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Health Promotion and Nursing Care

Doris Schaeffer

(last update 02 March 2015)

That health promotion also plays a major role in nursing is today taken as given in Germany. Nevertheless, for many years this thought was considered strange: According to the sequential approach to care (something that is still valid for large parts of the discourse on care), nursing stood squarely at the end of the healthcare process and was activated only when all other preventive, curative and rehabilitative possibilities had been exhausted, that is, when the task remaining was solely one of safekeeping and safeguarding. This understanding is also reflected in the existing legislation (the Long-Term Care Insurance Act, SGB XI). Although the basic principle propagated there is that prevention goes before care (and before rehabilitation), a forward-looking idea in light of the long-neglected possibilities prevention offers, nevertheless this law contains ideas concerning the basic tasks of care which are no longer considered valid in international nursing science. The simple principle of prevention going before care fails to emphasize the inherent prevention potentials contained within care, but rather points to those links in the healthcare chain that lie before nursing.
Internationally, on the other hand, it has long been considered part of nursing to integrate health promotion and prevention into its central functions. This means rejecting the one-sided understanding of nursing as being oriented toward sickness and deficits and moving toward a more resource-oriented approach. This includes the goal of restitution and the preservation of health equilibrium - or at least preserving the best possible optimum and supporting existing health. The innovative part of this approach lies not in its emphasis on health, but in its rejection of the dichotomy of differentiating between sickness/impairment and health. The most important thing is to maintain the balance between health impairments and existing resources. Health is thus understood as a successful balance and sickness as a poor balance between impairments and resources - something that can, of course, change at any time. This approach, as mentioned, means to renounce the deficit-oriented means of access and favor a strengthening of resources.

Anchoring this understanding of nursing fulfills in the healthcare reality of Germany proves to be a challenge. It presumes that it is necessary to step away from the sequential understanding of care and take account of the fact that nursing does not mean simply a final safekeeping, but is part of all phases of healthcare and contains a number of unrealized health-promoting potentials. This approach also means modifying the concepts and strategies of nursing and anchoring them in legislation, which yet leaves little room for preventive, health-promoting and educational tasks. The journey toward this end has certainly been initiated, but the legal foundation is still missing.

The fact that health promotion and prevention have been given greater roles in nursing is, among other things, the result of the demographic and epidemiological changes that are rapidly progressing in Germany. They have confronted the healthcare system with many new challenges, including nursing. According to the reports of the Advisory Council on the Assessment of Developments in the Health Care System it may be assumed that the number of persons needing nursing will climb from 2.13 million today to 4.35 million by the year 2050 (SVR 2009, 2014). In order to meet this challenge, prevention will have to be given a much greater priority than is presently the case - alone for cost reasons. But also health promotion among the chronically ill and those in need of nursing care require more attention. Those are only two of the most important tasks facing the nation.

In nursing too prevention aims at warding off illnesses, long-term impairments and the need for intensive nursing care by eliminating the respective risks (e.g., risk of falls). But it also strives to prevent the extension of nursing and reducing - or at least delaying - exacerbations.

Health promotion, on the other hand, is concerned less with the specific illness or the risks leading to nursing as it is with the existing resources, protective factors and conditions that can strengthen people´s health and enable them to maintain their health, to deflect dangers to their health and to obtain more control over their health and finally their life. In the Ottawa Charter, health promotion is related to nursing and has as its goal to “enable people to maintain a high level of control over their health and thus to contribute to those things that determine their health”. However, in nursing - and this is what makes it special - we are dealing with persons with impaired health and great vulnerability. Most of them have irreversible impairments - one or more chronic illnesses, long-term physical restrictions (in part cognitive as well) and the need of nursing care. In many cases, they can no longer cope with their situation autonomously and are dependent on help. Also that makes them vulnerable. In addition, they often suffer from social vulnerability, such as the lack of a strong social network or social isolation, which limits their ability to participate. Even economic resource weakness is not uncommon. This particular sort of vulnerability of persons in need of nursing care must be addressed by health promotion in nursing. Thus, the goal is to stem the loss of resources, to remobilize those health potentials that still remain and to strengthen existing resources and resilience.

Preventing the need of care: One of the most important and little recognized tasks is the prevention of need for nursing care, whether by strengthening health literacy and other educational interventions (patient counseling/patient education) or by promoting physical activities and mobility which − in case of regular implementation/application - can contribute to maintain health and also to delay the occurrence of chronic illness and the need of nursing care, or by systematic monitoring (e.g., the concept of preventive homecare). Here there is a need for research and further evidence-based concepts.

If, however, the need for nursing care is already present, the task of prevention is to fend off the expansion of health and functional limitations, to prevent exacerbations and help stabilize the health situation, whether through preventive nursing (such as the mobility and physical activity; both of these themes were included in the National Expert Standards for Nursing of the German Network for Quality Development in Nursing, DNQP), continuous systematic monitoring of health and functional status (sight, hearing, dental health, healthy nutrition, mobility, etc.), measures to ensure greater security such as enabling safe environmental conditions (e.g., removing dangers of falls and accidents), the prevention of unnecessary deterioration, increased patient information and education, or limiting social vulnerability.

Health promotion in nursing: The literature shows that the three-pronged approach favored for other target groups - physical exercise, healthy nutrition and promotion of resilience − is also relevant for nursing care. Today, many studies have been published that reveal that even a brisk walk has a number of different healthy effects, such as extending one´s life expectancy, lowering the risk of mortality, lowering overall morbidity and improving mental well-being. Many of these studies, however, were concerned more with younger old people, though the presumption is that most elderly persons in need of nursing care would profit as well. Some of the programs have even been evaluated, such as “Fit for 100,” “PATRAS” or “SIMA-50+” and “SIMA-P” (Overview: cf. bfi.zqp.de).
Similar effects on health may lie in optimizing nutritional behavior and in preparing measures to promote resources and to strengthen resilience. How important these measures are can be seen in the fact that health promotion is generally directed toward persons with fragile health who have lost the balance between health losses and potentials and are in danger of chronification. Stopping this development by fostering all remaining resources and strengthening healthy well-being as well as mental resilience is one of the most important tasks of health promotion.

In conclusion, it can be stated that the importance of health promotion and prevention in nursing in Germany is increasingly recognized. This can be seen in the current draft of a Prevention Act, which explicitly calls for health prevention and promotion to be a part of inpatient care. And it has been introduced into the practice of nursing, with many examples of initial measures now being implemented. The most popular approaches at the moment are behavior-oriented concepts rather than relationship-oriented concepts, though the latter are of great relevance to the recipients of nursing. Presently, however, studies and evaluated evidence-based concepts supporting this venue are missing in Germany. Their implementation is at odds with existing structural hurdles, in particular the narrow official understanding of nursing and the present conditions. Removing hurdles of this type, however, is one of the most important tasks that lie ahead. This also means considering the working conditions and the health of those providing the nursing care and the relatives of the care recipients. Studies have shown that they are highly stressed and for their part in need of health promotion (company-wide health promotion, health promotion in the hospital).

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