“NOTICE: this is the author’s version of a work that was accepted for publication in Nursing Standard. Changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may have been made to this work since it was submitted for publication. A definitive version will be published in Nursing Standard Accepted 6th November 2014
Nurses have a history of engaging in health promotion and public health and both roles are reflected in the Nursing and Midwifery standards for education. However, future trends such as population growth, new technologies and climate change, suggest that their current understanding of these trends need to develop to adapt to a very different future. This paper argues that nurses need to quickly move beyond adopting individualistic and behaviour changing perspectives (Kemppainen, Tossavainen and Turunen (2012), to that of also adopting an ethico-socio-political role (Falk-Raphael 2006) in health promotion based on a wider understanding of what health promotion may mean. This paper reflects on climate change, an outline of the concept of ecological public health, and Kemppainen, Tossavainen and Turunen’s (2012) integrative review on the nurses’ role in health promotion to support this argument.
Despite the requirement to curb greenhouse gas emissions to prevent catastrophic climate change (Costello et al 2009, Roberts and Stott 2011, McCoy 2014) the world is experiencing a continuing rise in anthropogenic greenhouse gases (IPCC 2014). This emissions growth is expected to persist, driven by population growth and economic activity. This will result in global mean surface temperatures of 3.7o C to 4.8o C by 2100 if there is no further mitigation (IPCC 2014). This is way beyond the 2o C ‘safety’ threshold (Peters et al 2013, McCoy et al 2014, Marshall 2014), a threshold beyond which there may not be a ‘safe operating space for humanity’ (Rockström et al 2009).
McKie (2014) suggests that global evidence supports the assertion that climate change is already happening, resulting in severe floods, permafrost melts, rising sea levels and lack of snow in the Alps. He states: “In its latest report, the Intergovernmental Panel on Climate Change estimates that up to 139 million people could face food shortages at least once a decade by 2070”. According to Marshall (2014) we will routinely experience heat waves and extinctions; the feeding of 10 billion people becomes more difficult; the loss of glaciers and ice sheets will result in two-thirds of our major cities under water; and ocean acidification will be adversely affecting the ecosystem over two-thirds of its surface.
According to Climate Central (2014), the risk of record flooding in Washington DC this century is virtually guaranteed. This is a backdrop to thoughts about where it will be better, and safer, to move to in the United States. Alaska, the Mid West and the Pacific North West will fare much better than California and the South East when, according to Mora et al (2014) unprecedented high temperatures could become the norm by 2047. Mora et al go on to argue that Washington DC will reach its tipping point in 2047; Los Angeles, 2048; San Francisco, 2049 and Chicago, 2052. Detroit has until 2051, and Anchorage, 2071.
In other words, some scientists have accepted that temperature and sea level rises will severely impact on cities in the next few decades, requiring major adaptation responses around population migration, land and flood defences and major structural changes in economics and society. This is in accord with the National Climate Assessment (2014) third report which outlines the rises in temperatures and makes it clear we are talking in decades not centuries for the changes to impact.
The health impacts of climate change have been documented elsewhere (WHO 2014a) and is partly based on the social and environmental determinants of health (Barton and Grant 2006, WHO 2008). Barna et al (2012) have also set out what nurses need to know about climate change but the urgency of addressing this issue is increasing, as the National Health Service Sustainability Unit outlines in its ‘Fit for the Future Scenarios 2030 (NHS SDU 2014). All of this this leads us to consider what the health promotion role of the nurse might be in relation to this context.
Ecological and Planetary Public Health.
Horton et al (2014) call for a new social movement in their ‘manifesto from public to planetary health’ to support collective action on Public Health. They introduce the concept of ‘planetary’, rather than just public health. As with Lang and Rayner’s (2012) discussion of Ecological public health, there is a strong focus on the unsustainability of current consumption and linking this with poorer health outcomes. It implicitly draws upon Barton and Grant’s (2006) health map which has climate stability in its outer ring. Interestingly, an overt political statement is introduced in the ‘manifesto’:
“We have created an unjust global economic system that favours a small wealthy elite over the many who have so little”.
The call is for an urgent transformation in values and practices based on recognizing our interdependence and interconnectedness on a finite planet, and a new vision of democratic action and cooperation. A principle of ‘planetism’ is invoked which requires us to conserve and sustain ecosystems upon which we rely. Finally, they suggest that public health and medicine can be independent voices of conscience who, along with ’empowered communities’, can confront entrenched interests.
In the same vein, Ottersen et al (2014) are explicitly political on the links between health inequity, globalisation and the current system of global governance, including the actions of ‘powerful global actors’. The tone of the report makes it quite clear that there is a need to address global governance and an analysis of power. This would put the fossil fuel industry clearly in sight as a major contributor to carbon emissions and therefore as a direct threat to Public Health.
Ecological Public Health (Lang and Rayner 2012) might be, they suggest, the 21st century’s ‘big idea’. Lang and Rayner point out that public health proponents, and by implication public health nurses, have allowed themselves to be positioned within the language of individualism and choice. This leads of course to behaviour change models and theories of rational action. However, their view is that public health is about the bigger social (and political) picture that might threaten vested interests, e.g. of the fossil fuel lobby. They review public health developments over the decades and suggest a rethink is in order. They outline 4 current models of public health but suggest that they are anthropocentric, meaning that the health of the living, natural and physical world – ecosystems health – is marginalised. Climate change challenges those models as it is fundamentally about ecosystem damage and the concomitant threats to health on a global scale. Ecological Public Health (EPH) focuses on interactions, one strand on the biological world, e.g. biodiversity, and one on the material issues such as industrial pollution, including carbon emissions as pollution, energy use and toxicity. This is based on systems thinking and complexity in understanding health. EPH has four dimensions – the material, biological, cultural and social. This takes us way beyond simplistic behaviour change models which cannot deal with socio-political contexts.
“Telling families who live in poverty that they should make healthy choices ignores the conditions that prevent them doing so and is insulting and even futile” (Lang and Rayner 2012 p4).
Telling families to eat less red meat, fly less and to stop consuming without addressing the actions of global corporations is, arguably, similarly insulting and possibly futile in trying to curb carbon emissions.
The domains of Public Health, Medicine and Nursing may be insufficiently politically aware of the scale of these issues that impact on human health. This might be due to the possibly, up to now, necessary ‘ahistoric’ and ‘apolitical’ education of health care professionals, resulting in a lack of a sociological or political imagination underpinned by a critical analysis of the link between current unsustainable lifestyles, political economies and public health. However, adopting the perspective of Ecological Public Health or seeing the world through a ‘sustainability lens’ (Goodman and East 2012) might move more health practitioners and policy makers into critique and action on current economic and political structures that result in health inequities, and indeed, if some are to be believed, threaten civilisation (Costello et al 2009, Hamilton 2010, Oreskes and Conway 2014, Klein 2014, Marshall 2014). There are countervailing voices who do not see the same level of threat or who even deny climate change is really occurring (Goklany 2007, 2009a,b,c, ben-Ami 2010, Stakaitye 2014, Delingpole 2014, Lehman 2014), but this view is not shared by many health groups such as the WHO (2008, 2014b,c) the Faculty of Public Health (2014) and the International Council of Nurses (2008).
Nurse’s role in health promotion practice
Kemppainen, Tossavainen and Turunen’s (2012) integrative review on the nurses’ role in health promotion is based on an analysis of research papers from 1998-2011 and therefore misses important research that might have been published since. That being said, some of their conclusions resonate today, and if they still hold, then there is a requirement to change our understanding of health promotion to one that fits more readily with more recent arguments over climate change and the determinants of health. They argue that studies suggest that nurses have adopted an individualistic and behaviour changing perspective to health promotion (p490). This perspective is underpinned by nurses working from either a holistic/patient centred theoretical basis or a chronic disease/medical orientated approach (p492). Neither of these theoretical groundings equip nurses with the knowledge or attitudes to address the emerging public health concept of planetary health as outlined above. Although a common defining concept of health promotion found in the studies, along with the ‘individual perspective’ and ‘empowerment’, was ‘social and health policy’. However ‘nurses were not familiar with social and health policy documents…did not apply them to their nursing practice’ (p494). Again, if still true then the policy initiatives such as the WHO’s ‘social determinants of health’ and Horton et al’s ‘Manifesto for planetary and public health’ will not be found in nurses’ concepts of health promotion.
As for the health promotion expertise nurses have, this is about being ‘general health’ promoters, ‘patient focused’ health promoters and ‘project management’ health promoters. Commonly this involved health education. The competencies outlined were based on multi-disciplinary knowledge, skill related competence and competence related to attitudes and personal characteristics. Nurses were expected to be aware of economic, social and cultural issues and their influence on lifestyle and health behaviour. Whether this included knowledge of climate change or other ecological issues is not clear and is not mentioned.
This review highlighted the need to clarify the concept of health promotion, and clearly stated that ‘health policies have little impact on nursing practice’ (p499). Therefore health policies directed at future trends, such as the ecological changes indicated above, will gain little traction in practice unless changes are made. Indeed, ‘knowing about future trends affecting population health were not identified as nurses’ health promotion competencies’ (p499). The review concludes ‘it appears that nurses have not yet demonstrated a clear and obvious political role in implementing health promotion activities….instead…their health promotion activities (are) based on knowledge and giving information to patients. (p499). Lang and Rayner (2012) argue that public health must…address complexity and dare to confront power. This understanding ought then to be part of the conceptual language of health promotion used by nurses.
Student nurses will be introduced to the Social Determinants of Health (SDoH) approach as outlined by the World Health Organisation (2008) and in the Rio declaration on the social determinants of health in 2011. The reason for this is that the UK’s Nursing and Midwifery Council state in their 2010 standards for education:
“All nurses must understand public health principles, priorities and practice in order to recognise and respond to the major causes and social determinants of health, illness and health inequalities. They must use a range of information and data to assess the needs of people, groups, communities and populations, and work to improve health, wellbeing and experiences of healthcare; secure equal access to health screening, health promotion and healthcare; and promote social inclusion”.
I think this introduces an ethical imperative and a socio-political role for nursing (Falk-Raphael 2006) as the NMC explicitly state that nurses are to “work to improve health….”. If health has social determinants based on the ‘distribution of money, power and resources’ then nurses are required to understand what this means. Indeed public health principles are now embracing concepts such as the SDoH and going further in the Ecological Public Health approach (Lang and Rayner 2012).
Climate change and threats to ecosystems are very real health concerns for individuals, communities and populations both currently and in the medium to long term. The long term, in this instance, being defined as ‘this century’. The world’s scientific community is agreed on the direction of travel towards a warmer world. The wider health community and some nursing organisations are aware of the issues and are advocating for changes to practice and education. There are many who disagree either about the phenomenon of climate change itself or on what to do about it. There is distrust of politicians based on fears of the introduction of global governance and state interference (Klein 2014, Marshall 2014) and many even distrust the scientists themselves. So who is left to trust with health issues? Nurses already have a health promotion role but it has been defined in particular ways that result in an inability to grapple with the new challenges that climate change and ecosystem damage are bringing. There is thus an urgent need to address the emerging paradigm of ecological or planetary public health into nurses’ health promotion definitions and competencies, to confront ‘entrenched interests’ through individual and community empowerment. As Falk-Raphael (2006 p2) argued:
“Nursing’s fundamental responsibilities to promote health, prevent disease, and alleviate suffering call for the expression of caring for humanity and environment through political activism at local, national, and international levels to bring about reforms of the current global economic order”.
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