Throughout history, the word "health" has had various meanings. It was derived from the old English word "hoelth," which meant a state of being sound, and was generally used to infer a soundness of the body (Dolfinan, 1973). In more recent times, health has been defined in many ways, such as being the opposite of disease (Tillich, 1961) and a state of well-being "characterized not merely by the absence of disease or infirmity but also by a state of complete physical, moral, and social well-being" (WHO, 1947, p. ii). Health has also been used in reference to performance of social roles (Parsons, 1958) and as a hierarchical biophysical status that is a social goal (Twaddle, 1974).
The adaptive process of health was proposed by Dubos: "health or disease are the expressions of the success or failure experienced by the organism in its efforts to respond adaptively to environmental challenges" (Dubos, 1965, p. xvii). The process of growth as well as the process of adaptation was proposed by Dunn (1959). Man was described as "a physical, mental, and spiritual unity - a unity which is constantly undergoing a process of growth and adjustment within a continually changing physical, biological, social, and cultural environment" (Dunn, 1959, p. 789).
Originally the word health had a holistic connotation and has been viewed as the dichotomy of disease. Health and illness have also been viewed at opposite ends of a continuum inferring various degrees of health and illness. Additionally, health has been viewed as a product and a process. The definition of health has included the process of growth and development, effective functioning and adaptation, and effective role performance.
In the discipline of nursing, the majority of nurses agree that health is a major concept (Flaskerund & Halloran, 1980); however, this agreement does not extend to a consensus regarding the meaning of health. Health is viewed as a process of life (King, 1981; Newman, 1979; Rogers, 1970; Roy & Roberts, 1981), normal functioning (Orem, 1985), and the process of adaptation (Neuman, 1982; King, 1981; Roy & Roberts, 1981). Health is also viewed as a process of growth and development (King, 1981; Newman, 1979; Parse, 1981). The unity of man is either explicitly or implicitly implied in these definitions (King, 1981; Neuman, 1982; Newman, 1979; Orem, 1985; Parse, 1981; Rogers, 1970; Roy et al, 1981).
The meaning of health varies among major nursing theorists; therefore, it must also vary among students. In the educational process, it is important to assess where the learner is in relation to the concept to be learned. As health is a major concept for the discipline of nursing, the perception of graduate nursing students regarding the definition of health is important to the educational process. The purpose of this qualitative study was to examine the meaning of health for graduate nursing students based on their Ufe experiences. The research question to be answered was: What is the meaning of health for graduate nursing students?
Review of Literature
The majority of literature consists of definitions of health proposed by nurses, yet there is a lack of research on nurses' definition of health. Nurse scientists have conducted a limited number of studies on the meaning of health held by actual or potential consumers of health care. Studies on the meaning of health for nurses are needed.
Health is viewed as a dynamic process of "developing and living" (Alien, 1981). Health and illness are denned as two different variables that have a negative relationship: along the illness continuum, as the level of illness increases the level of health decreases. A similar view is held by Fry (1980) in that health and illness are different states.
Hollen (1981) describes health as a continuum and proposes a health/choice continuum. This continuum is delineated into three sections of maximum health with determination of choices, impaired health with hazardous choices, and depleted health without determination of choices.
An evolutionary model of biopsychosocial health is proposed by Dixon and Dixon (1984). Based on evolutionary assumptions, well-being is proposed to be connected with being a member of a group; group members who deplete or do not contribute to the group are eliminated.
Upon completion of a linguistic analysis, Brubaker (1983) defines health promotion as "health care directed toward high level wellness through processes that encourage alteration of personal habits or the environment in which people live" (p. 12). The health continuum is illustrated as a curved line to reflect growth of the person.
Health Definitions of Consumers
Natapoff (1978) explored how 264 children in first, fourth, and seventh grades view health through use of an interview format. Content analysis of answers delineated the health categories as: feel good, do desired things, not sick, ability to eat food, exercise, cleanliness, happiness, strong body, good condition, and good check-ups. The number of categories and the complexity of the answers increased with age, reflecting a developmental trend. Health was viewed as more than the absence of symptoms of illness and was perceived as a long-term condition whereas illness was perceived as short-term.
Definitions of health and health behaviors as well as their relationship to each other were explored by Laffrey (1985). A health conception scale was developed based on response statements from interviews. These responses were categorized into four dimensions related to the clinical role performance and adaptive and eudemonistic health models. Persons defining health according to the eudemonistic model (self-actualization or striving to reach one's potential) tended to have higher levels of health promoting behaviors whereas those defining health according to the clinical model had health behaviors related to preventing illness or symptoms.
Using a phenomenological approach, Parse, Coyne, and Smith (1985b) explored the life experience of health. A written description to the request to "describe a situation in which you experienced a feeling to health" asked of 400 subjects was analyzed. For the 7- to 19-year olds, health was hypothesized to be a "resonating clarity powered by an invigorating force in constructing successftillness" (p. 31); a "symphonic integrity manifested in the spirited intensity of fulfilling inventiveness" (p. 31) for 20- to 45-year olds; "serene unity lived in exhilarated potency toward creating triumphs" (p. 32) for 45- to 65-year olds; and a "synchronous contemplation fixed by transcendent vitality in generating completeness" (p. 34) for those over 65 years of age.
The qualitative descriptive approach of phenomenology was used to answer the research question. Phenomenology is the study of the life experience of the subject (Field & Morse, 1985; Knaack, 1984; Oiler, 1982; Ornery, 1983; Parse, Coyne & Smith, 1985a). Understanding the meaning of the experience is desired, not prediction and control. The meaning is subjective in relation to the subject/participant; the researcher should approach the study of the life experience or phenomenon without any preconceived definitions, conceptual frameworks, or expectations. The goal of the pheomenological approach is "to describe the total systematic structure of the lived experience, including the meaning that these experiences had for the individuals who participated in them" (Ornery, 1983, p. 50). This method is inductive and generates hypotheses, with the emphasis on answering "what" questions (Knaack, 1984). With no available data on the meaning of health for graduate nursing students, this approach is appropriate to determine the meaning of health for graduate nursing students.
Structuring the study included specifying the research question, researcher's perspective, and sample. The sample selected was 29 registered nurses who were graduate nursing students at two schools of nursing. According to Parse et al (1985a) the sample should be drawn from a population who is living the experience. In addition, the experience should be in the participant's consciousness (Field et al, 1985; Knaack, 1984). Nurses satisfy these two requirements. The subjects were asked to participate and completion of the written answers was considered consent. Assurances of anonymity were given.
The researcher's perspective is illustrated in the following definition of health: health is a life process of the individual - a unity who is growing while effectively functioning and adapting to developmental changes and to environmental conditions, events, or Stressors. Wellness and illness are consequences of adaptation on the part of the individual. Health as a product is the state of wellness or illness reflecting the unity of the individual at that specific point.
Gathering the data consisted of requests of the subjects to describe their meaning of health. Data is retrospective and thus questions need to promote reflective descriptions (Parse et al, 1985a). Based on a study conducted by Parse et al (1985b), the subjects were asked to "describe a situation in which you experienced a feeling of health. Share your thoughts, perceptions, and feelings about the situation" (p. 29). Subjects were asked to respond at their convenience, but to return the description within two weeks. Additional information elicited was age and years of experience as a registered nurse.
DESCRIPTIVE EXPRESSIONS OF AWARENESS OF PHYSICAL STATE RELATED TO ABILITY, APPEARANCE, AND ENERGY LEVEL
The data was analyzed according to a process described by Parse et al (1985a): eliciting descriptive expressions; identifying common elements of experience; eliminating those expressions not related to the phenomenon; formulating a hypothetical definition of the phenomenon; applying the hypothetical definition to the original descriptions; and identifying the structural definition. Aspects of the process that are involved in these steps are contemplative dwelling (reading descriptions for the sense of the whole), intuiting (attentions to meaning described by the subjects without interpretations by the researcher), and describing. Characteristics and relationships are delineated systematically in analyzing common elements and relationships. Common elements, descriptive expressions, and structural definitions were verified (97% inter-rater reliability) in relation to raw data descriptions by two judges who were doctorallyprepared nurses familiar with qualitative research.
Descriptions of experiences of feelings of health were completed and returned by 29 (81%) of the 36 graduate nursing students who were approached. The participants ranged in age from 25 to 45 years; their experience as registered nurses ranged from 2 to 25 years. Descriptive expressions of feelings of health were obtained from 26 of the participants. One participant did not provide a descriptive expression of a feeling of health, but rather described enviromnental/situational conditions; another participant described the perception of another individual who was healthy.
From the participants' response, 68 descriptive expressions were obtained. Of these, 33 reflected an awareness of a physical state and 35 reflected a mental state. Three elements composed the physical state: physical ability, physical appearance, and energy level. Similarly, three elements also composed the mental state: happiness/contentment, anticipation/excitement, and clarity of thinking. Figures 1 and 2 delineate the descriptive expressions and elements of the physical and mental states, respectively.
DESCRIPTIVE EXPRESSIONS OF MENTAL STATE RELATED TO HAPPINESS/CONTENTMENT, ANTICIPATION/ EXCITEMENT, AND CLARfTY OF THINKING
From these descriptive expressions and elements, a structural definition was proposed: health is an awareness of a physical state related to abilities, appearance, and energy level as well as a mental state of happiness/ contentment, anticipation/excitement, and clarity of thinking.
Descriptions of experiences of health for 16 participants who were less than 35 years of age involved both a mental state and an awareness of a physical state. For the 12 participants who were 35 years of age or older, only seven descriptive expressions reflecting an awareness of physical state were noted; otherwise, the descriptive expressions reflected a mental state.
Along with describing experiences of feelings of health, many participants described environmental, situational, or developmental conditions. Being outdoors and enjoying nature were described by six participants. Physical activities such as skiing, jogging, hiking, walking, and regular exercise was mentioned by 16 participants (55%). Sharing and being with significant people were described by four participants; one participant described a relaxed atmosphere. Being pregnant was mentioned by three participants and discovering self was mentioned by one participant. The absence of symptoms, the confirmation of physical health, and a decrease in the amount of stress were each mentioned once.
The structural definition reflecting a mental state as well as physical awareness for this sample of 25- to 45-year-old nurses was similar to the "symphonic integrity" and "invigorating force" of 20- to 45-year-olds and 7- to 19-yearolds described by Parse et al (1985a). The greater focus on mental state for nurses 35 years or older possibly reflect a developmental trend towards self-actualization. Laffrey (1985) reported higher levels of health behaviors for persons who viewed health eudemonistically (in a self-actualizing way). Developmental conditions were implicitly or explicitly mentioned by participants. The developmental conditions were discovering self, sharing with a significant person, and being pregnant. These could be a reflection of Erikson's (1950) developmental tasks of identity, intimacy, and generativity, respectively.
The findings support contemporary definitions of health. Feelings of health were generally positive and were more than the absence of illness, reflecting définitions proposed by WHO (1947). The physical and mental aspects of the findings reflect Dunn's (1959) definition although spirituality was not explicitly addressed. Growth and developmental aspects of health definitions proposed by Newman (1979), King (1981), and Parse (1981) are reflected in the developmental trends that were noted.
The descriptive expressions reflect health as a product or as a specific point. The way in which requests were phrased influenced the response toward descriptions that reflected a product instead of a process. The situational and developmental conditions that were described reflected process aspects as proposed by several researchers (King, 1981; Newman, 1979; Rogers, 1970; Roy & Roberts, 1981). The descriptive expressions did not appear to reflect normal functioning (Orem, 1985) or adaptation (Dubos, 1965; King, 1981; Neuman, 1982; Roy et al, 1981).
These findigns add to the body of knowledge of the meaning of health for nurses, specifically graduate nursing students. Although the sample size is small by quantitative research standards, it appears to be adequate by qualitative research standards. The majority of the data or descriptive expressions were subordinate to six elements. According to Field and Morse (1985), when the data provide no new information, the sample size is adequate. These findings are not generalizable to the population of graduate nursing students, but they add to the body of knowledge upon which further research can be conducted.
The meaning of health was described by nurses as an awareness of a physical and mental state. Health was defined as an awareness of physical abilities, appearance, and energy level as well as a mental state of happiness/ contentment, anticipation/excitement, and clarity of thinking. A potential developmental trend was noted.
Graduate nursing students need to be cognizant of the meaning of health that they hold. Provision of nursing care is influenced by the meaning of health held by the nurse. Additionally, nurses need to be cognizant of the client's personal meaning of health. Both the nurse's and the client's meanings of health influence nurse-client interactions related to health care. Interactions between nurse and client regarding meanings of health and subsequent health care and behaviors should be examined further. In addition, the potential developmental trend needs to be explored.
The teaching process in relation to the concept of health could be facilitated by increasing the awareness of graduate nursing students of their own définition of health. Clarification of the concept of health is important for both the discipline of nursing and for the individual nurse.
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