Professional Documents
Culture Documents
It is no coincidence that in setting the agenda for primary health care (PHC), it was
acknowledged that nurses would have to play a major role in helping to shift the
health system away from a predominant focus on illness and cure, toward increased
attention to health promotion and disease prevention. The goal in primary health
care is to protect and promote the health of all people of the world where health is
defined in a positive sense as well-being, not merely as absence of illness. Health so
defined has always been the concern of nurses.
In this paper, the relationship between modern professional nursing and PHC will
be discussed. The notion that advancing the primary health care agenda is inherently
within the domain of nursing practice will be developed, citing examples from a PHC
project that involved nurses working with family physicians in a primary care
practice. The position will be taken that primary health care provides an opportunity
to revitalize the nursing workforce, by recapturing the vision of early nursing leaders,
such as Florence Nightingale, who recognized the need for social reform in
improving population health and understood nurses role in achieving that.
Key words: community nursing; nursing leadership in primary health care; practice
nursing
If the millions of nurses in a thousand there is substantial evidence that the call to action
different places articulate the same ideas toward health for all has not resonated with a
and convictions about primary health care, majority of nurses, particularly with those
and come together as one force, then they employed in acute care settings. If nurses are to
could act as a powerhouse for change. I play leadership roles in advancing the PHC
believe that such a change is coming, and agenda, they must understand the relationship
that nurses around the globe, whose work that exists between PHC and professional nursing
touches each of us intimately, will greatly practice and refocus their practice as necessary.
help to bring it about. (Mahler, 1985) In this paper, the relationship between
PHC and modern professional nursing is dis-
It has been almost 20 years since nurses were cussed and illustrated. The notion that advanc-
challenged (Mahler, 1985) to take a lead in ing the primary health care agenda is
advancing primary health care throughout the inherently within the domain of nursing prac-
world (WHO=UNICEF, 1978). Yet, many would tice is developed, citing examples from a Cana-
agree that we have made relatively little global dian PHC project that involved registered
progress in realizing this social goal. Although nurses working with family physicians in a pri-
PHC reflects the values and principles that have mary care practice. The position is taken that
always guided registered nurses in their practice, primary health care provides an opportunity to
revitalize the nursing workforce, by recapturing
the vision of early nursing leaders, such as
Address for correspondence: Jeanne Besner, Research Florence Nightingale, who recognized the need
Initiatives in Nursing and Health, Calgary Health Region, for health and social reform in improving
10101 South Port Road SW, Calgary, Alberta, Canada, TSW
3N2. population health.
#Arnold 2004 10.1191/1463423604pc225oa
352 Jeanne Besner
The driving force behind the global primary It is clear from the writings of Florence
health care movement was the recognition that Nightingale the founder of modern pro-
health is a fundamental human right that is ineq- fessional nursing that she viewed health as a
uitably distributed within and between the concept that was to a large extent devoid of the
countries of the world. A PHC focused health idea of illness. She wrote Notes on Nursing
system is aimed at improving population health (1860=1969) with the intent of giving hints for
and wellness (i.e., quality of life). This requires thought to women who have personal charge of
that individuals and communities accept greater others . . . distinct from medical knowledge, which
responsibility for their own health, supported by only a profession can have (p. xi). In earlier
well coordinated and appropriate multidisciplinary writings, she seemed not to see a need for nurses
teams of health care providers whose work is to possess any medical knowledge, but she
closely aligned with that of other social and econ- eventually altered her position as evidence of the
omic sectors, since health cannot be attained by germ theory changed the nature of nursing.
the health sector alone (WHO=UNICEF, 1978: Nonetheless, she clearly did not situate nursing
40). PHC reform is aimed at building a sustain- primarily within the medical paradigm, for she
able, coordinated health system focused on notes experience teaches me that nursing and
improving population health by ensuring that the medicine must never be mixed up (quoted
right care is provided to the right people, by the in Baly, 1991: 68). She made little distinction,
most appropriate provider, in the right setting however, between nursing knowledge and health
and using the most suitable and cost-effective knowledge. The same laws of health or of nurs-
technology. Technology in this sense refers to the ing, for they are in reality the same, obtain
structure and delivery of health services, the among the well as among the sick (Nightingale,
deployment of human resources, and medical 1860=1969: xii). Thus, whether nursing is prac-
equipment, pharmaceutical agents or new inter- tised among individuals who are ill, merely at risk
ventions and techniques (Alberta Association of of disease or disability or perfectly healthy, there
Registered Nurses, 2003). is something unique that defines the practice and
The PHC approach highlights the complexity is grounded in a body of knowledge that is dis-
involved in any effort to improve population tinct from medical knowledge. Nightingale
health and addresses the need for fundamental defined nursing practice as putting (people) in
social change targeted at the broad determinants the best possible conditions for nature to restore
of health (e.g., income, social status, social or to preserve health, where health was viewed as
supports, etc.). Health promotion is defined as the not only to be well, but to be able to use well
process of enabling people to increase control every power we have (quoted in Ulrich, 1992:
over and improve their health (World Health 80). That is similar to the World Health Organi-
Organization, Health and Welfare Canada, zation (WHO=UNICEF 1978) concept that pri-
Canadian Public Health Association, 1986). mary health care is aimed at enabling people to
Thus, health promotion is directed at helping achieve the highest possible level of health in
individuals, families and=or communities develop order that they may contribute to the social and
the competence and capabilities they require to economic development of their communities,
gain control over day to day life events or which in turn facilitates health development (p.
circumstances, thereby achieving a sense of well- 39). Nurses often work in settings in which the
being. Instead of focusing almost exclusively on medical paradigm predominates and frequently
curative or rehabilitative services, in this positive perform tasks that support the medical manage-
view of health, practitioners focus attention on ment of patients. That does not mean, however,
the deeper causes of illness, such as poor housing that nurses operate from within the medical para-
or unemployment, and seek to mobilize personal digm while performing those tasks. Nursing man-
and community resources in enabling people to agement of patients incorporates assessment of
become agents of their own development (World the physical, psychological, social, cultural and
Health Organization, 1978). spiritual factors that influence peoples ability to
Primary Health Care Research and Development 2004; 5: 351358
Nurses role in advancing primary health care 353
recover from illness, injury or disability or to ach- munities develop strategies to achieve improved
ieve optimum health. It is in the implementation health and well-being, in the spirit of self-reliance.
of strategies to address the major social and In mid-nineteenth century England, the
health needs of individuals, families and com- relationship between poverty and ill health could
munities that nursing adds value to the health not be denied and a surge of humanitarianism led
system. to the introduction of important health and social
reforms. It was in this seedbed of reform that
professional nursing first took root. Nightingale
The nature of nursing
felt herself called for a special mission and the
provision of trained nurses to help alleviate the
The principles of PHC are closely aligned with
suffering of the poor was the fulfilment of that
the values of nursing. Nursing, as a profession, is
responsibility (Baly, 1991). She was convinced of
socially mandated to promote strategies for
the importance of preventive social policies and
achieving improved population health by devel- certainly saw that health depended on the whole
oping within its members the skills and knowl-
environment, not just the state of the body. She
edge necessary to respond to emerging health
wrote in 1861, It is mere childishness to tell us
needs (American Nurses Association, 1980). The that it is not important to know what houses
object and philosophical underpinnings of the
people live in. The connection between health and
discipline of nursing are captured in the ANA
the dwellings of the population is one of the most
statement that
important that exists (quoted in Baly, 1991: 39).
Nightingale saw concern for humankind and
Nursing helps to serve societys interests in social reform as key features of the work of
the area of health. . . . One of the most dis- nurses in her day and that is no different in
tinguishing characteristics of nursing is that todays environment.
it involves practices that are nurtrative, gen- There are many other examples of early
erative, or protective in nature. They are nursing leaders whose entire professional lives
developed to meet the health needs of were dedicated to the application of nursing
individuals as integrated persons rather than science in correcting social inequities between the
as biological systems. . . . Nursing care is rich and poor. They were masters in putting
provided in an interpersonal process of health on the agenda of policy makers and were
nurse-with-a-patient, nurse-with-a-family, responsible for initiating many social reforms.
nurse-with-a-group. (p. 18) For example, Lillian Wald (1915) said of the
work carried out at the nurses settlement in East
For nurses, the client is always viewed within the New York we do not believe that what we offer
context of family (e.g., culture, beliefs and values) is of great consequence unless . . . applicable to the
and environment (e.g., housing, employment, problems of the community (p. 143).
social support). Since nursing has biological, Nursing is directed toward helping to create the
psychological and social health as an end in view, environments physical, social and emotional
the outcomes of nursing practice reflect practi- that are conducive to the attainment of the high-
tioners contributions to promoting individual est possible level of health and well-being for
and family development during periods of tran- individuals, families and communities. To quote
sition or crisis (nurtrative function). There should again from Lillian Wald (1934):
also be evidence that nursing has influenced
changes in health state or behaviour (generative When we went to press for housing reform
function), in a manner that safeguards respect for or for child protection, we always called
individuals and families, and promotes self- those most interested the mothers into
reliance (protective function). Nursing assessment our council, to ask their views on what evils
is inherently focused on understanding the they would most like to see abolished and
relationship between determinants of health and what they felt the remedy should
actual health status and nursing intervention is be. . . . Now they most admirably formulate
directed at helping individuals, families or com- and state their convictions as to needed
Primary Health Care Research and Development 2004; 5: 351358
354 Jeanne Besner
to better understand the health needs of this in the practice. Unlike the fee-for-service
group of patients. Analysis of data revealed that reimbursement system, the capitation model
the largest single group of patients was adult removed the need for physicians to have direct
females (age 20 44), followed by adult males and contact with all patients accessing services in
mature (45 64 years) females. the practice. Registered nurses employed by the
These data were supplemented with a review of family physicians (i.e., practice nurses), as well
the literature and other information (e.g., annual as the public health and home care nurses were
health status report for the region) to identify thus able to assume greater responsibility in
major risk factors associated with this popu- providing comprehensive services to clients of
lation. For example, analysis of regional data the practice. This introduced greater flexibility
indicated that suicide, breast and lung cancer, in how services were delivered. By focusing on
heart disease, motor vehicle accidents and stroke previously unmet needs in the population (e.g.,
are among the leading causes of loss of life or initiating routine screening for stress and family
productivity in the adult age groups. violence in the adult female population) there
Diagnoses related to coughs and colds were was greater opportunity to broaden the range
the primary reason that women visit a phys- of services offered. The public health nurse was
ician, followed by mental health, reproductive instrumental in enabling the practice nurses to
and developmental concerns, injuries and fully utilize the knowledge and skill they pos-
hypertension. Coughs and colds are also the sessed in assessing the physical, emotional and
leading reason why men visit a physician, fol- social needs of the practice population and in
lowed by joint injuries, neurotic and non- educating clients on health issues. This con-
psychotic disorders, hypertension and otitis tributed to enhanced quality of work life for
media. Regional physician utilization data were all providers, as well as better service to clients.
consistent with observed patterns for patients Without data obtained through comprehen-
registered with the physician practice involved sive analysis of the health needs of the specific
in the project (Shandro, 2001). population served by the practice, it is unlikely
Although the physicians in the practice were that the public health nurse could have ident-
funded under a capitation model, they con- ified for other members of the health team
tinued to perform shadow billing (i.e., as what needed to be done differently to shift the
though they were still billing under the fee- focus of the practice away from medical man-
for-service system) for evaluation purposes. agement of the population toward primary
These utilization data were grouped into prevention and health promotion. For nurses to
broad diagnostic categories (e.g., cardiovascular, use the knowledge they gain through contacts
respiratory) to facilitate analysis of the major with individuals to effect health and social
underlying reasons for accessing services (i.e., change, they must be able to record, analyse
the numerator) from the practice. Analysis of and then disseminate data about how peoples
the various types of data revealed significant social and environmental contexts influence
gaps between what services were being deliv- their health. Current health records are woe-
ered and what could or should be provided for fully inadequate in that respect. It is essential
the type of population being served. As a that nurses, funding bodies and employers dem-
result, new approaches to service delivery were onstrate commitment to ensuring that nursing
initiated, involving regional personnel and serv- assessment data (e.g., social, emotional, cul-
ices (e.g., diabetes education clinic) to enhance tural, spiritual determinants) are incorporated
management of patients with such conditions into the development of personal electronic
as diabetes, asthma, depression and cardio- records. In building health information infra-
vascular risk factors (e.g., hypertension and structures, we must not make the mistake of
elevated cholesterol). simply converting existing medical records into
One of the most significant impacts of this electronic formats. That will simply perpetuate
population-focused approach to addressing the the inability to link social determinants to
health needs of the practice clients was the health and will continue the relative invisibility
increased appropriate use of registered nurses of nurses contributions to population health.
Primary Health Care Research and Development 2004; 5: 351358
356 Jeanne Besner
Disease=injury prevention and health current health reform environment, nurses have
promotion been challenged to reorient their practice to be
consistent with primary health care philosophy
There is no area of practice in which the role of and principles (Clarke, 1995). The primary health
nurses is more clearly complementary to that of care approach demands that more effort be made
physicians than in disease prevention and health by nurses to empower clients to assume control
promotion. In this project, registered nurses played over personal, social and political determinants of
a key role in leading and facilitating initiatives that health. Nursing has a key role to play in develop-
were aimed at refocusing service delivery toward ing new approaches to improving population
primary prevention. Analysis of demographic data health approaches that recognize the essential
and risk factors associated with the practice popu- role of clients as active participants and that
lation identified a need to target womens health emphasize the positive view of health. If nurses
issues and to concentrate more attention on are to respond to the challenge of demonstrating
reduction of cardiovascular risk for the adult popu- that their practice makes a viable difference to
lation. The public health nurse assumed a the health of individuals and populations, they
leadership role in involving physicians, clients, will need to be guided by appropriate conceptual
practice nurses and other office and regional models that align their practice with that purpose.
personnel in the development of care pathways to Management expectations will also need to be
ensure that all clients visiting the practice would be revised, since practice is to a large extent directly
assessed for the presence of risk factors. For influenced by organizational and programme
example, a womens health initiative was imple- structures (Besner, 1999). At the very least, the
mented to develop programmes and policies that nursing skills required to engage individuals and
were more responsive to womens health needs. families meaningfully in goal setting and develop-
Women visiting the practice for routine check-ups ment of health promoting strategies will need to
or episodic health issues are now asked about their be as highly valued and nurtured by employers as
emotional well-being (e.g., unusual stress, phys- is clinical expertise. Primary health care is an
ical=mental abuse) and receive lifestyle assessment approach that offers the opportunity of using the
(exercise history, tobacco use, alcohol=substance education, knowledge and skills of registered
abuse, seat belt use, etc.) in addition to screening nurses for the greatest benefit of patients and the
for cancer and heart disease, as appropriate. Using health system. Unless nurses are able to make
this systematic, focused approach to identifying explicit their unique focus on the health of indi-
population health needs led to development of tar- viduals, they risk missing the opportunity offered
geted health education programmes and increased through health care reform to reaffirm their role
preventive screening (Gerlock et al., 2003). Patient in assisting individuals, families and communities
involvement on a patient advisory committee to function at the highest level of their potential
established for this project provided some assur- (International Council of Nurses, 1996). If nurses
ance of the acceptability of programme changes health promoting role is ever to be fully realized,
that evolved over the course of the project. Fur- changes will need to occur at the academic, prac-
thermore, clients who participated on committees tice and policy levels (International Council of
became informed consumers whose knowledge of Nurses, 1996; Mahler, 1985).
health care issues increased dramatically over time.
They became outspoken advocates of the multi-
disciplinary care model that incorporates an References
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