Throughout this assignment the author will demonstrate knowledge of health promotion and its link in addressing health needs. The role of the nurse in delivering health promotion at primary, secondary and tertiary levels will be discussed and how national policy influences that delivery on the chosen topic of smoking. Barriers to health promotion will also be discussed and how these barriers could be overcome. To define health promotion, health should first be defined.
There are many definitions of health, one of which is the Western Medical Model, which describes health as in the “absence of disease and illness” (Seedhouse, 2004, p1). Irvine, (2010, p2) describes it as “a challenging concept to define as it means different things to different people, and our understanding of health is influenced by cultural, socio-economic and personal contexts”. A heavy smoker with mild emphysema may adapt their lifestyle to cope with reduced lung function and describe themselves as well whereas the medical model would categorise them as ill.
In criticism of the medical model, the medical writer Thomas Mckeown wrote that improved sanitation and living conditions of the 19th century had eradicated more disease and improved mortality rates than the invention of antibiotics and immunization programmes (Naidoo & Wills, 2009, p 8). It is essential to understand, therefore, how people view their own health and to study health beliefs of the local population if successful health promotion is to be achieved (Tones & Green, 2004, p81).
Greig (2007, p9) explains that diversities in religion, culture and social economic status mean that health beliefs are varied and may differ greatly from that of the nurse’s. Good interpersonal skills are required and a client centred approach used when assessing health needs. This should ensure that the health promotion is directed towards enabling a person to take action, with the patient autonomous in planning lifestyle changes rather than the nurse persuading or coercing, which is not only unethical but unlikely to be effective. Maville & Huerta, 2002, p92). Defining health promotion has become more difficult as it encompasses theory from many areas such as psychology, social policy, social health, and health education (Cross, 2010, p42). Tanahill described it as “a meaningless concept as it was used so differently” (cited in Naidoo & Wills, 2009, p52).
According to the Health Protection Agency (HPA) “health promotion is a process directed towards enabling people to take action. Thus, health promotion is not something that is done on or to people; it is one by, with and for people either as individuals or as groups. The purpose of this activity is to strengthen the skills and capabilities of individuals to take action and the capacity of groups or communities to act collectively to exert control over the determinants of health and achieve positive change” (HPA, 2009, p1). Health promotion models are used to theorise what influences the public health beliefs and lifestyle choices and assist in finding pathways to tackle health issues (Davies, 2006, p252).
Nutbeam (2006, p35) theorises the Social Cognitive Theory helps to explain that human behaviour is shaped by internal and external influences. That human’s have the ability to modify their behaviour by using past experiences and learning from others; can then set goals for change by self motivation and visualising the benefits to change. Self belief and environmental factors can act as both negative and positive to effecting change. This model works on the theory that an individual has reached the decision to change.
Prochaska and DiClemente’s trans theoretical model, (1984) “the stages of change” explain that an individual will go through stages of “precontemplation” where change is not even considered, “contemplation” where a change is thought about and then “preparation to change” where the benefits to a change can be visualised and then moving on to “making the change”. The model is cyclical and an individual can, after making a change, have a relapse and begin the process again.
It is important for nurses to assess at which stage a patient is within this process as they may well not be ready for smoking cessation advice but health promotion can still be delivered in the form of motivating the patient to see the benefits to change (Murphy & Bennett, 2002, p43). Part of the nurse training programme is dedicated to educating student nurses on the importance of delivering health promotion but Pender, Murdaugh and Parsons (2002, p3) explain that there still remains a lack of knowledge in this area.
They maintain that up to date theories on health promotion, which is evidence based, is not being delivered by nurses at primary, secondary and tertiary levels and advocate more emphasis should be placed on this part of health care. Warne & McAndrew (2010, p47) concur that, although health promotion theory is included within the training, nurses are viewing health promotion as just behaviour change and lifestyle choices and offering health education whereas, the wider view of supporting, empowering and non judgmental health promotion needs to be adopted.
Tod (2003 p56) explains that, as nurses are the largest body of health care professionals, they are the best placed to assess, deliver and follow up with smoking cessation. The Nursing and Midwifery Council (NMC) state in their Standards of Conduct that the role of the nurse is “to work with others to protect and promote the health and wellbeing of those in your care, their families and carers, and the wider community” (NMC, 2008, p1). The nurse delivers health promotion at three levels.
Firstly primary health promotion which is promoting the health of the general population and stopping the commencement of health damaging behaviour to prevent future ill health and improve quality of life (Greig, 2007, p27). Promoting a healthy lifestyle can begin before a person is born. The midwife gives information and advice on issues such as diet and smoking in pregnancy and the effects it may have on the unborn child as per National Institute of Health and Clinical Excellence (NICE, 2008, p10) guidelines.
One in fourteen babies have low birth weights, possibly due to smoking, and smoking is linked to birth defects and complications in labour (Tod, 2003, p56). Midwives can refer women to local smoking cessation services who offer advice and help such as behavioural therapy and substitutes such as nicotine patches, nicotine lozenges and chewing gum (DH, 1998 chapter 4). The school nurse has a major role in providing primary health promotion and education, in a non judgemental and safe environment, to children (Quinlivan, 2008, p318).
The nurse can help them to make informed choices on their future health on issues such smoking and hopefully prevent health damaging behaviour. Thomas, Wainwright and Jones ( 2005, p59) explains, however, that due to the lack of resources and job prospects, school nursing has not attracted the more dynamic calibre of staff and therefore, does not achieve its potential in health promoting and assisting families with health issues.
Jackson, (2005, p1) argues that since the Every Child Matters Green Paper and the subsequent Children’s Act passed in 2004, school nurses have become pivotal in tackling health issues such teenage smoking and obesity although Thomas, Wainwright and Jones (2005, p 65) claim very little research has been done to establish how successful health promotion is in this area. Secondary health promotion is delivered at a stage where patients are beginning to show the effects of health damaging behaviour (Scriven, 2005, p3).
A patient’s visit to the practice nurse for a routine health check, displaying signs of a productive cough and difficulties with breathing, may alert the nurse to ask if the patient is a smoker. Further testing, such as a chest x-ray and lung function test, will determine any lasting damage done. Health promotion can then be delivered to the patient by the practice nurse on the benefits of smoking cessation before chronic illness occurs and the possibility of reversing the damage already done (Scriven, 2005, p3).
Ali (2001, p232) explains however, that the powerful addictive qualities of nicotine makes giving up extremely difficult and smokers, although they know the health risk associated with smoking, may make several attempt to quit before they succeed. Roberts (2002, p346) advocates for practice nurse’s to be vigilant in offering smoking cessation to all patients whom assessment has identified as wishing to give up smoking as at least two thirds of patients will be seen at the practice each year offering optimum opportunity for both primary and secondary health promotion.
Tertiary health promotion is the promotion of health to an individual where serious health damage has already occurred due to health damaging behaviour (Ewles & Simnett, 2003, p29). An inpatient with chronic obstructive pulmonary disease (COPD) on a respiratory hospital ward, who is still a smoker, will be offered smoking cessation advice after the nurse has assessed whether the patient wants to give up smoking.
Although irreversible lung damage has already occurred, possibly due to the effects of years of smoking, the nurse can advise the patient on reducing the risks of further damage and perhaps slowing down the disease process by stopping the health damaging behaviour (Coakley & Ruston, 2001, p20). The patient may be more receptive to the idea of giving up smoking at this point having realised the consequences of their behaviour and the nurse, using the social cognitive theory, can reiterate the health benefits to change and assist the patient in planning how to achieve their goal (Pender, Murdaugh & Parsons, 2002, p47).
Approximately ten million of the UK adult population are smokers (Office of National Statistics, 2009) and, according to the survey carried out by the British Medical Journal, Tobacco Control, it cost the National Health Service over ?5 billion in smoking related illnesses, such as cancers, COPD, cardiovascular disease and peripheral vascular disease (Nursing Times, 2009). It is estimated that around 80,000 smokers in England will die prematurely as a result of smoking (Royal College of Physicians, 2011) and it is one of the highest causes of preventable death and disease in the UK along with obesity and alcohol abuse.
It is, therefore, one of the most important public health issues to be addressed by Governments not only in the UK, but worldwide. Lord Darzi’s report of 2008 recommended the NHS should focus as much on promoting good health as treating disease and illness (DH, 2008, p4). It is necessary that in order to tackle health promotion, that assessment of the health needs of the population are established. The WHO conference in Jakarta in 1997 recognised the change in the determinants of health, with higher rates of deaths from preventable illness and the decline in infectious diseases, stating the tobacco trade was “detrimental to world health”.
They called for Governments to provide more stringent legislation to limit production and control the marketing of tobacco products (WHO, 1997, p3-6). The UK Government answered that call in 1998 by producing the White Paper “Smoking Kills”, the first of its kind on tobacco. This document laid out new legislation on banning advertising tobacco products and increasing tax on cigarettes with the attempt at decreasing demand. Over ?100 million of new money was promised to fund a publicity campaign and NHS smoking cessation services.
One week’s free Nicotine Replacement Therapy (NRT) was to be offered to those most in need such as those from lower socio economic areas, pregnant women and young people. Nurses, in every area of healthcare, were advised to offer smoking cessation service at any available opportunity in primary, secondary and tertiary health care with close monitoring of progress. Specialist nurses were to set up local smoking cessation services in areas where they could make the most impact such as shopping centres, community centres, hospitals or town halls (DH, 1998, Chapter 4)
In 2007 the age limit for buying tobacco was raised from 16 to 18 years and a ban on smoking in indoor public areas was introduced in England. The demand on smoking cessation services increased in the run up to the ban and nurses found that they had to find ways to maintain and improve the services they offered (O’Connell, 2008, p142). Bishop and Redman (2008, p53) explains that nurses found that becoming nurse prescribers allowed them to prescribe nicotine replacement therapy (NRT), which research has shown to double the chances of success (Percival & Milner, 2002, p204), allowing for a more efficient service.
O’Connell (2009, p486) advocates for tailor made programmes, rather than just the standard programme, to be made available to the more hardened smokers. Studies have shown that pre-cessation, which allows the smoker to slowly reduce the amount they smoke and supplement with NRT is proving successful with those who feel less confident in stopping smoking. The White Paper Healthy Lives, Healthy People, A Tobacco Control Plan for England was published in March 2011 and outlined the Governments proposals on how to further tackle smoking within the new public health system over the next five years.
It promises nurses more freedom to tackle smoking health promotion at a local level, offering services to those areas most in need to address the inequalities in health in the more deprived areas of England. It advocates for the introduction of evidence based tailor made smoking cessation programmes to increase individuals success in quit attempts and the use of NRT, which is seen as a reduction in harm. Manufacturers are urged to produce more long term and cheaper NRT products. Nurses are, once again, seen as pivotal in offering and delivering smoking cessation and are encouraged to offer this at every available opportunity. DH, 2011) There are barriers to health promotion and social pressures on an individual, such as being surrounded by family and friends who also smoke, can make it difficult to give up. Porter (2009, p18) in his research on the uptake of smoking cessation services explains that psychological barriers such as the loss of the habit or the fear of mood swings, worry of failure and, more predominately for women, the fear of weight gain can discourage individuals from attempting to quit. Percival and Milner (2002, p203) agree with this, adding that withdrawal symptoms can include feelings of loss and depression which can last for months.
Phillips (2010, p195) feels that nurses time constraints can sometimes mean consultation times do not allow for motivational discussion and that just giving patient’s information on the harmful effects of smoking is not enough. The emotional needs of the smoker also need to be addressed and Forrest (2009, p 3) advocates for the use of psychotherapy to be included in nurses’ delivery of smoking cessation to lessen the chance of relapse due to negative emotional experiences. Nurses’ time constraints can also mean building a therapeutic relationship, hich can empower the patient to make lifestyle changes to improve their health, can be difficult. (Johnson, 2006, p159). The nurse may not have the opportunity to meet the patient again and, therefore, not have an opportunity to follow-up on a patient’s progress on lifestyle changes such as smoking cessation or weight loss. Good record keeping can ensure continuity of care and will inform the next health professional who comes into contact with the patient, who can then continue with the health promotion advice and support (Johnson, 2006, p159).
Organisational barriers can hinder a nurse’s confidence in delivering health promotion, such as hospital wards where the medical model of treating the illness only is adopted and the nurses task oriented regime does not allow for holistic care to be provided (Warne & McAndrew, 2010, p50). Ewles and Simnett (2003, p323) advocate the introduction of the WHO’s initiative “Health Promoting Hospitals” which, after reviewing and recognising these barriers, introduced new policy designed to address the problem with health promotion in the hospital setting (WHO, 2007, p8)
Gender can be a barrier to health promotion and Naidoo and Wills (2009, p23) explain that men are more likely than women to engage in health damaging behaviour such as smoking and alcohol misuse. Smoking is increased in men from lower socio economic groups, unskilled workers and the unemployed. Men’s self belief that masculinity should depict strong and healthy and viewing illness as a sign of weakness has meant they are less likely to access primary health care (Peate, 2004, p542).
This has made promoting health for this group more challenging and nurses need to take every available opportunity to provide health promotion to this client group. With this in mind men’s health promotion has been taken to areas where men tend to congregate in large numbers such as gyms and workplaces (Baker, 2002, p289). Occupational health nurses during routine checks can offer help and advice on lifestyle behaviours such as smoking and refer to smoking cessation services if required (National Institute for Health and Clinical Excellence (NICE), 2008, p19).
Smoking can be linked to men’s reproductive health, causing erectile dysfunction and poor sperm morbidity and Peate (2005, p362) advocates for the use of leaflets giving information on the harmful effects of smoking to be displayed at opportunistic places such as gyms, barber shops and drinking venues. While (2002, p52) feels that men’s health has been neglected in all areas and that further research is needed to improve health services for this group.
Mental health illness can also be a barrier to health promotion and Robson and Gray (2005, p18) feels that mental health nurses are reluctant to offer this group smoking cessation due to the worry of increasing anxiety levels. This has meant that those with mental health problems are more likely to smoke and be heavier smokers than the rest of the population, and subsequently have a higher rate of smoking related illnesses and a reduction in lifespan by around 25 years (Banham & Gilbody, 2010, p1176).
Smoking in mental health units, to reduce anxiety and boredom, was an accepted practice until UK Government legislation in 2008 was extended to include a ban on smoking in these areas (Williams, 2010, p328). Robson and Gray (2005, p18) explains that this has done little to reduce the number of smokers and that there is limited evidence available to aid mental health nurses practise in offering smoking cessation to those with mental health illness.
Banham and Gilbody (2010 p) concluded in their studies of smoking cessation with this client group, that using the same strategy’s that work with the general population in those with stable psychiatric conditions, would not have any further detrimental effect on their mental health. In conclusion, nurses have a crucial role and are best placed to offer health promotion at primary, secondary and tertiary levels in all health care settings on smoking cessation.
Government legislation and initiatives have emphasised the role of the nurse and have acknowledged the contribution that nurses play in the success of health promotion and smoking cessation services. Health promotion theories can be used by nurses to assist in assessing and evaluating individuals for smoking cessation and, although there are many barriers to health promotion, these could be overcome with further training and research.