This section deals with definitions of health from the accepted World Health Organization (WHO) definition and critiques of its shortcomings from an Indigenous Australian perspective. Also considered is the nature of a ‘health promoting hospital’. Many attempts have been made to define human health (for example, Bright 2002, Smith 2002, Thompson 2002), and it may seem strange that such a simple word could cause so much debate. In the light of differing opinions, nurses and caring professionals may resort to the World Health Organization definition that has gained increasing acceptance, that ‘health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’ (WHO 1974, p l). While this definition of health seems reasonable, because it is from a reputable source and it encompasses a holistic view, it has been criticised for being more closely applied to happiness than to health, thus having no practical use (Saracci 1997) and for failing ‘to capture the dynamic or action-oriented nature of being healthy and well’ (McMurray 2003, p 9).

Saracci’s argument is that the WHO definition of health of inherent completeness corresponds most closely with the notion of happiness when individuals are seen to be healthier and happier (1997, p 1409). His contention is that health and happiness do not necessarily increase in the same direction and that it is possible to be healthier, say from stopping smoking, but to be a lot less happy as a result. He goes on to argue that happiness is subjective and elusive, particular only to how it is felt and interpreted subjectively by an individual, whereas health is a ‘positive and universal human right’. He suggests a better descriptor would be that ‘health is a condition of well being free of disease or infirmity and a basic human right’ (1997, p 1410).

McMurray (2003, p 9) applauds the WHO’s attempt to incorporate ‘physical, psychological, cultural and social factors’ in their definition of health, but she claims that it does not represent health as a dynamic phenomenon. Her contention is that ‘health is not always experienced as the ideal described above’; rather, it is relative to the person, changing with individual ‘circumstances, context and perceptions’. She suggests that we consider ‘individual perspectives on health, or the extent to which people define themselves as healthy’ and offers examples of people who consider themselves healthy, even though they may have a disability, or be recovering from surgery, illness or injury. She makes the point that people interpret adversity and limitations differently and, while some people may see themselves in terms of their disability others may use their disability as a challenge to excel in their lives and to ‘achieve higher levels of health than they had previously experienced’ (McMurray 2003, p 10).

However, other definitions of health far extend the WHO’s parameters. For example, consider an Australian Aboriginal perspective on holistic health (Warrawee’a 2000, p 6), that:

The nature of holism in this definition considers all life, matter and energy, including humans as one, thus rejecting separateness and singularity. Therefore, it is possible to not only to consider differing perspectives of health, but to also to contemplate different degrees of holism, ranging from a combination of parts to an inseparable mass of oneness, depending on the perspective with which you resonate. There will be further discussion on holism later in this chapter.

Given that health is a right for all people, it is promoted actively at individual, community, global and universal levels. Andrew’s ability to manage his asthma created a sense of wellness and confidence in him as he was setting and achieving goals that were important to him. As health increases feelings of wellness and predictions of life expectancy, it gives quality to those years. A change in the focus of hospitals from the business of illness management mainly, to include active strategies in health promotion, has been influenced by the WHO. Cullen (2002, p 41) describes a health promoting hospital as a WHO:

The concept of health promoting hospitals is an exciting one for nurses, and involves a change from an almost exclusive focus on providing illness care in hospitals to one where the focus is on improving health. This means that people living with an acute or chronic illness need to be supported by nurses in their efforts to learn as much about their health problems as they can, and the treatments being offered to them. In this scenario, hospitals become much more than places where medical treatment is given and nursing care provided. In a health promoting hospital, health promotion is valued as a life process, and the recipients of health care are acknowledged as the key players in health promotion rather than the various health professionals (Cullen 2002). The active collaboration required to achieve health promotion of this kind reflects beliefs in partnership and proactivity in nursing that may come some distance in realising the WHO’s definition of health, or the adjustments suggested to it by Saracci (1997) and McMurray (2003). These concepts of partnership are described in some detail in Chapter 12 of this text.

Health and health promotion are related to wellness and this section explores definitions of wellness, how it can be achieved as a way of life, and some research examining wellness factors. McMurray (2003, p 10) asserts that when ‘people are healthy, they recognize the potential for higher levels of wellness’. She traces the origins of the definition of wellness to Dunn (1959, 1961), who emphasised dynamic relationships between people and their environments ‘to maintain balance and purposeful direction’ and the goal of ‘living life at maximum potential and in harmony with the circumstances of one’s life’ (McMurray 2003, p 10).

Wellness is a broad and complex concept that has been described in the ‘Wheel of Wellness’ model (Sweeney & Witmer 1991, Witmer and Sweeney 1992). The original Wheel of Wellness proposed five life tasks interconnected and interrelated like spokes of a wheel, and these included spirituality, selfregulation, work, friendship and love. After research using an assessment instrument with 3000 people (The Wellness Evaluation of Lifestyle (WEL), Myers et al 2000), the original model was refined to divide the life task of ‘work’ into ‘work and leisure’ and to change the life task of ‘self-regulation’ into ‘self-direction’, the latter including twelve subtasks of sense of worth, sense of control, realistic beliefs, emotional awareness and coping, problem solving and creativity, sense of humour, nutrition, exercise, self-care, stress management, gender identity and cultural identity.

In spite of its complexities and challenges, the idea of wellness has been so well appropriated into the health care language and culture that a Distinguished Professor of Wellness and Gerontology in America suggests that the position of Surgeon General of the United States be converted to Wellness General of the United States (Haber 2002). He proposes changes to institutions and policies, including most notably for the general public, a tax on junk food, such as candy bars, cookies, cakes, pastries, ice cream, soft drink, corn chips and so on, that are the high fat, high sugar, high salt foods ‘that constitute over 20% of Americans’ calories’ (p 73). His motivation in suggesting these reforms is ‘to stimulate ideas and actions among policymakers, researchers, practitioners, educators, and students’. Interestingly, the general public is not included in the group to which his ideas are targeted, even though they would be affected directly by the changes he proposes to create family and community health. These well intentioned ideas carry overtones of the totalitarianism to which Saracci (1997) refers, in which it could be inferred that the general public will be required to embrace wellness, even if they choose to do otherwise.

Wellness is the subject of research projects that seek to explore its facilitation in a number of areas; for example, in disabilities (Putnam, Geenen & Powers 2003), physical activity (Bezner, Adams & Whistler 1999) and spiritual and psychological wellness (Adams & Bezner 2000).

Putnam et al (1999) used focus groups of two to ten participants for a total of 99 adults with long-term disabilities, to discuss with them how they define and conceptualise health and wellness and to explore with them their perceptions of barriers and facilitators in relation to living with disabilities. The participants defined health and wellness as (p 38):

Data also suggested that appropriate interventions are required at personal and community levels, within social and physical environments ‘to facilitate greater levels of health and wellness among persons living with disability’ (Putnam et al 1999, p 37).

Bezner et al (1999) surveyed a sample of 243 hospital employees using the Perceived Wellness Survey (Adams et al 1997), which is designed to assess wellness in physical, social, emotional, intellectual, psychological and spiritual dimensions. The results showed that higher scores for wellness were associated with participation in greater amounts of leisure time and moderate amounts of activity.

In a project involving 112 undergraduates enrolled in a health education class in Texas, USA, Adams & Bezner (2000) assessed the spiritual and psychological dimensions of wellness. The researchers found that ‘an optimistic outlook and sense of coherence must be present for life purpose to enhance an overall sense of well-being’ (Adams & Bezner 2000, p 165).

Illness is perceived generally as the opposite to wellness and it is represented as something to be dreaded, avoided and treated, but the experiencing person may also see illness as something to be acknowledged, endured and valued for the life insights it offers. This section describes illness by differentiating it from disease, locating it on a continuum to wellness, and in exploring the rights and obligations of the sick role. Illness is also described from lay perspectives, patients’ experiences, and social causes. McMurray (2001, p 3) explains illness has been considered variously as ‘ranging from disease, the presence of symptoms, or suffering, to deviance from normal expectations of good health’. However, unlike the objective state of disease, illness is also perceived as a ‘subjective appraisal, in terms of how a person perceives or experiences ill health’. She gives the example of how two people may respond differently to the symptoms of the disease of diabetes and how they might interpret their disability uniquely, according to their inability to function at their usual level. She concludes that ‘health, illness, disease, disability and wellness are therefore parts of the same process’. Travis & Ryan (1981) devised a model for assessing a person’s health level, by depicting a health–illness continuum from high-level wellness to severe illness. At the midpoint of the continuum are risk factors that may determine a person’s propensity to be healthy or ill, such as genetic, environmental, social and cultural factors that are a compilation of all the inherent risks in being human and being involved in everyday life. For example, a person’s cultural factors influencing their health or wellness may include dietary habits dictated by their respective social group’s norms and traditions. It may be more common to detect higher rates of cardiac disease in cultural groups who eat high fat, high salt diets.

If a person becomes ill, how does one act differently from being well? The rights and obligations of a person who becomes sick have been documented in the well-known work of Talcott Parsons (1951), a sociologist, who described the sick role. Parsons claimed that sick people have the right to be exempt from their normal tasks and responsibilities, but that they need to want to get well to return again to the normal fabric of functioning society. He also suggested that sick people have the right not to be blamed for their illness, because they cannot be held responsible for it. However, they have an obligation to seek help from doctors and to cooperate with them in getting well as soon as possible. The underlying assumptions of the rights and obligations of the sick role are that the normal functioning of society relies on a healthy population and medical practice assists society and individuals to become and remain well, to assist in maintaining society and people in optimal biological, economic, psychological and social functioning.

How do lay people perceive illness?Schmidt & Frohling (2000) studied lay concepts of health and illness from a developmental perspective. They were interested in the nature of the concepts held by people of different age groups. Using a questionnaire, they explored with 99 children, and 48 mothers of the children, their perceptions of five diseases (cold, measles, heart infarction, cancer and AIDS). They found that many (p 230):

How do people experience illness? Patients’ experiences of illness are receiving more attention and add to nurses’ understanding of what it means to be ill. For example, Young-Mason (1997, p ix) documents ‘autobiographical accounts of psychiatric and somatic illnesses’ emphasising ‘the implications of illness and spiritual distress and the ways in which individuals express their views of compassionate care’. The richness of patients’ accounts is evidenced in the following excerpt from Allan McMurdy’s (in Young-Mason (1997, p 9) account of living with muscular dystrophy:

Other stories within the collection (Young-Mason 1997) are as told by the mother of Raoul, a 27-year-old man with cerebral palsy (pp 18–33), and of Gertrude, aged 11, with a long medical history because of being born prematurely with multiple systems abnormality (pp 35–39). Even though their experiences of illness have included many challenges and struggles, they are able to celebrate their small daily triumphs and offer words of insightful wisdom to health care professionals. For example, Raoul’s mother concluded her account of 27 years of trying to help and educate her son, by writing:

Experiences of illness are central to improving health care. The accounts of people experiencing illness offer nurses deep insights into how it is to be ill and how it is to care for someone you love who is ill. When illness becomes a lifetime experience, it becomes assimilated into daily life and integrates into ordinary human activities. In becoming assimilated, illness loses some of its biomedical objectivity as it infuses into the uncomplicated reality of activities such as unplugging the kitchen sink, peeling the vegetables for dinner and putting out the garbage. The ordinary, everyday lives of people and how they manage illness are instructive for nurses who may espouse to offer healing to patients through holistic caring practices. Experiences of illness are a cornerstone of this text, and you will find that many other chapters offer more insights into what it is like to be ill.