ORIGINAL ARTICLE
‘Let other people do it…’: the role of emergency department nurses in health promotion Noordeen Shoqirat
Aims and objectives. To explore emergency department nurses’ roles in health promotion and contributing factors involved. Background. In many healthcare systems, emergency departments are increasingly urged to play a crucial role in health promotion. Although much has been written about health promotion and nurses in acute care settings, less has focused on emergency departments. Design. A qualitative design was used. Methods. In-depth semi-structured interviews were used with a convenient sample of 15 nurses in a Jordanian emergency department. Data were analysed using NVIVO 9 (QSR International, Doncaster, Victoria, Australia). Results. The analysis identified two themes. The first focused on nurses’ roles in health promotion, comprising two categories: having no roles and ‘let other people do it’. The second theme focused on the context and constraints of health promotion comprising fear of violence, the nature of healthcare service and patients’ beliefs. The majority of nurses in emergency departments do not associate health promotion with their practice, hold some negative attitudes and devote more time to clinical tasks than health promotion, which is seen as a second priority. Conclusions. The ideology of medicalised tasks has penetrated deeply into the core principles of health promotion, and thus, nurses’ roles and potential in this area are questioned. Relevance to clinical practice. Decision-makers and nurses within the hospital are urged to address the constraints identified in this study and debate them further. Failure to do so may lead to emergency nursing not being optimally achieved, with the absence of sustained and concerted health promotion work matching patients’ cultural needs and sensitivities. Key words: emergency department, health promotion, Jordan, nurses, semi-structured interviews Accepted for publication: 3 April 2013
Introduction Internationally, emergency departments (EDs) have become one of the most acute areas and play a main role in providing care, treatment for injured people and promoting health (Cross 2005, Cummings et al. 2006, Jonsson & Halabi 2006). In particular, EDs address the needs of those patients at risk of sexual abuse, domestic violence and asthma (Hotch et al. 1996, Fanslow et al. 1998, Yonaka et al. 2007), and identify lifestyle practices and indicators for obesity and diabetes (McNaughton et al. 2011, Vaughn Author: Noordeen Shoqirat PhD, Assistant Professor and Head of Fundamental and Adult Health Nursing, Faculty of Nursing, Mutah University, Karak, Mutah, Jordan
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et al. 2012). In many healthcare systems, the late discovery of illnesses and diseases contributes to a significant burden, often requiring more expensive and involved treatments (Seedhouse & Kessel 2005, Stiffler & Gerson 2006). Whilst health promotion in nursing has increasingly been studied in acute care settings (Casey 2007, Irvine 2007, Whitehead et al. 2008), EDs have been largely excluded, yet there is a growing international demand for ED nurses to have a more visible function and potential in health promotion (Abdallat et al. 2000, Bensberg et al. 2003, Cross 2005). Correspondence: Noordeen Shoqirat, Assistant Professor and Head of Fundamental and Adult Health Nursing, Faculty of Nursing, Mutah University, Karak 61710, Mutah, Jordan. Telephone: +962 32372380 ext. 6707. E-mails: [email protected]; [email protected]
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 232–242, doi: 10.1111/jocn.12383
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Consequently, there is a need for recent and specific research examining ED nurses’ roles, values and willingness to promote health, together with those factors involved. In the light of the paucity of research in this area, the current study qualitatively explored ED nurses’ roles in promoting patients’ health. The emerging findings can be considered as a cornerstone for future cross-cultural studies and evidencebased health promotion in EDs and other clinical areas.
Background Health promotion whether it is a discipline in its own right or an umbrella covering the activities of a wide range of disciplines committed to cover the health of the population in different settings. Whilst health promotion is a complex concept to define, scholars argued that nurses’ roles in this area need to include sociopolitical actions, participation in public health policy formulation, social education programme development and political advocacy (Whitehead 2004, Whitehead et al. 2011, Shoqirat & Cameron 2012). In the clinical context, the reviewed literature showed that EDs are still viewed as suitable settings for health promotion because they are credible sources of health information and they are established health system entry points for many individuals (Williams et al. 2000, Bensberg et al. 2003, Stuhlmiller et al. 2004). Although hospitalisation in general may be stressful for patients, it often acts as a catalyst for change (McBride 2004, Groene & Jorgensen 2005). It is argued that moderate stress enhances an individual’s ability to learn, in particular, when information is given in a simple way (Laverack 2004, Shors 2004). It is not surprising, therefore, that nurses in EDs are urged to use an episode of illness as an opportunity to promote health through providing rehabilitation service, empowering patients and preventing recurrent injuries (Bensberg et al. 2003, Cross 2005). Nurses worldwide have close contact with patients and in patient advocacy, more than other health professionals, and this creates a significant opportunity for delivering health promotion (Kelley & Abraham 2007, Chambers & Thompson 2009, Shoqirat 2009) and leading its movement (Whitehead 2004, Piper 2008). This can be achieved by incorporating health promotion principles such as health education, health policy, empowerment and advocacy in the framework of care (Caelli et al. 2003, Rice & Wicks 2007, Whitehead et al. 2011). However, to date, a large volume of international research has investigated health promotion within nursing in surgical care settings (Casey 2007, Piper 2008, Whitehead et al. 2008, Whitehead 2009, Shoqirat & Cameron 2012) and to a lesser extent in ED (Cross 2005). Regardless of the methodologies of these studies and their contexts, their find© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 232–242
Emergency department nurses in health promotion
ings are underpinned by similar and recurring themes: nurses’ roles and actions in health promotion are mostly confused, haphazard and lacking evaluation and sociopolitical considerations. Factors that led to this situation included poor understanding of health promotion, power imbalance between doctors and nurses, the predominance of the biomedical model of health, lack of time and limited resources (Cross 2005, Kelley & Abraham 2007, Shoqirat 2009). The existing evidence, however, is often descriptive, based on a limited number of studies in EDs, has a medical rather than a nursing focus, and is carried out mainly in the UK and Australia (Williams et al. 2000, Bensberg et al. 2003, Cross 2005, Casey 2007). Other studies are old, and their findings have not been verified by recent research, taking into account the increasing development and debate in health promotion (McKenna 1994, Dunlop 1999). As is the case in many countries (e.g. the UK, Australia and China), Arab states such as Lebanon, Kuwait and Egypt call for integrating health promotion into the framework of nursing education and health policies in various settings (Al-Kandari et al. 2008, Herman et al. 2009, Sibai et al. 2012). Yet, much of health promotion work and research is directed towards schools and primary healthcare centres (Shama & Abdou 2009). In Jordan, preventing illness and early screening of diseases is a high priority of the Ministry of Health, and nurses are required to take a vital role in health promotion (Gharaibeh et al. 2005). Against this background, a large scale Jordanian research found that nurses’ roles in promoting patients’ health in surgical and medical wards are limited and not operating at the level of empowerment and political actions (Shoqirat & Cameron 2012). However, these findings might not be applicable to EDs due to the differences in the clinical context and the type of patients. It is argued that reforming the whole organisation in Jordan towards health promotion needs to be examined first in a small clinical area (Shoqirat 2009). By examining ED nurses’ roles in health promotion in Jordan, it is hoped that this study will contribute to the grounds of national and international evidence.
Aim The aim of the study was to explore ED nurses’ roles in health promotion, and contributing factors involved, in a large teaching hospital in Jordan.
Methods The study examined ED nurses’ roles in health promotion through semi-structured interviews. This qualitative method
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The study was carried out in a 16-bed ED located in a big public hospital in the southern province of Jordan. The hospital serves almost a quarter of a million people from the city and surrounding towns and villages, and thus it was considered as an appropriate study setting. The target ED deals with a wide range of cases, including, but not limited to trauma, food poisoning, road traffic accidents, and patients with diabetes and hypertension. The current researcher recruited conveniently all ED registered nurses (n = 15). Emergency department nurses in military hospitals were not included due to the lack of fund and access difficulties.
to probe for details (Wengraf 2001). That is, the topic guide for the interviews was developed using an iterative process whereby issues and topics were developed for later interviews according to responses offered in earlier interviews. Such responses included the impact of violence and patients’ belief on nurses’ roles in health promotion. The interview schedule was guided by the international literature relevant to health promotion and nursing (Laverack 2004, Cross 2005, Whitehead 2011). Primarily, the interview schedule consisted of various questions, including the following: How do you understand health promotion? What is your role in health promotion? Any role in counselling? Sexual health? What are the facilitators/barriers that affect your role in health promotion? Do you think that EDs are suitable for health promotion? Why? All interviews were conducted in private rooms, recorded digitally and transcribed verbatim. At the end of each interview, the participants’ demographic characteristics were collected. Each interview lasted between 30–45 minutes. All the interviews were conducted in Arabic, but occasionally English terms were used. All data were collected during 2012.
Ethical considerations
Data analysis
Ethical approval was granted by the Research Ethics Committee of the Faculty of Nursing, Mu’tah University, Jordan, and subsequently by the hospital management. Informed consent was signed and obtained from each participant before data collection took place. Participation in the study was voluntary. Confidentiality was achieved by using codes, and all data were kept in a secured office, and access to data was restricted to the authors. All participants had the right to withdraw from the study at any stage without giving reasons. The current author was not involved in any evaluation activity for ED nurses in a way that might affect their responses and thus the quality of data.
Data collection and analysis were carried out simultaneously. The digitally recorded interviews were translated from the Arabic language into English transcriptions. Measures were employed to ensure that the obtained English transcripts were comparable with the original data. First, translation was made independently by the first author and a nursing researcher, who was also a bilingual speaker of both Arabic and English. Second, the two translated versions were examined by the authors, and in the case of any difference, the recorded discussions were reviewed until consensus was reached. Transcripts were read several times and coded, and emergent themes were identified. An independent researcher checked the plausibility of the data interpretation and ensured that the qualitative data analysis was systematic and verifiable. The final version of translated transcripts was uploaded into NVIVO 9 (QSR International, Doncaster, Victoria, Australia) for analysis using the thematic approach aiming to identify commonalities in the transcripts (Thorne 2008). Initially, transcripts generated from interviews were examined separately. Then, all sets of data emanating from all the interviews were examined to identify commonalities between different transcripts. Data analysis commenced with data collection, continued with the translation of data plus multiple replays of the digitally recorded interviews.
was deemed appropriate, as it explores individuals’ views and experiences (Flick et al. 2007), and allows participants to respond flexibly to the questions (Bryman & Teevan 2004) with minimal pollution from the interviewer’s own assumptions (Potter & Hepburn 2005). Employing faceto-face interviews can assist the researcher in clarifying vague statements and thus generate a better understanding of the real world (Mason 2002).
Setting/Sampling
Data collection The current researcher was responsible for collecting all the data. Semi-structured interviews were conducted with a fairly open framework which allow for focused, conversational, two-way communication. Main topic such health promotion was initially identified, and the possible relationship between the topic and issues in the ED and its environment become the basis for more specific questions which do not need to be prepared in advance. The majority of questions were created during the interview, allowing both the interviewer and the person being interviewed the flexibility
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© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 232–242
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Trustworthiness The trustworthiness of findings has been enhanced by a number of interventions. Prior to conducting the interviews, three qualitative research experts and three nonparticipants reviewed the interview items and assessed its validity. To enhance the reliability, participants were given the chance to correct the summary following each interview and following the transcription process. The involvement of an independent researcher in the process of translation and data analysis achieved conformability (Potter & Hepburn 2005, Polit et al. 2006). Conformability was also enhanced by the bilingual competencies of the author. Finally, transferability was assured by offering the reader sufficient details about the research and how the themes were developed from the data through rich descriptions and extracts.
Results The overall sample (n = 15) included seven women and eight men. The average experience in ED was 1.7 years, and the average age was 31 years. Two broad themes and related categories were identified, see Table 1.
Theme one: health promotion: roles and attitudes Having no roles When ED nurses were asked about their role in health promotion, their responses showed conceptual confusion, and to some extent, a perceived absence of any role. Under the category of ‘having no roles’, participants expressed their limited understanding of health promotion itself. This is encapsulated in the following quotes: We do not have a role in health promotion in emergency department; we need to save lives as our top priority. (RN2)
Another participant pointed out that, despite the absence of a ‘real’ role in health promotion, patients are given individual health advice:
Emergency department nurses in health promotion Table 1 Main themes and cluster of meanings Themes
Categories
Cluster of meanings
Health promotion: roles and attitudes
Having no roles
The absence of a ‘real’ role in health promotion The absence of key health promotion elements such as empowerment and advocacy ‘Already we are busy in EDs’ ‘Staff in primary [health care] centers need to have this role in health promotion’ Lack of competency The absence of training courses in health promotion Unsafe work environment and violence The absence of health promotion policy ‘Free treatment does not cure’ Sexual health: ‘the red line you should not cross’
‘Let other people do it’
Theme two: context and constraints
Personal factors
Factors within the hospital
Patients’ beliefs
experiences are addressed under health education. In other words, nurses in EDs carry out some minor health promotion activities but without being cognizant of their role. Such activities are largely exemplified by giving health advice about medical issues. However, health advice and education are instigated by patients’ questions as opposed to nurses’ recognition of their role in health promotion. In addition to the absence of key health promotion elements such as empowerment and advocacy, the focus of health in general is linked to the nature of the health problem itself rather than the expressed needs of individuals.
Other findings revealed the nature of the approach being used for promoting patients’ health:
‘Let other people do it’ Analysis of emerging data shows that many participants (n = 13) summed up their views towards promoting patients’ health in EDs as: ‘let other people do it’. Participants felt that health promotion work should be carried out by other nurses and departments. These views were justified by statements such as ‘already we are busy in EDs’ and ‘others are better suited than us’:
We answer patients’ questions and tell the patients what to do and
You know we are busy here… I think nurses on wards are better
not at home before leaving the emergency doors. (RN10)
suited than us to have a vital role in health promotion. (RN7)
It is interesting to note that, albeit nurses have no clear picture about their role in health promotion, some of their
These views were also confirmed by a senior participant who argued that:
We have no real roles like carrying out health education programs… we only focus on side-effects of the medications before patients go home. (RN4)
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We do not have enough knowledge and skills… frankly I do not
think that staff in primary centers need to have this role in health
feel competent at all… my role in health promotion is out of ser-
promotion. (RGN5)
vice… [laughing] (RN11)
These findings are indicative of the lack of understanding of health promotion as an integrated part of nursing care. The extract ‘the time should be well spent’ might suggest that health promotion is seen a second priority in EDs. That is, participants in this study believed that due to the lack of time and the business of the clinical area, the top priority is treating complex cases as opposed to promoting health. It is not surprising, therefore, that some participants felt that other nursing staff located in different areas should take up the role in health promotion. However, contrary to the prevailing view outlined previously, a further examination of data found that two participants disagreed:
Other participants (n = 8) alluded to the emotional ambience of the ED, pointing out that in addition to the lack of knowledge and skills, the nature of staff themselves might contributes to poor communication:
I think it is our responsibility to promote health in EDs… you know many health problems are diagnosed here, and the majority of patients have minor medical problems. (RN1)
Specifically, the suitability of EDs for health promotion was explored by the following participant:
I am a senior nurse here and I can tell you that health promotion needs good communication, but unfortunately many of our staff are moody… patients are hesitant to talk to them… (RN10)
These findings show that at the personal level, nurses feel that their role in health promotion is confined by their limited knowledge and skills in health promotion. It is worth noting that being ‘moody’ was seen as an obstacle to effective communication with patients. On this basis, it can be argued that the prevailing emotional ambience of ED wards due to staff outlook could not only restrict the scope of a more effective intervention operating at the individualised level, but also broad reaching health promotion work encapsulating socio-economic and political factors.
We have 12 beds here and not all patients admitted in EDs are suffering from life threatening illness or injurers… we deal with cases such as asthma, diabetes and hypertension. (RN6)
These findings are promising in terms of recognising the suitability of EDs for health promotion. However, participants did not refer to wider issues of importance to the ideology of health promotion–based setting. These include operating at the socio-economic levels, lobbying and advocating on behalf of less privileged people in society.
Theme two: context and constraints The second theme that emerged focuses on the overall context and constraints that affect the development of nurses’ roles in health promotion. Factors identified can be addressed under three categories.
Personal factors Participants (n = 10) expressed concerns about the lack of competency in health promotion. In particular, the absence of any training courses makes participants incompetent in delivering wide-reaching health promotion activity. The following participant worked in the ED for nine years but felt incompetent in health promotion:
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Factors within the hospital The absence of health promotion policy Further issues identified in the data were concerned about those factors affecting ED nurses’ roles at the hospital level. The absence of a health promotion policy was referred to by participants as ‘walking on a landmine’: I never seen any documents regarding the importance of health promotion… we have no map or protocol – it is like walking on a landmine! (RN13)
Another participant blamed the Ministry of Health for not explicitly urging hospitals to have an ‘active policy’ in health promotion: The Ministry of Health in Jordan gives little attention to health promotion responsibility and other health policies are just out of order… we are still awaiting new job descriptions. (RN14)
The above evidence points out the need for a more systematic approach to nurses’ roles in health promotion by certain health policies. However, no evidence was found to suggest that ED nurses were engaged in health policy formulation. In this context, it seems that nurses are willing to have health policies in place, but their abilities to get engaged in their formulation are unclear. Despite the lack of data, the extent to which nurses are being involved in
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making decisions about improving patients’ socio-economic status might be questioned.
Emergency department nurses in health promotion Some patients underestimate the quality of nursing care… one of the patients told me one day that what is free is free, which means in our culture that it is useless. I do not think they will accept my
Unsafe work environment and violence The emerging evidence revealed that ED nurses’ roles in health promotion might be compromised by unsafe hospital environment and, in particular, violence. These findings are illuminated by the following anecdote: Before promoting health, we need to work without fears of violence… last year an angry relative of a patient was not happy about the care and started shouting and slamming the doors and windows… he threatened all of us… (RN3)
Another participant blamed the hospital security department, stating that: How can you talk about health promotion while some patients and their relatives threaten you? When we call the security guards they arrive late so we need to get the work done as fast as we can and avoid health promotion chat. (RN15)
With the above evidence in mind, it seems that nurses in EDs might be a subject to violent behaviours that make their role in health promotion impossible. In other words, some ED nurses might feel less motivated to undertake health promotion due to unsafe working environment and lack of effective safety and protection measures in place. This, in addition to its detrimental effect on nurses’ own health and well-being, may produce lower standards of care for patients. This is exemplified by the attitudes of avoiding as opposed to engaging in the health promotion process.
role in health promotion. (RN9)
Participants’ accounts and experiences imply that ED nurses’ roles in health promotion are affected negatively by patient’s beliefs. These include underestimating the overall quality of nursing care and negative attitudes towards free of charge treatment. It should be noted that it seems that the type of health service sector might affect the development of nurses’ role in health promotion. In this context, participants believe that in the private sectors, as a result of costly treatment, patients are more willing to get involved in health promotion than their counterparts in the public hospitals. However, statements such as ‘listening and following our instructions’ might indicate narrow development in health promotion manifested by a one-way and an expert-led approach as opposed to collaborative and negotiating ideology of health promotion. Sexual health: ‘the red line you should not cross’ Although some ED patients might require sexual health advice, particularly those suffering from diabetes, this aspect of health promotion has been marginalised. Data suggest that due to patients’ beliefs and conservative culture, discussing sexual matters is not acceptable. However, in one case, a participant reported the following interesting encounter with a 52-year-old diabetes patient suffering from a sexual problem: Last year a patient took me to a hidden corner in the ED and was
Patients’ beliefs ‘Free treatment does not cure’ During all the interviews (n = 15), participants reported that many patients come to the ED with a belief that free health service will not cure them, but it is the only option they have. Some participants went further to argue that if patients paid all the costs of the treatment, they would take better care of themselves and follow a prescribed medication carefully: I worked before in a private ED.. because patients pay for everything… they used to listen and follow our instructions precisely… but in this public hospital many patients do not. They believe that free treatment is not good and some ignore even the time of their prescribed medications… (RN7)
According to participants, some patients are suspicious about nursing staff’s knowledge and clinical skills:
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embarrassed to tell me that he does not have erection anymore so he was wondering if we can give out some Viagra …when I told him that he should first be referred to the clinic, he just left and I have never seen him again [laughing]! (RN2)
Although the ED nurse suggested that the patient should be referred to a specialised clinic, it appears that an appropriate history of the patients’ concerns was not taken. Thus, it is not clear whether patients’ needs might fit with ethos of their ED. Another participant stressed that the need for sexual health promotion is expressed by patients indirectly, as shown below: Some patients do not suffer from anything and they come for the ED asking for something make them fit and strong!… If they trust you they tell you openly they meant boosters for sex… we have no clear idea or training about how to promote sexual health; it is a red line topic we should not cross. (RN8)
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The evidence outlines the valuable opportunity for promoting sexual health within the ED. This opportunity, however, is not without obstacles, such as feeling embarrassment, social taboos and lack of clear guideline or protocols on how to deal with this issue. It seems that this situation gets more complicated in ED, where no private room is available to explore patients’ concerns and needs in a confidential way without the fear of publicising their private life.
Discussion Education of nurses now and in the future The study examined ED nurses’ roles in health promotion and identified factors involved. The overall findings indicate that the majority of nurses do not associate health promotion with their practice, and devote more time to clinical duties than to health promotion, which is seen as a secondary priority. These findings resonate with previously reported international studies in acute surgical areas (Casey 2007, Kelley & Abraham 2007, Wilhelmsson & Lindberg 2007), and thus the discussion is largely focused on the context of ED and constraints to nurses’ roles in health promotion. However, it is worth noting that some negative attitudes towards nurses’ role in health promotion that emerged in this study – such as ‘let other people do it’ – are not consistent with earlier work conducted in the UK, in which it was found that ED nurses hold positive attitudes and values towards their role in health promotion, despite the lack of time in which to conduct duties associated with this role (Cross 2005). Whilst differences in research methods are recognised, this finding might be explained by the nature of nursing education and job descriptions in Jordan, which are largely driven by a disease prevention approach as opposed to a health promotion philosophy (Shoqirat 2009). Internationally, whilst ED is regarded as being suitable for health promotion, this perception is grounded in a medical paradigm wherein most staff are educated to think exclusively about medical care (Bensberg & Kennedy 2002). As a result, there is an urgent need for increasing ED nurses’ awareness about the importance of their responsibilities in health promotion through training, implementing guidelines and updating health polices at the hospital and national levels. However, academics, nurses and researchers alike must be cautioned and acknowledge that relying only on the health policies and nurses’ competency in health promotion might not be enough. For instance,
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Swedish nurses reported that despite health promotion being a central part of their training and a professionally legislated-for competence, they were not able to practise it due to the dominance of medicalised tasks. Therefore, the challenge is not only how to educate and train ED nurses in health promotion and offer a package of health policies, but also how to create a health promoting setting in which they might release their potential and better understand their roles. Consistent with international studies (Sempere-Selva et al. 2001, Carret et al. 2007), the qualitative findings pointed out that many patients admitted to EDs had no critical condition. Statistically speaking, it was found that 91% of cases admitted in Jordanian EDs were not lifethreatening (Abdallat et al. 2000). On this basis, nurses in EDs should take advantage of these opportunities by encouraging patients with nonurgent medical conditions to get involved in health promotion activities within the hospital. Using the evidence-based agenda map could be effective in identifying health promotion goals, opportunities and the negative consequences of not using it thus attracting the support needed from policy makers (Rychetnik & Wise 2004). Participants felt that some patients are dissatisfied about nursing care and nurses’ potential in health promotion within the public hospital. These findings are similar to previous research, suggesting that patients often prefer receiving care in private hospitals, where they experience more ‘modern’ treatment (Lee 2006, Alhusban & Abualrub 2009, Zamil et al. 2012). In Jordan, regardless of the type of care providers (i.e. private or public), people often believe that paying for treatment will most likely lead to better care and recovery. How the type of the healthcare sector shape patients’ receptivity and attitudes towards nurses’ roles in health promotion is worth investigating further.
Creating a culture for health promotion One aspect that constrains any attempt to introduce concerted efforts for healthcare promotion by ED nurses was the factor of the fear of violent patients and/or their families, which was cited by many participants as something that contributes negatively to their personal safety and their willingness to promote health. Violence affects nurses’ psychological, cognitive, emotional and behavioural aspects, and has a negative impact on public healthcare costs and organisational effectiveness (Lyneham 2001, Mayhew & Chappell 2001). However, violence within the ED is not only limited to the Jordanian healthcare system, © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 232–242
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but is also considered to be a worldwide challenge (O’Connell et al. 2000, Stirling et al. 2001, Luck et al. 2007). This situation poses an important question: how can ED nurses promote health whilst they experience the fear of violence? This important finding necessitates the development of a violence assessment tool to understand the context and individual precipitating factors within the ED. The absence of any systematic event reporting, documentation and security measures in place might make ED nurses feel defenceless. Although the prevalence and effects of violence in EDs are beyond the aim of this study, it seems that it would be naive to urge nurses to promote health at a time and place wherein their own health and personal safety is at risk. Finally, patients’ beliefs and social taboos about sexual health within the ED affected nurses’ roles and motivation in health promotion. These findings echo those reported by other researchers who found the difficulties experienced in disclosing such problems to healthcare professionals (Taylor & Gosney 2011). The research found that nurses do not address sexual health issues with patients, although they believe this to be a part of holistic care and part of the nurse’s role (Lavin & Hyde 2006, Rana et al. 2007). Nevertheless, visiting the ED specifically in search of treatment to enhance sexual behaviour is surprising within a conservative culture such as that of Jordan. This might be explained by the massive development in media, and dramatic modernisations Jordan has witnessed in the last decade. Interest in sexuality, particularly among older men, has increased over the last 10 years, possibly due to the effective and wellpublicised drugs for erectile dysfunction, starting with Viagra in 1998 (Lindau & Gavrilova 2010). However, current and international evidence found that seeking treatment for sexual dysfunction is commonly inhibited by embarrassment (Baldwin et al. 2003, Gott et al. 2004). In this study, lack of time during consultation, social taboos and lack of expertise or training have been found to be the main barriers to discussing sexual issues with ED patients. Thus, it is expected that ED nurses avoid getting involved in promoting sexual health. This was also the case with general practitioners in the UK, who believed that talking about sexual issues with patients may open a ‘can of worms’ which there was no time to explore (Gott et al. 2004). However, because sexual health is an important component of health promotion (Glanz et al. 2008), more training is needed for ED nurses to impart knowledge of sexuality and the skills required to discuss it sensitively. In the light of current findings, I should agree with the argument asserting that: © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 232–242
Emergency department nurses in health promotion nurses must… ask themselves why, in the 21st century, patients’ sexuality still is taboo and why they avoid the topic. (Saunam€ aki et al. 2010, p. 1314)
Study limitations The study offers valuable insights into ED nurses’ roles in health promotion and the constraints involved. However, before interpreting the study’s findings, there are some limitations to keep in mind. Using face-to-face semi-structured interviews might have introduced social desirability that may have affected what respondents reported to the researcher. Given the uniqueness of each ED in terms of polices and roles and the convenient sampling procedure, caution must be exercised against the generalisation of the current findings to other EDs. Therefore, further research is necessary with other populations of ED nurses working in different hospitals so that a fuller picture can be obtained. Qualitative themes and issues identified in this study might be used to inform the development of a quantitative tool measuring ED nurses’ attitudes towards their role in health promotion in different healthcare sectors.
Conclusion Keeping in mind the limitations of this study, the emerging evidence to some extent complements findings from the existing international literature, particularly in surgical areas: nurses’ role and functions in health promotion are largely guided by biomedical approach to health and lack political and socio-economic actions. However, the current findings should be interpreted taking into consideration the context and constraints that shape ED environment and thus nurses’ roles in health promotion. This research is part of the step towards a more widespread reform for health promotion within the ED. Future work may question whether it is possible for emergency nursing to achieve and sustain concerted health promotion work matching patients’ cultural needs and sensitivity.
Relevance to clinical practice The current findings provide hospital nurses and decisionmakers with an opportunity to assess what changes are needed, and barriers to overcome, in order to improve ED nurses’ role in health promotion. Nurses need to be aware that integrating health promotion in general, and in particular, sexual health into the framework of care should not be done in a mechanistic way without taking into account cultural issues and challenges put forward in this research.
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Acknowledgements The author is grateful to all participants who took part in this study. Many thanks go to Mutah University for funding the project.
conception and design of, or acquisition of, data or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content; and (3) final approval of the version to be published.
Conflict of interest Disclosure The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_ 1author.html), as follows: (1) substantial contributions to
The authors indicate that they have no any affiliations with or involvement in any organisation or entity with any financial interest in the subject matter or materials discussed in this manuscript.
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‘Let other people do it…’: the role of emergency department nurses in health promotion Noordeen Shoqirat
Aims and objectives. To explore emergency department nurses’ roles in health promotion and contributing factors involved. Background. In many healthcare systems, emergency departments are increasingly urged to play a crucial role in health promotion. Although much has been written about health promotion and nurses in acute care settings, less has focused on emergency departments. Design. A qualitative design was used. Methods. In-depth semi-structured interviews were used with a convenient sample of 15 nurses in a Jordanian emergency department. Data were analysed using NVIVO 9 (QSR International, Doncaster, Victoria, Australia). Results. The analysis identified two themes. The first focused on nurses’ roles in health promotion, comprising two categories: having no roles and ‘let other people do it’. The second theme focused on the context and constraints of health promotion comprising fear of violence, the nature of healthcare service and patients’ beliefs. The majority of nurses in emergency departments do not associate health promotion with their practice, hold some negative attitudes and devote more time to clinical tasks than health promotion, which is seen as a second priority. Conclusions. The ideology of medicalised tasks has penetrated deeply into the core principles of health promotion, and thus, nurses’ roles and potential in this area are questioned. Relevance to clinical practice. Decision-makers and nurses within the hospital are urged to address the constraints identified in this study and debate them further. Failure to do so may lead to emergency nursing not being optimally achieved, with the absence of sustained and concerted health promotion work matching patients’ cultural needs and sensitivities. Key words: emergency department, health promotion, Jordan, nurses, semi-structured interviews Accepted for publication: 3 April 2013
Introduction Internationally, emergency departments (EDs) have become one of the most acute areas and play a main role in providing care, treatment for injured people and promoting health (Cross 2005, Cummings et al. 2006, Jonsson & Halabi 2006). In particular, EDs address the needs of those patients at risk of sexual abuse, domestic violence and asthma (Hotch et al. 1996, Fanslow et al. 1998, Yonaka et al. 2007), and identify lifestyle practices and indicators for obesity and diabetes (McNaughton et al. 2011, Vaughn Author: Noordeen Shoqirat PhD, Assistant Professor and Head of Fundamental and Adult Health Nursing, Faculty of Nursing, Mutah University, Karak, Mutah, Jordan
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et al. 2012). In many healthcare systems, the late discovery of illnesses and diseases contributes to a significant burden, often requiring more expensive and involved treatments (Seedhouse & Kessel 2005, Stiffler & Gerson 2006). Whilst health promotion in nursing has increasingly been studied in acute care settings (Casey 2007, Irvine 2007, Whitehead et al. 2008), EDs have been largely excluded, yet there is a growing international demand for ED nurses to have a more visible function and potential in health promotion (Abdallat et al. 2000, Bensberg et al. 2003, Cross 2005). Correspondence: Noordeen Shoqirat, Assistant Professor and Head of Fundamental and Adult Health Nursing, Faculty of Nursing, Mutah University, Karak 61710, Mutah, Jordan. Telephone: +962 32372380 ext. 6707. E-mails: [email protected]; [email protected]
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 232–242, doi: 10.1111/jocn.12383
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Consequently, there is a need for recent and specific research examining ED nurses’ roles, values and willingness to promote health, together with those factors involved. In the light of the paucity of research in this area, the current study qualitatively explored ED nurses’ roles in promoting patients’ health. The emerging findings can be considered as a cornerstone for future cross-cultural studies and evidencebased health promotion in EDs and other clinical areas.
Background Health promotion whether it is a discipline in its own right or an umbrella covering the activities of a wide range of disciplines committed to cover the health of the population in different settings. Whilst health promotion is a complex concept to define, scholars argued that nurses’ roles in this area need to include sociopolitical actions, participation in public health policy formulation, social education programme development and political advocacy (Whitehead 2004, Whitehead et al. 2011, Shoqirat & Cameron 2012). In the clinical context, the reviewed literature showed that EDs are still viewed as suitable settings for health promotion because they are credible sources of health information and they are established health system entry points for many individuals (Williams et al. 2000, Bensberg et al. 2003, Stuhlmiller et al. 2004). Although hospitalisation in general may be stressful for patients, it often acts as a catalyst for change (McBride 2004, Groene & Jorgensen 2005). It is argued that moderate stress enhances an individual’s ability to learn, in particular, when information is given in a simple way (Laverack 2004, Shors 2004). It is not surprising, therefore, that nurses in EDs are urged to use an episode of illness as an opportunity to promote health through providing rehabilitation service, empowering patients and preventing recurrent injuries (Bensberg et al. 2003, Cross 2005). Nurses worldwide have close contact with patients and in patient advocacy, more than other health professionals, and this creates a significant opportunity for delivering health promotion (Kelley & Abraham 2007, Chambers & Thompson 2009, Shoqirat 2009) and leading its movement (Whitehead 2004, Piper 2008). This can be achieved by incorporating health promotion principles such as health education, health policy, empowerment and advocacy in the framework of care (Caelli et al. 2003, Rice & Wicks 2007, Whitehead et al. 2011). However, to date, a large volume of international research has investigated health promotion within nursing in surgical care settings (Casey 2007, Piper 2008, Whitehead et al. 2008, Whitehead 2009, Shoqirat & Cameron 2012) and to a lesser extent in ED (Cross 2005). Regardless of the methodologies of these studies and their contexts, their find© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 232–242
Emergency department nurses in health promotion
ings are underpinned by similar and recurring themes: nurses’ roles and actions in health promotion are mostly confused, haphazard and lacking evaluation and sociopolitical considerations. Factors that led to this situation included poor understanding of health promotion, power imbalance between doctors and nurses, the predominance of the biomedical model of health, lack of time and limited resources (Cross 2005, Kelley & Abraham 2007, Shoqirat 2009). The existing evidence, however, is often descriptive, based on a limited number of studies in EDs, has a medical rather than a nursing focus, and is carried out mainly in the UK and Australia (Williams et al. 2000, Bensberg et al. 2003, Cross 2005, Casey 2007). Other studies are old, and their findings have not been verified by recent research, taking into account the increasing development and debate in health promotion (McKenna 1994, Dunlop 1999). As is the case in many countries (e.g. the UK, Australia and China), Arab states such as Lebanon, Kuwait and Egypt call for integrating health promotion into the framework of nursing education and health policies in various settings (Al-Kandari et al. 2008, Herman et al. 2009, Sibai et al. 2012). Yet, much of health promotion work and research is directed towards schools and primary healthcare centres (Shama & Abdou 2009). In Jordan, preventing illness and early screening of diseases is a high priority of the Ministry of Health, and nurses are required to take a vital role in health promotion (Gharaibeh et al. 2005). Against this background, a large scale Jordanian research found that nurses’ roles in promoting patients’ health in surgical and medical wards are limited and not operating at the level of empowerment and political actions (Shoqirat & Cameron 2012). However, these findings might not be applicable to EDs due to the differences in the clinical context and the type of patients. It is argued that reforming the whole organisation in Jordan towards health promotion needs to be examined first in a small clinical area (Shoqirat 2009). By examining ED nurses’ roles in health promotion in Jordan, it is hoped that this study will contribute to the grounds of national and international evidence.
Aim The aim of the study was to explore ED nurses’ roles in health promotion, and contributing factors involved, in a large teaching hospital in Jordan.
Methods The study examined ED nurses’ roles in health promotion through semi-structured interviews. This qualitative method
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The study was carried out in a 16-bed ED located in a big public hospital in the southern province of Jordan. The hospital serves almost a quarter of a million people from the city and surrounding towns and villages, and thus it was considered as an appropriate study setting. The target ED deals with a wide range of cases, including, but not limited to trauma, food poisoning, road traffic accidents, and patients with diabetes and hypertension. The current researcher recruited conveniently all ED registered nurses (n = 15). Emergency department nurses in military hospitals were not included due to the lack of fund and access difficulties.
to probe for details (Wengraf 2001). That is, the topic guide for the interviews was developed using an iterative process whereby issues and topics were developed for later interviews according to responses offered in earlier interviews. Such responses included the impact of violence and patients’ belief on nurses’ roles in health promotion. The interview schedule was guided by the international literature relevant to health promotion and nursing (Laverack 2004, Cross 2005, Whitehead 2011). Primarily, the interview schedule consisted of various questions, including the following: How do you understand health promotion? What is your role in health promotion? Any role in counselling? Sexual health? What are the facilitators/barriers that affect your role in health promotion? Do you think that EDs are suitable for health promotion? Why? All interviews were conducted in private rooms, recorded digitally and transcribed verbatim. At the end of each interview, the participants’ demographic characteristics were collected. Each interview lasted between 30–45 minutes. All the interviews were conducted in Arabic, but occasionally English terms were used. All data were collected during 2012.
Ethical considerations
Data analysis
Ethical approval was granted by the Research Ethics Committee of the Faculty of Nursing, Mu’tah University, Jordan, and subsequently by the hospital management. Informed consent was signed and obtained from each participant before data collection took place. Participation in the study was voluntary. Confidentiality was achieved by using codes, and all data were kept in a secured office, and access to data was restricted to the authors. All participants had the right to withdraw from the study at any stage without giving reasons. The current author was not involved in any evaluation activity for ED nurses in a way that might affect their responses and thus the quality of data.
Data collection and analysis were carried out simultaneously. The digitally recorded interviews were translated from the Arabic language into English transcriptions. Measures were employed to ensure that the obtained English transcripts were comparable with the original data. First, translation was made independently by the first author and a nursing researcher, who was also a bilingual speaker of both Arabic and English. Second, the two translated versions were examined by the authors, and in the case of any difference, the recorded discussions were reviewed until consensus was reached. Transcripts were read several times and coded, and emergent themes were identified. An independent researcher checked the plausibility of the data interpretation and ensured that the qualitative data analysis was systematic and verifiable. The final version of translated transcripts was uploaded into NVIVO 9 (QSR International, Doncaster, Victoria, Australia) for analysis using the thematic approach aiming to identify commonalities in the transcripts (Thorne 2008). Initially, transcripts generated from interviews were examined separately. Then, all sets of data emanating from all the interviews were examined to identify commonalities between different transcripts. Data analysis commenced with data collection, continued with the translation of data plus multiple replays of the digitally recorded interviews.
was deemed appropriate, as it explores individuals’ views and experiences (Flick et al. 2007), and allows participants to respond flexibly to the questions (Bryman & Teevan 2004) with minimal pollution from the interviewer’s own assumptions (Potter & Hepburn 2005). Employing faceto-face interviews can assist the researcher in clarifying vague statements and thus generate a better understanding of the real world (Mason 2002).
Setting/Sampling
Data collection The current researcher was responsible for collecting all the data. Semi-structured interviews were conducted with a fairly open framework which allow for focused, conversational, two-way communication. Main topic such health promotion was initially identified, and the possible relationship between the topic and issues in the ED and its environment become the basis for more specific questions which do not need to be prepared in advance. The majority of questions were created during the interview, allowing both the interviewer and the person being interviewed the flexibility
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Original article
Trustworthiness The trustworthiness of findings has been enhanced by a number of interventions. Prior to conducting the interviews, three qualitative research experts and three nonparticipants reviewed the interview items and assessed its validity. To enhance the reliability, participants were given the chance to correct the summary following each interview and following the transcription process. The involvement of an independent researcher in the process of translation and data analysis achieved conformability (Potter & Hepburn 2005, Polit et al. 2006). Conformability was also enhanced by the bilingual competencies of the author. Finally, transferability was assured by offering the reader sufficient details about the research and how the themes were developed from the data through rich descriptions and extracts.
Results The overall sample (n = 15) included seven women and eight men. The average experience in ED was 1.7 years, and the average age was 31 years. Two broad themes and related categories were identified, see Table 1.
Theme one: health promotion: roles and attitudes Having no roles When ED nurses were asked about their role in health promotion, their responses showed conceptual confusion, and to some extent, a perceived absence of any role. Under the category of ‘having no roles’, participants expressed their limited understanding of health promotion itself. This is encapsulated in the following quotes: We do not have a role in health promotion in emergency department; we need to save lives as our top priority. (RN2)
Another participant pointed out that, despite the absence of a ‘real’ role in health promotion, patients are given individual health advice:
Emergency department nurses in health promotion Table 1 Main themes and cluster of meanings Themes
Categories
Cluster of meanings
Health promotion: roles and attitudes
Having no roles
The absence of a ‘real’ role in health promotion The absence of key health promotion elements such as empowerment and advocacy ‘Already we are busy in EDs’ ‘Staff in primary [health care] centers need to have this role in health promotion’ Lack of competency The absence of training courses in health promotion Unsafe work environment and violence The absence of health promotion policy ‘Free treatment does not cure’ Sexual health: ‘the red line you should not cross’
‘Let other people do it’
Theme two: context and constraints
Personal factors
Factors within the hospital
Patients’ beliefs
experiences are addressed under health education. In other words, nurses in EDs carry out some minor health promotion activities but without being cognizant of their role. Such activities are largely exemplified by giving health advice about medical issues. However, health advice and education are instigated by patients’ questions as opposed to nurses’ recognition of their role in health promotion. In addition to the absence of key health promotion elements such as empowerment and advocacy, the focus of health in general is linked to the nature of the health problem itself rather than the expressed needs of individuals.
Other findings revealed the nature of the approach being used for promoting patients’ health:
‘Let other people do it’ Analysis of emerging data shows that many participants (n = 13) summed up their views towards promoting patients’ health in EDs as: ‘let other people do it’. Participants felt that health promotion work should be carried out by other nurses and departments. These views were justified by statements such as ‘already we are busy in EDs’ and ‘others are better suited than us’:
We answer patients’ questions and tell the patients what to do and
You know we are busy here… I think nurses on wards are better
not at home before leaving the emergency doors. (RN10)
suited than us to have a vital role in health promotion. (RN7)
It is interesting to note that, albeit nurses have no clear picture about their role in health promotion, some of their
These views were also confirmed by a senior participant who argued that:
We have no real roles like carrying out health education programs… we only focus on side-effects of the medications before patients go home. (RN4)
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N Shoqirat We deal with complex cases and time should be well spent… I
We do not have enough knowledge and skills… frankly I do not
think that staff in primary centers need to have this role in health
feel competent at all… my role in health promotion is out of ser-
promotion. (RGN5)
vice… [laughing] (RN11)
These findings are indicative of the lack of understanding of health promotion as an integrated part of nursing care. The extract ‘the time should be well spent’ might suggest that health promotion is seen a second priority in EDs. That is, participants in this study believed that due to the lack of time and the business of the clinical area, the top priority is treating complex cases as opposed to promoting health. It is not surprising, therefore, that some participants felt that other nursing staff located in different areas should take up the role in health promotion. However, contrary to the prevailing view outlined previously, a further examination of data found that two participants disagreed:
Other participants (n = 8) alluded to the emotional ambience of the ED, pointing out that in addition to the lack of knowledge and skills, the nature of staff themselves might contributes to poor communication:
I think it is our responsibility to promote health in EDs… you know many health problems are diagnosed here, and the majority of patients have minor medical problems. (RN1)
Specifically, the suitability of EDs for health promotion was explored by the following participant:
I am a senior nurse here and I can tell you that health promotion needs good communication, but unfortunately many of our staff are moody… patients are hesitant to talk to them… (RN10)
These findings show that at the personal level, nurses feel that their role in health promotion is confined by their limited knowledge and skills in health promotion. It is worth noting that being ‘moody’ was seen as an obstacle to effective communication with patients. On this basis, it can be argued that the prevailing emotional ambience of ED wards due to staff outlook could not only restrict the scope of a more effective intervention operating at the individualised level, but also broad reaching health promotion work encapsulating socio-economic and political factors.
We have 12 beds here and not all patients admitted in EDs are suffering from life threatening illness or injurers… we deal with cases such as asthma, diabetes and hypertension. (RN6)
These findings are promising in terms of recognising the suitability of EDs for health promotion. However, participants did not refer to wider issues of importance to the ideology of health promotion–based setting. These include operating at the socio-economic levels, lobbying and advocating on behalf of less privileged people in society.
Theme two: context and constraints The second theme that emerged focuses on the overall context and constraints that affect the development of nurses’ roles in health promotion. Factors identified can be addressed under three categories.
Personal factors Participants (n = 10) expressed concerns about the lack of competency in health promotion. In particular, the absence of any training courses makes participants incompetent in delivering wide-reaching health promotion activity. The following participant worked in the ED for nine years but felt incompetent in health promotion:
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Factors within the hospital The absence of health promotion policy Further issues identified in the data were concerned about those factors affecting ED nurses’ roles at the hospital level. The absence of a health promotion policy was referred to by participants as ‘walking on a landmine’: I never seen any documents regarding the importance of health promotion… we have no map or protocol – it is like walking on a landmine! (RN13)
Another participant blamed the Ministry of Health for not explicitly urging hospitals to have an ‘active policy’ in health promotion: The Ministry of Health in Jordan gives little attention to health promotion responsibility and other health policies are just out of order… we are still awaiting new job descriptions. (RN14)
The above evidence points out the need for a more systematic approach to nurses’ roles in health promotion by certain health policies. However, no evidence was found to suggest that ED nurses were engaged in health policy formulation. In this context, it seems that nurses are willing to have health policies in place, but their abilities to get engaged in their formulation are unclear. Despite the lack of data, the extent to which nurses are being involved in
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making decisions about improving patients’ socio-economic status might be questioned.
Emergency department nurses in health promotion Some patients underestimate the quality of nursing care… one of the patients told me one day that what is free is free, which means in our culture that it is useless. I do not think they will accept my
Unsafe work environment and violence The emerging evidence revealed that ED nurses’ roles in health promotion might be compromised by unsafe hospital environment and, in particular, violence. These findings are illuminated by the following anecdote: Before promoting health, we need to work without fears of violence… last year an angry relative of a patient was not happy about the care and started shouting and slamming the doors and windows… he threatened all of us… (RN3)
Another participant blamed the hospital security department, stating that: How can you talk about health promotion while some patients and their relatives threaten you? When we call the security guards they arrive late so we need to get the work done as fast as we can and avoid health promotion chat. (RN15)
With the above evidence in mind, it seems that nurses in EDs might be a subject to violent behaviours that make their role in health promotion impossible. In other words, some ED nurses might feel less motivated to undertake health promotion due to unsafe working environment and lack of effective safety and protection measures in place. This, in addition to its detrimental effect on nurses’ own health and well-being, may produce lower standards of care for patients. This is exemplified by the attitudes of avoiding as opposed to engaging in the health promotion process.
role in health promotion. (RN9)
Participants’ accounts and experiences imply that ED nurses’ roles in health promotion are affected negatively by patient’s beliefs. These include underestimating the overall quality of nursing care and negative attitudes towards free of charge treatment. It should be noted that it seems that the type of health service sector might affect the development of nurses’ role in health promotion. In this context, participants believe that in the private sectors, as a result of costly treatment, patients are more willing to get involved in health promotion than their counterparts in the public hospitals. However, statements such as ‘listening and following our instructions’ might indicate narrow development in health promotion manifested by a one-way and an expert-led approach as opposed to collaborative and negotiating ideology of health promotion. Sexual health: ‘the red line you should not cross’ Although some ED patients might require sexual health advice, particularly those suffering from diabetes, this aspect of health promotion has been marginalised. Data suggest that due to patients’ beliefs and conservative culture, discussing sexual matters is not acceptable. However, in one case, a participant reported the following interesting encounter with a 52-year-old diabetes patient suffering from a sexual problem: Last year a patient took me to a hidden corner in the ED and was
Patients’ beliefs ‘Free treatment does not cure’ During all the interviews (n = 15), participants reported that many patients come to the ED with a belief that free health service will not cure them, but it is the only option they have. Some participants went further to argue that if patients paid all the costs of the treatment, they would take better care of themselves and follow a prescribed medication carefully: I worked before in a private ED.. because patients pay for everything… they used to listen and follow our instructions precisely… but in this public hospital many patients do not. They believe that free treatment is not good and some ignore even the time of their prescribed medications… (RN7)
According to participants, some patients are suspicious about nursing staff’s knowledge and clinical skills:
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 232–242
embarrassed to tell me that he does not have erection anymore so he was wondering if we can give out some Viagra …when I told him that he should first be referred to the clinic, he just left and I have never seen him again [laughing]! (RN2)
Although the ED nurse suggested that the patient should be referred to a specialised clinic, it appears that an appropriate history of the patients’ concerns was not taken. Thus, it is not clear whether patients’ needs might fit with ethos of their ED. Another participant stressed that the need for sexual health promotion is expressed by patients indirectly, as shown below: Some patients do not suffer from anything and they come for the ED asking for something make them fit and strong!… If they trust you they tell you openly they meant boosters for sex… we have no clear idea or training about how to promote sexual health; it is a red line topic we should not cross. (RN8)
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The evidence outlines the valuable opportunity for promoting sexual health within the ED. This opportunity, however, is not without obstacles, such as feeling embarrassment, social taboos and lack of clear guideline or protocols on how to deal with this issue. It seems that this situation gets more complicated in ED, where no private room is available to explore patients’ concerns and needs in a confidential way without the fear of publicising their private life.
Discussion Education of nurses now and in the future The study examined ED nurses’ roles in health promotion and identified factors involved. The overall findings indicate that the majority of nurses do not associate health promotion with their practice, and devote more time to clinical duties than to health promotion, which is seen as a secondary priority. These findings resonate with previously reported international studies in acute surgical areas (Casey 2007, Kelley & Abraham 2007, Wilhelmsson & Lindberg 2007), and thus the discussion is largely focused on the context of ED and constraints to nurses’ roles in health promotion. However, it is worth noting that some negative attitudes towards nurses’ role in health promotion that emerged in this study – such as ‘let other people do it’ – are not consistent with earlier work conducted in the UK, in which it was found that ED nurses hold positive attitudes and values towards their role in health promotion, despite the lack of time in which to conduct duties associated with this role (Cross 2005). Whilst differences in research methods are recognised, this finding might be explained by the nature of nursing education and job descriptions in Jordan, which are largely driven by a disease prevention approach as opposed to a health promotion philosophy (Shoqirat 2009). Internationally, whilst ED is regarded as being suitable for health promotion, this perception is grounded in a medical paradigm wherein most staff are educated to think exclusively about medical care (Bensberg & Kennedy 2002). As a result, there is an urgent need for increasing ED nurses’ awareness about the importance of their responsibilities in health promotion through training, implementing guidelines and updating health polices at the hospital and national levels. However, academics, nurses and researchers alike must be cautioned and acknowledge that relying only on the health policies and nurses’ competency in health promotion might not be enough. For instance,
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Swedish nurses reported that despite health promotion being a central part of their training and a professionally legislated-for competence, they were not able to practise it due to the dominance of medicalised tasks. Therefore, the challenge is not only how to educate and train ED nurses in health promotion and offer a package of health policies, but also how to create a health promoting setting in which they might release their potential and better understand their roles. Consistent with international studies (Sempere-Selva et al. 2001, Carret et al. 2007), the qualitative findings pointed out that many patients admitted to EDs had no critical condition. Statistically speaking, it was found that 91% of cases admitted in Jordanian EDs were not lifethreatening (Abdallat et al. 2000). On this basis, nurses in EDs should take advantage of these opportunities by encouraging patients with nonurgent medical conditions to get involved in health promotion activities within the hospital. Using the evidence-based agenda map could be effective in identifying health promotion goals, opportunities and the negative consequences of not using it thus attracting the support needed from policy makers (Rychetnik & Wise 2004). Participants felt that some patients are dissatisfied about nursing care and nurses’ potential in health promotion within the public hospital. These findings are similar to previous research, suggesting that patients often prefer receiving care in private hospitals, where they experience more ‘modern’ treatment (Lee 2006, Alhusban & Abualrub 2009, Zamil et al. 2012). In Jordan, regardless of the type of care providers (i.e. private or public), people often believe that paying for treatment will most likely lead to better care and recovery. How the type of the healthcare sector shape patients’ receptivity and attitudes towards nurses’ roles in health promotion is worth investigating further.
Creating a culture for health promotion One aspect that constrains any attempt to introduce concerted efforts for healthcare promotion by ED nurses was the factor of the fear of violent patients and/or their families, which was cited by many participants as something that contributes negatively to their personal safety and their willingness to promote health. Violence affects nurses’ psychological, cognitive, emotional and behavioural aspects, and has a negative impact on public healthcare costs and organisational effectiveness (Lyneham 2001, Mayhew & Chappell 2001). However, violence within the ED is not only limited to the Jordanian healthcare system, © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 232–242
Original article
but is also considered to be a worldwide challenge (O’Connell et al. 2000, Stirling et al. 2001, Luck et al. 2007). This situation poses an important question: how can ED nurses promote health whilst they experience the fear of violence? This important finding necessitates the development of a violence assessment tool to understand the context and individual precipitating factors within the ED. The absence of any systematic event reporting, documentation and security measures in place might make ED nurses feel defenceless. Although the prevalence and effects of violence in EDs are beyond the aim of this study, it seems that it would be naive to urge nurses to promote health at a time and place wherein their own health and personal safety is at risk. Finally, patients’ beliefs and social taboos about sexual health within the ED affected nurses’ roles and motivation in health promotion. These findings echo those reported by other researchers who found the difficulties experienced in disclosing such problems to healthcare professionals (Taylor & Gosney 2011). The research found that nurses do not address sexual health issues with patients, although they believe this to be a part of holistic care and part of the nurse’s role (Lavin & Hyde 2006, Rana et al. 2007). Nevertheless, visiting the ED specifically in search of treatment to enhance sexual behaviour is surprising within a conservative culture such as that of Jordan. This might be explained by the massive development in media, and dramatic modernisations Jordan has witnessed in the last decade. Interest in sexuality, particularly among older men, has increased over the last 10 years, possibly due to the effective and wellpublicised drugs for erectile dysfunction, starting with Viagra in 1998 (Lindau & Gavrilova 2010). However, current and international evidence found that seeking treatment for sexual dysfunction is commonly inhibited by embarrassment (Baldwin et al. 2003, Gott et al. 2004). In this study, lack of time during consultation, social taboos and lack of expertise or training have been found to be the main barriers to discussing sexual issues with ED patients. Thus, it is expected that ED nurses avoid getting involved in promoting sexual health. This was also the case with general practitioners in the UK, who believed that talking about sexual issues with patients may open a ‘can of worms’ which there was no time to explore (Gott et al. 2004). However, because sexual health is an important component of health promotion (Glanz et al. 2008), more training is needed for ED nurses to impart knowledge of sexuality and the skills required to discuss it sensitively. In the light of current findings, I should agree with the argument asserting that: © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 232–242
Emergency department nurses in health promotion nurses must… ask themselves why, in the 21st century, patients’ sexuality still is taboo and why they avoid the topic. (Saunam€ aki et al. 2010, p. 1314)
Study limitations The study offers valuable insights into ED nurses’ roles in health promotion and the constraints involved. However, before interpreting the study’s findings, there are some limitations to keep in mind. Using face-to-face semi-structured interviews might have introduced social desirability that may have affected what respondents reported to the researcher. Given the uniqueness of each ED in terms of polices and roles and the convenient sampling procedure, caution must be exercised against the generalisation of the current findings to other EDs. Therefore, further research is necessary with other populations of ED nurses working in different hospitals so that a fuller picture can be obtained. Qualitative themes and issues identified in this study might be used to inform the development of a quantitative tool measuring ED nurses’ attitudes towards their role in health promotion in different healthcare sectors.
Conclusion Keeping in mind the limitations of this study, the emerging evidence to some extent complements findings from the existing international literature, particularly in surgical areas: nurses’ role and functions in health promotion are largely guided by biomedical approach to health and lack political and socio-economic actions. However, the current findings should be interpreted taking into consideration the context and constraints that shape ED environment and thus nurses’ roles in health promotion. This research is part of the step towards a more widespread reform for health promotion within the ED. Future work may question whether it is possible for emergency nursing to achieve and sustain concerted health promotion work matching patients’ cultural needs and sensitivity.
Relevance to clinical practice The current findings provide hospital nurses and decisionmakers with an opportunity to assess what changes are needed, and barriers to overcome, in order to improve ED nurses’ role in health promotion. Nurses need to be aware that integrating health promotion in general, and in particular, sexual health into the framework of care should not be done in a mechanistic way without taking into account cultural issues and challenges put forward in this research.
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Acknowledgements The author is grateful to all participants who took part in this study. Many thanks go to Mutah University for funding the project.
conception and design of, or acquisition of, data or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content; and (3) final approval of the version to be published.
Conflict of interest Disclosure The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_ 1author.html), as follows: (1) substantial contributions to
The authors indicate that they have no any affiliations with or involvement in any organisation or entity with any financial interest in the subject matter or materials discussed in this manuscript.
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