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Functionalism and holism: community nurses' perceptions
of health
ANNANN LONGLONG BSc, MSc, DPhil , RGN, RMN, RNT, HV, RHVT
Senior Lecturer in Nursing and Health Visiting, School of Health Sciences, University of Ulster,
Jordanstown, Newtownabbey, Co Antrim, Northern Ireland, BT37 0QB, UK
ROSARIOROSARIO BAXTERBAXTER BSc, MPhil , RSCN, RGN, RNT
Lecturer in Nursing, School of Health Sciences, University of Ulster, Jordanstown, Newtownabbey,
Co Antrim, Northern Ireland, BT37 0QB, UK
Accepted for publication 23 August 2000
Summary
· This paper reports the results of a study that was designed to explore and
examine the perceptions of two groups of newly quali®ed community nurses
about the factors they considered to be embedded within the concepts of health,
health-enhancing behaviours at individual, family and community levels and
their `innermost self '.
· The research was exploratory in nature, and included two sample groups:
group 1 comprised 16 newly quali®ed health visitors; group 2 comprised 16
newly quali®ed community mental health nurses. Purposive sampling was used
and data were collected using semi-structured interviews.
· The group of health visitors perceived health in terms of physical ®tness and
functional states. At a global level they perceived the need to provide education
on health matters. They gave generously to `charities' and perceived the `inner
self' as `that part that matters'.
· The group of community mental health nurses perceived health in terms of
holism and being states. Their concept of health was related to listening to each
individual's perception of what is `right' and `health-enhancing' for them. At a
global level they considered the protection of the ozone layer and the promotion
of a just and equitable society which focused on the reduction of poverty, to be
key health-enhancing activities. They perceived their `innermost self' to be `that
part of me that makes life worth living', and the soul.
· The ®ndings have implications for developing new and creative approaches for
teaching the holistic concept of health and healing. Educational activities could
be designed which strive to ensure that nurses themselves have safe and health
embracing opportunities for exploring all the elements that are embedded within
Correspondence to: A. Long, School of Health Sciences, University ofUlster, Jordanstown, Newtownabbey, Co Antrim, Northern Ireland,BT37 0QB, UK (tel.: 028 90368113; fax: 028 90366087; e-mail:[email protected]).
Journal of Clinical Nursing 2001; 10: 320±329
320 Ó 2001 Blackwell Science Ltd
the topic of health. Their role in facilitating holistic health promoting activities
for all clients also needs to be addressed.
Keywords: community mental health nursing, health, health-enhancing beha-
viours, health visiting, self-awareness.
Introduction
The concept of health may be ascribed miscellaneous
meanings according to the agenda of the particular groups
who are describing it in society (Scrambler, 1991). Nurses
may perceive health as the anticipated result of caring for
patients (Bournaki, 1993). Alternatively, politicians may
regard it as a largely economic endeavour which should
reap net gains for a de®ned ®nancial investment and in the
long run might save future governments monies (Depart-
ment of Health, 1991). To midwives, health might involve
®nding ways to marry the rights of women to choose their
own type of care and delivery to midwives' duty to provide
safe deliveries for mothers and their infants (Dowswell
et al., 1996). At times, all of these interests converge
(Cribb & Harran, 1991; Fleming, 1999). In addition,
Dines & Cribb (1994) claimed that the concept of `dis-
ease' encompasses much more than medical determinants
of health. Given the weight of local (CAPP, 1993; DHSS,
1995), national (Kinlen et al., 1995) and international
evidence (Procter, 1996), which claims that the health of
individuals, groups and communities as well as the planet
Earth is threatened from many sources, it would seem
appropriate to incorporate all of these realities into any
de®nition of health.
PROMOTING HEALTH-RELATED ACTIVITIESPROMOTING HEALTH-RELATED ACTIVITIES
Most professional health-related activities assume that
effective communication contributes to the process of
moving health status beyond simple adherence to therapy
(Ogden, 2000). This assumption is re¯ected in commonly
agreed de®nitions of health promotion that identify
concepts such as `process', `enabling', `facilitating' and
`control' as essential elements of health promotion
approaches (WHO, 1984). The mental and spiritual health
status of individuals is now widely believed to be essential
to promoting health and at least partly a product of the
degree to which one is valued and respected by `self' and
colleagues. Feeling valued and respected by others
(nurses) are important dimensions in the process of
providing therapeutic care. Indeed, Radwin (1996) claims
that knowing the patient is one of the most fundamental
facets of caring that marks expertise in nursing. This is
said to include learning the patient's thoughts, concerns,
fears and hopes (Benner et al., 1992).
It is acknowledged in community mental health nursing
that clients have a high regard for the bene®ts they receive
from effective communication and having an empathetic
listener (Long, 1995). Ten years earlier Lanceley (1985)
argued that patients who are involved in emotional
disclosure are themselves more likely to exercise control
over communication with nurses. Nursing theorists have
transposed essential humanistic concepts into frameworks
for nursing care which embrace and recognize the values
of human beings as being more than the sum of their parts
(Parse et al., 1985; Benner et al., 1992). Nurses who adopt
this style of working interact therapeutically with people,
revealing their real `self' and not merely their professional
image. This type of `being' facilitates congruence between
the thoughts that are in nurses' minds, the feelings in their
hearts, the words that they articulate and the demonstra-
tion of their caring actions ± within the entirety of the
caring experience.
Nurses working in the ®eld of mental health care can
use the work of theorists in counselling and psychother-
apy, who, irrespective of emphasis, methods or approaches
to treatment, have proposed common core conditions.
These conditions are widely considered to be at least
necessary and sometimes suf®cient conditions for engag-
ing in a helping relationship (Carkhuff & Berenson, 1967;
Long, 1997). They can also ®t comfortably within any
health promotion paradigm. Within this framework nurses
should be able to `read' clients' communication as it seems
to clients, and strive to grasp the meaning of both verbal
and non-verbal communication as they seem to clients,
whilst experiencing empathy with them. Nurses should
also value and respect clients for what they are and for
what they are going through right now, during this period
in their life histories. This very deep and meaningful
condition has been called `unconditional positive regard'
by Rogers (1957). He advanced his argument by claiming
that therapeutic conditions are necessary antecedents to
(health) change. Hence it could be assumed that a value of
`self' and a value of health are inextricably linked.
Acceptance of `self' with unconditional positive regard
and living life in the `here and now' experience goes some
way towards de®ning the `being' part of the human being.
Functionalism and holism 321
Ó 2001 Blackwell Science Ltd, Journal of Clinical Nursing, 10, 320±329
PERCEPTIONS OF `SELF'PERCEPTIONS OF `SELF'
`The `self' is what the individual is when considered
separately from other human beings. It is me in my
individuality, in my inwardness, in my uniqueness' (Long
1997: 1999). The `self' is embraced within the spiritual
dimension of health. Searching for the spiritual dimension
of health begins from the inside. Co-evolving with the
`self' is the concept of becoming a person and self-
actualizing (Rogers, 1957). Becoming a person is `me'
considered in relationships with other human beings, in
my social context, in my solidarity, `in-touchness' or
communication with others in moments of sharing and in
times of listening. It re¯ects my innermost `self' in silence
as almost nothing else does (Long, 1997). How `I'
experience having a sense of `self' dramatically affects
how `I' experience `being in touch', whether this is
entering into communion with others (clients) as in the
I±thou relationship, or with my innermost `self' (Buber,
1935). Promoting health and an understanding and
acceptance of `self' means helping people to make
rewarding, enlivening, nurturing and caring contacts with
others, without losing the sense of and being at ease with
who `I' am, in healthy self-nourishing and self-af®rming
ways. It is not surprising therefore that within this
framework reside major opportunities to proactively
promote the holistic health of all clients.
This research was conceived from the notion that
health awareness and self-awareness are related. If this
proposition is true then embracing health and self-
awareness would naturally progress to accepting and
valuing the health and self of others as well as oneself.
The aims of the present study were to explore and
examine a group of 16 newly quali®ed health visitors'
(group 1) and a group of 16 newly quali®ed community
mental health nurses' (group 2) personal perceptions of
health, self and health-enhancing activities at individual,
family and community levels. These two specialist groups
were chosen primarily because they were the only groups
of community nurses completing an integrated BSc
(Hons) community nursing degree programme who had
exactly the same numbers of students enrolled in the year
that this research took place. The researchers made the
decision to focus on the interviewees' own perceptions
because all of the interviewees had just completed degree
courses during which they had presented assignments and
examinations that focused on synthesizing the work of
other authors who had published relevant research
and scholarship. Therefore, rather than evoking `book'
answers, the researchers sought to elicit the personal
views of the interviewees.
Methodology
This research was exploratory and the study undertaken
was non-experimental and descriptive in design. Infor-
mation was collected from two groups of 16 interviewees
using semi-structured, tape-recorded interviews. The
interviewers attempted to capture a complete and unique
picture of the themes outlined as perceived by the
interviewees and it was established that there were no
right or wrong answers to the themes explored. Five key
topics were explored, namely: personal perceptions of
health; health-enhancing behaviours at individual; family
and global levels; and perceptions of their `inner self'. The
interview schedule is presented in Table 1. There was an
honest acknowledgement of, and respect for, each inter-
viewee's response. This study used a purposeful or
purposive sampling approach to selecting a group of 32
interviewees by using a sample of convenience (Parahoo,
1998). The two cohorts of 16 were chosen mainly because
there were 16 health visitors and 16 community mental
health nurses completing the community programme at
the time the research was being carried out.
The research protocol was approved and access was
granted through the University's School of Health
Sciences. All 32 interviewees were contacted by personal
letter and given appointment dates. Data were analysed
using the tried and tested theoretical proposition of Miles
Table 1 Interview schedule
Personal perceptions of health
How do you de®ne health?
What do you consider being healthy means?
Personal perceptions of your `inner self'
How would you de®ne your `inner self'?
Do you think the `inner self' has any relationship with your health?
In what way do you think the two might be linked?
How might the `inner self' manifest itself in terms of your health?
Health-enhancing behaviours at an individual level
What do you do to keep yourself healthy?
How do you pamper/spoil yourself?
In what ways are you good to yourself?
Health-enhancing behaviours at a family level
What kind of things do you do to promote your family's health?
Do you do anything to maintain your family's health?
Health-enhancing behaviours at a global level
What do you do to protect the health of the planet earth?
Do you have a personal role to play in promoting the health of
people in other countries?
Who do you think is responsible for promoting health at this wider
level?
Where might you start promoting health for all?
Ó 2001 Blackwell Science Ltd, Journal of Clinical Nursing, 10, 320±329
322 A. Long and R. Baxter
& Huberman (1984), that data analysis can be achieved in
three concurrent activities. They are: (i) data reduction,
which consisted of forming narrative texts and summary
sheets derived from transcribed interviews; (ii) the coding
technique, which involved reducing the data to `gestalts'
and categories that were easily recognized, examined and
synthesized; and (iii) content analysis, which involved
tabulating codes that signalled meaningful quotations and
provided a descriptive overview of the data. We invited
two `experts' in health research to independently scruti-
nize the transcripts for emerging categories and this
enhanced inter-reader reliability.
Findings and discussion
The purpose of this research was to examine two groups of
newly quali®ed community nurses' perceptions on health
and self-awareness. Group one (n� 16) comprised health
visitors and group two (n� 16) comprised community
mental health nurses. Two researchers who came from
different backgrounds were involved in the total process.
All participants were interviewed individually using a
semi-structured tape-recorded interview technique. Inter-
viewees were given time to think about and re¯ect upon
the topics and concepts presented before self-disclosing.
We assured con®dentiality and anonymity and the inter-
viewees were informed that anything they had to say
would be valued by us, listened to and processed. These
assurances seemed to encourage interviewees to commu-
nicate openly, thus introducing more rich and meaningful
material.
PERCEPTIONS OF HEALTHPERCEPTIONS OF HEALTH
The health visitors perceived and de®ned health in
`functional' categories and in terms of physical well-being
and the ability to carry out physical activities including
sports and jogging. The most frequent responses from 10
health visitors were `Health is a state of physical well-
being' and four said health was `a state of mental well-
being.' Ten of the health visitors perceived health to be
related to `the absence of illness or handicap'. All 16 health
visitors said that they would not consider themselves to be
healthy if they had a chronic physical illness or if they
were disabled in any way. The entire group of health
visitors also perceived health to be embraced within
the theme of `gratitude' and viewed it to be a `priority'
and as a `coping strategy' for carrying out physical
activities. These included caring for their nutritional
status, effective cooking and having the health to work and
raise a family. `Health means being able to do all the things
I want to do in life' was the response from one of the
interviewees.
The community mental health nurses perceived health
in a holistic manner and in `being' states. They viewed the
themes of `freedom' and `mental and emotional health' as
their personal concepts of health. Fifteen of this group
suggested that if people are not mentally healthy then this
affects their overall `freedom to be' healthy and 14
associated health with mental well-being, for example, `If
people are mentally healthy then everything else follows'.
Thirteen of the group perceived that people might have
had a chronic illness or a disability and still remain healthy
because they had adjusted to their circumstances in life
and more especially `if they feel good inside'. Twelve
suggested that people should be facilitated to make
informed health choices in life and they re¯ected concerns
about the dif®culties some individuals experience as a
result of living in an oppressive society which denies
certain groups both their freedom and the right to make
healthy choices. Three perceived health to be associated
with `contentment' and three with `the ability to love and
be loved'. Some of their comments about health were of a
self-actualizing nature, for example one said, `Health
means being happy and being able to achieve all the things
I want to achieve in life' and another said, `Health means
feeling good about me and about my friends and relations'.
HEALTH-ENHANCINGHEALTH-ENHANCING BEHAVIOURSBEHAVIOURS
The entire group of health visitors said that they kept
physically healthy. The key concepts that emerged were:
physical exercise, healthy nutrition including healthy
cooking, an increase in eating fresh fruit, reduction of
sugar intake and getting a balance in their alcohol
consumption. However, six of the group admitted that
they still smoked and enjoyed their over-indulgence in
alcohol intake `especially at the weekend'.
The group of community mental health nurses stated
that they `prayed a lot', `used meditation', and attended to
their aesthetic needs by listening to music and going for
walks on the beach and in the forest. Four of the group
worked continually at maintaining their emotional health.
For example, one said, `I know to take stock daily, to talk
to someone, to air my problems and not to bottle them
up'. Four said they believed in `keeping themselves
physically ®t' and four over-indulged in smoking and
drinking alcohol. They stressed that they knew `at a
cognitive level' that these behaviours were not good for
their health but `when you are young you don't think too
deeply about the harm too much booze causes in the long
term'.
Ó 2001 Blackwell Science Ltd, Journal of Clinical Nursing, 10, 320±329
Functionalism and holism 323
PERCEPTIONS OF THEIR `INNER SELF'PERCEPTIONS OF THEIR `INNER SELF'
Five of the health visitors said that they did not know what
the inner self was. When they were probed further one
said, `I am going through a period of de-personalization at
this time'. Five stated that the inner self was the `person
within' and three said that it was that `private place within,
that place that no-one knows'. One perceived the inner self
as `the soul' and another said that it was her `reality.'
When this was further explored this interviewee said, `I
live in a fantasy world where I pretend everything is all
right, but in here (pointing to her heart) I know that
nothing is right at the moment'.
Five of the community mental health nurses considered
the inner self to be `a private inner force or drive within'.
Four said, `It's me' and one added, `It's the part of me that
makes life worth living.' Three considered the inner self to
be the soul and one continued `It's that part of me that
helps me to look through people and not at them' and
another, `It makes me realize that when I am surveying
people I am not surveying a shell but a person within'.
Two said the inner self was their core, for example, `It's
the core of my being' and `the part of me I feel ®rst when
under pressure'. One de®ned the inner self as, `It's that
person within, that person I keep from getting hurt, I am
her keeper, I hold the key to my inner self'. Another
stated, `It's the hurt within, the whole me, the good and
the bad, an angel and a devil'.
SELF-ENHANCINGSELF-ENHANCING BEHAVIOURSBEHAVIOURS ENGAGEDENGAGED
IN TO `SPOIL' THEMSELVESIN TO `SPOIL' THEMSELVES
This particular exploration had to be rephrased several
times, for example, `What do you do to pamper yourself?'
and `What special actions do you engage in order to be
good to you?' There were 30 responses from the group of
health visitors. Eight responses were related to eating out,
for example, `I use food ± a night out'. A further seven
responses were related to `buying new clothes'. Aesthetic
self-valuing behaviours ranked highly; for example seven
health visitors enjoyed a `walk by the sea' or a `walk in the
forest'. Four considered that they pampered themselves by
participating in physical exercise ± in the form of keeping
®t. Three of the health visitors said that they pampered
themselves by doing things they liked to do and one
added, `but then I can afford these things', thus acknow-
ledging that their health- and self-enhancing behaviours
were related to having a surplus of money. One health
visitor said she took a holiday three times each year.
The group of community mental health nurses made 28
responses to this question, of which 10 related to soaking
in a warm bath, for example, `a bubbly bath with hot
towels and light music'. Six of the community mental
health nurses listened to music and walked by the sea.
Four added statements such as, `to clear my head'. Five
responses were related to `spending a quiet night just for
me' and three mentioned `spending a quiet evening with a
friend'. Two community mental health nurses said they
`love food'. One seized the moment and said, `I spoil
myself by doing the things I really want to do at that
moment in time' and another said, `I buy new clothes,
that's my retail therapy'.
THEIR ROLE IN PROMOTING THEIR FAMILY'S HEALTHTHEIR ROLE IN PROMOTING THEIR FAMILY'S HEALTH
The health visitors focused on preventative concepts as
the category most highly valued by this group. For
example, 15 responses were related to making sure that
their children were clean and well dressed and 14 related
to ensuring that their children were immunized. Thirteen
responses from this group were associated with watching
their children's lifestyles and ensuring that they ate
`healthy diets' and guaranteeing that they (the health
visitors) carried out `healthy shopping' for their families.
Eleven said that they took the children to the swimming
pool and 10 considered that preventative strategies such as
getting routine dental checks and early GP appointments
were related to promoting their families' health. In
addition, 12 responses were associated with the role they
play in relation to their partner's health, but 10 admitted
that their partners refused to listen to them.
Twelve of the 16 community mental health nurses
focused on their families' mental and emotional health.
They used statements such as `I listen to my children'. `I
give my children time'. `I give my children a say in all
family situations' and `I allow them to show their
emotions'. Eleven responses were related to preventative
strategies such as buying healthy food, healthy cooking,
diet, hygiene and time for recreation. Ten of the group's
responses were clustered into the category of self-actual-
izing, for example, `I enjoy giving my children their
freedom to think and to feel' and `Just because I am a
parent doesn't mean that I am always right.' Nine
community mental health nurses highlighted their role
in promoting their families' aesthetic, cultural and spir-
itual health. For example, four were related to `I take them
[the children] to dancing and to music' and another four
reported `We pray together'. One said, `My mother always
said `The family that prays together stays together'. Five
responses were related to the importance of the family as a
unit, for example, `If one of us does not feel well then we
all suffer'. There were 10 statements regarding the
Ó 2001 Blackwell Science Ltd, Journal of Clinical Nursing, 10, 320±329
324 A. Long and R. Baxter
political issues in Northern Ireland and how `the troubles'
had impacted on the quality of family life and health, for
example, `I believe in integrated education but where we
live we do not have a choice'. Four focused on their
geographical location, for example `It depends where you
work, some professionals try to indoctrinate people with
their own points of view and value systems regarding
politics and religion'.
THEIR ROLE IN PROMOTING HEALTHTHEIR ROLE IN PROMOTING HEALTH
AT A GLOBAL LEVELAT A GLOBAL LEVEL
The group of health visitors made 39 statements about
their personal role in valuing global health. For example,
eight of the health visitors' responses were related to,
`Yes, we all have a part to play'. Eight identi®ed their role
and the role of the government and the media in health
education: `People need education and direction about
their health'. Six were related to the suggestion that `The
government has a responsibility to provide more educa-
tion to other countries'. Four made statements such as,
`The media has a role to play in enhancing the health of
residents of other countries ¼I am glad the media is
bringing it home to us'. Four other responses were
related to the concept of `victim blaming'. For example,
there were statements such as `There are plenty of jobs
out there if only people would get up and look for them'
and `Many people do not want a job yet they complain
about not being healthy¼what's the use of helping
people like that?' Another said, `They [the unemployed]
could get up and look for a job instead of sitting there
smoking all day affecting their children's health'. Two
stated that they did not believe there would be health for
all by the year 2000.
The community mental health nurses made a total of
59 statements on this theme. Eight were related to
unemployment: `The great despair of unemployment and
the soul destroying sickness of unemployment'. Six were
concerned about Third World poverty and four were
concerned about inequalities in income and health. One
said, `The great need to continue to strive for an
equitable global society'. Six of the responses were
associated with the great need to try to alleviate AIDs,
infectious illnesses, skin cancers, postnatal depression and
anxiety and stress.
The concept of freedom was referred to by eight of the
community mental health nurses; for example one said,
`People should have the freedom to make religious choices
and political decisions and to air one's opinions' and
`People have a right to freedom of speech about every-
thing'. Eight interviewees made reference to their concern
about the ozone layer and the way in which people are
destroying the Earth and abusing the world. A social
category of responses followed, with eight of this group of
interviewees expressing their concern for, and interest in,
the prevention of children being abused. Four believed
that it was important to work on reducing paranoia and
fear in Northern Ireland, as well as drug traf®cking and
alcohol abuse. Three interviewees mentioned animal
rights. Two interviewees admitted that global issues only
¯ash in and out of their minds at times. One said, `I turn
the television off, I cannot look at the atrocities that
happen to other people in other countries'. One concluded,
`It's too vast for me to worry about' and another believed,
`I can't really think about people miles away when I am
still thinking of protecting the people in Northern
Ireland'.
HEALTH-ENHANCINGHEALTH-ENHANCING BEHAVIOURSBEHAVIOURS THEY ENGAGETHEY ENGAGE
IN TO PROMOTE HEALTH AT A GLOBAL LEVELIN TO PROMOTE HEALTH AT A GLOBAL LEVEL
The entire group of 16 health visitors stated that they were
aware that they should be doing something but also
admitted that they were not doing enough. They made 55
responses related to this theme. Twenty were associated
with protecting the ozone layer, for example, `saving
bottles and cans, using recycled paper and ozone friendly
aerosols'. Nine health visitors used organic food, while
eight carried out sponsored walks for voluntary organiza-
tions. Three donated money and clothing to charities; for
example one health visitor said, `I sponsor a child in
Burma but I never tell anyone as that would take all the
good out of it'.
Community mental health nurses made 65 responses
when exploring this theme. Isolating and alleviating
political, oppressive, religious and social factors, such as
poverty `at home and abroad in developing countries'
was the main category of responses from this group.
The entire group of 16 community mental health nurses
believed in `protection of the ozone layer'. Ozone-
friendly gardening material was used by 15 of this
group. Twelve responses were related to anger about
the expense of ozone-friendly materials and organic
foodstuffs. Ten interviewees used recycled paper and
worked at keeping the environment clean and litter-free.
Ten donated funds to charities and six admitted that
they would like to provide more for those who are less
well off than themselves in a material sense. Four
interviewees stated that they would gladly give more in
taxes to help the poor. One illustration of this was, `It's
pay back time. I have enough money to keep my family
and me'.
Ó 2001 Blackwell Science Ltd, Journal of Clinical Nursing, 10, 320±329
Functionalism and holism 325
Summary
Synthesis of both sets of data demonstrates that the group
of health visitors perceived health in terms of physical
®tness and in functional states. The most frequent
responses were associated with `a state of physical and
mental well-being'. They also viewed health to be related
to the absence of illness or disability. They perceived
health to be embraced within the theme of `gratitude' and
claimed that they valued their health when they looked at
someone who was less well off than themselves in terms of
their physical capabilities. They perceived that people
could not be healthy if they had a chronic illness such as
diabetes or if they were disabled in any way. They viewed
the preventative aspects of health to be the primary health-
enhancing behaviours they engaged in. This group de®ned
their `inner self' as `that private place within' and ®ve of the
group had never thought about the `inner self' before the
interview. They promoted their families' health by attend-
ing to their physical needs and by ensuring that they were
immunized and had regular appointments with the dentist.
At a global level, health visitors highlighted the need for
education on health matters, gave generously to `charities'
and believed that people would be healthier if they `found a
job for themselves as there was plenty of employment out
there'. Their health-enhancing behaviours at a global level
focused mostly on the protection of the ozone layer.
Community mental health nurses' de®nition of health
was holistic as it included the physical, psychological,
spiritual, social, environmental, governmental and political
dimensions of health. This group considered that there is a
need to `listen' to each individual's perception of what is
`right' and `health-enhancing' for them in terms of their
health-enhancing and health-defying behaviours and
needs. They portrayed a strong focus on the promotion
of their family's emotional and mental health needs as well
as their physical needs. They used prayer and meditation
to develop these health domains. At a societal and global
level they perceived that the concept of freedom was
denied to many people because ®nancially they did not
have the resources to make healthy choices when living in
an oppressive society. They believed that people could be
chronically ill and/or disabled and remain healthy because
they had adjusted to their circumstances in life. They
insisted that there `is a quality of life that goes with being
healthy'. This group perceived the `inner self' to be the
part of them that makes `life worth living' and `the soul'.
At a global level they focused on the protection of the
ozone layer and the promotion of an equitable society,
where the reduction of poverty was the key health-
enhancing behaviour needing to be addressed.
Discussion
This research was conceived from the notion that if
people, in this instance Registered Nurses, became self-
aware then they would come to accept and value
themselves and colleagues. Ultimately they would also
learn to accept and value their health, as health is
embraced within the concept of self. It is dif®cult to value
one without valuing the other. This valuing of self and
health could eventually lead people to respect and value all
living creatures. The primary aim of embracing this
proposition would be to improve human relationships with
self, meaningful others, the community and at a wider
level the planet Earth. The secondary aim would be to
equip and encourage people to increase their understand-
ing and appreciation of life's meaning and purpose and the
unique role we all play in the greater scheme of life.
Health is a personal matter; therefore, individuals de®ne
the concept according to their beliefs, values and satisfac-
tion. Indeed, the World Health Organization (1949)
de®ned health as `not merely the absence of disease'.
They were clearly dealing with health as a value-concept.
Over 30 years later the World Health Organization
released a new de®nition of health that included the
extent to which individuals or groups are able to realize
aspirations and ful®l needs, which might also mean ®nding
ways to either change or cope with their environment.
Health was viewed as `a resource for everyday life, not an
objective of living: it is a positive concept emphasizing
social and personal resources as well as physical capabil-
ities' (World Health Organization, 1984, p.23). Even
though the de®nition has broadened and to some extent
deepened, functional de®nitions of health seem to remain
more useful to health professionals such as the health
visitors in this study. Functional de®nitions enable
professionals to identify the various factors that contribute
to health status, to search for problems and needs, and to
plan health promotion in a concrete manner.
In addition, the last century sanctioned phenomenal
change in health perceptions. Up until the early 1960s
many people believed they could smoke, drink, drink-and-
drive, as well as eat excessively with very little to fear other
than a smoker's cough, being a bit overweight and a
hangover the day after a night out. The period of cheerful
naivete was ended in 1964 with the ®rst Surgeon General's
Report on the hazards of cigarette smoking and the
disapproval of food high in cholesterol (USDHEW, 1964).
Following this report, many health-related epidemiolog-
ical ®ndings were disseminated to the public and this
resulted in visible changes in perceptions and behaviours.
Many people could be seen drinking bottles of water,
Ó 2001 Blackwell Science Ltd, Journal of Clinical Nursing, 10, 320±329
326 A. Long and R. Baxter
eating vegetarian foods, jogging regularly and wearing seat
belts. The onus was on individuals to change their health-
related behaviours and consequently it was the role of
health promoters to provide health information based on
research ®ndings (Dines & Cribb, 1994). This might have
been one of the reasons why the health visitors in this
study focused primarily on the physical dimensions of
health and health-enhancing behaviours. The history of
health visiting demonstrates that they were respectable
working women who went from door to door teaching the
`poorer classes' of the population and provide advice on
hygiene and child welfare, mental and moral health, as well
as offering social support (McCleary, 1933). Since then it
has been widely argued that the practice of nursing and
health visiting cannot be regarded as socially and politically
neutral activities, nor blindly support an ideology that
requires only individual analysis (Allen, 1999):
The explanation of [health] behaviours is not sought
in a psychological analysis of individuals, but in a
socio-economic, historical analysis of relations
between people and the way these have shaped the
world we have to live in (Mason, 1987, p.70).
However, even today there is a de®cit of research
relating to the emotional and spiritual dimensions of
health, as well as the importance of human relationships
within the total spectrum of health and health-related
behaviours (McDonald & Hodgdon, 1991). Holistic health
has been de®ned as `The cumulative effect of the dynamic
interaction within the physical, psychosocial and spiritual
dimensions of the individual and the transactions that
occur between these and the social and physical environ-
ments' (Fleming, 1999, p.233). This holistic portrait of
health provides community nurses with wider scope to
promote the health of individuals, families and communi-
ties, a snapshot of which was clearly demonstrated by the
group of community mental health nurses in this study.
The community mental health nurses perceived health
in a holistic manner and in `being' states. They re-iterated
the concept of freedom and related it to the promotion of
mental health and well-being. They suggested that if
people are not mentally healthy then it affects their overall
freedom to be healthy and if people are mentally healthy
then `everything else follows'. They expressed the need to
facilitate people to make informed health choices. How-
ever, they re¯ected concern about the dif®culties some
individuals experience in making sound health choices.
They also said that health means being happy and being
able to do all the things that people want to do in life.
Health was also related to the ability to love and be loved,
hence incorporating health into the wider domain of
human relationships.
On the topic of unemployment, it was interesting to
®nd that health visitors in this study differed from
community mental health nurses, in considering that there
are `plenty of jobs out there, if people would only go out
and look for them'. Examining why this difference
occurred between the two groups would be an interesting
study in itself. Meanwhile, the authors tentatively infer
that there might be at least three reasons why this
happened. Firstly, the history of health visiting is the
history of middle class home visitors providing support
and advice to `the poor' (Mason, 1995). Orr (1992) argued
that many current health visitors are also middle class
women. Therefore, they are endowed with middle-class
attitudes and values, which might act as barriers to
perceiving the lived experiences of clients. The history of
mental health nursing, on the other hand, focused on `the
unity of the individual in relationship with his fellow man
(sic), because of its religious basis in creation' (Temple,
1942, p.129). Temple advances this argument, suggesting
this proposition was a basis for freedom, fellowship
and service and it is because of this basis that the
character of care found in mental health nursing embraces
an inextricable relationship with cure. This leads to the
second tentative reason why a difference occurred between
the health visitors and the community mental health
nurses.
Secondly, health visitors visit the well population and in
this section of the population most unemployment is
because work is a scarce commodity. Alternatively,
community mental health nurses visit people who are
unable to work either because of their illness or because
employers fear `taking a risk' with people who are mentally
ill. Thirdly, health visitors are viewed as having a
facilitator role and their primary function is to provide
health information to clients, the majority of whom are
mothers (Mason, 1995). Community mental health nurses
are viewed as having an empowering role and their
primary function is to `empower people and communities
by restoring their sense of personal worth and dignity and
to advocate proactively on behalf of people who are
mentally ill and their carers' (Long, 1995, p.250).
However, why the difference between the two groups
revealed itself so poignantly over the issue of unemploy-
ment will remain a `surprise' factor in this study until
further work in this area has been carried out.
The importance of communication in nursing cannot be
over-emphasized (Ogden, 2000). Nurses interact contin-
uously with human beings. Therefore questions about
their health and well-being, including personal percep-
tions regarding the quality, meaning and purpose of life
are value-laden (Fleming, 1999). It is meaningful to note,
Ó 2001 Blackwell Science Ltd, Journal of Clinical Nursing, 10, 320±329
Functionalism and holism 327
however, that even though good health and a good life are
important goals for many people, they are not the only
goals. Becker (1976) argued that people might be heavy
smokers and also be aware of the consequences of their
smoking but continue to value their smoking more than
the projected life years they are sacri®cing. It is very
probable that most people have heard the health debates
before they have been in contact with nurses; therefore
hearing them once again will not change their minds or
in¯uence their behaviours. If nurses really want to
promote health they must ®nd out the reasons why people
continue to engage in health-defying behaviours that they
already know are damaging to their health.
IMPLICATIONS OF THIS RESEARCHIMPLICATIONS OF THIS RESEARCH
It is acknowledged that this was a small-scale exploratory
study with limited generalizability. Nevertheless, it may
have implications for nurse education, research and
practice. It is imperative that nurses are provided with
opportunities in the classroom to explore and re¯ect on
de®nitions and perceptions of health. In addition, it is
suggested that these debates on health are linked
fundamentally with exploring concepts such as the `inner
self', self-awareness, the meaning of life and what it
means to value self and colleagues. Exploring these
theoretical concepts might go some way towards helping
nurses to view human beings holistically and to practise
their caring in a holistic manner. A range of opportu-
nities for further research on the topics explored in this
study has also become apparent. It would be of potential
value to carry out a similar project using interviewees
from other community specialisms, such as learning
disability, occupational health or practice nursing, in
order to discover personal perceptions and values that
might exist in individuals who choose different careers in
nursing. Determination of the possible effects of such
perceptions and values on nurse±client relationships
might also be useful as a future topic of study, thus
increasing our understanding of some of the dynamics of
health care delivery. Meanwhile, the nature of this study
requires modesty in respect of claims made on the basis
of these unique populations examined. In terms of
interviewees, it could be tentatively concluded that,
either by personality or through the selection and
education process, nurses working in diverse ®elds
demonstrate commonalties with their peer group in
terms of health perceptions. If there is any validity in
this proposition then it might also be that, depending on
one's personal vision, these perceptions might in¯uence
their entire approach to life and living. An approach that
encompasses one or other worldviews may be instru-
mental in helping our understanding of a whole variety
of health perceptions and activities and intimately
enhance our understanding of the population we serve.
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