Legacy of nursing’s history

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Legacy of Nursing’s History 

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F E AT U R E S

Wellness Promotion and the Institute of
Medicine’s Future of Nursing Report
Are Nurses Ready?

■ Kelley Strout, MSN, RN

This article highlights the gap between wellness in nursing practice and the mission statement of the Institute of
Medicine’s Future of Nursing Report. It explores wellness from 3 philosophical arguments, provides a historical
evolution of wellness, and explores nurses’ current understanding of wellness. Future directions for implementing
wellness 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 the
Institute of Medicine (IOM) symbolizes a paradigm
shift in health care delivery from sick care to well
care.1 The IOM envisions a health care system where
nurses intentionally promote wellness and disease
prevention and improve health care outcomes
throughout the lifespan.1 The nursing profession is
well recognized for the role of disease prevention and
health promotion as established in the seminal article
of Donaldson and Crowley2 to the recent Future of
Nursing Report from the IOM.1 Within the scope of
nursing practice, the words “health,” “health
promotion,” and “wellness” appear to be used
interchangeably. Florence Nightingale, Virginia
Henderson, and Margaret Newman developed
frameworks that conceptualize wellness; however,
wellness is not clearly defined within these theories.3–6

Nurses’ ability to achieve the mission of the IOM and
intentionally promote wellness is limited by the
absence 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, Northeastern
University, for her time and support in editing the manuscript for publication.

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

Correspondence: Kelley Strout, MSN, RN, c/o Elizabeth P. Howard, School
of Nursing, Bouvé College of Health Sciences, Northeastern University, 360
Huntington Ave, Boston, MA 02115 ([email protected]).

DOI: 10.1097/HNP.0b013e31824ef581

the concept of wellness and a common paradigm to
promote wellness in nursing practice.7 The purpose of
this article is to conceptualize the historical evolution
of wellness and highlight the gap in nursing practice
between knowing and promoting wellness.

THE CONCEPT OF WELLNESS

The absence of a universally recognized concept of
wellness in the nursing profession is better understood
after examining the complexity of wellness through 3
philosophical arguments: ontology, realism, and
empiricism.

Plato’s ontological argument establishes wellness
as a state of being. Patient lives represent diversity and
ever-changing circumstances; patients will define
what it means to be well based on their changing
world. Their perception of wellness will generate from
their current circumstances and will continuously
change.8 Thus, the concept of being well is not static,
but fluid. According to Plato, all living things aim and
aspire to “good being.” From this perspective, all
people naturally hope to gravitate toward a state of
wellness, or “good being.” As people experience
enhanced wellness, they will become more self-aware
and learn about additional experiences that will
promote 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 simply
apply to people in poor health, or people who need to

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129

130 HOLISTIC NURSING PRACTICE • MAY/JUNE 2012

prevent certain diseases. Every person continues on a
journey to achieving his or her full potential and
maximizing his or her wellness.8

The philosophical argument of realism aligns with
the concept of wellness. Realism explains the reality
of a phenomenon. Wellness from a realist perspective
asks, “What is the reality of wellness? What does
wellness look, act, and feel like? Wellness will look,
act, and feel different for every patient. Realities are
unique to individuals’ environments, genetics, and
experiences.9 Patients’ realities will influence their
views and perception of wellness.

Wellness embraces an empirical philosophy;
however, this philosophy differs from empirical
research and practice and expands to the patient’s
experience. John Locke, a philosophical empirical
thought leader, proclaims that knowledge is derived
through experience.8 Personal patient experiences will
determine his or her definition of wellness. Nurses
cannot possibly acquire the experience of each
individual patient. Every patient who interacts with a
nurse will possess different knowledge compared with
the previous patient. Knowledge creates worlds for
patients, worlds that translate into unique and diverse
definitions and understandings of wellness.

Wellness is difficult to conceptualize, which may
explain the omission in definition and paradigm
development within the nursing profession. In the
absence of a universal, clearly defined understanding
of the word and concept of wellness, the National
Wellness Institute10 provides this clear definition of
wellness: wellness is a multidimensional and holistic
state of being that is conscious, self-directed, and
constantly evolving to achieve one’s full potential.
Wellness is an ever-changing process that
encompasses multiple dimensions, known as the Six
Dimensions of Wellness: intellectual, spiritual,
emotional, physical, occupational, and social
dimensions.10,11 The Six Dimensions of Wellness
reflect unique characteristics that interconnect with
one another to represent the person as a whole. Table 1
provides the definition for each of the Six Dimensions
of Wellness.

HISTORY OF WELLNESS IN NURSING

According to the National Wellness Institute,10 a
professional can determine whether he or she practices
within 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 of
Wellnessa

Dimension of
Wellness Definition

Occupational
wellness

Ability to contribute unique skills to
personally meaningful and
rewarding paid or unpaid work

Social wellness Ability to form and maintain positive
personal and community
relationships

Intellectual
wellness

Commitment to lifelong learning
through continuous acquisition of
skills and knowledge

Physical wellness Commitment to self-care through
regular participation in physical
activity, healthy eating, and
appropriate health care utilization

Emotional
wellness

Ability to acknowledge personal
responsibility for life decisions and
their outcomes with emotional
stability and positivity

Spiritual wellness Having purpose in life and a value
system

aBased on definitions from Hettler.11

achieve their full potential? Does this recognize and
address the whole patient? Does this affirm and
mobilize positive qualities and strengths?”10 The
nursing frameworks of Florence Nightingale, Virginia
Henderson, and Margaret Newman are examined for
congruency with wellness profession guidelines of the
National Wellness Institute.

Florence Nightingale’s theory supports wellness by
addressing the whole patient and affirming his or her
positive qualities and strengths.6 Nightingale believed
that patients should be placed in optimal environments
that allow nature to act. Her theory promoted nature as
the ultimate cure for any disease process. According to
Nightingale’s theory, environments are
multidimensional. The air people breathe, the food
people eat, the company people keep, and the
conditions people live will interact to promote or
prevent healing.6

Nightingale believed that nurses should work to
prevent disease and care for well patients with the
same approach as caring for sick patients.6 She
explained that diseases proliferate for years before
manifesting into clinical symptoms. Therefore, nurses
can improve the environment of well patients to
prevent disease. Improving the environment could be

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Wellness Promotion 131

as simple as helping a patient create a healthy menu
plan to helping a community improve air quality.
Nightingale encouraged nurses to empower society to
improve environments outside hospitals such as
schools, homes, and communities in order to prevent
disease.6

Nightingale’s theory represents affirming and
mobilizing positive qualities within patients.6 She
believed that the patient, whether sick or well, is the
best person to care for his or her own health. She
encouraged nurses to view patients in the moment.
She warned nurses not to judge patients with
condescending thoughts or words. Nightingale
believed that nurses should recognize that patients
would do better in a supportive environment.6

Nightingale’s theory of placing the patient in an
optimal environment for healing and preventing
disease promotes a wellness approach by addressing
the patient positively and holistically. However,
Nightingale does not define well, or wellness. Through
her descriptions, the state of wellness is reflected by
the absence of disease. Nightingale’s theory does not
support the concept of assisting patients to achieve
their full potential. Patients who are not sick are not
necessarily achieving their full potential.6 The absence
of disease is not reflective of full potential.10

Henderson’s theory supports wellness by
addressing the patient from a multidimensional
perspective and encourages them to provide their own
care.3 In Henderson’s complex, multidimensional
model, she defines health as a person’s ability to
perform 14 activities independently.3 Although the
word “wellness” is not used in Henderson’s theory, her
activities align with the Six Dimensions of Wellness
framework.11 Table 2 organizes Henderson’s theory in
the Six Dimensional Framework.

Henderson believes that the nurses’ role is to assist
patients with the 14 activities when they lack the
strength, knowledge, or will. At the same time, she
emphasizes that nurses should care for all patients; she
believes that basic human needs exist in patients who
are sick and patients who are well. She believes
that nurses should promote health and prevent
disease.3

Henderson’s theory affirms and mobilizes the
strength of patients. She further states that nurses must
encourage and empower patients to care for
themselves.3 Nurses should not do everything for a
patient; the best care is the care that the patient gives
himself or herself. Nurses should recognize that health
is multidimensional and affected by variables such as

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

Dimension of
Wellness

Fourteen Activities
That Define Health

Occupational
wellness

Work at something that provides
sense of accomplishment

Social wellness Avoid dangers in environment and
avoid injuring others

Play or participate in various forms of
recreation

Intellectual
wellness

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

Physical wellness Eat/drink adequately
Move and maintain desirable posture
Sleep/rest

Emotional
wellness

Communicate with others in
expressing emotions, fears, and
needs

Spiritual wellness Worship according to his or her faith

aBased on definitions from Henderson3 and Hettler.11

age, environment, genetics, culture, emotional
balance, and intellectual abilities.3

Henderson encourages nurses to also care for well
people. She defines health as the ability to perform 14
functions independently. Although Henderson
encouraged and believed that nurses should provide
care to well patients, not just sick patients, she never
provided an explanation for how the nurse would care
for a patient who could independently perform the 14
functions. Her theory addresses patients holistically
and promotes affirmation; however, similar to
Nightingale, her theory does not address helping the
person achieve his or her full potential or maximal
level of wellness. She defined health and even
emphasized the nurses’ role in caring for well patients,
but she did not define wellness, nor did she provide a
framework to promote wellness.

Newman’s theory, Health as an Expanding
Consciousness, supports 3 wellness approaches:
addressing the whole patient; assisting the patient to
rise to his or her full potential; and affirming the
qualities within a patient.4 In Newman’s theory,
disease is an underlying manifestation of an imbalance
within a patient. Health is more than the absence of
disease; health is the expansion of consciousness, or
personal growth. Newman’s theory supports the idea
that even in the face of illness, a patient can grow and
make progress. Although disease appears negative,
Newman believes that disruption eventually

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132 HOLISTIC NURSING PRACTICE • MAY/JUNE 2012

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

Health as a state of consciousness, according to
Newman, is represented through the quality and
interaction of a patient with his or her environment.
Newman addresses the complexities that exist between
every individual and his or her environment. Every
patient’s relationship with his or her environment will
generate different reactions. The reflections on
experiences that occur within the environment provide
growth or expanded consciousness. Newman stresses
that for nurses to promote expanded consciousness,
they must provide highly individualized care to every
patient. She also believes that the process of
expanding consciousness can occur anywhere,
anytime. The process is not limited to a specific health
care setting, or the presence or absence of a disease.4

Nurses’ responsibility in promoting consciousness
reflects the wellness approach of affirming and
addressing the whole person. Newman believes that to
promote consciousness, nurses need to look at patients
as a whole, greater than the sum of their physiologic
systems. Health is not something someone achieves or
loses. Patients can have consciousness even in the face
of illness and disease; you cannot lose consciousness
or achieve consciousness. Illness or diseases create an
opportunity for growth.4

For optimal effectiveness of Newman’s model, the
relationship and environment created between a
person and a nurse are essential. Nurses must provide
individualized care focused on listening attentively to
the person’s life, and rhythm. Nurses need to embrace
uncertainty 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 and
unique; disequilibrium is necessary for growth. Nurses
need to give patients the opportunity to reflect, think,
and generate their own growth. Nurses cannot
manipulate and control patients; the partnership
between nurses and patients is essential to expanding
consciousness.12

Newman’s theory embraces the concept that
wellness is a state of being, ever changing and
continuously evolving. Newman does not use the word
“wellness” to describe her theory; however, her theory
suggests that nurses cannot define wellness for
patients because wellness will mean something
different to every patient. Nurses need to promote
wellness by accepting uniqueness and developing a
deep understanding for each patient’s environment and
experience.

Although each of the theorist believe that caring for
patients who are well is essential to the nurses’ role,
none clearly define the concept of wellness or provide
a framework for nurses to practice and promote
wellness.3,4,6,12 To examine the relationship between
the theoretical foundations of wellness and current
nursing practice, a review of the literature was
completed using CINHAL. Literature examining the
role of wellness in nursing practice was notably
absent. The CINHAL thesaurus suggested using the
search terms “health promotion.” Five qualitative
research studies aiming to explore nurses’ perceptions
of the definition of health promotion, how they
promote health in practice, and barriers to promoting
health in practice were included in the review. The
sample sizes ranged from 8 to 20. Nurses working in
acute care, geriatrics, advanced practice, academia,
community, and mental health care were represented.
Because of the expanded search, a definition of health
promotion is provided in the following text.

HEALTH PROMOTION

The World Health Organization13 defines health
promotion as a process to help individuals increase
control of their health with the desired outcome of
physical, mental, and social well-being. The World
Health Organization distinctly emphasizes that before
health promotion can occur, a patient must recognize
his or her aspirations, satisfy his or her needs, and
change or cope with his or her environment. Health
and wellness promotion is a fundamental role within
the nursing profession, yet a review of the literature
highlights a gap in nursing knowledge about how and
when to promote health and wellness.

NURSES DEFINITION OF HEALTH
PROMOTION

The results of 5 qualitative research studies suggest
that nurse’s definition of health promotion is
ambiguous and uncertain.14-18 The common definition
of health promotion among nurses, in a variety of
health care settings, refers to providing health
education and advice about healthy life styles.15-18 For
example, nurses believed that health promotion is
telling someone why he or she should change his or
her behavior or life to protect or improve his or her

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Wellness Promotion 133

health.18 Nurses with more experience commonly
perceived health promotion as empowerment.17

Advanced practice nurse practitioner students with
at least 2 years of nursing experience participated in a
research study that evaluated their perceptions of
health promotion. The students completed qualitative
questionnaires before and after a health promotion
course. Before the health promotion course, the
students described health promotion as advice giving
and health education. After the health promotion
course, the student’s views of health promotion
evolved to empowering the patient.18

HOW NURSES PROMOTE HEALTH

In the research studies included in the review, the most
common theme about how nurses promote health is
giving information about healthy lifestyles to patients
with specific health conditions.16-18 For example, if a
patient presented to the hospital post–myocardial
infarction, the nurse would encourage the patient to
exercise more frequently and eat more fruits and
vegetables.16 Some nurses believe that they promote
health without any deliberate efforts because
promoting health is a natural and automatic
component to their work. Consequently, they are
unable to recall specific examples about the last time
they promoted health.15

BARRIERS TO HEALTH PROMOTION

The most common perceived barrier to promoting
health in nursing practice is time,15,17,18 followed
closely by not enough education and training.15,17

Some nurses believe that they needed more evidence
that health promotion is an effective method for
helping patients improve their health.17

Nurses perceive patients as barriers to promoting
health. Some nurses believe that patients are unwilling
to accept health promotion.15 More than half of nurses
who perceived that patients should not have a choice
to receive health promotion believed that patients
frequently ignore advice given to them.17 Patients’
knowledge deficit about healthy lifestyles and
patients’ unwillingness to change emerged as health
promotion barriers for nurses.18

The health care system and work environments do
not support nurses in the role of health
promotion.14,15,18 Some nurses believed that nursing

management does not empower nurses to promote
health and daily nursing tasks are burdensome and
prevent them from practicing health promotion.15 The
percentage of nurse practitioner students who
perceived the work environment as a barrier to
practicing health promotion increased at the
completion of a health promotion course.18

DISCUSSION

The literature included in the review contains
limitations. The most notable limitation is the absence
of literature examining nurses’ perception of wellness
in practice. The vision of the IOM is for nurses to
intentionally promote wellness. Before this can occur,
research that examines nurses’ current understanding
of wellness and how to promote wellness in practice is
needed. Research in this review contained small,
convenience samples of nurses who were required to
answer questions about health promotion while being
recorded by the interviewer. Nurses interested in
health promotion may be overrepresented using
convenience samples. Furthermore, the use of tape
recorders may lead some nurses to withhold
information or exaggerate information due to concerns
about confidentiality, or social desirability.
Acknowledging the limitations, however, this review
provides insight about the gap between wellness
promotion and nursing practice.

Nurses believe that health promotion is at the core
of nursing practice.15-18 Currently, nurses promote
wellness by promoting health. Nurses cannot
intentionally promote wellness and achieve the vision
of the IOM1 if they are unable to confidently define
and provide specific examples of health and wellness
promotion. Nurses should have time to promote health
and wellness if they believe that it is the core of the
profession.

Nurses believe that patients are barriers to the
practice of health promotion.15-18 Nurses’ belief that
patients are unwilling to accept health promotion
warrants further examinations. How can patients have
knowledge deficits about their own perception of
health and wellness? If a patient is unwilling to
change, should he or she be considered a barrier?
Reflecting on each question philosophically reminds
us that patients’ health and wellness are their own
state of being. Their experiences and perceptions
define how wellness and health will look, act, and feel
for them.8,19 According to ontology, every patient is

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134 HOLISTIC NURSING PRACTICE • MAY/JUNE 2012

on a journey to optimal wellness.8 Reflecting on each
question through the lens of nursing theorists suggests
that nurses may be the true barriers in promoting
health. Nightingale warns against judging patients who
are unwilling to change. She would say that patients
would do better if their environment supported them
better.6 Henderson3 would argue that the patient does
not have the strength, knowledge, or will to accept
health promotion how the nurse desires, but this does
not mean that the patient never wants to promote his
or her health. Newman12 posits that the nurse is not
asking the right questions, not listening with her
whole heart, and not getting into the patient’s life.

WELLNESS AND THE ART AND
EPISTEMOLOGY OF NURSING

The review of the literature highlights a gap between
nurses’ perception of health and wellness promotion
in nursing practice and how and when to promote
health and wellness in practice. The subjective nature
of wellness, the absence of a clear and universal
wellness definition, and the absence of a wellness
framework in nursing practice create fundamental
challenges to achieving the IOM’s vision.1 Nurses
need to know how to assess, design, document, and
validate wellness outcomes. Carper’s20 seminal work,
The Four Fundamental Patterns of Knowing in
Nursing, provides a framework to address the art and
epistemology of wellness in nursing.

Empirical understanding of wellness

Nurses need an empirical understanding of the
concept of wellness. To intentionally promote
wellness, nurses need to know in what context the
phenomena of wellness are to be viewed. Nurses need
to develop an abstract and theoretical explanation for
wellness in nursing practice. Nurses need to know
what questions are to be raised about wellness, and the
methods of study to examine evidence of wellness
promotion.2 For nurses to intentionally promote
wellness in nursing practice, they need the knowledge
to describe and explain wellness to patients, society,
and other health care professionals.

In nursing practice, the essence of wellness may lie
within an understanding of the realities, experiences,
and world of the patient. Nurses, therefore, will need
to know how to empower, encourage, and inspire
patients to realize their own visions of wellness. Nurse

researchers need to design empirical studies to
examine techniques to promote wellness in nursing
practice. Nurse educators need to develop frequent
continuing educational activities about when, how,
and why to promote wellness in practice. Nursing
administration needs to examine nursing tasks to
ascertain whether health and wellness promotion, a
core value in nursing, is not absent in practice because
of time constraints. Nursing practice needs to develop
a documentation system that captures the patient’s
empirical view of wellness and tracks wellness
outcomes from the patient’s perspective. Most
importantly, nursing education needs to develop an
evidenced-based curriculum that provides nurses with
a strong foundation for promoting wellness in nursing
practice. Currently, clinical prevention and population
health are essential education requirements for
baccalaureate prepared nurses.21 These requirements
do not aim to prepare all nurses for the role of
intentional wellness promoters. First, clinical
prevention, as defined by the American Association of
Colleges of Nursing, is disease focused. Nurses
practicing clinical prevention will demonstrate
knowledge around immunizations, screenings, and
counseling aimed to prevent disease or disease
escalation. Second, population health aims to improve
the health at the community, or aggregate, level.
However, since the baccalaureate degree is the
minimum level of education required to practice and
promote population health, half of the nursing
workforce who hold an associate degree in nursing is
not adequately trained or qualified to perform this
role21,23 The absence of wellness as an essential
requirement in nursing education is evident. To
achieve the vision of the IOM, all licensed nurses
require education and training about the meaning of
wellness and how to promote wellness to all patients
in all care settings.

Esthetic understanding of wellness

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

The patients’ growth will depend on nurses’ ability to

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Wellness Promotion 135

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 to
promote wellness in nursing practice. Personal
knowledge in wellness promotion will require nurses
to relinquish the authoritarian role and accept that
patients are free to create their meaning and
experience of wellness.20 Carper20 states, “An
authentic personal relation requires the acceptance of
others in their freedom to create themselves and the
recognition that each person is not a fixed entity, but
constantly engaged in the process of becoming.”(p155)

Nursing practice needs to develop dynamic
relationships with policy makers and interdisciplinary
health care professionals to design a wellness
infrastructure within the community and the health
care system. The new system should capitalize on
nurses’ personal knowledge and ability to promote
wholeness and integrity.20

Ethical understanding of wellness

Nurses need an ethical understanding of how to
promote wellness in nursing practice. Patients’
perception of wellness will depend on their
experiences and values. Only patients can determine
what is good and bad for them. However, nurses need
the knowledge to recognize behavior that is harmful or
dangerous. Nurses need to adhere to moral obligations
when promoting wellness in nursing practice.20

FUTURE DIRECTION FOR SCIENCE
AND NURSING

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

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

Finally, the pivotal change that needs to occur is a
shift in the percentage of nurses working in acute care
hospital settings to nurses promoting wellness within
the community. Currently, 62.2% of nurses work in

hospitals compared with 7.8% in public health and
community settings.22 Patients in acute care settings
are in a new environment. Before optimal health and
wellness promotion can occur, patients must cope with
the new environment, a process that may not occur
before patient discharge.13

Nurses’ role in the community is multidimensional.
Nurses have an opportunity to apply empirical,
aesthetic, personal, and ethical wellness knowledge in
schools, businesses, prisons, day care centers, and any
other place people gather. Removing the barrier of the
hospital environment14,15,18 may prove the best
method for nurses to assume their role as intentional
promoters of wellness.

CONCLUSION

The Future of Nursing Report from the IOM1

symbolizes a turning point for change in health care
delivery. Nurses are prepared to rise to the challenge
and embrace changes that promote positive health
outcomes for society. However, to realize a vision that
explicitly emphasizes the contribution of intentional
wellness promotion to positive patient outcomes,
nurses are challenged to develop a universal
understanding and paradigm to promote wellness in
nursing practice. Before nurses can value their role as
wellness promoters, nursing education, nursing
research, and nursing administration need to work
together to make wellness a priority. Without proper
education about how and why to promote wellness,
without research to provide evidence-based wellness
guidelines, and without administration to monitor
wellness promotion practice and outcomes, nurses
cannot truly value their role as intentional wellness
promoters.

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Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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