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Wellness Promotion and the Institute ofMedicine’s Future of Nursing ReportAre Nurses Ready?

■ Kelley Strout, MSN, RN

This article highlights the gap between wellness in nursing practice and the mission statement of the Institute ofMedicine’s Future of Nursing Report. It explores wellness from 3 philosophical arguments, provides a historicalevolution of wellness, and explores nurses’ current understanding of wellness. Future directions for implementingwellness in nursing practice are provided for science, education, and leadership. KEY WORDS: disease prevention,Institute of Medicine Future of Nursing Report, health promotion, wellness in nursing Holist Nurs Pract 2012;26(3):129–136

The Future of Nursing Report published by theInstitute of Medicine (IOM) symbolizes a paradigmshift in health care delivery from sick care to wellcare.1 The IOM envisions a health care system wherenurses intentionally promote wellness and diseaseprevention and improve health care outcomesthroughout the lifespan.1 The nursing profession iswell recognized for the role of disease prevention andhealth promotion as established in the seminal articleof Donaldson and Crowley2 to the recent Future ofNursing Report from the IOM.1 Within the scope ofnursing practice, the words “health,” “healthpromotion,” and “wellness” appear to be usedinterchangeably. Florence Nightingale, VirginiaHenderson, and Margaret Newman developedframeworks that conceptualize wellness; however,wellness is not clearly defined within these theories.3–6

Nurses’ ability to achieve the mission of the IOM andintentionally promote wellness is limited by theabsence of a universally recognized understanding of

Author Affiliation: School of Nursing, Bouvé College of Health Sciences,Northeastern University, Boston, Massachusetts.

The author thanks Elizabeth P. Howard, PhD, RN, ACNP, associate pro-fessor, School of Nursing, Bouvé College of Health Sciences, NortheasternUniversity, for her time and support in editing the manuscript for publication.

The author has disclosed that she has no significant relationships with, orfinancial interest in, any commercial companies pertaining to this article.

Correspondence: Kelley Strout, MSN, RN, c/o Elizabeth P. Howard, Schoolof Nursing, Bouvé College of Health Sciences, Northeastern University, 360Huntington Ave, Boston, MA 02115 (Kelley.A.Strout@gmail.com).

DOI: 10.1097/HNP.0b013e31824ef581

the concept of wellness and a common paradigm topromote wellness in nursing practice.7 The purpose ofthis article is to conceptualize the historical evolutionof wellness and highlight the gap in nursing practicebetween knowing and promoting wellness.

THE CONCEPT OF WELLNESS

The absence of a universally recognized concept ofwellness in the nursing profession is better understoodafter examining the complexity of wellness through 3philosophical arguments: ontology, realism, andempiricism.

Plato’s ontological argument establishes wellnessas a state of being. Patient lives represent diversity andever-changing circumstances; patients will definewhat it means to be well based on their changingworld. Their perception of wellness will generate fromtheir current circumstances and will continuouslychange.8 Thus, the concept of being well is not static,but fluid. According to Plato, all living things aim andaspire to “good being.” From this perspective, allpeople naturally hope to gravitate toward a state ofwellness, or “good being.” As people experienceenhanced wellness, they will become more self-awareand learn about additional experiences that willpromote wellness. Wellness is a process of becoming,a process that does not have an end point; therefore,every person strives for wellness throughout life.Wellness expands beyond health and does not simplyapply to people in poor health, or people who need to

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prevent certain diseases. Every person continues on ajourney to achieving his or her full potential andmaximizing his or her wellness.8

The philosophical argument of realism aligns withthe concept of wellness. Realism explains the realityof a phenomenon. Wellness from a realist perspectiveasks, “What is the reality of wellness? What doeswellness look, act, and feel like? Wellness will look,act, and feel different for every patient. Realities areunique to individuals’ environments, genetics, andexperiences.9 Patients’ realities will influence theirviews and perception of wellness.

Wellness embraces an empirical philosophy;however, this philosophy differs from empiricalresearch and practice and expands to the patient’sexperience. John Locke, a philosophical empiricalthought leader, proclaims that knowledge is derivedthrough experience.8 Personal patient experiences willdetermine his or her definition of wellness. Nursescannot possibly acquire the experience of eachindividual patient. Every patient who interacts with anurse will possess different knowledge compared withthe previous patient. Knowledge creates worlds forpatients, worlds that translate into unique and diversedefinitions and understandings of wellness.

Wellness is difficult to conceptualize, which mayexplain the omission in definition and paradigmdevelopment within the nursing profession. In theabsence of a universal, clearly defined understandingof the word and concept of wellness, the NationalWellness Institute10 provides this clear definition ofwellness: wellness is a multidimensional and holisticstate of being that is conscious, self-directed, andconstantly evolving to achieve one’s full potential.Wellness is an ever-changing process thatencompasses multiple dimensions, known as the SixDimensions of Wellness: intellectual, spiritual,emotional, physical, occupational, and socialdimensions.10,11 The Six Dimensions of Wellnessreflect unique characteristics that interconnect withone another to represent the person as a whole. Table 1provides the definition for each of the Six Dimensionsof Wellness.

HISTORY OF WELLNESS IN NURSING

According to the National Wellness Institute,10 aprofessional can determine whether he or she practiceswithin a wellness approach if he or she answers “yes”to the following 3 questions: “Does this help patients

TABLE 1. Definitions of the Six Dimensions ofWellnessa

Dimension ofWellness Definition

Occupationalwellness

Ability to contribute unique skills topersonally meaningful andrewarding paid or unpaid work

Social wellness Ability to form and maintain positivepersonal and communityrelationships

Intellectualwellness

Commitment to lifelong learningthrough continuous acquisition ofskills and knowledge

Physical wellness Commitment to self-care throughregular participation in physicalactivity, healthy eating, andappropriate health care utilization

Emotionalwellness

Ability to acknowledge personalresponsibility for life decisions andtheir outcomes with emotionalstability and positivity

Spiritual wellness Having purpose in life and a valuesystem

aBased on definitions from Hettler.11

achieve their full potential? Does this recognize andaddress the whole patient? Does this affirm andmobilize positive qualities and strengths?”10 Thenursing frameworks of Florence Nightingale, VirginiaHenderson, and Margaret Newman are examined forcongruency with wellness profession guidelines of theNational Wellness Institute.

Florence Nightingale’s theory supports wellness byaddressing the whole patient and affirming his or herpositive qualities and strengths.6 Nightingale believedthat patients should be placed in optimal environmentsthat allow nature to act. Her theory promoted nature asthe ultimate cure for any disease process. According toNightingale’s theory, environments aremultidimensional. The air people breathe, the foodpeople eat, the company people keep, and theconditions people live will interact to promote orprevent healing.6

Nightingale believed that nurses should work toprevent disease and care for well patients with thesame approach as caring for sick patients.6 Sheexplained that diseases proliferate for years beforemanifesting into clinical symptoms. Therefore, nursescan improve the environment of well patients toprevent disease. Improving the environment could be

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as simple as helping a patient create a healthy menuplan to helping a community improve air quality.Nightingale encouraged nurses to empower society toimprove environments outside hospitals such asschools, homes, and communities in order to preventdisease.6

Nightingale’s theory represents affirming andmobilizing positive qualities within patients.6 Shebelieved that the patient, whether sick or well, is thebest person to care for his or her own health. Sheencouraged nurses to view patients in the moment.She warned nurses not to judge patients withcondescending thoughts or words. Nightingalebelieved that nurses should recognize that patientswould do better in a supportive environment.6

Nightingale’s theory of placing the patient in anoptimal environment for healing and preventingdisease promotes a wellness approach by addressingthe patient positively and holistically. However,Nightingale does not define well, or wellness. Throughher descriptions, the state of wellness is reflected bythe absence of disease. Nightingale’s theory does notsupport the concept of assisting patients to achievetheir full potential. Patients who are not sick are notnecessarily achieving their full potential.6 The absenceof disease is not reflective of full potential.10

Henderson’s theory supports wellness byaddressing the patient from a multidimensionalperspective and encourages them to provide their owncare.3 In Henderson’s complex, multidimensionalmodel, she defines health as a person’s ability toperform 14 activities independently.3 Although theword “wellness” is not used in Henderson’s theory, heractivities align with the Six Dimensions of Wellnessframework.11 Table 2 organizes Henderson’s theory inthe Six Dimensional Framework.

Henderson believes that the nurses’ role is to assistpatients with the 14 activities when they lack thestrength, knowledge, or will. At the same time, sheemphasizes that nurses should care for all patients; shebelieves that basic human needs exist in patients whoare sick and patients who are well. She believesthat nurses should promote health and preventdisease.3

Henderson’s theory affirms and mobilizes thestrength of patients. She further states that nurses mustencourage and empower patients to care forthemselves.3 Nurses should not do everything for apatient; the best care is the care that the patient giveshimself or herself. Nurses should recognize that healthis multidimensional and affected by variables such as

TABLE 2. Henderson’s Definition of Health and theSix Dimensions of Wellness Frameworka

Dimension ofWellness

Fourteen ActivitiesThat Define Health

Occupationalwellness

Work at something that providessense of accomplishment

Social wellness Avoid dangers in environment andavoid injuring others

Play or participate in various forms ofrecreation

Intellectualwellness

Learn, discover, or satisfy the curiositythat leads to “normal” health

Physical wellness Eat/drink adequatelyMove and maintain desirable postureSleep/rest

Emotionalwellness

Communicate with others inexpressing emotions, fears, andneeds

Spiritual wellness Worship according to his or her faith

aBased on definitions from Henderson3 and Hettler.11

age, environment, genetics, culture, emotionalbalance, and intellectual abilities.3

Henderson encourages nurses to also care for wellpeople. She defines health as the ability to perform 14functions independently. Although Hendersonencouraged and believed that nurses should providecare to well patients, not just sick patients, she neverprovided an explanation for how the nurse would carefor a patient who could independently perform the 14functions. Her theory addresses patients holisticallyand promotes affirmation; however, similar toNightingale, her theory does not address helping theperson achieve his or her full potential or maximallevel of wellness. She defined health and evenemphasized the nurses’ role in caring for well patients,but she did not define wellness, nor did she provide aframework to promote wellness.

Newman’s theory, Health as an ExpandingConsciousness, supports 3 wellness approaches:addressing the whole patient; assisting the patient torise to his or her full potential; and affirming thequalities within a patient.4 In Newman’s theory,disease is an underlying manifestation of an imbalancewithin a patient. Health is more than the absence ofdisease; health is the expansion of consciousness, orpersonal growth. Newman’s theory supports the ideathat even in the face of illness, a patient can grow andmake progress. Although disease appears negative,Newman believes that disruption eventually

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transforms a patient’s life into a higher state of being,or consciousness.4

Health as a state of consciousness, according toNewman, is represented through the quality andinteraction of a patient with his or her environment.Newman addresses the complexities that exist betweenevery individual and his or her environment. Everypatient’s relationship with his or her environment willgenerate different reactions. The reflections onexperiences that occur within the environment providegrowth or expanded consciousness. Newman stressesthat for nurses to promote expanded consciousness,they must provide highly individualized care to everypatient. She also believes that the process ofexpanding consciousness can occur anywhere,anytime. The process is not limited to a specific healthcare setting, or the presence or absence of a disease.4

Nurses’ responsibility in promoting consciousnessreflects the wellness approach of affirming andaddressing the whole person. Newman believes that topromote consciousness, nurses need to look at patientsas a whole, greater than the sum of their physiologicsystems. Health is not something someone achieves orloses. Patients can have consciousness even in the faceof illness and disease; you cannot lose consciousnessor achieve consciousness. Illness or diseases create anopportunity for growth.4

For optimal effectiveness of Newman’s model, therelationship and environment created between aperson and a nurse are essential. Nurses must provideindividualized care focused on listening attentively tothe person’s life, and rhythm. Nurses need to embraceuncertainty and not focus on fixing the patient but,instead, listen and promote what is working well.People’s lives are not certain, they are all different andunique; disequilibrium is necessary for growth. Nursesneed to give patients the opportunity to reflect, think,and generate their own growth. Nurses cannotmanipulate and control patients; the partnershipbetween nurses and patients is essential to expandingconsciousness.12

Newman’s theory embraces the concept thatwellness is a state of being, ever changing andcontinuously evolving. Newman does not use the word“wellness” to describe her theory; however, her theorysuggests that nurses cannot define wellness forpatients because wellness will mean somethingdifferent to every patient. Nurses need to promotewellness by accepting uniqueness and developing adeep understanding for each patient’s environment andexperience.

Although each of the theorist believe that caring forpatients who are well is essential to the nurses’ role,none clearly define the concept of wellness or providea framework for nurses to practice and promotewellness.3,4,6,12 To examine the relationship betweenthe theoretical foundations of wellness and currentnursing practice, a review of the literature wascompleted using CINHAL. Literature examining therole of wellness in nursing practice was notablyabsent. The CINHAL thesaurus suggested using thesearch terms “health promotion.” Five qualitativeresearch studies aiming to explore nurses’ perceptionsof the definition of health promotion, how theypromote health in practice, and barriers to promotinghealth in practice were included in the review. Thesample sizes ranged from 8 to 20. Nurses working inacute care, geriatrics, advanced practice, academia,community, and mental health care were represented.Because of the expanded search, a definition of healthpromotion is provided in the following text.

HEALTH PROMOTION

The World Health Organization13 defines healthpromotion as a process to help individuals increasecontrol of their health with the desired outcome ofphysical, mental, and social well-being. The WorldHealth Organization distinctly emphasizes that beforehealth promotion can occur, a patient must recognizehis or her aspirations, satisfy his or her needs, andchange or cope with his or her environment. Healthand wellness promotion is a fundamental role withinthe nursing profession, yet a review of the literaturehighlights a gap in nursing knowledge about how andwhen to promote health and wellness.

NURSES DEFINITION OF HEALTHPROMOTION

The results of 5 qualitative research studies suggestthat nurse’s definition of health promotion isambiguous and uncertain.14-18 The common definitionof health promotion among nurses, in a variety ofhealth care settings, refers to providing healtheducation and advice about healthy life styles.15-18 Forexample, nurses believed that health promotion istelling someone why he or she should change his orher behavior or life to protect or improve his or her

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health.18 Nurses with more experience commonlyperceived health promotion as empowerment.17

Advanced practice nurse practitioner students withat least 2 years of nursing experience participated in aresearch study that evaluated their perceptions ofhealth promotion. The students completed qualitativequestionnaires before and after a health promotioncourse. Before the health promotion course, thestudents described health promotion as advice givingand health education. After the health promotioncourse, the student’s views of health promotionevolved to empowering the patient.18

HOW NURSES PROMOTE HEALTH

In the research studies included in the review, the mostcommon theme about how nurses promote health isgiving information about healthy lifestyles to patientswith specific health conditions.16-18 For example, if apatient presented to the hospital post–myocardialinfarction, the nurse would encourage the patient toexercise more frequently and eat more fruits andvegetables.16 Some nurses believe that they promotehealth without any deliberate efforts becausepromoting health is a natural and automaticcomponent to their work. Consequently, they areunable to recall specific examples about the last timethey promoted health.15

BARRIERS TO HEALTH PROMOTION

The most common perceived barrier to promotinghealth in nursing practice is time,15,17,18 followedclosely by not enough education and training.15,17

Some nurses believe that they needed more evidencethat health promotion is an effective method forhelping patients improve their health.17

Nurses perceive patients as barriers to promotinghealth. Some nurses believe that patients are unwillingto accept health promotion.15 More than half of nurseswho perceived that patients should not have a choiceto receive health promotion believed that patientsfrequently ignore advice given to them.17 Patients’knowledge deficit about healthy lifestyles andpatients’ unwillingness to change emerged as healthpromotion barriers for nurses.18

The health care system and work environments donot support nurses in the role of healthpromotion.14,15,18 Some nurses believed that nursing

management does not empower nurses to promotehealth and daily nursing tasks are burdensome andprevent them from practicing health promotion.15 Thepercentage of nurse practitioner students whoperceived the work environment as a barrier topracticing health promotion increased at thecompletion of a health promotion course.18

DISCUSSION

The literature included in the review containslimitations. The most notable limitation is the absenceof literature examining nurses’ perception of wellnessin practice. The vision of the IOM is for nurses tointentionally promote wellness. Before this can occur,research that examines nurses’ current understandingof wellness and how to promote wellness in practice isneeded. Research in this review contained small,convenience samples of nurses who were required toanswer questions about health promotion while beingrecorded by the interviewer. Nurses interested inhealth promotion may be overrepresented usingconvenience samples. Furthermore, the use of taperecorders may lead some nurses to withholdinformation or exaggerate information due to concernsabout confidentiality, or social desirability.Acknowledging the limitations, however, this reviewprovides insight about the gap between wellnesspromotion and nursing practice.

Nurses believe that health promotion is at the coreof nursing practice.15-18 Currently, nurses promotewellness by promoting health. Nurses cannotintentionally promote wellness and achieve the visionof the IOM1 if they are unable to confidently defineand provide specific examples of health and wellnesspromotion. Nurses should have time to promote healthand wellness if they believe that it is the core of theprofession.

Nurses believe that patients are barriers to thepractice of health promotion.15-18 Nurses’ belief thatpatients are unwilling to accept health promotionwarrants further examinations. How can patients haveknowledge deficits about their own perception ofhealth and wellness? If a patient is unwilling tochange, should he or she be considered a barrier?Reflecting on each question philosophically remindsus that patients’ health and wellness are their ownstate of being. Their experiences and perceptionsdefine how wellness and health will look, act, and feelfor them.8,19 According to ontology, every patient is

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on a journey to optimal wellness.8 Reflecting on eachquestion through the lens of nursing theorists suggeststhat nurses may be the true barriers in promotinghealth. Nightingale warns against judging patients whoare unwilling to change. She would say that patientswould do better if their environment supported thembetter.6 Henderson3 would argue that the patient doesnot have the strength, knowledge, or will to accepthealth promotion how the nurse desires, but this doesnot mean that the patient never wants to promote hisor her health. Newman12 posits that the nurse is notasking the right questions, not listening with herwhole heart, and not getting into the patient’s life.

WELLNESS AND THE ART ANDEPISTEMOLOGY OF NURSING

The review of the literature highlights a gap betweennurses’ perception of health and wellness promotionin nursing practice and how and when to promotehealth and wellness in practice. The subjective natureof wellness, the absence of a clear and universalwellness definition, and the absence of a wellnessframework in nursing practice create fundamentalchallenges to achieving the IOM’s vision.1 Nursesneed to know how to assess, design, document, andvalidate wellness outcomes. Carper’s20 seminal work,The Four Fundamental Patterns of Knowing inNursing, provides a framework to address the art andepistemology of wellness in nursing.

Empirical understanding of wellness

Nurses need an empirical understanding of theconcept of wellness. To intentionally promotewellness, nurses need to know in what context thephenomena of wellness are to be viewed. Nurses needto develop an abstract and theoretical explanation forwellness in nursing practice. Nurses need to knowwhat questions are to be raised about wellness, and themethods of study to examine evidence of wellnesspromotion.2 For nurses to intentionally promotewellness in nursing practice, they need the knowledgeto describe and explain wellness to patients, society,and other health care professionals.

In nursing practice, the essence of wellness may liewithin an understanding of the realities, experiences,and world of the patient. Nurses, therefore, will needto know how to empower, encourage, and inspirepatients to realize their own visions of wellness. Nurse

researchers need to design empirical studies toexamine techniques to promote wellness in nursingpractice. Nurse educators need to develop frequentcontinuing educational activities about when, how,and why to promote wellness in practice. Nursingadministration needs to examine nursing tasks toascertain whether health and wellness promotion, acore value in nursing, is not absent in practice becauseof time constraints. Nursing practice needs to developa documentation system that captures the patient’sempirical view of wellness and tracks wellnessoutcomes from the patient’s perspective. Mostimportantly, nursing education needs to develop anevidenced-based curriculum that provides nurses witha strong foundation for promoting wellness in nursingpractice. Currently, clinical prevention and populationhealth are essential education requirements forbaccalaureate prepared nurses.21 These requirementsdo not aim to prepare all nurses for the role ofintentional wellness promoters. First, clinicalprevention, as defined by the American Association ofColleges of Nursing, is disease focused. Nursespracticing clinical prevention will demonstrateknowledge around immunizations, screenings, andcounseling aimed to prevent disease or diseaseescalation. Second, population health aims to improvethe health at the community, or aggregate, level.However, since the baccalaureate degree is theminimum level of education required to practice andpromote population health, half of the nursingworkforce who hold an associate degree in nursing isnot adequately trained or qualified to perform thisrole21,23 The absence of wellness as an essentialrequirement in nursing education is evident. Toachieve the vision of the IOM, all licensed nursesrequire education and training about the meaning ofwellness and how to promote wellness to all patientsin all care settings.

Esthetic understanding of wellness

An esthetic understanding of how to promote wellnessin nursing practice is needed. Wellness is intimate tothe person experiencing the phenomenon. Successfulwellness promotion in nursing practice will depend onhow nurses ask patients questions about what wellnessmeans to them. Patients’ responses will depend on hownurses listen to the words the patients speak and hownurses insert themselves into the patients’ world.4,20

The patients’ growth will depend on nurses’ ability to

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be in the moment; nurses will express empathy, joy,and heart ache with the patients to promote wellness.20

Personal understanding of wellness

Nurses need a personal understanding of how topromote wellness in nursing practice. Personalknowledge in wellness promotion will require nursesto relinquish the authoritarian role and accept thatpatients are free to create their meaning andexperience of wellness.20 Carper20 states, “Anauthentic personal relation requires the acceptance ofothers in their freedom to create themselves and therecognition that each person is not a fixed entity, butconstantly engaged in the process of becoming.”(p155)

Nursing practice needs to develop dynamicrelationships with policy makers and interdisciplinaryhealth care professionals to design a wellnessinfrastructure within the community and the healthcare system. The new system should capitalize onnurses’ personal knowledge and ability to promotewholeness and integrity.20

Ethical understanding of wellness

Nurses need an ethical understanding of how topromote wellness in nursing practice. Patients’perception of wellness will depend on theirexperiences and values. Only patients can determinewhat is good and bad for them. However, nurses needthe knowledge to recognize behavior that is harmful ordangerous. Nurses need to adhere to moral obligationswhen promoting wellness in nursing practice.20

FUTURE DIRECTION FOR SCIENCEAND NURSING

Nurses are recognized for their unique ability to carefor patients holistically.23 The goal of nursing practiceis to foster behavior that leads to health and wellness.2

However, nurses cannot rise to their full potential andrealize the vision of the IOM1 to intentionally promotewellness based on this premise.2,23 Nurses need aclear understanding of the phenomenon of wellness.Nursing science needs to develop a universal wellnessparadigm to promote wellness in nursing practice.7

Finally, the pivotal change that needs to occur is ashift in the percentage of nurses working in acute carehospital settings to nurses promoting wellness withinthe community. Currently, 62.2% of nurses work in

hospitals compared with 7.8% in public health andcommunity settings.22 Patients in acute care settingsare in a new environment. Before optimal health andwellness promotion can occur, patients must cope withthe new environment, a process that may not occurbefore patient discharge.13

Nurses’ role in the community is multidimensional.Nurses have an opportunity to apply empirical,aesthetic, personal, and ethical wellness knowledge inschools, businesses, prisons, day care centers, and anyother place people gather. Removing the barrier of thehospital environment14,15,18 may prove the bestmethod for nurses to assume their role as intentionalpromoters of wellness.

CONCLUSION

The Future of Nursing Report from the IOM1

symbolizes a turning point for change in health caredelivery. Nurses are prepared to rise to the challengeand embrace changes that promote positive healthoutcomes for society. However, to realize a vision thatexplicitly emphasizes the contribution of intentionalwellness promotion to positive patient outcomes,nurses are challenged to develop a universalunderstanding and paradigm to promote wellness innursing practice. Before nurses can value their role aswellness promoters, nursing education, nursingresearch, and nursing administration need to worktogether to make wellness a priority. Without propereducation about how and why to promote wellness,without research to provide evidence-based wellnessguidelines, and without administration to monitorwellness promotion practice and outcomes, nursescannot truly value their role as intentional wellnesspromoters.

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