Running head: CONCEPT ANALYSIS: HEALTH
Concept Analysis: Health
Jill Collins RN, BSN
Jerilyn Rodgers, RN BSN
Washburn University
Theoretical Foundations for Advanced Nursing Practice
NU 500
Washburn University
December 2nd, 2009
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CONCEPT ANALYSIS: HEALTH
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“Health is something of an enigma. Like the proverbial elephant, it is difficult to define
but easy to spot when you see it” (Bury, 2005). The professional nurse of today is faced with
many challenges. Maybe the grandest of those challenges is to help a client understand, achieve,
and maintain health. The actual process involved in understanding and achieving health is not
difficult in and of itself. The biggest challenge lies in defining what it is to have “good health”
or to be “healthy”. The challenge lies in the fact that a person’s definition of health is always
subjective and is dependent on a multitude of factors which will be reviewed in this concept
analysis of health.
A concept analysis is a tool that “gives framework and purposiveness to thinking that
might otherwise meander indefinitely and purposelessly among the vast marshes of intellect and
culture” (Wilson, 1969). There are eight steps to approaching a concept analysis (Walker &
Avant, 1995). These steps are illustrated in Table 1 in appendix A and will be used to conduct
this concept analysis of health.
Why the concept of health? The authors of this concept analysis have 20 years of
combined emergency nursing experience. They have had the opportunity to interact with a
multitude of people ranging in age, socioeconomic status, cultures, disease processes and acute
illnesses. They have a relatively short period of time to interact with their clients, getting them
back up on their feet and on their way to restoring health. In reflecting upon this, however,
these authors have realized it is their own perception of health they are attempting to restore their
clients to. They have realized a need to be able to define what it means to be “healthy” from the
client’s perspective. There also seems to be relatively little in the review of literature on health
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as a concept in regard to how the nursing profession can utilize the concept to help clients to
achieve better outcomes.
Purpose of Analysis
One of, if not the ultimate goal of nursing is to help clients achieve health. This is
difficult to achieve and can be quite frustrating if one does not fully understand what it means to
a particular client to be “healthy”. The client’s perception may be quite different than the
perception of the nurse. It should be recognized that for nurses, health may be a great concern
but it is not necessarily so for the client. Health is often part of the “natural attitude” to life
where the meanings are often taken for granted and are unconsidered most of the time until one
becomes ill (Bury, 2005). Once the nurse can fully grasp the concept of health from a client’s
perspective, the nurse becomes more productive in helping the client to achieve and maintain
their health. The nature of nursing care is determined by the understanding of health concepts.
In fact, in the foundation of all nursing theories is the consideration of health and how it is
perceived by the nursing theorist. These concepts of health are important and useful to the
theoretical foundation of nursing practice. It is important to clarify the concept of health in order
to develop both theory and research and for the development of instruments to measure health
(Wang, 2005).
Review of Literature
Introduction
On November 11th, 2009 a literature search was conducted on Washburn University’s
Mabee Library website. This was done by using the Cinahl and Proquest databases. Within the
data bases, an initial search was done with the word “health”. This search brought 167,614 hits
on Cinhal. The search was then narrowed by using the terms “health” and “concept” which
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brought 4696 hits on Cinhal and 7251 on Proquest. The authors then narrowed the search to
“health” and “concept analysis” which gave 149 hits in Cinahl and 131 hits on Proquest. The
authors also conducted a Google scholar search on November 11th, 2009 using the terms “health”
and “concept analysis” giving 2,340,000 hits. For purposes of this analysis, those were
narrowed to only studies specifically relating to defining health. The final list of articles and
books can be found in the references.
Article Review
Yurkovich and Lattergrass conducted a study to define health and perceptions of illness
from the perspective of American Indians experiencing persistent mental illness. The purpose of
this study was to enhance the health care providers’ awareness and knowledge of the existence of
difference clients’ perception of health. With this understanding, health care providers in turn
enable their clients to better understand their own health-seeking behaviors (Yurkovich &
Lattergrass, 2008). The study focused on the 40% of American Indian/Alaska Natives who live
in rural reservations. Significance of the research was based on multiple reports and studies
indicating minority groups, because of lower income, under education, types of occupation and
acculturation, have a higher percentage of experiencing mental illness. This, coupled with
reduced availability of support systems, places this vulnerable population at great risk.
Grounded theory methodology was used in collecting data and analysis. Forty four interviews of
Native American Indians (NAI) experiencing persistent mental illness (PMI) were interviewed.
Results indicated a composite definition of health as “being in balance/equilibrium, having a
sense of harmony, and not being out of control of spiritual, cognitive, emotional and physical
domains” (Yurkovich & Lattergrass, 2008). The Circle of Wellness model fit the NAI due to the
spiritualism of this population. The authors concluded “deficits in healthy social environments
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and relationships affect the ability of NAI with PMI to maintain health” (Yurkovich and
Lattergrass, 2008). Health professionals must integrate spirituality and advocate for healthy
environments to be able to manage culturally competent care.
A qualitative study was conducted by Johansson, Weinehall and Emmelin on Swedish
health professionals’ view of health and health promotion. The overall objective of this study
was to gain an understanding of how health professionals interpret the concept of health and
health promotion and how they perceive their role in health promotion practices (Johansson,
Weinehall & Emmelin, 2009). The study was based on focus group discussions and analyzed the
data using qualitative content analysis. Seven focus group discussions with a total of 34
participants were carried out. The results were categorized into three main topics: concept of
health, concept of health promotion and health promotion in practice. Their findings lead them
to conclude the participants described health as “a multi-faceted concept”, “a subjective
assessment” and “health is about life, the whole life” (Johansson, Weinehall & Emmelin, 2009).
The description of health promotion was described as diffuse, elusive and difficult to apply and
was viewed very differently by the participants based on their personal practice. This study
suggests different interpretations of health promotion can lead to “misunderstandings and pose
barriers to further development of a health promoting practice” (Johansson, Weinehall &
Emmelin).
An article written by Bennett, Perry and Lawrence (2009) discussed the meaning of
health, approaches to health promotion, public health and health protection as it relates to
primary care. This was in direct relation to the United Kingdom shifting towards developing
policies with an emphasis on the promotion of health in recent years. The purpose was to
encourage nurses to build up the skills necessary to look at their communities and appropriately
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assess the health promotion requirements, then provide culturally sensitive interventions.
Throughout the article the authors established eleven “time out” boxes, asking the readers to
participate in exercises designed to help the reader develop strategies of health promotion related
to their communities. In conclusion, the authors wrote the article to provide nurses with key
issues to be aware of in order to promote the health of their respective communities, thus
tackling some of the “inequalities in health that persist in the UK today” (Bennett, Perry &
Lawrence, 2009).
Summary
There seems to be one common theme in regard to the concept or definition of health in
the review of literature. Most people know what it means to be “healthy” for them but it
becomes very difficult to put it into an exact definition that fits every person. Most of the
literature reviewed provided definitions of what “health” is in reference to the World Health
Organization’s (WHO) definition. There were only 2 articles that these authors could find that
were specifically a concept analysis of health. One of those articles was in Chinese and the other
was written in 1989 (Simmons, 1989). This made the concept analysis a little more difficult and
shows that this concept is one that could benefit from updated literature.
Definitions
Merriam-Webster defines health as “the condition of being sound in body, mind, or spirit;
especially: freedom from physical disease or pain” or “the general condition of the body”
(Merriam-Webster, 2009). The most prevalent definition used in the literature reviewed is the
WHO definition. The WHO defines health as “a state of complete physical, mental, and social
well-being and not merely the absence of disease or infirmity (WHO, 1946). The WHO also
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added to this in 1986 during the Ottawa Charter for Health Promotion by saying health is “a
resource for everyday life, not the objective of living. Health is a positive concept emphasizing
social and personal resources, as well as physical capacities” (WHO,1986).
In the study on
health in Native American Indians, Yurkovich and Lattergrass emphasize “health is not merely
and end in itself, but rather a means of attaining human well-being within the constraints in
which man finds himself.” “Health then is a process of gaining a sense of personal well-being at
any moment in time within one’s established boundaries/context” (Yurkovich & Lattergrass,
2008).
Nursing theorist Dorothy Johnson defines health as “a purposeful, adaptive response
physically, mentally, emotionally, and socially to internal and external stimuli in order to
maintain stability and comfort “ (Fawcett, 2005). Theorist Myra Levine states “every individual
defines health for himself or herself” (Fawcett, 2005).
Most of the literature breaks down health into two categories, the bio or medical portion
and the social portion. The bio portion focuses on the body viewing health and disease as
opposites of each other. The social or “holistic” portion also encompasses spiritual and
emotional aspects and indicates that health and disease are concepts related to the whole human
being (Johansson, Weinehall, & Emmelin, 2009). For the purposes of this paper, health will be
difined as a process by which one is able to attain overall personal well-being with regard to
physical, social (which includes environment, culture and lifestyle), emotional (which includes
mental and intellect), and spiritual aspects of his/her life.
Defining Attributes
Defining attributes are a cluster of characteristics that are frequently associated with the
concept and are seen over and over again in the literature (Walker & Avant, 1995). There are
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several attributes that are consistent in the literature review about health and what it means to be
healthy. The five major attributes noted are: health is subjective, health has a physical or bio
component, health has a spiritual component, health has a social component and health has a
emotional component. Each of these will be reviewed briefly.
In the review of literature, health is repeatedly talked about as being subjective in nature.
Though as nurses we often want the client to ultimately become what is engrained in us as
healthy, it is really the client’s perception of what being healthy is that should guide is in the care
of that particular client. Nurses must realize every client they work with will have a different
notion of what being healthy is. This presents a major challenge to the nursing profession.
Nursing theories, research and nursing processes revolve around this notion.
The physical or bio component of health refers to the body itself and disease processes or
acute illnes that may be present. This component of health is what most health professionals are
largely focused on. “This is hardly surprising, given the fact people turn to medicine in times of
trouble, not when they are feeling well” (Bury, 2005). According the Bury, healthcare has been
largely individualistic in orientation and has paid less attention to the client’s social situation or
the larger environment (Bury, 2005). Having a physical disability does not necessarily cause
one to believe they are “unhealthy”. For people who have stable disabilites like diabetes, being
healthy may be redefined to incorporate how the person feels at a particular moment and not in
relation to the general norm. “Adaptation to illness or disability alters the baseline from which
the individual judges the nature of health and its implications” (Bury, 2005).
The spiritual component is structured around the assumption that most people have a
higher power they look to for guidance in their lives. This higher power does not have the same
meaning for everyone but often a disruption in this relationship has consequences in the client’s
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health. The spiritual component supports other components and helps to maintain, for example,
the mental/emotional component (Yurkovich & Lattergrass, 2008).
The social component takes into account culture, environment, and lifestyle. For
example, in the Native American Indian culture, people often define healthy as simply being able
to work everyday (Yurkovich & Lattergrass, 2008). Some people view themselves healthy if
they are able to get out of the house and interact with others on a day to day basis while this may
be of less important to others. Lifestyle factors such as smoking, exercise, and diet often define
how healthy people view themselves (Bennett, Perry, & Lawrence, 2009). “Additional
significant determinants of health include the broader socioeconomic, cultural, environmental
and political structures, as well as global issues. Through being aware of these issues, healthcare
professionals will be mindful that factors affecting health are multifactorial and are much more
complex than individual lifestyle choices” (Bennett, Perry, & Lawrence, 2009)
Intellect, which is considered a part of the mental component for purposes of this
analysis, also affects how clients view their health. “Quoting data from India and the USA, Sen
shows the higher the level of education in a population, the higher the level of reported illness”
(Bury, 2005). This is directly related to the fact that with higher levels of education, clients often
spend time researching and reporting symptoms they have been observing in themselves (Bury,
2005).
The mental/emotional component is a large driving factor in how clients view their
health. A client may be in the best physical shape of his/her life but if an adverse life event
occurs, mental state often declines (i.e. depression) and the client has a difficult time viewing
himself/herself as healthy. On the same note, if a client strongly believes that he/she is
physically ill or will die, this is often the end result. This can be illustrated in cancer patients.
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Those who have a strong will to live and be as healthy as possible often outlive those who
mentally are ready to give up after the diagnosis.
Antecedents
Antecedents are events, conditions, or situations that must occur prior to the occurrence
of the concept (Walker & Avant, 1995). The antecedents identified for the concept of health
are: a perceived need to be healthy, access to health services, access to basic human needs such
as clean water and nutrition, the ability to gain knowledge in order to make rational decisions
and lifestyle choices in regard to one’s health, the ability to adapt and/or adjust to life events, and
support from people surrounding the client.
Consequences
Consequences are the outcomes of the concept having taken place (Walker & Avant,
1995). Consequences of health include: improved quality of life, the ability to actively engage
in life, and maximization of a client’s potential.
Emperical Indicators
Emperical indicators are observable and measureable phenomena that give evidence to
the existence of the concept (Walker & Avant, 1995). The emperical referents for health are
difficult to define due to the fact that health is a subjective experience for each client
encountered. There are obviously many ways to measure physical health such as BMI, blood
pressure, cholesterol levels, blood glucose levels, etc. There is IQ scoring to measure intellect.
There is not a way identified to measure spiritual health. There is little in the literature to
support a way to measure social health. Using a ProQuest search, there were many tools found
for self-assessments of health. However, people often find it easier to define what mental illness
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is rather that mental health. “No matter how many definitions people try to come up with
regarding mental health, its assessment is still a subjective one” (Nordqvist, 2009).
Model Case
A model case is one that incorporates all of the defining attributes of health which are
that health is subjective and has physical, mental/emotional/intellectual, social/cultural/lifestyle,
and spiritual components. Mr. Smith is a 46 year-old African American, 1 pack per day smoker,
with a familial history of cardiac disease. He suddenly experiences excruciating chest pain. He
calls 911 and is transported to the nearest chest pain center where is he is diagnosed with an
acute myocardial infarction and taken to the cardiac catheterization lab where his blocked artery
is opened with a cardiac stent and blood flow to his heart muscle is returned. He is admitted to
the hospital for continued treatment. He is educated on cardiovascular disease including a risk
factor assessment. He is offered information on smoking cessation and diet modification as well
as advice on implementing an exercise program. He is started on medication appropriate for his
condition. He was visited by pastoral care and assessment was made of his spiritual well-being.
He was visited by social work to assess finances, access to appropriate health care needs, and his
social support system. In the next six months, Mr. Smith was able to quit smoking, and make
appropriate diet adjustments, maintain appropriate medication and exercise regimens and follow
up with his physician. He was able to express he has an improved quality of life, is able to enjoy
time with his wife and kids, and is able to actively participate in life. He feels “healthy”.
Invented Case
An invented case involves using thoughts, which are fabricated, often reading like
science fiction, to represent the concept. Frannie the Ford truck was driving to see her friend
Ginny the GMC. On her way to Ginny’s, her engine began to make a terrible noise and Frannie
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didn’t feel so well. She quickly found a service station and pulled in. A quick diagnostic test,
done by the mechanic, showed Frannie had a loose belt. The mechanic was able to replace the
belt and Frannie’s engine was soon up and running again. The mechanic educated Frannie on
the need for routine maintenance of her engine (physical), tires, and transmission as well as
keeping fluid levels (spiritual) checked and her interior (mental/emotional/intellect) and exterior
could drive forever. She had herself serviced every 3000 miles. She was able to drive in the Indy
500 with her friend Ginny the GMC and was able to drive faster than she ever did before.
Conclusion
This concept analysis brings to light there are many “definitions” and “perceptions” of
what health is. The important factor for the nursing profession to take into consideration is
health is subjective to the client. The nursing profession must utilize this concept in order to help
our clients achieve what is an ideal state for them to live life to its fullest and to be happy and
“healthy”.
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References
Bennett, C., Perry, J., & Lawrence, A. (2009). Promoting health in primary care. Nursing
Standard, 23, 48-56.
Bury, M. (2005). Health and Illness. Malden, MA: Polity Press.
Fawcett, J. (2005). Contemporary Nursing Knowledge: Analysis and Evaluation of Nursing
Models and Theories. Philadelphia, PA: F. A. Davis Company.
Johansson, H., Weinehall, L, & Emmelin, M. (2009). “It depends on what you mean”: a
Qualitative study of Swedish health professionals’ views on health and health promotion.
BMC Health Services Research, 9, 191-203.
Merriam-Webster. (2009). Merriam-Webster Online. Retrieved November 20th, 2009, from
Merriam-Webster Online: http://www.merriam-webster.com/dictionary/health.
Nordqvist, C. (2009). Medical News Today. Retrieved November 16th, 2009, from Medical
News Today: http://www.medicalnewstoday.com/articles/150999.php.
World Health Organization (1946). Constitution of the World Health Organization. Geneva.
World Health Organization (1986). Ottawa Charter for Health Promotion. Geneva.
Simmons, S. (1989). Health: a concept Analysis. International Journal of Nursing Studies,
26, 155-161.
Walker, L.O. & Avant, K.C. (1995). Strategies for Theory Construction in Nursing. Norwalk,
CT: Appleton & Lange.
Wang, Y. (2005). A concept analysis of health (abstract). Hu Li Za Zhi, 52, 40-43.
Wilson, J. (1969). Thinking With Concepts. New York: Cambridge University Press.
Yurkovich, E.E. & Lattergrass, I. (2008). Defining health and unhealthiness: Perceptions held
by Native American Indians with persistent mental illness. Mental Health, Religion &
CONCEPT ANALYSIS: HEALTH
Culture, 11, 437-459.
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Appendix A
Table 1 Eight-step approach to concept analysis
1. Decide on a concept
2. Determine the aims or purposes that can be revealed
3. Identify all uses of the concept that can be revealed
4. Determine the defining attributes
5. Construct a model case
6. Construct additional cases
7. Identify antecedents and consequences
8. Define empirical referents
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Appendix B
Model: Health as a concept with defining attributes
PHYSICAL
SOCIAL
CULTURAL
SPIRITUAL
HEALTH
ENVIRONMENT
MENTAL
EMOTIONAL
INTELLECT