Commentary on Whitehead D (2004) Health‐promoting hospitals: the role and function of nursing. <i>Journal of Clinical Nursing</i> 14, 20–27

Dean Whitehead provides a comprehensive review of the published literature related to health-promoting hospitals and the role and function of nursing. While he makes many important and relevant comments, his central argument is that nurses should be taking leadership roles in radical health promotion reform, an activity that to date they have failed to grasp. While a leadership role might be desirable, the realities of working in a hospital environment make creating such opportunities extremely difficult. Despite this, there is some evidence that nurses in hospitals undertake activities consistent with a health-promoting hospital approach. Given the environment nurses in hospitals work in, these initiatives should be commended and the effort involved in such change, even though it is relatively small, not underestimated. That nursing could contribute more extensively to the health promotion activities in hospital is surely both desirable and, at least in theory, possible but is not likely to occur without strong support and leadership from the organization as a whole. Whitehead suggests that nurses must accept the blame for failing to take the lead with the health-promoting hospital concept. Nurses have been highlighted by Whitehead as the most important group to lead the change to health-promoting hospitals because of their large numbers. Unfortunately, while nurses may work in hospitals in large numbers, their power base – and thus capacity to make change – is limited. Higher acuity, increased use of technology, increased consumer demands, ever-tighter budgets and increased medical specialization are all areas where nurses often lack significant influence. Therefore, the expectation that nurses could reorient the health system away from medicine and disease towards health is likely to be highly problematic. If many hospitals have been reluctant to take on the health-promoting hospital concept, as Whitehead suggests, how can nurses then be held responsible for failing to reform the system when it is well articulated that an essential component for a successful health-promoting hospital is strong organizational support on multiple levels (Johnson & Baum 2001)? In addition, health promotion activities do not tend to be funded within the hospital setting (World Health Organization 2004). Absence of funding makes system wide change, particularly in major hospitals, less likely. Nurses alone are unlikely to change this situation. Reorientation will only occur if strong policy direction and support are implemented across the organization from the Hospital Board level down. For nurses to be in a position to implement significant change within the hospital, they need to be both competent and confident in the area of health promotion. It needs to be recognized that radical health promotion reform is new to nurses and many other health professionals and that organizational policy support that provides for adequate funding, education and initiative development, staff support and assistance are required to realize and legitimize the nurses role in proactively undertaking health promotion. It is clear that, if nurses are to undertake a significant health promotion role, strong nursing leadership is essential. The importance of leadership from within the nursing division must be recognized as a key initiative in promoting, supporting and directing nurses to undertake health promotion activities and to introduce the language into their organizational culture. Without support at every level of nursing management, change will not occur. While strong nursing leadership will make some impact on changing the health services approach to health promotion, it will not be sufficient for major institutional change. This requires a genuine commitment from all areas of the organization. The day-to-day reality for nurses working in a hospital system often inhibits health promotion reform. Whitehead discusses a range of studies where nurses cited a lack of time, resources, training and support as reasons for not participating in an active health education and promotion role. These are not simply excuses and must be acknowledged and discussed. For many nurses, they are every day realities. An international shortage of nurses and heavy workloads in many hospitals (Buchan & Calman 2004) make additional activities, regardless of their desirability, very difficult to achieve. For nurses to meet the health promotion reform agenda, these issues need to be addressed. If it is implied that nurses should simply continue to broaden their role and add to their responsibilities, resistance to change will inevitably occur. In addition, the provision of holistic-nursing care sits well within a health promotion agenda. The reality, however, for nurses working in today's hospital environment, with its increased level of activity and client acuity, is that it does not enable nurses to meet the requirements for holistic-nursing care consistently. Thus the areas viewed as least important because of their health rather than specific medical orientation, fall off the nursing agenda. This is a major difficulty requiring strong organizational support along the lines discussed earlier. Multiple initiatives are reported, particularly in conference proceedings, indicating nursing involvement in client-focused educational activities that aim to develop the knowledge and skills of the client, family and significant others. These are, as Whitehead indicates, often localized and focused on the individual and their behaviour. Why this is so is not irrelevant. Rather, it indicates the position of nursing in the hospital hierarchy. On a positive note, however, these initiatives indicate a commitment to one aspect of health promotion that is feasible given hospital culture and priorities. In addition, given the current medical emphasis in the structure of hospitals, the focus is likely to remain essentially disease oriented. There are multiple opportunities to improve the health education provided to clients. Moving increasingly from a preventative authoritarian model or perspective to an empowering one (Tones & Tilford 2001) is an example. The limited benefits of isolated client education initiatives are discussed by Whitehead at length. Consistent with an empowerment framework, nurses can implement actions based on the five strategies of the Ottawa Charter for health promotion (World Health Organization 1986) and increase the likelihood of long-term change. This is often only possible, however, in collaboration with other professionals and employee groups within the hospital and in partnership with clients, their families and the broader community. One area where this currently occurs is during discharge planning. Policies around discharge planning link the hospital with the community and ensure the hospital becomes better integrated with the overall health and social systems within the community. The provision for discharge planning, though variable in its application, enables nurses to act from a health-promoting perspective as they consider with the client the knowledge and supports the client and family require to remain independent and well at home. Adequate discharge planning is not going to occur, however, without the support of the organization. This of course includes the nursing division, but is not limited to it. It may be that hospital-based nurses have not, to date, tended to articulate their practice within a health promotion framework. The language used around health promotion sometimes conveys the impression that it has nothing to do with ill-health or acute care and this can then persuade nurses that it is not something they need to embrace. As discussed above, discharge planning falls within the domain of health promotion as this often requires client education and collaboration with community agencies in the interests of ongoing care and wellness. It may not be obvious to all nurses that this is health promotion. It is, therefore, important that nurses learn to reorient their thinking to one that conceptualizes their activities within a health promotion framework. This may not require changes to their practice; just better recognition of this role. From this perspective, small changes in role maybe viewed as possible where as major shifts may be seen as not feasible. The context of nursing practice will also influence the extent to which nurses are able to incorporate health promotion activities. The size of the hospital can influence effectiveness. Some small community-based hospitals, for example, develop a health promotion focus effectively while larger organizations struggle. In addition, the size, role, philosophy and leadership within departments can influence the capacity of the service to develop a health promotion approach. In conclusion while nursing has been slow to embrace health-promoting hospitals, many administrators and other health professionals have also. For successful health promotion to occur, support is required from all sectors of the hospital. Nurses have the mandate and potential to offer far more to the health-promoting hospitals movement but their achievements to date should not be dismissed or trivialized. Bringing about changes to reflect a health promotion perspective in organizations that primarily emphasize safety, clinical governance and risk management require a reorientation in philosophy as well as practice. To blame nurses for failing to reform the hospital system is inappropriate. Rather, strong nursing leadership, in conjunction with comprehensive organization wide policies that support an interdisciplinary approach, is the best combination for advancing both the health-promoting hospital and the nursing role in health promotion within this setting. Nurses need to move forward within the health-promoting hospital but they need to do so mindful of the benefits, obstacles and challenges and not shackled by a sense of blame.

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