7887608

Health Promotion in Nursing

NURS21050

7887608

2’260 words
7887608

This essay will begin by discussing health promotion offering a number of alternative

perspectives and definitions of health promotion. The importance of health promotion will

be identified and the nurse’s role as an agent of health promotion shall be discussed. The

body of the essay will discuss the health promotion challenge of smoking in mental health

services.

The World Health Organisation (1985, p5) (WHO) define health promotion as “the

process of enabling people to increase control over, and to improve their health”. The WHO

is explaining that health promotion is almost a method of giving individuals control over

their health and empowering them to improve their health. Though an accurate definition,

the WHO’s possibly a little vague focussing largely on the individual as a catalyst in the

process of health promotion. This definition is possibly distracting from the influence of the

wider socio-economic determinates of health, and focuses entirely on the idea of health

improvement, failing to mention the strengths of prevention of health problems.

Anderson (1983, p11) offers the definition of health promotion as “any combination

of health education and related organisational, political and economic intervention designed

to facilitate behavioural and environmental adaptions which will improve or protect health”.

Anderson’s definition offers a more complex and intricate perspective giving a deeper

understanding of many of the factors one must consider when considering health

promotion. A real strength of Anderson’s definition is in its inclusion of the protection of

health and the concept of prevention; it gives rise to the concepts of primary, secondary and

tertiary approaches to prevention (Jones 2003).

1|Page
7887608

The Jakarta declaration concluded that health promotion is a valuable asset that

undoubtedly is effective and works. This conclusion was reached on the basis of global

research and multiple case studies considering how different health promotion strategies

have been developed. Many of the various health promotion strategies have successfully

modified determinates of health such as lifestyles as well as the social environment and

economic conditions (WHO 1997).

The role of nurses in health promotion is clearly defined by the NMC code (2008)

nurses must work to promote the care of individuals in their care as well as their families,

carers and the wider community. Nurses are required to participate in health promotion

interventions in some key areas, these include maintaining an awareness of health and

social factors impacting on individuals, as well as being consensuses of a nurse’s role in

promoting health and self-care. Nurses are very often the key health professional in

providing health promotion; a nurse should always consider the role of other health

professionals and be ready to consider the contributions others may bring to interventions

(Linsely 2011). Ewles and Simmnett (1999) discuss the possible health promotion activities

that nurses undertake or are involved in. nurses find they are providing front line education

supplying educational materials and giving information. Nurses often consult and gather

data. Nurses are often central to the development of policies or lobbying for public health

policies taking on roles of advocacy for health and initiating services, often working in

partnership with community organisations and co-ordinating multiagency health promotion.

When working with clients with mental health difficulties either in a community or

inpatient setting nurses should be promoting healthy lifestyle choices such as smoking

cessation, dietary information, physical activity and alcohol and drug awareness. Llopis and

2|Page
7887608

Saxena et al (2005) discuss the link between mental health and physical health they explain

how interventions in one service may affect the other, this link has important implications

when considering public health.

The challenge of smoking cessation in mental health clients presents as a significant

health promotion challenge. Smoking rates are proportionately higher in people diagnosed

with mental health illnesses (Dwyer, Bradshaw & Happell 2009). A personal reflection of

practice areas is one of clients often preoccupied with cigarettes and smoking times and

also of supervising staff often taking the opportunity to have a cigarette themselves. A 2006

Australian study puts prevalence of smoking at 31.8% of adults with a mental health illness

(Access economics 2007). Leon and Diaz (2005) explain that smoking has 90% prevalence in

diagnosed schizophrenics and smoking has been identified as the highest risk factor for

mortality in mental health patients .Lawn and Condon (2006) discuss explain that mental

health nurses have an important role to play in smoking cessation and ultimately in smoking

prevention, they are perfectly placed to offer such interventions with these aims.

When one considers the client group amongst mental health services there is

overrepresentation from lower social classes. There are strong and historical links between

mental health and poverty and as Marmot and Wilkinson (1999) demonstrated smoking is a

behaviour widely demonstrated in lower social classes. When one considers this is seems to

be logical that smoking is higher amongst individuals with mental illnesses. In individuals

with mental illness smoking is often used to help alleviate the symptoms of their mental

illness as well as helping individuals to deal with boredom and to build relationships with

others (lawn & Condon 2006).

3|Page
7887608

Linsely (2011) describes the prerequisites of change which are part of the

transtheoretical model of change. For change to take place a person’s behaviour should not

be part of their coping mechanism unfortunately lawn and Cowden (2006) have described

how individuals often use smoking to alleviate the symptoms of their mental illness as well

as to cope with boredom. Another prerequisite of change is that an individual’s life should

be unproblematic and relatively free of uncertainty, this is something that is often difficult

to attain for an individual with a long standing mental illness as mental illness is regularly

extremely disruptive on an individual’s life.

A 2011 study made the observation that a large component of health promotion

took the form of websites and online health promotion activities. The study claims that

people with severe mental illness struggle to use and access online materials having

difficulty navigating through websites and understand the language of the material

(Brunette et al 2012). The findings of this study do show a gap in health promotion and raise

an important point; the study did only consider the four most accessible websites using

Google as a search engine so its findings may not be transferable as individuals may look

more extensively at other literature on line.

It is important to consider that in the illness of schizophrenia and abrupt stop or

decrease in nicotine can have severe complications. The symptoms of schizophrenia have

been exasperated by the removal of nicotine and medication levels have been shown to

fluctuate. Therefore some say that nurses are obliged to not deny any opportunities for

schizophrenics to smoke (Mccloughen 2003).

4|Page
7887608

When considering the higher incidences and rates of tobacco consumption in people

diagnosed with mental health illnesses it is important to question do individual factors of

clients totally account for this? Buchanan et al (1994) estimated that 88% of individuals with

a mental health illness who smoke would like to stop, Resnick and Bosworth (1989) found a

third of inpatients were agreeable to attending smoking cessation programmes. It seems

surprising considering Buchanan’s findings that incidences of smoking remain so high

amongst patients diagnosed with mental health illnesses. Buchanan’s finding seem to

illustrate that 88% of mental would be considered at stage two of the transtheoretical

model of change described by Linsely (2011) , they are at the point where they are seriously

considering giving up smoking. It leads to the question is there something in mental health

services that actively encourages individuals to smoke or that does not discouraging

smoking? Dickens et al (2004) suggests that smoking may somehow be an integral part of

the culture of mental health services. Smoking may also be viewed as a positive experience

and even some kind of intervention or interaction between staff and clients. Cigarettes may

even be used as some kind of therapy to positively reinforce good behaviour or to punish

bad behaviour. However Dickens and Stubbs (1994) explain that nurses who promote

smoking therapeutically are generally smokers themselves, this may result in staff enjoying

unchecked and unabated smoking breaks. Could it be that mental health services are

reinforcing smoking in clients, or health care workers who do smoke do not wish to promote

smoking cessation as a result of the implications of a smoke free mental health services on

their personal life.

A personal reflection of ward politics is of smokers viewed as less efficient members

of the team possibly having an excessive number of breaks, with non-smoking nurses

5|Page
7887608

describe 12 hour shifts of working without so much as a drink of water. It is an area of

contention and conflict not just in ward settings but in many work places.

Mcleroy et al (1988) discuss how informal structures can be an institutional factor

that influences individual behaviour, if Dickens et al (2004) suggestion that smoking is

engrained in the culture of mental health services it is a very real possibility that smoking

and cigarettes are an informal structure on wards. Community factors such as social

networks and social norms all influence individual’s behaviour this factor of influence again

seems to suggest that if tobacco use is a norm in the mental health community it will be

more difficult to eradicate its use. In theories of health related behaviour attitudes of the

individual are considered an important step and an attitude change often results in a

behaviour change (Linsely 2011). If incidences of smoking in mental health services were

reduced in both staff and clients it may be the beginning of a culture change leading to

smoking cessation being more widely and enthusiastically accepted and promoted.

Dwyer, Bradshaw & Happell’s (2009) paper suggests incidences of smoking amongst

mental health nurses are higher than of those amongst the general population. However

there were fewer smokers amongst the sample of mental health nurses used in the study

than in the general population, it is difficult to ascertain whether the nurses in this study are

typical of nurses in general. Rowe and Clarke (2000) argue that data about smoking patterns

amongst nurses is insufficient and accurate conclusions cannot be made. It is suggested that

nurses who smoke may be poor role models and are poorly placed be involved in smoking

cessation interventions with clients understandably questioning anti-smoking messages on

the basis of the individual delivering that message being a smoker themselves (Reilly,

Murphy & Alderton 2006, Dwyer, Bradshaw & Happell 2009). McKenna et al (2001)

6|Page
7887608

describes how nurses who are smokers are less willing to offer smoking cessation

interventions. Lawn and Cowdon (2006) in their paper on the ethical stance of nurses

towards smoking, describe a history of reinforcement of smoking in hospitals. Sarna et al

(2005) suggest that smoking is an intervention that the majority of mental health nurses do

not address with clients. An explanation for this lack of enthusiasm towards smoking

cessation interventions could be explained as nurses often view smoking as entitlement or

right clients have that should not be threatened (Reilly, Murphy & Alderton 2006). A

challenge to smoking cessation in mental health services may result from the mind-set of

nurses who simply cannot envisage smoke free mental health (Dwyer, Bradshaw & Happell

2009). A 1999 study seems to suggest that a nurses smoking habits was not a strong

determinate of their attitudes about smoking (Hughes & Riesel 1999). Dwyer, Bradshaw &

Happell (2009) explain that in there study the majority of nurses held the belief that health

care facilities are obligated to discourage tobacco consumption and that most of the

participants asked felt confident in their skills to offer health promotion interventions aimed

at smoking cessation. However if Dwyer, Bradshaw & Happell’s (2009) views are more

accurate it would be that social support is not available for clients wishing to stop smoking.

This would mean a vital prerequisite of change part of the transtheoretical model of change

was not met (Linsely 2011).

Mccloughen (2003) offers the findings of mental health professionals considering

mental health from a purely biophysiological stance. A more holistic stance would be

beneficial to clients and the link between physical health and mental health more widely

accepted, and the health promotion role of mental health nurses should be reinforced.

7|Page
7887608

Smoking amongst those diagnosed with a mental health illness presents as a thorny

issue with many interpersonal factors affecting the individual behaviour of smokers.

Smokers are using tobacco almost to self-medicate and deal with their illnesses. If one

considers the percentage of those wishing to stop smoking clients with mental health

illnesses should be demonstrating lower incidences of smoking. When one considers the

transtheoretical model of change it is not difficult to understand why smoking cessation

seems to be so difficult in mental health services. The assertion of some that tobacco use is

engrained in the culture of services is a valid point and this may well be encouraging clients

and staff alike to continue to smoke. Though, the thought of nurses actively encouraging

those in their care to continue with such a destructive and harmful behaviour seems

unrealistic and alarming. A personal belief is that nurses could do a lot more to modify the

behaviour of smokers in mental health services as the message of anti-smoking does tend to

get lost in the haze. However it may be out of affection and respect for individuals that the

issue has been overlooked for such a long time. Though a lack of holistic care may be a

contributory factor to the prevalence of smoking within mental health services, mental

health nurses perhaps need to consider the link between physical and mental health in a

more diligent fashion.

References

Access Economics (2007). Smoking and Mental Illness: Costs. Canberra: SANE Australia Canberra.

Anderson R (1983). Health promotion: an overview. Copenhagen: world health organization regional office for Europe.

Buchanan, C. R., Huffman, C. & Barbour, V. M. (1994). Smoking health risks: Counseling of psychiatric patients. Journal of
Military Nursing Research, 2, 28–32.

Mary F. Brunette, Joelle C. Ferron, Timothy Devitt, Pamela Geiger, Wendy M. Martin, Sarah Pratt1, Meghan Santos &
Gregory J. McHugo. (2012) Do smoking cessation websites meet the needs of smokers with severe mental illnesses?.
HEALTH EDUCATION RESEARCH. Vol.27 no.2 2012 Pages 183–190.

8|Page
7887608

Dickens, G. L., Stubbs, J. H. & Haw, C.M. (2004). Smoking and mental health nurses: A survey of clinical staff in a
psychiatrichospital. Journal of Psychiatric and Mental Health Nursing, 11, 445–451.

Ewels L & Simmnett I. (1999). Promoting health a practical guide. (4th ed.).Edinburg. Bailliere Tindall.

Hughes, A. & Rissel, C. (1999). Smoking: Rates and attitudes among nursing staff in central Sydney. International Journal of
Nursing Practice, 5, 147–154.

Jones I (2003). Health Promotion And The New Public Health. Scambler G. ed. Sociology As Applied to Medicine. (5th ed.).
London: Saunders. Pp265-276.

Linsley P, Kane R, Owen S (2011). Nursing for Public Health – promotion. Principles and practice. Oxford: oxford university
Press.

Lawn, S. & Condon, J. (2006). Psychiatric nurses’ ethical stance on cigarette smoking by patients: Determinants and
dilemmas in their role in supporting cessation. International Journal of Mental Health Nursing, 15, 111–118.

de Leon, J. & Diaz, F. (2005). A meta-analysis of worldwide studies demonstrates an association between schizophrenia and
tobacco smoking behaviours. Schizophrenia Research, 76, 135–157.

Marmot, M. & Wilkinson, R. (1999). Social Determinants of Health. New York: Oxford University Press.

McKenna, H., Slater, P., McCance, T., Bunting, B., Speirs, A. & McElwee, G. (2001). Qualified nurses’ smoking prevalence:
Their reasons for smoking and desire to quit. Journal of Advanced Nursing, 35 (5), 769–775.

Mcleroy R., Bibeau D., StecklerA., & Glanz K. (1988). An ecological perspective on health promotion programs.Health
Education Quarterly. 15: 351 -337.

McLoughlen, A. (2003). The association between schizophrenia and cigarette smoking: A review of the literature and
implicationsfor mental health nursing practice. International Journal of Mental Health Nursing, 12, 119–129. Minichello, V.,
Sullivan, G., Greenwood, K. & Axford,

Nursing and Midwifery council(2008). The Code- standards of conduct, performance and ethics for nurses and Midwives.
London: NMC.

Paul Reilly, Leeann Murphy, & Deirdre Alderton (2006). Challenging the smoking culture within a mental health service
supportively .International Journal of Mental Health Nursing. 15, 272–278

Resnick, M. P. & Bosworth, E. E. (1989). A smoke free psychiatric unit. Hospital and community. Psychiatry, 40, 525–527.

Rowe, K. & Clark, J. M. (2000). The incidence of smoking amongst nurses: A review of the literature. Journal of Advanced
Nursing, 31, 1046–1053.

Sarna, L., Bialous, S., Wewers, M., Froelicher, E. & Danao, L. (2005). Nurses, smoking, and the workplace. Research in
Nursing & Health, 28, 79–90.

S. SAXENA, M. VAN OMMEREN, K. C. TANG, & T. P. ARMSTRONG(2005).Mental health benefits of physical activity. Journal
of Mental Health. 14(5): 445 – 451

Trudy Dwyer. Julie Bradshaw & Brenda Happell (2009). Comparison of mental health nurses’ attitudes towards smoking
and smoking behaviour. International Journal of Mental Health Nursing. 18, 424–433

World health organization (1997). The Jakarta declaration on leading health promotion in to the 21st century. Geneva:
WHO

World Health Organization (1985). Targets for health for all: targets in support of the European strategy for health for all.

Copenhagen: world health organization regional office for Europe.

9|Page