may be hesitant to provide information about such issues as housing or food insecurity, and technology is required to collect social needs data and once obtained, to share these data across settings and incorporate them into nursing practice in a meaningful way. While nurses have an educational foundation for building the skills needed to expand their role from assessing health issues to conducting assessments and incorporating findings related to social needs into care plans, this focus needs to be supported by policies where nurses are employed. As the incorporation of social needs into clinical consideration expands, nurses’ education and training will need to ensure knowledge of the impact of social needs and SDOH on individual and population health (see Chapter 7 ). Communicating appropriately with people about social needs can be difficult, and training is required to ensure that people feel comfortable responding to personal questions related to such issues as housing instability, domestic violence, and financial insecurity ( Thomas-Henkel and Schulman, 2017 ). Finally, the utility of social needs screening depends on networks of agencies that offer services and resources in the community. Without the ability to connect with relevant services, screenings and care plans can have little impact. Consequently, it is important for health care organizations to dedicate resources to ensuring that people are connected to appropriate resources, and to follow up by tracking those connections and offering other options as needed ( Thomas-Henkel and Schulman, 2017 ).

• ADDRESSING SOCIAL NEEDS AND SOCIAL DETERMINANTS OF HEALTH IN THE COMMUNITY

While interest in and action to address social needs in the clinical setting is rapidly expanding, nurse engagement in these issues in community settings has been long-standing. Nurses serving in the community often work directly to address social needs at the individual and family levels, and often work as well to address SDOH at the community and population levels. Public health nurses in particular have broad knowledge of health issues and the associated SDOH, as well as needs and resources, at the community level. Embedded within the community, they also are well positioned to build trust and are respected among community leaders. Also playing important roles in addressing social needs within the community are home visiting nurses. At the individual and family levels, home visiting nurses often represent the first line of health care providers with sustained engagement in addressing social needs for many individuals. They recognize and act on the limitations associated with social needs, such as the inability to afford transportation, or may work with an interdisciplinary team at the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinic to address food issues and other social needs. By connecting with individuals in their neighborhoods and homes, public health and other community-based nurses promote health and well-being for families within communities and engage in this work with partners from across social, health, and other services.

At the population health level, public health nurses work to achieve health equity within communities through both health promotion and disease prevention and control. They often work in municipal and state health departments and apply nursing, social, epidemiology, and other public health sciences in their contributions to population health ( Bigbee and Issel, 2012 ; IOM, 2011 [see AARP, 2010 ]; Larsen et al., 2018 ). They offer a wide range of services to individuals and community members and are engaged in activities ranging from policy development and coalition building to health teaching and case management ( Minnesota Department of Health, n.d. ). Public health nurses serve populations that include those with complex health and social needs, frail elderly, homeless individuals, teenage mothers, and those at risk for a specific disease ( Kulbok et al., 2012 ). Their interventions may target specific health risks, such as substance use disorder, HIV, and tobacco use, or populations at risk for health problems, such as individuals with complex health and social needs. Specific knowledge and skills they bring to communities include the ability to perform assessments of individual, family, and community health needs; use data and knowledge of environmental factors to plan for and respond to public health issues in their community; provide community and health department input in the development of policies and programs designed to improve the health of the community; implement evidence-based public health programs; and develop and manage program budgets ( Minnesota Department of Health, n.d. ).

Public health nursing roles are characterized by collaboration and partnerships with communities to address SDOH ( Kulbok et al., 2012 ). Core to public health nursing is working across disciplines and sectors to advance the health of populations through community organizing, coalition building, policy analysis, involvement in local city and county meetings, collaboration with state health departments, and social marketing ( Canales et al., 2018 ; Keller et al., 2004 ). Yet, while the work of public health nurses is foundational to the health of communities, their work is rarely visible. Additionally, regarding measurable reductions in health disparities, little research is available that connects directly and explicitly to public health nursing roles ( Davies and Donovan, 2016 ; Schaffer et al., 2015 ; Swider et al., 2017 ).

Recent experiences with H1N1, Ebola, Zika, and COVID-19 underscore the importance of having strong, well-connected, well-resourced social services, public health, and health care systems, matched by an adequate supply of well-educated nurses. A 2017 report from the National Academies of Sciences, Engineering, and Medicine focused on global health notes that when infectious disease outbreaks occur, significant costs are often associated with fear and the worried-well seeking care ( NASEM, 2017b ). In their role as trusted professionals, and given their widespread presence in communities, incorporating public health nurses into community, state, and federal government strategies for health education and dissemination of information can help extend the reach and impact of messaging during infectious disease outbreaks and other public health emergencies. Nurses can serve as expert sources of information (e.g., on preventing infectious disease transmission within their communities) ( Audain and Maher, 2017 ). In the United States, for example, as Zika infections were identified and spreading, one of the strategies used by the U.S. Department of Health and Human Services (HHS) was to work through nursing associations to reach nurses and through them, help reach the public with factual information and minimize unnecessary resource use (Minnesota Department of Health, 2019 ). Given their expertise in community engagement and knowledge of local and state government health and social services assets, public health nurses are well positioned to link to and share health-related information with community partners to help reach underresourced populations, including homeless individuals, non-English-speaking families, and others.

• WORKING ACROSS DISCIPLINES AND SECTORS TO MEET MULTIPLE NEEDS

As nurses work in concert with other sectors and disciplines, interventions that address multiple and complex needs of individuals and communities can have far-reaching impacts on health outcomes and health care utilization. Through partnerships, community-based nurses work to address an array of health-related needs ranging from population-level diabetes management to community-based transportation to enable low-income families to access health care services.

Because multiple factors influence individual and population health, a multidisciplinary, multisectoral approach is necessary to improve health and reduce health inequity. While an approach focusing on only one SDOH may improve one dimension of health, such as food insecurity, intersectional approaches that simultaneously address complex, holistic needs of individuals, families, and communities are often required. Commonly found across underresourced communities are layers of intersecting challenges impacting health, ranging from adverse environmental exposures to food deserts. Health care systems, community-based organizations, government entitities, nurses, and others are increasingly working together to design interventions that reflect this complexity ( NASEM, 2017a , 2019 ). Creative alliances are being built with for-profit and not-for-profit organizations, community groups, federal programs, hospitals, lending institutions, technology companies, and others ( NASEM, 2019 ).

Work to prioritize and address health disparities and achieve health equity is predicated on meaningful, often multidimensional, assessments of community characteristics. One key opportunity to inform multisectoral efforts lies in community health needs assessments. The Patient Protection and Affordable Care Act requires nonprofit hospitals to conduct these assessments every 3 years, with input from local public health agencies. These assessments are then used to identify and prioritize significant health needs of the community served by the hospital while also identifying resources and plans for addressing these needs. Conducting a community health needs assessment is itself a multisectoral collaboration as it requires engaging community-based stakeholders ( Heath, 2018 ). The results of the assessment present opportunities for multiple sectors to work together. For example, a hospital may partner with public health and area food banks to address food insecurity. Or it may partner with a health technology company and a local school board to address digital literacy for underserved youth and their families, and also extend the reach of broadband to support health care access through telehealth technology and strengthen digital literacy. In assessing the community’s health needs, these hospitals are required to obtain and consider community-based input, including input from individuals or organizations with knowledge of or expertise in public health. The reports produced as part of this process are required to be publicly available ( IRS, 2020 ).

These and other community engagement efforts can involve nurses from a variety of clinical and community-based settings in any and all steps of the process, from design to implementation and evaluation of the assessments themselves or the processes and programs established to address identified priorities. For example, the Magnet recognition program of the American Nurses Credentialing Center requires participating hospitals to involve nurses in their community health needs assessments ( ANCC, 2017 ).

A variety of models feature nurses directly addressing health and social needs through multidisciplinary, multisectoral collaboration. Two illustrative programs are described below: the Camden Core Model and Edge Runner.

Camden Core Model

The Camden Coalition, based in Camden, New Jersey, is a multidisciplinary, nonprofit organization that works across sectors to address health and social needs. The Coalition’s formation was based on the recognition that the U.S. health care system far too often fails people with complex health and social needs. These individuals cycle repeatedly through multiple health care, social services, and other systems without realizing lasting improvements in their health or well-being. The Coalition employs multiple approaches that include using faith-based partnerships to deliver health services and encourage healthy choices; sharing data among the criminal justice, health care, and housing sectors to identify points of intervention; and building local and national coalitions to support and educate others interested in implementing this model ( Camden Coalition, n.d. ). One of the Coalition’s best-known programs is the Camden Core Model. This nationally recognized care management intervention is an example of a nurse-led care management program for people with complex medical and social needs. It applies the principles of trauma-informed care and harm reduction with the aim of empowering people with the skills and support they need to avoid preventable hospital use and improve their well-being ( Finkelstein et al., 2020 ; Gawande, 2011 ). The model uses real-time data on hospital admissions to identify “superutilizers,” people with complex health issues who frequently use emergency care. An interprofessional team of registered nurses (RNs) and licensed practical nurses (LPNs), social workers, and community health workers engage in person with these individuals to help them navigate their care by connecting them with medical care, government benefits, and social services ( Camden Coalition, n.d. ; Finkelstein et al., 2020 ). With federal funding, similar versions of the model have been extended to cities outside of Camden (AF4 Q, 2012 ; Crippen and Isasi, 2013 ; Mann, 2013 ).

Camden Coalition partnerships optimize the use of nurses in the community in several ways. An interprofessional team of nurses, social workers, and community health workers visits program participants, helps reconcile their medications, accompanies them to medical visits, and links them to social and legal services. Critical to the model’s success is recruiting nurses who are from the local community, capitalizing on their cultural and systems-level knowledge to facilitate and improve access to and utilization of local health and social services. The culture of the Camden Coalition model has been key to its success. The uniform commitment of nurses, staff, and leadership to addressing people’s complex needs has created a supportive work environment in which each team member’s role is optimized. Care Team members have accompanied people to their meetings and appointments for primary care, helped with applications for such public benefits as food stamps, provided referrals to social services and housing agencies, arranged for medication delivery in partnership with local pharmacies, and coordinated care among providers.

The Camden Coalition focuses on “authentic healing relationships,” defined as secure, genuine, and continuous partnerships between Care Team members and patients. This emphasis has evolved into a framework for patient engagement known as COACH, which stands for C onnect tasks with vision and priorities, O bserve the normal routine, A ssume a coaching style, C reate a backward plan, and H ighlight progress with data. An interprofessional team of nurses, social workers, and community health workers visits participants in the community. Team members are trained to problem solve with patients to achieve the program goals of helping them manage their chronic health conditions and reducing preventable hospital admissions.

Early evidence of the program’s effect in a small sample showed a 56 percent reduction in monthly hospital charges, a roughly 40 percent reduction in monthly visits to hospitals and emergency departments, and an approximately 52 percent increase in rates of reimbursement to care providers ( Green et al., 2010 ), although later evidence from a randomized controlled trial (RCT) indicated that the Camden Core Model did not reduce hospital readmissions ( Finkelstein et al., 2020 ). Other RCTs, conducted in Philadelphia and Chicago, showed that similar social care programs using case management and community health workers can reduce hospital admissions and save money in addition to improving health and quality of health care. Kangovi and colleagues (2018) conducted an RCT in Philadelphia to assess Individualized Management for Patient-Centered Targets (IMPaCT), a standardized community health worker intervention addressing unmet social needs across three health systems ( Kangovi et al., 2018 ). After 6 months, patients in the intervention group compared with controls were more likely to report the highest quality of care and spent fewer total days in the hospital (reduced by about two-thirds), saving $2.47 for each dollar invested by Medicaid annually ( Kangovi et al., 2020 ). The RCT in Chicago assessed the effectiveness of a case management and housing program in reducing use of urgent medical services among homeless adults with chronic medical conditions and found a 29 percent reduction in hospitalizations and a 24 percent reduction in emergency department visits ( Sadowski et al., 2009 ).

Edge Runner

The American Academy of Nurses’ Edge Runner initiative identifies and promotes nurse-designed models of care and interventions that can improve health, increase health care access and quality, and/or reduce costs ( AAN, n.d.a ). As of February 2020, 59 such programs had been evaluated against a set of criteria and designated as part of this initiative. Many Edge Runner programs are built around the needs of underserved communities and seek to improve health through holistic care that addresses social needs and SDOH, including a range of upstream, midstream, and downstream determinants. Mason and colleagues (2015) assessed 30 Edge Runner models identified as of 2012, finding four main commonalities that illustrate these programs’ broad and encompassing approach to health.

A holistic definition of health. Across the programs, health was defined broadly to include physical, psychological, social, spiritual, functional, quality-of-life, personal happiness, and well-being aspects. Additionally, the definition of health was based on the values of clients and shaped around their preferences. Typically, programs were grounded in SDOH to inform their design of individual- and community-level interventions.

Individual-, family-, and community-centric design. Most programs prioritized individual, family, and community goals over provider-defined goals through a “participant-led care environment” and “meeting people where they are.” Thus, interventions were tailored to the values and culture present at each of these three levels.

Relationship-based care. The programs reflected the importance of building trusting relationships with individuals, families, and communities to help them engage in ways to create and sustain their own health.

Ongoing group and public health approaches to improving the health of underserved populations. The nurses who designed the programs viewed serving underserved populations as a moral imperative. Through peer-to-peer education, support groups, and public health approaches, they sought to empower clients, give them a sense of control, build self-care agency, and increase resilience.

An in-depth study of three Edge Runner programs (the Centering Pregnancy model, INSIGHTS, and the Family Practice and Counseling Network) revealed particular lessons: the essential role of collaboration and leaders who can collaborate with a wide range of stakeholders, the need for plans for scalability and financial sustainability, and the importance of social support and empowerment to help people ( Martsolf et al., 2017 ). In these and other models, the capacity and knowledge associated with building meaningful, sustained partnerships across sectors is a key dimension of nursing practice that impacts health equity. The Edge Runner programs emphasize how, in the pursuit of improving care, lowering costs, and increasing satisfaction for people and families, nurses are actively working to achieve person-centered care that addresses social needs and SDOH and focusing on the needs of underserved populations to promote health equity ( Martsolf et al., 2016 , 2017 ; Mason et al., 2015 ). However, evidence directly linking the programs to decreases in disparities is generally not available. Two examples of Edge Runner programs are described in Box 5-2 .

Examples of Edge Runner Programs.

As models continue to evolve and be disseminated, it is critical to establish an evidence base that can help understand their impact on health and well-being and their contribution to achieving the broader aim of health equity. For care management programs incorporating social care, it is important to consider a broad array of both quantitative and qualitative measures beyond health care utilization ( Noonan, 2020 ). Although RCTs generate the most reliable evidence, this evidence can be limited in scope. For example, the RCTs cited above assessed neither the multidimensional nature of care management/social care models that might be reflected in such outcomes as client self-efficacy, satisfaction, or long-term health outcomes nor their potential social impacts. Also important to note is that care management models incorporating social care are limited by the availability of resources in the community, such as behavioral health services, addiction treatment, housing, and transportation. Programs that connect clients to health and social services are unlikely to work if relevant services are unavailable ( Noonan, 2020 ). Important to underscore in the context of this report is that multisector engagement, as well as health care teams that may involve social workers, community health workers, physicians, and others engaging alongside nurses, all are oriented to a shared agenda focused on improving health and advancing health equity.

• ADVOCATING FOR POLICY CHANGE

Public policies have a major influence on health care providers, systems, and the populations they serve. Accordingly, nurses can help promote health equity by bringing a health lens to bear on public policies and decision making at the community, state, and federal levels. Informing health-related public policy can involve communicating about health disparities and SDOH with the public, policy makers, and organizational leaders, focusing on both challenges and solutions for addressing health through actions targeted to achieving health equity.

When nurses engage with policy change as an upstream determinant of health, they can have a powerful and far-reaching impact on the health of populations. In the National Academy of Medicine’s Vital Directions series, Nancy Adler and colleagues (2016) note that “powerful drivers of health lie outside the conventional medical care delivery system…. Health policies need to expand to address factors outside the medical system that promote or damage health.” Because health inequities and SDOH are based in social structures and policies, efforts to address them upstream as the root of poor health among certain populations and communities need to focus on policy change ( NASEM, 2017a ). Nurses alone cannot solve the problems associated with upstream SDOH that exist outside of health care systems. However, by engaging in efforts aimed at changing local, state, or federal policy with a Health in All Policies approach, 2 they can address SDOH that underlie poor health ( IOM, 2011 ; NASEM, 2017a ; Williams et al., 2018 ). Whether nurses engage in policy making full time or work to inform policy part time as a professional responsibility, their attention to policies that either create or eliminate health inequities can improve the underlying conditions that frame people’s health. Nurses can bring a health and social justice lens to public policies and decision making at the community, state, and federal levels most effectively by serving in public- and private-sector leadership positions. Much of this work is discussed in Chapter 9 on nursing leadership, but it is noted in this chapter given the substantial influence that policy decisions have on health equity. Nurses can and should use their expertise to promote policies that support health equity.

For example, a nurse in Delaware was influential in getting the state’s legislature to pass legislation to implement a colorectal cancer screening program that has increased access to care and reduced disparities in morbidity and mortality from colorectal cancer (see Box 5-3 ). While individual nurses, often through their workplace and professional associations, engage in upstream efforts to impact health equity, there have been repeated calls from within the nursing community for more nurses to engage in informing public policy to improve health outcomes for individuals and populations.

Delaware Cancer Consortium.

• CONCLUSIONS

In the coming decade, the United States will make substantial progress in achieving health equity only if it devotes resources and attention to addressing the adverse effects of SDOH on the health of underresourced populations. As 2030 approaches, numerous initiatives to address health equity are likely to be launched at the local, state, and national levels. Many of these initiatives will focus on health care equity. Yet, while expanding access to quality care is critical to reducing disparities and improving health outcomes, such efforts need to be accompanied by additional efforts to identify and change the social institutions, dynamics, and systems underlying health inequities from the local to the national level. Nurses can contribute to reshaping the landscape of health equity over the coming decade by serving in expanded roles, working in new settings and new ways, and partnering with communities and other sectors beyond health care. Some nurses are already working in roles and settings that support health equity and are engaged in educating about and advocating for health equity through their professional associations. Nonetheless, broader engagement as a core activity of every nurse will help advance health equity nationwide. To achieve this aim will require

• support for and the willingness of the nursing workforce to take on new roles in new settings in the community;
• consistency in nurses’ preparation for engaging in downstream, midstream, and upstream strategies aimed at improving health equity by addressing issues that compromise health, such as geographic disparities, poverty, racism, homelessness, trauma, drug abuse, and behavioral health conditions;
• more experiential learning and opportunities to work in community settings throughout nursing education to ensure that nurses have skills and competencies to address individuals’ complex needs and promote efforts to improve the well-being of communities;
• nursing education that goes beyond teaching the principles of diversity, equity, and inclusion to provide sustained student engagement in hands-on community and clinical experiences with these issues;
• funding to support new models of care and functions that address SDOH, health equity, and population health; and
• evaluation of models to build the evidence needed to scale programs and the policies and resources necessary to sustain them.

These issues are discussed in the chapters that follow. Programs described in this chapter, such as the Camden Coalition and the Edge Runner initiatives, are exemplars of the kind of multidisciplinary, multisector efforts that will be necessary to address the complex needs of individuals and communities and make a lasting impact by eliminating health disparities, with the goal of achieving health equity. Central to these future efforts, however, are parallel efforts that evaluate and provide the evidence base on which to determine the effectiveness of models. One of the greatest challenges this committee faced was finding evidence directly linking the efforts of nurses to address social needs and SDOH to reductions in health disparities that would signal improved population health outcomes and health equity. Such evidence is essential to informing payment policy decisions that can ensure the sustainability of and nurse engagement in these models (discussed further in Chapter 6 ). Through evidence, the nursing profession can leverage its own potential, and the public, other professionals, and other sectors can understand the impact and value of such nursing engagement.

Conclusion 5-1: Nurses are in a position to improve outcomes for the underserved and can work to address the structural and institutional factors that produce health disparities in the first place. Conclusion 5-2: Nurses can use their unique expertise and perspective to help develop and advocate for policies and programs that promote health equity.

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These five domains of social needs are part of the Centers for Medicare & Medicaid Services’ Accountable Health Communities Model ( Fraze et al., 2019 ).

Health in All Policies (HiAP) is a collaborative approach that integrates health considerations into policy making across sectors. It recognizes that health is created by a multitude of factors beyond health care and in many cases, beyond the scope of traditional public health activities. In accordance with HiAP, for example, decision makers in the health care sector should consider transportation, education, housing, commerce, and other sectors impacting communities. HiAP stresses the need to work across government agencies and with private partners from these different sectors to achieve healthy and safe communities. It also encourages partnerships between the health care sector and community developers, for example ( CDC, 2016 ).

• Cite this Page National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030; Flaubert JL, Le Menestrel S, Williams DR, et al., editors. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington (DC): National Academies Press (US); 2021 May 11. 5, The Role of Nurses in Improving Health Equity.
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Nurses' role in health promotion and prevention: A critical interpretive synthesis

Affiliations.

• 1 Primary Health Care Service, Navarra Health Service, Navarra, Spain.
• 2 Department of Community, Maternity and Pediatric Nursing, School of Nursing, University of Navarra, Navarra, Spain.
• 3 IdiSNA, Navarra Institute for Health Research, Navarra, Spain.
• 4 Department of Nursing, Universidad Camilo José Cela, Madrid, Spain.
• PMID: 32757432
• DOI: 10.1111/jocn.15441

Background: Role confusion is hampering the development of nurses' capacity for health promotion and prevention. Addressing this requires discussion to reach agreement among nurses, managers, co-workers, professional associations, academics and organisations about the nursing activities in this field. Forming a sound basis for this discussion is essential.

Aims and objectives: To provide a description of the state of nursing health promotion and prevention practice expressed in terms of activities classifiable under the Ottawa Charter and to reveal the misalignments between this portrayal and the ideal one proposed by the Ottawa Charter.

Methods: A critical interpretive synthesis was conducted between December 2018 and May 2019. The PubMed, CINAHL, Scopus, PsychINFO, Web of Science and Dialnet databases were searched. Sixty-two papers were identified. The relevant data were extracted using a pro-forma, and the reviewers performed an integrative synthesis. The ENTREQ reporting guidelines were used for this review.

Results: Thirty synthetic constructs were developed into the following synthesising arguments: (a) addressing individuals' lifestyles versus developing their personal skills; (b) focusing on environmental hazards versus creating supportive environments; (c) action on families versus strengthening communities; (d) promoting community partnerships versus strengthening community action; and (e) influencing policies versus building healthy public policy.

Conclusions: There are notable misalignments between nurses' current practice in health promotion and prevention and the Ottawa Charter's actions and strategies. This may be explained by the nurses' lack of understanding of health promotion and prevention and political will, research methodological flaws, the predominance of a biomedical perspective within organisations and the lack of organisational prioritisation for health promotion and prevention.

Keywords: critical interpretive synthesis; disease prevention; health promotion; nursing role.

© 2020 John Wiley & Sons Ltd.

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The Nursing Process in Health Education and Promotion Essay

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Introduction

Health education plays a key role in health promotion, as it provides individuals with knowledge and skills to make healthy life choices and encourages them to take responsibility for their health and well-being. The nursing process is employed to create an effective, tailored health education program (Toney-Butler, 2022).

This process involves assessment, diagnosis, planning, implementation, and evaluation (Sharma, 2021). During the assessment phase, the nurse assesses the individual’s health needs and risk factors, as well as their knowledge and attitudes towards health. During the implementation stage, health education materials are delivered to the individual or group. The evaluation phase is utilized to assess the efficacy of the health education program and make necessary changes.

A contemporary issue that a family may experience today is food insecurity. Food insecurity is a growing problem both locally and globally, and it is defined as limited access to nutritionally adequate and safe foods or uncertain availability of food due to economic constraints (Kopparapu et al., 2020). This leads to health disparities, such as increased risk of malnutrition, and can have an especially profound impact on vulnerable populations, such as children and the elderly.

As a nurse, there are several steps that can be taken to address this issue as part of a health education plan. First, the nurse should assess the family’s access to food and resources. It includes looking at available resources in the community, such as food banks and other hunger relief services. The nurse should also assess the family’s level of knowledge about nutrition and dietary needs, as this is important for making informed decisions about food choices. Finally, the nurse can assist the family in achieving a healthy lifestyle by providing education on food safety and nutrition including the selection of nutritious foods, proper storage techniques, safe meal preparation, and the significance of meal planning (Kopparapu et al., 2020).

Furthermore, the nurse should consider referring the family to other healthcare professionals and community organizations such as nutritionists, dietitians, and food pantries for further support (Kopparapu et al., 2020). Through these efforts, the nurse can ensure the family has the appropriate information and resources for making informed decisions about food and nutrition.

Sharma, M. (2021). Theoretical foundations of health education and health promotion (4 th ed.). Jones & Bartlett Learning.

Kopparapu, A., Sketas, G. & Swindle, T. (2020). Food insecurity in primary care: Patient perception and preferences . Family Medicine, 52(3), 202-205. Web.

Toney-Butler, T. & Thayer J. M. (2022). Nursing process . National Library of Medicine . Web.

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NURSES’ ROLES IN HEALTH PROMOTION PRACTICE: A SYSTEMATIC REVIEW

• Budi Widiyanto
• Published 2017

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