Health Promotion International, Vol. 24 No. 2 doi:10.1093/heapro/dap015
# The Author (2009). Published by Oxford University Press. All rights reserved. For Permissions, please email:
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EDITORIAL
Have the health services reoriented at all? Recently, I had an opportunity to observe the workings of the health care system from the inside. I was admitted to a mixed surgical ward in an Australian public hospital with a mysterious ailment. My personal health required acute promotion. My participant observation research demonstrated that the calls for action in the Ottawa Charter are still urgent. The Charter, twentythree years ago, stated The responsibility for health promotion in health services is shared among individuals, community groups, health professionals, health service institutions and governments. They must work together towards a health care system which contributes to the pursuit of health. The role of the health sector must move increasingly in a health promotion direction, beyond its responsibility for providing clinical and curative services. Health services need to embrace an expanded mandate which is sensitive and respects cultural needs. This mandate should support the needs of individuals and communities for a healthier life, and open channels between the health sector and broader social, political, economic and physical environmental components. Reorienting health services also requires stronger attention to health research as well as changes in professional education and training. This must lead to a change of attitude and organization of health services which refocuses on the total needs of the individual as a whole person.
In all my misery I discovered a number of important things: HOSPITAL OPERATIONS REVOLVE AROUND STAFF AND PROCEDURES, NOT AROUND THE HEALTH OF PATIENTS A hospital is like any other professional bureaucracy: it has to adopt a number of operating procedures to maintain the integrity of the
organisation. But based on tradition, historical fact, belief system and some degree of cultural bias (and not on any salutogenic principle), the health care institution works towards a continuity of work, not continuity of care. Night shifts end at six o’clock in the morning: for the sake of a false sense of continuity of care this means that the patient population is risen, poked, attached to machines, squeezed, pinched by other machines, and thermometers are stuck into at utterly unholy hours. Following this, there is a twilight period when nurses do their hand-overs, but other auxiliary personnel start messing about on wards. Foul-smelling (at least, when you’re sick enough) breakfasts are distributed, cleaners cheerfully moisten floors. Then the wait starts for the distribution of pharmaceuticals by the day shift, the washing, cleaning of linens, and finally, the droves of doctors.
NO MATTER HOW EMPOWERED YOU ARE IN HEALTH, A FEVER MAKES YOU FEEBLE A thirty year career in health, great health literacy, and complete mastery of the literature on health promotion and empowerment should have facilitated my access to the best possible care in the world. But here I found myself for six hours in a surgical gown on a hard examination couch, in pain and shivering with fever. And I was asked to sign a couple of forms required to admit me to hospital, including one where – as a ‘private patient’ (and what an odd concept did that become) – I was asked to nominate my own consulting doctor. I was prepared to sign anything as long as it was going to make me healthy. How was I to know whether Dr. K. was the most appropriate specialist to 105
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treat my predicament? Who would advise me on that? Did I have the composure to ask?
TOO MUCH CARE IS PROVIDED BY ASSUMPTION, TOO LITTLE BASED ON OBSERVATION Across the ward I could observe one of the key subjects of my participatory research. Here was a 92 year old war veteran who had suffered an acute life-threatening condition and had received surgery that should restore him to complete health within days. I found out that he was a Major and had survived the Burma Railway when he talked – coherently and fully respondent – to an official from the Department of Veterans’ Affairs. The official had arranged for the Major’s hearing aids and dentures to be brought in from his nursing home; obviously they had been forgotten in the rush to get to hospital. Amazingly, the nurses did not know that the Major used hearing aids. They talked to him as if he were a totally imbecile child because he did not respond to communication. When his repeated cries “I’m deaf! I’m deaf! Give me my hearing aids!” were finally recognised, staff fumbled for many wasted minutes to apply the aids and switch them on. I saw the Major’s learned helplessness set in, culminating in an 18-year old junior nurse shouting at him in a shrill voice “Good morning sweetie! Do you like to have a little wash?!” The Major complied by responding in similar infantile fashion.
THE PATIENT IS A CASE; A CASE IS NOT NECESSARILY A PERSON Following the important learnings from ‘Our Bodies, Ourselves’ (2005) I have the impression that I know my body. Not well enough to diagnose the condition that brought me into hospital, but quite sufficiently to tell the nurse who is trying to find a vein to insert a drip that she should look on the side of my wrist, not on the top of my hand. The latter is more fragile, and will hurt more. No, she finds: Side of wrist is nonsense. Back of hand is always good. I suffer unnecessary pain (quickly dealt with through the dispensing of pain killers as Smarties) for three days.
We teach our medical students cultural awareness, and utter respect for the patient. Archie Cochrane, in the gospel of evidencebased medicine (1999), viewed patients as critical co-producers of their own health, not just as the recipients of care. My experience with the cetes of surgeons, herds of urologists, and flocks of pharmacists walking through my bed and the beds of my fellow sufferers indicates that ‘respect’ is often a case protocol and not driven by a profound belief in human dignity. ‘Privacy’ is an esoteric principle not applicable to the fast paced runs through wards (my neighbour’s horrendous clinical details I could not avoid hearing . . .). ‘Cultural awareness’ an academic concept without bearing on reflexive practice. Regrettably, of the almost ten thousand pages that we have published in this Journal since the Ottawa Charter only a few dozen focus on the reorientation of health services. These pages, then, usually address political or organisational aspects of health promoting hospitals (e.g., Johnson & Baum, 2001), and not what most appropriate quality care can be provided to patients. It is perhaps good to consider that the network of Health Promoting Hospitals/Health Promoting Health Care Institutions has been operating since the development of the Ottawa Charter (Pelikan, Krajic & Dietscher, 2001), and is organising it’s 17th international conference this year. The vision of this network follows four dimensions: † good quality treatment and care in a healthy health care setting; extending the treatment of current diseases towards disease prevention and promotion of positive health; strengthening patient orientation towards empowering patients to take control over the factors that influence their health † healthy workplaces for staff † strong partners for public health in the communities † healthy and sustainable organisations. Assuming my experience with the health care system was not a-typical, there still seems to be an urgency towards the empowerment of patients to truly take control over a hospital environment that too often seems counter to their health. A modicum of literature exists on the role of the largest professional workforce in the system: what are the roles of nurses in health promoting hospitals (Whitehead, 2005)?
Have the health services reoriented at all?
Interestingly, an analysis of the role of the most powerful professional workforce in the system (the doctors) seems still to have to rely on the classics of David Mechanic, Lowell Levin and Howard Waitzkin. Obviously, the nursing profession has considered its role in a health promoting institution. There has been an interesting discourse in its own literature deliberating nurses’ role in the empowerment of patients (Hewitt, 2002); the most critical antagonists of such a role suggest that nurses empowering patients would potentially damage their own stature versus the medical profession: by choosing to align themselves with the disempowered, they would loose whatever little power they hold in relation to the medicos. The most vocal proponents of a patient advocate role for nurse professionals argue that no-one else in the health care environment would be able to take on the role. Hewitt (2002) in her comprehensive review ultimately finds that “advocacy may be serving the best interests of the nurse, rather than that of the patient.” The discourse on further reorientation of health services towards the promotion of health should clearly be continued, especially in the health promotion community. The Journal
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invites papers and viewpoints to fill this, regrettably slightly neglected, element of our belief system. Evelyne de Leeuw Assistant Editor E-mail:
[email protected]
REFERENCES Boston Women’s Health Book Collective & J. Norsigian (2005) Our Bodies, Ourselves: A New Edition for a New Era. Simon & Schuster/Touchstone, New York Cochrane, A.L. (1999) Effectiveness and Efficiency: Random Reflections on Health Services. The Royal Society of Medicine Press, London Hewitt, J. (2002) A critical review of the arguments debating the role of the nurse advocate. Journal of Advanced Nursing 37(5) 439–445 Johnson, A. and Baum, F. (2001) Health promoting hospitals: a typology of different organizational approaches to health promotion. Health Promotion International 16(3) 281– 287 Pelikan, J., Krajic, K. and Dietscher, C. (2001) The health promoting hospital: concept and development. Patient Education and Counseling, 45, 239– 243 Whitehead, D. (2005) Health promoting hospitals: the role and function of nursing. Journal of Clinical Nursing. 14(1) 20–27
