The Future of Nursing Report published by the Institute of Medicine (IOM) symbolizes a paradigm shift in health care delivery from sick care to well care.1 The IOM envisions a health care system where nurses intentionally promote wellness and disease prevention and improve health care outcomes throughout the lifespan.1 The nursing profession is well recognized for the role of disease prevention and health promotion as established in the seminal article of Donaldson and Crowley2 to the recent Future of Nursing Report from the IOM.1 Within the scope of nursing practice, the words "health," "health promotion," and "wellness" appear to be used interchangeably. Florence Nightingale, Virginia Henderson, and Margaret Newman developed frameworks that conceptualize wellness; however, wellness is not clearly defined within these theories.3-6 Nurses' ability to achieve the mission of the IOM and intentionally promote wellness is limited by the absence of a universally recognized understanding of the concept of wellness and a common paradigm to promote wellness in nursing practice.7 The purpose of this article is to conceptualize the historical evolution of wellness and highlight the gap in nursing practice between knowing and promoting wellness.
THE CONCEPT OF WELLNESS
The absence of a universally recognized concept of wellness in the nursing profession is better understood after examining the complexity of wellness through 3 philosophical arguments: ontology, realism, and empiricism.
Plato's ontological argument establishes wellness as a state of being. Patient lives represent diversity and ever-changing circumstances; patients will define what it means to be well based on their changing world. Their perception of wellness will generate from their current circumstances and will continuously change.8 Thus, the concept of being well is not static, but fluid. According to Plato, all living things aim and aspire to "good being." From this perspective, all people naturally hope to gravitate toward a state of wellness, or "good being." As people experience enhanced wellness, they will become more self-aware and learn about additional experiences that will promote wellness. Wellness is a process of becoming, a process that does not have an end point; therefore, every person strives for wellness throughout life. Wellness expands beyond health and does not simply apply to people in poor health, or people who need to prevent certain diseases. Every person continues on a journey to achieving his or her full potential and maximizing his or her wellness.8
The philosophical argument of realism aligns with the concept of wellness. Realism explains the reality of a phenomenon. Wellness from a realist perspective asks, "What is the reality of wellness? What does wellness look, act, and feel like? Wellness will look, act, and feel different for every patient. Realities are unique to individuals' environments, genetics, and experiences.9 Patients' realities will influence their views and perception of wellness.
Wellness embraces an empirical philosophy; however, this philosophy differs from empirical research and practice and expands to the patient's experience. John Locke, a philosophical empirical thought leader, proclaims that knowledge is derived through experience.8 Personal patient experiences will determine his or her definition of wellness. Nurses cannot possibly acquire the experience of each individual patient. Every patient who interacts with a nurse will possess different knowledge compared with the previous patient. Knowledge creates worlds for patients, worlds that translate into unique and diverse definitions and understandings of wellness.
Wellness is difficult to conceptualize, which may explain the omission in definition and paradigm development within the nursing profession. In the absence of a universal, clearly defined understanding of the word and concept of wellness, the National Wellness Institute10 provides this clear definition of wellness: wellness is a multidimensional and holistic state of being that is conscious, self-directed, and constantly evolving to achieve one's full potential. Wellness is an ever-changing process that encompasses multiple dimensions, known as the Six Dimensions of Wellness: intellectual, spiritual, emotional, physical, occupational, and social dimensions.10,11 The Six Dimensions of Wellness reflect unique characteristics that interconnect with one another to represent the person as a whole. Table 1 provides the definition for each of the Six Dimensions of Wellness.
|TABLE 1. Definitions of the Six Dimensions of Wellness|
HISTORY OF WELLNESS IN NURSING
According to the National Wellness Institute,10 a professional can determine whether he or she practices within a wellness approach if he or she answers "yes" to the following 3 questions: "Does this help patients achieve their full potential? Does this recognize and address the whole patient? Does this affirm and mobilize positive qualities and strengths?"10 The nursing frameworks of Florence Nightingale, Virginia Henderson, and Margaret Newman are examined for congruency with wellness profession guidelines of the National Wellness Institute.
Florence Nightingale's theory supports wellness by addressing the whole patient and affirming his or her positive qualities and strengths.6 Nightingale believed that patients should be placed in optimal environments that allow nature to act. Her theory promoted nature as the ultimate cure for any disease process. According to Nightingale's theory, environments are multidimensional. The air people breathe, the food people eat, the company people keep, and the conditions people live will interact to promote or prevent healing.6
Nightingale believed that nurses should work to prevent disease and care for well patients with the same approach as caring for sick patients.6 She explained that diseases proliferate for years before manifesting into clinical symptoms. Therefore, nurses can improve the environment of well patients to prevent disease. Improving the environment could be as simple as helping a patient create a healthy menu plan to helping a community improve air quality. Nightingale encouraged nurses to empower society to improve environments outside hospitals such as schools, homes, and communities in order to prevent disease.6
Nightingale's theory represents affirming and mobilizing positive qualities within patients.6 She believed that the patient, whether sick or well, is the best person to care for his or her own health. She encouraged nurses to view patients in the moment. She warned nurses not to judge patients with condescending thoughts or words. Nightingale believed that nurses should recognize that patients would do better in a supportive environment.6
Nightingale's theory of placing the patient in an optimal environment for healing and preventing disease promotes a wellness approach by addressing the patient positively and holistically. However, Nightingale does not define well, or wellness. Through her descriptions, the state of wellness is reflected by the absence of disease. Nightingale's theory does not support the concept of assisting patients to achieve their full potential. Patients who are not sick are not necessarily achieving their full potential.6 The absence of disease is not reflective of full potential.10
Henderson's theory supports wellness by addressing the patient from a multidimensional perspective and encourages them to provide their own care.3 In Henderson's complex, multidimensional model, she defines health as a person's ability to perform 14 activities independently.3 Although the word "wellness" is not used in Henderson's theory, her activities align with the Six Dimensions of Wellness framework.11Table 2 organizes Henderson's theory in the Six Dimensional Framework.
|TABLE 2. Henderson's Definition of Health and the Six Dimensions of Wellness Framework|
Henderson believes that the nurses' role is to assist patients with the 14 activities when they lack the strength, knowledge, or will. At the same time, she emphasizes that nurses should care for all patients; she believes that basic human needs exist in patients who are sick and patients who are well. She believes that nurses should promote health and prevent disease.3
Henderson's theory affirms and mobilizes the strength of patients. She further states that nurses must encourage and empower patients to care for themselves.3 Nurses should not do everything for a patient; the best care is the care that the patient gives himself or herself. Nurses should recognize that health is multidimensional and affected by variables such as age, environment, genetics, culture, emotional balance, and intellectual abilities.3
Henderson encourages nurses to also care for well people. She defines health as the ability to perform 14 functions independently. Although Henderson encouraged and believed that nurses should provide care to well patients, not just sick patients, she never provided an explanation for how the nurse would care for a patient who could independently perform the 14 functions. Her theory addresses patients holistically and promotes affirmation; however, similar to Nightingale, her theory does not address helping the person achieve his or her full potential or maximal level of wellness. She defined health and even emphasized the nurses' role in caring for well patients, but she did not define wellness, nor did she provide a framework to promote wellness.
Newman's theory, Health as an Expanding Consciousness, supports 3 wellness approaches: addressing the whole patient; assisting the patient to rise to his or her full potential; and affirming the qualities within a patient.4 In Newman's theory, disease is an underlying manifestation of an imbalance within a patient. Health is more than the absence of disease; health is the expansion of consciousness, or personal growth. Newman's theory supports the idea that even in the face of illness, a patient can grow and make progress. Although disease appears negative, Newman believes that disruption eventually transforms a patient's life into a higher state of being, or consciousness.4
Health as a state of consciousness, according to Newman, is represented through the quality and interaction of a patient with his or her environment. Newman addresses the complexities that exist between every individual and his or her environment. Every patient's relationship with his or her environment will generate different reactions. The reflections on experiences that occur within the environment provide growth or expanded consciousness. Newman stresses that for nurses to promote expanded consciousness, they must provide highly individualized care to every patient. She also believes that the process of expanding consciousness can occur anywhere, anytime. The process is not limited to a specific health care setting, or the presence or absence of a disease.4
Nurses' responsibility in promoting consciousness reflects the wellness approach of affirming and addressing the whole person. Newman believes that to promote consciousness, nurses need to look at patients as a whole, greater than the sum of their physiologic systems. Health is not something someone achieves or loses. Patients can have consciousness even in the face of illness and disease; you cannot lose consciousness or achieve consciousness. Illness or diseases create an opportunity for growth.4
For optimal effectiveness of Newman's model, the relationship and environment created between a person and a nurse are essential. Nurses must provide individualized care focused on listening attentively to the person's life, and rhythm. Nurses need to embrace uncertainty and not focus on fixing the patient but, instead, listen and promote what is working well. People's lives are not certain, they are all different and unique; disequilibrium is necessary for growth. Nurses need to give patients the opportunity to reflect, think, and generate their own growth. Nurses cannot manipulate and control patients; the partnership between nurses and patients is essential to expanding consciousness.12
Newman's theory embraces the concept that wellness is a state of being, ever changing and continuously evolving. Newman does not use the word "wellness" to describe her theory; however, her theory suggests that nurses cannot define wellness for patients because wellness will mean something different to every patient. Nurses need to promote wellness by accepting uniqueness and developing a deep understanding for each patient's environment and experience.
Although each of the theorist believe that caring for patients who are well is essential to the nurses' role, none clearly define the concept of wellness or provide a framework for nurses to practice and promote wellness.3,4,6,12 To examine the relationship between the theoretical foundations of wellness and current nursing practice, a review of the literature was completed using CINHAL. Literature examining the role of wellness in nursing practice was notably absent. The CINHAL thesaurus suggested using the search terms "health promotion." Five qualitative research studies aiming to explore nurses' perceptions of the definition of health promotion, how they promote health in practice, and barriers to promoting health in practice were included in the review. The sample sizes ranged from 8 to 20. Nurses working in acute care, geriatrics, advanced practice, academia, community, and mental health care were represented. Because of the expanded search, a definition of health promotion is provided in the following text.
The World Health Organization13 defines health promotion as a process to help individuals increase control of their health with the desired outcome of physical, mental, and social well-being. The World Health Organization distinctly emphasizes that before health promotion can occur, a patient must recognize his or her aspirations, satisfy his or her needs, and change or cope with his or her environment. Health and wellness promotion is a fundamental role within the nursing profession, yet a review of the literature highlights a gap in nursing knowledge about how and when to promote health and wellness.
NURSES DEFINITION OF HEALTH PROMOTION
The results of 5 qualitative research studies suggest that nurse's definition of health promotion is ambiguous and uncertain.14-18 The common definition of health promotion among nurses, in a variety of health care settings, refers to providing health education and advice about healthy life styles.15-18 For example, nurses believed that health promotion is telling someone why he or she should change his or her behavior or life to protect or improve his or her health.18 Nurses with more experience commonly perceived health promotion as empowerment.17
Advanced practice nurse practitioner students with at least 2 years of nursing experience participated in a research study that evaluated their perceptions of health promotion. The students completed qualitative questionnaires before and after a health promotion course. Before the health promotion course, the students described health promotion as advice giving and health education. After the health promotion course, the student's views of health promotion evolved to empowering the patient.18
HOW NURSES PROMOTE HEALTH
In the research studies included in the review, the most common theme about how nurses promote health is giving information about healthy lifestyles to patients with specific health conditions.16-18 For example, if a patient presented to the hospital post-myocardial infarction, the nurse would encourage the patient to exercise more frequently and eat more fruits and vegetables.16 Some nurses believe that they promote health without any deliberate efforts because promoting health is a natural and automatic component to their work. Consequently, they are unable to recall specific examples about the last time they promoted health.15
BARRIERS TO HEALTH PROMOTION
The most common perceived barrier to promoting health in nursing practice is time,15,17,18 followed closely by not enough education and training.15,17 Some nurses believe that they needed more evidence that health promotion is an effective method for helping patients improve their health.17
Nurses perceive patients as barriers to promoting health. Some nurses believe that patients are unwilling to accept health promotion.15 More than half of nurses who perceived that patients should not have a choice to receive health promotion believed that patients frequently ignore advice given to them.17 Patients' knowledge deficit about healthy lifestyles and patients' unwillingness to change emerged as health promotion barriers for nurses.18
The health care system and work environments do not support nurses in the role of health promotion.14,15,18 Some nurses believed that nursing management does not empower nurses to promote health and daily nursing tasks are burdensome and prevent them from practicing health promotion.15 The percentage of nurse practitioner students who perceived the work environment as a barrier to practicing health promotion increased at the completion of a health promotion course.18
The literature included in the review contains limitations. The most notable limitation is the absence of literature examining nurses' perception of wellness in practice. The vision of the IOM is for nurses to intentionally promote wellness. Before this can occur, research that examines nurses' current understanding of wellness and how to promote wellness in practice is needed. Research in this review contained small, convenience samples of nurses who were required to answer questions about health promotion while being recorded by the interviewer. Nurses interested in health promotion may be overrepresented using convenience samples. Furthermore, the use of tape recorders may lead some nurses to withhold information or exaggerate information due to concerns about confidentiality, or social desirability. Acknowledging the limitations, however, this review provides insight about the gap between wellness promotion and nursing practice.
Nurses believe that health promotion is at the core of nursing practice.15-18 Currently, nurses promote wellness by promoting health. Nurses cannot intentionally promote wellness and achieve the vision of the IOM1 if they are unable to confidently define and provide specific examples of health and wellness promotion. Nurses should have time to promote health and wellness if they believe that it is the core of the profession.
Nurses believe that patients are barriers to the practice of health promotion.15-18 Nurses' belief that patients are unwilling to accept health promotion warrants further examinations. How can patients have knowledge deficits about their own perception of health and wellness? If a patient is unwilling to change, should he or she be considered a barrier? Reflecting on each question philosophically reminds us that patients' health and wellness are their own state of being. Their experiences and perceptions define how wellness and health will look, act, and feel for them.8,19 According to ontology, every patient is on a journey to optimal wellness.8 Reflecting on each question through the lens of nursing theorists suggests that nurses may be the true barriers in promoting health. Nightingale warns against judging patients who are unwilling to change. She would say that patients would do better if their environment supported them better.6 Henderson3 would argue that the patient does not have the strength, knowledge, or will to accept health promotion how the nurse desires, but this does not mean that the patient never wants to promote his or her health. Newman12 posits that the nurse is not asking the right questions, not listening with her whole heart, and not getting into the patient's life.
WELLNESS AND THE ART AND EPISTEMOLOGY OF NURSING
The review of the literature highlights a gap between nurses' perception of health and wellness promotion in nursing practice and how and when to promote health and wellness in practice. The subjective nature of wellness, the absence of a clear and universal wellness definition, and the absence of a wellness framework in nursing practice create fundamental challenges to achieving the IOM's vision.1 Nurses need to know how to assess, design, document, and validate wellness outcomes. Carper's20 seminal work, The Four Fundamental Patterns of Knowing in Nursing, provides a framework to address the art and epistemology of wellness in nursing.
Empirical understanding of wellness
Nurses need an empirical understanding of the concept of wellness. To intentionally promote wellness, nurses need to know in what context the phenomena of wellness are to be viewed. Nurses need to develop an abstract and theoretical explanation for wellness in nursing practice. Nurses need to know what questions are to be raised about wellness, and the methods of study to examine evidence of wellness promotion.2 For nurses to intentionally promote wellness in nursing practice, they need the knowledge to describe and explain wellness to patients, society, and other health care professionals.
In nursing practice, the essence of wellness may lie within an understanding of the realities, experiences, and world of the patient. Nurses, therefore, will need to know how to empower, encourage, and inspire patients to realize their own visions of wellness. Nurse researchers need to design empirical studies to examine techniques to promote wellness in nursing practice. Nurse educators need to develop frequent continuing educational activities about when, how, and why to promote wellness in practice. Nursing administration needs to examine nursing tasks to ascertain whether health and wellness promotion, a core value in nursing, is not absent in practice because of time constraints. Nursing practice needs to develop a documentation system that captures the patient's empirical view of wellness and tracks wellness outcomes from the patient's perspective. Most importantly, nursing education needs to develop an evidenced-based curriculum that provides nurses with a strong foundation for promoting wellness in nursing practice. Currently, clinical prevention and population health are essential education requirements for baccalaureate prepared nurses.21 These requirements do not aim to prepare all nurses for the role of intentional wellness promoters. First, clinical prevention, as defined by the American Association of Colleges of Nursing, is disease focused. Nurses practicing clinical prevention will demonstrate knowledge around immunizations, screenings, and counseling aimed to prevent disease or disease escalation. Second, population health aims to improve the health at the community, or aggregate, level. However, since the baccalaureate degree is the minimum level of education required to practice and promote population health, half of the nursing workforce who hold an associate degree in nursing is not adequately trained or qualified to perform this role21,23 The absence of wellness as an essential requirement in nursing education is evident. To achieve the vision of the IOM, all licensed nurses require education and training about the meaning of wellness and how to promote wellness to all patients in all care settings.
Esthetic understanding of wellness
An esthetic understanding of how to promote wellness in nursing practice is needed. Wellness is intimate to the person experiencing the phenomenon. Successful wellness promotion in nursing practice will depend on how nurses ask patients questions about what wellness means to them. Patients' responses will depend on how nurses listen to the words the patients speak and how nurses insert themselves into the patients' world.4,20 The patients' growth will depend on nurses' ability to be in the moment; nurses will express empathy, joy, and heart ache with the patients to promote wellness.20
Personal understanding of wellness
Nurses need a personal understanding of how to promote wellness in nursing practice. Personal knowledge in wellness promotion will require nurses to relinquish the authoritarian role and accept that patients are free to create their meaning and experience of wellness.20 Carper20 states, "An authentic personal relation requires the acceptance of others in their freedom to create themselves and the recognition that each person is not a fixed entity, but constantly engaged in the process of becoming."(p155) Nursing practice needs to develop dynamic relationships with policy makers and interdisciplinary health care professionals to design a wellness infrastructure within the community and the health care system. The new system should capitalize on nurses' personal knowledge and ability to promote wholeness and integrity.20
Ethical understanding of wellness
Nurses need an ethical understanding of how to promote wellness in nursing practice. Patients' perception of wellness will depend on their experiences and values. Only patients can determine what is good and bad for them. However, nurses need the knowledge to recognize behavior that is harmful or dangerous. Nurses need to adhere to moral obligations when promoting wellness in nursing practice.20
FUTURE DIRECTION FOR SCIENCE AND NURSING
Nurses are recognized for their unique ability to care for patients holistically.23 The goal of nursing practice is to foster behavior that leads to health and wellness.2 However, nurses cannot rise to their full potential and realize the vision of the IOM1 to intentionally promote wellness based on this premise.2,23 Nurses need a clear understanding of the phenomenon of wellness. Nursing science needs to develop a universal wellness paradigm to promote wellness in nursing practice.7
Finally, the pivotal change that needs to occur is a shift in the percentage of nurses working in acute care hospital settings to nurses promoting wellness within the community. Currently, 62.2% of nurses work in hospitals compared with 7.8% in public health and community settings.22 Patients in acute care settings are in a new environment. Before optimal health and wellness promotion can occur, patients must cope with the new environment, a process that may not occur before patient discharge.13
Nurses' role in the community is multidimensional. Nurses have an opportunity to apply empirical, aesthetic, personal, and ethical wellness knowledge in schools, businesses, prisons, day care centers, and any other place people gather. Removing the barrier of the hospital environment14,15,18 may prove the best method for nurses to assume their role as intentional promoters of wellness.
The Future of Nursing Report from the IOM1 symbolizes a turning point for change in health care delivery. Nurses are prepared to rise to the challenge and embrace changes that promote positive health outcomes for society. However, to realize a vision that explicitly emphasizes the contribution of intentional wellness promotion to positive patient outcomes, nurses are challenged to develop a universal understanding and paradigm to promote wellness in nursing practice. Before nurses can value their role as wellness promoters, nursing education, nursing research, and nursing administration need to work together to make wellness a priority. Without proper education about how and why to promote wellness, without research to provide evidence-based wellness guidelines, and without administration to monitor wellness promotion practice and outcomes, nurses cannot truly value their role as intentional wellness promoters.