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• To understand health promotion and the role of emergency department nurses in health promotion
• To increase your awareness of the social determinants of health and the health inequalities they produce
• To count towards revalidation as part of your 35 hours of CPD, or you may wish to write a reflective account (UK readers)
• To contribute towards your professional development and local registration renewal requirements (non-UK readers)
The concept of health promotion emerged in the 1970s, prompting global health leaders to adopt a perspective on maintaining and improving the population’s health that accounts for the underlying causes of ill-health and mortality. Health is affected by social, economic and environmental factors, which explains why there are health inequalities within and between countries. Health services have been partly reoriented to focus on promoting health as well as treating ill-health, but health promotion is still misunderstood, including in the nursing profession. Health promotion is often viewed as being concerned with addressing patients’ lifestyle behaviours, but this is only one aspect of a much broader framework of health promotion strategies.
This article introduces the concept of health promotion, explains its relevance to nurses working in the emergency department (ED), and identifies activities ED nurses can undertake to promote the health of patients, staff and the wider community. It also explains how ED nurses can play a role in health activism to better understand the social determinants of health and address health inequalities.
Emergency Nurse. doi: 10.7748/en.2021.e2103
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondenceadele.phillips@canterbury.ac.uk
Conflict of interestNone declared
Phillips A, Laslett S (2021) Health promotion in emergency care: rationale, strategies and activities. Emergency Nurse. doi: 10.7748/en.2021.e2103
Published online: 16 September 2021
This article aims to introduce the concepts of health promotion, explain its relevance to nurses working in the emergency department (ED) and explore how it can be embedded in everyday practice to enhance the health of patients, staff and the community. After reading this article and completing the time out activities you should be able to:
• Describe the concept of health promotion.
• Explain how health promotion relates to your role as an ED nurse.
• Identify health promotion activities that you can undertake to benefit yourself, your colleagues, your patients and the wider community.
• Understand how social determinants of health affect health outcomes and create health inequalities.
• Reflect on the role nurses can play in health activism.
• Health promotion involves a perspective on maintaining and improving the population’s health that accounts for the underlying causes of ill-health and mortality
• Health promotion is often viewed as being concerned with addressing patients’ behaviours, but this overlooks the wider structural factors influencing health
• The spectrum of health promotion strategies ranges from those with an individual focus to those with a population focus
• Nurses working in emergency care can undertake a range of activities to promote their own health and the health of colleagues, patients and the wider community
• Health activism can enable nurses to attempt to address the social determinants of health
The concept of health promotion rose to prominence in 1974 when Marc Lalonde, then Canadian Minister of National Health and Welfare, published a landmark document entitled ‘A New Perspective on the Health of Canadians’ (Lalonde 1974). In this document, Lalonde (1974) argued that the traditional perspective of health, according to which the quality of the population’s health can be equated with the quality of medical treatment services, was inadequate to address modern public health challenges such as the rise of chronic conditions, mental health issues and road traffic accidents. Lalonde (1974) recommended to depart from this narrow biomedical stance and shift towards a broader perspective on maintaining and improving the population’s health that would account for the underlying causes of ill-health and mortality. Furthermore, Lalonde (1974) argued that more work needed to be done to identify and promote positive health factors to enable people to live longer lives free from disease.
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.
Human biology
Health factors within the human body related to its biological constitution and functioning, for example:
• Inheritance and the genetic make-up of an individual
• Internal body systems, such as the cardiovascular system
• The process of maturation and ageing
Environment
• Health factors external to the human body and over which individuals are likely to have limited control, for example:
• Air and water quality
• Waste and sewage disposal
• Communicable disease prevention
• Access to food and medicines
• Working conditions
Lifestyles
• An individual’s personal decisions, habits and behaviours that affect their health, for example:
• Use of tobacco, alcohol and drugs
• Diet and nutrition
• Levels of physical exercise
• Sexual behaviour – for example, using condoms to prevent sexually transmitted infections
• Careless driving and failure to wear seat belts
Healthcare organisations
The resources for healthcare provision, including the nature, quantity and quality of healthcare services, organisations, activities and staff
(Adapted from Lalonde 1974)
Think of a patient you have recently encountered who presented to the ED with acute exacerbation of chronic obstructive pulmonary disease. With the Health Field Concept (Box 1) in mind, list potential health factors that could have contributed to the patient’s condition
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 five health promotion actions in the Ottawa Charter for Health Promotion are:
• Build healthy public policy – putting health on the agenda of all policies in all sectors and at multiple levels
• Create supportive environments – creating living and working conditions that are safe, stimulating, satisfying and enjoyable
• Strengthen community action – working to ensure that communities set priorities, make decisions, plan strategies and are able to implement them to achieve improved health
• Develop personal skills – providing people with information and education, enhancing life skills and enabling them to cope
• Reorient health services – developing healthcare services that focus on the total needs of the whole person and are sensitive to their cultural needs
These health promotion actions can be achieved through three health promotion strategies:
• Enabling – taking action in partnership with individuals or groups to empower them, through the mobilisation of human and material resources, to promote and protect their health
• Mediation – a process through which the different interests (personal, social, economic) of individuals and communities, and different sectors (public and private), are reconciled in ways that promote and protect health
• Advocacy – a combination of individual and social actions designed to gain political commitment, policy support, social acceptance and systems support for a particular health goal or programme
(Adapted from World Health Organization 1986, 1998, Phillips 2019)
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).
Since the concept of health promotion was adopted, it has been recognised that suboptimal living and working conditions have a negative effect on health outcomes throughout the life course (WHO 2008). Living and working conditions, coupled with the distribution of power, income, goods, services and access to healthcare, constitute the social determinants of health, which account for why optimal health is not distributed equally within and between countries. Health inequalities that are preventable are sometimes called health inequities. The Ottawa Charter (WHO 1986) contained a commitment to addressing health inequities in order to achieve optimal health for all.
The Ottawa Charter identified healthcare professionals as having an important role in reorienting health services, which involved them undergoing professional education and training to foster a practice focused on promoting health as well as on treating ill-health (WHO 1986). However, although that vision has been widely accepted, the role of health promotion in nursing policy and practice is still misunderstood, both within the profession and externally (Whitehead 2009). One important issue is that health promotion is often viewed as being concerned with addressing patients’ lifestyle behaviours, while the wider structural factors influencing health are overlooked (Casey 2007).
The lack of acknowledgement of the importance of addressing social and environmental determinants of health is not limited to nursing. Hunter et al (2009) proposed the term ‘lifestyle drift’ to describe a phenomenon whereby policies initially set out to address the social determinants of health end up drifting, during the course of their implementation, towards individual lifestyle factors. The Marmot Review (Marmot 2010) found that even if lifestyle factors such as smoking were addressed, health inequalities would likely persist between socioeconomic groups.
In 2016, the UK government launched a health promotion policy called Making Every Contact Count (MECC). The idea of MECC is that healthcare professionals use every encounter with patients to prompt and support them to initiate behaviour change, thereby improving their physical and mental health and well-being (Public Health England 2016). That policy is based on the principle that patients are responsible for their health and that personal motivation produces positive health outcomes. Although MECC has demonstrated potentially far-reaching benefits obtained at a relatively low cost (Lawrence et al 2016), it diminishes the importance of the socioecological approach, and commitment to addressing health inequities, of the Ottawa Charter.
In March 2021, the Department of Health and Social Care announced that an ‘Office for Health Promotion’ will be set up in autumn 2021 (Department of Health and Social Care 2021a). This new government body will aim to ‘lead national efforts to improve and level up the health of the nation by tackling obesity, improving mental health and promoting physical activity’. However, the King’s Fund commented that this announcement needed ‘to be swiftly followed by a clear plan for improving the health of the nation, at the centre of which should be a new cross-government health inequalities strategy backed by clear national goals’ (The King’s Fund 2021).
Addressing patients’ lifestyle behaviours is only one aspect of a much broader framework of health promotion strategies. A comprehensive literature review conducted by Bensberg and Kennedy (2002) demonstrated that the spectrum of health promotion strategies ranges from those with an individual focus to those with a population focus. Examples of health promotion strategies with an individual focus include screening, individual risk assessment and immunisation. Examples of health promotion strategies with a population focus include working with community practitioners, social marketing of healthy lifestyles through national campaigns such as Dry January or World Cancer Day (NHS Employers 2021), developing organisational infrastructure and participating in economic and regulatory activities such as lobbying.
In response to the Ottawa Charter’s proposed action of reorienting health services, it was considered that hospitals would be a crucial setting for health promotion (Whitehead 2004) and in 1988, the ‘Health Promoting Hospitals’ project was launched (WHO 1991). A health-promoting hospital is one that orients its governance, structures, processes and culture towards maximising the health of patients, staff and the wider population (International Network of Health Promoting Hospitals and Health Services 2020).
Emergency departments (EDs) may be historically viewed as having a downstream and individualised focus, whereby they concentrate on the management of acute illness and injury rather than its causes (Bensberg and Kennedy 2002). However, Bensberg and Kennedy (2002) argued that EDs are potentially suitable settings for health promotion for several reasons:
• Emergency medicine and health promotion generally share similar goals for improving the health of individuals and communities.
• EDs are a credible source of health information.
• EDs have an existing infrastructure for health promotion, such as planning processes and community networks.
• EDs provide an established entry point to healthcare.
In 2005, as part of the Health Promoting Hospitals project, the WHO Regional Office for Europe published a document designed to assist healthcare professionals and managers to implement health promotion activities in hospitals (Groene and Garcia-Barbero 2005). The document gives examples of health promotion activities in hospitals, shown in Table 1, which are a useful way for ED nurses to think about how the ED can contribute to health promotion for patients, staff, the healthcare organisation and the local and global community.
(Adapted from Groene and Garcia-Barbero 2005)
How is the health of patients, staff and the community promoted in your workplace? Can you think of health promotion activities that could be usefully implemented? What could be the role of nurses in these activities?
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:
• Providing advice about immunisation, assessing patients’ vaccination status and administering vaccines for tetanus and hepatitis B.
• Screening patients, or referring them for screening, for issues such as osteoporosis, mental health, substance misuse and domestic abuse.
• Providing health information and education by distributing patient information leaflets, explaining conditions, advising on medicine administration, educating on accident prevention and discussing smoking cessation.
• Delivering brief interventions to address behaviours such as excessive alcohol consumption (Barata et al 2017) or reduced physical activity (Duignan and Duignan 2017).
• Dispensing ‘teachable moments’ that facilitate behaviour change and enable referrals to specialist services (Robson et al 2020).
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.
The Code (NMC 2018) states that registrants must ‘be supportive of colleagues who are encountering health or performance problems’. How can you contribute to create an environment and work culture that promote your colleagues’ health and well-being?
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.
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.
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).
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.
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.
Although EDs may be historically viewed as having a downstream and individualised focus because of their remit to respond rapidly to acute illness and injury, there are opportunities for ED nurses to undertake health promotion activities as part of their practice. These activities include the traditional promotion of healthy behaviours, such as smoking cessation, among patients. They also include maintaining one’s health and supporting colleagues to maintain theirs, although this responsibility is shared between individual members of staff and their organisation.
ED nurses also have a role to play in promoting the health of the local and global community through sustainability initiatives. Furthermore, ED nurses can play a part in addressing the wider social, economic and environmental factors that affect health by developing their critical awareness of the social determinants of health and engage in health activism.
Consider how health promotion in emergency care relates to the Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates (Nursing and Midwifery Council 2018) or, for non-UK readers, the requirements of your regulatory body
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