Health Promotion in Nursing Care

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By Angel Falkner

Essential Questions

• How has health and health promotion changed throughout history, and what influence has this had on governmental agencies to help promote health? How can nurses be instrumental in this process?
• What are social determinants of health (SDOH), and how do they affect health promotion?
• How do culture, socioeconomic status, lived experience, and personal preference influence definitions of health?
• How can nurses work to establish primary, secondary, and tertiary plans of prevention in diverse populations?

Introduction

According to the World Health Organization (n.d.a), health promotion is “the process of enabling people to increase control over, and to improve, their health. It moves beyond a focus on individual behavior toward a wide range of social and environmental interventions,” (para. 1). Nurses play an integral role in providing health promotion education and resources to a wide range of patients. Health promotion is embedded in the daily routine of nursing practice.

The nurse may begin the day by educating a middle-age man about postoperative care following a cardiac catheterization, informing him of health promotion skills such as modifications in diet and exercise in order to prevent progression of coronary artery disease (CAD). Later, the nurse may educate a patient being discharged about the importance of following up with her primary care provider (PCP) and completing the full course of antibiotics prescribed to her. Utilizing the different models of health, therapeutic communication, and assessment skills, nurses personalize the patient plan of care (POC) and provide the tools necessary to make choices that improve patients’ overall health quality.

Historical Perspective of Health

The definition of health has changed over time. In the early 19th century, infectious diseases were widespread and difficult to contain largely because of the lack of proper sanitation methods, including insufficient disinfection of drinking water and improper removal of human waste. During this time, health was viewed in basic terms as being free of disease.

Diseases became more manageable once proper sanitation measures were instituted in the late 19th and early 20th centuries, shifting the definition of health to mean the ability to remain a functional part of society. Disease affected overall health if it led to chronic disability or inability to fulfill expected role duties. With the invention and administration of vaccinations in the 20th century, disease prevention became a priority, as many diseases were almost totally eradicated (American Academy of Pediatrics, 2015).

As prevention of illness took center stage, the definition of health evolved into more than being disease-free, and in 1948, the World Health Organization (WHO) was formed. The WHO’s focus was, and continues to be, health promotion for populations worldwide. As health promotion grew, the definition of health became viewed as an accumulation of factors such as physical, mental, and spiritual wellness.

Health promotion and the prevention of disease have taken precedence in the United States in an effort to decrease chronic health conditions and promote healthy living. The goal is to create a culture of health in which health promotion and disease prevention is the focus rather than seeking treatment after disease has set in.

In response to the focus on prevention of disease, the U.S. Office of Disease Prevention and Health Promotion (ODPHP) partnered with states to address public health and provided funding for the expansion of hospitals in order to meet the growing needs for health promotion throughout the country (Mallee, 2017). ODPHP focuses on a handful of primary public health concerns such as nutrition, physical activity, health literacy, and health care quality. Additionally, ODPHP has created federal programs for health, such as Healthy People 2020. The Healthy People program was created in 1979 as a way to help decrease rising morbidity and mortality rates associated with disease by setting new goals every 10 years to improve health based on the issues of that time period (Green & Fielding, 2011). Healthy People 2020 identifies the nation’s current health concern priorities and has formulated action plans to attain varying goals related to these issues. The Healthy People 2020 goals include:

1. Attain high quality, longer lives free of preventable disease, disability, injury, and premature death.
2. Achieve health equity, eliminate disparities, and improve the health of all groups.
3. Create social and physical environments that promote good health for all.
4. Promote quality of life, healthy development, and health behaviors across all life stages. (Office of Disease Prevention and Health Promotion [ODPHP], 2018a).

The combined efforts of federal agencies, health care facilities, and health care providers have a collective goal of forming a healthier population through incorporation of health promotion measures. This effort is necessary to improve health in the United States because, despite it being one of the wealthiest and most modern countries in the world, health care and health generally fall short of other developed countries worldwide (Egen, Beatty, Blackley, Brown, & Wykoff, 2017).

Perspectives of Health and Illness

The illness-wellness continuum, developed by John Travis, defines wellness or health as a continued process, with movement between illness and high-level functioning throughout the lifespan (The Wellspring, n.d.). This spectrum portrays wellness as achievable through a combination of factors, including health promotion behaviors and healthy living choices, such as health screenings and proper nutrition, respectively. Illness occurs in the event of physical or emotional shifts from physiological homeostasis and requires treatment and health promotion factors to move back toward the center of the spectrum and achieve balance; however, contrary to common perception, illness is not always directly correlated to having a disease (The Wellspring, n.d.). An individual may have a disease process but is able to manage the symptoms and live in a state of wellness.

Figure 2.1

Illness-Wellness Continuum

Note. Adapted from “Key Concept #1: The Illness-Wellness Continuum,” by The Wellspring. Copyright 2018 by The Wellspring.

The interactions individuals have with their environment further influence health and wellness. This is discernable when examining community health concerns such as clean drinking water or air pollution. For instance, increased levels of air pollution in highly populated urban areas could increase the risk of lung disease for those who enjoy recreational bicycling or running. The environment has a direct impact on an individual’s health because they may be unable to be physically active because of an increased risk of contracting a pulmonary disease.

Cultural factors also play a major role in the perception of health and illness. The way individuals define and maintain health, when to seek treatment, what treatments to use, and who to seek treatment from are all heavily influenced by different cultural elements.

Example

Mary is a 42-year-old woman living with type 2 diabetes (DM). She is managing her disease with oral antidiabetic medication and has started a diet and exercise regimen. She monitors her blood-sugar levels twice a day and follows up on her physician appointments regularly. Despite having to modify her diet, the disease has not had a major impact on her work or social life, and she is able to continue functioning as she did prior to her diagnosis two years ago. Though Mary does have a discernable disease, she is able to achieve a positive level of wellness.

Conceptual Models of Health

Models of health provide the framework for the nurse’s understanding of the patient’s perceptions of health. The models assist the nurse in the nursing process by providing the basis for plans of action that incorporate applicable health promotion strategies, leading to positive patient outcomes. In many instances, multiple models may be applicable to a patient’s specific situation.

Clinical Model of Health

The clinical modelis very basic and views health in terms of the absence of signs or symptoms. When obvious signs or symptoms of disease occur, they indicate illness and warrant medical attention. Health care professionals utilize this model when their focus of care is relief of the patient’s symptoms rather than curing the disease. Patients for whom this model can be applied may not seek treatment until symptoms are severe and require emergency intervention (Nursing Theories, 2012).

Example

A patient is seen in the Emergency Room (ER) with diabetic ketoacidosis. The patient indicates that she did not even know she had diabetes, and she hasn’t been to a doctor since she had her first child 25 years ago. She complains of foot pain and extreme nausea. Using the clinical model, the health care team’s primary objective is to stabilize the patient and treat her immediate signs and symptoms of the disease.

Adaptive Model of Health

The adaptive model, developed by Sister Callista Roy, reflects the individual’s ability to acclimate to a disruption in his or her health. When the disruption presents, it requires the individual to change some aspect within his or her lifestyle. This adaptation can be on a physical or psychological level, and the goal is for the individual to be able to continue to function in the face of change (Nursing Theories, 2012).

Figure 2.2

Adaptation Model

Note. Adapted from “Sister Callista Roy’s Adaptation Model of Nursing,” by M. Vera, 2014, Nurseslabs. Copyright 2014 by Nurseslabs.

In Figure 2.2, the stimuli is considered the disruption in health, which can include receiving a new medical diagnosis such as diabetes or cancer. The center is representative of the individual’s process of adaptation and learning to cope with the stimuli. There are many elements that contribute to an individual’s adaptation, including physical, self-concept, interdependence, and role function. Physical refers to the symptoms that the disease process might produce, such as pain, discomfort, and nausea. Self-concept includes psychological and spiritual elements, which includes the patient’s understanding of how he or she is handling this change. Interdependence refers to support the individual receives from friends and family. Finally, role function refers to how this new disease will affect the individual’s roles within his or her family and in society. Once adaptation is successful, the individual can move forward.

Example

A newly diagnosed breast cancer patient is able to adapt and incorporate her treatment into her busy life. The patient experiences some grief, but copes by seeking out counseling and spiritual support. The patient continues to function well in spite of her illness and remains optimistic. Even though the patient has a physical illness, she is maintaining optimal health with positive coping mechanisms.

Role Performance Model of Health

The role performance model entails the individual’s ability to fulfill the duties of his or her varying social roles in spite of the onset of illness. The social role is defined by the individual’s relationship with colleagues, family, and perceived social expectations. In this model, health is viewed as the ability to fulfill duties to the same capacity as their peers (e.g., coworkers, other parents, colleagues). When these individuals are unable to fulfill their role expectations, they are expected to be formally excused from obligations through means such as a physician’s note for “excused absences.” (Nursing Theories, 2012). The health care team uses this model when caring for patients who seek treatment and are in need of a medical excusal from social role expectations.

Example

A working mother of four develops a cold but is still able to perform her usual daily functions as a parent and employee. Days go by, the cold worsens, and she is diagnosed with pneumonia. She has a high fever and is bedridden for the time being, leaving her unable to perform her usual role responsibilities. She obtains a physician’s note to excuse her from work while she recuperates and relies on her spouse and friends to help her care for her children temporarily.

Eudaimonistic Model of Health

Eudaimonistic health refers to health across all spectrums: physical, psychological, spiritual, and social. The individual who views health from this perspective remains actively involved in his or her life, regardless of diagnosed disease and attempts to remain optimistic. This view of health requires care of physical and psychological health. Patients who utilize this framework may also seek complementary and alternative methods (CAM) or seek counsel in a spiritual leader for guidance (Nursing Theories, 2012). The health care team applies this model in the care of patients by addressing and acknowledging their varying needs and caring for them holistically.

Example

Max is a 72-year-old male who has been treated successfully for prostate cancer twice. During a routine follow-up appointment, he learned that his cancer has reoccurred and has now metastasized to his liver and bones. He chooses to forego being treated as he has in the past, knowing that he only has six months to a year to live. He decides to use what savings he has left to cross off some things on his “bucket list.” He seeks support from both his pastor and his wife as he makes this decision. Though he has an incurable disease, he remains positive and contented and, in doing so, achieves wellness according to the eudaimonistic model of health.

Functional Model

The functional model views the individual’s health in terms of ability to function to his or her optimal level in all areas of life. Similar to the clinical model,functional health focuses on the disease process that is causing physiologic or psychologic damage; however, the functional model examines how the disease process affects the individual’s daily functioning. Activities of daily living (ADLs), such as bathing, toileting, dressing, and even ambulation can be affected. This would directly impact the individual’s ability to fulfill roles such as parent, employee, student, or volunteer (Disability in Public Heath, n.d.).

Example

Jeff is a 28-year-old male who was in a motorcycle accident and sustained multiple compound fractures. The functional model of health would view the patient’s acute injuries as a primary concern as well as consider how these injuries will affect the patient’s ability to return home or work and get back to normal. The health care team for a patient for whom this model applies would focus on formulating a POC that helps set goals related to returning the patient back to optimum functioning capacity.

Social-Ecological Model

The social-ecological modelviews health on an individual and community level. The model considers individual factors and how these interplay with factors within the environment and community. This widely recognized and used model considers various social determinants of health (SDOH) within each part of the environment that interact with the individual effecting his or her overall health (Richard, Gauven, & Raine, 2011).

Figure 2.3

Social Ecological Model

Note. Adapted from “How & Where Youth Live, Learn & Play Matters: The Social-Ecological Health Promotion Model & Social Determinants of Health,” by the Healthy Teen Network, 2013. Copyright 2013 by Healthy Teen Network.

Social Determinants of Health

The SDOH include a variety of factors that all have a major effect on an individual’s life and health status. Each has the ability to improve or worsen the individual’s overall health. These factors typically are not directly influenced by the individual’s choices, but rather stem from circumstance, such as poverty level, ethnicity, or physical environment (World Health Organization [WHO], n.d.b). ODPHP defines SDOH as “conditions in the environment in which people are born, live, learn, work, play, worship and age that affect a wide range of health, functioning, and quality of life outcomes,”(WHO, n.d.b).

Figure 2.4

Social Determinants of Health

Note. Adapted from “Social Determinants of Health,” by HealthyPeople.gov, 2018, Office of Disease Prevention and Health Promotion. Copyright 2018 by the Office of Disease Prevention and Health Promotion.

Understanding the SDOH and their impact on overall health and wellness is essential in addressing health promotion needs. When SDOH are examined and improved upon, health and wellness begin to improve as well, leading to health equity. Health equity is the provision of resources necessary to live well to all individuals regardless of varying SDOH (Ramirez, Baker, & Metzler, 2008). For instance, if policy makers are made aware that a certain area has high rates of childhood obesity, steps might be taken to increase the number of parks in the community to encourage physical activity.

Figure 2.5

Health Equity

The Robert Wood Johnson Foundation (2010) published a review on best practices in communicating about SDOH, highlighting six phrases that help the public to understand SDOH and how they impact health:

• Health starts—long before illness—in our homes, schools and jobs.
• All Americans should have the opportunity to make the choices that allow them to live a long, healthy life, regardless of income, education, or ethnic background.
• Your neighborhood or job shouldn’t be hazardous to your health.
• Your opportunity for health starts long before you need medical care.
• Health begins where we live, learn, work and play.
• The opportunity for health begins in our families, neighborhoods, schools and jobs. (Robert Wood Johnson Foundation, 2010, p. 7)

These statements provide an easy way to understand the concept that health begins with personal decisions, but it is also directly affected by many external factors within an individual’s daily environment. While many SDOH cannot be changed entirely, steps can be taken to make improvements and provide the tools and resources necessary to enable individuals to make healthy decisions that lead to better overall health.

Agent-Host Environment Model

The agent-host environment model can go hand-in-hand with several of the previously described models of health. Contextually, this model is used to explain the infectious disease process. When viewing this model in terms of health promotion, the biggest factor is the host’s relationship to the environment. When the environment is not safe because of an infectious agent, the host becomes susceptible and contracts disease (Dicker, Coronado, Koo, Gibson Parrish, 2012). The health care team’s objective when applying this model is to treat the disease caused by the environmental factor and then work collaboratively with other members of the interdisciplinary team to help rectify the environmental issue. The nurse can also educate the patient regarding health promotion strategies to decrease the risk of contracting disease related to environmental issues, such as cooking foods to the proper temperature to avoid food-borne illness.

Example

A prominent example of this model’s application is the water crisis in Flint, Michigan. In 2014, Flint residents began developing lead poisoning related to high levels of lead in the drinking water. This is directly applicable to the agent-host environmental model, with the agent being lead in the environment and the host being citizens living in the area. While this is not an infectious disease process, lead is a toxic agent within the environment that has directly impacted health within this community (Guyette, 2017).

Figure 2.6

Agent-Host Environment Model

Levels of Prevention

Prevention refers to the actions required to deter the formation of a problem or complication of an existing problem. In health promotion, there are three levels of such prevention, each having their own respective place in the health promotion process. The nurse uses the different levels to determine the patients’ education needs depending upon the patients and where they are in their health care journey.

Figure 2.7

Levels of Prevention

Primary Prevention

Primary prevention occurs before the onset of illness or injury and may involve preventative treatments, such as vaccinations and wellness exams, to prevent the contraction of illness. This is referred to as specific protection. Primary prevention also includes health promotion and education interventions. For example, community programs aimed at increasing activity level and improving dietary choices for people at risk of heart disease offer an active intervention to prevent heart disease for this population. The idea is to help the patient make informed decisions on a daily basis.

This stage of prevention utilizes active and passive involvement. Active involvement requires the individual to participate in some way, either when going to the clinic to receive a flu vaccine or attending a local seminar that teaches how to adopt healthy eating habits. Passive involvement does not require the participation of the individual. This type of involvement includes public health strategies, such as the addition of iodine in salt to prevent iodine deficiency thyroid disorders (Leung, Braverman & Pearce, 2012).

Secondary Prevention

Secondary prevention focuses on the early detection and treatment of disease processes before they progress and cause irreparable damage. This stage of prevention is executed through health screenings and early treatment. By educating patients regarding health promotion, nurses, who are proponents of such screenings, can implement measures to prevent further complications. The goal is to prevent progression of early stages of disease and comorbidities from occurring.

Tertiary Prevention

Tertiary prevention occurs when a disease process has caused permanent damage of some form. The focus of this level of prevention is to help the patient achieve some semblance of normalcy and acclimate back into their lives and society. Depending on the patient and the magnitude of their complications, they may require extensive rehabilitation. The nurse must also advocate for resources that may be indicated within the patient’s home for daily functioning. Nurses accomplish this by determining the patient’s needs and accessing appropriate members of the health care team to provide resources such as home health care or medical equipment. In addition, tertiary prevention includes patient education. The nurse utilizes this time to present or reiterate education strategies to help prevent further issues from arising.

Transtheoretical Model of Nursing

The transtheoretical model of nursing (TTM) teaches health promotion prevention measures. This model helps the nurse identify patient readiness to adopt changes necessary to improve health. There are five phases within the model that deal with levels of readiness to accept change.

• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance

Depending on the patient’s level, the nurse can tailor the POC to have the most impact and relevancy (see Table 2.1)

Table 2.1

Transtheoretical Model (TTM)

Nurses’ Role in Health Promotion

The nurse is key in the provision of health promotion strategies in all care settings. As the focus is shifted to prevention measures, the role of the nurse in health promotion education is expanding rapidly. The nurse assesses the patient and implements evidence-based practice (EBP)while assuming each role and providing health promotion measures to patients and the community.

Advocate

Nurses are the first contact for a patient, which is why patient advocacy is a fundamental nursing role. Nurses must utilize the power of advocacy in order to identify and address patients’ specific needs. This is also consistent with Provision 3 of the American Nurses Association (ANA) Code of Ethics, which specifically endorses the role of the nurse as a patient advocate (American Nurses Association [ANA], 2015).

Deliverer of Services

Strictly speaking, the nurse’s role as the deliverer of services encompasses the typical nursing duties familiar to nurses and the public. In health promotion, this includes administration of vaccinations, conducting health screenings, and providing health education. This role also carries an expectation of clinical excellence and knowledgeable practice, while functioning within the registered nurse’s (RN) scope of practice that is consistent with the ANA Code of Ethics (ANA, 2015).

Care Manager

The role of the care manager involves collective collaboration with the interdisciplinary team. This type of collaborative relationship between disciplines is essential to provide safe, high quality care to patients. Because nurses are at the forefront of patient care, they are often the ones who coordinate meetings between staff, family, and patients. This role blends with the role of the patient advocate, as this coordination of care also involves indicating patient needs that have been expressed to the nurse.

Educator

A major role for the nurse is that of the educator. In health promotion, this role expands and becomes a primary role and focus. The nurse must acclimate to the role of the health educator and find new ways to assess the patient readiness, ability, and desire to learn. Teaching health promotion and prevention strategies are key to saving lives and helping patients and families live their best lives.

Researcher

In all circumstances, nurses must continually strive to be knowledgeable caregivers who base their practice on sound scientific evidence founded through EBP. EBP is acknowledged in nursing as the gold standard for driving change in nursing practices to improve patient care. What makes EBP unique is the incorporation of the latest evidence, clinical expertise, and patient preferences and values in order to make changes that improve patient care (Stevens, 2013). The latest evidence is accumulated through qualitative and quantitative nursing research and provides the statistical evidence necessary to support suggestions for change. This evidence is then combined with clinical expertise and observations to make a sound claim for recommending changes to patient care procedures. Nurses’ expertise and experience is critical to the research process and can make the difference of moving forward with changes that can affect patient care outcomes and save lives. Within health promotion, changes can be seen in the different levels of prevention. This may mean instituting a new type of education program or creating new health screenings based upon needs. The National Institute for Nursing Research (NINR) advocates for nurses’ involvement in scholarly research and application of EBP to nursing practices.

Improvements in Health

The Aging Population

As health care has advanced over the past century, life expectancy has increased dramatically. Many in the baby boomer generation have reached the age of retirement and will require health care services and appropriate patient-centered care in order to live their best lives as they advance in age. In fact, “by 2030 approximately 71 million Americans will be 65 or older,” (Health and Aging Policy Fellows, 2017, p. 1). Additionally, the number of Medicare beneficiaries is set to increase substantially by the year 2030, expanding the need for efficient primary care providers and a well-trained nursing workforce (Gaudette, Tysinger, Cassil, & Goldman, 2015). The perception of aging has changed; while once equated with illness or disability, many senior citizens are now living full, functional lives free of illness or debilitation. Those geriatric patients who do require more care may need support from friends and family as well as financial and medical resources. This requires nurses to collaborate with members of the interdisciplinary team and family to develop a POC that addresses the patients’ specific needs.

Health promotion is crucial to this patient population’s ability to continue to avoid illness. In addition to avoiding illness, health promotion can also help those with diagnosed diseases to live well and properly manage their illness, reducing the impact on their daily lives. Nurses are primary administrators of health promotion education that will foster health care choices and management within the patient population. Nurses are an essential proponent to ensuring these promotion factors are integrated into the POC for this rapidly growing population.

Health Care Access

The Patient Protection and Affordable Care Act (ACA) made it possible for many Americans to purchase health insurance, something they were unable to do before this policy was enacted. This has led to an increased demand for health care providers across the country. The ANA advocated for this health care policy and continues to support the right to high-quality health care and primary care services that encompass preventative care and health promotion measures, regardless of preexisting conditions (ANA, n.d.). This need for an influx of primary care providers has also increased the demand for advanced practice registered nurses (APRNs) to provide quality care for more patients, as there are not enough primary care physicians to fill the demand for care. As providers of primary care, APRNs will be crucial to providing health promotion education to these patients in order to help them live well and avoid disease and illness.

Emerging Health Concerns

There are different health concerns in addition to SDOH that contribute to the wellness of patient populations across the United States. From environmental factors to drug abuse, these issues directly affect how nurses address health promotion and the different needs of patients. The nurse should become familiar with these concerns, the ways in which care is provided, and promotion measures that target varying issues.

Environmental Hazards

From air pollution in urban areas to carcinogens found within everyday products, people are exposed to a number of health hazards in all interactions within the environment. Education is part of what nurses can do to help their patients live well in spite of these environmental hazards. Nurses must constantly provide information, resources, and education that will aid the patient in making smart decisions that will help them to avoid health hazards. Prevention education starts early, before there is an actual crisis, and continues during and after the event occurs. Nurses work with other members of the health care team to provide education and resources. Government agencies, such as the Centers for Disease Control and Prevention (CDC), offer educational resources that the nurse can utilize and direct the patient to as a reference. Nurses can provide advice that is more applicable to daily life, which may include advising patients to watch the news for reports of high pollution days so they know when to avoid outside activity, learn to test foods for appropriate temperatures to avoid food-borne illnesses, or learn the necessary steps in childproofing the home to protect small children from accidents.

Environmental Health in Practice

There are many opportunities to incorporate environmental health into practice. A patient who is an avid runner and frequently jogs alongside the busy street near his home may be advised to jog early in the morning when the air is clearer, thus helping him to avoid inhaling high levels of pollution, which is associated with the development of lung cancer (Hamilton, 2013). A mother may be advised to avoid the use of baby powder in caring for her infant because the talcum used in the powder has been associated with lung disease and ovarian cancer (Rabin, 2017).

Substance Abuse

Substance abuse continues to impact populations worldwide. Today, the development of new illicit drugs and the opioid abuse epidemic demands attention. From 2002 to 2013, illicit drug use in the United States increased by 8.3% (Ahrnsbrak, Bose, Hedden, Lipari, & Park-Lee, 2017). Reports of parents overdosing while with their minor children have flooded news reports in recent years, and the issue of opioid abuse has recently been named a national public health emergency by the president of the United States (Allen & Kelly, 2017). Statistics show that, on average, each day approximately 115 Americans die from opioid-related abuse (CDC, 2017a).

Figure 2.8

Drug Abuse

Note. Adapted from “SAMHSA Shares Latest Behavioral Health Data, Including Opioid Misuse,” by the Substance Abuse and Mental Health Services Administration, 2017. Copyright 2017 by the U.S. Department of Health and Human Services.

The increase in overdose-related deaths and the overall impact that drug addiction has on individuals and their families is lifelong and life altering. On an individual level, drug abuse causes devastating health consequences, including comorbidities associated with drug abuse such as liver failure, infections, and the potential for overdose-related death. These patients often face financial consequences as well, often depleting their resources to obtain their drug of choice. Addiction impacts the patients’ families as well; patients who have children may lose custody or visitation rights if convicted of drug possession, DUI, or other drug-related offenses. In addition, the relationship between patients addicted to drugs and their families is often very troubled, causing estrangement and emotional strain. Addicts have high rates of noncompliance with medical care or treatment for other disease processes they may have; they also often neglect to care for themselves because their addiction is often the only thing on their minds (Herbeck, Fitek, Svikis, Montoya, Marcus, & West, 2010). The risks of contracting diseases such as hepatitis and human immunodeficiency virus (HIV) are very high, especially for those who inject illicit drugs using shared needles with other drug abusers.

Nurses face challenges in working with patients who struggle with addiction. Care should be taken to individualize the patient’s POC and assess his or her specific needs. Needs for addicted patients may vary. If the patient is ready to seek treatment, the nurse can advocate for social work and case management to arrange for inpatient or outpatient drug addiction treatment centers; however, if the patient does not wish to seek treatment, the nurse should assess for other needs such as housing, concurrent mental illnesses, compliance with medical treatment, and arranging health care follow ups to test for diseases such as hepatitis or HIV, and advocating for psychotherapy if the patient is willing.

Figure 2.9

Overdose Related Deaths

Note. Adapted from “Increases in Drug and Opioid Overdose Deaths – United States, 200-2014,” by R. A. Rudd, N. Aleshire, J. Zibbell, & R. M. Gladden, 2016, the Centers for Disease Control and Prevention.

Poverty

Poverty in the United States has a longstanding effect on health that nurses frequently see in nursing practice. Poverty has been noted to decrease average life expectancy compared to those living in middle-class or wealthy areas (Egen et al., 2017). Individuals and families living in poverty have limited means and often choose between eating a meal and paying for necessary medications or medical supplies. The stigma associated with living in poverty often deters these individuals from seeking assistance, which further compounds their health issues (Whittle, Palar, Ranadive, Turan, Kushel, & Weiser, 2017). Nurses often care for these individuals in acute-care settings in which the disease process or processes are out of control, and the situation becomes urgent. Nurses must advocate diligently for necessary resources for these individuals, working within the interdisciplinary team to help them gain access to emergency funding, health care, and housing, if needed.

Mental Illness

Mental illness affects millions of people worldwide and can lead to devastating results when overlooked (de Jacq, Norful, & Larson, 2016). Mental illnesses encompass a wide range of psychological disorders. Serious mental health disorders include depression, anxiety, bipolar disorder, and schizophrenia. The WHO projects, “that by the year 2020, depression will be the second leading cause of disability throughout the world” (Marcus, Yasamy, van Ommeren, Chisholm, & Saxena, 2012). Social stigmas attached to being dubbed “mentally ill” or “crazy” often impact the decision to seek help and subsequent treatment (Davey, 2013). Patients would rather suffer with the symptoms of the illness than seek out help because they may not want to feel judged by anyone involved in their care. In addition to lack of care, those suffering from mental illness are at an increased risk of having other chronic illnesses such as hypertension, asthma, diabetes, heart disease, and stroke (Hyde, 2012).

There remains a negative social stigma surrounding those afflicted with mental illness. Several stereotypes are assumed regarding those who are mentally ill, including notions that they are dangerous, naïve, and helpless (Coman & Sas, 2016). These stigmas often lead to a great deal of discrimination, ranging from loss of employment to less than optimum health care services (Quinn, Williams, & Weisz, 2015). Education regarding mental illness and associated behaviors is one way to combat these preconceived notions and help those with mental illness receive fair and compassionate treatment while remaining compliant with treatment plans. The nurse’s responsibility is to provide advocacy for those in a mental health crisis to ensure they receive the services that are needed.

Figure 2.10

Mental Health in America

Note. Adapted from “Highlighting innovation during Mental Health Awareness Week 2015,” by H. Mooney, The Catalyst. Copyright 2015 by PhRMA.

The mentally ill are a vulnerable population group because they often cannot advocate for their own needs and require a great deal of support from loved ones and the health care community. Nurses must be aware of personal feelings and biases when caring for those who are mentally ill. A broken provider/patient relationship has been shown to lead to patients’ deciding to leave treatment entirely (de Jacq et al., 2016). Often those with a mental illness become impoverished or homeless because of a variety of issues, such as loss of stable employment and familial support. Approximately 66% of homeless people in the United States suffer from some form of mental illness (Helfrich, Simpson, & Chan, 2014). This further increases their risk for complications related to mental illness, such as suicide (Ljungqvist, Topor, Forssell, Svensson, & Davidson, 2016). Nurses must be aware of these issues and include psychological distress within their basic assessment. A nurse’s ability of to perceive small details and home in on psychological distress could mean the difference between life and death for individuals struggling with untreated mental illness.

There are several aspects between a standard assessment and a mental health assessment. During the assessment process, the nurse should observe the patient’s overall mood and affect throughout the assessment, as well as speech and thought content. These observations provide valuable details to the nurse regarding the patient’s needs. In asking open-ended questions in which the patient is allowed to elaborate freely, the nurse may be able to detect whether the patient is having hallucinations or delusions. Additionally, the nurse should be very direct when asking the patient about self-harm (suicidal thoughts) or thoughts of harming others (homicidal thoughts), as these are indicators for immediate intervention. If the nurse discovers either of these symptoms, collaboration with the health care team will need to be expedited to provide the care needed to ensure the safety of the patient and those around him or her.

The concept of therapeutic communication is essential in this type of assessment. Therapeutic communication involves the use of communication skills that convey a sense of trust and respect in order to understand the patient’s needs. In working with any patient, this skill set is a valuable tool for forming a trusting patient/provider relationship. A trusting patient/provider relationship is even more important when working with the mentally ill because of the social stigma attached to the mentally ill population and symptoms of certain mental illnesses that make the individual feel paranoid or unwilling to communicate.

Table 2.2

Therapeutic Communication Techniques

Nutrition, Physical Activity, and Obesity

Proper nutrition and physical activity are essential elements to maintaining a healthy body weight and living well. Unfortunately, the average American’s habits typically do not include healthy eating habits, which has resulted in 34% of the population becoming overweight (National Institute of Child Health and Human Development, 2016). Obesity related diseases such as heart disease, stroke, depression, and type 2 DM often lead to a lifetime of disability, increased financial burden, and even early death (ODPHP, 2018b). In addition, nearly 82% of adults in the United States do not get the daily recommended amount of physical activity, which also contributes to obesity rates (ODPHP, 2018b). Promoting healthy eating and physical activity is essential to helping individuals live healthy, disease-free lives. Nurses use their knowledge of dietary choices to help educate patients and families on the importance of healthy eating and the effect it can have on health and healthy living.

Government Influences

The effects of illness have a large impact on society. Individuals who suffer from acute or chronic illnesses may require extended time off work or disability benefits related to the extent of the situation. This has a financial effect on employers, employees, insurance, and health care, with the CDC noting that a staggering 86% of the nation’s $2.7 trillion dollar annual health care expenses being related to treatment for chronic illnesses (CDC, 2017b). In addition, the leading causes of death in the United States were equated to chronic illnesses such as heart disease and obesity (CDC, 2017b). Federal agencies are key in the development of programs that foster health promotion measures in order to help individuals and communities stay well.

The CDC offers a model for employers to follow that helps to guide them with assessment, planning, implementation, and evaluation of health promotion resources offered to employees such as gym membership discounts and health education programs that promote healthy living.

Figure 2.11

Workplace Health Model

Note. Adapted from “Workplace Health Model,” by the Centers for Disease Control and Prevention, 2016.

With the implementation of the ACA, employers have been able to receive financial grants that allow them to develop and incorporate wellness initiatives for their employees that encourage healthy living habits and decrease incidence of illness and disease (Anderko et al., 2012). The programs also offer employees discounted rates on their insurance premiums, which helps attract interest in participation. These types of wellness programs are devised to help reach benchmarks that support the goals of the ACA. This type of program is concurrent with primary prevention measures geared toward education and health promotion strategies to prevent disease and falls in line with secondary prevention because screening can help detect early stages of disease. These programs also are part of primary prevention. The goal of these programs is to create the perfect environment in which to promote health and provide education and tips to making health choices and avoiding disease.

Reflective Summary

As the face of health care continues to change, it is clear that prevention of disease is essential. Nurses are a major component of the prevention process, fostering health promotion measures and assuming many different roles in order to support patients and families in living their best lives. The nurse has many nursing models to choose from that can assist in providing holistic care, while integrating related family health promotion education and prevention strategies. Government involvement and creation of new programs are focused on helping provide resources that help improve different elements of SDOH in order to help people live well and prevent disease. Health promotion will continue to be the central focus for helping all individuals and families live full and healthy lives.

Key Terms

Adaptive Model of Health: Model of health associated with an individual’s ability to adapt to a change in health status.

Clinical Model of Health:Basic model that defines health as the absence of signs and symptoms of disease.

Delusions: A misconception or belief that is not true, heavily associated as a symptom of mental illness (e.g., patient believes he is the president of the United States).

Disease:Malfunction of the body that causes notable signs and symptoms.

Evidence-Based Practice (EBP): he integration of clinical expertise, the most up-to-date research, and patient’s preferences to formulate and implement best practices for patient care.

Functional Health Model:Model of health that measures wellness by the ability of an individual to continue to function in spite of a change in health.

Hallucinations: Perceptions of something or someone who is not truly present.

Health Equity: Provision of resources necessary to live well to all individuals regardless of varying social determinants of health (SDOH).

Health Promotion: Educating people about healthy lifestyles, reduction of risk, developmental needs, activities of daily living and preventive self-care that enables them to improve their health by making positive decisions.

Health:Many definitions, traditionally thought of as the absence of disease; however, a more modern definition encompasses multiple factors, including the ability to cope and continue to live well in spite of disease states.

Healthy People 2020: A federal program developed by the U.S. Department of Health and Human Services that sets goals related to prominent health concerns and works to achieve them through health education and health promotion strategies.

Homicidal Thoughts: Thoughts of harming others.

Illness:State of physiologic dysfunction that has an impact on physical, mental, and social well-being and functioning.

Illness-Wellness Continuum: Fluid relationship between wellness and illness that is defined by multiple factors such as adaptability, functionality, and coping.

Levels of Prevention:Primary, secondary, and tertiary; these levels have a collective goal of preventing or improving health by promoting positive health promotion behavior changes.

Models of Health: Frameworks that help define different perceptions of health, wellness and illness, and contributing factors.

Role Performance Model of Health:Health is defined as the ability to fulfill social and familial obligations in spite of health issues.

Social Determinants of Health (SDOH):Conditions of living, such as housing, socioeconomics, transportation needs, or quality of education, that directly impact health and access to health care needs.

Social-Ecological Model of Health:Model of health that acknowledges the correlation between physical and social environment and their impact on health and wellness.

Suicidal Thoughts: Thoughts of self-harm or ending one’s own life.

Therapeutic Communication: Use of communication skills that convey a sense of trust and respect in order to understand the patient’s needs.

Wellness:State of well-being that is not necessarily equated with the absence of disease, ability to adapt, and continue to function and live life well are contributing factors to wellness.

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