Health Field Concept

To identify and promote positive health factors, Lalonde (1974) proposed the Health Field Concept, which is based on four broad and mutually reinforcing elements: the human biology, the environment, lifestyles and healthcare organisations. Lalonde (1974) assessed how each of these four elements affected the Canadian population’s health and identified several health factors relating to each element. Box 1 summarises the Health Field Concept.

Ottawa Charter for Health Promotion

Lalonde’s (1974) seminal document inspired global health leaders and paved the way for the World Health Organization’s (WHO) first International Conference on Health Promotion, held in Ottawa, Canada, in 1986. At that conference, an international agreement called ‘The Ottawa Charter for Health Promotion’ was drawn up and health promotion was formally defined as ‘the process of enabling people to take control over, and to improve, their health’ (WHO 1986). The Ottawa Charter outlined five health promotion actions that can be achieved through three health promotion strategies (Box 2).

The Ottawa Charter (WHO 1986) adopted a socioecological approach whereby individuals and their environment are considered to be inextricably linked. This conceptual shift marked a global turning point: from then onwards, health was no longer deemed to be the sole responsibility of the medical profession but required collaboration between governments, communities and the public (Pinder and Rootman 1998).

Patients

A small qualitative study conducted in an ED in Jordan found that ED nurses did not necessarily perceive health promotion as relevant to their role (Shoqirat 2014). However, ED nurses are already involved in many activities aimed at promoting the health of patients, such as:

Activities directed towards promoting the health of patients are important, but they are only one part of the health promotion activities in hospitals outlined by Groene and Garcia-Barbero (2005) that ED nurses can undertake.

Staff

The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates states that registrants must ‘maintain the level of health’ they need to carry out their professional role in order to ‘promote professionalism and trust’ and ‘uphold the reputation of the nursing profession at all times’ (Nursing and Midwifery Council (NMC) 2018). This is designed to ensure not only that nurses are physically and mentally able to provide patient care, but also that they are convincing as health promoters and role models. According to While (2015), the social judgements of patients on the personal health behaviours of primary care staff, who are on the front line of promoting healthy behaviours, may undermine their credibility as health promoters. However, according to Kelly et al (2017), the assumption of a causal relationship between nurses’ health behaviours and patients’ responses to, and adoption of, public health messages is not supported by the research evidence.

There is a risk that nurses’ professional duty to maintain their health is viewed as a moral judgement on their health behaviours and an inappropriate use of professional authority to persuade them to conform to certain societal norms. Rather than being considered in isolation, the duty to maintain one’s health should be considered as a team endeavour, as illustrated by section 8.7 (‘Be supportive of colleagues who are encountering health or performance problems’) and section 19.4 (‘Take all reasonable personal precautions necessary to avoid any potential health risks to colleagues, people receiving care and the public’) of the Code (NMC 2018). Nurses’ responsibility to maintain their health is therefore not only individual but also collective.

Resilience is often considered important for maintaining optimal mental health. Resilience is generated by protective factors that assist people to overcome adversity (Herrman et al 2011). Protective factors can be personal (Herrman et al 2011) – for example, hope, flexibility, competence, optimism, a sense of purpose, the use of positive language, humour, self-awareness and self-care (Duncan 2020). However, protective factors can also be external (Herrman et al 2011) – for example, living and working conditions.

It is important that healthcare organisations remember that nurses are subject to the same socioecological factors that influence the health of their patients and that nurses’ physical and mental health and well-being is therefore affected by their working conditions. Nurses’ professional duty to maintain their health is therefore not only their own responsibility but also the responsibility of the organisation.

Andrews and Thorne (2015) identified that interpersonal resilience and organisational resilience are as important as personal resilience for promoting the well-being of NHS staff and highlighted the importance of social support and optimal team working. Maben and Bridges (2020) suggested that nurses ask about each other’s well-being, check that their colleagues have taken breaks and had something to eat and drink, are approachable and compassionate, are positive towards each other, and check up on each other outside work.

Healthcare organisation

Maben and Bridges (2020) also noted the importance of the organisation’s role in promoting the health of their staff, rather than focusing on nurses’ personal responsibility, which fits into the ‘healthcare organisation’ domain of Groene and Garcia-Barbero’s (2005) examples of health promotion activities in hospitals (Table 1). The NHS Constitution for England (Department of Health and Social Care 2021b) states that ‘The NHS pledges to… provide support and opportunities for staff to maintain their health, well-being and safety’, and similar values are expressed by the NHS in the devolved nations.

NHS Employers (2019) recommended that employers ensure staff have access to dedicated rest rooms, healthy food, drinking water and food storage and cooking facilities, and implement initiatives aimed at preventing moving and handling injuries, supporting people with long-term health conditions and promoting exercise. Ideally, a healthy work environment arises through organisational development, but concerted action from staff may be required if their health promotion needs are not fully addressed. For example, nurses may need to collaborate with colleagues to raise concerns with managers and improve the organisation’s health promotion strategy.

Local and global community

ED nurses have a role to play in promoting the health of the local and global community through sustainability initiatives. For example, disposing of hospital waste through landfill or incineration results in high levels of greenhouse gas emissions (Rizan et al 2021). Greenhouse gases contribute to global warming, which affects the health of people around the world through heat-related deaths, increased air pollution, increased natural disasters and increased risk of infection and spread of disease (WHO 2018). ED nurses can contribute to the efforts to minimise such harmful effects by correctly disposing of waste, cutting down on unnecessary cannulation and unnecessary use of non-sterile gloves, limiting the use of single-use plastic cups (Spruell et al 2021) and recycling where possible (Rizan et al 2021).

Lessons from the pandemic

The Marmot review into the coronavirus disease 2019 (COVID-19) pandemic and socioeconomic and health inequalities in England (Marmot et al 2020) found that the pandemic has exacerbated already widening health inequalities. The review found that there had been consistently higher mortality rates among black British people and people of South Asian descent, much of which can be attributed to where people live (level of area deprivation), socioeconomic disadvantage and structural racism (Marmot et al 2020). The review also identified a high correlation between low pay and having to continue to work in frontline roles, including as a nurse or a care worker, and found that frontline workers had put themselves at risk by providing essential services to keep society functioning throughout the pandemic (Marmot et al 2020). This led the authors of the review to state the need to recognise the value of people ‘who play such a vital role in society’ through better pay, education, training and opportunities for career progression (Marmot et al 2020).

Horton (2020) argued that the COVID-19 pandemic should not be viewed only as a pandemic but also as a ‘syndemic’, a syndemic being characterised by biological and social interactions between conditions and states that ‘increase a person’s susceptibility to harm or worsen their health outcomes’. According to Horton (2020), seeing COVID-19 as a syndemic underlines the vulnerability of certain population groups, such as older people, people from black, Asian and minority ethnic communities. This demonstrates the importance of addressing social determinants of health.

Taking collective action through health activism

Some ED nurses may think that it is unrealistic to hope to operate at the structural levels of influence required to promote a socioecological approach to health promotion. However, many of the reasons why people attend the ED have root causes in deprivation, environmental factors and structural racism, and these issues need to be addressed if healthcare organisations are to address health inequalities (Marmot et al 2020).

Health activism can enable nurses to participate in community action and attempt to influence organisations and governments. Martin (2007) defines activism as ‘action on behalf of a cause, action that goes beyond what is conventional or routine’, so health activism challenges nurses to think beyond their everyday practice and consider taking action outside work. Laverack (2013) lists a number of direct and indirect actions that can be taken, including advocacy activities, political lobbying, petitions, boycotts, peaceful protests, strikes and media campaigns. The increased use of social media to raise issues, promote the nursing profession and initiate collective action facilitates engagement in health activism.

Some nurses may be suspicious about activism, equating it with negative stereotypes of activists being violent or eccentric (Bashir et al 2013). Some nurses may be concerned about the effect of activism on their professional reputation, since section 21.5 of the Code (NMC 2018) states: ‘Never use your status as a registered professional to promote causes that are not related to health’. However, the Code (NMC 2018) also states, in section 3.1, that registrants must ‘pay special attention to promoting wellbeing, preventing ill-health and meeting the changing health and care needs of people during all life stages’, and some have argued that this means nurses have a responsibility to challenge social injustice and work towards social change (Nemetchek 2019).

There are many examples of nurses promoting health through activism. Nurses have taken action to address environmental issues, reporting these to relevant environmental health agencies, participating in community education and empowerment, making changes to waste disposal at home and at work, engaging in political campaigns, and supporting other nurses to become activists (Terry et al 2019). Neomi Bennett, an agency nurse, founded the advocacy group Equality 4 Black Nurses (Scott 2020), which grew out of a group of black nurse colleagues who were concerned about discrimination in the allocation of work and personal protective equipment during the COVID-19 pandemic. Equality 4 Black Nurses is now challenging institutional racism in fitness-to-practise referrals as well as supporting individuals. At the Royal College of Nursing (RCN) Congress in 2019, sexual health nurse Ruth Bailey put forward a resolution to end period poverty – which refers to the fact that some women cannot afford sanitary products – to raise awareness among nurses and encourage the RCN to become involved in campaigning (Williams 2019).

What these examples have in common is the use of group action. Laverack (2019) emphasised the importance of collective rather than individual action to bring about broader social change. Empowerment is at the centre of health promotion and it applies as much to healthcare professionals as to patients, since ‘before practitioners can empower others, they must first be themselves empowered’ (Laverack 2013). Being part of a group can support nurses to become empowered by developing their critical awareness of the social determinants of health through education, the sharing of ideas and experiences, and joint decision-making.