I S S U E S A N D IN N O V A T I O N S I N N U R S I N G P R A C T I C E

A stage planning programme model for health education/

health promotion practice
Dean Whitehead MSc PGDipHE PGCE RN
Doctoral Student and Senior Lecturer, Institute of Health Studies, University of Plymouth (Exeter), Exeter, Devon, UK

Submitted for publication 30 November 2000

Accepted for publication 30 July 2001

Correspondence: WHITEHEAD D. (2001) Journal of Advanced Nursing 36(2), 311±320

Dean Whitehead, A stage planning programme model for health education/health promotion practice
Institute of Health Studies, Aim. To investigate the validity of a stage planning programme model for health
University of Plymouth (Exeter),
education/health promotion practice in nursing settings and to develop a speci®c
Veysey Building,
model for this purpose.
Earl Richards Road North,
Exeter, Background/rationale. The last decade or so has seen a marked increase in the
Devon EX2 6AS, amount of health educational/health promotional activities that nurses are expected
UK. to undertake. This has followed concerted calls to make health promotion a familiar
E-mail: dwhitehead@plymouth.ac.uk and recognized part of nursing practice. Despite this, however, current health-
related practices are still unstructured, haphazard and under-evaluated. This state of
affairs is further compounded by the lack of any generic and systematic nursing
planning process model by which health education/health promotion programmes
are applied in practice. This paper puts forward the case for such a model, develops
it, and demonstrates its possible application in clinical settings.
Method. A systematic literature review was conducted in order to develop a new
theoretical perspective for health promotion/health education nursing practice. The
proposed model has evolved from this new perspective. The process of developing
this model has drawn on existing contemporary planning models ± using them as a
means to develop a conceptual framework. Consequently, the proposed model seeks
to critique, adapt and adopt some of their components within a nursing context.
Conclusion. If the current situation continues, in which planning process models
are not adopted as a routine part of practice, then nursing may well remain a
`bystander' in health promotion/health education.

Keywords: health promotion, health education, stage planning programme models,

nursing practice

viewpoints also point to the fact that where nurses do

Introduction
For some time now there has existed either an implied or a
contractual obligation for many nurses to undertake and
participate in health promotional activities as part of their
routine clinical activity (DeAmicis 1997, Thomson & Kohli
1997, Norton 1998). According to some, however, these
practices are not as prevalent as might be expected and that
where attempts at these activities occur they are usually
limited by their unstructured, haphazard, `ad hoc' and under-
evaluated nature (Caraher 1994, Whitehead 2000a). Other
implement these activities, they are far more likely to practice
opportunistic and limited information-giving `health educa-
tion' techniques (Thomson 1998, Piper & Brown 1998a).
I argue that the position that nursing ®nds itself in, in
relation to its health promotional role, is predominantly
underpinned by the lack of any formally identi®ed structured
and ordered planning process, model or framework, for this
sort of activity that is used in nursing practice. Norton (1998)
stresses that nurses need to continue to strive for clari®cation
of their role alongside the processes of health promotion

Ó 2001 Blackwell Science Ltd 311

312
D. Whitehead

Figure 1 A stage planning programme model for health education/health promotion activity.

Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(2), 311±320

Issues and innovations in nursing practice
programmes. Focusing on the processes that nurses adopt in
this ®eld of activity appears to be one of the main ways
forward ± particularly in relation to its planning processes.
Indeed, it is claimed that a systematic approach to health
promotion programme planning will signi®cantly improve
the chances of a successful outcome in this ®eld of endeavour
(Tones & Tilford 1994, De Vries 1998, Nutbeam 1999).
Scott and Weston (1998) state that as part of the process of
health promotion, planning is extremely important if one
wishes to successfully facilitate the translation of currently
established theory into practice. Certain government agencies
are beginning to recognize that alongside other health
professions, this is the case for the nursing profession and
are seeking to address this issue by developing new frame-
works (National Health Service Executive ± South West
1999). In this particular instance the development of an audit
tool for health promotion initiatives appears to be useful, in
that it could be used alongside the proposed planning model
put forward in this paper (Figure 1). I feel that adopting a
series of frameworks to this same end would ultimately serve
to increase the chances of successful intervention and
outcome. Kaplan et al. (1993) support the notion that many
health professionals do attempt to draw their inspiration
from more than one model or framework.
This paper attempts to identify a speci®cally adapted and
sequentially structured planning tool, in which one or more
processes can be used as a template and measuring device for
planning any nursing-related health promotional/health
educational programme (Figure 1). This tool seeks to put in
place a predominantly cyclic `stage' planning process model
that takes into account the most likely scenarios of a nurse's
clinical practice. It draws upon and critiques existing ele-
ments of established contemporary planning models, as well
as recent nursing-led attempts at adaptation of these models,
as a means to establish a clearer base-line for consensus and
action. In doing so, it attempts to contradict the `strange'
phenomenon whereby most health promotion model-makers
appear to be unaware of the existence of each other's models
(Rawson 1992). Associated literature is reviewed throughout.
The case for an applied health promotion
planning process model in nursing activities
Despite the fact that several established contemporary health
promotion planning models exist, Ross and Rosser (1989)
state that these models are in need of further modi®cation.
Similarly, Serembus (1998) identi®es that these contemporary
models may have yielded signi®cant results but go on to argue
that they have produced inconsistent ®ndings in clinical
nursing settings. Perhaps this is related to the way that they
Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(2), 311±320
A stage planning model
are actually applied by nurses. There is suggestion that many
nurses feel that their main health promotion role merely
entails initially assessing the health status of individual clients
and then applying a preventative behavioural-change strategy
(Whitehead 2000b). King (1994) argues that there is still a
need for health promotion models to move beyond the simple
assessment of health. Similarly, Warren and Alstrom (2000)
assert that it is essential that any health assessment is not seen
merely as a tool to determine a client's current health status,
but that it forms a `starting point' for planning any health-
related programme. Assessment, like planning, should not be
viewed as a unitary stage in any process. Existing planning
models should be seen to be more encompassing in that they
seek to move any health promotion programme beyond a
simple assessment procedure, and thus incorporate both this
and other distinct phases as part of their cyclic or linear
process.
A conceptual framework is required in order to provide a
rationale focus for any health promotional model develop-
ment (Burke & Smith 2000). Proper attention to such
procedures effectively avoids the situation where a health
promotion intervention is implemented before it is suf®-
ciently developed (Nutbeam 1999). Adherence to such
procedures is also stressed by Labonte (1999), who states
that the main dilemma facing health promotional pro-
grammes is not so much what the issue is (i.e. heart disease,
poverty, etc.) but how rigidly explanatory (socio-cognitive or
planning) models are applied in practice. Failure to strive
towards this rigidity has resulted in authors such as Ziglio
et al. (2000) being critical of the fact that a paradigmatic shift
of health promotional activities, leading to newly devised
processes, is still yet to happen. MacDonald (2000) mirrors
this sentiment when stating that health promotion needs to
explicitly recognize its growing theoretical evidence for
determining the nature of an intervention (i.e. planning
process models) when planning health-related interventions.
Similarly, Nutbeam (1999) argues that all health promotion
interventions programmes need to be informed and under-
pinned by established theory and models relevant to the type
of planned intervention.
Thomson (1998) stresses the planning link between health
promotional activities and nursing practice in stating that
each activity must be underpinned by a `dynamic' cycle of
activity. This cycle involves the key stages of assessment of
need, planning, setting aims and objectives, methodology and
evaluation of outcomes. A simple example that very closely
follows this particular process is McCarthy's model of
rational health planning (McCarthy 1982). In nursing terms
we are referring to the `nursing process' as described origin-
ally by Hall (1955). Klug-Redman (1993) highlights the close
313
D. Whitehead
similarity between the teaching process required for any
effective health educational encounter and the nursing
process. Lindsey and Hartrick (1996), on the other hand,
criticize the nursing process as a biomedically de®ned
approach to health care that is useful for health education
interventions, but not conducive to more encompassing
health promotion initiatives. DeAmicis (1997), nevertheless,
in her adapted health promotion model refers to a similar
process to that of the nursing process that instead, identi®es
the key stages of `therapeutic modalities, identi®cation of
support systems and the exact settings in which the interven-
tions are to occur'. Attempts to link these complementary
process activities are also supported by Aggleton and Chalmers
(2000), who state that such frameworks offer appropriate
structures around which to plan health promotion interven-
tions. It is acknowledged, however, that some established
health promotion planning models adhere to a fundamentally
`linear' process ± unlike the nursing process itself.
Although planning itself constitutes just one component of
the overall planning process, it cannot be realistically
applied on its own and therefore its place is governed by
the other parts of the process around it. This is in spite of
the fact that in reality, planning may often be applied in a
piecemeal or incremental fashion (Naidoo & Wills 1994).
DeAmicis (1997) suggests that all of the components of the
nursing process itself can be adapted for use by all health
promoters. It seems particularly appropriate (in this case)
that a process devised by nurses should be incorporated into
nursing health promotion practice. On the other hand,
Pender (1984) has critically asserted that whilst nursing
process models are widely used, they have usually failed to
acknowledge health promotion within them. This offers
further validation of the need for nurses to develop an
appropriate planning model for health promotion activity ±
as this paper sets out to do.
Dilemmas associated with existing health promotion
planning models and the current nursing climate
Over recent years, some authors have sought to adapt
contemporary models to suit speci®c nursing-related situa-
tions and events for example, Simmons (1990) and Serembus
(1998). Molloy and Caraher (2000), however, identify that
there does not appear to be any particular dominant health
promotional model of working ± particularly when applied to
public health nursing. I argue that all previous attempts to
adapt contemporary models have been too limiting or limited
in their scope and will go on to state how and why a little
later on. This is compounded by the fact that, given the
complexity of health promotion programmes, there is no
314 Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(2), 311±320
single or `absolute' form of evidence in this ®eld of endeavour
(Nutbeam 1999). This is perhaps indicative of the fact that no
one model is right for all circumstances. In nursing's case,
however, it is felt that is compounded by the premise that
most health promotional activity is limited to a few approa-
ches (for example, medical/preventative or empowerment)
(Beattie 1991). As long as this state of affairs exists then one
model could provide nearly all of the necessary requirements
for most circumstances. As nursing's position changes and its
health promotion activities become more diverse and encom-
passing there may be a need to provide a wider range of such
models for all types of clinical/educational settings. Some
evidence exists to suggest that some nurses are already
attempting to move in such a direction. For instance,
Thomson (1998) demonstrates the use of an adaptation of
Hanlon et al.'s (1995) `planning compass' model for health
promotion practice, whereby its primary focus is upon
enabling pre-registration students to `theoretically' apply a
planning process to the development of certain health
promotion scenarios.
The sequence of any health promotion planning model will
generally, at some point, address some components of a
social-cognitive approach (Green & Kreuter 1991). Essen-
tially, the intention will be to acknowledge and monitor any
change in risk-related behaviour and/or change in risk-related
environment, which subsequently leads to a modi®cation of
disease incidence. Any mention of this type of framework is
generally indicative of a disease/illness-speci®c preventative/
medical model of health-related practice. Preventative frame-
works tend to sit comfortably within nursing practice, with
anecdotal evidence stating that this is the favoured health
promotion/health education approach of most nurses in most
settings (O'Regan 2000, Snape 2000, Whitehead 2000c).
Indeed, Goel and McIsaac (2000) state that what is viewed by
most health professionals as health promotion simply equates
to `disease prevention' activities. Labonte (1999) asserts that
this is nothing new, as there exists a `disease-speci®c default'
in most health care systems. Downie et al. (1996) states that
this situation is reinforced by the fact that most politicians
and health service managers are strong advocates of this type
of system. In the model proposed in this paper the health
education/preventative approach is representative of the
disease-speci®c issues discussed. Unfortunately, for health
promotion itself, preventative frameworks do not tend to
advocate the current `vogue' for more `humanistic' empower-
ment-led approaches to health-related initiatives. Within the
context of the proposed model, empowerment approaches to
health-related provision can be matched against and along-
side preventative frameworks (Beattie 1991) ± as they are in
my proposed model. Indeed it is considered by some to be
Issues and innovations in nursing practice
favourable to do so. For instance, McFarland (1999) states
that health promotion models should offer the possibility of
providing a systematic approach to care, built on a more
humanistic nursing framework, as opposed to only using a
biomedical and disease-speci®c framework of care delivery.
Although not a dilemma for health educational activities in
nursing, health promotional activities face formidable
barriers in the current climate. Health promotional initiatives
are often designed to incorporate more encompassing and
wide-ranging activities that advocate client empowering
components. These strategies also attempt to in¯uence the
clients' socio-economic, political and environmental condi-
tions. Unfortunately, whilst working well alongside preven-
tative-driven frameworks, the predominance of `traditional'
health education frameworks in nursing are seen to serve as a
barrier to achieving radical and much needed health promo-
tional reform (Robinson & Hill 1998). To add to the current
dilemma, many nurses also have problems conceptualizing
their health-related activities. Where they often believe
themselves to be practising health promotion the reality is
that they are far more likely to be practising the more limiting
and limited health educational techniques already described
(Norton 1998). Downie et al. (1996) inform us that where
these health programmes are implemented in practice settings
they continue to `lag behind' theoretical developments. This
state of affairs, it is suggested, is indicative of nursing's poor
standing, as a health-promoting force, when compared with
many other health professional groups. Nursing's position on
this matter appears to have remain unchanged for many
years, leaving some to question the validity of its claim to
offer a valid contribution to the discipline of health promo-
tion (Caraher 1994, Antrobus 1997).
The currency of existing health promotion
planning models
We are not always best advised to accept conventional health
promotional models purely at `face value'. This mirrors
Seedhouse's (1997) notion that we should not necessarily
accept that existing conventional models always re¯ect or
represent the reality of practice. He states that being critical
of conventional assumptions, related to these models, repre-
sents best practice. With this in mind this section explores the
facets of existing models against those of the model proposed
in this paper.
The distinction is made here between `planning' models,
`behavioural' (social-cognitive) models and `change theory'
models of health promotion. Planning models of health
promotion act as a guide to the main phases and `planning
steps' of any given health promotion encounter. Behavioural
Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(2), 311±320
A stage planning model
models are explanatory models that aim to describe why
individuals adopt certain health behaviours and change
theory models identify how we can stimulate behavioural
change (De Vries 1998). Exploration of the latter two types
of models are beyond the scope of this article but many
examples exist of nursing description and adaptation of these
particular approaches, for example, Pender (1987), Piper and
Brown (1998b), Whitehead (1999), Stuifbergen et al. (2000)
and Dilorio et al. (2000). This being said, De Vries (1998)
acknowledges that all health promotion models and strategies
ultimately have a central aim of stimulating the adoption of
health behaviours amongst communities, groups or individ-
uals. This commonality means that planning programme
models may also incorporate some elements of social-cogni-
tive behavioural and change theory model activities (Ross &
Rosser 1989). They will invariably acknowledge elements of
risk reduction and behavioural change as a `matter of course'.
For instance, if we take Green et al.'s (1980) popular
PRECEDE planning model, it exists as a health education
model that primarily focuses on behavioural change activ-
ities.
The PRECEDE model
Green et al.'s (1980) Predisposing Reinforcing and Enabling
Causes in Educational Diagnosis and Evaluation (PRECEDE)
model is one of the most popular and extensively used
contemporary health promotion planning models of recent
years. The original PRECEDE model is a four-phase model
that draws from the ®elds of epidemiology, social-cognitive
psychology (behavioural diagnosis), education and manage-
ment (administrative diagnosis). Its intention is to establish
the relationship between health-related programmes and their
targets in such a way that its `proximal, intermediate and
distal outcomes' can be initially identi®ed and then assessed
to ensure that the programme is internally consistent
(MacDonald 1998). A demanding, complex, highly struc-
tured and linear `effect' model, it is unlikely that it is used
much, if at all, within nursing arenas for these reasons alone.
Naidoo and Wills (1994) state that where it is used, the
reality and practice is that it is rarely used as it is meant to be,
usually being simpli®ed by the user. It is worth noting that
despite its complexity, the popularity of Green et al.'s
PRECEDE model of planning has meant that it has been
revised and emulated by others, such as Bonaguro and
Miaoulis (1983), who adapted it to incorporate a `social
marketing' approach to health promotion. The merits of
social marketing as an in¯uential aspect of mass media in
health promotion strategies is already noted (Whitehead
2000d). Kreuter's (1992) Planned Approach To Community
315
D. Whitehead
Health (PATCH) model is also a later variation on the
PRECEDE model.
The PRECEDE model has not been universally adopted by
nursing professionals, despite its overall popularity and the
fact that it sits predominantly within a biomedical framework ±
as do several other planning process models. This is also in
spite of the fact that it is most likely to be incorporated into
preventative-focused health education strategies which are
often favoured by nursing health educationalists. Naidoo and
Wills (1994) identify that as a health education model and
not a health promotion model, the PRECEDE model of
planning is primarily focused on behavioural change. Green
and Kreuter (1991) did go on to further develop the model
and produced a cyclic add-on component called PROCEED.
This has produced an overall model that has, in essence,
a preparatory effect component and a stage component to
follow. This makes the model more encompassing and health
promotional in its nature, yet more complex to use.
Sanderson et al. (1996) describe the two different approaches
that are used in the PRECEDE/PROCEED model as the
two most common types of `diagrammatic' models. They
refer to the former sequence of activities or events as actual
or hypothetico-causal relationship `effect' (how-it-works)
models and the latter as `stage' (how-to-do-it) models. The
model proposed in this paper essentially subscribes to the
prescriptive how-to-do-it `stage' model of planning. Nurses,
in my experience, are more likely to favour a cyclic stage
model that mirrors elements of the nursing process and other
established processes of care, although their own health-
educational practice usually adopts a mostly linear approach
that fails to evaluate and reassess their programmes of
delivery. Cyclic models might also suit nursing initiatives in
light of the fact that linear models may not always provide
a suitable framework for many health promotional
programmes because they often lack suf®cient process detail
(Grossman & Scala 1993). The model proposed in this paper
is largely cyclic in its nature in an attempt to avoid over-
simplifying its process detail.
Other contemporary models
Examples of other `mainstream' contemporary planning
models, include Ewles and Simnett's (1992) cyclic stage
planning model. It offers a far less complex approach and one
that is more likely to have been adopted within a nursing
framework, where health promotion planning models are
used in practice settings. A somewhat generalized model, it is
not so often adopted in mainstream health promotion
practice and for that matter, rarely mentioned in its published
texts. Certainly this model would most likely lack suf®cient
316 Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(2), 311±320
detail to clearly guide the nursing practitioner, with limited
experience of using any of these models, through the
complicated procedures associated with any successful
health promotion programme. Tones and Tilford (1974)
Planning Model for Health Education has been adapted and
revised to offer a planning approach for more experienced
health promotionalists. Another complex and linear effect
model, this model is most likely to appeal to experienced
health promotionalists. It differs from the PRECEDE/
PROCEED model in that it is primarily focused on educa-
tional outcomes rather than on behavioural change (Naidoo
& Wills 1994).
Nursing examples of planning models
It is evident from the literature that there are only a few
examples where nurses have sought to adapt contemporary
planning models and apply them directly to a nursing setting.
Serembus (1998) has developed a simple linear stage-plan-
ning model and called it the `Healthy Heart Promotion
Model'. Although easy to follow, I argue that it is limited by
its simplistic design and the fact that it only caters for a very
speci®c group of clients-focusing only on coronary heart
disease issues. No means is offered by which to evaluate the
outcomes of a programme that follows this model. Simmons
(1990) devised a more comprehensive and generic effect
planning model called the `Health-Promoting Self-Care
System'. The criticism of this model is aimed at the fact that
it too follows a mostly linear process and assumes that clients
are mainly autonomous, will accept responsibility for their
own `self-care' and that nurses will readily relinquish their
`expert' role in order to accommodate such a process. It is
suggested that this is rarely the case with nursing/client
encounters (Mackintosh 1995). The model proposed in this
paper, on the other hand, supports the use of a more
prescriptive and expert-driven health education approach, yet
also acknowledges the possibility of adopting a more encom-
passing initiative via an empowerment approach, if the
appropriate measures are in place.
The proposed model
Rationale
Health promotion is a dynamic process and not one that can
be applied loosely or piecemeal (Pender 1984, Kiger 1995).
Attempts have been made over the last decade or so to apply
this fact to nursing but usually with somewhat limited results.
Consequently, there is still no commonly established nursing
process model for this ®eld of activity. King (1994, p. 214)
Issues and innovations in nursing practice
highlights the need for nursing to develop a collaborative
`multi-disciplinary' health promotion model for nursing ± but
one that is still speci®c enough to `delineate the amenable
interventions for each involved discipline'. A `generic' health
promotion planning model would be useful for nursing, as it
could provide a means to guide choices and allows represen-
tation of the best way to achieve desired results, through a
process of key stages or `logical stepping stones' (Naidoo &
Wills 1994). Naidoo and Wills (1998) single out such models
as a means of conceptualizing health promotion and integ-
rating different health disciplines. It is every nurse's respon-
sibility to be involved in the planning of his or her client's
health improvements (Kiger 1995).
Description
The model in question (Figure 1) is a ¯owchart model which
at a theoretical level, according to Marks et al. (2000), is
designed to use a mix of constructs from ontologically
distinct paradigms that are causally connected by their inter-
related association. It is designed, as are most ¯owchart
models, to provide a simpli®ed representation of aspects of
the `real world' of particular interest to the practitioner and
which then allows them to focus on key elements of a process
(Tones & Tilford 1994). The model put forward by this paper
proposes a two-stage approach emanating from the initial
step of its process. The two stages/approaches (empowerment
and preventative) are represented in the proposed model by
the two shadowed boxes. These boxes represent the starting
point for each of the two routes described. In recognition of
Beattie's (1991) position that most health promotion encoun-
ters entail either one of two approaches (medical/preventative
or empowerment), this model branches to include both
eventualities. The labels of health education and health
promotion are assigned to these approaches, respectively.
These contexts are based on the notion that `traditional'
health education is seen to work within a medical/preventa-
tive model framework. This paradigm is representative of an
`authority' model of health care which is derived from
medical science and whereby its focus is speci®cally on
disease prevention (Naidoo & Wills 1998). On the other
hand, `radical' (modern) health education or `health promo-
tion' involves facilitating social, economic and political
change as part of an empowering process. It demands that
nurses play their part in attempting to address the wider
societal and environmental issues that affect their clients'
health (Mackintosh 1996).
Starting at the beginning of the process, the nurses' ®rst
task in identifying which would be the most appropriate
route for them to take, would be to identify which approach
Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(2), 311±320
A stage planning model
is most likely to be adopted. Current evidence indicates that,
in most cases, the most common option would be the route
of a biomedical/preventative approach (Antrobus 1997,
Brown & Piper 1997, Whitehead 2000b). This route is
represented, within the proposed model schematic, by the
information contained in the dotted line boxes. This being
said, Smith et al. (1999) also contest that some nurses are
trying to move away from such frameworks towards more
empowering approaches. The preventative approach path-
way of this proposed model, unlike its empowerment
approach pathway, does tend to follow a mostly linear
route but does allow the option to realign it with an
empowerment-based approach at any time as part of any
on-going evaluation. However, it is stressed that this is only
if this particular route is followed. If the process breaks
down at any point, as is also the case with the empower-
ment process, the intended health intervention is most likely
to re¯ect many of the current `ad hoc' and `haphazard'
health education practices that are prevalent in nursing
practice today (Caraher 1994, Whitehead 2000a).
The empowerment approach route is mainly cyclic in its
nature as well as being noticeably more involved, encompas-
sing, demanding and resource-intensive than its counterpart
preventative route. The empowerment route is represented in
the model schematic by the information contained within the
solid line boxes, following on from the health promotion
box. Its more demanding nature needs to be borne in mind
carefully before undertaking this approach. It should be
remembered that in many cases, a nurse's potential to
empower or act as a client advocate in a societal, political
or environmental role generally remains unrealized (Lindsey
& Hartrick 1996, Benson & Latter 1998). This is not to say
that the approach cannot be adopted in a more limited
capacity whereby such a role might be undertaken by
signi®cant others, i.e. social workers, whilst nurses assist
where able to. Collaboration with other health service
disciplines ± even aside from work with other agencies ± is
also seen as a problematical area for nursing (Mackintosh
1995, Whitehead 2001), but again this does not have to be
viewed as an insurmountable barrier. It should also be noted
that this route also separates into community-based and
hospital-based settings. This is because health promotion
activities may possible take on a different momentum,
depending on the nature of the setting itself. This being said,
it should also be noted that they are seen as been integrated
and inter-related in this model. Health promotion should be
seen as a key part of all health service activities wherever they
take place. This re¯ects the views of Pike (1995) who states
that it is inappropriate to view any setting outside the
hospital as being `community'. The hospital setting should be
317
D. Whitehead
viewed as being ®rmly located within the community. The
preventative route is not divided into hospital and community
paths because the intervention pathway is unlikely to be
affected by the setting itself.
The commonality of both approaches of the proposed
model lies with the actual stage processes themselves. As
stated previously, because they both adhere to planning
processes they use common constructs, i.e. assessment,
planning, implementation and evaluation. Like all health
promotion planning models, this proposed model is distin-
guished by three main phases: a preparatory phase (formative
assessment), programme development and implementation
and programme diffusion (formal evaluation) (De Vries
1998) (Figure 1). These phases are identi®ed at the bottom
of the model schematic by the dashed boxes and apply to
both the preventative and empowerment approaches. The
model is based on the common assumption that because
health behaviour is determined by many different factors,
health promotional/health educational activities must be
multidimensional (Klug-Redman 1993). This justi®es the
need to identify more than one approach. It may even be
possible to `mix and match' various components of both
approaches to produce as encompassing a programme as
possible within identi®ed constraints. The accompanying
words of warning, with doing this come in highlighting the
potential for this to lead to a higher likelihood of confusion
and breakdown of the adopted process. A further example of
commonality between the two approaches relates to the
shaded boxes of the proposed model. These are the common
decisions/actions required of the nurse, regardless of the
approach to be undertaken, in order that the particular
course of action can be rationalized and placed in context.
The contextualization of the nurse's health-related attitudes,
beliefs and values, against those of the client's are particularly
important in this part of the process (Shaw 1999).
It is felt that it might be useful in offering an example of
how the model process might be applied in practice. Smoking
cessation programmes are generally regarded as a popular
means of utilizing health education/health promotion
programming in nursing settings (Haddock & Burrows
1997, Moore & Andrews 2000), and can be applied here.
With the preventative approach the focus is on the smoking
activity itself. Intervention is based on either targeted (epi-
demiologically driven) resources or the attitude of the nurse
to smoking behaviour. The assumption is that a change in
behaviour, on the clients part, will result in reduction/
prevention of any smoking-related disease. The client is
viewed as a biomedical entity whereby any failure to comply
or relapse will generally result in `blame acquisition'. If the
intervention is successful, the client will demonstrate a
318 Ó 2001 Blackwell Science Ltd, Journal of Advanced Nursing, 36(2), 311±320
noticeable reduction/cessation of smoking behaviour and a
subsequent improvement in health status.
With the empowerment approach, the client's own prior-
itization of health needs is paramount. If the client identi®es a
desire to stop smoking then the nurse acts as a facilitator to
aid this process ± through education, empowerment or
directly in¯uencing the client's socio-economic environment.
Failure or non-compliance is seen as a rational choice of the
client. Personal beliefs, attitudes or values of the nurse are not
considered unless the client feels that they might be useful
(e.g. in offering empathy). Even if the client does not initially
identify smoking cessation as a health priority it may well be
that the empowering change process enables the client to
`naturally' alter their health behaviours, as their personal
circumstances change. This way `unhealthy' behaviours may
alter as a by-product of the health programme. The nurse is
likely to be just one of many resources assisting the client and
thus collaborative planning and negotiation is an important
part of the process. The eventual evaluation and reassessment
of an empowerment approach programme, because of its
more encompassing structure, is very likely to occur.
As suggested earlier, it is likely that the proposed model
would need to be adapted, beyond the use of just medical/
preventative and empowerment, as nurses begin to extend
their range of health promotional activities. These extensions
could include both educational and socio-political approa-
ches (Ewles & Simnett 1992). Further adaptation may be
required in order that the process is made more applicable to
speci®c nursing disciplines and specialities. Simply adding
specialist-speci®c contexts and terminology to the broader
contexts of the model would prove useful.
Summary
In highlighting many of the issues, dilemmas and attributes of
the different types of contemporary health promotion plan-
ning models, it is hoped that the reader of this paper will
appreciate the need for a revision and up-date of current
activities in nursing health promotion practice. If health is
viewed as based on a `process of becoming' (McKenna 1997)
then, presumably, nursing should be clear about the processes
that need to take place in order that clients can attain the
health-related changes that are asked of them. Health
promotion planning models are useful because they `force'
planners to address the logistics and realities of conducting
health programmes and acknowledge the underpinning
theoretical considerations (Kaplan et al. 1993).
This paper presents an alternative to some of the popular
contemporary planning models in use and the few nursing-
related adaptations of these that are in existence. The model
Issues and innovations in nursing practice
presented is designed to be general to nursing, bearing in
mind its current health promotion constraints and yet, on the
other hand, speci®c enough to be applied to most specialist
nursing settings. If nothing else, this planning model is
designed to move nurses away from the current situation
whereby many implement their health education/health
promotion activities on a basis of chance, rather than proven
need (Thomson 1998). Failure to adopt a framework for
health promotion planning, it is argued, may result in nursing
being `left out in the cold' with regard to its health-
promoting role. If nurses can routinely apply planning
models to their health promotion/health education activities
they are more likely to avoid existing dilemmas, implement
more encompassing health-related programmes of care and
evaluate progress. Consequently, they can also elevate the
current standing of health promotion within the nursing
professions so as to begin to compete with other health-care
professions.
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