Promoting Health And Wellbeing Essay Writer

What is health? According to the World Health Organization (WHO), health is ‘a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources as well as physical capacities’ (WHO). Decades ago governmental officials of the world, agreed to come together, despite of whatever conflicts, or political disagreements, to attain health for all the people of the world by the year 2000.

They wanted citizens of the world to all have access to basic, essential health care.

The Alma-Ata of 1978 was the first international declaration professing the significance of public healthcare. The Alma-Ata commences by stating that health, ‘which is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal” (WHO) The countries of the world, worked towards their goal but unfortunately did not achieve it by their targeted date.

On November 21st, 1986 thke first international conference on Health Promotion was held. Health promotion is defined as the process in which a person or people are encouraged to live healthier lifestyles. This promotion is expected to be holistic-physically, mentally and socially, so that everyone’s basic needs can be satisfied. A person cannot function in this world if he doesn’t know where his next meal is coming from. How can he focus on his health, if he has no home? An unemployed man’s last thought is to get his annual physical done. Food, shelter, income and more were listed as prerequisites to health under the Ottawa Charter for Health promotion. Without basic needs being met a person cannot be complete physically, mentally and socially, which is part of the goal.

According to the Department of Health and Human Services (DHHS) there are seven principles of health promotion, which are as follows:

i. Evidence informed practice
ii. Determinants of health
iii. Equity
iv. Partnerships
v. Action across the continuum
vi. Cultural change
vii. Supportive environments
viii. Community participation (DHHS, 2012).

Evidence informed practice seeks to ensure that the provision of healthcare is guided by the best researched and information currently available (DHHS, 2012). Purveyors of healthcare should understand the presenting problems and based on evidence, know what has been used to successfully treat the problem, Finally, the provider must know how to adopt the solutions to the current situation(DHHS, 2012) In health promotion, the evidence used, must be of excellent quality and be derived from a reliable source. It should take into account that cultural, moral, ethical and spiritual values have a direct influence on what we do to improve health both as clients and as practitioners (DHHS, 2012). Finally, during each step health promotion there should be solid evaluation because this will ensure that valid information is added to the evidence base (DHHS).

Determinants of health are about the factors that affect health. Typically, it involves looking at how and where people live and play as well as examining their work environment, and evaluating how these factors affect their health and behavior (DHHS, 2012).

Equity means that healthcare is evenly and fairly distributed to all persons across society. This is a mean of ensuring that the vulnerable and ‘at risk’ groups ‘ minorities – in society will also have access to modalities that can be life -saving (DHHS, 2012).

Partnership in healthcare means working with different people or organization to improve the health and well- being in individuals as well as communities (DHHS, 2006). One such partnership is the nurse-client relationship in healthcare.

Action across the continuum adopts a myriad of strategies to create change in how healthcare is offered. Changes can start with the individual, then progress to the community and eventually changes in public policies. According to the DHHS, ‘action across the continuum is about looking for opportunities to develop a comprehensive approach to promoting health and well- being in our communities’ (DHHS, 2006).

Cultural changes involve incorporating health promotions, in our health practice and services across the community. Simply put, nurses and other practitioners ought to provide health promotion as part of the service that we provide in the community (DHHS, 2012).

Supportive environments seek to ensure that patients and indeed the society in general are provided with healthy choices, for example fresh fruits and vegetables, so the consumer has options with regards to things that can increase his well-being (DHHS, 2012).

Community participation require healthcare workers to have a good understanding of the communities, groups and individuals with whom they work so that they can foster acceptance and participation of the health promotion principles( DHHS, 2012).


Nola J. Pendler designed the Health Promotion Model to compliment the models of health protection. Health promotion is directed at increasing a patient’s level of well-being. The health promotion model describes the multi-dimensional nature of persons as they interact within their environment to pursue health. Her model focuses on individual characteristics and experiences, behavior-specific cognitions and affect, and behavioral outcomes. Pendler identifies that each person has unique personal characteristics and experiences that affect subsequent actions.

Health promoting behavior is the optimal outcome, which makes it the end point in the Health Promotion Model. These positive behaviors should result in improved health, which strengthens functional potential and improves quality of life in all stages of development. The Health promotion Model makes four assumptions:

1. Individuals seek to actively regulate their own behavior.
2. Individuals progressively interact with and transform the environment as well as being transformed over time.
3. Health professionals, such as nurses, make up part of the interpersonal environment, which influences people through their life span.
4. Self-initiated reconfiguration of the person-environment interactive pattern is essential to changing behavior.

Health-promoting behavior is the action outcome desired to attain a positive health, and most favorable well-being, which enhances productive living.

Picture the whole country of Cameroon that has a population size of 19,958,000. Based on the Center of Disease Control, that and more people in the United States have Chronic Kidney Disease (CKD). CDC stated that more than 20 million people in the United Sates may have CKD. That is about ten percent of the U.S. population. So, what is Chronic Kidney Disease? Chronic Kidney Disease is a condition in which your kidneys can not perform its normal function to the best of its ability. The kidneys have many functions but one of its main roles is to filter the waste or toxins from the blood that passes through it. Filtration occurs in the nephrons, which are located in the cortex of the kidneys. There are millions of nephrons in each kidney to facilitate the process. The waste that is filtered out of the system is then excreted from the body in the form of urine. Without the filtration process wastes from the bloodstream stays and accumulates in the body and can be very hazardous to the individual’s health. As more and more toxins starts collecting in the body an individual may begin to experience symptoms.

Chronic Kidney Disease is diagnosed by the results of blood and urine samples. The blood tests checks the GFR (glomerular filtration rate) and the urine test checks for albumin or protein. The GFR tells how well your kidneys are filtering. Your GFR should be 60mL ?? min’1 per 1.73 m2 or higher for normal function. If the GFR is below 60mL ?? min’1 per 1.73 m2 it means that the person has kidney disease. A GFR of 15mL ?? min’1 per 1.73 m2 or less means kidney failure. Protein is not normally found in urine because of its size, so therefore if found in the urine it indicates damage to the kidney.

It is of great importance to have urine and blood test done annually. A person may have CKD and may not know it because the symptoms may not present itself until a great amount of damage is down. CKD can progress to Kidney Failure if left untreated. Kidney Failure is when the kidneys stop working. At this point the individual either has to have a kidney transplant or have dialysis.

There are numerous risk factors of CKD and some of them are genetics, high blood pressure, obesity, high cholesterol, kidney stone, kidney infection and many more. The two main risk factors for CKD are hypertension and diabetes and will be discussed in this paper. African Americans, Hispanics and American Indians are the populations at highest risk for CKD and those two risk factors are prevalent amongst these cultural groups. It is said that CKD occurs in African Americans four times as much as in Caucasians. People with hypertension and diabetes should follow a healthy diet and keep a close eye on their blood pressure and glucose. Uncontrolled diabetes and hypertension causes damage to organs in the body including the kidneys. It is said that 1 in 3 people with diabetes develop CKD and 1 in 5 with hypertension develops it ( Their foods should be low in sodium and sugar. They should have lots of fruits and vegetables.

Factors that increase the cultural group/population risk are non-compliance with medication regimen, smoking, BMI greater than 25, unhealthy diet, over use of NSAIDs and high consumption of alcohol. Factors that decrease the risk for CKD are exercise, smoking cessation, constant monitoring of blood pressure and glucose, a diet low in sodium and sugary foods and following medication regimen. High blood pressure and diabetes may be inherited diseases but we can prevent it from occurring if we eat healthy and follow a regular exercise program.

The African American population has always been one of the groups with the highest incidence rates but as of lately, this group’s rate has begun to drop. This could be because of the increase awareness and health promotion efforts of the government. CKD is un-bias to age, it occurs in the elderlies above age 60 but it also occurs in the younger population, mainly due to uncontrolled diabetes and hypertension. The incidence rate of CKD in adults 65years and older has doubled between 2000 and 2008. In the adults between ages 20 and 64, the incidence rate is less than 0.5 percent. The prevalence of CKD in adults 60 years and older went from 18.8 to 24.5 between 1988-1994 surveys and 2003-2006 surveys. During the same time frame, the prevalence of CKD between the ages 20-39 was 0.5 ( As stated above, CKD leads to kidney failure and according to CDC’s fact-sheet, in 2011 forty-four percent of new cases had a primary diagnosis of diabetes. Twenty-eight percent of the new cases had a primary diagnosis of hypertension (

One of the objectives, listed on Healthy People 2020 for CKD is to reduce the proportion of the U.S. population with chronic kidney disease. The baseline they have is 15.1 of the population for the years 1999-2004. They are aiming to have this number reduced by 10%, which will be 13.6 of the population.

Pathophysiology of Risk Factors for CKD

Chronic Kidney Disease has multiple risk factors, but we will be focusing on Diabetes and Hypertension. Hypertension is a major cause of morbidity and mortality because of its association with coronary heart disease, cerebrovascular disease and renal disease. The blood pressure level which treatment is indicated is now 140/90 mm Hg. Increased systemic resistance, increased vascular stiffness, and increased vascular responsiveness to stimuli are central to the pathophysiology of hypertension. Morbidity and mortality attributable to hypertension result from target organ involvement. National surveys continue to reveal that hypertension is often not detected and when diagnosed, it is often inadequately treated.

Blood pressure is the combination of cardiac output and systemic vascular resistance. Cardiac output is usually elevated in younger people and decreases with age. This is due to increased systemic vascular resistance and increased stiffness of the vasculature. Stiffening of the aorta and elastic arteries increases the pulse pressure, this result in an increase in left ventricular afterload, and contributes to left ventricular hypertrophy. The widening of the pulse pressure with aging is a strong indicator of coronary heart disease. (Frey & Wexler, 2013).

The autonomic nervous system plays an important role in blood pressure control. (Leach, 2013) Increased release and enhanced peripheral sensitivity to norepinephrine can be found in hypertensive patients, and also increased responsiveness to stressful stimuli. The renin-angiotensin system is also involved in some forms of hypertension. Elderly or black patients usually have low ‘renin hypertension. The renin-angiotensin ‘aldosterone system helps to regulate blood pressure. When blood pressure falls, the kidneys release the enzyme renin into the blood stream. Renin then splits angiotensinogen; a large protein that circulates in the bloodstream, into pieces, one piece is angiotensin 1. Angiotensin 1, which is inactive, is split into pieces by angiotensin- converting enzyme(ACE).One piece is angiotensin 11, a hormone , which is very active. Angiotensin 11 causes the muscular walls of small arteries to constrict, increasing blood pressure. Angiotensin 11 also triggers the release of the hormone aldosterone from the adrenal glands and antidiuretic hormone from the pituitary gland. Aldosterone and antidiuretic hormone cause the kidneys to retain salt. Aldosterone also causes the kidneys to excrete potassium. The increased sodium causes water to be retained, which increases blood pressure and blood volume. Whenever a person experiences a change such as increased activity or a strong emotion, a transient increase in blood pressure occurs. One of the body’s compensatory mechanisms is triggered to counteract the change and keep the blood pressure at normal levels. An increase in the amount of blood pumped out by the heart increases blood pressure, which causes dilation of blood vessels and an increase in the kidney’s excretion of salt and water which decreases blood pressure. Renal disease may progress slowly and becomes evident in later year. Diabetes mellitus is a disorder in which the blood sugar is elevated because the body cannot produce enough insulin to meet its needs. Diabetes damages blood vessels, which increases the risk of strokes, heart attack and kidney failure.

Impaired insulin secretion and insulin resistance contribute to the development of pathophysiological conditions. Impaired insulin secretion is a decrease in glucose responsiveness, which occurs before the clinical onset of the disease. Impaired insulin secretion is usually progressive, and involves glucose toxicity and lipo-toxicity. The progression of the impairment of pancreatic B cell production affects the long term control of blood glucose. Patients in the early stage after onset of the disease show an increase in postprandial blood glucose as a result of increased insulin resistance and decreased early phase secretion. This in turn causes permanent elevation of blood glucose (Kaku, 2010).

Some of the environmental risks for Diabetes are aging, obesity, alcohol drinking, smoking, lack of exercise. Decreased activity is accompanied by a decrease in muscle mass, induces insulin resistance, and is associated with the rapid increase in the number of middle age and elderly patients. The changes in diet such as increased fat intake, and consumption of simple sugars, and decrease of dietary fiber promotes obesity, and cause deterioration of glucose tolerance. Diabetes may cause many long term complications as a result of the effect it has on blood vessels, which cause narrowing of the blood vessels, which in turn reduces the flow of blood to many parts of the body. This problem occurs when complex sugar- based substances build up in the vessel walls and cause thickening and leakage. Fatty substances in the blood also rise as a result of poor glucose control, and the vessels accumulate plaque, leading to Atherosclerosis, which is high risk factor for strokes and heart attacks. Over time, uncontrolled blood glucose and inadequate circulation can affect the brain, legs, eyes kidneys, and nerves. (Kaku, 2010). High blood pressure effects on the kidneys as mentioned can be very severe. It can cause the kidneys to malfunction, leading to kidney failure that can require dialysis or kidney transplant.
Chronic kidney disease (CKD) has several risk factors including, but not limited to diabetes, high blood pressure (HTN), age 65 and older and obesity (Ernst, 2010). Diabetes and HTN accounts for almost 70% of CDK incidence (Ernst, 2010). Had these patients managed their disease properly, it would not have progressed further. An important element in disease management is knowledge and this is where the nurse’s role as a teacher becomes important in the prevention and management of CKD (Ernst, 2010). There is an old saying that, ‘Prevention is better than cure’ and this is absolutely true with regards to CKD. To successfully prevent the occurrence of CKD, patients need to know the cause of the disease, the modes of transmission and the identified risk factors (Levey et al, 2008). Nurses as primary care givers have the enviable task of teaching primary, secondary and tertiary methods of prevention (Ernst, 2010).

The World Health Organization (WHO) defines health as a process of enabling people to increase control and improvement in their health (WHO, 1996). This definition apply aptly describes the nurse’s interventions in the primary prevention of CKD. Diabetes and HTN are the primary risk factors associated with CKD, and as such nurses has a key role in providing information to clients affected by these chronic illnesses, as well as to the public in general(Levey et al, 2008). Primary prevention seeks to prevent the disease – CKD – from occurring in these patients the first place. Nurses should teach all their patients ‘ with HTN and diabetes ‘ about the impact of mismanagement of these diseases. They must be encouraging them to take their medication in a timely manner as well as adopt a healthy lifestyle ‘ diet and exercise. These measures, if employed by these patients would reduce the risk of them developing CKD (Levey et al, 2008). A further strategy that can be employed is screening. Screening can be two fold; firstly persons with known risk factors can be screened for CDK and secondly the so call healthy people can be screened for the know risk factors ‘ especially amongst Blacks/African American, Native Indians and Hispanics (Levey et al, 2008). Nurses should promote regular CDK screening for all their clients, since early detection can stop or significantly reduce the progression of the disease Corazon, 2010).

Another intervention in primary prevention could include health fairs in targeted communities ‘ blacks/African American, Native Indians and Hispanics – where the disease is most devastating. Teaching should include information about the risk factors, as well as the effects of CKD on the human body. Participants should also be screened for the known/modifiable risk factors ‘ diabetes and HTN – because early detection means early intervention and prevention of CKD (Levey et al, 2008). Nurses can also use the internet to self-educate themselves about risk factors and ways to reduce them; so that they can answer particular queries by clients and point them to reputable website for information (Levey et al, 2008). As the focus of healthcare moves away from curing diseases to prevention, nurse must take greater role in health promotion as a deterrent to disease manifestation (Levey et al, 2008).

Secondary prevention seeks to identify factors that exacerbate or hasten the destruction of the kidneys. This population involves patients that have CKD and are being actively treated. Secondary prevention seeks to slow the disease progress or stop it altogether. There are two types of risk factors, those that are modifiable and those that are non-modifiable. Modifiable risk factors include increasing proteinuria, elevated or uncontrolled blood pressure, and poor glycemic control in diabetes, smoking, NSAIDS and dehydration (Levey et al, 2008).

Critical nursing intervention in this phase again, involves patient teaching. Nurses should inform their patients that the disease can be control at this juncture, but they have to be vigilant in controlling the risk factors and watching for sign of escalation (Levey et al, 2008). One of the most significant intervention, is regular screening for proteinuria- protein in the urine ‘ as this is a tell tale sign of disease progression (Levey et al, 2008). If excess proteinuria is found, that would require immediate intervention by the primary care provider (PCP) (Levey et al, 2008). Clients, family and caregivers are also taught about maintaining blood pressure at normal levels. Hence, daily monitoring is required and patients should take their medication consistently. Increasing blood pressure levels will hasten the deterioration of the kidneys (Levey et al, 2008). Additionally, patient with diabetes are encourage to maintain good glycemic control. Medication must be taken regularly and PCP instructions followed. Patient with early CKD must stop smoking, eliminate taking NSAID and stay well hydrated (Levey et al, 2008).

Also important in patient teaching is diet and exercise. Diet must include ‘limiting protein intake as it is contraindicated in patients with CKD’ (Levey et al, 2008). Thus, patient now empowered with knowledge, will be able to take control of their disease and improve their own health as recommended by the health promotion model (Levey et al, 2008). They will know the warning signs of escalation and know the corrective actions to take, whether it be calling the PCP or doing a simple blood test (Levey et al, 2008).

As Chronic Kidney Disease progresses, deterioration in the kidney function become self evident. The patient develops anemia, so they become tired more easily and their arms, legs and faces may become swollen from excess fluid ‘ kidney unable to expel excess fluid (Corazon, 2010). Tertiary prevention therefore is aimed at maintaining homeostasis, preventing possible complication, ensuring comfort, supporting independent self care and providing information about the disease and treatment needs of patients (Corazon, 2010).

A person suffering from kidney failure is most likely to retain excess body fluid which is manifested in swollen arms, legs and face. Nursing intervention for such a client is focus on maintaining homeostasis in the body and hence specific intervention may include monitoring the client’s vitals, heats sounds, lungs sound, pulse, blood pressure, pain, temperature, mentation and ability to respond (Corazon, 2010). It is important that these vitals be monitored to detect any sudden changes in the client’s internal environment or signs of complications (Corazon, 2010). It is indeed extremely serious if any changes occur, particularly with regards to fluid shifts, because this could signal the worsening of the person’s condition which can lead to heart failure (Corazon, 2010).

People who suffer from kidney failure are generally very weak and get tired easily because they do not have enough have enough oxygen flowing throughout the body (Corazon, 2010). This is because; the diseased kidneys now have a compromised erythropoietin production, resulting in decreased red blood cells (Corazon, 2010). Nursing intervention is geared towards ensuring the comfort of the patient; therefore the nurse should note reports of client weakness and fatigue as well as observe and also note signs of anemia and difficulty in breathing (Corazon, 2010). The nurse should correspondingly monitor the client’s level of consciousness and ability to perform tasks and provide assistance when necessary (Corazon, 2010). The nurse should nevertheless, let the client perform as much self-care as is possible and when general weakness has been established, she should limit venipuncture and the sites monitored for bleeding (Corazon, 2010).

Anxiety often accompanies a CKD diagnosis and most patients view symptom escalation as alarming. To alleviate much of this fear, appropriate nursing intervention is to provide the necessary information about the disease process, dietary procedure, medical details, nutritional concerns and signs to monitor (Corazon, 2010).

Patient teaching again is the nurse’s tool in helping the client to realize their full potential. Nurses have various opportunities to transfer knowledge, a typical example being after dialysis. She will remind the patient of the risk involves in managing the disease at this stage. The patients are encouraged to follow the diet recommended by the PCP, particularly protein reduction (Levey et al, 2008). Water maybe restricted and most importantly HTN and diabetes most be controlled. Nurses could also introduce the patient to the nutritionist, who could help with nutritious meal that is CKD compliant. She encourages the patent to join the American CKD Association, where they could get support and encouragement from people with similar condition (Levey et al, 2008). Dialysis nurses and nurses in general can have forums in the communities, which aims to provide information about ways to control the disease and necessary steps to take in improving quality of life (Levey et al, 2008). These health teaching should be designed to help patient, in taking greater interest in their healthcare and wellbeing, as well as providing the necessary information to help them to have a good quality of life when faced with this challenging disease (Corazon, 2010).

The role of the nurse in health promotion

rodrigo | November 26, 2012

WritePass - Essay Writing - Dissertation Topics [TOC]



This assignment proposes to discuss the role of the nurse in health promotion.  To facilitate the discussion in the delivery of primary, secondary and tertiary levels of health promotion, the health risk of tobacco smoking in relation to Lung Cancer has been chosen.  National policies will be explored in relation to smoking and how these influence the delivery of health promotion by the nurse.  The barriers to health promotion will be identified along with ways in which these may be overcome.

The intention of the World Health Organisation (WHO) to achieve “Health for All” by the year 2000 was published in their Ottawa Charter, the outcome of which was to build healthy public policy, create supportive environments, strengthen communities, develop personal skills and reorient health services.  They identified key factors which can hinder or be conducive to health; political, economic, social, cultural, environmental, behavioural, and biological (WHO 1986).

The current health agenda for the UK aims to improve the health of the population and reduce inequalities with particular emphasis on prevention and targeting the number of people who smoke (DH 2010).

Inequalities in health have been extensively researched and although attempts have been made to overcome these, there is evidence to support that the divide between the rich and the poor still exists in society.  Marmot (2010) highlighted the lower social classes had the poorest health and identified social factors such as low income and deprivation as the root causes which affect health and well being.   Increased smoking levels were found to be more prevalent in this cohort.  Bilton et al (2002) suggests the environment an individual lives in can have an adverse effect on health in that it can influence patterns of behaviour.  For example, families living in poor housing conditions, in poverty or in an environment away from a social support network can suffer psychological stress; which in turn can prompt coping behaviours such as tobacco smoking (Blackburn 1991, Denny & Earle 2005).

Smoking is a modifiable risk factor to chronic disease such as Cancer of the Lung, with 90% of these cases being the result of smoking (Cancer Research UK 2009) it   is the single biggest preventable cause of premature death and illness and is more detrimental to the poorer in society.  Responsible for 80,000 lives per year, the huge financial burden on the NHS to treat illness associated with smoking is estimated at £2.7 billion each year (DH 2010).  This illustrates the huge opportunity for public health to address the wider issues associated with inequalities and to target people who smoke.  Various White papers have demonstrated the Government’s commitment in reducing smoking figures and preventing uptake, both at individual and population levels, through health promotion activity, empowering individuals and enabling them to make healthier lifestyle choices (DH 2004, DH 2006, DH 2010).

Health promotion is a complex activity and is difficult to define.  Davies and Macdowall (2006) describe health promotion as “any strategy or intervention that is designed to improve the health of individuals and its population”.   However perhaps one of the most recognised definitions is that of the World Health Organisation’s who describes health promotion as “a process of enabling people to increase control over their health and its determinants, and thereby improve their health (WHO 1986).

If we look at this in relation to the nurse’s role in smoking cessation and giving advice to a patient, this can be seen as a positive concept in that with the availability of information together with support, the patient is then able to make an informed decision, thus creating empowerment and an element of self control.  Bright (1997) supports this notion suggesting that empowerment is created when accurate information and knowledgeable advice is given, thus aiding the development of personal skills and self esteem.

A vital component of health promotion is health education which aims to change behaviour by providing people with the knowledge and skills they require to make healthier decisions and enable them to fulfil their potential.   Healthy Lives Healthy People (2010) highlight the vital role nurses play in the delivery of health promotion with particular attention on prevention at primary and secondary levels.   Nurses have a wealth of skills and knowledge and use this knowledge to empower people to make lifestyle changes and choices.  This encourages people to take charge of their own health and to increase feelings of personal autonomy (Christensen 2006).   Smoking is one of the biggest threats to public health, therefore nurses are in a prime position to help people to quit by offering encouragement, provide information and refer to smoking cessation services.

There are various approaches to health promotion, each approach has a different aim but all share the same desired goal, to promote good health and prevent or avoid ill health (Peate 2006).  The medical approach contains three levels of prevention as highlighted by Naidoo and Wills (2000), primary, secondary and tertiary prevention.

Primary health promotion aims to reduce the exposure to the causes and risk factors of illness in order to prevent the onset of disease (Tones & Green 2004).  In this respect it is the abstinence of smoking and preventing the uptake through health education and preventative measures.  One such model of prevention is that of Tannahill’s (1990) which consists of three overlapping circles; health education for example a nurse may be involved in the distribution of leaflets educating individuals or a wider community regarding health risks of smoking, prevention, aimed at reducing the exposure to children, for example, in 2007 the legal age for tobacco sales increased from age 16 to 18 years in an attempt to reduce the availability to young people and prevent them from starting to smoke (DH 2008),  health protection such as lobbying for a ban on smoking in public places.

If we look at this in relation to the role of the school nurse, this is a positive step when implementing school policies such as no smoking on school premises for staff and visitors, as this legislation supports the nurse’s role when providing information regarding the legal aspects of smoking.   Research demonstrates that interventions are most effective when combined with strategies such as mass media and government legislation (Edwards 2010).   Having an awareness of such campaigns and legislation is essential to aid best practice and the nurse must ensure that knowledge and skills are regularly updated, a standard set by the Nursing and Midwifery Council (NMC 2008).

Croghan & Voogd (2009) identify the school nurse’s role as essential in the health and well-being of children in preventing smoking.    Many people begin to smoke as children, the earlier smoking is initiated, the harder the habit is to break (ASH) and this unhealthy behaviour can advance into adulthood.   Current statistics illustrate that in 2009 6% of children aged 11-15 years were regular smokers (Office for National Statistics 2009).  These figures demonstrate the importance of prevention and intervention at an early stage as identified by the National Service Framework (NSF) for Children, Young People and Maternity Services (DH 2004).  Smith (2009) highlights the school nurse as being in an advantageous position to address issues such as smoking and suggests that by empowering children by providing support and advice, this will enable them to adopt healthy lifestyles.

NICE (2010) suggest school based interventions to prevent children smoking aimed at improving self esteem and resisting peer pressure, with information on the legal, economic and social aspects of smoking and the harmful effects to health.   Walker et al (2006) argue self esteem is determined by childhood experiences and people with a low self esteem are more likely to conform to behaviours of other people.   This can be a potential barrier in the successful delivery of health promotion at this level, with young children exposed to pressure to conform; they are more likely to take up unhealthy behaviours such as smoking (Parrott 2004).   The nurse can overcome this by working in partnership with teachers and other staff members to promote self-esteem by ensuring an environment conducive to learning, free from disruptive behaviour which promotes autonomy, motivation, problem solving skills and encourages self-worth (NICE 2009).

Despite the well known health risks to tobacco smoking, unfortunately 1 in 5 individuals continue to smoke (DH 2010).  Whitehead (2001) cited in Davies (2006) argues the nurse must recognise and understand health related behaviour in order to promote health.  Therefore, when delivering health promotion the nurse needs to be aware of all the factors which can affect health, some of which can be beyond individual control.  Smoking cessation is one of the most important steps a person can make to improve their health and increase life expectancy, as smokers live on average 8 years less than non smokers (Roddy & Ross 2007).

Secondary prevention intends to shorten episodes of illness and prevent the progression of ill health through early diagnosis and treatment (Naidoo & Wills 2000).  This can be directed towards the role of the practice nurse in a Primary Care setting, where patients attend for treatment and advice that have symptoms of illness or disease as a result of smoking, such as Bronchitis.  Nice guidelines (2006) recommend that all individuals who come into contact with health professionals should be advised to cease smoking, unless there are exceptional circumstances where this would not be appropriate, and for those who do not wish to stop, smoking status should be recorded and reviewed once a year.  It is therefore essential the nurse maintains accurate and up to date record keeping.

Smoking cessation advice can be tailored to the specific individual and therefore it is important that the nurse has the knowledge and counselling skills for this to be effective.  The process of any nursing intervention is ultimately assessment, planning, implementing and evaluating (Yura & Walsh 1978), this applies to all nurses in any given situation including health promotion.  One such method of smoking cessation which can be used as an assessment tool is known as the 5 ‘A’s approach, ‘ask, assess, advise, assist, arrange’ (Britton 2004).  “Ask” about tobacco use, for example how many cigarettes are smoked each day, and “assess” willingness and motivation to quit, taking a detailed history to assess addiction.   Objective data can be obtained using a Smokerlyser which measures Carbon Monoxide levels in expired air (Wells & Lusignan 2003).  These simple devices can be used as a motivational tool to encourage cessation and abstinence.    Castledine (2007) suggests the principle of a good health promoter is to motivate people to enable them to make healthier choices; this is made possible by the ability to engage with individuals at all levels.  Individuals who are not motivated are unlikely to succeed (Naidoo & Wills 2000).   “Advise” patients to stop smoking and reinforce the health benefits to quitting, “assist” the patient to stop, setting a quit date and discussing ways in which nicotine withdrawal can be overcome.  Being unable to cope with the physical symptoms of withdrawal can cause relapse and be a barrier to success, therefore it is essential the nurse possesses a good knowledge base of the products available to assist in reducing these symptoms if she is to persuade people to comply with treatment, such as the use of nicotine replacement therapy (NRT).    NRT is useful in assisting people to stop smoking and has proved, in some instances to double the success rate (Upton & Thirlaway 2010).  NRT products are continually changed and updated; therefore the nurse must ensure she has the knowledge and skills to identify which products are available, the suitability, how it works and any potential side effects.  Identifying triggers and developing coping strategies is useful for maintenance of a new behaviour, measures such as substituting cigarettes for chewing gum and changing habits and routines are just some of the ways in which self control can be achieved (Ewles & Simnett 1999).  Finally “arrange” a follow up, providing continual support and engagement. For patients who do not wish to stop smoking, advice should be given with encouragement to seek early medical treatment on detection of any signs and symptoms of disease.  Good communication skills are essential to the therapeutic relationship between the nurse and a patient and these must be used effectively by providing clear, accurate and up to date information.  The nurse should be an active listener and encourage the patient to talk, using open-ended questions helps demonstrate a willingness to listen, listening and showing concern for a patient’s condition demonstrates respect (Peate 2006).  The use of medical jargon and unfamiliar words can be a barrier to communication and should be avoided as these can affect a patients understanding.  Leaflets can reinforce information provided by the nurse and increase patient knowledge, however the nurse must ensure these are in a format and language the patient can understand.  Lack of literacy skills can prevent a patient reading and understanding the content of a leaflet, the nurse can assist with this by reading and explaining to them.

To assist in the assessment process the nurse may utilise a model of behaviour such as Prochaska & DiClemente’s stages of change model (1984).  This works on the assumption that individuals go through a number of stages in order to change behaviour, from pre -contemplation where a person has not considered a behaviour change, to maintenance, when a healthier lifestyle has been adopted by the new behaviour.   The stage a person is at will determine the intervention given by the nurse; therefore it is essential that an effective assessment takes place.  Walsh (2002) highlights patient motivation as central to success using this model, in that a patient will have more motivation; the more involved they are in planning the change.

Despite the health promoting activities mentioned and the increasing public awareness of the health risks to smoking, there are people who continue to smoke and some further develop illness as a consequence.  Lung cancer has one of the lowest survival rates, and as little as 7% of men and 9% of women in England and Wales will live five years after diagnosis (Cancer Research UK 2011).  Acknowledging this, the governments “Cancer Plan” aimed to tackle and reform cancer care in England by raising awareness of the signs and symptoms of cancer by investing in staff and extending the nurses role (DH 2000).  This involves further training and education for nurses to develop their skills and knowledge to enable them to provide the treatment and/or advice required.  This was succeeded by “Improving outcomes: a strategy for cancer” the aim being to enable patients living with cancer a “healthy life as possible”.   The government pledged £10.75 million into advertising a “signs and symptoms” campaign to raise awareness of the three cancers accounting for the most deaths, breast, bowel and lung, to encourage the public to seek early help on detection of any symptoms (DH 2011).  Currently no results are available on the effectiveness of this intervention due to its recent publication, however, one national policy that has had a positive effect on the health of individuals and the population is that of the “smoke-free England” policy implemented in 2007 prohibiting smoking in workplaces and enclosed public places.  Primarily this policy was enforced to protect the public from second hand smoke; however, on introduction of the law smoking cessation services saw an increase in demand by 20%, as smokers felt the environment was conducive to them being able to quit (DH 2008).  This policy also extended to hospital grounds, and the nurse must ensure a patient who smokes is aware of this on admission and use every opportunity possible to promote health.

Tertiary prevention aims to halt the progression, or reduce the complications, of established disease by effective treatment or rehabilitation (Tones & Green 2004).  A diagnosis of cancer can cause great distress and a patient may go through a whole host of emotions.  Naidoo and Wills (2000) suggest the aim of tertiary prevention is to reduce suffering and concerns helping people to cope with their illness.   The community nurses role has been identified as pivotal in providing support for patients and families living with cancer (DH 2000).  The World Health Organisation describe Palliative care as treatment to relieve, rather than cure, the symptoms caused by cancer,  and suggest palliative care can provide relief from physical, psychosocial and spiritual problems in over 90% of cancer patients (WHO 2011).

Assessment and the provision of health education and information at this stage remains the same as that in secondary prevention, and it is not uncommon for the two to overlap.  Providing advice and education on symptom control may alleviate some of the symptoms the patient experiences,  for example breathlessness is a symptom of lung cancer (Lakasing & Tester 2006), and relaxation techniques may reduce this (Cancer Research UK 2011), therefore the nurse may be involved in teaching these techniques to the patient and family members.  Continual smoking despite a lung cancer diagnosis can exacerbate shortness of breath and reduce survival rate (Roddy & Ross 2007), therefore the nurse can use this opportunity to reinforce the risks of smoking.  However, the nurse must use her judgement effectively and be sensitive to the patient’s condition, as the willingness to learn and respond to teaching can be affected by emotional state (Walsh 2002).  Establishing effective pain control is essential in the care of a cancer patient and this may involve discussion with the patients GP if medication needs adjusting.  A referral to specialist help lines such as those provided by Macmillan cancer support may be useful in assisting a patient and/or family to cope with cancer, these services can be accessed in person or by telephone.  These are just two examples of collaborative working and demonstrate the importance of inter-professional working.

In conclusion, with the emphasis of health promotion concerning prevention of illness and disease, the role of the nurse is essential in raising awareness and providing education and advice to individuals to facilitate behaviour change. The complexities of health promotion indicate the extensive competences a nurse must possess to empower and motivate individuals.  However, governments also have a responsibility to promote and protect health and are pivotal in introducing national policy to build “healthy publics” and environments conducive to health.


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