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N. Shoqirat ¹

إعداد نموذج مفاهيمي لدور ممرضي المستشفيات في تعزيز الصحة في الأردن

نور الدين الشقيرات

الخلاصة: لقد كشفت أدلة دولية أن ممرضي المستشفيات غير قادرون على دمج تعزيز الصحة - بصورة فعالة - في إطار رعايتهم. ويمكن أن يعزى ذلك إلى عدم وجود مفاهيم واضحة لما يعرقل وما ييسر دور الممرضين في تعزيز الصحة. وقد تم إجراء مراجعة تكاملية لإعداد نموذج مفاهيمي يساعد ممرضي المستشفيات في الأردن على فهم كيفيةٍ تمكنهنَّ من تطوير أنشطة تعزيز الصحة. إن العوامل التي تؤثر على إشراك الممرضين في تعزيز الصحة – بدءاً من محدودية المعارف المتعلقة بتعزيز الصحة إلى الصورة الاجتماعية للتمريض – يمكن أن تتم هيكلتها ضمن ثلاثة مستويات: الجزئي (الفردي) والمتوسط (التنظيمي) والكلي (السكاني). ومن خلال فهم تفاعل العوامل فيما بين المستويات وضمن المستوى الواحد، يمكن للممرضين ولغيرهم من المهنيين الصحيين أن يعتمدوا على العوامل الفردية والاجتماعية والتنظيمية التي تؤثر على دور الممرضين في تعزيز الصحة. يمكن اعتبار النموذج المقترح نقطة انطلاقة لإنشاء و تطوير أنشطة تعزيز الصحة المتعلقة بالمستشفيات في سياقات أخرى ذات أغلبية مسلمة.

ABSTRACT International evidence reveals that hospital nurses have not been able to incorporate health promotion effectively into the framework of their care. This can be attributed to unclear conceptualizing of the barriers and facilitators to the role of nurses in health promotion. An integrative review was carried out to develop a conceptual model to assist hospital nurses in Jordan to understand how health promotion activities can be developed. Factors affecting the involvement of nurses in health promotion — ranging from limited knowledge about health promotion to the social image of nursing — can be structured into three levels: the micro (individual), meso (organizational) and macro (population). By understanding the interplay of factors between and within the levels, nurses and other health professionals can draw on the individual, social and organizational factors that influence nurses’ role in health promotion. The proposed model can be considered as a springboard for developing health promotion activities related to hospitals in other Muslim-majority contexts.

Élaboration d’un modèle conceptuel du rôle du personnel infirmier dans la promotion de la santé en Jordanie

RÉSUMÉ Les données internationales révèlent que le personnel infirmier en milieu hospitalier n’a pas été en mesure d’intégrer efficacement la promotion de la santé dans le cadre des soins. Cette situation peut s’expliquer par une conceptualisation floue des freins et des accélérateurs influant sur le rôle du personnel infirmier dans la promotion de la santé. Un examen intégratif a été mené pour élaborer un modèle conceptuel visant à aider le personnel infirmier en milieu hospitalier en Jordanie à comprendre comment les activités de promotion de la santé pouvaient être élaborées. Les facteurs pesant sur l’implication du personnel infirmier dans la promotion de la santé, allant d’un niveau de connaissances limité sur le sujet à l’image sociale des soins infirmiers, peuvent être structurés en trois niveaux : le microniveau (individuel), le mésoniveau (organisationnel) et le macroniveau (population). En comprenant les interactions des facteurs inter et intraniveaux, le personnel infirmier et les autres professionnels de santé seront en mesure de jouer sur les facteurs individuels, sociaux et organisationnels qui influent sur le rôle du personnel infirmier dans la promotion de la santé. Le modèle proposé peut être envisagé comme un tremplin pour élaborer des activités de promotion de la santé liées aux hôpitaux dans d’autres contextes où l’influence musulmane est dominante.

¹Faculty of Nursing, Mutah University, Karak, Jordan (Correspondence to: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ; This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).

Received: 01/09/14; accepted: 12/01/15

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Introduction

Internationally there is a consensus that an effective role for nurses in health promotion can not only lead to positive health outcomes for patients through improved adherence to treatment, self-management and illness prevention, but also can be cost-effective for the health system as a whole (1–3). Yet over the last decade the ability of hospital nurses to promote the health of patients has been questioned worldwide (4–6).

Despite the increasing importance placed on health promotion, nurses’ knowledge and practice of health promotion in hospitals are influenced by medically oriented health education activities as opposed to health promotion approaches that empower the individual (7). Factors that affect the role of nurses in hospitals are diverse and include nurses’ lack of time and education, a lack of resources, the organizational culture and the poor image of nursing (8,9). However, such factors have not yet been integrated in a way that helps nurses and decision-makers to re-evaluate health promotion in the daily care plans of patients. The literature offers a wide range of health promotion models that can be used to guide nurses’ practice in health promotion (2,9,10). However, these models have not considered exclusively the barriers and facilitators to hospital nurses developing a role in health promotion. The existing models have also largely been developed within the context of high-income countries and therefore may not be applicable to hospital nurses in developing countries.

In Jordan, as in many countries, healthy lifestyle initiatives have been emphasized by a number of scholars (7,11), but there is no conceptual model available to achieve this goal. There are concerns that the existing models and theories of health promotion might not fit with other health-care systems, specifically in Jordan. Adopting such theories and models in isolation from the setting and context perpetuates the traditional medically oriented health education paradigm (12). The current article attempts to bridge this gap in the literature by proposing a conceptual model of the role of hospital nurses in health promotion in Jordan.

Methods

The paper describes how an integrative review approach was used to develop a conceptual model. This approach involves using diverse sources of data and concepts from the theoretical and empirical literature to capture a deeper understanding of the topic of interest (13).

The materials relevant to the paper’s objective were located from different sources. Papers were located by an online search of the worldwide web using the keywords health promotion, models/frameworks, Jordanian culture and health-care system. The search employed a range of health-related literature databases, in particular those which have a nursing focus such as Medline, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, British Nursing Index and the World Health Organization database. Google Scholar search engine was also used. Initially the search focused on the period between 1986 and 2006 when many health promotion models/frameworks were developed. Then the search was updated to include more recent related literature from 2006 to 2013. Classic models of health promotion were also considered. Faced with hundreds of articles about health promotion, the search was narrowed down to focus on health promotion in combination with relevant keywords, such as culture, health, gender, Islam, spirituality, models, health, health-care system and nursing, and by region, such as Middle East, Mediterranean area and Jordan.

The main debates current in the health promotion literature and the relevant models identified were synthesized together to inform the development of the new conceptual model.

Review outcomes: conceptual development

Based on the review, it seems that when health promotion and health education programmes are developed, nurses are urged take into account all of the processes and challenges involved (4,5). In particular, health professionals need to offer convincing data that health promotion does actually work in a particular setting. This can be achieved by incorporating existing health promotion models and their ideas into the framework of nursing care. The literature offers many health promotion/health education models, including the health behaviour and social cognitive models, such as the health belief model (14), the stages of change mode (15), the health action model (16), the theory of reasoned action model (17), Pender’s (1987) health promotion model and the KwaZulu-Natal health promotion model (10). Yet their effectiveness as well as their cultural sensitivity in different regional contexts can be questioned.

The models identified above are developmentally based on health belief and social cognitive models (9). Indeed, a focus on disease, fear and behaviour control are the key elements of many such models which are the cornerstone of traditional health promotion (e.g. the health belief model). Such an approach can be criticized for being ineffective in practice and ethically questionable as well as lacking a community context (8,12). Likewise, the available models tend to be abstract and academic, thus creating a challenge for any health organization to implement them, and they might not be culturally accepted by the local community.

Although the medical, social and biopsychosocial models of health might have contributed to the development of wide-reaching health promotion activities (3), they have largely been generated and tested within a so-called “Western” paradigm of health, and the current models might not fully and specifically meet the needs of all patients (18). It is often argued that health promotion is more effective when it is informed by local traditions and beliefs (19). In many developed countries today, people’s religious beliefs tend not to have a wide impact on their daily lives. This contrasts with many Muslim-majority countries in the Eastern Mediterranean Region (18), where health-care professionals need to acknowledge the importance of integrating patients’ beliefs into the health promotion agenda.

It is not surprising, therefore, that in order to deliver effective health promotion, we must develop a model/framework that suits a particular health-care setting and is underpinned by relevant theoretical constructs (4). Conceptual models provide the most comprehensive and holistic approach to health promotion in a certain context (10). On this basis, it is plausible to argue that health promotion needs to be discussed not only in relation to the planned actions but also the development of a suitable agenda and frameworks for delivering this.

Theoretical drivers of the model

Some theoretical drivers of health promotion within the context of Islam were used to guide the development of the conceptual model. These drivers are explored below at the levels of the community, organization and individual.

Organization and community level

Certain structural and organizational aspects of society are central to Islam and they could provide real opportunities for nurses to build healthy public policies (20). For example, the Islamic concept of ummah refers to the belief that humankind should live as one unified society not separated by ethnicity, religion and nationality (21). This belief is in line with modern health promotion principles that embrace equity and social justice (12) and could be considered as a springboard for the reform of nurses’ role in health promotion.

In line with this reform, radical change in health organizations might be better implemented when their base values are congruent with the cultural context of a country. For example, in Morocco, a successful implementation of total quality management in hospitals occurred by associating it with Islamic norms and values (22). Likewise, in Jordan, development of nurses’ role in health promotion and health promoting hospitals might be more effective if guided by an Islamic perspective on management. Such an approach is driven by issues of equity, justice, teamwork, mutual respect, dialogue and rational action (18). These values are detailed in the Islamic scriptures, and indeed are echoed in the modern ideology of organizational development (21). However, they are often violated in practice within organizations in Arab countries in which decisions may lack effectiveness due to a lack of effective planning (23).

At the community level, examples of successful health promotion which involve religious leaders in Muslim society are well documented. In Uganda and Senegal, 3000 Muslim leaders were educated about how to prevent and reduce the risk of HIV within their communities (24). Education was tailored to Islamic beliefs, such as the idea that not protecting your health is a sin. It was found that individuals were more willing to take part in education sessions associated with such religious beliefs. While the complexity of preventing such a disease is valued, the study also pointed out that promoting health in general might be more effective when it is informed by values that are highly respected by the community.

Another relevant concept in Islam is zakat, whereby each financially capable Muslim is required to pay a portion of their income to the poor every year (21). The belief that wealth derives from Allah and that wealthy people need to consider the poor in society provides a guideline for the provision of social justice, positive healthy behaviour and an equitable socioeconomic system (18).

Individual and family level

Family involvement in planning of care is crucial for patients in Muslim-majority countries. In Saudi Arabia it strong family support was found to be a key issue that affected the health of Muslim patients, particularly older people (25).

Islam teaches us that our healthy body is a gift from Allah, we should not misuse it and we need to give it the best care and nutrition (18). Evidence has shown that the practice of Islam has a positive impact on women’s health behaviours in respect of breastfeeding and birth spacing, diet and non-consumption of alcohol and cigarettes (18,23). Thus, Islam and the concept of health promotion share some similar principles that advocate a better life. This includes exercise, good nutrition, adequate rest, mental calmness, cleanliness, tranquillity of family life and sexual health (18). These are of course key concepts in the international literature on health promotion, but it can be argued that in some countries they are more valued and welcomed by people when they are placed within a religious framework (26).

Hospital nurses need to empower hospital patients to adopt healthy lifestyle behaviours. Islam urges health professionals in general to provide care to all patients regardless of their religion and lifestyle practices. That is, at the individual level, Islam does not look at the beliefs of sufferers and their ethnic background and social status (18). To provide culturally sensitive health promotion activities, it is important to remember that each individual is unique in terms of expectations and beliefs and thus nurses need to identify and take account of such elements.

The proposed model

A large-scale Jordanian study found that the factors affecting the development of nurses’ roles in health promotion operated at different levels, that is, at the level of the individual, the organization and the Jordanian community (7). Consequently, the conceptual model proposed here emphasizes the development of health promotion with other sectors that affect the overall health of the community (Figure 1 and Table 1). In line with the Vienna Recommendations on Health Promoting Hospitals, health promotion should be delivered in conjunction with governments and the existing health services in the community (27). While the factors that affect the development of hospital nurses’ role in health promotion are closely interrelated, they can be classified into micro, meso and macro levels of influence.

The micro level refers to the intrapersonal/individual domain (at the ward level) and includes nurses’ knowledge and beliefs and the interaction between nurses and their patients. For instance, the lack of empowerment among nurses and the utilization of a medical-oriented and lifestyle change approach with patients can minimize the effectiveness of the nurse’s role in health promotion. An active learning process and a two-way communication between health promoters and patients, as opposed to an expert-led, top-down approach, are needed to neutralize the power differences between nurses and patients.

The meso level includes the organizational structure (the workplace), while the macro level refers to the level of the community, which includes links to health-care organizations and national policies. Within these two levels the barriers to health promotion are more complex, involving gender issues and the low public image of nursing.

It has been argued that nurses’ limited ability to express their issues and needs to a hospital management which is dominated by physicians plays a vital role in limiting health promotion work within nursing (28). Indeed, imbalances in the power relationships between hospital doctors and nurses might play an instrumental role in the lack of development of nurses’ role in health promotion within the hospital setting (9).

We also argued in an earlier paper that hospital nurses in Jordan might not be comfortable in broadening their role in health promotion due to shortages of nurses, low salaries, lack of time and organizational support and thus their lack of ability to implement changes (7). There is therefore a need for serious commitments from health organizations and policy-makers to address not only nurses’ salary-related issues but, more importantly, the nature and causes of their disempowering working conditions.

This analysis by micro, meso and macro levels is validated not only by findings from previous studies but also by the notion that the health-care system is a cultural system. More specifically it is reinforced by Kleinman’s model of the components of health-care systems which includes three social arenas within which health is experienced, shaped and enacted: popular, professional and folk (29). The popular, as reported in health promotion literature, includes the family context of health and illness (2). The professional involves specifically nurses in the health-care system and their broader links to the community. The folk is related to traditional ways of curing illness.

By analysing the issues at these three levels and understanding how they influence each other, nurses and other health professionals can draw on what individual, social and organizational factors affect the nurse’s role in health promotion and thus affect patients’ health gains. The model is multi-level in order to address diverse issues. Although informed by evidence from Jordanian research and the international literature (6,7), it differs from those models described earlier in that it attempts to incorporate all the factors that interact to affect nurses’ role in health promotion, together with strategies to tackle related barriers in a cultural setting (Table 1). The major models of health promotion deal only with specific knowledge, tasks and activities in formulating strategies for interventions and they fail to address the factors involved in planning and evaluation of health promotion work.

As discussed earlier, religious tenets can have a role to play in health promotion in Jordan. Currently, Jordan is largely populated by Muslims (95%), with only 5% of the population being Christian. If we are to Islamicize the role of hospital nurses in health promotion we need to encapsulate both individualized and community-based approaches using faith-based interventions that are driven by a collaborative synergy among religious leaders as well as the community. However, it is essential to ensure that a faith-based model/framework of health promotion is flexible enough to address the needs of other faiths and can adjust its components to the cultural and religious needs of other groups. The flexibility of the model will be judged by its ability to deal with the diversity of populations and by its social acceptability (3). Integrating hospital nurses’ role in health promotion within existing social, cultural and genuine religious ideology and working with religious leaders as key collaborators could be the first step on the ladder of enhancing the health of both hospital staff and the local community.

The model might enable cross-cultural comparisons to be made about hospital nurses’ role in health promotion. As a result, educators and decision-makers worldwide might be better prepared to plan and deliver culturally suitable educational programmes matching the needs of a diverse population. Nevertheless, no claims are made here that the model is a quick fix to overcome barriers to nurses’ role in health promotion in any hospital. This is due to the differences in the nature of the health-care system itself, the existing resources and the training opportunities for hospital staff. It should be noted that conceptual models differ from theory in that they are usually concerned not with resolving global problems but with addressing a specific issue within a certain context (30). The model therefore could be considered as a springboard for developing a theory of health promotion specifically related to health-care systems in Muslim countries. However, such a development cannot be pressure-cooked and it requires time and a specific assessment and evaluation of individuals’ needs.

Conclusion

The article describes a conceptual model for the role of nurses in health promotion in Jordan. Understanding the complexity of such a role as illuminated by the model might increase the likelihood of targeting the multiple factors that inhibit the development of such a role. While nurses have a potential role in health promotion, they represent only one spoke in the wheel of the whole model. That is, given the macro factors affecting the development of such a role, health promotion is a dynamic and cooperative process that requires key players to foster and maintain its success. Future empirical work needs to test the model and examine how addressing different contributing factors might foster nurses’ roles in health promotion within the hospital.

Funding: None.

Competing interests: None declared.

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