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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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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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‘Nurses have an essential role in promoting accurate health messages’

06 May, 2020 By Rebecca Garcia

Nurses are well placed to promote and deliver health messages during and after the coronavirus pandemic, to patients and the wider public. However, there is much more to health promotion than just repeating accurate health messages.

According to the Skills for Life Survey , 44% of adults are reported to have a reading level of below entry level 2 (e.g. a literacy level equivalent to 7-9 year-old). This equates to an estimated 19.8 million UK adults who have difficulty in reading or writing short messages.

Once health information is added to text-based messages, the number of adults having difficulty reading and understanding the health information is likely to increase.

The World Health Organisation defines health literacy as having “cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health”.

In real terms, it means that health literate people need to read, understand and be empowered to make healthful decisions to participate and protect their own health status.

Jessup and colleagues found associations to lower levels of health literacy with older age, being culturally diverse, having lower educational attainment, lower social economic status and using the internet less often.

It has also been suggested that, clinicians and healthcare staff fail to properly understand the value of health literacy, which has led to a paucity of attention in practice.

Nurses delivering health messages also need to be mindful that English might not the person's first language. Some concepts in English do not exist in other languages or are hard to literally translate.

During these occasions it is important to check the person's level of understanding (through an adult interpreter), to ensure that the message does not become diluted or misunderstood, during translation. Taken together, this shows that addressing health literacy is far from straightforward.

Due to the extensive information available to the public on Covid-19, particularly via social media, people are being bombarded with health-related messages. However, health psychology research shows that people often rely on their own perceived sources of trusted health information, in preference to official organisations.

For example, listening to partners, friends or celebrities’ ideas of health-related information.

Therefore, shared health information on social media can be both powerfully persuasive and inadvertently promote misinformation, increasing erroneous health beliefs and adverse health behaviours, such as breath holding or drinking alcohol.

Nurses have an essential role in promoting accurate health messages and remembering the Make Every Contact Count initiative .

Nurses can use their skills to identify lower health literacy levels with people who they are in in/direct contact with and help to build Covid-19 related health messages that are more easily understood by individuals and, who may have lower literacy levels.

This may include people in their care, patients’ relatives and carers, or informally as the nurses’ friends and neighbours.

While Covid-19 presents an unusual situation, nurses need to give attention to the extent of which their patient, relative and carer may be health literate to empower healthful behaviour from the wealth of health information that is available. Below are some tips to support their understanding:

• Use clear and concise language;
• Build on a person's existing level of understanding;
• Check back frequently for understanding of new messages;
• Use simple pictures to support ideas;
• Repeat the health messages often;
• Allow time for people to process new information;
• Give small amounts of information at any one time, repeat often and add new information slowly (if possible);
• Provide access to written sources/pictures – often a family member will be able to read the health information;
• Allow time for questions and if possible, a contact number for any late questions.

Rebecca Garcia is lecturer adult nursing, The Open University

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The economic imperative of health promotion.

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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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The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity (2021)

Chapter: 4 the role of nurses in improving health care access and quality, 4 the role of nurses in improving health care access and quality.

Of all the forms of inequality, injustice in health care is the most shocking and inhumane.

—Dr. Martin Luther King, civil rights activist

Health care equity focuses on ensuring that everyone has access to high-quality health care. As shown in the Social Determinants of Health and Social Needs Model of Castrucci and Auerbach (2019) (see Chapter 2 ), health care is a downstream determinant of health, but disparities in health care access and quality can

widen and exacerbate disparities produced by upstream and midstream determinants of health outcomes.

According to Healthy People 2020, access to quality health care encompasses the ability to gain entry into the health care system through health insurance, geographic availability, and access to a health care provider. Health care quality has been defined as “the degree to which health care services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge” ( IOM, 1990 , p. 4). The Agency for Healthcare Research and Quality (AHRQ) defines quality health care “as doing the right thing for the right patient, at the right time, in the right way to achieve the best possible results” ( Sofaer and Hibbard, 2010 ). Nurses deliver high-quality care by providing care that is safe, effective, person-centered, timely, efficient, and equitable ( IOM, 2001 ).

As noted, frameworks for social determinants of health (SDOH) place the health care system downstream, often operating in response to illness, rather than upstream, impacting the underlying causes of health outcomes ( Castrucci and Auerbach, 2019 ). Therefore, health care itself does not address most of the upstream factors, or root causes of illness, that affect health equity; such upstream social factors as economic and housing instability, discrimination and other forms of racism, educational disparities, and inadequate nutrition can affect an individual’s health before the health care system is ever involved ( Castrucci and Auerbach, 2019 ). Health equity is discussed in detail in Chapter 5 . Some estimates indicate that a small portion of health outcomes is related to health care, while equity in health care is an important contributing factor to health equity ( Hood et al., 2016 ; Remington et al., 2015 ).

Major shifts occurring both within society at large and within health care will transform the environment in which the next generation of nurses will practice and lead. These shifts encompass changing demographics, including declining physical and mental health; increased attention to racism and equity issues; the development and adoption of new technologies; and changing patterns of health care delivery. The widespread movement for racial justice, along with the stark racial disparities in the impacts of COVID-19, has reinforced the nursing profession’s ethical mandate to advocate for racial justice and to help combat the inequities embedded in the current health care system. The commitment to social justice is reflected in provision 9 of the Code of Ethics of the American Nurses Association ( ANA, 2015 ), and its priority has been elevated by the increased demand for social justice within communities and society at large.

Changing health outcomes will require action at all levels—upstream, midstream, and downstream—and nurses have a major role at all levels in reducing gaps in clinical outcomes and improving health care equity. Nurses can strengthen their commitment to diversity, equity, and inclusion by leading large-scale efforts to dismantle systemic contributors to inequality and create new norms and competencies within health care. In that process, nurses will need to meet the

complex ethical challenges that will arise as health care reorients to respond to the rapidly changing landscape ( ANA, 2020 ; Beard and Julion, 2016 ; Koschmann et al., 2020 ; Villarruel and Broome, 2020 ). To ensure nursing’s robust engagement with these major shifts in health care and society, investments in the well-being of nurses will be essential ( ANA, 2015 ) (see Chapter 10 ).

This chapter examines ways in which nurses today work to improve health care equity, as well as their potential future roles and responsibilities in improving equity through efforts to expand access to and improve the quality of health care. Existing exemplars are also described, as well as implications of COVID-19 for health care access and quality.

NURSES’ ROLES IN EXPANDING ACCESS TO QUALITY HEALTH CARE

The United States spends more than $3.5 trillion per year on health care, 25 percent more per capita than the next highest-spending country, and under-performs on nearly every metric ( Emanuel et al., 2020 ). Life expectancy, infant mortality, and maternal mortality are all worse in the United States than in most developed countries. In the United States, moreover, disparities in health care access and health outcomes are seen across racial lines; however, being able to use social and financial capital to buy the best health care is not necessarily associated with the world’s best health outcomes. Even among White U.S. citizens and those of higher socioeconomic status (SES), U.S. health indicators still lag behind those in many other countries ( Emanuel, 2020 ). The U.S. population will not fully thrive unless all individuals can live their healthiest lives, regardless of their income, their race or ethnicity, or where they live. As discussed in Chapter 2 , however, race and ethnicity, income, gender, and geographic location all play substantial roles in a person’s ability to access high-quality, equitable, and affordable health care. A variety of professionals from within and outside of health care settings participate in efforts to ensure equitable access to care. But the role of nurses in these efforts is key, given their interactions with individuals and families in providing and coordinating person-centered care for preventive, acute, and chronic health needs within health settings, collaborating with social services to meet the social needs of individuals, and engaging in broader population and community health through roles in public health and community-based settings.

Both in the United States and globally, the rapid growth in the number of older people in the population will likely lead to increased demand for services and programs to meet their health and social care needs ( Donelan et al., 2019 ; Spetz et al., 2015 ), including care for chronic conditions, which account for approximately 75 percent of all primary care visits ( Zamosky, 2013 ). The aging population will also bring change in the kinds of care the patient population will need. Older people tend to require more expensive care, and to need increasing

support in managing multiple conditions and retaining strength and resilience as they age (Pohl et al., 2018). These realities underscore the importance of designing, testing, and adopting chronic care models, in which teams are essential to managing chronic disease, and registered nurses (RNs) play a key role as chronic disease care managers ( Bodenheimer and Mason, 2016 ). Studies of exemplary primary care practices ( Bodenheimer et al., 2015 ; Smolowitz et al., 2015 ) define key domains of RN practice in primary care, including preventive care, chronic illness management, practice operations, care management, and transition care.

Since the passage of the Patient Protection and Affordable Care Act, substantial changes have occurred in the organization and delivery of primary care, emphasizing greater team involvement in care and expansion of the roles of each team member, including RNs ( Flinter et al., 2017 ). Including RNs as team members can increase access to care, improve care quality and coordination for chronic conditions, and reduce burnout among primary care practitioners by expanding primary care capacity ( Fraher et al., 2015 ; Ghorob and Bodenheimer, 2012 ; Lamb et al., 2015 ).

In primary care, RNs can assume

at least four responsibilities: 1) Engaging patients with chronic conditions in behavior change and adjusting medications according to practitioner-written protocols; 2) Leading teams to improve the care and reduce the costs of high-need, high-cost patients; 3) Coordinating the care of chronically ill patients between the primary care home and the surrounding healthcare neighborhood; and 4) Promoting population health, including working with communities to create healthier spaces for people to live, work, learn, and play. ( Bodenheimer and Mason, 2016 , pp. 11–12)

Findings from a 2013 study of The Primary Care Team: Learning from Effective Ambulatory Practices (LEAP) suggest that a large majority of LEAP primary care practices, regardless of practice type or corporate structure, use RNs as a key part of their care team model ( Ladden et al., 2013 ). This contrasts with a study of 496 practices in the Centers for Medicare & Medicaid Services (CMS) Comprehensive Primary Care initiative ( Peikes et al., 2014 ) that found that only 36 percent of practices had RNs on staff, compared with 77 percent of LEAP sites ( Flinter et al., 2017 ).

The health needs of individuals exist across a spectrum, ranging from healthy people, for whom health promotion and disease prevention efforts are most appropriate, to people who have limited functional capacity as a result of disabilities, severe or multiple chronic conditions, or unmet social needs or are nearing the end of life. Access to quality health care services is an important SDOH, and equitable access to care is needed for “promoting and maintaining health, preventing and managing disease, reducing unnecessary disability and premature death, and achieving health equity” ( ODPHP, 2020 ). Likewise, “strengthening

the core of primary care service delivery is key to achieving the Triple Aim of improved patient care experiences, better population health outcomes, and lower health care costs” ( Bodenheimer and Mason, 2016 , p. 23). The 2011 The Future of Nursing report echoes these themes:

while changes in the healthcare system will have profound effects on all providers, this will be undoubtedly true for nurses. Traditional nursing competencies, such as care management and coordination, patient education, public health intervention, and transitional care, are likely to dominate in a reformed healthcare system as it inevitably moves toward an emphasis on prevention and management rather than acute [hospital] care. ( IOM, 2011 , p. 24)

Given the increased evidence supporting the focus on addressing social needs and SDOH to improve health outcomes, these competencies are even more important a decade later. While progress has been made, there is still work to be done, and leveraging and expanding the roles and responsibilities of nurses can help improve access to care ( Campaign for Action, n.d. ).

For people who have difficulty accessing health care because of distance, lack of providers, lack of insurance, or other reasons, nurses are a lifeline to care that meets them where they are. Nurses work in areas that are underserved by other health care providers and serve the uninsured and underinsured. They often engage with and provide care to people in their homes, they work in a variety of clinics, they use telehealth to connect with people, and they establish partnerships and create relationships in schools and communities. In addition to expanding the capacity of primary care, nurses serve in vital roles during natural disasters and public health emergencies, helping to meet the surge in the need for care (see Chapter 8 ). Yet, the potential for nurses to advance health equity through expanded access to care is limited by state and federal laws and regulations that restrict nurses’ ability to provide care to the full extent of their education and training (see Chapter 3 ). Ways in which nurses can fulfill this potential to increase access to care for populations with complex health and social needs are discussed below.

INCREASING ACCESS FOR POPULATIONS WITH COMPLEX HEALTH AND SOCIAL NEEDS

Many individuals cannot access health care because of lack of insurance, inability to pay, and lack of clinics or providers in their geographic area. To bridge this gap, access to care is expanded through a variety of settings where nurses work, including federally qualified health centers (FQHCs), retail clinics, home health and home visiting, telehealth, school nursing, and school-based health centers, as well as nurse-managed health centers. Across all of these settings, nurses are present and facilitate access to health services for individuals and families, often serving as a bridge to social services as well.

Federally Qualified Health Centers

Through FQHCs—outpatient facilities located in a federally designated medically underserved area or serving a medically underserved population—nurses expand access to services for individuals regardless of ability to pay by helping to provide comprehensive primary health care services, referrals, and services that facilitate access to care. The role of advanced practice registered nurses (APRNs) in FQHCs has grown over time ( NACHC, 2019 ). The emerging role of RNs in FQHCs is seen in increased interactions with patients, involvement in care management, and autonomy in the delivery of care. Nurses also work to address key social factors in partnership with care coordinators, health coaches, and social workers to improve health outcomes ( Flinter et al., 2017 ).

Retail Clinics

Health care delivery in the United States has been undergoing transformation, and these changes provide new opportunities for more patients and greater access to nurses as new policies are implemented, new payment models take hold, resources are focused on SDOH, and consumerism shapes care choices. One change in particular since the prior The Future of Nursing report ( IOM, 2011 ) has been and will continue to be impactful for nursing: the emergence of nontraditional health care entities, such as retail clinics. The evolution and rapid growth of these established retail clinics provide increased accessibility of basic care, health screenings, vaccines, and other services for some populations ( Gaur et al., 2019 ). The number of such is growing rapidly, from around 1,800 in 2015 to 2,700 operating in 44 states and the District of Columbia by 2018.

Retail clinics provide more accessible primary care for some populations. In 2016, 58 percent of retail clinic visits represented new utilization instead of substitution for more costly primary care or emergency department visits ( Bachrach and Frohlich, 2016 ). Many individuals and families use retail clinics for their convenience, which includes long hours of operation, accessible location, and walk-in policies, as well as low-cost visits. These attributes are important for those with lower income or without insurance who may not have a regular source of care or be able to access a primary care provider ( Bachrach and Frohlich, 2016 ). However, research shows retail clinics are typically placed in higher-income, urban, and suburban settings with higher concentrations of White and fewer Black and Hispanic residents ( RAND Corporation, 2016 ). The RAND Corporation (2016) study found that while 21 percent of the U.S. population lived in medically underserved areas, only 12.5 percent of retail clinics were located in these areas. RAND concluded that “overall, retail clinics are not improving access to care for the medically underserved.” Thus, while these new models of care have the potential to advance health care equity and population-level health, the available data do not indicate that this potential has been realized ( RAND

Corporation, 2016 ). The equity impact of these retail clincs depends in large part on who utilizes the services, and whether the utilization patterns are similar to or different from those of traditional health care.

Retail clinics are staffed largely by nurse practitioners (NPs) ( Carthon et al., 2017 ). These clinics in pharmacies and grocery stores often have been constrained by restrictive scope-of-practice laws. In 2016, a study by the University of Pennsylvania School of Nursing’s Center for Health Outcomes and Policy Research investigated scope-of-practice regulatory environments and retail-based clinic growth. Looking at three states with varying levels of scope-of-practice restrictions, the study found an association between relaxation of practice regulations and retail clinic growth. Evidence suggests that optimization of innovative health care sites such as retail clinics will require moving toward the adoption of policies that standardize the scope of practice for NPs, the providers who largely staff retail clinics ( Carthon et al., 2017 ).

Home Health and Home Visiting

Visiting people in their homes can advance equitable access to quality health care. Home health care has increased access to care for many Americans, from older individuals to medically fragile children. Yao and colleagues (2021) recently explored trends in the U.S. workforce providing home-based medical care and found that less than 1 percent of physicians participating in traditional Medicare provide more than 50 home visits each year (a rate unchanged between 2012 and 2016). By contrast, the number of NPs providing home visits nearly doubled during that same period. Home health nurses address a fragmented system by coordinating care for patients transitioning from a tertiary care facility to ongoing health care within their own homes. Since the onset of the COVID-19 pandemic, these nurses have increasingly provided families with respite for caregivers and offered mental health services in many forms, but certainly in decreasing social isolation for elderly people. Delivering care at home has offered a window for physicians and NPs to see where patients live, to engage in telehealth video calls with family members present, and to see the features of neighborhoods that impact health (e.g., sidewalks, playgrounds, stairs).

With the expansion in the home health care industry driven by an aging population, home visiting nurses are essential to providing care and enhancing health care equity ( Walker, 2019 ). Prior to 2020, Medicare rules allowed only physicians to order home health services for Medicare beneficiaries. However, the Coronavirus Aid, Relief, and Economic Security (CARES) Act permanently authorizes physician assistants and NPs to order home health care services for Medicare patients. In addition, CMS has instituted new policies outlining comprehensive temporary measures for increasing the capacity of the U.S. health care system to provide care to patients outside a traditional hospital setting amid the rising number of COVID-19-related hospitalizations nationwide. These measures include

both the Hospital Without Walls and Acute Hospital Care At Home programs, both initiated during the pandemic. Under previous federal requirements, hospitals had to provide services within their own buildings, raising concerns about capacity for treating COVID-19 patients, especially those requiring ventilator and intensive care. Under CMS’s temporary new rules, hospitals can transfer patients to outside facilities, such as ambulatory surgery centers, inpatient rehabilitation hospitals, hotels, and dormitories, while still receiving hospital payments under Medicare. Provision for at-home care, which is often preferred by patients, is especially important during a crisis such as the pandemic, when hospital care means family and/or caregivers cannot be present. Moreover, some research has shown home care to be less costly and to result in fewer readmissions relative to hospital care ( Levine et al., 2020 ). These programs also will create new demand for nurses to work in the community and are the types of adaptations that occurred as a result of the COVID-19 pandemic that should remain permanent to expand high-quality access to care.

The locus of care delivery will continue to follow personal preferences of individuals and families. To improve health care access, nurses will need to be intentional about meeting patients where they are in the most literal sense, and to serve as advocates with and within public health, retail clinics, and health systems to ensure that patients can access the care they need in their homes and neighborhoods. Box 4-1 describes several innovative nurse-led, in-home care programs.

In addition to home health, nurse home visiting programs often include such services as health check-ups, screenings, referrals, and guidance in navigating other programs and services in the community ( Child and Family Research Partnership, 2015 ). Growing evidence suggests that home visits by nurses during pregnancy and in the first years of a child’s life can improve the health and well-being of both child and family, including by promoting maternal and child health, prevention of child abuse and neglect, positive parenting, child development, and school readiness. This positive impact has been found to continue into adolescence and early adulthood ( NASEM, 2019 ).

The proliferation of mobile devices and applications offers an opportunity for nurses to use telehealth more broadly to connect with individuals. Telehealth, including video visits, email, and distance education, serves as a tool to connect with people on an ongoing basis without their having to leave their homes, workplaces, or other settings, and allows for long-distance patient and clinician contact for purposes of clinical interventions, health promotion, education, assessment, and monitoring. The use of telehealth is especially helpful for those who have difficulty traveling to obtain care and those who reside in rural or remote areas. Vulnerable populations with multiple chronic illnesses, poor health literacy, and lack of supportive resources may benefit the most from telehealth use. However, use of telehealth or virtual health tools is limited by access to reliable Internet

connections and the availability of the necessary hardware, including smartphones, computers, or webcams. A recent report in the Journal of the American Medical Association looks at 41 FQHCs serving 1.7 million patients. Prior to the COVID-19 pandemic, there was minimal telehealth use at these facilities. During March 2020, FQHCs rapidly substituted in-person visits with telephone and video visits. For primary care, however, 48.5 percent of telehealth visits occured by telephone and 3.4 percent by video. In addition, CMS estimated that 30 percent of telehealth visits were audio-only during the pandemic. These numbers indicate that telehealth appointments for lower-income Americans were in large part audio-only, raising questions about the quality of care ( Uscher-Pines et al., 2021 ).

There have been examples of telehealth activities that have demonstrated great success. The Mississippi Diabetes Telehealth Network, for example, implemented a program that uses telehealth in the home as a viable way to bring a care team to patients to assist them as they manage their illnesses. NPs provide daily health sessions and remote monitoring for individuals with diabetes ( Davis et al., 2020 ; Henderson et al., 2014 ). A prospective, longitudinal cohort study design evaluated the relationship between using telehealth for chronic care management and diabetes outcomes over a 12-month period, finding a significant difference in HbA1c values from baseline to 3-, 6-, 9-, and 12-month values ( Davis et al., 2020 ). In another example, Mercy Hospital, a virtual care center, delivers telehealth services to rural communities in Arkansas, Kansas, Missouri, and Oklahoma. One of its many services is Nurse on Call, which provides timely clinical advice and is available around the clock. In still another example, Banner Health’s skilled nursing model delivers home care combined with telehealth services to people at home instead of their having to move to a nursing home facility ( Roth, 2018 ).

School Nursing

School nurses are front-line health care providers, serving as a bridge between the health care and education systems. Hired by school districts, health departments, or hospitals, school nurses attend to the physical and mental health of students in school. As public health sentinels, they engage school communities, parents, and health care providers to promote wellness and improve health outcomes for children. School nurses are essential to expanding access to quality health care for students, especially in light of the increasing number of students with complex health and social needs. Access to school nurses helps increase health care equity for students. For many children living in or near poverty, the school nurse may be the only health care professional they regularly access.

School nurses treat and help students manage chronic health conditions and disabilities; address injuries and urgent care needs; provide preventive and screening services, health education, immunizations, and psychosocial support; conduct behavioral assessments; and collaborate with health care providers,

school staff, and the community to facilitate the holistic care each child needs ( Council on School Health, 2008 ; Holmes et al., 2016 ; HRSA, 2017 ; Lineberry and Ickes, 2015 ; Maughan, 2018 ). By helping students get and stay healthy, school health programs can contribute to closing the achievement gap ( Basch, 2011 ; Maughan, 2018 ). According to Johnson (2017) ,

Healthy children learn better; educated children grow to raise healthier families advancing a stronger, more productive nation for generations to come. School nurses work to assure that children have access to educational opportunities regardless of their state of health. (p. 1)

Meeting the mental health needs of children can be particularly challenging. Researchers estimate that about a quarter of all school-age children and adolescents struggle with mental health issues, such as anxiety and depression. Approximately 30 percent of student health visits to the school nurse are for mental health concerns, often disguised by complaints of headaches and stomachaches ( Foster et al., 2005 ). School nurses have experience with screening students at risk for a variety of such concerns and can assist students in addressing them ( NASN, 2020a ). However, most youth—nearly 80 percent—who need mental health services will not receive them ( Kataoka et al., 2005 ); schools are not always equipped to deal with students’ emotional needs, and parents often lack the awareness or resources to get help for their children. Additionally, a recent study found disparities in access to mental health treatment for students along racial and ethnic lines ( Lipson et al., 2018 ), and structural racism undergirds many risk factors for mental illness (see Chapter 2 ). The COVID-19 pandemic has revealed—and exacerbated—inequities among children of different incomes and races/ethnicities. School closures and social isolation have affected all students, but especially those living in poverty. In addition to the damage to student learning, the loss of access to mental health services that were offered by schools has resulted in the emergence of a mental health crisis ( Leeb et al., 2020 ; Patrick et al., 2020 ; Singh et al., 2020 ).

Schools are increasingly being recognized not just as core educational institutions but also as community-based assets that can be a central component of building healthy and vibrant communities ( NASEM, 2017 ). Accordingly, schools and, by extension, school nurses are being incorporated into strategies for improving health care access, serving as hubs of health promotion and providers of population-based care ( Maughan, 2018 ). Yet, while there have been calls for every school to have access to a nurse ( Council on School Health, 2016 ; NASN, 2020b ), only 39.9 percent of schools employed a full-time nurse in 2017. The remainder of schools (39.3 percent) employed a part-time nurse or did not employ a nurse at all (25.2 percent) ( Willgerodt, 2018 ). The availability and staffing levels of school nurses vary greatly by geography ( Willgerodt, 2018 ) (see Figure 4-1 ).

To address the lack of health care resources in rural school settings, telehealth programs have been implemented with success ( RHI, 2019 ). An example is

Health-e-Schools, in which onsite school nurses connect sick students with health care providers. The program employs a full-time, off-site family NP who uses telehealth to evaluate and diagnose patients with such health issues as earaches, sore throats, colds, and rashes, as well as to provide sports physicals, medication, chronic disease management, and behavioral health care. It began as a telehealth program implemented by only 3 schools in 2011 and has since expanded to more than 80 schools serving more than 25,000 students. Health-e-Schools has helped increase classroom attendance and decrease the amount of time parents or guardians must take off from work to bring their children to appointments. This model relies heavily on the school nurses employed within each school district to serve as primary telehealth providers, thus requiring that funding be allocated to provide a school nurse in each school.

School-Based Health Centers

School-based health centers (SBHCs) also make care accessible to students in the school setting. In 2017, 2,584 SBHCs were operating in the United States ( Love et al., 2019 ). SBHCs often operate as a partnership between the school and a community health organization, such as a community health center, hospital, or local health department; more than half are supported by or are an extension of FQHCs ( SBHA, n.d. ). SBHC services include primary care, mental health care, social services, dentistry, and health education, but vary based on community needs and resources as determined through collaborations among the community, the school district, and health care providers ( CPSTF, 2015 ; HRSA, 2017 ). Services are provided by interprofessional teams of health care professionals that include nurses, mental health care providers, physicians, nutritionists, and others. As of 2017, NPs provided primary care services onsite and through telehealth services at 85 percent of SBHCs ( Love et al., 2019 ; SBHA, 2018 ).

One example of an SBHC is the nurse-run Vine School Health Center (VSHC) located at the Vine Middle Magnet School in Knoxville, Tennessee, a

Title I school where 100 percent of the students qualify for free lunch. VSHC provides onsite and telehealth services to anyone up to 21 years of age who lives in the county. It also serves 10 other Title I schools through direct health care or telehealth services. The clinic is a partnership between the University of Tennessee College of Nursing and Knox County Schools and is staffed by nurses, nursing students, social workers, and special education professionals. Staff assist families with social needs, including food, housing, clothing, linkages to health insurance, and financial support for rent and utilities ( AAN, 2015 ; Pittman, 2019 ). Services rendered during the 2016–2017 school year included 1,110 early and periodic screening, diagnostic and treatment (EPSDT) exams; 1,896 immunizations; 4,455 physical health visits; and 1,796 mental health clinic visits. VSHC estimates that its services enabled the avoidance of more than 2,500 potential emergency room visits per academic year, associated with savings of about $375,000 per year ( AAN, 2015 ).

IMPROVING THE QUALITY OF HEALTH CARE

Access to comprehensive health care services is a precursor to equitable, quality health care. Nurses are uniquely qualified to help improve the quality of health care by helping people navigate the health care system, providing close monitoring and follow-up across the care continuum, focusing care on the whole person, and providing care that is culturally respectful and appropriate. Nurses can help overcome barriers to quality care, including structural inequities and implicit bias, through care management, person-centered care, and cultural humility.

Care Management

In the current health care system, care is often disjointed, with processes varying between primary and specialty care and between traditional and emerging care sites. People may not understand the processes of the health care system, such as where they will receive care, how to make appointments, or the various providers with whom they may come into contact. Perhaps most important, patients may not understand why all the providers across settings where they receive care should be knowledgeable about the services they receive and the problems that have been identified to ensure seamless, continuous high-quality care. Social factors affecting people with complex health needs may also adversely affect their ability to receive optimal care. Care management, care coordination, and transitional care are activities that nurses perform as members of a health care team to decrease fragmentation, bolster communication, and improve care quality and safety. A care management approach is particularly important for people with complex health and social needs, who may require care from multiple providers, medical follow-up, medication management, and help in addressing their social needs.

Care management—a set of activities designed to “enhance coordination of care, eliminate duplication of services, reduce the need for expensive medical services, and increase patient engagement in self-care”—helps ensure seamless care ( CHCS, 2007 ; Goodell et al., 2009 ). The components of care management include care coordination, transitional care, and social care.

Care coordination is defined as the “deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of healthcare services.” It is needed both to overcome obstacles of the health care system, such as fragmentation, communication, and billing/cost, and to increase access ( McDonald et al., 2007 , p. 4).

Transitional care entails coordinating care for people moving between various locations or levels of care, providing navigation, coordination, medication reconciliation, and education services ( Storfjell et al., 2017 ). The Transitional Care Model, developed by Mary Naylor (see Box 4-2 ), and the Care Transitions Intervention, developed by Eric Coleman, are prominent nurse-centered care models focused on the often disjointed transition from an inpatient hospital stay to follow-up ambulatory care. Both models engage people with chronic illness from hospitalization to postdischarge, and employ a nursing coach or team “to manage clinical, psychosocial, rehabilitative, nutritional and pharmacy needs; teach or coach people about medications, self-care and symptom recognition and management; and encourage physician appointments” ( Storfjell et al., 2017 , p. 27). Both reduce readmissions and costs ( Storfjell et al., 2017 ).

Health care delivery models that incorporate social care have created critical roles for nurses in coordinating care across providers and settings and collaborating with other professionals and community resources to improve the health of individuals with complex health and social needs. Chapter 5 provides examples of nurse-centered programs incorporating social care. Nurses are vital to carrying out these functions of care management. Common to nurses’ roles are functions including providing care coordination, developing care plans based on a person’s needs and preferences, educating people and families within care settings and during discharge, and facilitating continuity of care for people across settings and providers ( ANA, n.d. ).

Person-Centered Care

The person-centered care model embraces personal choice and autonomy and customizes care to an individual’s abilities, needs, and preferences ( Kogan et al., 2016 ; Van Haitsma et al., 2014 ). Through person-centered care, nurses collaborate with people, including the patient and other care team members, to deliver personalized quality care that addresses physical, mental, and social needs ( CMS, 2012 ; Terada et al., 2013 ). Features of person-centered care include an emphasis on codesign of interventions, services, and policies that focus on what the person and

community want and need; respect for the beliefs and values of people; promotion of antidiscriminatory care; and attention to such issues as race, ethnicity, gender, sexual identity, religion, age, socioeconomic status, and differing ability status ( Santana et al., 2018 ). And person-centered care focuses not only on the individual but also on families and caregivers, as well as prevention and health promotion. Integrating person-centered care that improves patient health literacy is necessary to ensure patient empowerment and engagement and maximize health outcomes. Health literacy ensures that “patients know what they must do after all health care encounters to self-manage their health” ( Loan et al., 2018 , p. 98).

Research has demonstrated the efficacy of person-centered care, for example, in reducing agitation, neuropsychiatric symptoms, and depression, as well as improving quality of life, for individuals with dementia ( Kim and Park, 2017 ). In another example, people with acute coronary syndrome receiving person-centered care reported significantly higher self-efficacy ( Pirhonen et al., 2017 ). Person-centered care is person-directed, such that people are provided with sufficient information to help them in making decisions about their care and increase their level of engagement in care ( Pelzang, 2010 ; Scherger, 2009 ), and nurses who engage people in their care are less likely to make mistakes ( Leiter and Laschinger, 2006 ; Prins et al., 2010 ; Shiparski, 2005 ). Person-centered care leads to better communication between patients and caregivers and improves quality of care, thereby increasing patient satisfaction, care adherence, and care outcomes ( Hochman, 2017 ).

Cultural Humility

As discussed in Chapter 2 , implicit bias can lead to discrimination against others. In particular, structural racism in health care compromises the ability to deliver culturally competent care ( Evans et al., 2020 ).

Historically, nursing has been at the forefront of advocacy, and there are many examples of how nurses have addressed, and are addressing, inequities in many aspects of our teaching, research, scholarship, and practice. Yet, there remain too many examples of structural racism throughout nursing and we must be open to continuing to examine, identify, and change these within our own profession. ( Villaruel and Broome, 2020 , p. 375)

Nurses may contribute to structural inequities in how they facilitate or hamper access to quality health care services since they are frequently the first point of contact for many individuals who need care. Cultural humility—“defined by flexibility; awareness of bias; a lifelong, learning-oriented approach to working with diversity; and a recognition of the role of power in health care interactions” ( Agner, 2020 , p. 1)—is therefore essential for nurses.

Cultural humility enables nurses to participate in more respectful partnerships with patients in order to advance health care equity. According to Foronda and colleagues (2016) , cultural humility has been found to result in effective

treatment, decision making, communication, and understanding; better quality of life; and improved care. In contrast, clinicians with implicit bias may show less compassion toward and spend less time and effort with certain patients, leading to adverse assessment and care ( Narayan, 2019 ). Because implicit bias can negatively affect patient interactions and health outcomes, it is important for nurses to be aware of their bias and how it may directly or indirectly impact patient interactions and the quality of care they provide ( Hall et al., 2015 ).

Multiple strategies exist to help nurses achieve cultural humility and manage implicit bias to ensure that they provide high-quality, equitable care. Chapter 7 details the importance of incorporating cultural humility in nursing education. Instead of focusing broadly on the general population, quality improvement interventions characterized by cultural humility focus on needs that are unique to people of color (POC) and tailor care to overcome cultural and linguistic barriers that cause disparities in care (Green et al., 2010). With this approach, data on disparities are used to assess an intervention, with an emphasis on addressing barriers that are specific to underrepresented groups ( ANA, 2018 ; Green et al., 2010; Villarruel and Broome, 2020 ). Box 4-3 describes culturally and linguistically appropriate services, designed to equip nurses with the knowledge, skills, and awareness to provide high-quality care for all patients regardless of cultural or linguistic background.

When nurses are educated and empowered to act at multiple levels—upstream, midstream, and downstream—they help reduce the effects of structural inequities generated by the health care system. This includes education about how structural inequities may affect their practice environments (as well as research and policy) and, by association, the people with whom they work in clinical and community-based settings (see the detailed discussion of nursing education in Chapter 7 ).

IMPLICATIONS OF COVID-19 FOR HEALTH CARE EQUITY

The COVID-19 pandemic has highlighted the pivotal role of nurses in addressing health care equity. During public health emergencies, nurses in hospitals and in public health and other community settings need to function collaboratively and seamlessly. The pandemic has heightened the need for team-based care, infection control, person-centered care, and other skills that capitalize on the strengths of nurses ( LaFave, 2020 ). Broadening of scope-of-practice regulations and expansion of telehealth services during the COVID-19 pandemic have allowed nurses to practice to the full extent of their education and training, providing equitable care and increasing access to care.

The surge of critically ill people due to the pandemic created the need to rapidly increase the capacity of the health care workforce, especially to replenish workforce members who needed to quarantine or take time to care for sick family members or friends ( Fraher et al., 2020 ). In response, multiple governors issued executive orders expanding the scope of practice for NPs. As of April 10, 2020, five states (Kentucky, Louisiana, New Jersey, New York, and Wisconsin) had temporarily suspended all practice agreement requirements, providing NPs with full practice authority ( AANP, 2020 ). Thirteen states (Alabama, Arkansas, Indiana, Massachusetts, Michigan, Mississippi, Missouri, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, and West Virginia) had enacted a temporary waiver of selected practice agreement requirements. By December 7, 2020, executive orders had expired for Kansas, Michigan, and Tennessee, and all practice agreement requirements had been temporarily suspended for Kentucky, Louisiana, New Jersey, New York, Virginia, and Wisconsin ( AANP, 2020 ). Maintaining these broadened scopes of practice for nurses after the pandemic has ended would increase NPs’ opportunities to increase access to quality health care for individuals with complex health and social needs.

Hospitals are also redeploying health care workers—physicians, NPs, nurses, and others—from areas with decreasing patient volumes (resulting from, for example, limitations on elective procedures) to higher-need intensive care unit (ICU), acute care, and emergency service areas. For example, nurse anesthetists have been redeployed from operating rooms to ICUs to intubate and place central lines for patients in the surge response to COVID-19 ( Brickman et al., 2020 ). As of December 2020, CMS was finalizing changes that allow NPs to “supervise the

performance of diagnostic tests within their scope of practice and state law, as they maintain required statutory relationships with supervising or collaborating physicians” ( CMS, 2020a ). These changes will help make permanent some of the workforce flexibilities that were allowed during the pandemic.

Although much attention has been paid to the dire need for health care supplies and hospital beds to treat patients with severe cases of COVID-19, less attention has been directed at impacts of the pandemic on communities; their ability to weather the crisis; and individuals’ physical, mental, and social health. Nurses, including public health nurses, working in and with communities continue to be critical to efforts to contain the COVID-19 pandemic, as well as other pandemics that may occur in the future.

Older Adults

Older adults have been disproportionately affected by COVID-19, and older POC are even more likely to experience disproportionate morbidity and mortality. CMS data show that Black Medicare beneficiaries were hospitalized four times as often and contracted the virus nearly three times as often compared with Whites of similar age ( CMS, 2020b ; Godoy, 2020 ). According to the Centers for Disease Control and Prevention (CDC), 8 of 10 deaths from COVID-19 in the United States have been among adults 65 and older ( Freed et al., 2020 ). Nursing homes have been particularly hard hit and faced multiple unique challenges in serving those most vulnerable to the virus.

The pandemic has had significant emotional, social, and mental health effects on older adults and their caregivers, and nurses and nursing assistants in nursing homes have borne a great burden in carrying out the front-line work of trying to keep residents healthy, care for recovered patients, and help mitigate isolation and its detrimental effects on residents. These tasks in many cases have been performed in the absence of residents’ family members and friends, who have not been allowed to visit as part of efforts to prevent the spread of infection. Inside nursing homes, the nursing staff have had to act as both caregivers and confidants, carrying out their usual tasks while also supporting many residents through confusion, depression, and suicidal ideation. In multigenerational homes, additional steps have been required to mitigate COVID-19 risk for older adults, such as using separate bathrooms, wearing masks within the household if someone is sick, or avoiding visitors. Demand for home health nursing services, inclusive of following strict public health measures (masks, handwashing, quarantining), has increased during the pandemic.

Changes in Medicare policy during the COVID-19 pandemic have given older adults greater access to a variety of mental health services, including those provided in their homes. Access to telehealth has also been expanded to meet the urgent need to provide safe access to care. Medicare payment for telehealth visits in nursing homes was previously restricted to rural areas, but under the

1135 waiver and the Coronavirus Preparedness and Response Supplemental Appropriations Act, CMS temporarily broadened access to telehealth services to ensure that Medicare beneficiaries could access services from the safety of their homes ( CMS, 2020b ). Accordingly, NPs and other health care professionals have used telehealth to screen people for COVID-19 and treat noncritical illnesses that can be managed at home.

Telehealth also has helped address concerns about workforce capacity for adult health care due to the surging numbers of COVID-19 cases and reports of exposure among health care workers: “as many as 100 health care workers at a single institution have to be quarantined at home because of COVID-19” ( Hollander and Carr, 2020 ). NPs who are quarantined because of exposure can provide telehealth services. It is important to note that the barriers discussed earlier due to restrictive scope-of-practice regulations may include limitations on providing telehealth services across state lines. Recognition of clinical licenses across states, such as through interstate agreements, could ease these barriers ( NQF, 2020 ).

Although CDC has reported that COVID-19 poses a relatively low risk for children, research on natural disasters has shown that, compared with adults, children are more vulnerable to the emotional impact of traumatic events that disrupt their daily lives. The pandemic has required that children make significant adjustments to their routines (e.g., because of school and child care closures and the need for social distancing and home confinement), disruptions that may interfere with a child’s sense of structure, predictability, and security. Young people—even infants and toddlers—are keen observers of people and environments, and they notice and react to stress in their parents and other caregivers, peers, and community members ( Bartlett et al., 2020 ). While most children eventually return to their typical functioning when they receive consistent support from sensitive and responsive caregivers, others are at risk of developing significant mental health problems, including trauma-related stress, anxiety, and depression. Children with prior trauma or preexisting mental, physical, or developmental problems, as well as those whose parents struggle with mental health disorders, substance misuse, or economic instability, are at especially high risk for emotional disturbance. Thus, in addition to keeping children physically safe during a public health emergency such as the COVID-19 pandemic, it is important to care for their emotional health ( Bartlett et al., 2020 ).

Barriers to mental health care result in serious immediate and long-term disadvantages for young people, especially students of color. Mental health—a key component of children’s healthy development—was already a growing concern prior to the pandemic and the concurrent nationwide protests in response to racial injustice and anti-Black racism, with the demand for mental health

services among U.S. adolescents increasing in the past decade ( Mojtabai et al., 2020 ). This concern has been fueled by increases in the incidence of anxiety and depression, as well as a trend in which victims of suicide have been younger. As noted earlier, programs such as Nurse-Family Partnership (see Box 4-1 ), as well as school nurses and school-based health centers, represent channels through which nurses can assist children and families with health care access to address mental health needs.

The health care system is being transformed by an increased focus on community-based coordinated care and the use of technology to improve communication so as to achieve better population health outcomes at lower cost. At the local level, providers in public health and school settings can collaborate strategically to increase their community’s capacity to address the root causes of illness and improve overall population health by implementing broad social, cultural, and economic reforms that address SDOH. Such collaboration can benefit the entire health care system by leading to seamless care, reducing duplicative services, and lowering the costs of care.

CONCLUSIONS

Whether in an elementary school, a hospital, or a community health clinic, nurses work to address the root causes of poor health. As the largest and consistently most trusted members of the health care workforce, nurses practice in a wide range of settings. They have the ability to manage as well as collaborate within teams and connect clinical care, public health, and social services while building trust with communities. However, nurses are limited in realizing this potential by state and federal laws that prohibit them from working to the full extent of their education and training. The COVID-19 pandemic in particular has revealed that the United States needs to do a much better job of linking health and health care to social and economic needs, and nurses are well positioned to build that bridge.

Conclusion 4-1: Nurses have substantial and often untapped expertise to help individuals and communities access high-quality health care, particularly in providing care for people in underserved rural and urban areas. Improved telehealth technology and payment systems have the potential to increase access, allowing patients to obtain their care in their homes and neighborhoods. However, the ability of nurses to practice fully in these and other settings is limited by state and federal laws that prohibit them from working to the full extent of their education and training.

Conclusion 4-2: Nurses are uniquely qualified to improve the quality of health care by helping people navigate the health care system;

providing close monitoring, coordination, and follow-up across the care continuum; focusing care on the whole person; and providing care that is culturally respectful and appropriate. Through a team-based approach, nurses can partner with professionals and community members to lead and manage teams and connect clinical care, public health, and social services while building trust with communities and individuals.

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The decade ahead will test the nation's nearly 4 million nurses in new and complex ways. Nurses live and work at the intersection of health, education, and communities. Nurses work in a wide array of settings and practice at a range of professional levels. They are often the first and most frequent line of contact with people of all backgrounds and experiences seeking care and they represent the largest of the health care professions.

A nation cannot fully thrive until everyone - no matter who they are, where they live, or how much money they make - can live their healthiest possible life, and helping people live their healthiest life is and has always been the essential role of nurses. Nurses have a critical role to play in achieving the goal of health equity, but they need robust education, supportive work environments, and autonomy. Accordingly, at the request of the Robert Wood Johnson Foundation, on behalf of the National Academy of Medicine, an ad hoc committee under the auspices of the National Academies of Sciences, Engineering, and Medicine conducted a study aimed at envisioning and charting a path forward for the nursing profession to help reduce inequities in people's ability to achieve their full health potential. The ultimate goal is the achievement of health equity in the United States built on strengthened nursing capacity and expertise. By leveraging these attributes, nursing will help to create and contribute comprehensively to equitable public health and health care systems that are designed to work for everyone.

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity explores how nurses can work to reduce health disparities and promote equity, while keeping costs at bay, utilizing technology, and maintaining patient and family-focused care into 2030. This work builds on the foundation set out by The Future of Nursing: Leading Change, Advancing Health (2011) report.

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• Empowerment Measures in Health Promotion Words: 594
• Health and Health Promotion Words: 629
• Health Promotion Role and Practice Words: 582
• The Purpose of Health Promotion Words: 1015
• Nursing Health Promotion and Its Importance Words: 574
• Health Promotion and Three Levels of Prevention Words: 951
• Community Health Promotion as a Nurse’s Role Words: 904
• Health Promotion and Patient Empowerment Words: 337
• Health Promotion Among Diverse Populations Words: 826
• Health Promotion in Minority Populations Words: 1162

Nurse’s Role in Health Promotion

A significant role in maintaining and forming the principles of a healthy lifestyle and motivation to preserve health is played by medical workers, particularly nurses. It is possible to form skills for maintaining health and the need to strengthen it at the preclinical stage. A nurse should give the necessary recommendations considering age, physical development, and belonging to a particular culture.

For measures to form a healthy lifestyle of the population to bring the expected effect, it is necessary to consider the patient’s cultural specifics. The set of methodological recommendations for the organization and conduct of work with patients should differ depending on the cultural background. Methods at different levels of preventive work of the average medical staff rely on the target audience, which guarantees the effectiveness of the measures taken.

It is worth applying the Health Belief Model to each specific culture when planning patient care. For example, when conducting health education among black men, it is necessary to appeal to an increasing number of sexually transmitted infections among the black population (Plowden, 2003). Training in the prevention of diseases of the reproductive system will be of increased importance for this group of people. Therefore, the methods of organizing sanitary and hygienic education should be based on the prevention of STIs.

For measures to form a healthy lifestyle of the population to bring the expected effect, it is necessary to take cultural peculiarities into account. Prevention of diseases and promotion of a healthy lifestyle should consider the risk factors for the health of a particular ethnic group. Measures to ensure all conditions for observing a healthy lifestyle should also be selected according to the population affiliation to ensure that they can be followed.

Plowden, K. (2003). A theoretical approach to understanding black men’s health-seeking behaviour. Journal Of Theory Construction & Testing , 7(1), 27-31.

Cite this paper

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StudyCorgi. (2022, September 16). Nurse’s Role in Health Promotion. https://studycorgi.com/nurses-role-in-health-promotion/

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Health Promotion in Nursing Analysis Essay

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Introduction

Purpose in nursing practice, roles and responsibilities, implementing health promotion, comparisons, reference list.

Health promotion has become imperative in the control and prevention of diseases. The concept of integrating health promotion in all aspects of life has been informed by the high prevalence of diseases and conditions that are preventable. The creation of a healthy lifestyle has developed tremendously in the last few decades as observed in the process of maintaining health and delivery of quality healthcare. The social and economic impacts of these conditions are enormous to the family and other countries, particularly in the developed world. In this essay, a review of the literature of three journals will be put in perspective with a view of knowing the definition of health promotion, and the roles of the nurses in the overall implementation program.

Health promotion can be defined using several definitions depending on the contextual application in nursing. In Richard et al (2008) article, health promotion is regarded as the measures put in place to ensure that individuals are cushioned against receiving injuries or various debilitating conditions. With regard to this, interventions and other preventive measures are put in place to safeguard the well-being of elderly persons. In fact, the researchers set to assess the level of utilization of primary prevention in several community settings where elderly individuals are catered for using theoretical approaches. In their article, Mao and Anastasi (2010) discuss the vital role and implications of the diagnosis and the overall management of endometriosis in women. As part of the nurses’ role, the researchers acknowledge the useful roles played by advanced nursing practice in the overall prevention and mitigation of the occurrence of terrible effects. Health promotion thereby focuses on providing adequate diagnostic measures coupled with treatment procedures aimed at curtailing the progress of a disease. In this case, the researchers devise activities that ensure there is a reduction in severity. Bouman et al (2008) look at the effects that home visiting programs would offer in terms of health-related measures to individuals suffering from terminal or debilitating conditions. The majority of these conditions are untreatable thus occasioning the need to offer palliative care coupled with emotional support. Using random controlled trials, the researchers try to understand the impact emotional and psychosocial support activities have on bettering the lives and health of terminally ill persons. According to the article, health promotion refers to those interventions directed to sick individuals with the aim of checking the occurrence of complications and deterioration of the overall health of the patients.

Nursing practice has evolved greatly in the last few decades whereby nurses have become more involved in the management of the patients. In view of the change in the preferences of patients and advancements in technology, nursing practice has transformed to accommodate cultural practices, technology, and more professionalism (Bouman et al, 2008). The intertwining of disease causation with economic and social life has occasioned the nurses to act as important avenues in providing guidance and instilling knowledge on disease causation to individuals. Health promotion has therefore become useful in breaking the disease causation cycle (Mao & Anastasi, 2010). Nurses are also bolstered thus enabling them to disseminate information on patients and utilize evidence-based practices that offer lasting impacts on diseases prevention and management. More importantly, nursing practice is enhanced since the nurses receive useful tips on the approach and information to be disseminated to the individuals and at which stage of the disease.

A paradigm shift has taken place in the nursing profession in terms of responsibilities according to the nurses. Due to their close interaction with the patients, the nurses’ responsibilities have soared to accommodate emotional and psychological support to patients. Moreover, nurses have become more involved in palliative care and offering culturally competent care. In this regard, nurses remain the major avenue that will ensure the success of health promotion due to the immense time they spend with the patients (Richard et al, 2008)

Nursing roles cut across all vital processes offered in healthcare facilities thereby bringing into fore specialization in various fields. Improvement in the curriculums and training has equipped the nurses with vital and immense knowledge that enhances their capabilities to advise and share vital information at any level and setting. Their holistic training and exposure give them an edge over other health professionals since they are equipped with communication skills and the basics of disease etiology.

Health promotion aims to lower the risks, the occurrence of disease, and lessen the complications occasioned by the diseases. All three levels of health promotion aim to lower the number of suffering patients undergo. In addition, the three levels involve actions that are overly directed in ensuring the recipients of the information are empowered through the acquisition of vital skills. The individuals are thus empowered to influence their actions towards achieving healthy living hence reorienting the healthcare services delivery.

Health promotion in nursing has therefore played a crucial role in enhancing their responsibilities and shaping the profession. In fact, health promotion has become an integral component of the nursing profession as espoused in the reviewed articles and thus the need to strategies on ways of integrating it into overall health programs.

Bouman, A., Rossum, E., Ambergen, T., Kempen,G. & Knipschild, P. (2008). Effects of a Home Visiting Program for Older People with Poor Health Status: A Randomized, Clinical Trial in the Netherlands. Journal of American Geriatric Society, 56, 397–404.

Mao, A. & Anastasi, K. (2010). Diagnosis and management of endometriosis: The role of the advanced practice nurse in primary care. Journal of the American Academy of Nurse Practitioners, 22, 109–116.

Richard, L., Gauvin, L., Gosselin, C., Ducharme, F., Sapinski, J. & Trudel, S. (2008). Integrating the ecological approach in health promotion for older adults: a survey of programs aimed at elder abuse prevention, falls prevention, and appropriate medication use. International Journal of Public Health , 53, 46–56.

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IvyPanda. (2022, March 22). Health Promotion in Nursing Analysis. https://ivypanda.com/essays/health-promotion-in-nursing-analysis/

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Evidence and practice    

Open access promoting health through nurse-led healthy conversations, anne mills senior lecturer, department of medical sciences and public health, faculty of health and social sciences, bournemouth university, bournemouth, england.

• To recognise the role of nurses in the prevention of non-communicable diseases

• To enhance your ability to initiate and engage in effective healthy conversations with service users

• To be aware that training can provide nurses with the knowledge, skills and confidence to discuss health with service users, and that it is available to all NHS staff

Nurses in all settings have an important role in preventing non-communicable diseases such as cardiovascular disease, cancer, respiratory disease and diabetes mellitus. They have multiple daily opportunities in their practice to discuss health with people, with the aim of supporting behaviour changes that reduce the risk of non-communicable diseases and the associated health-related and economic challenges. Incorporating the principles of healthy conversations into all daily interactions provides opportunities for nurses collectively to promote health on an individual basis to millions of people. However, many nurses have not received training in such behaviour change interventions. This article explains the principles and potential benefits of healthy conversations, and emphasises the importance of training to promote nurses’ knowledge, skills, confidence and motivation to engage in such conversations.

Nursing Standard . doi: 10.7748/ns.2023.e11912

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

[email protected]

None declared

Mills A (2023) Promoting health through nurse-led healthy conversations. Nursing Standard. doi: 10.7748/ns.2023.e11912

This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International (CC BY-NC 4.0) licence (see https://creativecommons.org/licenses/by-nc/4.0/ ) which permits others to copy and redistribute in any medium or format, remix, transform and build on this work non-commercially, provided appropriate credit is given and any changes made indicated.

Published online: 13 March 2023

clinical - communication - health literacy - health promotion - patient education - patients - person-centred care - professional - public health - well-being

Non-communicable diseases are responsible for the deaths of 41 million people globally each year, accounting for 74% of all deaths ( World Health Organization (WHO) 2022a , 2022b ). The four main non-communicable diseases worldwide are cardiovascular disease, cancer, respiratory disease and diabetes mellitus. Tobacco use, unhealthy diets, physical inactivity and harmful use of alcohol increase the risk of death from non-communicable diseases.

Individual behaviour is an important factor that affects people’s overall health ( National Institute for Health and Care Excellence (NICE) 2007 ), although that behaviour is often influenced by the social and commercial determinants of health ( WHO 2021a , 2021b ). The Health Survey for England 2017 ( NHS Digital 2018 ) examined five behavioural risk factors – cigarette smoking, excess alcohol consumption, unhealthy diet, physical inactivity and obesity – and reported that 32% of adults had two of these behavioural risk factors and 19% had three or more factors.

Nurses work at an individual and community level, so are well placed to support the prevention of disease at all stages of people’s lives ( Alleyne et al 2011 ). One way of doing this is by having healthy conversations with people they encounter in their day-to-day practice, which aim to encourage individuals to identify health issues that are important for them, support the development of health goals and ascertain timelines for action ( Health Education England (HEE) 2020 ). This article discusses the skills and knowledge that nurses require to initiate and engage in healthy conversations effectively.

Healthy conversations

Healthcare professionals, including nurses, frequently provide advice and information to service users to facilitate behaviour change; however, it is well recognised that this approach alone is generally insufficient ( Olshansky 2007 , Kasila et al 2018 , Hollis et al 2021 ). Behaviour change is complex and if healthy conversations are to be effective, they need to explore and acknowledge the complexities and context of people’s lives, recognise their personal resources or agency (one’s ability to act in a given situation) and support the development of change action plans ( HEE 2020 ).

Healthy conversations use a person-centred approach and aim to empower people to take control of their behaviours and subsequently increase their self-efficacy and self-esteem ( Black et al 2014 , Hollis et al 2021 ). Bandura’s (1991) social cognitive theory forms the foundation for healthy conversations, recognising that personal agency regulates goal-directed behaviour, while also acknowledging that people need to believe they have the required skills, qualities and capabilities to carry out and maintain the new health behaviour ( Naidoo and Wills 2016 , Buckworth 2017 ). Healthy conversations can be achieved in as little as 30 seconds, or longer if more time is available ( Aveyard et al 2012 ).

Making Every Contact Count

Making Every Contact Count (MECC) is a brief or very brief behaviour change intervention that uses the main elements of healthy conversations to discuss health with service users ( HEE 2020 ). It is a long-term national strategy, launched in 2010, that builds on the many interactions that NHS staff have with people in their daily practice. A consensus statement on MECC was published by Public Health England, NHS England and HEE in 2016, showcasing their commitment to the intervention and their aim to upskill all NHS staff to deliver it ( Public Health England et al 2016 ). MECC is aligned with the national and global move away from an authoritarian biomedical approach to healthcare towards a person-centred holistic approach. It seeks to explore issues that are important to an individual, rather than focusing on ‘what is the matter’ with them. Person-centred conversations aim to empower service users to take control of their behaviour by developing their self-esteem and self-efficacy ( Hollis et al 2021 ).

MECC training provides healthcare professionals with the skills required to use time-limited opportunities efficiently and to support people to identify the health behaviours they wish to change. These may include adopting a healthy diet, losing weight, reducing alcohol intake, stopping smoking, becoming increasingly physically active or other health behaviours that are relevant and important to the person ( HEE 2020 ). The training encourages the use of open-ended questions that start with ‘How’ or ‘What’ and aim to explore and understand the person’s situation by encouraging them to share their stories and voice their concerns, thereby providing insight into what matters to them. In contrast, closed questions merely require the person to answer ‘yes’ or ‘no’, providing little information to work with ( HEE 2020 ). Examples of open-ended questions that might be used include:

• ‘What would you like to change?’

• ‘How will you make these changes?’

• ‘What have you tried before?’

• ‘What previously worked well for you?’

The aim of MECC is to use the many daily conversations that nurses are involved in to assist service users in making healthy choices, identifying the issues important to them, focusing on the person’s strengths and abilities, exploring the obstacles to the new behaviour, and supporting the person to devise their own solutions and action plans based on their strengths and abilities. People should also be supported to decide who will collaboratively review their change plan; some people may wish to review their plan with a trusted friend, family member or work colleague, while others may want to be supported by a healthcare professional ( HEE 2020 ).

Nursing skills for healthy conversations

Ekman et al (2022) acknowledged that service users’ first impressions of healthcare professionals are crucial in determining the consequences of conversations, so it is essential they display body language that is respectful and welcoming, for example an open friendly posture and unfolded arms. It is also important that they maintain appropriate eye contact, speak at a steady pace and use a friendly tone of speech. Healthcare professionals who show empathy and take a genuine interest are regarded as trustworthy; as a result, people are increasingly likely to share their personal stories with them ( Hubley et al 2021 ).

Nurses need to be non-judgemental, open and alert to what the person wishes to talk about. Using open questions encourages the person to contribute to the dialogue ( Golsäter et al 2012 ) and take control of the conversation, moving away from the healthcare professional giving recommendations or offering advice and towards the person identifying potential actions and solutions themselves ( Hollis et al 2021 ). Nurses should work with service users to develop behaviour goals that are SMARTER (specific, measurable, action-oriented, realistic, timed, evaluated and reviewed) ( HEE 2020 ). Nurses should avoid using statements such as ‘In my experience’, telling people what to do, and suggesting actions ( Black et al 2014 ).

To build on an individual’s personal strengths and enhance their confidence, the nurse should use active listening skills, listen more than talk, and use open questioning to explore the importance of the new behaviour as identified by the person ( Black et al 2014 ). At the same time, nurses need to be alert to issues, be responsive to what has worked well in the past for the person, and recognise what enablers and barriers may facilitate or hinder the change ( de Normanville et al 2011 ).

Scriven (2017) maintained that although nurses are not trained as counsellors, to be effective in health promotion conversations they need to adopt and use counselling techniques, such as motivational interviewing and health coaching. Motivational interviewing uses empathy to reduce people’s resistance and increase their motivation for change ( Rollnick and Allison 2004 ), while health coaching seeks to enable people to acquire and use knowledge and skills that will enable them to become active in their care and take action towards achieving their well-being goals ( NHS England and NHS Improvement 2020 ).

Box 1 provides an example of the content of a healthy conversation a nurse could have with a service user.

Box 1.

Example of the content of a healthy conversation.

A nurse could have a healthy conversation with a person diagnosed with type 2 diabetes who is not taking their prescribed medicines to manage the condition. In this situation, the nurse could support the person to develop the confidence and self-efficacy required for effective self-management of type 2 diabetes by demonstrating their knowledge of the condition, being aware of the community resources that are available and using the skills they have learned from healthy conversation training. The nurse could identify the reasons why the person is not taking their prescribed medicines, for example they might not understand the importance of taking them or might be unable to collect their prescription because of transport issues. Furthermore, the nurse can use the healthy conversation as an opportunity to discuss the importance of a healthy diet, how to shop and cook for such a diet, the value of being physically active and any additional support that could enhance the person’s well-being.

• Nurses are well placed to support prevention of non-communicable disease through healthy conversations with people they encounter in their day-to-day practice

• Healthy conversations aim to encourage individuals to identify health issues that are important for them, support the development of health goals and ascertain timelines for action

• Making Every Contact Count training provides healthcare professionals with the skills required to use time-limited opportunities efficiently and support people to identify health behaviours they wish to change

• Nurses should recognise the social and economic context of people’s lives and understand how this influences health outcomes

• Healthy conversations can enhance individual’s health literacy, which may contribute to increased knowledge, confidence in personal abilities, resilience and self-belief in their ability to make health behaviour changes

Areas to consider when having healthy conversations

Determinants of health.

Healthy conversations provide opportunities for nurses to support people who are adversely influenced by the social and commercial determinants of health ( Lathrop 2013 ). The social determinants of health are the factors that affect a person’s health and well-being and include political, cultural and socioeconomic factors, as well as access to healthcare, education, safe and appropriate housing, and healthy food ( WHO 2021b ). The commercial determinants of health include the private sector’s production and marketing of various products and activities, for example processed foods, sugary drinks, tobacco and gambling. These can negatively affect people’s health, potentially leading to non-communicable diseases such as heart disease, obesity and type 2 diabetes, as well as mental health issues ( WHO 2021a ).

These social, economic and commercial circumstances can inhibit behaviour change and may strengthen harmful behaviours ( NICE 2007 ). As a first step, nurses need to be able to recognise the social and economic context of people’s lives and how this influences health outcomes ( Hemingway and Bosanquet 2018 ). They should also be aware that sensitivity and compassion is required when discussing topics such as food poverty, suboptimal housing, unemployment and financial hardship.

Health literacy

It has been identified that 61% of the working-age population in England has difficulty understanding information on health and well-being, which influences their ability to manage long-term conditions, participate in health-enhancing behaviours and access services ( Public Health England and Institute of UCL Health Equity 2015 ). Health literacy enables people to make sense of and use information, and access health and social care services, based on their knowledge and capabilities. It is helped or hindered by organisational structures and the availability of resources ( WHO 2022c ), and is recognised as a social determinant of health that nurses need to be aware of during healthy conversations.

Low rates of health literacy are linked to higher rates of hospital admission and readmission, increased use of emergency services for disease treatment, suboptimal health outcomes, higher mortality and lower use of preventative healthcare services ( Berkman et al 2011 , Cloonan et al 2013 ). People with low health literacy are often ashamed of their lack of understanding or low skill level ( Wolf et al 2007 ), so if nurses are to have an effect on health behaviours they need to be approachable, make time to clearly explain issues and answer questions. Healthy conversations can enhance an individual’s health literacy, which may contribute to increased knowledge, confidence in personal abilities, resilience and self-belief in their ability to make health behaviour changes ( Public Health England and UCL Institute of Health Equity 2015 ).

In healthy conversations there are two important elements that relate to health literacy: the nurse’s ability to communicate effectively and the service user’s capacity to understand, process and use the information. During the conversation it is important to use language that is easy to understand and avoid medical or technical jargon, abbreviations and complex terminology. Any written information that nurses provide should be clearly written and structured ( Koh et al 2012 ). If they provide links to internet resources, the nurse should be aware of the content of the website material, how understandable it is and if the person can easily access the internet.

Signposting to other services

Nurses who are knowledgeable about local services and resources can provide people with support, information and options for improving their health ( Tallon et al 2017 ). Several organisations provide useful information online that can support healthcare professionals to have healthy conversations with service users, including NICE ( www.nice.org.uk/about/nice-communities/local-government ), elearning for healthcare ( www.e-lfh.org.uk/programmes/all-our-health ) and charities such as the British Heart Foundation ( www.bhf.org.uk/for-professionals/healthcare-professionals/resources-for-your-role/resources-for-primary-care-nurses ).

In addition, social prescribing aims to connect people in primary and secondary care with sources of community support and services using non-medical interventions that seek to meet people’s physical, social and psychological needs ( Rempel et al 2017 ). Social prescribing link workers can connect people to services within local communities such as support and information on increased physical activity, alleviation of loneliness, debt support, creative activities and volunteering, including statutory services such as housing and welfare ( Islam 2020 , NHS 2023 ). Much of what supports people’s health happens outside clinical settings ( Buck and Gregory 2013 ), so it is important that nurses are aware of the health-enhancing services available to people in their local area.

Training for healthcare professionals

Low confidence linked to lack of knowledge and skill base is cited by healthcare professionals as a barrier to the delivery of behaviour change interventions ( Keyworth et al 2018 ). Additionally, the National Institute for Health and Care Research (2021) has reported that many NHS staff miss opportunities to promote health because they lack the skills to discuss sensitive issues that may cause distress. However, Public Health England (2013) guidance recognises the essential public health role of all nurses, while the Standards of Proficiency for Registered Nurses ( Nursing and Midwifery Council 2018 ) requires nurses to actively promote the health of service users.

MECC training can provide nurses with the knowledge, skills and confidence to discuss health with service users and to support goal setting ( Jarman et al 2019 ). This training is available in many locations across the UK, delivered online and face-to-face. MECC Healthy Conversation Skills Training is delivered across two three-hour sessions, while MECC Lite Training consists of one three-hour session ( Healthy Conversation Skills 2020 ).

Training addresses all features and types of healthy conversations, ranging from very brief opportunistic encounters to longer discussions. It can provide nurses with the skills to develop empathic relationships, increase their confidence in identifying and creating opportunities for healthy conversations, and support them to gain an understanding of the context and lived experiences of individuals ( Black et al 2014 , HEE 2020 ). A Royal Society for Public Health (2022) report found that staff who had completed MECC for mental health training were increasingly confident and motivated to find opportunities to engage in conversations with people. Meanwhile, a study involving 108 nursing students who had completed MECC training found that 84% ( n =91) valued this training, with many using the knowledge and skills they had learned with service users and in their own lives ( Mills et al 2021 ). However, if their nurse mentors were unaware of or did not practise healthy conversation skills or MECC, the nursing students were less likely to develop these skills ( Mills et al 2021 ).

Healthy conversations use the millions of everyday interactions between nurses and service users to improve individuals’ health and support them to make behaviour changes that will reduce the risk of non-communicable diseases. These conversations are person-centred and provide opportunities to support people with the health and well-being concerns that are important to them. Training is available to all NHS staff and aims to equip them with the skills and knowledge to engage in healthy conversations with confidence. Nurse managers and leaders should demonstrate their commitment to public health initiatives by ensuring that all nurses can access this training.

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What are the barriers and facilitators to effective health promotion in urgent and emergency care? A systematic review

B. schofield.

1 University of West of England School of Health and Social Wellbeing, Faculty of Health and Applied Sciences, Glenside Campus, Bristol, BS16 1DD England

2 Bournemouth University, Faculty of Health and Social Sciences, Bournemouth House, Christchurch Road, Bournemouth, Dorset, BH1 3LH UK

3 University of the West of England Faculty of Health and Social Sciences, Frenchay Campus, Coldharbour Lane, Bristol, BS16 1QY England

Associated Data

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

There are potential health gains such as reducing early deaths, years spent in ill-health and costs to society and the health and care system by encouraging NHS staff to use encounters with patients to help individuals significantly reduce their risk of disease. Emergency department staff and paramedics are in a unique position to engage with a wide range of the population and to use these contacts as opportunities to help people improve their health. The aim of this research was to examine barriers and facilitators to effective health promotion by urgent and emergency care staff.

A systematic search of the literature was performed to review and synthesise published evidence relating to barriers and facilitators to effective health promotion by urgent and emergency care staff. Medical and social science databases were searched for articles published between January 2000 and December 2021 and the reference lists of included articles were hand searched. Two reviewers independently screened the studies and assessed risk of bias. Data was extracted using a bespoke form created for the study.

A total of 19 papers were included in the study. Four themes capture the narratives of the included research papers: 1) should it be part of our job?; 2) staff comfort in broaching the topic; 3) format of health education; 4) competency and training needs. Whilst urgent and emergency care staff view health promotion as part of their job, time restraints and a lack of knowledge and experience are identified as barriers to undertaking health promotion interventions. Staff and patients have different priorities in terms of the health topics they feel should be addressed. Patients reported receiving books and leaflets as well as speaking with a knowledgeable person as their preferred health promotion approach. Staff often stated the need for more training.

Conclusions

Few studies have investigated the barriers to health promotion interventions in urgent and emergency care settings and there is a lack of evidence about the acceptability of health promotion activity. Additional research is needed to determine whether extending the role of paramedics and emergency nurses to include health promotion interventions will be acceptable to staff and patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00651-3.

The NHS is committed to using all staff encounters with patients to help individuals significantly reduce their risk of disease [ 1 , 2 ]. This could reduce early deaths, years spent in ill-health and costs to society and the health and care system. NHS staff have the opportunity to recognise appropriate times and situations in which to engage with patients and help them on the pathway to improving their health and wellbeing. Emergency Department and Emergency Medical Services (Ambulance) staff are in a unique position to engage with a wide range of the population and to use these contacts as opportunities to help people improve their health.

The World Health Organisation describes health promotion as a process of enabling people to increase control over, and to improve, their health [ 3 ]. Patient education and effective communication can support individuals to make healthy choices [ 4 ]. A range of factors may complicate communication in the Emergency Department (ED). These include variable workloads, crowding, uncertainty and time constraints [ 5 ]. Some of these factors also apply to the work environment of paramedics. Whilst the nature of urgent and emergency care may offer challenges when considering health promotion activities, it may also be the ideal environment to create opportunities for a ‘teachable moment’ that will promote subsequent health behaviour change [ 6 ]. There is also an economic evidence base for health promotion and disease prevention, as reducing the risk of chronic diseases and injury through interventions aimed at modifying lifestyle risk factors is known to be cost-effective, and could reduce health inequalities [ 7 ].

Given the potential health gains, research should be encouraged to organise and deliver effective health promotion interventions in urgent and emergency care settings. The aim of this systematic review was to examine barriers and facilitators to effective health promotion by urgent and emergency care staff. This paper reports on an evidence synthesis relating to the barriers and facilitators to effective health promotion interventions in urgent and emergency care settings. The paper will inform the direction of future research in this field by providing a basis to further explore areas of interest and expressed needs.

Study design

The search methodology and reported findings comply with the relevant sections of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [ 8 ]. Prior to performing this review, a protocol was developed and registered with PROSPERO (registration number CRD42020205180). The research question guiding this systematic review was as follows: “What are the barriers and facilitators to effective health promotion interventions in urgent and emergency care settings?”

Consensus was reached among all reviewers on search syntax, inclusion and exclusion criteria, and the criteria for assessment of validity and relevance in the identified articles.

Eligibility criteria

Our eligibility criteria followed the Participant, Exposure, Outcome and Study design (PEOS) framework [ 9 ]. We only included papers written with publication dates limited from January 2000 to August 2020 in all our information sources. Limiting the search period to 2000 onwards sought to identify all relevant research published in a contemporary timeframe.

Search strategy

The search strategy was informed by an initial overview of literature in the field and the assistance of a subject librarian. The following bibliographic databases were searched: CINAHL, MEDLINE, Cochrane Central, Cochrane sensitive RCT search strategy, Scopus and PsycINFO on 18th August 2020. The search was repeated on 14th December 2021 to capture any relevant papers published since the original search date. The search included title, abstract, keywords and subject headings to describe the population (paramedics, doctors, nurses and support staff in emergency departments) and the setting (pre-hospital emergency medical (ambulance) services and hospital emergency departments). A detailed strategy for MEDLINE is given in (Table  1 ) and was adapted to the other databases. All articles that met the search terms were exported from the search engines to the Covidence systematic review management system [ 10 ]. Backward chaining within the final sample was reviewed for potentially relevant papers.

detailed search strategy

Selection of studies

A range of research methods was considered including randomised controlled trials, observational studies, surveys and qualitative research. Any literature (quantitative, qualitative or mixed methods) that reported on the facilitators or barriers to health promotion in urgent and emergency care settings was considered for inclusion. This included research papers of any kind but not systematic reviews, literature reviews, editorials, commentaries or letters. Unpublished data was not included.

Based on the inclusion criteria (Table  2 ), two reviewers (BS and UR) independently screened the titles and abstracts of eligible articles to eliminate articles not meeting the inclusion criteria. Articles not meeting the inclusion criteria based on the title and abstract were excluded at this point. The full text of the agreed included articles was screened independently by the same two reviewers (BS and UR). Articles were excluded at the full-text stage if they did not directly meet the eligibility criteria on closer inspection of the full article. Additionally, references in review articles were screened using the same criteria. Any conflicts during the screening process were resolved through discussion by the two reviewers with reference to the inclusion and exclusion criteria.

Inclusion criteria

Due to heterogeneity between study settings, designs and screening tools used, the included studies have been described narratively [ 11 ].

Data extraction and quality assessment

A bespoke data extraction form was designed in consultation with the review team and piloted on two papers identified during the scoping search. No changes to the data extraction form were recommended following the pilot phase. The data extraction form is reproduced in Additional file  1 Appendix 1. Two authors extracted data separately from the eligible studies (BS and UR). The reviewers conferred and agreed on studies to be included.

The Mixed Methods Appraisal Tool (MMAT) was used to assess the studies for risk of bias, relevance, trustworthiness and results [ 12 ]. The authors of the MMAT encourage the provision of a detailed presentation of the ratings of the five criteria within the tool to reflect the quality of the included studies. In this review the studies were ranked as high (all criteria met), medium (four out of five criteria met) and low (three or less criteria met). Much of the MMAT assessment process focuses on the risk of bias in the study under consideration, and therefore studies judged as low quality are at the highest risk of bias when this tool is applied. Conflicts in risk of bias assessment were resolved through discussion by the two reviewers and with reference to the appraisal tool. The methodological quality of each study was independently analysed by two authors (BS and UR). No studies were excluded based on quality assessment. The quality rankings for each study are presented in Table  3 .

Characteristics of included studies ( n =  19)

Study selection

Overall, research into barriers and facilitators of health promotion activity in urgent and emergency care settings was found to be limited. No relevant research was identified regarding paramedics. It was therefore necessary to increase the scope of the review to include community paramedicine programmes in rural settings in North America and Australia. Whilst these programmes are not directly transferable to the role of paramedics more generally, they are able to demonstrate the acceptability of this non-traditional role, which includes health promotion, amongst the wider paramedic profession.

154 papers were identified through database searching. Following the removal of duplicates, 108 records were reviewed by title and abstract. Of these, 63 were removed. 45 records were assessed for eligibility based on a full text review. 26 were excluded, with 19 records being included in the review. Inter-rater agreement for full text exclusion was strong (k = 0.86). A flow-chart of the search strategy and selection is presented in Additional file  1 Appendix 2.

Studies took place in the following countries: 11 in the US [ 13 , 14 , 16 , 18 , 20 , 22 , 23 , 25 – 28 ], 1 in Jordan [ 30 ], 2 in the UK [ 17 , 24 ], 4 in Australia [ 15 , 19 , 21 , 31 ] and 1 in Canada [ 29 ]. The characteristics of the included studies and participants are described in Table ​ Table3 3 .

Data synthesis

The 19 studies were published between 2000 and 2020 and included a range of populations and research methodologies. Ten studies were surveys, four were randomised controlled trials, two were retrospective reviews of records and three were qualitative interviews/focus groups. Sample sizes ranged from 2149 to 11 participants. Four themes capture the narratives of the included research papers: 1) should it be part of our job?; 2) risk of offending patients; 3) format of health education; 4) competency and training needs. These four themes capture the reported barriers and facilitators to effective health promotion interventions in urgent and emergency care settings.

Should it be part of our job?

In general staff support health promotion taking place in the ED. [ 17 , 18 , 21 , 24 , 26 , 28 ] Paramedics in rural communities and emergency services technician firefighters also see health promotion as an acceptable part of their jobs [ 20 , 27 , 29 ]. However, ED nurses in one Jordanian study felt it was not part of their role [ 30 ].

Whilst nurses felt that health promotion was part of their role, they reported providing health promoting advice less than half the time when these interactions would have been indicated. They reported lack of time and a lack of support systems for patient follow up as barriers [ 18 ]. Although ED doctors reported feeling responsible for promoting the health of their patients, only a minority reported routinely screening and counselling their patients with identified modifiable risk factors. Most reported not feeling confident in their ability to help patients change their behaviour [ 26 ]. In one study doctors reportedly offered health promotion intervention more often than nurses. Time constraints and a lack of health promotion infrastructure in the ED were cited as challenges to intervention delivery [ 17 ]. Patients and carers attended to by community paramedics accepted paramedics in a non-traditional preventative healthcare role [ 29 ].

Staff comfort in broaching the topic

The health conditions of interest to ED patients in one study were stress and depression and among the health topics, participants were most interested in exercise and nutrition [ 22 ]. Smoking is the health topic most commonly discussed according to ED doctors in one study [ 26 ]. Whilst ED staff in another study stated that drug and alcohol misuse were the most appropriate risk factors to discuss in ED and that the interventions in the ED were most appropriate when risk factors were directly related to the ED presentation [ 17 ]. Paramedics had success with injury prevention advice as part of their role in community paramedicine [ 27 ]. The recording of health risks and counselling was noted in only 22% of nonacute patients with one or more modifiable risk factors; with doctors documenting more health risks than nurses [ 28 ].

Whilst 20% of all calls for an ambulance service involve alcohol, not many ambulance officers ask the patients they attend about quantity and frequency of alcohol use [ 21 ].

Format of health education

Educational, and to a lesser extent behavioural change, approaches are the main forms of health promotion described in the urgent and emergency care setting [ 32 ]. Patients and visitors stated they preferred traditional forms of books and leaflets to support the information they were given on health-related topics [ 22 ]. An educational video used during ED waiting was shown to improve knowledge and act as an acceptable low-cost teaching tool for focused patient education that may allow clinicians to use patient waiting time for health promotion [ 16 , 25 ]. The use of learning style-tailored information led to patients perceiving improved knowledge [ 14 ]. Using a structured education tool improved nurse confidence in undertaking personalised education prior to discharge from the ED. [ 19 ] A computer kiosk to promote child safety in a randomised controlled trial in an urban paediatric emergency department demonstrated the applicability of computer technology for education in a busy ED. [ 13 ]

Inadequate patient education has been cited as a potential cause of re-attendance of asthma patients to the ED. A randomised study aimed to compare the effectiveness of patient-centred education (PCE) and standard asthma patient education on ED re-attendance. PCE patients had fewer re-attendances at 4 and 12 months. A learner-centred approach to education may be useful in reducing re-attendances to the emergency department [ 15 ]. Internet referrals may provide a potential solution to limited staff time in emergency departments for health education [ 23 ].

Competency and training needs

There was a statement of continued need for education in health promotion roles in those studies where staff views were collected [ 19 , 21 , 24 , 26 , 30 , 31 ]. Nurses felt they lacked competency [ 30 ], were less knowledgeable on some health topics than others [ 24 , 26 , 31 ], and requested a structured approach [ 16 ]. Paramedics requested specific training to deal with patients affected by excessive alcohol intake [ 21 ]. Staff were concerned that existing health promotion interventions were not systematic and had not been evaluated and risked becoming a marginalised part of their work [ 31 ]. Lack of health promotion knowledge, lack of time and not wanting to extend a patient’s stay in the ED were reported as barriers.

Nineteen studies with varying designs were identified as relevant for our exploration of barriers and facilitators to effective health promotion in urgent and emergency care. The evidence base is not well developed. There is limited evidence describing the barriers to health promotion activities in EDs, and facilitators are particularly poorly captured. Two literature reviews suggest that educational interventions in the ED are both possible and feasible, while indicating that additional research is needed to provide a more substantial evidence base from which to identify effective approaches designed specifically for this healthcare setting [ 33 , 34 ]. This review supports these statements and highlights a need for further research in this area, in particular to understand the views of staff and patients on the potential for an expansion of the role of ED nurses and paramedics.

Almost all relevant research has suggested that urgent and emergency care staff view health promotion as a part of their job, however time restraints and a lack of knowledge and experience are identified as barriers to undertaking health promotion interventions. If emergency nurses feel more confident in their educating practices, and are supported by a structured format, patients may benefit from better quality patient education provided in the ED. The provision of a health promotion infrastructure in the ED will be a positive step towards providing a standard approach and is likely to include training and support pathways for ED staff to ensure that health promotion is an integral part of their role.

Whilst patients have reported that the health promotion topics they are most interested in are exercise and nutrition, ED staff shy away from health promotion interventions relating to weight management, diet and exercise [ 18 , 22 , 26 ] There may be worries around seeming insensitive to patients and further stigmatising patients that prevent staff from engaging in these interactions. Staff in general report providing health promotion interventions on blood pressure management, smoking and alcohol use. ED staff agree that health promotion interventions are most effective if related to an acute ED presentation. This may be one reason why diet and weight management are not seen as appropriate interventions in this setting. A study of General Practitioners and practice nurses in the UK on talking to primary care patients about weight found that staff had concerns about raising the issue of overweight; the most common being that patients would react emotionally to the message [ 35 ].

Patients reported receiving books and leaflets as well as speaking with a knowledgeable person as their preferred health promotion approach. A systematic review of the effectiveness of traditional media (leaflet and poster) to promote health in a community setting, demonstrated that traditional health promotion media such as leaflets and posters are still useful in the current digital era, especially for adult respondents [ 36 ].

A number of studies have demonstrated the feasibility of video and internet use in the ED waiting areas as acceptable methods of patient education. A disease-specific educational video may be a relatively low-cost tool for focused patient education in the ED waiting room. These combined approaches may have the potential to offer improved outcomes for patients visiting the ED but adopting them will require structural and cultural changes. A systematic review of the effectiveness of video-based education in modifying health behaviours demonstrated that for certain health messages and conditions video interventions appear to be effective [ 37 ].

Patient discharge from the ED appears to be an effective time to maximise engagement with ED recommendations and improve self-care according to the literature reviewed. A variety of potential teaching methods and teaching materials have been used in the ED; however, it is still unclear which of these are most effective, and for which subgroup of the population [ 38 ]. Given the potential for health gains, research should examine how to organise and deliver the most effective patient education in the ED.

The role of the paramedic in health promotion is beginning to receive some attention [ 39 , 40 ]. Health promotion and healthy lifestyle interventions are outlined in the Paramedic Specialist in Primary and Urgent Care Core Capabilities Framework produced by the College of Paramedics [ 41 ]. The included literature demonstrates support from community paramedics and emergency medical technicians in Canada, US and Australia for the expanded role of health promotion as part of their activities when treating patients in the community [ 20 , 21 , 27 , 29 ]. This literature highlights how paramedics in the ambulance service may be able to adapt to health promotion activities when treating and discharging patients at home.

The themes identified in this review can be both facilitators and barriers to undertaking effective health promotion interventions in urgent and emergency care settings. If staff view health promotion as part of their role it will be a facilitator to undertaking effective health promotion interventions in urgent and emergency care settings. Conversely, if staff feel there is a tension between their role as urgent and emergency care practitioners and health promotion, it is likely to act as a barrier with restraints on time and lack of confidence having an impact on the likelihood of staff engagement with health promotion interventions in these settings. On the theme of staff comfort of broaching the topic, if staff view the health promotion discussion as sensitive, it will act as a barrier, and they are less likely to engage in the conversation. Conversely, if staff feel comfortable with the health promotion topic it will act as a facilitator, and they are likely to engage with the patient more readily. Additionally, if the format of the health education approach is patient-centred, and appropriate for their learning needs, it is likely to act as a facilitator to undertaking effective health promotion interventions in urgent and emergency care settings. Conversely, inappropriate health education approaches could act as a barrier in these settings. Finally, if staff feel they lack competency and training in health promotion it is likely to act as a barrier to undertaking effective health promotion interventions in urgent and emergency care settings. Conversely, staff who feel they have adequate competency and training will be more likely to undertake effective health promotion interventions.

Heterogeneity in study settings, designs and the screening tools used in the included studies affects the conclusions and recommendations of this systematic review as it decreases the generalisability of the findings to the management of health promotion interventions in the urgent and emergency care settings [ 42 , 43 ]. This variability in participants and methodological diversity is the reason we decided to describe the included studies narratively, rather than attempting any form of statistical analysis.

The lack of evidence on the acceptability of health promotion for patients and service providers in urgent and emergency care settings, coupled with an imperative to ensure staff talk to the public they are treating about their health and wellbeing across all health and social care organisations, requires further exploration. There is a need to efficiently integrate existing information and determine the extent to which findings are generalisable across health care settings. This will guide future research on health promotion in urgent and emergency care to generate evidence on patient benefit. This review draws together a disparate literature to identify themes and create an overview with pointers towards future research that has the potential to change practice.

Limitations

This review was limited to research papers published since January 2000. There is a risk of missing grey literature and relevant literature published prior to 2000. The wide range of methods, countries and interventions described in the included studies makes generalisation difficult.

Future directions

Future research is necessary to define and understand the barriers and facilitators to health promotion interventions in urgent and emergency care settings. Current evidence does not support changes to clinical practice, and further research is required to build an evidence base that will justify the introduction of new interventions and staff behaviours when caring for patients in emergency care. We anticipate existing clinical practice will be modified if high quality research demonstrating the clinical and cost effectiveness of one or more defined interventions relevant to a particular health system is published.

Few studies have investigated the barriers to health promotion interventions in urgent and emergency care settings. The papers reviewed in this article demonstrate a willingness amongst staff in urgent and emergency care to undertake health promotion activities. The studies included highlight what emergency department nurses may need to undertake the role of health promotion in their clinical setting. The included papers are mainly from the US, Canada and Australia and there are cultural considerations that need to be considered in future research. Additional research is needed to determine whether extending the role of paramedics and emergency nurses to include health promotion interventions will be acceptable to staff and patients, and to generate an emerging evidence base that will direct future research and practice.

Acknowledgements

We would like to acknowledge Pauline Shaw (Subject Support Librarian: Health and Applied Sciences, University of the West of England, Bristol) for her help in creating the search syntax.

Authors’ contributions

BS and UR conducted the review of the literature. BS was responsible for the writing of the manuscript. BS UR SM RH SV JB contributed to revisions of the manuscript. BS UR SM RH SV JB read and approved the final manuscript.

This research was funded by University Hospitals Bristol and Weston NHS Foundation Trust Research Capability Funding 2020/21.

Availability of data and materials

Declarations.

Not applicable.

The authors declare that they have no competing interests.

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Contributor Information

B. Schofield, Email: [email protected] .

U. Rolfe, Email: ku.ca.htuomenruob@efloru .

S. McClean, Email: [email protected] .

R. Hoskins, Email: [email protected] .

S. Voss, Email: [email protected] .

J. Benger, Email: [email protected] .