Nurses as Imperfect Role Models for Health Promotion1

Western Journal of Nursing Research 

March 2005, Vol. 27, No. 2 

Western Journal of Nursing Research, 2005, 27(2), 166-183 

10.1177/0193945904270082 

Nurses as Imperfect Role 

Models for Health Promotion 1 

Kathy L. Rush 

Carolyn C. Kee 

Marti Rice 

The purpose of this qualitative study was to discover ways in which nurses describe themselves 

as health-promoting role models. Focus groups and individual interviews were conducted with 

nurses working in a variety of settings. Transcribed interviews were analyzed thematically. 

Nurses defined themselves as role models of health promotion according to the meaning they 

gave the term, their perceptions of societal expectations, and their self-constructed personal and 

professional domains. The term role model evoked diverse interpretations ranging from negative 

perceptions of the idealized image to a humanized, authentic representation. Nurses perceived 

that society expected them as role models to be informational resources and to practice what they 

preached. Nurses defined themselves independently of societal expectations according to personal 

and professional domains. Valuing health, accepting imperfections, and self-reflecting 

were aspects of the personal domain, whereas gaining trust, caring, and partnering were facets 

of the professional domain. 

Keywords: health promotion; nurse; role model; role; qualitative study 

With health promotion at the forefront of health care, the teaching role of 

the nurse is more important than ever. The credibility of nurses as health educators 

is linked to the expectation that they model healthy behaviors, and 

their effectiveness as role models is judged on the basis of observable compliance 

with these behaviors. Using observable indicators of healthy behaviors 

as a gauge for determining whether nurses are adequate role models may 

have negative repercussions. When nurses feel that they do not meet healthpromotion 

role model standards, health teaching may be compromised. For 

Kathy L. Rush, R.N., Ph.D., Professor, Mary Black School of Nursing, University of 

South Carolina Upstate; Carolyn C. Kee, R.N., Ph.D., Professor and Associate Dean, 

Byrdine F. Lewis School of Nursing, Georgia State University; Marti Rice, R.N., Ph.D., 

Associate Professor, Graduate Studies, School of Nursing, University of Alabama at 

Birmingham. 

DOI: 10.1177/0193945904270082 

© 2004 Sage Publications 

166 

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March 2005, Vol. 27, No. 2 167 

example, nursing students and graduate nurses who never or only occasionally 

engaged in teaching patients health-promotion practices were found to 

have low participation rates in self-breast examination, seat belt usage, and 

daily exercise (Valentine & Hadeka, 1986). 

The concept of health promotion has shifted from a sole focus on the 

influence of personal lifestyle practices on health to encompass the effects 

of economic, social, and political forces on health. The notion of using personal 

healthy lifestyle behaviors, the primary basis for determining effectiveness 

as a role model of health promotion, however, persists. The degree 

to which this expanded conception of health determinants affects the ways 

in which nurses regard themselves as role models for health promotion is not 

known. Very few studies were found that focused on nurses and role modeling 

activities for health promotion. 

AN ABBREVIATED HISTORY OF 

HEALTH PROMOTION IN NURSING 

The evolution of health promotion in nursing has paralleled the historical 

development of the concept of health promotion. At one time, nursing was at 

the forefront of the public health movement with pioneers like Lillian Wald 

instituting major changes. Ms. Wald developed the Henry Street Settlement 

in response to the need for a healthier community and went on to influence 

legislation and policy to forge broad health-promotion initiatives (Baldwin, 

1995). With the advent of the biomedical model, the early beginnings of 

nursing in health promotion were redirected from community determinants 

of health to individual lifestyle practices. More recently, nursing has begun 

to reincorporate the idea that healthy individual behaviors are a function of 

interpersonal and societal factors as well as personal ones. 

CONCEPTUALIZATIONS OF THE 

HEALTH-PROMOTING ROLE MODEL 

Conceptions From the Empirical Literature 

The narrow healthy lifestyle conception has been perpetuated in the few 

research studies that have examined nurses as role models for health promotion 

(Callaghan, Kuk Fun, & Ching Yee, 1997; Connolly, Gulanick, 



168 Western Journal of Nursing Research 

Keough, & Holm, 1997; Haughey, Mathewson-Kuhn, & Dittmar, 1992). In 

these studies, inferences about nurses as role models for health promotion 

have been based solely on whether they practice outwardly observable 

healthy behaviors. Nurses’ views of themselves have been consistent with 

this conceptualization. One study reported that critical care nurses felt optimistic 

about being role models for patients, and 70% would recommend 

their lifestyle to patients “because they watch their weight, eat well enough, 

and think that they set a good example” (Connolly et al., 1997, p. 264). Support 

for an expanded conceptualization of what a role model for health promotion 

should be appeared in only one study. Dalton and Swenson (1986) 

found that in addition to practicing good health measures themselves, nurses 

believed role models should also teach health behaviors effectively, be 

knowledgeable, provide good nursing care, and be a practicing nurse. 

Conceptions From the Theoretical Literature 

Expanded conceptions of health-promotion role models have appeared in 

the theoretical literature. These alternative conceptions challenge the prevailing, 

narrow, healthy-lifestyle definition of the health-promotion role 

model. Scott (1996) commented that mandating standardized behaviors in 

the name of professionalism is a violation of personal freedoms and rights. 

Curtin (1986) rejected the position that nurses have a responsibility to be 

role models, because aggressive, condemning, and arrogant attitudes and 

approaches to patients may result. The need for health professionals to be 

facilitators of informed decision making and motivators of behavior change 

through use of their own flaws rather than being perfect role models has also 

been noted (Gobble & Mullen, 1983; Mitic, 1981). Clarke (1991) suggested 

that a subjective, personal dimension that gives attention to who the nurseis 

rather than what she or he does is important for role modeling health promotion. 

An interpersonal dimension has also been presented in the literature 

(Robinson & Hill, 1998). The role model for health promotion has been further 

defined in terms of empowerment and social-political activism (Tones, 

1992; Williams, 1993). 

PURPOSE 

The purpose of this exploratory study was to discover how nurses define 

and describe themselves and other nurses as role models for health promo- 



March 2005, Vol. 27, No. 2 169 

tion. Understanding how nurses conceptualize themselves as role models for 

health promotion is a beginning step in maximizing their influence with clients 

in the promotion of health. 

DESIGN 

To elicit nurses’ views and perspectives about themselves and other 

nurses as role models for health promotion, a qualitative, descriptive design 

was chosen for the study. The use of such a design allowed for maximumvariation 

sampling and in-depth, semistructured interviews. 

SAMPLE 

Maximum-variation sampling was used in this exploratory study so that 

diverse views on role modeling could be obtained (Kuzel, 1992; Maykut & 

Morehouse, 1994). Thus, the sample consisted of registered nurses (RNs) 

working in a variety of professional positions in Eastern Canada. Nurse educators 

and nurses working in community health clinics and traditional institutional 

settings such as acute and rehabilitation settings, public health 

regions, and the federal government were invited to participate because of 

their educational and practice experiences in health promotion. 

To assess nurses’ perceptions of the role model for health promotion, two 

focus-group discussions and four individual interviews were conducted. 

Focus-group participants were sought from (a) nurse educators involved in 

the professional socialization of nursing students who might be expected to 

be role models for health promotion and (b) nurses working in community 

health clinics who were actively involved in health teaching and promotion. 

Nurse educators from the subsidiary branch of a school of nursing affiliated 

with one of the province’s major universities were invited to participate. The 

school offered a bachelor’s of science in nursing program, and all faculty 

members working in the program were invited to participate. This offcampus 

site was selected because the pool of faculty represented variability 

in terms of gender, age, clinical practice expertise, and years of experience 

in nursing education. Nurse educators were recruited for the focus groups 

directly by the researcher through electronic mail communication using an 

information letter explaining the purposes and procedures involved. Those 

interested in participating were asked to respond to the researcher by e-mail. 




Nurses working in community health clinics were recruited for the focus 

groups through a regional clinical nurse specialist (CNS) who served as the 

gatekeeper for accessing this population. The regional CNS served as a liaison, 

manager, supporter, consultant, and coordinator for the widely dispersed, 

community health clinic nurses in her rural health region. The CNS 

distributed an information letter to potential nurse participants who were 

asked to e-mail or telephone the lead researcher if they were interested in 

participating. 

Individuals participating in the individual interviews were handpicked 

for their direct but differing involvement in health promotion. This was done 

to add variability in practice experience and different insights into the concept 

of nurses as health-promotion role models. A total of 11 nurses participated 

in the two focus groups, and 4 nurses participated in the individual 

interviews. All were women with at least 2 years of experience in health 

care. A description of the sample appears in Table 1. 

METHOD 

Approval to conduct the study was obtained from a university institutional 

review board. Two sessions of approximately 1 to 1.5 hours were held 

with the focus groups. Focus-group discussions with the nurse educator 

group took place in a classroom at the school of nursing where the nurse 

educators were employed. The first focus-group discussion with nurses 

from the community clinics took place in a conference room at a centrally 

located regional health office. The second group discussion took place by 

teleconference from one of the local community clinics. 

Initially, only focus-group discussions were planned to obtain a range of 

perspectives. However, as data collection proceeded, it became necessaryto 

conduct individual interviews with key informants representing the larger 

population of nurses to elicit variability in the construct. Even though the 

intent was not to produce consensus, the focus-group participants were so 

well known to one another that they brought similar perspectives to the discussion 

with the result that variability was limited to some extent. Individual 

interviews also allowed for greater depth in eliciting the meaning and 

dimensions than was possible to achieve with focus groups alone. Individual 

interviews were conducted during a single session of 1 to 1.5 hours at a location 

convenient to participants including home, work, or the researcher’s 

office. Immediately following the sessions, the researcher made general 



March 2005, Vol. 27, No. 2 171 

TABLE 1: Description of Sample 

Focus Group Individual 

(N = 11) Interview (N = 4) 

Gender 

Male 0 0 

Female 11 4 

Nursing education 

Diploma/associate’s 5 1 

Bachelor’s 6 2 

Master’s 0 1 

Nursing experience 

2 to 5 years 0 1 

6 to 10 years 0 1 

10 to 15 years 2 1 

16 to 20 years 3 1 

21 to 25 years 6 0 

Focus groups 

Nurse educators 6 — 

Nurses in community health clinics 5 — 

Individual interviews 

Policy development consultant — 1 

Public health nurse educator — 1 

Rehabilitation nurse 1 

Mental health nurse 1 

observations of group and individual interactions and noted individual 

participant’s verbal contributions. 

The focus-group discussions and individual interviews were conducted 

using a semistructured interview guide. Participants were asked initially to 

respond to general questions about “what health promotion meant to them” 

and “how they perceived nurses should role model health promotion.” Next, 

they were asked to talk more specifically about themselves as role models of 

health promotion. Questions elicited the objective (expectations) and subjective 

(meaning) dimensions nurses used to define and describe themselves 

and other nurses as health-promoting role models. All interviews were 

tape-recorded and transcribed verbatim to ensure accuracy and allow subsequent 

data analysis. Confidentiality was maintained by storing tapes in a secure 

place accessible only to the lead researcher, having only one of the researchers 

transcribe the tapes, and using pseudonyms for all transcriptions. 




DATA ANALYSIS 

Data were thematically analyzed following the processes described by 

Knafl and Webster (1988) and Stewart and Shamdasani (1990). Data consisting 

of words, phrases, sentences, or paragraphs used to describe a role 

model for health promotion were compared for similarities and differences 

and coded according to themes. Themes reflecting the range of participants’ 

responses were then compared. Similar themes were grouped into preliminary 

categories that were refined as additional data were collected. To 

ensure that the themes arising from the analysis reflected the participants’ 

descriptions of a health-promoting role model, a follow-up session was held 

with each focus group and individual participants to discuss study findings. 

Trustworthiness 

Evidence of the trustworthiness of the data was obtained by peer examination 

and member checking (Krefting, 1990). Independent coding of 

focus-group discussions by two of the researchers revealed remarkable similarity 

in the emergent themes. Differences were found only in the naming of 

conceptual categories, and these were easily resolved through discussionby 

research team members. Member checking with participants in both focusgroup 

discussions and individual interviews also provided support for the 

credibility of findings. Feedback revealed that participants believed the 

findings reflected what was true for them. 

FINDINGS 

Analysis revealed that nurse participants defined themselves as role models 

for health promotion according to the meaning that they ascribed to the 

term role model, perceptions of societal expectations, and self-constructed 

personal and professional domains. A visual depiction of the major themes 

appears in Table 2. 

Theme 1: Giving Meaning to the Term Role Model 

In defining themselves as role models, nurse participants first gave meaning 

to the term itself. For all of these participants, the words role model con- 



March 2005, Vol. 27, No. 2 173 

jured up an image of the ideal accompanied by expectations for perfection. 

Nurse participants, however, expressed both negative and positive views in 

response to the idealized image of the role model. They could not think 

about the expectations implied in the concept without thinking about how 

they compared with the ideal. The ideal was a mirror participants used to 

look at themselves, and what they saw reflected related to the meaning they 

ascribed to role model. 

Negative and Positive Meaning 

of the Idealized Role Model 

Those who perceived the idealized role model negatively felt threatened 

and uncomfortable by high and lofty expectations. Less-than-perfect selfcomparison 

to the ideal left these nurse participants feeling invalidated as 

role models. This invalidation was expressed as, “I’m doing some of it but 

not all,” and, “To me, the role model is supposed to be almost perfect, which 

we are not.” Falling short of the absolute rendered the ideal invalid. 

The ideal as negative created an undesirable hierarchy by setting nurse 

participants “on a pedestal,” “at a higher level,” “apart,” and “better than.” 

Being positioned at this level created a sense of separation and superiority, 

which was very uncomfortable. Participants felt that the ideal role model 

image imposed “expectations that maybe we’re not going to live up to.” The 

only way to be a role model was to stay on the pedestal, and yet it was so 

easy to fall. To fall off the pedestal was to fail as a role model. 

The idealized role model was additionally seen by some participants to 

create a lack of genuineness by cloaking the nurse in the garb of pretentiousness 

and insincerity. In seeking to uphold the ideal standard, these nurse participants 

saw themselves as playing a role and projecting an image that 

denied the self and humanness. This view was captured by one participant 

who noted, “I don’t like the word [role model], because to me it’s like false. 

It’s like you’re playing a role, this is not really you.” 

The idealized role model was viewed positively by other nurse participants. 

For them, the ideal role model represented a nonthreatening standard 

and an ideal for which to strive. One participant commented, “But without 

models, we’re never going to learn anything that we could possibly strive for 

if we’re not ready to do that there and then.” Other participants described the 

ideal as a source of inspiration and motivation: “I’ve been inspired by seeing 

people look after their own health, so I’d like to be that inspiration, too, for 

other people.” 




TABLE 2: Conceptual Schema Describing the Nurse as a Health-Promoting 

TABLE 2: Role Model 

Theme 1: Giving Meaning to the Term Role Model 

Negative and positive meanings of the idealized role model 

Humanizing the role model of health promotion 

Theme 2: Defining Self According to Society’s Expectations 

Theme 3: Personal and Professional Definitions of Role Modeling 

The personal domain 

Valuing health 

Accepting the self with imperfections 

Engaging in self-reflection 

The professional domain 

Gaining trust 

Caring 

Partnering 

Even though nurse participants who viewed the role model positively 

acknowledged that the ideal did not always represent reality, this did not 

invalidate the ideal. These participants continued to articulate the merit found 

in the ideal despite perceived shortcomings. The ideal was supported even 

while acknowledging personal realities: 

We should role model what health is so that people can see through us what 

health is or what a healthy lifestyle is. I say that. Part of me doesn’t like it, 

because part of me says, “Why should I, I’m a person, too, and if those are my 

vices or if those are my downfalls, then so be it. Those are my weaknesses.” But 

if we are health care professionals, then I think we really need to put our money 

where our mouths are and model healthy lifestyles. 

Humanizing the Role Model of Health Promotion 

Countering the idealized role model were definitions of the healthpromoting 

role model in humanistic terms. Because of their visibility and 

proximity to people who could see them as less than ideal, some nurse participants 

felt more comfortable with defining themselves in terms of being 

imperfect and sharing human struggles. One nurse participant commented, 

Everybody seems to think it is the best model, and yet a role model is that 

maybe we aren’t perfect and we do have the same struggles and frustrations as 



March 2005, Vol. 27, No. 2 175 

everybody else in the public and in the community. And how we cope and manage 

with our health and with our problems is as much a role model as just being 

totally perfect. 

In defining the term role model in humanistic terms, these participants 

described the need to be seen “on the same level” and “equal” with patients, 

not better or above them. Defining the role model as more egalitarian than 

authoritative countered the hierarchy some participants perceived as characterizing 

traditional conceptions of a role model. A more humanistic definition 

of role model also was seen to confer an authenticity that was problematic 

with the idealized role model: 

If you look at Oprah Winfrey, now people love her because she is just like them. 

She’s getting fat again. But everyone is right there with her. They identify with 

her because she is a real person, and I think that’s what we are, too. 

Most participants struggled with giving meaning to role modeling within 

the context of their practice. Not only did these nurse participants use the 

term health promoter interchangeably with role model but wondered if being 

a role model influenced how they promoted health. In their professional practice, 

they acknowledged that they were often health promoters despite being 

imperfect examples of what they were promoting. One nurse captured it in 

the following way: “I mean, I can educate people and be a health promoter 

about a lot of things, and I may not be the perfect example of any of it.” 

For these participants, health promoter rather than role model better 

reflected what they did within the context of practice with their patients: 

I like the word promoter (not role model), because we do promote it. We are 

saying this is the way we should strive to go, again using the word we not you. 

In giving meaning to the term role model, both negative and positive 

images were found. For some, the idealized role model was impossible to 

enact and conveyed a false reality. For others, it represented a goal to aspire 

to. Another perspective conveyed a humanistic but more acceptable reality 

where nurses and patients alike struggled to achieve health-promotion goals. 

Theme 2: Defining Self According to Society’s Expectations 

The second theme encompassed nurses’ definitions of themselves as role 

models for health promotion in terms of societal expectations. Nurse participants 

perceived two societal expectations of themselves as role models: to 




be informational resources and to practice what they preached. Participants 

saw themselves as needing to have a repertoire of health information to be a 

resource to patients. They also felt a need to practice what they taught. 

Defining themselves as informational resources was often associated 

with nurse participants experiencing a sense of being “put on the spot.” 

These participants spoke of being asked questions in informal situations by 

neighbors, friends, or patients that “force us into modeling situations” or 

“create my role as a role model for positive behaviors.” To be an informational 

resource, nurses felt the need to be knowledgeable. 

Self-definitions as role models were further influenced by a belief in a 

societal expectation that they should practice what they preached. In both formal 

situations (e.g., a professional teaching situation) and informal settings 

(e.g., eating out at a restaurant), some participants felt visible and experienced 

a very real pressure to meet the expectations of others. They spoke of 

being watched and receiving clear messages of expectations for them to 

engage in the behaviors they promulgated. For some, these situations were an 

accepted reality, but for others, they created a sense of discomfort by drawing 

attention to the inconsistency between what they taught and what they did: 

I believe it’s [being a role model] like being a preacher in a small town, because 

they watch everything you do whether you want to be watched or not. Look at 

me. I’m not skinny; however, I eat properly if I possibly can and I exercise 

everyday, because if I don’t exercise, [I would get a comment like, “I didn’t see 

you this morning, Jane.”] 

For some nurse participants, societal expectations were demanding and 

uncomfortable. Others, although recognizing societal expectations, did not 

interpret them as behavioral imperatives. 

Theme 3: Personal and Professional 

Definitions of Role Modeling 

In this theme, nurse participants defined themselves as role models for 

health promotion independently of societal expectations. This self-definition 

occurred to varying degrees within or across two interconnected 

domains: personal and professional. Personal self-definition was expressed 

in terms of the individual person distinct from the professional nurse. Professional 

self-definitions were related to participants’ professional practice 

and were targeted toward nurturing a health-promoting relationship with 

patients. 



March 2005, Vol. 27, No. 2 177 

The Personal Domain 

The personal domain encompassed three areas: valuing health, accepting 

the self with imperfections, and engaging in self-reflection. Participants valued 

health for themselves and, in turn, cared for their own health and wellbeing. 

Visible health-related behaviors and practices reflected participants’ 

personal values and beliefs and were grounded in “who I am” or “who we 

are.” As participants cared for their own health, they had the potential to be 

role models in turn: 

It’s not because we’re a nurse that we do those things. I mean, there are lots of 

things we do that we probably shouldn’t do if we were truly exemplifying all 

health-promoting activities. It’s because of who we are and what we believeto 

be important. I think that’s it. It’s not because we’re nurses that we do these 

things, and its not because we have the knowledge. 

Nurse participants who defined themselves in terms of the personal 

domain were comfortable and self-accepting of themselves as role models 

with imperfections. Self-acceptance seemed to come as they shifted from 

being externally controlled by others’expectations to assuming internal control 

of themselves as role models. By setting personal standards, participants 

exercised control of when and how they were role models for health promotion 

and constantly strove to be the best they could be. One participant 

described coming to self-acceptance as a role model with imperfections: 

I feel comfortable being a health-promotion role model. I guess now becauseI 

feel I have a choice. I feel that I can still choose to be a role model; if I choose 

not to, that’s fine. If I choose to go out and have a drink one night and someone 

chooses to say, “Karen, that’s not very healthy,” okay, [I] hear you. That’s cool. 

I’m just not being a role model right now. But I’m okay with that. Are you? So 

I’ve reached that point of being okay that I’m not perfect and I will try to be as 

best I can a role model, but there will be times that I will not emulate good 

health practices. I try. I’m okay if I don’t. 

Nurse participants who self-defined within the personal domain possessed 

a degree of self-reflection and self-awareness about where they were 

and what they wanted to be as role models. 

I’m thinking of when I’m going to Saint John and I’m driving 140 kms an hour. 

Seriously, I’m thinking, “I’m a health promoter and this is not promoting 

health, slow down. This is not promoting my health, your health, or anyone 

else’s health if I ran into someone.” 




Another nurse participant did not define herself in this way and was less 

reflective and self-aware: 

If I was speeding, I wouldn’t think of it in terms of being a role model of health 

promotion. I’d be thinking, “I hope I don’t get a ticket,” but I wouldn’t be thinking 

I wasn’t a role model. 

For this participant, speeding was not linked to promoting health but associated 

with breaking the law. 

The Professional Domain 

Self-definition as a role model for health promotion within the professional 

domain occurred as nurse participants situated themselves within the 

context of their practice. Nurse participants who defined themselves in this 

domain were those who nurtured health-promoting relationships through 

gaining trust, caring, and partnering. 

Gaining trust was critical in nurturing the development of a healthpromoting 

relationship. Participants gained trust by being open and honest 

about their own struggles with promoting personal health and by being 

nonjudgmental about other peoples’ health practices. According to one participant, 

“I think it is seeing us as human beings and not trying to hide that 

but admitting to them, ‘Well, yes, I have done this or I have done that.’” 

Nurse participants also gained trust by being accepting of patients who 

had had repeated failures with incorporating health-related behaviors into 

their lives. As one participant described, “Another thing, they know they can 

fail and we aren’t going to condemn them.” By not blaming the victim or 

conveying impatience and disappointment, a health-promoting relationship 

based on trust was fostered. 

Nurse participants exemplified caring in nurturing, health-promoting 

relationships. Relating and connecting with people on a personal level was 

one way that caring was demonstrated. Through use of their own personal 

experiences, participants reduced professional distance and connected with 

patients and their struggles. In turn, they believed this helped to engage 

patients in health-promoting efforts: 

For me, it’s personal, but in the last year, I’ve made some changes to my lifestyle 

and people have noticed and have commented and how they may try the 

same thing or asking if it made a difference in my health, like how I feel. And 

some students have commented, “I think it’s time for me to do something about 

my lifestyle.” So for me, it’s lifestyle choices. I think I’ve done a little role modeling 

that way. 



March 2005, Vol. 27, No. 2 179 

Nurse participants also exemplified caring by being patient and persevering 

with patients who had difficulty making health-promoting changes. Participants 

were not always able to see visible changes or tangible outcomes of 

their health-promotion work. Despite this, they remained committed to helping 

patients. As one participant reflected, “People come to us and they’ve 

tried 50 times to quit smoking. We may not get there the first time or the second 

time or the third time either.” Nurse participants were attuned to the 

patient’s context and its impact on health-promoting activities and made 

every effort to connect with patients: 

First off, you have to find out who this person is and why they are in this situation 

and what difficulties they had to overcome. . . . Maybe their lifestyle is 

such because they are so poor that all they can afford to buy is macaroni and 

therefore their diet is not that healthy, and it has nothing to do with the fact they 

don’t know what they should eat from Canada’s Food Guide. 

In partnering with patients, nurse participants saw themselves as equals 

and on the same journey of health promotion even while acknowledging that 

they were all at different places in the journey. In guiding patients, participants 

gently and noncritically pointed them in the right direction to make 

health-promoting changes while valuing their experiences and their capacity 

to participate in decision making: 

We need to work in partnership with patients, that we don’t know it all, nor 

should we be the ones that know it all, that the patients have rich experienceto 

share with us. We can just be a guide for them on their journey to healthy 

lifestyles. 

Listening to the needs and priorities of individuals and communities was 

an important component of partnering. As illustrated by one nurse participant, 

I can’t say, “If you don’t breastfeed, you’re the worst mother in the world.” 

You’ve got to let the facts fall and let her come to the decision, and then if she 

does, we have the groups to support her. 

Both personal and professional domains were important components in 

definitions of role modeling. Valuing health, accepting imperfections, and 

self-reflection were aspects of the personal domain, whereas developing 

trust, caring, and partnering were facets of the professional domain. 




LIMITATIONS 

Maximum-variation sampling was used for this study with variability 

sought in nursing practice settings where health promotion was a primary 

focus. The lack of variability in the sample with respect to gender and race 

may limit applicability of the study findings to others. The small sample size 

might be seen as a limitation of this study, although the emergence of recurring 

themes in the data suggests that 15 participants adequately captured the 

various dimensions for describing the health-promotion role model. The 

qualitative criterion of fittingness and transferability requires readers to 

assess applicability to their own personal and professional lives. 

DISCUSSION 

Nurse participants in the current study articulated an expanded conception 

of themselves as role models for health promotion. Their views challenge 

long-standing conceptions of the term role model, reflect diverse 

interpretations, and reject the historical position that nurses have a duty to 

engage in healthy lifestyles (Haughey et al., 1992). Scott (1996) similarly 

rejected the traditional view by arguing that mandating standardized behaviors 

in the name of professionalism is a violation of personal rights and freedoms. 

The view that nurses need to be facilitators in decision making for 

health rather than role models (Mitic, 1981) was alluded to by some study 

participants. These participants often used the term health promoter, which 

some believed more accurately reflected their practice, interchangeably with 

role model. 

Nurse participants in this study redefined the boundaries that have typically 

extended personal lifestyle practices into the professional domain. 

They created distinct and independent personal and professional domains 

and emphasized health-promoting practices as reflecting who they were as 

people, not who they were as nurses. Limiting health-promoting practices to 

the personal domain counters the position that nurses have a professional 

responsibility to model healthy behaviors and supports the idea that a 

nurse’s credibility is based on more than simply practicing healthy lifestyles 

(Borchardt, 2000; Clarke, 1991; Haughey et al., 1992; O’Connor, 2002). 

Nurse participants criticized the ideal standard as creating unrealistic and 

undesirable expectations. Instead, these nurse participants offered a more 

humanized, realistic, and imperfect standard to which patients could more 



March 2005, Vol. 27, No. 2 181 

easily relate. This view of the role model for health promotion reflects the 

position expressed by Gobble and Mullen (1983) that health professionals’ 

flaws can be used to motivate behavior change. Participants also believed 

that relating to patients in a personal and caring way reduced professional 

distance and was influential in prompting patients to make health behavior 

changes. The importance of the relational dimension in health-promoting 

nursing practice has been highlighted in the literature (Clarke, 1991; Falk- 

Rafael, 2001; McWilliam, Spence-Laschinger, & Weston, 1999; Robinson 

& Hill, 1998). In the current study, nurturing the patient-nurse relationship 

was viewed as an essential characteristic of the role model for health promotion. 

Nurse participants in this study believed such a relationship models a 

nontraditional approach to health promotion—one that counters the traditional, 

authoritative, prescriptive approach. Findings in a recent study, noting 

that an enabling nurse-patient model was used by nurse preceptors and 

their students, support this perspective (McWilliam et al., 1999). 

If nurses perceive that they cannot be role models because of selfassessed 

imperfections, health-promoting efforts with patients may be 

adversely affected. When nurses feel invalidated as role models because of 

dissonance between what they practice and what they teach, information 

may be withheld or distorted (Dalton & Swenson, 1986; Swenson, 1991). 

Withholding knowledge and information fails to give patients an important 

resource for promoting personal health and may contribute to poor health 

outcomes. Poor outcomes may also result when nurses have unrealistic 

expectations of others. Nurses who have had personal success in achieving 

the ideal standard and believe others need to reach the same standard must 

be sensitive to the struggles of others and gauge expectations accordingly. 

Conveying to patients that, for the great majority of nurses, healthpromotion 

practices are an ideal to strive for rather than one to be fully realized 

offers a more realistic and balanced approach to role modeling. If 

nurses perceive that limitations in promoting personal health make them 

more believable role models, they can use this to great advantage in teaching 

patients. By offering personal stories about their own challenges with healthpromoting 

practices and by sharing strategies in making health-promoting 

changes, nurses can be powerful in effecting behavior changes. This 

approach may be especially helpful when patient or societal expectations are 

inconsistent with nurses’ self-perceptions. For example, nurses not meeting 

expectations for eating right, exercising, and maintaining a healthy weight 

have the opportunity to relate in a more humanistic way. A different perspective 

is posed by Borchardt (2000) who wrote that nurses who meet 

patient expectations for healthy behaviors place themselves in a position to 




advise with conviction. Such nurse exemplars must heed Curtin’s (1986) 

concern that they not do so in an aggressive, condemning manner. 

Gaining trust, caring, and partnering were integral to nurse participants’ 

self-definitions as role models in the professional domain and formed the 

context within which the nurse-patient health-promoting relationship 

occurred. Acceptance of individual patient foibles as well as their own 

enhanced the effectiveness of these participants in establishing relationships 

that led toward better health outcomes. 

Health promotion does not have to be a quest for perfection. Instead, the 

mutual sharing of difficulties and shortcomings enables the development of 

health-promoting relationships through which both nurses and patients can 

make healthier lifestyle changes. The reciprocity characterizing the nursepatient 

relationship reflects a unique nursing approach to the health-promoting 

role model and captures both the human science of caring and primary 

health care essential to nursing practice. A vision of the ideal role model and 

beliefs in the necessity of perfect lifestyle behaviors can be impedimentsto 

nurses’ effectiveness in health promotion. Having more realistic and 

humanistic expectations provides nurses with an avenue for nurturing 

health-promoting relationships with patients that are more likely to lead to 

better health outcomes. 

NOTE 

1. We wish to thank Georgia State University for the Katherine Suggs Chance Dissertation 

Award, which provided financial support for this study. We are indebted to all the nurses and 

nurse educators who made invaluable contributions to this study. 

REFERENCES 

Baldwin, J. H. (1995). Are we implementing community health promotion in nursing? Public 

Health Nursing, 12, 59-164. 

Borchardt, G. L. (2000). Role models for health promotion: The challenge for nurses. Nursing 

Forum, 35, 29-32. 

Callaghan, P., Kuk Fun, M., & Ching Yee, F. (1997). Hong Kong nurses’ health-related behaviors: 

Implications for nurses’ role in health promotion. Journal of Advanced Nursing, 25, 

1276-1282. 

Clarke, A. C. (1991). Nurses as role models and health educators. Journal of Advanced Nursing, 

16, 1178-1184. 

Connolly, M. A., Gulanick, M., Keough, V., & Holm, K. (1997). Health practices of critical care 

nurses: Are these nurses good role models for patients? American Journal of Critical Care, 6, 

261-266. 



March 2005, Vol. 27, No. 2 183 

Curtin, L. L. (1986). The case of the reluctant role model: From health to heresy. Nursing Management, 

17, 7-8. 

Dalton, J. A., & Swenson, I. (1986). Nurses and smoking: Role modeling and counseling behaviors. 

Oncology Nursing Forum, 13, 45-48. 

Falk-Rafael, A. R. (2001). Empowerment as a process of evolving consciousness: A model of 

empowered caring. Advances in Nursing Science, 24, 1-16. 

Gobble, D., & Mullen, K. (1983). Relationships between wellness role modeling and professional 

training in health education. Health Values: Achieving High Level Wellness, 7, 19-24. 

Haughey, B. P., Mathewson-Kuhn, M. A., & Dittmar, S. S. (1992). Health care of critical care 

nurses: Health practices of critical care nurses. Heart and Lung: The Journal of Critical 

Care, 21, 203-208. 

Knafl, K. S., & Webster, D. C. (1988). Managing and analyzing qualitative data: A description of 

tasks, techniques, and materials. Western Journal of Nursing Research, 10, 195-218. 

Krefting, L. (1990). Rigor in qualitative research: The assessment of trustworthiness. The American 

Journal of Occupational Therapy, 45, 214-222. 

Kuzel, A. J. (1992). Sampling in qualitative inquiry. In B. F. Crabtree & W. L. Miller (Eds.), 

Doing qualitative research (pp. 31-44). Newbury Park, CA: Sage. 

Maykut, P., & Morehouse, R. (1994). Beginning qualitative research: A philosophic and practical 

guide. Washington, DC: Falmer. 

McWilliam, C. L., Spence-Laschinger, H. K., & Weston, W. W. (1999). Health promotion 

amongst nurses and physicians: What is the human experience? American Journal of Health 

Behavior, 23, 95-105. 

Mitic, W. R. (1981). The health educator as a role model. Canadian Association of Health and 

Physical Education Review, 48, 12-14. 

O’Connor, M. (2002). Nurse leader: Heal thyself. Nursing Administration Quarterly, 26, 69-79. 

Robinson, S., & Hill, Y. (1998). The health promoting nurse. Journal of Clinical Nursing, 7, 232- 

238. 

Scott, L. A. (1996). Are health educators socialized to perceive role modeling as a professional 

responsibility? Unpublished master’s thesis, Purdue University, Lafayette, IN. 

Stewart, D. W., & Shamdasani, P. N. (1990). Focus groups: Theory and practice. Newbury Park, 

CA: Sage. 

Swenson, I. (1991). Nurses counseling patients about smoking cessation: Why, when, and how. 

Hospital Topics, 69, 27-29. 

Tones, B. K. (1992). The theory of health promotion: Implications for nursing. In J. W. Barnett & 

J. M. Clark (Eds.), Research in health promotion and nursing (pp. 3-12). London: MacMillan. 

Valentine, A. S., & Hadeka, M. A. (1986). Do nurses practice what they preach? A study of 

nurses’ health behaviors. Vermont Registered Nurse, 52, 3-4. 

Williams, A. (1993). Community health learning experiences and political activism: a model for 

baccalaureate curriculum revolution content. Journal of Nursing Education, 32, 352-356. 



189 

Exercise for Article 27 

Factual Questions 

1. What is the total number of nurses who partici- 

pated in the focus groups? 

2. Did the researchers initially plan to include indi- 

vidual interviews in this study? 

3. Did the nurses in the focus groups know each 

other before participating in this study? 

4. How many of the nurses who participated in the 

focus groups had 21 to 25 years of experience? 

5. What steps did the researchers take to maintain 

confidentiality? 

6. Did the researchers use "member checking" (i.e., 

having participants review the findings of the 

study for credibility)? 

Questions for Discussion 

7. The researchers refer to their study as "explora- 

tory." Do you agree? Why? Why not? (See 

highlighted area #7.) 

8. The researchers used "maximum-variation sam- 

pling" (e.g., using a sample of nurses who are di- 

verse in their backgrounds). Do you think this was 

a good idea? Explain. (See See highlighted area 

#8.) 

9. How important is it to know that the researchers 

conducted "independent coding" of the focus- 

group discussions? Explain. (See See highlighted 

area #9.) 

10. In the Findings section of the report, the research- 

ers provide a number of direct quotations from 

participants. To what extent do the quotations help 

you understand the findings? Is there a sufficient 

number of quotations? (See See highlighted area 

#10.) 

11. Do you consider the small sample size an impor- 

tant limitation of this study? Explain. (See See 

highlighted area #11.) 

12. If you were planning a follow-up study to explore 

the topic of this research further, would you plan 

an additional qualitative study or a quantitative 

study? Explain.

Quality Ratings 

Directions: Indicate your level of agreement with each 

of the following statements by circling a number from 

5 for strongly agree (SA) to 1 for strongly disagree 

(SD). If you believe an item is not applicable to this 

research article, leave it blank. Be prepared to explain 

your ratings. When responding to criteria A and B 

below, keep in mind that brief titles and abstracts are 

conventional in published research. 

A. The title of the article is appropriate. 

SA 5 4 3 2 1 SD 

B. The abstract provides an effective overview of the 

research article. 

SA 5 4 3 2 1 SD 

C. The introduction establishes the importance of the 

study. 

SA 5 4 3 2 1 SD 

D. The literature review establishes the context for 

the study. 

SA 5 4 3 2 1 SD 

E. The research purpose, question, or hypothesis is 

clearly stated. 

SA 5 4 3 2 I SD 

190 

F. The method of sampling is sound. 

SA 5 4 3 2 1 SD 

G. Relevant demographics (for example, age, gender, 

and ethnicity) are described. 

SA 5 4 3 2 1 SD 

H. Measurement procedures are adequate. 

SA 5 4 3 2 1 SD 

I. All procedures have been described in sufficient 

detail to permit a replication of the study. 

SA 5 4 3 2 1 SD 

J. The participants have been adequately protected 

from potential harm. 

SA 5 4 3 2 1 SD 

K. The results are clearly described. 

SA 5 4 3 2 1 SD 

L. The discussion/conclusion is appropriate. 

SA 5 4 3 2 1 SD 

M. Despite any flaws, the report is worthy of publica- 

tion. 

SA 5 4 3 2 1 SD

Nurses as Imperfect Role Models for Health Promotion1

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