The two Scottish studies

The exploratory study (Watson et al., Reference Watson, McIntosh, Tolson and Runciman2004; Runciman et al., Reference Runciman, Watson, McIntosh and Tolson2006) first profiled using a questionnaire (n = 1062) the health promotion work undertaken by a range of community nurses with older people and then identified by means of a telephone interview (n = 20) their involvement in particular health promotion innovations and initiatives. Included were 250 DNs; 86 (34%) responded to the questionnaire and eight were interviewed. The telephone interviews illustrated DN involvement in what would be regarded as health promotion ‘projects’ – for example, setting up walking, well-being and lifestyle groups addressing exercise, healthy eating and mental health. Not known, however, was how the DNs interpreted health promotion within day-to-day nursing practice as being distinct from their involvement in health promotion innovations or initiatives. DN-free responses at the end of the questionnaire also suggested that health promotion could be elusive, hidden, unrecognised and ad hoc. These points of interest were further explored in the second study.

This two-phase qualitative multi-method study (Runciman, Reference Runciman2010) addressed health promotion with older people in relation to community nurse education for, and community nurse practice in, three roles: district nursing, general practice nursing and public health nursing/health visiting. Data presented in this article are drawn from the second study phase in district nursing practice.

The study was designed within the constructivist paradigm and adopted Stake's (Reference Stake1995; Reference Stake2003) case study approach. The constructivist paradigm allowed the meaning of health promotion work with older people to be interpreted and illuminated (Mills et al., Reference Mills, Durepos and Wiebe2010). It is described as hermeneutic and dialectic; that is, understanding study participants’ constructions and meanings was sought in real work contexts through interpretation (hermeneutics) and discussion (dialectics).

The DN's role currently requires a challenging combination of clinical, management, leadership and educational expertise and advanced decision-making skills (Dickson et al., Reference Dickson, Gough and Bain2011). The DNs invited to participate in the study were experienced registered nurses who held a graduate-level qualification as specialist practitioners in community nursing and led a skill mix team of community staff nurses and health-care assistants. In light of the study's interest in both education and practice perspectives on health promotion, the participating DNs were those who held responsibilities as practice teachers/mentors providing educational support to DN students. Two DNs were actively engaged in the practice phase of the study. Each selected two patients whose nursing care represented usual day-to-day work and included health promotion elements. Of the four cases selected to illustrate health promotion, two represented nursing in the context of the long-term conditions of multiple sclerosis and diabetes and two related to long-standing alcohol-related health problems.

The DNs were accompanied and observed by the researcher at a visit to each patient. Field notes were recorded immediately after each observed period. Two interviews were then conducted: first, with the patient at home on a return visit by the researcher, and, second, a final interview with the DN. The interviews were audio-recorded and transcribed in full. Content analysis of data was undertaken, combining the conventional approach, in which coding categories were derived directly from data, and a directed approach informed by existing theory and research findings (Hsieh and Shannon, Reference Hsieh and Shannon2005). Both studies received ethical approval from the relevant health boards and academic institutions.

Health promotion: a challenging concept

Defining health promotion in nursing practice is not straightforward. It has been argued that the landscape of health promotion is confusing and troubled, given its plethora of concepts, theories, models, approaches, frameworks and paradigm wars (Whitehead, Reference Whitehead2009). Much attention is given, for example, to the health promotion versus health education debate. Whitehead (Reference Whitehead2003; Reference Whitehead2004) sees health promotion as a set of socio-economic-political processes transforming communities through concern for the major determinants of health, and sees health education as informing individuals about the nature and causes of health and illness and their associated risks, motivating individuals towards prevention and recommended behaviour change. The biomedical-disease-illness model, associated with opportunistic lifestyle and behaviour-change health education, has been criticised as reductionist and professional-led with associated risk for a victim-blaming ethos. Alternatively, the empowerment paradigm is encouraged as a humanistic client-led approach (Green and Tones, Reference Green and Tones2010). Broadly, there is ‘big picture’ health promotion interpreted at global and national levels in relation to public health and health improvement policy; there is middle ground health promotion where policy and health priority issues are addressed at community levels often with local groups and through projects; and there is, for a DN in primary care, health promotion at the daily care interface with individual patients and their families in collaboration with health, social care and voluntary sector colleagues.

That health promotion presents challenges and sits uneasily within nurse education and practice is evident in many publications since the 1990s (Maben and Macleod Clark, Reference Maben and Macleod Clark1995; Robinson and Hill, Reference Robinson and Hill1995; Reference Robinson and Hill1998; Macleod Clark and Maben, Reference Macleod Clark and Maben1998; Smith et al., Reference Smith, Masterson and Lloyd Smith1999; Whitehead, Reference Whitehead1999; Reference Whitehead2000; Reference Whitehead2002; Reference Whitehead2007). For example, Smith et al. (Reference Smith, Masterson and Lloyd Smith1999) noted tensions for nurse educators, students and practitioners, between what they refer to as nursing's three discourses – caring for patients, treating disease and promoting health. The health promotion discourse was perceived as impractical for the realities of day-to-day work that related to treatment of disease and it was difficult to conceptualise a health promotion role within the care of sick people. Smith et al. (Reference Smith, Masterson and Lloyd Smith1999: 229) suggested that, although the three discourses make sense in isolation, they could be perceived as ‘implausible, incomprehensible and occasionally absurd in combination’.

Health promotion and district nursing

Many years ago, Turton (Reference Turton1983) explored DNs’ reluctance to spend time on health education. Conceptual separation of health education from nursing care was a fundamental constraint, together with lack of knowledge and effective communication skills to address older people's complex health issues. Gott and O'Brien (Reference Gott and O'Brien1990) similarly argued that community nurses regarded nursing as being different from health promotion. By the late 1990s, however, Sourtzi's (Reference Sourtzi1998) findings of a study on community nurses’ definitions of health promotion showed considerable development of conceptual awareness of health promotion in terms of its content, methods, target groups, goals and roles for nurse and client. However, Smith et al. (Reference Smith, Masterson and Lloyd Smith1999) suggested that, in giving priority to clinical needs of older people, DNs struggled to squeeze health promotion in to make it fit with everyday work demands.

Irvine (Reference Irvine2003; Reference Irvine2005; Reference Irvine2007) explored interpretations of the concept of health promotion and its translation to practice in a study that included semi-structured audio-recorded interviews with 21 DNs. The DNs talked of health promotion in terms of lifestyle and behaviour change (outcome) as well as education and advice (process). A disease-oriented approach was typical, linked to three elements: to specific illnesses where their role related to preventing or containing conditions; to administration of vaccinations; and to screening. There was reference to the importance of choice in decision making regarding lifestyle and to the issue of patients taking responsibility for their own health. The goal for some DNs was to help patients towards ‘optimum health’. Overall, however, Irvine suggests that there was no common understanding of the term health promotion, and the concepts of empowerment, community development and socio-political action did not feature in the DNs’ definitions. In terms of the process of health promotion, Irvine concludes that the DN's role is limited to health education. However, she also claims evidence of three dimensions: a primary focus on preventative work; a secondary focus on restoring good health; and a tertiary focus directed at illness containment.

Health promotion in district nursing practice has also been seen as opportunistic, ad hoc and reactive (Irvine, Reference Irvine2003; Watson et al., Reference Watson, McIntosh, Tolson and Runciman2004; Runciman, Reference Runciman2010), or as planned and proactive, evident in specific health promotion projects or initiatives (Watson et al., Reference Watson, McIntosh, Tolson and Runciman2004; Hunt, Reference Hunt2005; Kane, Reference Kane2007; Reference Kane2008; De Kleijn, Reference De Kleijn2008; Runciman, Reference Runciman2010). It has also been described as being integral and invisible. Difficulty recognising and acknowledging health promotion is noted in the following comments (Runciman, Reference Runciman2010: 60) from two DNs in the early exploratory study:

DNs in Irvine's (Reference Irvine2003: 219) study felt that they were engaged in health promotion work ‘all the time as we go’, ‘we do it automatically without thinking’ and ‘probably without knowing that we are doing it’. Irvine's (Reference Irvine2003: 218) response to this is, however, interesting as she appears to sidestep and does not explore the significance of what she calls the ‘integral’ dimension of health promotion practice. She notes:

Invisibility suggests something that is difficult to articulate, is hidden, requiring interpretation. It is a term commonly linked to the work of DNs (Goodman, Reference Goodman2001; Low and Hesketh, Reference Low and Hesketh2002; Kennedy, Reference Kennedy2004; Jarvis et al., Reference Jarvis, Mackie and Arundel2006). Goodman suggests that use of the metaphor of invisibility, in relation to the work of nursing in general and to its knowledge base, may in district nursing reflect both a general lack of understanding of the nature of DN work, much of which is out of sight in patients’ homes, and possibly the relative invisibility and marginalisation of the DN's main client group, namely, older people. Cantrell's (Reference Cantrell1998) qualitative study of DNs’ perceptions of their health education practice, using two focus groups and six individual interviews, found that health education was an aspect of care often engaged in but not consciously acknowledged; it was ‘not obvious’. It equated with the concept of ‘patient education’ and, as an integral part of all DN work, was part of holistic nursing care. Bryans (Reference Bryans2000a; Reference Bryans2000b), in her study on the use of simulation and post-simulation interviews with DNs to explore the knowledge involved in their nursing assessment practice, noted the problem of the ‘invisible’ elements of theoretical knowledge that are deeply internalised, difficult to access and whose use is hard to describe. Hawe et al. (Reference Hawe, King, Noort, Gifford and Lloyd1998) found in a focus group study with health promotion workers, examining capacity building in health promotion, that professionals had difficulty in describing aspects of their health promotion work to others. They were unpractised in talking about what they did and were ‘working invisibly’. Arnold et al. (Reference Arnold, Topping and Honey2004), in exploring DNs’ perceptions of their public health contribution, found that participants in their study had not recognised the extent of their role in health education and health promotion. Public health work ‘was going on silently’ and lacked clarity because of the integrated nature of DN activity; there was lack of awareness of the ‘vastness of what we do’ and failure to ‘reflect and take stock’ and recognise existing knowledge and skill. Arnold et al.'s (Reference Arnold, Topping and Honey2004) participants linked this lack of recognition to failure to encourage the celebration of achievement in the culture of nursing, a culture that might also foster a sense of guilt about work not regarded as ‘hands-on’ activity, such as health education.

The case study

Drawing on data from the study by Runciman (Reference Runciman2010), a case study from a DN and one of her patients, Mrs H, is now presented. No claim can be made regarding the representativeness of this case within the workload of DNs in Scotland. However, the case was originally chosen by the DN, and is selected here, as one that would be familiar to community nurses, illustrating health promotion in the context of the complex health, nursing and social care needs of an older person with a long-term condition, rather than as one focused primarily on a topic of policy concern such as alcohol. The case generated a wealth of interview and observational data. The DN's interpretations of health promotion below are drawn principally from interview data. A vignette of Mrs H, drawn from interviews with both the DN and Mrs H and from fieldwork notes following the observed home visit, is shown in Box 1.

Health promotion in day-to-day district nursing practice

Findings and discussion

The DN made an insightful contribution to conceptualisation of health promotion within day-to-day practice and she acknowledged accountability for it as a core element of her work (Nursing and Midwifery Council, 2008). However, comments such as ‘weaved into everything’ and ‘on the back of other things’ and something one might not be ‘consciously aware of’ support the notion of health promotion as invisible and embedded (Goodman, Reference Goodman2001; Irvine, Reference Irvine2003). When working ‘holistically’, health promotion became ‘just part of the mesh’. The DN's thoughts about her work with Mrs H reflect difficulties describing aspects of work and accessing internalised elements of theoretical knowledge (Hawe et al., Reference Hawe, King, Noort, Gifford and Lloyd1998; Bryans, Reference Bryans2000a; Appleton and Cowley, Reference Appleton and Cowley2008a; Reference Appleton and Cowley2008b).

However, it was notable that, when given time and opportunity to talk about her work, the DN was able to offer illustrations and interpretations of health promotion. It was, for example, linked to the promotion of independence, to the promotion of self-care, to secondary and tertiary prevention in the sense of health maintenance and prevention of progression of existing health problems, to the concept of advocacy, to health education in provision of information and advice, to skills training for patients and their family and carers, to risk assessment and management in relation to an older person, their family and to the health and safety of the DN herself. Even in the end-of-life care context, there were dimensions of health promotion work, but as the DN said, ‘you don't think about it’. Benner (Reference Benner1984) noted that expert holistic practice and the experienced practitioner's intuitive grasp can be illuminated and their elements teased out. To achieve this, opportunities to describe and reflect on practice scenarios need to be created. Where knowledge, albeit embedded, together with skill and positive attitudes towards older people come together in expert practice of experienced nurses, this needs to be captured, celebrated and used in education. Perhaps the health promotion perspective within expert practice might usefully be teased out in dialogue between community nurses and colleagues familiar with health promotion theory and practice. However, given the complex and demanding context of the work of experienced DNs (Dickson et al., Reference Dickson, Gough and Bain2011), which can limit opportunities for direct patient contact and hands-on care, some time targeted specifically by educators and practitioners for case analysis and building a bank of helpful practice scenarios might be of value.

Many years ago, Macleod Clark (Reference Macleod Clark1993: 258) called for a radical philosophical shift in thinking from ‘sick nursing’ to ‘health nursing’, to a ‘process of promoting health through nursing care’. She suggested that it is not what the nurse does that defines sick nursing or health nursing, but rather it is how she does it. That is, awareness of process is required. The key features of Macleod Clark's (Reference Macleod Clark1993) health nursing model and ethos were:

• • Recognising the uniqueness of each individual's need for care.

• • Involving patients in decisions about their care and participation in it.

• • Maximising potential for health and independence.

• • Building on existing knowledge and experience.

• • Helping patients become more autonomous.

• • Fostering an empowering relationship, collaborative and negotiated.

• • Supporting patients to take responsibility where possible for their own health.

Cowley (Reference Cowley2006: 663) notes that much energy has been expended on deciding whether actions represent ‘health promotion’ or ‘health education’ or ‘disease prevention’. She suggests that the focus is gradually shifting towards their intent and the manner in which they are performed, the key question being, is this being done in a health promoting way:

It could be argued that in the DN's conversations there was evidence of features of working according to Macleod Clark's (Reference Macleod Clark1993) health nursing model and of working in a health-promoting way. The DN recognised, however, that embedded aspects of work might not be explored explicitly with students. There was a continuing tendency in district nursing to regard health promotion as patient teaching or patient education (Cantrell, Reference Cantrell1998), as giving information and advice around priority policy topics such as smoking cessation and alcohol use (Bromley and Mindell, Reference Bromley and Mindell2011) and as a tacked-on activity. Opportunities to interpret health promotion elements in DN work were being missed: they were not, as the DN said, ‘being given their name’. It seemed, where health promotion was embedded, that DNs would first need to identify and describe the hidden elements, to recognise processes and interventions that are intrinsically health promoting and to describe where and how the caring clinical responsibilities contribute to health gain, thus making health promotion visible and explicit. In suggesting that it is possible to make sense of the discourses of caring, treating disease and health promotion in combination, Mrs H's case perhaps addresses Smith et al.'s (Reference Smith, Masterson and Lloyd Smith1999) concerns about difficulty conceptualising health promotion within the nursing care of sick people. Analysis of day-to-day nursing care work in terms of its processes, of ‘how’ health promotion principles feature, and of its outcomes in terms of actual and potential health gain could be fruitful exercises for DN education in both theory and practice.

Interpretation of the DN's descriptions of her work with Mrs H illuminates health promotion processes at work within her nursing role. The nature of the relationship and the way in which she worked showed evidence of an empowering partnership approach, collaborative, supportive and negotiated. There was confidence in communication and a leadership role in advocacy. Defined in these terms, her work demonstrated health promotion and features of Macleod Clark's (Reference Macleod Clark1993) health nursing model. Purists, whether nurses or health promoters, might not be happy about such a coterminous interpretation of the role as both health promotion and clinical caring, but concepts such as empowerment and advocacy are not exclusively owned by any single discipline or profession.

Where nursing and health promotion activities are seen as intrinsically related and coterminous rather than as mutually exclusive, there remains the difficulty for outcome measurement and evaluation. The challenge lies in interpreting and articulating the health promotion processes that can be regarded as measures of effectiveness, attributable to nursing.

Whether health promotion is regarded as a bounded and stand-alone activity, for example, as a project or particular initiative, or seen as embedded within nursing activity, within either interpretation an outcome might take the form of health gain. Macleod Clark (Reference Macleod Clark1993: 268) suggested that rather than a focus on ‘absence of ill-health indicators’, emphasis could be on ‘health increments’ such as changes in lifestyle or behaviour, adaptation and coping with chronicity, and facilitation of choice and decision making in care. However, as with the term health promotion, the meaning of the concept of health gain is debated. Ewles and Simnett (Reference Ewles and Simnett2003: 24) define health gain as ‘a measurable improvement in the status of health and social well-being in an individual or population, which is attributable to an earlier intervention’. The attribution issue is a well-recognised problem in health promotion where many factors of attitudes, values and ethics and of interventions such as treatments, therapies, professional and lay inputs, and social and environmental determinants contribute over time to favourable outcomes and health gain. Therefore, it is difficult to see an easy solution in terms of quantitative measurement to address the problem of defining health promotion, where both nursing and health promotion share processes and outcomes. The solution may emerge from increased acceptance of the value of qualitative descriptions of processes and outcomes, to better understand the integrated nature of much of health-care professionals’ practice.