- Email: [email protected]
Health promotion as a nursing function: Perceptions held by university students of nursing
hr. 1. Nun. Stud., Vol. 27. No. I, pp. 51-60. Printed in Great Britain.
1990.
oom.7489/90 13.00+ 0.00 0 1990Pngamon preu pie
Health promotion as a nursing function: perceptions held by university students of nursing JUDITH DONOGHUE, R.N., B.A. (How)* CHRISTINE DUFFIELD, R.N., B.Sc.N., M.H.P.t DIANNE PELLETIER, R.N., B.Sc.N., B.Ed.Studies M.Sci. Soc.$ and ANNE ADAMS, R.N., B.A., M.A.* *Senior Lecturer, ~AssociateProfessor, SLecturer. School of Nursing, Universityof Technology, Sydney, P.O. Box 123. Sydney NS W 2007, Australia
Abstract-Health care in Australia is more often perceived to be illness rather than health focused in nature. The increasing cost of health care has prompted a movement towards health promotion in the community demanding increasing involvement of health care professionals. This three year study was undertaken to determine the attitudes of students towards health promotion on entry and throughout a tertiary nursing programme. This longitudinal study was exploratory in nature and examined the attitudes of two student cohorts over the programme’s three years. Entering students cited the health promotion function more frequently than did those nearing programme completion. There is a need to emphasise health promotion as a role if this is seen as desirable behaviour for comprehensively educated nurses. The perceptions of three intakes of students were examined. The function of health promotion was perceived to be important by entry students and was within the three most frequently mentioned functions.
52
JUDITH DONOGHUE et al. Introduction
1985 the preparation of nurses for registration in New South Wales was transferred from hospital programmes to the universities and colleges of advanced education. Nurse education curricula in the hospitals were based mainly on an illness and cure model even though many schools of nursing presented material on community health following the introduction of these services into the health sector in the 1970’s. Certainly, under the apprenticeship type preparation in the hospitals, student nurses absorbed the emphasis on illness in clinical practice. Most working time was spent in caring for the ill person where nursing functions were directed to understanding the nature of the illness, the alleviation of its effect and, if possible, the hastening of the healing process. At worst, this model saw the patient in hospital reduced to a disorder at a point in the ward, “the cholecystectomy in bed 14”. At best, nursing efforts effected a good physical recovery and early discharge. Other aspects of a patient’s functioning were seen as either peripheral or incidental to this central objective. For example, deep anxiety about matters at home, surgical outcome or body image changes could be dismissed as irrelevant or not even acknowledged. Within this framework, the individual is defined as healthy if illness is not present. In contrast, the health or wellness model focuses on the optimum level of wellness at any point in an individual’s lifespan with consideration of all factors in operation at that time. Using this model, health promotion becomes a prime function of nursing. The curricula for the nursing courses in New South Wales higher education institutions are based on this model of health and usually present these concepts as beginning units of study. In
Statement of the Research Problem
These recent events in nursing set against the traditional knowledge and practice base provoke many questions about the outcomes of the new courses. From the health care organisations’ perspective these questions usually concern the level of function of the product. The educational institution is no less concerned about functional ability of its graduates but will necessarily compare results with broader educational aims. One question schools of nursing will need to ask concerns the relationship between the new emphasis on health and student held concepts. That is, will graduate behaviours be consistent with a new curriculum which on implementation has objectives that are at variance with those in earlier curricula as reflected by some of the attitudes that are strongly evident in clinical practice?
Background
and Purpose
of the Study
The transfer of nursing education from hospital based programmes to the tertiary sector brings a great change to the nursing profession. Not only has the organisation of nursing services undergone fundamental changes but the educational preparation of the registered nurse has been extended and presented from several different perspectives. One of the perspectives involves a basic premise about health and the role of the nurse as a health giver and promoter. University curriculum objectives maintain that nurses graduating from a nursing course will adopt the role of health promoter. The pre-registration course in which this study was conducted lists as graduate profile descriptors the ability to demonstrate, through practice, nursing’s concern with the
HEALTH
PROMOTION
AS A NURSING FUNCTION
53
restoration, promotion and maintenance of health and prevention of illness. The course objectives are stated in terms of seven expected competencies. Health promotion, as a competency, states that the graduate should be able to assume a health promotion role with self, patients, the family, groups and health professionals (NSWIT, 1984). Because these defined objectives relating to health promotion and the ensuing health promotion role of the nurse represent the widest departure from earlier curricular objectives, a study into the results of such a change in emphasis offered an opportunity for both course philosophy and curriculum evaluation. The beginning of a new course in a new educational setting further suggested a unique opportunity for the measurement of student behaviours.
Review of the Literature
The role of the nurse in the early twentieth century moved away from Nightingale’s ideas of education, theory and research and her emphasis on prevention in health care. Kozier and Erb (1983) describe this as a period when Nightingale’s ideals were temporarily misplaced and show how medicine frequently emphasised cure rather than prevention. Nurses worked long hours carrying out chores rather than giving direct patient care, were trained rather than educated and were usually permitted only to follow orders and not to make independent decisions. Henderson (1978) traces the development of nursing and its definition since Nightingale and shows how the recognition of health needs and the move away from teaching according to diseases of body systems began in the 1940’s. By the 1%0’s in North America, nursing theory stressing the health promotion role and the concept of the nurse as a health worker more interested than the physician in promoting health, had gained acceptance (Henderson, 1978). In the 1970’s King (1971) was able to state that, “The goal of nursing is to help individuals and groups attain, maintain and restore health”. Nay-Brock (1983) in reviewing the limitations of the existing health care system recommends that nurses’ efforts would be more beneficial if “the notion of curing” the patient was replaced by health promoting activities. Nay-Brock uses a sociological analysis to support ideas of decreased power for doctors and the increased use of health promotion and the holistic approach in health care. Moore and Williamson (1984) examined the recent literature on health promotion for nurses. These authors maintain it is essential that nursing respond to the strong societal trend for health promotion. They concluded that a significant overlap between health promotion and illness prevention existed, but definition of intent was secondary to the improvement of the quality of care. Strategies for health promotion can be applied in a variety of contexts and environments in which nurses are employed. The importance of health care planning as a nursing role is identified by de Bella-Baldigo (1984) who claims that this role is as essential for quality health care as are other nursing skills. In order to facilitate the health care planning role the author devised and tested a community simulation game for use with first year students at Sonoma State University, Robert Park, California. Such a learning experience permitted high levels of student involvement and was successful in gaining student enthusiasm to prepare them for the political, legal and financial aspects in the health promotion role. The health promotion component in nursing curricula has been examined in a number of courses in the United States. Ackerman et al. (1981) at Johns Hopkins University, Baltimore, Maryland surveyed both baccalaureate nursing programmes and nurses in
54
JUDITH
DONOGHUE
et al.
practice for their views and activities in health education. A study population of 543 nurses was surveyed for health education competencies, interests, skills and organisational factors related to health education practice. The nurses valued health education as a high priority in nursing practice. In 1982 these same authors requested curriculum documents related to health education from all the baccalaureate programmes in the United States (266) (Ackerman et al, 1982). The documents were anaiysed for course content and methods used to help students develop beginning competence in health education. The findings showed that onIy minimal explicit attention was given to the teaching role of nurses. There was little agreement on what health education encompassed or what were reasonable expectations for the students in this area. These findings were in contrast with the high value placed on health promotion by practicing nurses in the earlier phase of this research project. In response to current demands within the health care system for identifiable health education practices within nursing, Shine et al. (1983) assessed existing health education objectives and content in the nursing curriculum at George Mason University, Fairfax, Virginia. New objectives were set, implemented and evaluated from data collected from faculty members and students. The authors concluded that it was possible to integrate a health education model within the nursing programme while maintaining the integrity of the nursing curriculum. These findings were in accord with the desire to strengthen the health education aspect of the curriculum. Ersser et al. (1984) looked at the contribution of research to health education and found serious problems in the communication of research results to those who could use such findings. Hyperspecialisation and obtuseness in research method and language was becoming more frequent while resistance to a finding which challenged held beliefs was strong. The authors proposed that health education was important for higher standards of care but that it was a neglected area in terms of practice. Forty-three first year and 43 third year nursing students in a hospital based nursing programme in Australia were compared by Kelly (1983) for role perception and ideal expectations on nine issues currently influencing the nurses’ role. The role of health worker or health educator was included as one of the issues. Significant differences were revealed between the first and third year group and a 59% agreement from both groups that they were too busy giving physical care to carry out any other role. The study concluded that institutional influences would seem to affect the ideal professional goals in relation to role. A longitudinal evaluation of student behaviour is recommended by Conley (1973). The collection of data over a longer period at critical times allows for an analysis of behaviour change with a high degree of specificity. A comprehensive list of techniques and instruments for collecting and evaluating data about student behaviour includes tests of content and performance, questionnaires, rating scales, case method and self-appraisal. These instruments can be used singly or in combination. The purpose of this longitudinal study was to determine if students of nursing in a university programme developed the perception of themselves in the role of health promoter, bearing in mind that the role of health promoter is in contrast with the traditionally held nursing role. Entry beliefs were surveyed and compared throughout three years’ exposure to an educational course with an emphasis on health promotion. The illness and cure model, with its derivations in the medical model has, up to the present, provided the role model for nurses and there are currently practitioners who still use this concept as their framework for practice. This study also compared entry perceptions of students over three years, 1985-1987.
HEALTH
PROMOTION
AS A NURSING FUNCTION
55
Methodology
Subjects The study was conducted in a multi-disciplinary tertiary educational institution over a four-year period. The complete student population was surveyed on entry and throughout the programme until 1988. A summary of survey numbers and distribution by year of programme appears in Table 1. Table I. Su&ey responses 1985 1986 1987 1988 Year 1 Year 2 Year 3
191
Total
191
1% 142
203 144 132
116 94
338
479
210
Subjects surveyed had been accepted into a tertiary nursing programme on the basis of their Higher School Certificate (HSC) (with a standardized score of 250 or above) or as a mature age candidate. The population surveyed consisted of a total of 590 students who demographically comprised 503 females and 75 males (12 respondents unspecified), 95 were over the age of 21 and 472 entered as HSC candidates (23 respondents unspecified). Students were divided into two cohorts. The first cohort consisted of those students who entered the programme in 1985 and were surveyed until completion in 1987; the second cohort entered in 1986 and were surveyed until 1988. Students entering the programme in 1985, 1986 and 1987 were surveyed to provide comparative data on entry behaviour. Questionnaire The format of the questionnaire was open-ended and asked students to describe the functions of a nurse from an individual perspective. Two-thirds of a page was left for their response. Demographic data was limited to gender and age. Procedure All first year students who attended the first lecture of the course were asked to complete the questionnaire prior to the commencement of the academic programme. In this way a baseline of student perceptions was determined prior to any influence from academic staff, clinical facilities or more senior students. One of the researchers provided verbal instructions to the sample and sought their co-operation in completing the survey. Students were asked to present their own ideas as to the functions of a nurse and not to discuss their response with their peers. Time was allocated for the completion of this questionnaire and all responses were collected prior to any lecture input. The procedure adopted for second and third year students was different. The programme includes a compulsory class during which these students were surveyed within the first week of the academic year. One of the researchers asked students for their ongoing co-operation at the beginning of the class, again providing verbal instructions. This was done until all students had been asked to complete the survey. Certain resistance to completing the same questionnaire was noted and some students did not comply with the request. This accounts for the variability in student numbers, particularly in the third year (1988). Questionnaires were collected prior to the commencement of the class.
JUDITH
56
DGNOGHUE
et al.
To avoid change in curriculum content and introducing bias a complete analysis of data was not undertaken until 1988 when data collection was completed. Content analysis of each subject’s written responses was undertaken. All responses were evaluated and 12 categories of nursing functions were determined (shown in Table 2). A sample of 100 responses was independently categorised by two researchers and inter-rater reliability was very high at 88.24%. The remaining questionnaires were coded by one researcher and independently coded by a second researcher. When subjects gave data that was difficult to categorise agreement as to appropriate classification was resolved by discussion with the four researchers. Table 2. Comparison of rank order-student cohort one (1985-1987) and cohort two (1986-1988) 1986-1988
1985-1987
Cohort N=434
Cohort N=465 Rank order*
Function
Group mean
Function
2 3 4 5 6 7 8 9 10 II 12
Caring Educating Communicating Promoting health Problem-solving Advocacy Team member Intervening Assisting Organising Protecting Non-nursing
0.92 0.39 0.38 0.31 0.16 0.16 0.15 0.14 0.11 0.07 0.05 0.11
Caring Promoting health Educating Communicating Team member Advocacy Assisting Problem-solving Organising Intervening Protecting Non-nursing
Group mean 0.89 0.41 0.33 0.20 0.11 0.11 0.07 0.06 0.03 0.03 0.02 0.00
*Ranked according to group mean response for each function.
Results The use of open-ended design enabled multiple responses and this combined with the difference in group size made comparisons of relative importance difficult. To standardize results the raw scores attained for each function were divided by the number of students completing the questionnaire to give a group mean score. If ‘caring’ is viewed in isolation it can be seen that it is without exception mentioned most frequently in the study sample, always above 0.87. The second most frequently mentioned function across all distributions is 0.58 for ‘educating’. The consistency of frequency of mention (and thus group mean) across three years of the course for both cohorts suggests reliability of content analysis. The results for the two complete student cohorts and the 12 categories established through content analysis by the researchers appear in Table 2. Of note is the degree of similarity between the two cohorts. The four most frequently cited functions (by group mean reponse) are the same for both groups, with a slightly different order. From Table 2 it can be seen that for the first cohort, ‘promoting health’ ranks fourth in fequency of mention while for the second cohort it ranks second. ‘Caring’ is most frequently mentioned by a margin significantly above other categories.
HEALTH
PROMOTION
AS A NURSING FUNCTION
57
As one of the purposes of this research was to determine whether perceptions changed throughout the programme, Tables 3 and 4 provide a breakdown of the two student cohorts across the three years. For students entering the programme in 1985 and finishing in 1987, ‘promoting health’ is fourth in frequency in the first year, rises to third in the second year and falls to fifth place in the third year (see Table 3). ‘Caring’ is once again mentioned most frequently throughout their three years of the programme. ‘Intervening’ is mentioned in the first year of the programme but thereafter is replaced by ‘advocacy’. ‘Educating’ did not appear to be important to first year students but by the second and third year of their programme it had risen to a position of second in frequency.
Table 3. Rank order of top five functions for the first cohort of students over three years First year 1985 N= 191
Third year 1987 N= 132
Second year 1986 N= 142
Rank order 1 2 3 4 5= 5=
Caring Communicating Intervening Promoting health Problem-solving Assisting
0.87 0.39 0.21 0.26 0.19 0.19
Caring Educating Promoting health Communicating Advocacy
0.95 0.58 0.43 0.38 0.15
Caring Educating Communicating Advocacy Promoting health
0.91 0.55 0.46 0.34 0.23
Table 4. Rank order of top five functions for the second cohort of students over three years First year 1986 N= 196
Third year 1988 N=94
Second year 1987 N= 144
Rank order 1 2 3 4 5
Caring Promoting health Educating Communicating Assisting
0.88 0.32 0.22 0.16 0.11
Caring Promoting health Educating Communicating Team member
0.90 0.46 0.37 0.23 0.14
Caring Educating Advocacy Communicating Promoting health
0.87 0.48 0.34 0.24 0.21
The second cohort of students who entered the programme in 1986 and completed in 1988, again placed ‘caring’ first but ‘promoting health’ is second in their first two years, falling to fifth rank in their last year (Table 4). This will account for the difference found in Table 2, that as a sum of three years they cited ‘promoting health’ more frequently than did the first cohort. It is replaced in second position by ‘educating’ which in the first and second years of the programme was ranked third on group mean. This is in contrast to the first cohort who did not mention ‘educating’ in year one but thereafter it was second in frequency. It is of note that ‘promoting health’ was ranked fifth in the third year by this cohort (Table 3).
JUDITH
58
DONOGHUE
et al.
The five functions mentioned by these students in third year are the same as those in the previous cohort, but the order differs. ‘Team member’ is mentioned by the second year students but does not recur in any other tables. For this cohort ‘advocacy’ is only mentioned in third year. The second objective of this research was to identify entry perceptions of students about the function of promoting health. The group mean responses for three groups of entry students from 1985-1988 were determined. The function of ‘promoting health’ was ranked fourth in the 1985 intake but second in the 1986 and 1987 intakes (see Table 5). Again, ‘caring’ is mentioned most frequently throughout all three years. ‘Educating’ was not frequently mentioned by the 1985 intake while subsequent groups mentioned it sufficiently often for it to register in the five most frequently cited functions.
Table 5. Rank order of five most frequently mentioned functions for first year students 1985-1987 First year 1986 N= 196
First yeas 1985 N= 191
First year 1987 N=203
Rank order 1 2 3 4 5= 5=
Caring Communicating Intervening Promoting health Problem-solving Assisting
0.87 0.39 0.27 0.26 0.19 0.19
Caring Promoting health Educating Communicating Assisting
0.88 0.32 0.22 0.16 0.11
Caring Promoting health Communicating intervening Educating
0.95 0.26 0.15 0.14 0.13
Both cohorts of students can be compared with regard to their frequency of mention of ‘promoting health’ throughout their programme (see Table 6). There is a parallel pattern in response for this category when the two are compared. The highest frequency is in second year and it drops in third year to below entry levels. Table 6. Comparison of group mean scores for ‘promoting health’, first and second cohorts across three . years
Cohort one Cohort two
Year one
Year two
Year three
0.27 0.32
0.43 0.46
0.23 0.21
Discussion
There were two purposes of this study. The first was to determine whether students of nursing in a tertiary education institution entered the programme with a perception that health promotion was a nursing function and secondly, to determine whether the perception of health promotion changed during the programme. Using an open-ended questionnaire students were asked to identify the functions of the nurse from an individual perspective.
HEALTH
PROMOTION
AS A NURSING
FUNCTION
59
‘Caring’ was the most frequently mentioned function, irrespective of the stage and year of entry to the nursing programme (Tables 2-5). This confirms previous reseach findings that one of the main reasons students entered nursing was because of the focus on the helping and caring role (Adams et al., 1988). Interestingly, when students entered the programme they already had a view that one of the functions of nursing was the promotion of health. In fact for students entering the programme in 1986 and 1987 ‘promoting health’ was second only to ‘caring’ (Table 2). This was not so in 1985, the first year of the programme. This is perhaps because the courses were new and these students had very little knowledge of course content and direction, particularly the new emphasis on promoting health. Subsequent student intakes may have known or had access to students in the years preceding them, providing them with some knowledge as to curriculum emphasis. Of the first year students followed throughout the programme only two cohorts are complete at this time. The 1985 cohort mentioned ‘promoting health’ third most frequently in the first and second years of the programme but for the third year this fell to the fifth ranking (Table 3). The 1986 cohort, which mentioned ‘promoting health’ second most frequently in the first and second years ranked it fifth in the third year (Table 4). Overall, this first cohort of students cited ‘promoting health’ less frequently through their three years than did the second cohort. No explanation can be found for this. However as has been noted entering students surveyed were not yet influenced by the curriculum or associated educational aspects. However, students subsequently surveyed were influenced by other non-educational factors. These would include the media, family life and health experiences and the societal implications of the student of nursing role. The lack of control of these variables represents a limitation of the study. Further study needs to be undertaken to determine the strength of effect these factors have on perceptions which may serve to counter the benefits of a health-based curriculum. A comparison of the ‘promoting health’ function for both cohorts over two years (Table 6) shows a strong entry recognition of this nursing function. The function became even more important at the beginning of the second year of the programme but declined below entry at the beginning of the third year. This finding was duplicated for both samples. The change in view could be explained by the fact that the first year of the programme emphasised the nature of health promotion and content focused on healthy lifestyles, health education and promotion. At the beginning of the second year a self-directed clinical experience was undertaken related to community attitudes to healthy lifestyles. Understandably the students’ entry view that a function of nurses was to promote health was reinforced. However, by the beginning of the third year of the programme students had spent most of the previous year in theory and practice focused on pathology and illness both physiological and psycho-social. The lack of health-related theoretical input and role models combined with the illness focus in hospital-based clinical practice would seem to explain the decline in frequency of mention of the ‘promoting health’ function in the third year of the programme. While the frequency with which health promotion is mentioned as a nursing function may have decreased by the third year of the programme it should not be interpreted that this was due entirely to curriculum content. A variety of variables may be responsible, the most important of which is probably the institutional influences which have been shown to affect role perceptions (Kelly, 1983). Most students want to work in a hospital, at least in the short term after graduation, and hospitals are not viewed as institutions promoting
60
JUDITH DONOGHUE et al.
health but rather, they restore or maintain health. It may also be that other nursing functions became more important as students progressed throughout the programme and viewed the complexity of the nursing role. In summary, students entering a university nursing programme have a strong perception of health promotion as a nursing function. This perception may reflect changing community attitudes. Entry perception is influenced by curriculum content but it is also possible that role modelling and institutional influences play a significant part in the development of nursing role perceptions. The relative importance of each warrants further investigation if the nursing profession views health promotion as an important function which should be nurtured.
Ackerman, A. M.. Partridge, K. B. and Kaimen, H. (1981). Effective integration of health education into baccalaureate nursing curriculum. J. Nun. Educ., 20 (2). 37-43. Ackerman, A. M., Partridge,K. B. and Kalmer. H. (1982). Health education in baccalaureate nursing curriculum: myth or reality? J. Nurs. Educ., 21 (I), 15-22. Adams, A., Donoghue. J., Duffield, C. and Pelletier. D. (1988). An exploratory study of attrition in a tertiary nursing programme, Aust. Hlth Rev. 11 (4), 247-255. Conley, V. C. (1973). Curriculum and Instruction in Nursing. Little, Brown, Boston. de Bella-Baldigo, S. (1984). Fostering nurses’ participation in health care planning. J. Nurs. Educ. 23 (3), 124-125. Eraser, S., Taylor, S. and Wilkinson, J. (1984). Healthy and wise. Nurs. Times April 25, 54-55. Henderson, V. (1978). Practice of and preparation for nursing, in Principles and Practice of Nursing. Henderson, V. and Nite, G., eds. Macmillan, New York. Kelly, J. G. (1983). Role perception and expectations. Aust. Nurs. J. 12 (11). 41-43. King, I. M. (1971). Toward a Theoryfor Nursing. Wiley, New York. Koxier. B. and Erb, G. (1983). Fundamentals of Nursing, 6th Ed. Addison-Wesley, Menlo Park, California. Moore, P. V. and Williamson, G.: C. (1984). Health promotion-evolution of a concept. Nurs. clinics N. Am. 19 (2), 195-206. Nay-Brock, R. (1983). Changing attitudes to health. Aust. NW. J. 12 (II), 51-52. Shine, M. S., Silva, M. C. and Weed, F. S. (1983). Integrating health education into baccalaureate nursing education. J. Nurs. Educ. 22 (l), 22-27. The New South Wales Institute of Technology (1984). Proposal for the introduction of a Diploma of Applied Science in Nursing-Stage III submission. NSWIT, Sydney. (Received 27 April 1989; accepted for publication 2 October 1989)
1990.
oom.7489/90 13.00+ 0.00 0 1990Pngamon preu pie
Health promotion as a nursing function: perceptions held by university students of nursing JUDITH DONOGHUE, R.N., B.A. (How)* CHRISTINE DUFFIELD, R.N., B.Sc.N., M.H.P.t DIANNE PELLETIER, R.N., B.Sc.N., B.Ed.Studies M.Sci. Soc.$ and ANNE ADAMS, R.N., B.A., M.A.* *Senior Lecturer, ~AssociateProfessor, SLecturer. School of Nursing, Universityof Technology, Sydney, P.O. Box 123. Sydney NS W 2007, Australia
Abstract-Health care in Australia is more often perceived to be illness rather than health focused in nature. The increasing cost of health care has prompted a movement towards health promotion in the community demanding increasing involvement of health care professionals. This three year study was undertaken to determine the attitudes of students towards health promotion on entry and throughout a tertiary nursing programme. This longitudinal study was exploratory in nature and examined the attitudes of two student cohorts over the programme’s three years. Entering students cited the health promotion function more frequently than did those nearing programme completion. There is a need to emphasise health promotion as a role if this is seen as desirable behaviour for comprehensively educated nurses. The perceptions of three intakes of students were examined. The function of health promotion was perceived to be important by entry students and was within the three most frequently mentioned functions.
52
JUDITH DONOGHUE et al. Introduction
1985 the preparation of nurses for registration in New South Wales was transferred from hospital programmes to the universities and colleges of advanced education. Nurse education curricula in the hospitals were based mainly on an illness and cure model even though many schools of nursing presented material on community health following the introduction of these services into the health sector in the 1970’s. Certainly, under the apprenticeship type preparation in the hospitals, student nurses absorbed the emphasis on illness in clinical practice. Most working time was spent in caring for the ill person where nursing functions were directed to understanding the nature of the illness, the alleviation of its effect and, if possible, the hastening of the healing process. At worst, this model saw the patient in hospital reduced to a disorder at a point in the ward, “the cholecystectomy in bed 14”. At best, nursing efforts effected a good physical recovery and early discharge. Other aspects of a patient’s functioning were seen as either peripheral or incidental to this central objective. For example, deep anxiety about matters at home, surgical outcome or body image changes could be dismissed as irrelevant or not even acknowledged. Within this framework, the individual is defined as healthy if illness is not present. In contrast, the health or wellness model focuses on the optimum level of wellness at any point in an individual’s lifespan with consideration of all factors in operation at that time. Using this model, health promotion becomes a prime function of nursing. The curricula for the nursing courses in New South Wales higher education institutions are based on this model of health and usually present these concepts as beginning units of study. In
Statement of the Research Problem
These recent events in nursing set against the traditional knowledge and practice base provoke many questions about the outcomes of the new courses. From the health care organisations’ perspective these questions usually concern the level of function of the product. The educational institution is no less concerned about functional ability of its graduates but will necessarily compare results with broader educational aims. One question schools of nursing will need to ask concerns the relationship between the new emphasis on health and student held concepts. That is, will graduate behaviours be consistent with a new curriculum which on implementation has objectives that are at variance with those in earlier curricula as reflected by some of the attitudes that are strongly evident in clinical practice?
Background
and Purpose
of the Study
The transfer of nursing education from hospital based programmes to the tertiary sector brings a great change to the nursing profession. Not only has the organisation of nursing services undergone fundamental changes but the educational preparation of the registered nurse has been extended and presented from several different perspectives. One of the perspectives involves a basic premise about health and the role of the nurse as a health giver and promoter. University curriculum objectives maintain that nurses graduating from a nursing course will adopt the role of health promoter. The pre-registration course in which this study was conducted lists as graduate profile descriptors the ability to demonstrate, through practice, nursing’s concern with the
HEALTH
PROMOTION
AS A NURSING FUNCTION
53
restoration, promotion and maintenance of health and prevention of illness. The course objectives are stated in terms of seven expected competencies. Health promotion, as a competency, states that the graduate should be able to assume a health promotion role with self, patients, the family, groups and health professionals (NSWIT, 1984). Because these defined objectives relating to health promotion and the ensuing health promotion role of the nurse represent the widest departure from earlier curricular objectives, a study into the results of such a change in emphasis offered an opportunity for both course philosophy and curriculum evaluation. The beginning of a new course in a new educational setting further suggested a unique opportunity for the measurement of student behaviours.
Review of the Literature
The role of the nurse in the early twentieth century moved away from Nightingale’s ideas of education, theory and research and her emphasis on prevention in health care. Kozier and Erb (1983) describe this as a period when Nightingale’s ideals were temporarily misplaced and show how medicine frequently emphasised cure rather than prevention. Nurses worked long hours carrying out chores rather than giving direct patient care, were trained rather than educated and were usually permitted only to follow orders and not to make independent decisions. Henderson (1978) traces the development of nursing and its definition since Nightingale and shows how the recognition of health needs and the move away from teaching according to diseases of body systems began in the 1940’s. By the 1%0’s in North America, nursing theory stressing the health promotion role and the concept of the nurse as a health worker more interested than the physician in promoting health, had gained acceptance (Henderson, 1978). In the 1970’s King (1971) was able to state that, “The goal of nursing is to help individuals and groups attain, maintain and restore health”. Nay-Brock (1983) in reviewing the limitations of the existing health care system recommends that nurses’ efforts would be more beneficial if “the notion of curing” the patient was replaced by health promoting activities. Nay-Brock uses a sociological analysis to support ideas of decreased power for doctors and the increased use of health promotion and the holistic approach in health care. Moore and Williamson (1984) examined the recent literature on health promotion for nurses. These authors maintain it is essential that nursing respond to the strong societal trend for health promotion. They concluded that a significant overlap between health promotion and illness prevention existed, but definition of intent was secondary to the improvement of the quality of care. Strategies for health promotion can be applied in a variety of contexts and environments in which nurses are employed. The importance of health care planning as a nursing role is identified by de Bella-Baldigo (1984) who claims that this role is as essential for quality health care as are other nursing skills. In order to facilitate the health care planning role the author devised and tested a community simulation game for use with first year students at Sonoma State University, Robert Park, California. Such a learning experience permitted high levels of student involvement and was successful in gaining student enthusiasm to prepare them for the political, legal and financial aspects in the health promotion role. The health promotion component in nursing curricula has been examined in a number of courses in the United States. Ackerman et al. (1981) at Johns Hopkins University, Baltimore, Maryland surveyed both baccalaureate nursing programmes and nurses in
54
JUDITH
DONOGHUE
et al.
practice for their views and activities in health education. A study population of 543 nurses was surveyed for health education competencies, interests, skills and organisational factors related to health education practice. The nurses valued health education as a high priority in nursing practice. In 1982 these same authors requested curriculum documents related to health education from all the baccalaureate programmes in the United States (266) (Ackerman et al, 1982). The documents were anaiysed for course content and methods used to help students develop beginning competence in health education. The findings showed that onIy minimal explicit attention was given to the teaching role of nurses. There was little agreement on what health education encompassed or what were reasonable expectations for the students in this area. These findings were in contrast with the high value placed on health promotion by practicing nurses in the earlier phase of this research project. In response to current demands within the health care system for identifiable health education practices within nursing, Shine et al. (1983) assessed existing health education objectives and content in the nursing curriculum at George Mason University, Fairfax, Virginia. New objectives were set, implemented and evaluated from data collected from faculty members and students. The authors concluded that it was possible to integrate a health education model within the nursing programme while maintaining the integrity of the nursing curriculum. These findings were in accord with the desire to strengthen the health education aspect of the curriculum. Ersser et al. (1984) looked at the contribution of research to health education and found serious problems in the communication of research results to those who could use such findings. Hyperspecialisation and obtuseness in research method and language was becoming more frequent while resistance to a finding which challenged held beliefs was strong. The authors proposed that health education was important for higher standards of care but that it was a neglected area in terms of practice. Forty-three first year and 43 third year nursing students in a hospital based nursing programme in Australia were compared by Kelly (1983) for role perception and ideal expectations on nine issues currently influencing the nurses’ role. The role of health worker or health educator was included as one of the issues. Significant differences were revealed between the first and third year group and a 59% agreement from both groups that they were too busy giving physical care to carry out any other role. The study concluded that institutional influences would seem to affect the ideal professional goals in relation to role. A longitudinal evaluation of student behaviour is recommended by Conley (1973). The collection of data over a longer period at critical times allows for an analysis of behaviour change with a high degree of specificity. A comprehensive list of techniques and instruments for collecting and evaluating data about student behaviour includes tests of content and performance, questionnaires, rating scales, case method and self-appraisal. These instruments can be used singly or in combination. The purpose of this longitudinal study was to determine if students of nursing in a university programme developed the perception of themselves in the role of health promoter, bearing in mind that the role of health promoter is in contrast with the traditionally held nursing role. Entry beliefs were surveyed and compared throughout three years’ exposure to an educational course with an emphasis on health promotion. The illness and cure model, with its derivations in the medical model has, up to the present, provided the role model for nurses and there are currently practitioners who still use this concept as their framework for practice. This study also compared entry perceptions of students over three years, 1985-1987.
HEALTH
PROMOTION
AS A NURSING FUNCTION
55
Methodology
Subjects The study was conducted in a multi-disciplinary tertiary educational institution over a four-year period. The complete student population was surveyed on entry and throughout the programme until 1988. A summary of survey numbers and distribution by year of programme appears in Table 1. Table I. Su&ey responses 1985 1986 1987 1988 Year 1 Year 2 Year 3
191
Total
191
1% 142
203 144 132
116 94
338
479
210
Subjects surveyed had been accepted into a tertiary nursing programme on the basis of their Higher School Certificate (HSC) (with a standardized score of 250 or above) or as a mature age candidate. The population surveyed consisted of a total of 590 students who demographically comprised 503 females and 75 males (12 respondents unspecified), 95 were over the age of 21 and 472 entered as HSC candidates (23 respondents unspecified). Students were divided into two cohorts. The first cohort consisted of those students who entered the programme in 1985 and were surveyed until completion in 1987; the second cohort entered in 1986 and were surveyed until 1988. Students entering the programme in 1985, 1986 and 1987 were surveyed to provide comparative data on entry behaviour. Questionnaire The format of the questionnaire was open-ended and asked students to describe the functions of a nurse from an individual perspective. Two-thirds of a page was left for their response. Demographic data was limited to gender and age. Procedure All first year students who attended the first lecture of the course were asked to complete the questionnaire prior to the commencement of the academic programme. In this way a baseline of student perceptions was determined prior to any influence from academic staff, clinical facilities or more senior students. One of the researchers provided verbal instructions to the sample and sought their co-operation in completing the survey. Students were asked to present their own ideas as to the functions of a nurse and not to discuss their response with their peers. Time was allocated for the completion of this questionnaire and all responses were collected prior to any lecture input. The procedure adopted for second and third year students was different. The programme includes a compulsory class during which these students were surveyed within the first week of the academic year. One of the researchers asked students for their ongoing co-operation at the beginning of the class, again providing verbal instructions. This was done until all students had been asked to complete the survey. Certain resistance to completing the same questionnaire was noted and some students did not comply with the request. This accounts for the variability in student numbers, particularly in the third year (1988). Questionnaires were collected prior to the commencement of the class.
JUDITH
56
DGNOGHUE
et al.
To avoid change in curriculum content and introducing bias a complete analysis of data was not undertaken until 1988 when data collection was completed. Content analysis of each subject’s written responses was undertaken. All responses were evaluated and 12 categories of nursing functions were determined (shown in Table 2). A sample of 100 responses was independently categorised by two researchers and inter-rater reliability was very high at 88.24%. The remaining questionnaires were coded by one researcher and independently coded by a second researcher. When subjects gave data that was difficult to categorise agreement as to appropriate classification was resolved by discussion with the four researchers. Table 2. Comparison of rank order-student cohort one (1985-1987) and cohort two (1986-1988) 1986-1988
1985-1987
Cohort N=434
Cohort N=465 Rank order*
Function
Group mean
Function
2 3 4 5 6 7 8 9 10 II 12
Caring Educating Communicating Promoting health Problem-solving Advocacy Team member Intervening Assisting Organising Protecting Non-nursing
0.92 0.39 0.38 0.31 0.16 0.16 0.15 0.14 0.11 0.07 0.05 0.11
Caring Promoting health Educating Communicating Team member Advocacy Assisting Problem-solving Organising Intervening Protecting Non-nursing
Group mean 0.89 0.41 0.33 0.20 0.11 0.11 0.07 0.06 0.03 0.03 0.02 0.00
*Ranked according to group mean response for each function.
Results The use of open-ended design enabled multiple responses and this combined with the difference in group size made comparisons of relative importance difficult. To standardize results the raw scores attained for each function were divided by the number of students completing the questionnaire to give a group mean score. If ‘caring’ is viewed in isolation it can be seen that it is without exception mentioned most frequently in the study sample, always above 0.87. The second most frequently mentioned function across all distributions is 0.58 for ‘educating’. The consistency of frequency of mention (and thus group mean) across three years of the course for both cohorts suggests reliability of content analysis. The results for the two complete student cohorts and the 12 categories established through content analysis by the researchers appear in Table 2. Of note is the degree of similarity between the two cohorts. The four most frequently cited functions (by group mean reponse) are the same for both groups, with a slightly different order. From Table 2 it can be seen that for the first cohort, ‘promoting health’ ranks fourth in fequency of mention while for the second cohort it ranks second. ‘Caring’ is most frequently mentioned by a margin significantly above other categories.
HEALTH
PROMOTION
AS A NURSING FUNCTION
57
As one of the purposes of this research was to determine whether perceptions changed throughout the programme, Tables 3 and 4 provide a breakdown of the two student cohorts across the three years. For students entering the programme in 1985 and finishing in 1987, ‘promoting health’ is fourth in frequency in the first year, rises to third in the second year and falls to fifth place in the third year (see Table 3). ‘Caring’ is once again mentioned most frequently throughout their three years of the programme. ‘Intervening’ is mentioned in the first year of the programme but thereafter is replaced by ‘advocacy’. ‘Educating’ did not appear to be important to first year students but by the second and third year of their programme it had risen to a position of second in frequency.
Table 3. Rank order of top five functions for the first cohort of students over three years First year 1985 N= 191
Third year 1987 N= 132
Second year 1986 N= 142
Rank order 1 2 3 4 5= 5=
Caring Communicating Intervening Promoting health Problem-solving Assisting
0.87 0.39 0.21 0.26 0.19 0.19
Caring Educating Promoting health Communicating Advocacy
0.95 0.58 0.43 0.38 0.15
Caring Educating Communicating Advocacy Promoting health
0.91 0.55 0.46 0.34 0.23
Table 4. Rank order of top five functions for the second cohort of students over three years First year 1986 N= 196
Third year 1988 N=94
Second year 1987 N= 144
Rank order 1 2 3 4 5
Caring Promoting health Educating Communicating Assisting
0.88 0.32 0.22 0.16 0.11
Caring Promoting health Educating Communicating Team member
0.90 0.46 0.37 0.23 0.14
Caring Educating Advocacy Communicating Promoting health
0.87 0.48 0.34 0.24 0.21
The second cohort of students who entered the programme in 1986 and completed in 1988, again placed ‘caring’ first but ‘promoting health’ is second in their first two years, falling to fifth rank in their last year (Table 4). This will account for the difference found in Table 2, that as a sum of three years they cited ‘promoting health’ more frequently than did the first cohort. It is replaced in second position by ‘educating’ which in the first and second years of the programme was ranked third on group mean. This is in contrast to the first cohort who did not mention ‘educating’ in year one but thereafter it was second in frequency. It is of note that ‘promoting health’ was ranked fifth in the third year by this cohort (Table 3).
JUDITH
58
DONOGHUE
et al.
The five functions mentioned by these students in third year are the same as those in the previous cohort, but the order differs. ‘Team member’ is mentioned by the second year students but does not recur in any other tables. For this cohort ‘advocacy’ is only mentioned in third year. The second objective of this research was to identify entry perceptions of students about the function of promoting health. The group mean responses for three groups of entry students from 1985-1988 were determined. The function of ‘promoting health’ was ranked fourth in the 1985 intake but second in the 1986 and 1987 intakes (see Table 5). Again, ‘caring’ is mentioned most frequently throughout all three years. ‘Educating’ was not frequently mentioned by the 1985 intake while subsequent groups mentioned it sufficiently often for it to register in the five most frequently cited functions.
Table 5. Rank order of five most frequently mentioned functions for first year students 1985-1987 First year 1986 N= 196
First yeas 1985 N= 191
First year 1987 N=203
Rank order 1 2 3 4 5= 5=
Caring Communicating Intervening Promoting health Problem-solving Assisting
0.87 0.39 0.27 0.26 0.19 0.19
Caring Promoting health Educating Communicating Assisting
0.88 0.32 0.22 0.16 0.11
Caring Promoting health Communicating intervening Educating
0.95 0.26 0.15 0.14 0.13
Both cohorts of students can be compared with regard to their frequency of mention of ‘promoting health’ throughout their programme (see Table 6). There is a parallel pattern in response for this category when the two are compared. The highest frequency is in second year and it drops in third year to below entry levels. Table 6. Comparison of group mean scores for ‘promoting health’, first and second cohorts across three . years
Cohort one Cohort two
Year one
Year two
Year three
0.27 0.32
0.43 0.46
0.23 0.21
Discussion
There were two purposes of this study. The first was to determine whether students of nursing in a tertiary education institution entered the programme with a perception that health promotion was a nursing function and secondly, to determine whether the perception of health promotion changed during the programme. Using an open-ended questionnaire students were asked to identify the functions of the nurse from an individual perspective.
HEALTH
PROMOTION
AS A NURSING
FUNCTION
59
‘Caring’ was the most frequently mentioned function, irrespective of the stage and year of entry to the nursing programme (Tables 2-5). This confirms previous reseach findings that one of the main reasons students entered nursing was because of the focus on the helping and caring role (Adams et al., 1988). Interestingly, when students entered the programme they already had a view that one of the functions of nursing was the promotion of health. In fact for students entering the programme in 1986 and 1987 ‘promoting health’ was second only to ‘caring’ (Table 2). This was not so in 1985, the first year of the programme. This is perhaps because the courses were new and these students had very little knowledge of course content and direction, particularly the new emphasis on promoting health. Subsequent student intakes may have known or had access to students in the years preceding them, providing them with some knowledge as to curriculum emphasis. Of the first year students followed throughout the programme only two cohorts are complete at this time. The 1985 cohort mentioned ‘promoting health’ third most frequently in the first and second years of the programme but for the third year this fell to the fifth ranking (Table 3). The 1986 cohort, which mentioned ‘promoting health’ second most frequently in the first and second years ranked it fifth in the third year (Table 4). Overall, this first cohort of students cited ‘promoting health’ less frequently through their three years than did the second cohort. No explanation can be found for this. However as has been noted entering students surveyed were not yet influenced by the curriculum or associated educational aspects. However, students subsequently surveyed were influenced by other non-educational factors. These would include the media, family life and health experiences and the societal implications of the student of nursing role. The lack of control of these variables represents a limitation of the study. Further study needs to be undertaken to determine the strength of effect these factors have on perceptions which may serve to counter the benefits of a health-based curriculum. A comparison of the ‘promoting health’ function for both cohorts over two years (Table 6) shows a strong entry recognition of this nursing function. The function became even more important at the beginning of the second year of the programme but declined below entry at the beginning of the third year. This finding was duplicated for both samples. The change in view could be explained by the fact that the first year of the programme emphasised the nature of health promotion and content focused on healthy lifestyles, health education and promotion. At the beginning of the second year a self-directed clinical experience was undertaken related to community attitudes to healthy lifestyles. Understandably the students’ entry view that a function of nurses was to promote health was reinforced. However, by the beginning of the third year of the programme students had spent most of the previous year in theory and practice focused on pathology and illness both physiological and psycho-social. The lack of health-related theoretical input and role models combined with the illness focus in hospital-based clinical practice would seem to explain the decline in frequency of mention of the ‘promoting health’ function in the third year of the programme. While the frequency with which health promotion is mentioned as a nursing function may have decreased by the third year of the programme it should not be interpreted that this was due entirely to curriculum content. A variety of variables may be responsible, the most important of which is probably the institutional influences which have been shown to affect role perceptions (Kelly, 1983). Most students want to work in a hospital, at least in the short term after graduation, and hospitals are not viewed as institutions promoting
60
JUDITH DONOGHUE et al.
health but rather, they restore or maintain health. It may also be that other nursing functions became more important as students progressed throughout the programme and viewed the complexity of the nursing role. In summary, students entering a university nursing programme have a strong perception of health promotion as a nursing function. This perception may reflect changing community attitudes. Entry perception is influenced by curriculum content but it is also possible that role modelling and institutional influences play a significant part in the development of nursing role perceptions. The relative importance of each warrants further investigation if the nursing profession views health promotion as an important function which should be nurtured.
Ackerman, A. M.. Partridge, K. B. and Kaimen, H. (1981). Effective integration of health education into baccalaureate nursing curriculum. J. Nun. Educ., 20 (2). 37-43. Ackerman, A. M., Partridge,K. B. and Kalmer. H. (1982). Health education in baccalaureate nursing curriculum: myth or reality? J. Nurs. Educ., 21 (I), 15-22. Adams, A., Donoghue. J., Duffield, C. and Pelletier. D. (1988). An exploratory study of attrition in a tertiary nursing programme, Aust. Hlth Rev. 11 (4), 247-255. Conley, V. C. (1973). Curriculum and Instruction in Nursing. Little, Brown, Boston. de Bella-Baldigo, S. (1984). Fostering nurses’ participation in health care planning. J. Nurs. Educ. 23 (3), 124-125. Eraser, S., Taylor, S. and Wilkinson, J. (1984). Healthy and wise. Nurs. Times April 25, 54-55. Henderson, V. (1978). Practice of and preparation for nursing, in Principles and Practice of Nursing. Henderson, V. and Nite, G., eds. Macmillan, New York. Kelly, J. G. (1983). Role perception and expectations. Aust. Nurs. J. 12 (11). 41-43. King, I. M. (1971). Toward a Theoryfor Nursing. Wiley, New York. Koxier. B. and Erb, G. (1983). Fundamentals of Nursing, 6th Ed. Addison-Wesley, Menlo Park, California. Moore, P. V. and Williamson, G.: C. (1984). Health promotion-evolution of a concept. Nurs. clinics N. Am. 19 (2), 195-206. Nay-Brock, R. (1983). Changing attitudes to health. Aust. NW. J. 12 (II), 51-52. Shine, M. S., Silva, M. C. and Weed, F. S. (1983). Integrating health education into baccalaureate nursing education. J. Nurs. Educ. 22 (l), 22-27. The New South Wales Institute of Technology (1984). Proposal for the introduction of a Diploma of Applied Science in Nursing-Stage III submission. NSWIT, Sydney. (Received 27 April 1989; accepted for publication 2 October 1989)