In this Issue
Advanced Practice Nursing Students’ Perceptions of Health Promotion
Elizabeth Rash, PhD
Advanced Practice Nursing Students’ Perceptions of Health Promotion
While health promotion is considered a primary role of Advanced Practice Nurses (APNs), there is little evidence that APNs are allocating much time with patients for health promotion. The purpose of this study was to assess APN students’ perceptions of health promotion, and identify changes that might occur in these perceptions following a health promotion course. The outcome of this study could contribute to health promotion curricula that can encourage APN health promoting behaviors.
Students in a graduate online health promotion course were asked to complete pre-course and post-course surveys that asked about their perceptions of health promotion. Findings from this study support the contention that APN students’ attitudes toward health promotion are progressive but that their behaviors remain fixed in a disease centered health care model. Health promotion courses can strive to change these behaviors to a wellness oriented delivery model.
APN Students’ Perceptions of Health Promotion
More recently, a paradigm shift in health care from disease treatment to health prevention and wellness promotion has occurred.1 Many organizations, to include the World Health Organization, have acknowledged the importance of nurses’ roles in this shift.2 The American College of Nurse Practitioners, as well as the American Academy of Nurse Practitioners have identified health promotion as a primary function of advanced practice nurses (APNs).3 In concert with this, nurses are purported to value and have an enthusiasm for health promotion.4,5 However, there is a dissonance between this conjecture and nursing practice. For example, researchers have reported that student nurses expected to be engaged in health promotion far more frequently than their actual experiences demonstrated1 and despite the rhetoric, APNs spend less than 1% of their patient visits involved in health promotion activities.3
The difference between what is believed by nurses to be ideal and what is practiced has been attributed to little time allocated to health promotion in content intense undergraduate and graduate nursing curricula and the need to care for many patients in a minimal amount of time.2,3,5,6,7 In addition, organizations often emphasize disease management over health promotion activities and these values are imparted on the nursing staff.8 Perhaps reflective of this is a study that demonstrated that nursing students caring for ill patients felt that physical care was their most important function and that health promotion had a lower priority.5 Furthermore, stressful, time constrained work environments that engender unhealthy coping strategies, such as smoking or poor nutrition, result in less value placed by the nurse on changing clients’ similar behaviors and less credibility for the nurse as a health promoter.2,8,9
Nurses’ beliefs about others’ perceptions of their health promotion efforts may also contribute to the notable gap between intentions to promote health and implementation of these intentions. Many nurses believe that health promotion is perceived by patients as boring, blaming, or annoying, and that health promotion may induce patient worry.2,8 Nurses also feel that patients’ lifestyles are deeply and culturally engrained and that their efforts to encourage change are useless.2
When asked about the specific health promotion activities that they provided in a hospital environment, patient education and advice giving were the most common responses given by nurses.10,11,12 Nurses often view health education and health promotion as synonymous terms.13 While health education is viewed by some as an important component of health promotion and by others as a distinct construct, information giving alone has not been significantly effective in altering individual’s lifestyle behaviors.11,12,14 Nurses concur that simply providing health education is often ineffective in contributing to behavioral changes.9 Without evidence of outcome efficacy, nurses are less likely to persevere in health promoting activities.8
Educating and advising tend to place the nurse in the paternalistic role of information provider rather than in the cooperative role of health promoter.1 Additionally, when patient information is given, it is often based on the interests of the nurse and delivered as a generalized disease focused rather than patient tailored statement.6,13 Despite the contended paradigm shift to wellness, nurses continue to view nursing as primarily concerned with disease treatment.13 These approaches are contrary to the 1986 Ottawa Charter’s explication of health promotion as a patient centered and patient empowered endeavor.13
Repeatedly, authors have identified a lack of understanding of the definition as well as the process of health promotion. The apparent complexity and confusion surrounding the concept of health promotion may lead to reduced health promoter confidence and hence a failure to implement health promotion.15 Researchers investigating a process for health promotion implementation began by asking nurses deemed by their peers to be expert health promoters to describe health promotion. These experts had difficulty in defining and arriving at a consistent description of health promotion.14
Recognizing the impact that health promotion conceptualization confusion can contribute to the gap between the ideal and the actual practice of health promotion, there have been efforts to clarify health promotion. In response to a checklist developed to outline health promoter priorities, the following action oriented goals were identified: raising client health awareness, providing information, developing provider self-awareness, fostering client self-esteem, empowering client decision making, being a behavior and attitude change agent, and improving the physical and social environment.14 In addition, members of the Council on Cardiovascular Nursing identified the following attributes necessary to engage in health promoter behaviors: expertise in prevention strategies, therapeutic communication skills, relationship building skills, holistic assessment skills, an understanding of behavior change theories, an understanding of the multifactorial elements of health, personal confidence in promoting health, flexibility, technology and resource fluency and role modeling of healthy behaviors.15
While identifying the characteristics of health promoters and outlining the process of health promotion are indeed helpful, they do not necessarily result in nurses implementing these behaviors. The Theory of Planned Behavior has been suggested as a model for closing the gap between nurses’ health promotion intentions and their actions. This theory proposes that when attitudes about the behavior are positive, beliefs about others’ approval of the behavior are confirmatory and there is greater self-confidence in the ability to perform the behavior then there is greater effort and perseverance applied to enacting the behavior.8 Hence, nurses that view health promotion as a constructive endeavor that is supported by the organization and is within their power to implement, will be more likely to engage in health promoting activities.
The purpose of this study was to understand APN students’ perceptions of health promotion. Additionally, perceptions of health promotion were assessed before and after participation in a graduate level health promotion course to discover whether the health promotion course influenced health promotion perceptions. A better understanding of these perceptions may lead to interventions that can improve health promotion attitudes and behaviors.
This non-experimental study uses a combination of quantitative and qualitative methods in a pre-post survey design to determine APN students’ perceptions of health promotion before and after a graduate health promotion course. Data was collected over three semesters, one year, in three separate iterations of a health promotion course.
Setting and Sample
The study was conducted at a central Florida university within a college of nursing that offers a variety of nursing programs. Students in masters level adult, family, and pediatric nurse practitioner programs as well as students in masters level clinical nurse specialist and nurse educator programs are required to complete a graduate level health promotion course.
A single health promotion course taught online by the same instructor is offered during each of three semesters throughout the year. All aforementioned students are recommended to take the health promotion course early in their sequence of courses but since it is not a prerequisite course for any subsequent courses; students may be at various stages of completing their program of study when they take the health promotion course. All students enrolled in the health promotion courses taught during this study were included in this convenience sample.
The health promotion course includes the following topics: analysis of the concepts of health, wellness and health promotion, health promotion guidelines as identified by a number of leading organizations, health self-appraisals, epidemiologic and genomic issue in health promotion, global health promotion concerns, health promotion considerations in vulnerable populations, community level health promotion, behavior change and health promotion models, and design and evaluation of health promotion initiatives. During this course students participate in online topical discussions, group and individual assignments and also complete a series of quizzes and exams.
All students enrolled in each of the semester long (approximately 16 weeks) online graduate health promotion courses, were asked to voluntarily complete pre-course and post-course health promotion surveys on their perceptions of health promotion. The surveys were administered through an anonymous online class delivery tool (WebCT). Surveys were available to participants for the first week (pre-course survey) and last week (post-course survey) of the semester. Email messages were sent to all of the health promotion students at the beginning of each semester to remind them to consider participating in the pre-course survey and again at the end of the semester to remind them to complete the post-course survey if they had completed the pre-course survey. Informed consent information was included in the surveys’ opening instructions and approval to conduct this research was granted by the researcher’s Institutional Review Board.
The survey developed for this study was based on a comprehensive review of the literature describing nurses’ and APNs’ health promotion attitudes. An understanding of the potential implications of attributional and self-efficacy perceptions of health promotion that influence behavior as described in the Theory of Planned Behavior also informed the development of the survey.8 The pre-course and post-course surveys for this study included the same 5 open-ended narrative and 27 closed-ended, 4-point Likert scale (strongly disagree to strongly agree) items that requested the respondents to indicate their level of agreement with statements related to health promotion. Additionally, demographic information was collected in the pre-course survey. It has been suggested that socioeconomic class, demographic information, health values, and social circumstances are likely to influence nurses’ behaviors.16 Questions were divided into the following four categories: perceptions of the concept and context of health promotion (n=15 questions), others’ views of their health promoting behaviors (n=5 questions), self-confidence in health promoting behaviors (n= 8 questions) and practice of health promotion behaviors in the clinical setting (n=4 questions).
A pilot survey was given to several faculty members with knowledge of health promotion and was determined to be acceptable. No changes were made in the survey for the purpose of the study.
Descriptive statistics, frequencies and percentages, were used to report demographic data and the closed-ended question response findings. The WebCt survey function is anonymous and does not allow the researcher to identify individual respondents. Furthermore, the anonymity and voluntary nature of the survey did not allow the researcher to verify that the same students that took the pre-course survey also took the post-course survey. Therefore, individuals’ changes could not be assessed and correlational statistics could not be performed.
A directed content analysis of the five open-ended questions was employed to systematically classify and interpret meanings according to the questions that were developed from the researchers a priori understandings of nurses’ perceptions of health promotion17,18 and in accord with the major constructs of the Theory of Planned Behavior.8
Content analysis is a commonly used method of examination of artifacts of social communication for the purpose of making systematic and objective inferences.19 Content analysis involves identifying observations and patterns in the data and organizing and simplifying them into meaningful themes or categories.20
Each of the open-ended question responses was read for global content within and between pre-course and post-course surveys. Each response was then reread for re-occurring patterns and themes. As explicated in directed content analysis methods, categories were deductively defined by the survey questions.17,18 These categories included: perceptions of concept and context of health promotion, perceptions of health promoting self-efficacy, barriers to their health promotion efforts, and health promotion behaviors. The narrative responses were then read line by line and key phrases were highlighted and notes were made in the margins. The highlighted phrases became the category variables or indicators. Each of the responses was then compared for repeating as well as dissimilar response variables for each of the questions. Phrases that were not highlighted were analyzed to determine if they represented new variables or subcategories. Finally, the overall themes of the responses were extracted and interpreted by the researcher. Thematic comparisons were made between pre-course and post-course surveys. At a later date, the researcher read fresh copies of the responses to identify differences in the coding of the phrases. No significant differences were discovered. Interpretations were then summarized and read by an assistant researcher for inter-rater reliability. Interpretations were consistent between researchers and there were no changes made to the analysis.
A total of 106 students were enrolled in the three health promotion courses that were included in the study. Course enrollment varied slightly for each course taught in each of the three semesters. For the aggregate of the courses, the pre-course survey response rate was 92% (n=97) and likely due to the voluntary nature of the study and end of semester fatigue, the post-course response rate was 60% (n=64). Demographic information was only collected on the pre-course survey. Therefore, it is not known if the demographics of the student respondents differed on the post-course survey. Table 1 depicts the demographic characteristics of the pre-course survey student respondents and can be found in Appendix A. The majority of the pre-course survey student respondents were Caucasian women between the ages of 20 and 50 years. Most had worked as an RN for at least 2 years and were enrolled in the Family Nurse Practitioner program. The majority of students provided direct patient care in a hospital setting.
Closed-ended question responses were on a four-point Likert scale that included strongly disagree, disagree, agree and strongly disagree. For the purposes of analysis, the scale was collapsed into the following two response variables disagree/strongly disagree and agree/strongly agree. Table 2 identifies the questions and their respective frequencies and percentages of respondents in each of these variables for both pre-course and post-course surveys and can be found in Appendix B.
In general, student respondents defined health promotion in accord with the Ottawa Charter’s definition which describes a patient centered and patient empowered endeavor.13 However, and perhaps more characteristic of a provider-centered framework, the majority of respondents’ perception that health promotion involved information and advice giving and the provision of education. Interestingly, the percentage of respondents that saw advice giving as an integral component of health promotion decreased on the post-course survey.
In regard to self-efficacy, or the student respondents’ confidence that they were effective health promoters, most students perceived their health promoting efforts as beneficial to the patient and there was little change in these findings between the pre-course and post-course surveys. On the pre-course survey, approximately half of the student respondents felt that time constraints limited their health promoting efficacy. Intriguingly, student respondents’ perceptions of time constraints as a limiting health promotion efficacy factor appeared to increase on the post-course survey.
When considering others’ views of their health promoting behaviors, student respondents felt their efforts were positively received by patients. However, some did identify their work environment as unsupportive of health promotion activities. For unknown reasons, this perception increased on the post-course survey.
Student respondents overwhelmingly believed they were currently discussing healthy lifestyle behaviors with patients. They also viewed themselves as healthy and felt that they followed the healthy lifestyle behaviors that they were espousing to their patients.
The open-ended questions were also developed in concordance with the constructs of the Theory of Planned Behaviors: health promotion concept and context, health promotion self-efficacy and health promotion behaviors. In addition, students were asked to identify factors that might increase their health promotion self-efficacy. The questions and response summaries are reported in the following paragraphs.
Describe, in your own words, the concept of health promotion.
Consistent with the research that identified a lack of clarity in the definition of health promotion, student respondents differed in their descriptions of the concept of health promotion.14 While well being, reaching maximal potential, healthy behaviors and biopsychosocial health were identified, the respondents reported that these objectives could be achieved through encouragement as well as a preponderance of health education and information giving about disease processes. On the post-course survey student respondents emphasized provider-patient collaboration and patient empowerment and while they did not discuss patient education in response to this question they did continue to consistently describe their health promoting behaviors in terms of patient education on subsequent questions.
Describe how you currently provide health promotion to patients.
Respondents identified their health promoting activities as instructing a patient in what to do after surgery; providing education about the patients’ diseases, medications, lab values, and procedures; providing patient education materials (usually in the form of written handouts) and providing referrals to other health professionals. On the post-course survey, several also included strategies from some of the behavior change models discussed in the health promotion course.
Describe barriers or obstacles that limit your ability to provide health promotion.
The respondents felt that the following were barriers that limited their health promoting efforts: patients’ cultural and language differences; patients’ disease specific knowledge deficits; the immediacy of patients’ acute physical needs; patients’ unwillingness to change behaviors; and patients’ financial limitations. In a survey of Texas APNs, patient willingness to change was also identified as a barrier to health promotion.7 In addition and overwhelmingly, time constraints were cited as a health promotion limiting factor. The barriers identified on the pre-course survey were also identified on the post-course survey and time constraints continued to be a repeated theme.
Describe how adequately prepared you currently feel to provide health promotion.
Despite these aforementioned barriers, student respondents felt they were adequately prepared to engage in health promotion. Many mentioned more confidence in their abilities after the health promotion course and several indicated a better understanding of available preventive service resources as one of the factors that made them feel more prepared.
Describe things that might better prepare you to provide health promotion.
In response to what might assist them in becoming more efficacious health promoters, most expressed a desire to learn more specific disease prevention information. Student respondents also indicated a need for more health promotion clinical experiences.
The results of this study support the notion that nurses, specifically those going into APN roles, have adopted a patient-centered health promotion perspective. They began the health promotion class with these views and these perceptions persisted at the end of the course. Participation in the health promotion course also did not appear to influence their health promoting behaviors. Their perceived behaviors continued to remain disease focused, synonymous with patient education and inclusive of information and advice giving. The latter perceived behavior of advice giving did decrease on the post-course survey. It is suspected that this may have been a result of an emphasis on asking permission before giving advice discussed in one of the behavior change models covered in the course.
Time constraints and the health care system seemed to impede health promotion in their current workplace. Interestingly, these barriers were expressed more frequently on the post-course survey. Perhaps new insights gained during the health promotion course underscored the challenges that these barriers present in assisting patients to achieve healthy lifestyle behaviors beyond the task of providing disease focused patient education. In contention with the premise that the typically stressful hospital work environment results in unhealthy nursing staff coping behaviors, most respondents seemed resilient, considered themselves to be healthy and admitted to following healthy lifestyle practices.2,9
The students identified a need for more practical applications of health promotion. This may be one of the more important insights gleaned from this study. If APN students’ health promotion attitudes are in line with current health promotion ideals but their behaviors are stuck in a disease focused model, practical applications that reinforce health promotion behaviors may be what is most needed. The addition of experiential learning, perhaps in the form of a service learning project or some other creative application exercise might respond to this need and could be evaluated through further research.
The relatively small convenience sample for this study limits the ability to validate and generalize findings. However, many of the findings are reflective of previous research. 8 In order to maintain anonymity, the online survey tool compiles responses without identifying the respondents. Therefore, analyses were limited to descriptive statistics and no correlations could be made between responses and pre-course to post-course survey changes or demographic characteristics. In addition, only global aggregate changes in perception could be described. Undoubtedly, correlations might have contributed beneficial insights. Additionally, while students were asked to take the pre-course survey before reviewing any of the online course materials or the course textbook, there were no mechanisms in place to assure this and pre-course survey results could have been influenced by the available course materials. Non-responder demographic characteristics and their perceptions of health promotion may have also yielded important or different insights. It is possible that students may have doubted the anonymity of the surveys and provided responses that were perceived as desirable by the researcher.
Conclusions and Future Research
This study identifies some of the key beliefs about health promotion held by APN students. Some differences were identified between pre-course and post-course surveys and progressive and proactive health promotion attitudes were overshadowed by behaviors that appeared to be fixed in a disease focused patient passive health care delivery model. This model reportedly hinders health promotion.10,12 In general, APN students’ attitudes appear to be more in concert with guidelines such as those set forth by the Ottawa Charter than their behaviors would suggest and despite contrary rhetoric, these behaviors are undoubtedly supported by our current health care system.8
It is hoped that future APNs may be able to lead the call for the focus on health prevention and health promotion and much of this may begin at the academic level. It would be useful to explore various curricular interventions that could help to achieve this goal.
Further research that allows for statistical correlation between student demographics and health promotion perceptions as well as the impact of various educational and experiential interventions on perceptions and behaviors is suggested. Additionally, exploration of the barriers to health promotion within APN practices might be of benefit.