How committed are we health professionals to reducing the leading causes of morbidity and mortality in the United States through health promotion and prevention? AU of us may endorse high level wellness for our clients, but do our own lifestyles bear scrutiny? Is serving as a role model for health-promoting behaviors an integral part of professional role?
As research continues to validate how lifestyle - diet, exercise, stress management, moderation in alcohol use, abstinence from smoking - impacts on health (Hamburg, 1979; DHEW, 1979), we nurses are challenged to develop innovative approaches to assist individuals, families and communities to develop healthful habits and environments.
We educators are challenged to make a personal commitment to healthy lifestyle and to graduate nurses who can serve as role models for society.
Flynn (1980, p. 26) believes that clients have a right to have their health practitioners "... living examples of what we teach." She suggests intervention with clients may yield greater success since "there is an inner power and sense of strength that provides our argument with truth when our beliefs are reflected in our life and action." Carlin (1982), a professional nurse who changed her lifestyle and became a role model for clients, is also an advocate of this philosophy.
Society looks to health professionals for treatment and for example. Who has not heard a myocardial infarction victim say he will not stop smoking because his internist and staff nurses smoke? Can we remember feeling unsure of ourselves and a bit guilty when we completed instruction on a low saturated fat diet and then had a doughnut and coffee on our break?
In discussing nursing in the future, Schlotfeldt (1981, p. 301) points out the role of faculty in assuring that nurses be individually accountable to society: "Tb fulfill that responsibility, they must be properly educated. Let us decide now that by the year 2000 all new nursing professionals will enjoy education that will prepare them to fulfill their potential in improving the health status of the nation."
Baccalaureate nursing students at Alfred University, Alfred, NY, become familiar with the concept of health in their first nursing course. Health is a curriculum strand, along with individual, family, and community.
When students begin community health nursing in the senior year, holism, high level wellness, and optimal level of functioning are reviewed in depth (Archer & Fleshman, 1979, pp. 34-53; Ardell, 1977; & Flynn, 1980). Intervention tools such as contracting, a prevention model, and RQSenstock's health belief model are examined and analyzed in relation to the concept of self-iare (Jarvis, 1981, pp. 32-36; Pender, 1975; Spradley, 1981, pp. 123-146). In the clinical setting, students apply these concepts in a health hazard appraisal project.
Health hazard or health risk appraisal is an assessment and educational tool that personalizes an individual's risk of disease or injury over the next ten years by comparing an individuals risk with the total mortality risk of his age, sex, and racial group. The tool incorporates prognostic characteristics (risk factors) which alter total risk and are based primarily on epidemiological studies. Health appraisal ages are calculated and reflect the age ranking of an individual based on his risk factors. Achievable ages then reflect the age ranking presuming the individual has altered habits and health practices for risk reduction (Hall & Zwemer, 1979, pp. 5-11).
Criticism of Tool: Hall and Zwemer's health hazard/health risk appraisal tool (HHA/HRA) used in this project is one of a variety of instruments available (DHHS, 1981). Wagner, et al. (1982) criticize the validity, reliability, and usefulness of this technique in preventing disease and injury. They extensively reviewed the literature, made an inventory of programs using HHA/HRA, interviewed developers and users, and sought expert consultation.
Fielding (1982) concedes that the tool in its current developmental state has flaws, but he describes widespread use and popularity and ongoing research on how effective health risk appraisal can be in increasing knowledge and motivation to change and in actually changing behavior.
Individuals can hardly be expected to change behavior unless they know the diseases or injuries for which they are at risk (DHEW, 1979; Hall & Zwemer, 1979, p. 14). The HHA/HRA tool lists risks and heightens awareness of vulnerability. This student project then combines HHA/HRA with counselling in a high quality health promotion program, as recommended by Fielding (1982, p. 339).
HHA/HRA Profiles: Orientation to this clinical project includes explanation of pertinent epidemiological principles and instruction in how to develop health hazard appraisal profiles (Hall & Zwemer, 1979). Students are required to apply the tool to themselves in order to practice using the tables and making calculations and to heighten awareness of their own personal risks.
Students recruit a family of personal acquaintance or a family encountered during the clinical rotation who are interested in examining their health risks. Utilizing data gathered in a health history interview students apply the HHA/HRA tool to each family member over the age of five. Analysis reveals strengths and risks. Interventions relating to prognostic characteristics are hypothesized in order to allow calculation of achievable ages. For example, cessation or reduction of smoking reduces risk for arteriosclerotic heart disease, stroke, and cancer of the lung.
The Prevention Plan: Students begin to develop prevention plans based on prognostic characteristics. They include tentative goals, evaluative objectives, risk reduction measures and screening tests.
At this point, in accordance with instructions stressed in orientation, students integrate the tool into a broader prevention plan based on the primary causes of death for the age, sex, and racial group to which each individual belongs.
Drawing on theory encountered in previous courses and in current reading, students identify ways risk can be reduced that have not been incorporated into the appraisal tool. For example, learning to swim reduces risk of drowning, but it was not included in studies used to develop the tool. Sodium restriction reduces blood pressure, yet the tool does not mention diet. Healthy young people, not faced with stroke or lung cancer as a major cause of death in their age group, can develop health habits now that prevent the future development of chronic disease. Students consider these factors as well as others.
Students who develop comprehensive, prevention plans for individual members and the family as a whole are well prepared to respond to whatever goals are formulated in their second contacts with the family.
Students have also identified tentative risk reduction measures and early detection screening techniques appropriate to family risks. For example, if routine blood pressure readings seem advisable, students check the Heart Association schedule for a convenient time and place.
Whenever possible, students assume the role of guide to the family, who identify their own risks, goals, interventions, and evaluation or achievement measures. Students encourage family members to develop specific contracts among themselves as a method to achieve changes in lifestyle. If students plan continued involvement with the family, they may become party to a contract with specific roles and responsibilities beyond "checking up" (Steckel, 1980).
The family develops a mutually agreeable plan that addresses primary, secondary and tertiary levels of prevention. The plan may include only one aspect of lifestyle, such as increased exercise, or it may be more comprehensive. Goals may not be optimal outcomes, such as stopping smoking, but they may be realistic, such as reducing the number of cigarettes per day. Each student and family has a unique experience.
Reactions and Results
When family contacts are completed, students meet together to discuss experiences. Reports often reveal considerable frustration that lifestyle changes seem unlikely to be effected. Sometimes teaching plans were met with little or no enthusiasm and many excuses in defense of present practices. Family members challenge whether the suggested lifestyle changes have been proven effective in reducing risk. Everyone has read an article questioning the role of diet in cardiovascular disease! Everyone knows someone who would have suffered more extensive injuries in an automobile accident if he had been wearing a seat belt!
As anecdotes are related, students identify and analyze factors that may affect the success of interventions. Motivational factors, personal and interpersonal determinants of behavior become apparent. Does family history of disease make individuals feel more vulnerable? Do women feel the expense and embarrassment of a gynecological examination outweigh the benefits? Do individuals believe accidents strike randomly, and they have no control over the risk?
IMPACT OF PROFESSIONAL NURSES
Encouraged to evaluate the HHA/HRA tool itself, students become aware of its limitations, though most remain enthusiastic about the technique in combination with counselling as a means to reduce risk.
Faculty then guide students to focus on themselves, recalling they developed HHA/ HRA profiles for themselves and questioning whether students had identified need to alter their own habits and practices. Students are challenged to consider barriers to change or factors motivating change within themselves. They often find similarities between themselves and the families they have been discussing!
The issue of serving as a role model in both personal and professional life is explored. Students often endorse the philosophy, but realize how difficult it may be for themselves personally.
How effective can educators be in graduating nurses who can serve as role models of health-promoting lifestyles?
Pender (1982, pp. vii & viii) points out, "Despite an expressed commitment to the prevention of illness and promotion of health, the major emphasis of professional nursing education has been, and continues to be, on the knowledge and skills needed to provide care in illness or health crises."
Pender (1975, p. 388) describes preventive health behavior - actions that reduce risk of illness and accidents - as requiring a cue to convert a decision to engage in prevention into action. Developing their own health hazard profiles may serve as cues for some senior students. However, students should be examining the concept of health in relation to themselves early in the curriculum.
When a terminal objective of the curriculum specifically addresses role modeling of health-promoting behaviors as part of professional role, students can be expected to show growth cognitively and affectively in response to experiences at each level of the curriculum.
When the concept of health is introduced, faculty can emphasize personal application by using a simple health risk appraisal instrument. For example, Healthstyle: A Self-lkst is a Department of Health and Human Services' pamphlet (1981) which provides a numerically scored profile based on three or four questions in each of five behavioral areas - eating habits, substance abuse, fitness, safety, and stress management. Carlin (1982, p. 49) also endorses a self-assessment test.
Assistance to reduce risk and promote health may already exist in the college and surrounding communities. Nursing faculty, faculty in allied fields, and student health and counselling services may develop other opportunities.
Students may need stress management counseling, smoking cessation clinics, or weight reduction groups. Running clubs, flexible hours for gymnasium use, or aerobic dance classes will enhance fitness. Alternative food choices may be offered at cafeterias and vending machines.
Implementation of a curriculum plan would require commitment by faculty: commitment to enhance themselves as healthy role models and commitment to students. The impact of the plan is illustrated in the Figure. The potential rewards for individual students are great, but the rewards for nursing as a profession are greater.
Ultimately, the rewards for society are greatest, as healthy, professional nurses assist individuals and families to high level wellness.
In addition, at the community level nurses can make an impact on the social, organizational and environmental circumstances in which people live. "Health-promotion efforts within the larger society can support and enhance personal health behaviors by increasing the range of health- promoting options available, by decreasing opportunities for healthdamaging behaviors, and by assisting the public to discern the difference between them" (Pender, 1982, p. 368).
- Archer, S.E., & Fleshman, R.P. (1979). Community health nursing: Patterns and practice (2nd ed.). Boston: Duxbury Press.
- Ardell, D.D. (1977). High level wellness. Emmaus, PA: Rodale Press.
- Carlin, D.C. (1982). How to assess your wellness and become a mode] for your patienta. Nursing Life, 2(2), 48-49.
- Fielding, J.E. (1982). Appraising the health of health riak appraisal. American Journal of Public Health, 72(4), 337-340.
- Flynn, P.A.R. (1980). Holistic health: The art and science of care. Bowie, MD: Robert J. Brady.
- Hall, J., & Zwemer, J. (19791. Prospective medicine. Indianapolis: Methodist Hospital of Indiana.
- Hamburg, D.A. (1979). Disease prevention: The challenge of the future. American Journal of Public Health, 69(10), 1026-1033.
- Health risk appraisals: An inventory, (1981), (DHHS (PHS) Publication No. 81-50163) Washington, DC: U.S. Department of Health and Human Services.
- Healthstyle:Aself-test. (1981). (DHHS(PHSi Publication No. 81-50155) Washington, DC: U.S. Department of Health and Human Services.
- Healthy People: The Surgeon Generate Report on Health Promotion and Disease Prévention. (1979). (DHEW (PHS) Publication No. 79-55071) Washington, DC: U.S. Department of Health, Education, and Welfare.
- Jarvis, L. L. (1981). Community health nursing: Keeping the public healthy. Philadelphia: F.A. Davi s Co.
- Pender, N.J. (1975). A conceptual model: Preventive health behavior. N.O., 23(6), 368, 385-390.
- Pender, N.J. (1982). Health promotion in nursing practice. Norwalk, CT: Applet on-CenturyCrofts.
- Schlotfeldt, R,M. (1981). Nursing in the future. N.O., 29(5), 301.
- Spradley, B.W. (1981). The helping relationship and contracting. In Community Health Nursing: Concepts and Practice. Boston: Little, Brown and Co.
- Steckel, S.B. (1980). Contracting with patientselected reinforcers. American Journal of Nursing, 80, 1596-1599.
- Wagner, E.H., et al. (1982). An assessment of health hazard health risk appraisal. American Journal of Public Health, 72(4 ), 347-352.