Las siguientes nuevas Normas e Interpretaciones han sido adoptadas en estos estados financieros:

As evidenced from the review of literature the contribution made by Jordanian researchers to the health promotion is limited. The reason the lack of research in this area is not obvious perhaps could be because research in health promotion in Jordan is still a new idea. However, there is an increasing awareness about its importance (Haddad and Umlauf, 1998, Nawafleh et al (2005). Another reason could be associated with the lack of financial resources directed for the support of health promotion research. Thus, the area of health promotion in Jordan needs further research attention. Despite their limitations (see below), few studies (n=2) have explored critical issues about health promotion in nursing. Their methodologies, implications as well as weaknesses are reviewed below.

Many international researchers (McBride, 1994, Furber, 2000, Cross, 2005), Haddad and Umlauf (1998) preferred the questionnaire survey to examine the attitudes of Jordanian nurses and midwives working in primary health care settings. Given this

aim, it was expected that the reviewed literature would include adequate knowledge about health promotion in its broad meaning such as empowerment and political agendas. This unfortunately was not the case. In Haddad and Umlauf ‘s study (1998) the theoretical framework was dominated by health education related issues such as individual to individual teaching. Thus, the topic of health promotion in this study was evaluated in a limited way. In spite of this drawback, there are some interesting findings of relevance to the current research, which are worth comment.

A translated version of nurses’ views of health promotion questionnaire (Littlewood and Parker, 1992) was used. The instrument includes 18 attitudinal items that examine three areas of concern. This consists time constraints among nurses which could prevent them carrying out health promotion activities. The instrument

measures also the responsibility and advocacy to health promotion within the nurses’ role. Respondents were asked to indicate their agreement on a 4 pints Likert scale (Strongly agree to strongly disagree). A panel of four experienced nurses in public health tested its content validity. Some revisions were made to the Arabic version of the instrument but no items were deleted or added. Internal consistency (α=0.78) was computed from the responses of the target sample. Then, it was piloted with a sample of 23 Jordanian nurses. Although the above information is encouraging to use the scale, the review of its content raises some questions. For example one of the items was flawed as it contained more than questions, which would lead to unreliable response as explained below:

“ The physicians/nurses should take responsibility for health promotion” (P:522). The above item is difficult to answer as the respondents could think that nurses should take the responsibility for health promotion but not the physicians or vice versa.

With regard to the instrument validity, it is also limited as the majority of items reflect health education related issues rather than health promotion. Given theses problems inherent in the instrument, the robustness of the study’s conclusions is threatened.

The questionnaire was distributed to a sample of 120 nurses in primary health care settings and has achieved a 95% (n=1140) response rate. However, no information was given about the total numbers of nurses in health care centres and thus

representativeness of the sample is debatable.

The majority of respondents were midwives 59% (n=71) and about one third 28% (n=33) were nurses. However, the number of participants was not equal in the two groups to facilitate a meaningful statistical analysis. The findings were that 50% (n=75) of respondents believed that the lack of time was the main barrier to carrying out health promotion activities. The author suggests that nursing management needs to address this issue.

Undoubtedly, this is an important factor but because of the highly structured

questionnaire focusing only on time constraints, it was not possible to identify other factors. Evidence has shown that not only is the lack of time the main barrier to carry out health promotion activities but also the lack of knowledge, skills and resources (McBride, 1994, Davis, 1995, Furber, 2000, Irvine, 2007). Consequently, whether the former factors are applicable to Jordanian context is open to debate. Moreover, the responses to the item “I do not have time to carry out health promotion” cannot be thoroughly analysed, as no data were available from nurses about the meaning of health promotion. That is, it is not clear what is perceived as health promotion and that needs time to be investigated. Perhaps it would have been better if the

questionnaire was accompanied by qualitative methods (e.g. focus group discussions) in order to offer more breadth data.

Interesting findings were that respondents expressed mixed feelings about whether nurses or physicians were the most appropriate providers of health promotion. A total number of 62 (43%) supported nurses whereas as 42% (n=60) believe that physicians were more appropriate professionals to promote health. Moreover, when the

respondents were asked about whether or no they are willing to teach their clients about health related issues, again the respondents were equally divided. About 51% (n=73) agreed that teaching clients about their health is guilt inducing and victim

blaming whereas as 49% (n=71) did not agree with this. However, the above findings are mixed quantitative data and no conclusive evidence can be drawn to guide nurses’ practice. Indeed, from other items it seems that Jordanian nurses were not sure about whether or not providing patients with health related information is suitable. About two third 62% (n=74) of participants believed that giving

explanations to patients could worry them rather than reassuring them. On the other hand, 93% (n=111) suggested that helping patients to understand how their body works is vital for maintaining good health. It seems therefore that Jordanian nurses’ understanding of health promotion is dominated by the medical model view of health which focuses specifically on the function of the body. This explanation, however, should be taken with care as the questionnaire itself was structured around medical health education activities.

Haddad and Umlauf (1998) concluded that both groups of nurses and midwives felt incompetence in providing health promotion. This conclusion however, lacks credibility as no observational data were obtained about nurses’ ability to carry out health promotion activities. Further, it is not clear if this is related to the education, organisation culture or both.

Indeed, the highly structured questionnaire is not an effective method to evaluate skills (Polit et al, 2001). Thus, it could be suggested that using some observations of actual practices is advantageous. Haddad and Umlauf (1998) did not clearly

recommend that but they assert that nurses’ performance in health promotion needs to be addressed.

To summarise, the study offers vital but limited knowledge and insights into

Jordanian nurses’ attitudes towards health promotion. The study is a decade old now and needs to be replicated with different samples of nurses and methods. This is not only to verify its findings but also to update its evidence in the current growing debate in health promotion. Therefore, the need for more an updated research, including much more complex methods focusing on hospital nurses, is evident.

Whilst the following study has attempted to achieve this by using a multiple methods triangulation strategy, it has focused exclusively on primary health care nurses.

Nawafleh et al (2005) has explored the influence of HIV/AIDS on the practice of primary health care nurses. Whilst the study has focused on disease prevention and control, some emanating findings are of relevance to the current study’s scope. Data were collected by participant observations, in-depth semi-structured interviews and documentary analysis (e.g. nurses’ job descriptions). Six small health care centres were involved in Jordan. The study has focused on emergency nurses, as according to Nawafleh et al, (2005), they “provide direct nursing care” and they are in a good position to prevent HIV/ADS. These departments have included mainly aid nurses (a 1.5 year training nursing programme), practical nurses (a 2 year nursing programme) and registered nurses (a 4 year nursing programme). However, the number of nurses in each group was not given and thus it is not possible to examine the ratio of registered nurses to aid and practical nurses in this work.

Although the exact number of observations was not given, it was stated that, “an intensive period of participant observations were completed”. Observations have focused on the care offered to patients at Accident and Emergency departments and activities involved in preventing possible AIDS infection. The exact number is not clear but it is reported that the internal key informants were interviewed. Whilst further details about the nature of selection procedure was not offered, the authors have personally selected them as “ they have [certain] insights concerning the

observed events. However, from the extracts provided it would appear that those who have been interviewed are either practical or aid nurses. That is, it seems that the in- depth interviews are likely to reflect the insights of those less qualified nurses.

Similarly, in depth semi-structured interviews were also undertaken with external informants. Whilst their numbers were not documented, they were recruited from Nursing Council, Nursing Directorates at Jordanian universities. Data were analysed thematically and validated by “internal informants”. However, the inter-rater

emerged themes is called into question. Importantly, the study has shown that the support structure such as effective nursing leadership and local mentorship were not features of most health care centres. The clinical knowledge and competence was limited and the poor understanding of risk management policy was evident. However, no examination was made to the nature of nurses’ health promotion education. Although no empirical data were obtained from patients themselves, Nawafleh et al, (2005) suggest that their cultural beliefs affect the practice of nursing staff when it comes to control and prevention HIV/AIDS. Poor resources and the lack of education were the main factors affecting nursing practice. Interestingly these factors were reported elsewhere which are likely to prevent the development of nurses’ health promotion role (McBride, 1994, Cross, 2005, Casey, 2007). Whilst the study is contextually limited, it seem that such factors are worldwide contributing to the quality of nursing practice. Nawafleh et al, (2005) concluded that the:

“ability of nurses to raise awareness and therefore their ability to reduce the incidence of HIV/AIDs is currently is unrealistic” (p:205).

Nevertheless, the conclusion is mainly guided by evidence from less qualified nurses as outlined above. Such nurses have been criticised by an external key informant in this study, as “their standard of nursing practice is less than that provided by nurses in other settings” (P:204). Therefore, the study gives very sketchy evidence about the reality of Jordanian registered nurses’ ability to promote health. The central problem in this research is the confusion about how data were collected and linked to the conclusions. However, this highlights the need for a more robust research that might offer clear evidenced based implications for practice, education and research.