miracles take a little longer: project 2000 and the health-promoting nurse

Pergamon hf. J. Nurs. Stud., Vol. 32, No 6, pp. 568-579, 1995

Copyright c 1995 Elsevier Science Ltd Punted m Great Britain. All rights reserved

002&7489/95 $9 SO+O.OO

0020-7489(95)000216

Miracles take a little longer: Project 2000 and the health-promoting nurse

SALLY ROBINSON,* B.Sc.(Hons), R.G.N., M.A.(Ed.), M.I.H.E. Senior Lecturer, Health Education, Centrefor Health Education and Research, Christ Church College, Canterbury, Kent CT1 IQU, U.K.

YVONNEHILL, R.G.N., R.N.T., B.A., M.A. Senior Lecturer, Nursing Studies, Department of Nursing and Midwifery Studies, Christ Church College, Canterbury. Kent CTI IQU. U.K.

Abstract-This paper suggests that the new paradigm for nurse education is being prevented from fulfilling itself because of factors operating within the taught, hidden and wider curriculum. Firstly it is argued that the theoretical components relating to social science, health education/promotion and nursing need to be clearly integrated for nursing students. This integration is demonstrated through the analysis of two nursing models. Secondly it is argued that the taught curriculum needs to be supported by a suitable hidden curriculum both within the educational and clinical setting. Role models which demonstrate integrated theory occurring in practice are a vital component of this. Thirdly it is argued that without the wider social and political context supporting the aims of the ‘new’ nurse education, meaningful success will be very difficult to achieve.

Introduction

It could be argued that the goal to promote health, rather than treat disease, began in 1978 with the Alma Ata Declaration which emphasised primary health care and the rights of the

*To whom all correspondence should be addressed.

568

PROJECT 2000 AND THE HEALTH-PROMOTING NURSE 569

individual to have a say in their health care (Rohde et al., 1993). This was closely followed by the World Health Organisation’s Health For All by the Year 2000 strategy launched in 1981, and the Ottawa Charter for Health Promotion of 1986 (Ashton and Seymour, 1988). Promoting health was the fashionable, if often misunderstood, concept of the time (Williams, 1985). The simultaneous changes to nurse education were probably more in line with the ideas of many of the professionals and academics working in the field of health education and promotion than educational changes within other health professions. Nurs- ing adopted a broader, holistic, approach to promoting health rather than a comparatively narrow, preventative one seen elsewhere (Tones and Tilford, 1994). This translated to Project 2000 in terms of emphasising health, the community, empowerment of clients and healthy alliances through the medium of education rather than training (UKCC, 1985; Department of Health, 1993). Thus evolved a curriculum which emphasised health education/promotion and the study of philosophical, sociological and psychological subjects (Gott, 1990). This was no less than a shift to a new paradigm, and one which has created a number of tensions: not least that between traditional nurse education and the ‘new’ education, and between the theory of promoting health and its practice within the current political context.

This paper proposes that by examining nurse education, using a model taken from school health education, these tensions can be critically explored. The analysis will include an examination of the relationship between health education/promotion, social science and nursing. The Activities of Living Model by Roper, Logan and Tierney and Orem’s Self Care Model, as two of the most well-used nursing models in the UK, will be discussed within this framework.

A model from school health education

It has long been recognised within the field of health education for schools that the taught curriculum (the formalised content usually taught within the classroom), hidden curriculum (the school ethos) and the school-community relationship needs to be in harmony if children are to be encouraged to adopt and maintain healthy behaviour (Roberts, 1986; Ryder and Campbell, 1988; Farley, 1991). For example children may be taught that smoking has serious health consequences within a biology lesson. If the school allows staff to smoke and there is a large advertisement for cigarettes featuring a famous pop star outside the school gate, the work of the biology teacher can be quickly forgotten. Attitudes, and ultimately behaviour, can be powerfully swayed by the behaviour of respected role models and the context in which it takes place. Alternatively a biology teacher who teaches about the value of a high fibre, low sugar diet is more likely to see better dietary behaviour in the pupils if the school has a tuck shop and school meals which provide fruit and vegetables as alternatives to sweets and puddings because the school is able to make this a financially viable option. Add, to this idea, a sprinkle of the wealth of evidence that shows the value of experiential learning (Bligh, 1971; Rogers, 1983; Ewles and Simnett, 1992) and the result is a potentially useful recipe for nurse education. The taught curriculum of nurse education needs to relate to what students see and experience in both educational and clinical settings, and ultimately, this needs to occur within a supportive social and political framework.

This relationship between the taught curriculum, the hidden curriculum and the wider context within the ‘new’ education for nurses is shown in Figure 1.

570 S. ROBINSON and Y. HILL

pq pq m ~:~~~~e

+ + 6 * + 3. The nurse needs to be able to

Ability of tutors and Students’ Suitable practice witbin a supportive

Political RosourCe mvironm=ent. students to integate learning role ideology Manage-

theories experience models merit *

Fig. 1. Relationship between taught curriculum, hidden curriculum and wider social context within the ‘new’ education.

The new curriculum

The goals of teaching theory within the taught curriculum are many and varied. It could be argued that two of them should be: that its component parts should make an integrated whole and that it should have a clear relationship to practice.

One of the main differences between traditional nurse training and Project 2000 has been the inclusion of more social science, including specifically health education/promotion, into the taught curriculum. However evidence suggests that the interrelationship between health education/promotion, social science and nursing is far from clear to students both in terms of understanding links between theoretical concepts, and their ability to relate the theory to nursing practice. Without both of these the high expectations of the ‘new’ education will not be achieved. This was illustrated by Goad, a Project 2000 student, who remarked that his Common Foundation Programme had emphasised theoretical knowledge of little practical value, while his Branch programme marked a shift from “social implications of care to theory applicable to nursing practice” (Goad, 1992, p. 46). (Thus implying that theoretical study around social implications was not applicable to nursing practice.) These problems are fundamentally the result of an incomplete paradigm shift on the part of students and educators.

From hypothesis via process to health

In order to understand how theories integrate within the taught curriculum, it is necessary to consider the thinking process of a nurse.

Nurses approach a client with a hypothesis about what has caused a change in health status. The hypothesis is directly related to their views on health, illness and disease. (The diagnostic process is concerned with endorsing or replacing the hypothesis. In practice, nurses may rely on the doctor’s diagnosis. Although diagnosis may not be considered part of the nurse’s role, it is suggested that ‘new’ education is certainly encouraging nurses to critically consider the doctor’s diagnosis.) Nurses will subsequently carry out care and/or education in response to that hypothesis. This is shown in Figure 2.

Nurse education includes social analysis of health, illness and disease in order to help nurses to understand that changes in health status can be caused by a wide range of factors. It is proposed that nurses cannot adequately assess the health needs of clients, or begin to adequately meet them, without an understanding of the many views on causation. Aggleton (1990) would group these as follows: the traditional approach (emphasising holism and


Ihe. nurse will usually approach a client with a hypothesis about what has caused a change in health status.

Doctor’s Diagnosis

(usually based on positivist approach - objective, quantifiable, individuag

+ Nurse Education = Hypothesis of Causation

(includes range of (nurse pats together the psychosocial aspects of medical diagnosis and what causes changes in knowledge fim Nursing health statas - including Education to form a physiological andpositivist hypothesis about the client’s approaches) change in health statq)

Fig. 2. Process of nurses’ arrival at hypothesis.

balance-often the guiding philosophy of complementary therapies), the positivistic approaches which adopt a scientific approach to social facts (bio-medical positivism focuses on micro-organisms and physiological abnormalities as epitomised by current western medicine; social positivism looks at the individual’s relationship with their social context, for example in terms of their lifestyle), interactionism (concerning the subjective experience and interpretation of events) and structuralism (concentrating on the relationship between power, influence and health--classically reflected in social class and health data (Whitehead, 1992)).

Nurse education may therefore lead nurses to question whether obesity is caused by hormonal problems, lack of knowledge, attitude to food, parents’ influence on children’s diets, perception of body image, vested interests by the food industry to produce high calorie low bulk food at lower prices, nutrition education, or peer pressure?

Having hypothesised the cause of the change in health status nurses will decide on an intervention-be this care or education. It is suggested that conscious or sub conscious reference is made, at this point, to nursing and health education/promotion models as learnt within the taught curriculum. This is shown in Figure 3.

The process in which the care/education is carried out may be determined by a health education/promotion model. The goal will depend on the hypothesis. For example, if a nurse believed that a client’s choice of diet was responsible for weight gain, then the goal of the health education may be to change his knowledge, attitude and behaviour in the

The plan of nursing care. (including education) is primarily tiuenced by three key concepts.

Hypothesis of Causation + Nursing Model +

(&gt to assess about the &iividua[ rather than the diagnosis)

Health promotion Model - Intended Nursing Care (inc. education)

&the nurse @ariicularly relevant to the communicates initial nursing assessment, but with the client) also as an ongoingprocess)

Both will contain philosophies of what health means and notions of the power relationship behveen nurse and client.

Fig. 3. Taught curriculum.


context of his diet. However there are different ways (processes) of achieving this goal. Does the nurse give the client a leaflet, is there discussion, are the family involved, does the nurse consider what food is sold locally, how much money does the client have, and what are his food preparation skills like? Most importantly does he want to change his diet? The process, therefore, will depend on the client’s and the nurse’s perception of what health means.

Nursing models and health education/promotion models have much in common. Both are concerned with the relationship between the health worker and the client and both have evolved to move that relationship forward from that described in Parsons’ Classic Sick Role of 195 1 (Jones, 1994) to one where the client is encouraged to take on more responsibility for their health whilst acknowledging the wider social context. It is therefore possible to look at nursing models in terms of encompassing both social theories of health, disease and illness and health education/promotion models.

The taught curriculum may therefore examine these three conceptual areas in the hope of promoting the ideals of the ‘new’ education. However, the theory of these concepts and the reality of their interpretation in practice warrants discussion.

Health education/promotion: nurse-client interaction in theory and practice

Health education has a traditional role of trying to influence individual health choices through to a more radical one of encouraging healthy public policies through public awareness (Tones et al., 1990). It is sometimes viewed as a precursor to, and an important element of, the wider scope of health promotion (Ewles and Simnett, 1992). The debate about where health education ends and health promotion begins is complex, and the reader is referred to Tones and Tilford (1994) for an excellent summary. Like the nursing process, health education and health promotion are based around principles of assessment, planning implementation and evaluation. For the purposes of this discussion it is helpful to con- centrate on the process of communication and outcomes of each model. It should be noted that health education/promotion models include their own philosophies about health and about education, but these will not be considered in detail here. Ewles and Simnett’s models of health promotion will illustrate the salient points, and are summarised in Figure 4.

MODEL

PROCESS

OUTCOME

II Client Societal

CdXd

L-2

0

Change

r 1 , , 1 *,;I, /,.. -.;

Didactic 1 ( 1

I \ \ \ , 2-Way Nury.Led -... .-.. --.

Freedom From Disease

Personal Change (Nurse’s Norm)

2-Way Client Led w a i i

Fig. 4. Models of health promotion-adapted from Ewles and Simnett (1992).


The medical model utilises a ‘didactic’ approach and has the goal of disease prevention. The nurse, therefore, acts as expert and there is, essentially, one way communication.

The behaviour change model, used by a nurse, would incorporate persuasive tactics using a ‘didactic’ approach also. A successful outcome would be seen in terms of compliance with the ‘nurse’s norm’ (that is what the nurse defines as right for the client; usually reflecting the nurse’s philosophy of the meaning of health).

The educational model is one where the nurse and client have a ‘two-way’ discussion. The nurse acts as knowledgeable person and provides information and skills, but is also willing to listen to his/her client and respond appropriately. The interaction is therefore ‘nurse led’ in that the nurse has greater control over the agenda than the client. The health education is successful if the client makes an informed decision-that is the ‘lay norm’ (according to the client’s philosophy of what is healthy for them).

The client-centred model implies that the client ‘leads’ the interaction. The education is therefore ‘client led’. The nurse takes the role of facilitator and listener, and encourages self-help and self-care. Even more than the educational model, the client is in control, and success is based on the client making an informed decision (‘lay norm’).

The societal change model is concerned with the nurse as aiming to change some health- related aspect of society. The nurse may encourage ‘social action’ or lobby to change issues at a national or international level. The aim is to make the social environment conducive to health by producing ‘social change’.

The Project 2000 curriculum would normally explore all these approaches to promoting health. However in practice it is the medical and behaviour change approaches which dominate. The main criticism of which is that they are individualistic and can be victim blaming (Naidoo, 1986). (If the client has a health problem it is their responsibility, regardless of the context.) This has come about partly because of the relationship between these approaches and the dominance of the biomedical approach-a place in which patient compliance is welcome. Encouraging greater autonomy for the client not only requires time and skills on the part of the nurse, it requires a shifting of the traditional power relations (and raises questions about accountability). The nurse may encourage a client to a position of equal partnership, or even ‘chief initiator’, but to be an encourager of ‘social action’ is certainly very difficult in practice although some limited examples of social change have begun in the community (Department of Health, 1993). The reality of this is further hampered by the emphasis from the Government to measure health in quantifiable terms, and its own emphasis on individual behaviour change in line with its wider ideology of individual, rather than collective, achievement. This is best illustrated by the white paper, The Health of the Nation (Department of Health, 1992) which emphasises the medical and behaviour change models. There are therefore many practical and ethical obstacles to change, not least, the motivation of clients themselves (Tones and Tilford, 1994).

Integrating the curriculum-nursing models in theory and practice

Nursing models not only reflect a particular view of health, disease and illness they also incorporate a particular process through which the balance of power between nurse and client is exposed.

The activities qf‘living model-Roper, Logan and Tierney

The Activities of Daily Living Model of Nursing, developed from a research project carried out by Roper in 1976 is based on ‘living’. The emphasis of care is on the client’s


actual model for living rather than the one imposed by the nurse. Roper et al., 1980 believe that health can only be defined in relation to an individual, taking into consideration personal expectations and level of functioning in ordinary daily life. They therefore argue that health has a different meaning for each individual, and the acceptance of a situation by the individual is seen to be important. This acceptance is measured against the environment and the culture in which the individual lives and the damage which might be caused to him/herself, to others or to the environment. Therefore it is suggested that by emphasising the relationship between the individual and his/her relationship with physical, psychological, sociocultural, environmental and political factors the model, in theory, reflects a social positivist view.

However, the model is based on ‘observable’ behaviour, and therefore despite its holistic intentions, Chavasse (1987) suggests this leads to an emphasis on physical nursing problems in practice. The result is that the potential of the model can be lost in the pursuit of physical achievements (Aggleton and Chalmers, 1986). Coupled with potentially insufficient time and skills, on the nurse’s part, the social positivist foundations can also start to become bio-medical positivist ones in practice-not only observable and measurable behaviour, but observable and measurable scientific tests. Firstly, many will recognise these as qualities much in favour within audit mechanisms. Secondly the approach is both dominant, and fiercely guarded, within modern medicine despite a wealth of evidence to suggest that lay, non-scientific approaches have their own logic and truth (Williams and Popay, 1994). Thirdly it is an approach which has much support from the general public who are seduced by visible, shiny technology and magic medicine (Karpf, 1988; Posner, 1984). In summary, the wider social context supports the relatively narrowly focused bio-medical outcome much more strongly than the comparatively more holistic intention.

Within the model, the nursing assessment should involve the nurse and client having a dialogue around the Activities of Living, using these as a checklist against which the client’s normal levels of independence can be assessed. Kershaw and Savage (1986) quote McFarlane as suggesting that the nurse is in a collaborative role with the client particularly in the medically prescriptive component of the care. The framework offered by Roper, Logan and Tierney was not intended to be used rigidly, but as a flexible guide from which nurses can use their knowledge and skills to adapt the model to particular client needs (Pearson and Vaughan, 1989).

Looking at the content of the model first: in theory the holistic needs of the clients are therefore assessed and, ideally, met. However, in practice, the nurse may not be sufficiently skilled at assessing the client’s needs from the client’s perspective, and there may be insufficient time, knowledge and/or skills to fully utilise the data gathered from the assessment process. Also, the clients themselves may limit the extent to which the model can be used more broadly. If, as Roper et ~2. (1980) suggest, the assessment by the nurse is based on observable behaviour, then the assessment will only extend to what the client ‘allows’ the nurse to see. The result is that personal change in the individual’s health status is likely to conform to the nurse’s norm rather than matching the lay norm.

From a process point of view: the assessment process within the model stipulates that the nurse and client should carry out discussion as a ‘two-way’ communication. The Activities of Living provide a framework for the agenda which the nurse works within. The model therefore, in theory, tries to utilise an educational model of health promotion. However, a true educational model would result in a personal change based on the lay norm, and yet this does not occur as we have seen. The outcome of the model, in practice,

PROJECT2000 AND THE HEALTH-PROMOTING NURSE 515

is according to the nurse’s norm-the outcome of a behaviour change model. The implications of this are that the model is trying to achieve more client empowerment, in theory, than it actually does in practice. A summary is shown in Figure 5.

Possibly in response to this, the later writing of the authors of the model place more emphasis on the preventative role of the nurse as part of a team concerned with health and health promotion (Roper et al., 1985). However this is difficult to achieve in a medically orientated environment operating within a political ethos of observable and measurable health indicators.

Therefore despite the intentions of the model to be truly holistic and encourage a partnership between the nurse and client, in which the client’s needs are met, the reality of the hidden curriculum and the social context discourage the theory from being fully realised.

SelflCare Model-Orem

The title of Orem’s model, the Self-Care Model, suggests that the focus is on the client. She defines self-care as a concept which is only applicable to people in a state of health (Aggleton and Chalmers, 1986). The provision of self-care on a therapeutic level, and on a continuous basis, is seen as essential to health (Hanucharurnkul, 1989). It therefore values self-reliance, the ability to determine one’s own self-care requisites and ways of dealing with these. The focus on the client’s pre-developed coping mechanisms prevents it from becoming reductionist as some would describe Roper et al.‘s model.

Orem defines health as a “state of wholeness or integrity of human beings” (Orem, 1985), and speaks of physical, psychological, interpersonal and social aspects of health as being inseparable. It is a model which emphasises holism (Chalmers, 1988) and the importance of each individual’s own definition of health-however defined.

The nurse is encouraged towards joint decision-making with the client. These may focus

THEORIES OF HEALTH ILLNESS AND DISEASE

PROCESS

omcom~@~~ Fig. 5. The activities of living model-Roper, Logan and Tierney (1985).


around Orem’s eight ‘Universal self-care needs’ which are not dissimilar to Roper et d’s Activities of Living. Orem defines three broad categories of nursing intervention. Nurses may carry out wholly compensatory care for people, partly compensatory care or supportive-educative care. The level of intervention is dependent on the client’s level of self- care (Chalmers, 1988). Orem suggests five types of intervention: doing for or acting for another, guiding or directing another and providing an environment which supports development and teaching.

It is suggested that the model reflects both positivistic approaches in terms of the individual’s health. It is also traditional in terms of trying to reach a balance between self-care abilities and their self-care needs. The named Universal Self-Care Needs prevent the model from reflecting an interactionist approach. Within the latter, there would be scope for infinite needs. There is an emphasis on the individual’s view and personal skills with no reference to collective action. Therefore it is a model that does not reflect the community action and healthy alliances goals of the ‘new’ nurse education, for individual empowerment will not automatically bring about social change without specific facilitation to do so (Weare, 1992). It is also a model which, ironically, is supported by the wider context in that it reflects the individualistic achievement orientated political philosophy of the times. This, perhaps, highlights, most poignantly, the conflict between the ideals of nurse education and the current climate in which they are trying to emerge.

In theory the model tries to align itself with client centredness, but the pre-defined agenda (the eight Universal Care Needs) and the pre-defined process (encouragement of self-care) prevent this from becoming the reality in practice. The model more accurately reflects an educational model. There is a two-way dialogue between the nurse and client, and, it is suggested, that the outcome may be determined by the nurse or the client according to the dependency of the client. With increasing recovery, from sickness to health, more autonomy rests with the client. Like the Activities of Living Model the amount of client empowerment may be limited by nurses’ time, skills and the medical context in which the model operates. This is summarised in Figure 6.

It is suggested that Orem’s model tries to encourage a holistic approach to client empowerment, but fails to achieve it because of issues within the hidden and wider curriculum. It is also suggested that its goal of self-reliance is in line with current political philosophy, but in conflict with the wider goals of nursing within a health promotion framework.

“The failure of nursing models has as much to do with nurses and the context in which nursing is practised as it has to do with the limitations of the particular model.” (Kenny, 1993, p. 135).

We have thus demonstrated how the components of certain key aspects of the ‘new’ nurse education can be integrated in theory. We have also shown that the hidden curriculum (ethos and practice in clinical settings) can inhibit the theory being put into practice. Finally we have discussed some aspects of the wider context which further inhibit the translation of theory into practice. However there is one more piece of the jigsaw to add. Nursing students are not only looking to the clinical environment for experiential learning and role models-they are looking within their educational environment also.

Adjusting to the new paradigm-teaching and learning the new curriculum

Many nursing students enter nursing within the ‘traditional paradigm’ expecting to be told ‘how to be a nurse’ rather than expecting an ‘education for nursing’. The nurse


THEORIES OF HEALTH ILLNESS AND

Bio. & Sot. Positivism

Fig. 6. Self-Care Model-Orem (1985).

educators have, theoretically, moved from a training model to an education one. Policy documents and nursing curriculum validation documents expound the virtues of the nurse as an educator, thinker, reflective practitioner. Firstly, within the taught curriculum, nurse educators (and subsequently students) need to fully understand how health education, the social sciences and nursing theories integrate and, as importantly, understand that their relationship to nursing practice is of a different nature within an education model than a training model. Theory and practice have a direct, linear relationship within training. One is easily accessible to the other. It seems an efficient system, but falters in that there is little room for constructive critique and development, or situational differences. Whereas within education, the theoretical component has a complex branched relationship with practice. It requires critical thinking skills in order to make one accessible to the other. Having developed such skills the possibility of the educator, thinker and reflective practitioner can become reality.

Secondly, within the hidden curriculum, nurse educators need to be role models, and be seen to demonstrate these skills within an educational rather than training ethos. In order to learn how to empower clients towards their health goals, students need to experience empowerment through the process of their own education first. It is only when the qualified nurses emerge, fully equipped with all these competencies, can they begin to take on the next real impediment to achieving the health promoting goals of the ‘new’ education: the wider social and political context (see Figure 7).

Acknowledgements-The authors would like to thank Abigail Masterson, at the Institute of Advanced Nurse Education, Royal College of Nursing, for her support in the early stages of this paper.


WIDER SOCIAL CONTEXT

H.EALTHcARF, SETTJNGS

Actual Nursiq Care (inc. education)

Political and social faciitation or inhibition?

Positivistic or holistic’?

HIDDEN cuRRlcuLuM I

Witbin clinical Practice

(how nursing is pmctised) __-__-____-__-__-_____

Within Nurse Education

(how educators relate to students)

Experiential learning?

Appropriate role models?

Authoritarian or democratic?

Intended Nursing Care (inc. education)

TAUGHT cuRRIcuLuM

e Practical He&b Promotion Model Application?

f Nursing Model Theoretical

Integration? +

Hypothesis of Causation

CLASSROOM

Fig. 7. The ability of the nurse to put the taught curriculum into practice is inhibited by the hidden curriculum (both within nurse education and clinical settings), and by the wider social context.

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(Received I 5 December 1994; accepted for publication 15 February 1995)

miracles take a little longer: project 2000 and the health-promoting nurse

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