Commentary on 'Exploring district nursing competencies in health promotion: a Delphi technique'

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I always read with interest any nursing article that professes to deal with health promotion and this was no less so with Irvine’s recent article regarding ‘health promotion’ competencies as they relate to the discipline of district nursing. It is timely that more nursing-specific articles are addressing what they perceive to be health promotion issues – even if it is not actually health promotion that they are really addressing. Irvine’s article is no exception to the emerging tide of recent nursing-specific literature that is conceptually confused when it comes to health promotion activity. This is not a major problem, at this juncture, because such articles serve as a useful springboard to rectify the situation by allowing the real context and location of health promotion to surface through debate such as this. Where it becomes a problem, however, is if, in the face of the established position of health promotion in today’s context, nursing continues to disregard later perspectives in favour of ‘old-guard’ regimes and practices. I have been one of those who particularly seek to champion the real ‘new’ context of health promotion (which actually is not that new anymore) in the hope of moving things on for health-related activity in nursing (i.e. Whitehead 2001, 2003a,c, 2004, 2005). What Irvine (2005) refers to in her article as the ‘new paradigm’ of health promotion and her additional use of the term ‘traditional health promotion’ are very much out-of-date and outmoded concepts. She uses Maben and Macleod-Clark’s (1995) concept analysis as a basis for her interpretation of health promotion as it pertains to the study’s highlighted competencies. As we can already see this article is a decade old and has been both critiqued and superseded by a more recent concept analysis, that identifies current health promotion process in its much broader context of socio-political process, overall population health strategy and ‘whole’ community empowerment (Whitehead 2004). This type of activity is now inherent in the majority of mainstream health promotion literature – and what nursing should be striving to reflect in its health promotion activity. What Irvine (2005) is really referring to in her article is the notion of health education competencies as they relate to district nursing practice – not health promotion. There are different levels of health education practice and, admittedly, some of those highlighted in Irvine’s article do refer to less limiting health education techniques – namely those that acknowledge the contribution of individual empowerment, community presence and political awareness – what I would refer to as the ‘education’ component of health education practice (Whitehead 2004, Whitehead & Russell 2004). There is, however, a huge gap between community presence and ‘community empowerment’ and the same is true for the difference between political awareness and being ‘politically active’ – both, which are a mainstay of current health promotion activity. Irvine’s study mainly identifies the district nursing competencies of disease process, ill health, oppor- tunism, lifestyle and behaviour-change, psychomotor, cogni- tive and affective activity and epidemiology – which are very much entrenched within conventional and traditional approaches to health education. Irvine has demonstrated just how easy it is for nursing to fall into the trap of contextually confusing our practices and failing to move forward from current locations. Downie et al. (1996, p. 12) have described this phenomenon stating that: In effect, health promotion has become a dazzling bandwagon, gaining momentum and with all and sundry clamouring to climb aboard, without giving sufficient thought to what it is and where it is going. Irvine (2005, p. 973) goes on to state that her study outcomes may result in: a subsequent appreciation of the relevant competencies that will enable DNs (district nurses) to engage in health promotion in its broadest sense, from the traditional through to the new paradigm position. As stated previously though, this should be more correctly interpreted as ‘from the traditional through to the mid-range position’. Health promotion, in its broadest sense, is not represented in Irvine’s study. Such situations have created an uneasy tension between health education and health promo- tion practice in nursing and raised questions about the ability of nurses to move from a health education ethos towards a broader health promotion paradigm (Morgan & Marsh 1998, Norton 1998, Piper & Brown 1998, Whitehead 2001, 2004). Falk Rafael (1999) suggests that such tension has resulted in a situation where nurses are actively excluded from health promotion work by other health professional groups, are devalued as an ancillary medical service and are consequently ‘invisible’ in the world of health promotion. I wonder to what extent district nurses, if they were to adopt the competencies recommended by Irvine, would change this situation. If nursing wishes to become ‘visible’ amongst the health promotion community it needs to ensure that the current context for health promotion practice is acknow- ledged and measured – and appropriate competencies and programmes put forward for the task at hand. References Downie RS, Tannahill C & Tannahill A (1996) Health Promotion: Models and Values, 2nd edn. Oxford University Press, Oxford. Falk Rafael AR (1999) The politics of health promotion: influences in public health promoting nursing practice in Ontario, Canada from Nightingale to the nineties. Advances in Nursing Science 22, 23– 39. Morgan IS & Marsh GW (1998) Historic and future health promotion contexts for nursing. Journal of Nursing Scholarship 30, 379–383. Norton L (1998) Health promotion and health education: what role should the nurse adopt in practice? Journal of Advanced Nursing 28, 1269–1275. Piper SM & Brown PA (1998) The theory and practice of health education applied to nursing: a bi-polar approach. Journal of Advanced Nursing 27, 383–389. Whitehead D (2001) Health education, behavioural change and social psychology: nursing’s contribution to health promotion? Journal of Advanced Nursing 34, 822–832. Whitehead D (2003a) Viewing health promotion and health education as symbiotic paradigms: bridging the theory and practice gap between them. Journal of Clinical Nursing 12, 796–805. Whitehead D (2003b) Incorporating socio-political health promotion activities in nursing practice. Journal of Clinical Nursing 12, 668– 677. Whitehead D (2003c) The health-promoting nurse as a policy expert and entrepreneur. Nurse Education Today 23, 585–592. Whitehead D (2004) Health promotion and health education: advancing the concepts. Journal of Advanced Nursing 47, 311–320. Whitehead D (2005) Overview – the culture, context and progress of health promotion in nursing. In: Health Promoting Practice: The Contribution of Nurses and Allied Health Professions. (Scriven A ed.). Palgrave, London (in press). Whitehead D & Russell G (2004) How effective are health education programmes: resistance, reactance, rationality and risk? Recommendations for effective practice. International Journal of Nursing Studies 41, 163–172.

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