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Health: A Developing Concept in Nursing
Eman Tariq Alslman, RN, MSN, Muayyad M. Ahmad, RN, PhD, Manar Ali Bani Hani, RN, MSN, and
Huda Mohammad Atiyeh, RN, MSN
Eman Tariq Alslman, RN, MSN, is a PhD student at Faculty of Nursing, The University of Jordan, Amman, Jordan, Muayyad
M. Ahmad, RN, PhD, is a Professor at Faculty of Nursing, The University of Jordan, Amman, Jordan, Manar Ali Bani Hani,
RN, MSN, is a PhD student at Faculty of Nursing, The University of Jordan, Amman, Jordan, and Huda Mohammad Atiyeh,
RN, MSN, is a PhD student at Faculty of Nursing, The University of Jordan, Amman, Jordan
Search terms:
Concept analysis, health, health
measurement, health status,
nursing
Author contact:
eman.yassen@hotmail.com;
Emanyaseen0@gmail.com, with a
copy to the Editor:
journal@nanda.org
PURPOSE: The purpose of this paper is to evaluate the level of maturity of the
concept of health in the nursing discipline.
METHOD: The four principles of Morse and colleagues were used to evaluate the
level of maturity of the health concept—epistemological, logical, pragmatical, and
linguistical.
FINDINGS: This evaluation suggests that the concept of health in nursing is
immature, defined inconsistently, and with different instruments.
CONCLUSION: Health is a central concept for nursing. Additional concept devel-
opment and clarification are needed.
PRACTICE IMPLICATIONS: For the concept of health to be conceptualized, it is
important that nurses have consensus regarding the definition of health. The
nursing discipline should define health in a manner that is consistent with its
philosophical presuppositions. Further, it should be measurable, empirically based,
and capture the outcomes that are sensitive to the nursing interventions.
Introduction
Most concepts in nursing are relatively abstract. So the
multiple dimensions and characteristics of these concepts
should be specified and precise in their meanings (Waltz,
Strickland, & Lenz, 2010). Health is one of the central con-
cepts in nursing discipline (Johansson, Weinehall, &
Emmelin, 2009; Reynolds, 1988). It is one of the nursing
metaparadigms and the basic concept in nursing theories
(Lyon, 2012b).
How health is defined or understood is important for
both health professionals and patients to plan healthcare
interventions and health promotion programs. However,
health concept is considered complex and includes multiple
dimensions (Amzat & Razum, 2014). As a complex concept,
it is more difficult to be consistently defined, and its
operationalization becomes more complex (Waltz et al.,
2010). Concepts can be operationalized at a high level of
pragmatic development of the concept. Thus, the concept
should be relatively well developed and uniformly under-
stood in order to be appropriately operationalized (Penrod
& Hupcey, 2005). Therefore, the purpose of this paper is to
evaluate the maturity level of the concept of health in the
nursing discipline.
Definitions of Health
The World Health Organization’s (WHO’s) definition of
health is the most commonly used and cited definition in the
literature (Awofeso, 2005; Hwu, Coates, & Boore, 2001;
Johansson et al., 2009). The WHO provides a definition of
health that is holistic: “a state of complete physical, mental,
and social well-being, and not merely the absence of disease
and infirmity” (WHO, 1948). The definition includes three
interconnected components of health. First, the physical
component reflects the physiological or biological compo-
nent of the definition. It is used to imply the homoeostasis
maintenance and a soundness of the body. Unhealthy
people can be identified by physical problems that may be
detected by a series of laboratory tests or clinical examina-
tions. Second, the social component represents the behav-
ioral aspect of health. Social health means that a person is
able to participate in the network of social interaction and
fulfill social roles and expectations. Social abnormality can
be determined if the individual is inactive in the social
network and detached from the norms and values of
society. The social component of health also includes the
spiritual dimension. Finally, the mental component indicates
the psychological, emotional, and mental status of the indi-
vidual. Any problem that affects the mental component can
lead to mental illness. Examples of manifestations of mental
illness may include emotional apathy, fixation, and malad-
justed personality (Amzat & Razum, 2014).
On the other hand, medicine has traditionally held the
objective view of health. The biomedical model is the most
popular and widely used view of health in which health is
operationalized as the absence of disease (Lyon, 2012b). In
addition, the most powerful idea is that health is constituted
bs_bs_banner
1© 2015 NANDA International, Inc.
International Journal of Nursing Knowledge Volume ••, No. ••, •• 2015
by physical and mental balance. A person in balance is a
healthy person. That is, the various parts of the human body
and mind and their functions are harmoniously connected
and keep each other in check (Nordenfelt, 2007). Health is
also defined as “a dynamic state of well-being characterized
by a physical and mental potential, which satisfies the
demands of life commensurate with age, culture, and per-
sonal responsibility” (Bircher, 2005, p. 336).
In sociology, health can be defined by different social
groups or by cultural contexts. Also, health is connected
with socioeconomic class (Nettleton, 2006). Health in psy-
chology is not the absence of disease but the physical,
psychological, cultural, economical, and spiritual well-being
(Marks, Evans, & Estacio, 2011).
Health in Nursing Discipline
Prior to 1988, there was little concern about researching
the concept of health in nursing. Health in nursing studies
was most commonly defined as absence of illness, disability,
or symptoms. The multiple dimensions of health, such as
physical, mental, and sociological aspects, were also
ignored (Reynolds, 1988).
In the last several decades, the nursing discipline has
been concerned with the holistic and multidimensional view
of health. In addition, the nature of health is recognized and
accepted to be dynamic and subjective among both
researchers and patients (Hwu et al., 2001). Health profes-
sionals, including nurses, view health as a subjective expe-
rience and multifaceted concept, including physical, mental,
and spiritual dimensions. They also believe that the defini-
tion of health varies according to the individuals, culture,
and context (Johansson et al., 2009). Nurses define health
as absence of disease, living in a good environment, and
social and psychological satisfaction (Shoqirat, 2014).
Examples of definitions of health concept in nursing disci-
pline are included in Table 1.
Methodology
The maturity of a concept means that it should be
“relatively stable and clearly defined, with well-described
characteristics, demarcated boundaries, specified precon-
ditions and outcomes” (Morse, Hupcey, Mitcham, & Lenz,
1996, p. 256). In order to evaluate the maturity level of the
health concept, the four principles of Morse et al. (1996),
epistemological, logical, pragmatical, and linguistical, were
used.
The CINAHL database and Google Scholar were
searched using health, health concept, health status,
concept analysis, health measurement, and nursing key-
words. Searching was limited to full text, English language,
and publication years between 1995 and 2015. If full text
was not available, other databases were searched for the
full-text article. Those databases include Science direct,
SAGE journals, Wiley online library, and Springer. In addi-
tion, related references that were found in the articles were
included. Some nursing articles published before 1995 were
included because they covered valuable information such
as concept analysis, nursing definitions of health, and
instruments used in nursing.
Findings
Epistemological
In this principle, the concept is evaluated by identifying
the clarity and distinction of the definition. Concept should
be defined clearly and differentiated from other concepts
(Penrod & Hupcey, 2005).
In the literature, there was no absolute consensus on
the definitions of health (Amzat & Razum, 2014; Lyon,
2012b). The health concept has a form of vagueness
because it is multidimensional, complex, and sometimes
Table 1. Nursing-Focused Conceptualizations of Health
(Lyon, 2012a)
Author Definition of health
Henderson
(1966)
Health is viewed in terms of a person’s ability
to perform 14 self-care tasks and a quality
of life basic to human functioning.
Peplau (l952,
1988)
Health is defined as forward movement of the
personality that is promoted through
interpersonal processes in the direction of
creative, productive, and constructive
living.
Rogers (1970,
1989)
Health is defined as a value term for which
meaning is determined by culture or the
individual. Positive health symbolizes
wellness.
Orem (1971,
1980, 1995)
Health is defined as a state that is
characterized by soundness or wholeness
of bodily and mental functioning. It includes
physical, psychological, interpersonal, and
social aspects. Well-being is the individual’s
perceived condition of existence.
King (1971, 1981) Health is defined as a dynamic state of the
life cycle; illness is an interference in the
life cycle. Health implies continuous
adaptation to stress.
Neuman (1989) Health is defined as reflected in the level of
wellness.
Parse (1981,
1989)
Health is defined as a lived experience—a
rhythmic process of being and becoming.
Tripp-Reimer
(1984)
Health is defined as encompassing two
dimensions, the etic (objective) and the
emic (subjective), which include both
disease/nondisease and illness/wellness.
Lyon (1990) Health is defined as a person’s subjective
expression of the composite evaluation of
somatic sense of self (how one is feeling)
and functional ability (how one is doing).
The resulting judgment is manifested in the
subjective experience of some degree of
illness or wellness.
Note: Examples of nursing’s definition of health. Adapted from Lyon
(2012b, p. 13) with permission.
Health Concept in Nursing E. T. Alslman et al.
2
intangible (Amzat & Razum, 2014). Health is defined in dif-
ferent ways such as “a value judgment, as an objective
state, as a subjective state, as a continuum from illness to
wellness, and as a utopian state (rarely achievable)” (Lyon,
2012b). Sometimes the definitions contradict each other.
For example, the WHO definition reveals that health is not
merely the absence of disease. In contrast, health is defined
as the absence of disease based on biomedical model of
health (Amzat & Razum, 2014).
Although the WHO’s definition is the most commonly
cited, it has been criticized for many years (Awofeso, 2005;
Huber et al., 2011; Saracci, 1997). The WHO definition is
described as “utopian, inflexible, and unrealistic” (Awofeso,
2005). The word “complete” makes most people, if not all
people, unhealthy most of the time (Awofeso, 2005; Smith,
2008). The definition also makes people with chronic dis-
eases and disabilities unhealthy (Huber et al., 2011).
There is an inconsistency in the definition of health as a
central concept in nursing (Lyon, 2012b). Nursing studies
sometimes used only one dimension, such as physical or
psychological, to define health and others include multiple
dimensions (Hwu et al., 2001). Four concept analyses of
health were found and all were done by nurses (Noughabi,
Alhani, & Piravi, 2013; Sadat Hoseini, Panah, & Alhani, 2014;
Simmons, 1989; Wang, 2005). The concept analysis by
Wang (2005) was in Chinese. Based on the abstract, health
was defined as “a process and outcome that involves sub-
jectivity, individuality, objectivity, culture, dynamics, self-
control, external control, changeability, and development”
(Wang, 2005).
Simmons (1989) identified four themes for health
concept definition. Health was defined as the absence of
disease, as role performance, as adaptation, and as maxi-
mizing human potentials. She also identified two critical
attributes for health. The first is biomedical adaptation,
which includes a dynamic equilibrium among an individual’s
biological, psychological, and sociocultural systems,
“including the capacity to adjust to life events and roles”
(Simmons, 1989, p. 158). The second is self-actualization,
which is defined as the maximizing of the individual’s poten-
tial through goal-directed behavior, reflecting growth, and
reproductive living.
Sadat Hoseini et al. (2014) did a concept analysis of
health based on an Islamic source. Health in Islamic text
viewed as value and includes two main dimensions, physical
and spiritual. Spiritual health is superior over the physical
health and persons can use their intellect to attain spiritual
health. Spiritual health gives the ability to perceive life
events as normal or abnormal.
Noughabi et al. (2013) provided hybrid concept analysis
of health in old people. They concluded that health in old
people includes physical, social, mental, spiritual, familial,
and economical dimensions and the ability to perform
daily life activities that can be measured by medical and
functional approaches. Health in old people is affected
by genetic factors, environment, healthcare services, and
lifestyle.
Logical
In this principle, the concept is evaluated based on its
relation and integration with other concepts. It focuses on
the conceptual boundaries and if the concept overlaps with
other concepts (Penrod & Hupcey, 2005).
Health has many images that reveal the complexity of
the concept. Those images include the opposite of disease,
a balanced state, growth, a functional capacity, goodness of
fit, wholeness, well-being, transcendence, empowerment,
and health as a resource (Arnold & Janssen Breen, 2006).
There are some concepts that contribute to the confu-
sion of health concept such as wellness, well-being, quality
of life (Lyon, 2012b), and happiness (Johansson et al., 2009;
Saracci, 1997). For example, health and wellness are used
interchangeably (Lyon, 2012b); and also the term “well-
being” is used instead of health in some nursing research
(Hwu et al., 2001). Moreover, health professionals describe
that there is a close connection between health, well-being,
and happiness (Johansson et al., 2009). Furthermore,
Saracci (1997) revealed that the term “complete physical,
mental, and social wellbeing” used by the WHO reflects
happiness more than health. That is, any disturbance to
happiness may be construed as a health problem. Other
terminologies that are used interchangeably are health
status, health-related quality of life, functional status, and
frailty (Feeny, Eckstrom, Whitlock, & Perdue, 2013).
Pragmatical
In this principle, the focus is on the applicability and
usefulness of the concept and how it is operationalized
(Penrod & Hupcey, 2005).
How to describe or define health is a central challenge in
deciding on the measurement of health (Chatterji et al.,
2002). The multiple definitions, inconsistency in the defini-
tions, the multidimensionality, and the abstract nature of
the concept are making it difficult, if not impossible, to
clearly operationalize the concept of health (Johansson
et al., 2009; Lyon, 2012b; McDowell, 2006). For instance,
the term complete in the WHO’s definition is not practical
and cannot be measured or operationalized (Jadad &
O’Grady, 2008). The first step to measure health appropri-
ately is to reach an agreement regarding the definition of
health and what is to be measured (McDowell, 2006). There
are many instruments used by clinicians and researchers to
measure health. Nevertheless, consensus has not been
reached regarding which instrument is to be used in
research or clinical settings (Haywood, Garratt, &
Fitzpatrick, 2005). Health is mainly measured by reporting
perceived health because it can examine different dimen-
sions of health. In contrast, objective measures can only
assess one area of health such as level of glucose in blood
(Noughabi et al., 2013).
In nursing research, operational definitions of health were
varied and included one dimension of health (e.g., physical,
psychological or social dimension) or a combination of all
E. T. Alslman et al. Health Concept in Nursing
3
Table 2. Application of Health Concept in Nursing Researches
Author
(year) Title Purpose Target population Conceptual definition of health Operational definition of health
Term used to
reflect health Health dimensions measured
Doumit,
Nasser,
and Hanna
(2014)
Nutritional and health
status among nursing
home residents in
Lebanon: Comparison
across gender in a
national cross sectional
study
Explore the socio-demographic,
health, and nutritional status of
elderly residing in Lebanese
nursing homes (NHs) and
compare these characteristics
across gender.
Elderly people living
in Lebanese NHs
Not explicitly mentioned. Health
was reflected by functional
ability, psychological status, and
social relations.
The Mini Mental State Examination
The Geriatric Depression Rating
Scale
The Activities of Daily Living
Interview (question about
perceived health status and if
they are visiting others or being
visited by others)
Health status Cognitive functioning
(psychological)
Depression (psychological)
Basic functioning tasks (physical)
Perceived health status
Social relations (social)
Leaver
(2014)
Visiting Again? Subjective
well-being of children in
elementary school and
repeated visits to
school health nurses
To compare student reports of
subjective well-being between
children who do and do not
repeatedly visit the school nurse
with vague complaints
Children in grades 4
through 6
School Well-Being Model (school
environment, social
relationships, physical health
status, and means of
self-fulfillment)
School Well-Being Profile (SWBP) Well-being
Health
Health status
Health status (physical)
School environment
(environmental)
Social relationships (social)
School as a means of
self-fulfillment (psychological)
Pawl et al.
(2013)
Sleep loss and its effects
on health of family
caregivers of
individuals with primary
malignant brain tumors
Understanding correlates of sleep
loss and relationships to health
may enable improvement of
health of caregivers of
individuals with primary
malignant brain tumors (PMBTs).
Caregivers of
individuals with
PMBTs
Health is defined as four
dimensions: physical,
cognitive/behavioral, emotional,
and social health.
Serum markers of immune
functioning and the physical
health component of the Medical
Outcomes Study short form
(SF-36)
Fatigue subscale of the SF-36 and
Fox Simple Quality of Life Scale
The Center of Epidemiologic
Studies-Depression scale and
the Functional Assessment of
Chronic Illness Therapy-Spiritual
Well-Being Scale
The Interpersonal Support
Evaluation List and the Work
Limitations Questionnaire
Health Physical
Cognitive/Behavioral
(psychological)
Emotional (psychological)
Social health
Clendon and
Walker
(2013)
The health of nurses aged
over 50 in New Zealand
Examined the characteristics and
experiences of nurses aged over
50 in New Zealand
Nurses in New
Zealand aged over
50
Not explicitly mentioned. Health
was reflected by the ability of
nurse to do usual activities, the
presence of pain or discomforts,
or presence of anxiety or
depression.
The online EQ5D-3L survey Health status
Health-related
quality of life
Usual activities (physical)
Anxiety and depression
(psychological)
Pain and discomfort (physical)
Hørdam,
Sabroe,
Pedersen,
Mejdahl,
and
Søballe
(2010)
Nursing intervention by
telephone interviews of
patients aged over 65
years after total hip
replacement improves
health status: A
randomized clinical trial
Hypothesized that all areas of
health status after total hip
replacement (THR) could be
improved in patients aged 65
years and over by using
telephone support and
counseling
Patients aged over
65 years admitted
to elective THR
Patient’s normal activities in
relation to health issues and
activities of daily living:
well-being, expectations as to
physical function (PF) after
surgery and compared with
those before surgery, physical
symptoms, eating and appetite,
fluid intake, ability to follow
prescribed activity and exercise,
and need of support from family
SF-36 Health
Health status
Dysfunctions and general health
perceptions (physical,
psychological, and social)
Health Concept in Nursing E. T. Alslman et al.
4
dimensions. On the other hand, the spiritual dimension of
health was ignored because it is difficult to measure. Never-
theless, the majority of the health measures used in nursing
were multidimensional. Health concept was measured based
on variety of populations such as adults, adolescents, older
people, families, men, women, caregiver–recipient dyad,
communities, and children. Health was mainly measured
using self-report indicators and self-measurement instru-
ments, and some scales were specific for particular popula-
tions or groups (Hwu et al., 2001); for example, the General
Health Rating Index for children (Post, Kuyvenhoven,
Verheij, de Melker, & Hoes, 1998) and the Duke Older Ameri-
cans Resources and Services Questionnaire (OARS) for older
adults (Fillenbaum, 1988).
In the past, nursing researchers ignored the reliability
and validity of measures that assessed participants’ health
(Reynolds, 1988). The focus on the reliability and validity of
the instruments increased and they became more sophisti-
cated in the last years. Construct validity was the most
widely used method of validity. Factor analysis, convergent
validity, discriminant validity, and concurrent validity were
used. Also, the repeated use of well-established instru-
ments enhanced the validity of the instrument by testing
their application in various settings (Hwu et al., 2001).
Examples of well-established and most widely used
instruments in nursing research include (Hwu et al., 2001):
the Health Perception Questionnaire (Ware, 1976) and its
derivative the General Health Rating Index, Laffrey’s Health
Conception Scale (Laffrey, 1986), and Duke-UNC Health
Profile (Parkerson et al., 1981). However, there are inconsis-
tencies in the operational definitions or tools used in
nursing studies. In addition, more than one instrument is
mainly used in the same nursing study to measure health
(Doumit, Nasser, & Hanna, 2014; Pawl, Lee, Clark, &
Sherwood, 2013). Examples of applications and instruments
used in nursing research are included in Table 2.
Linguistical
In this principle, concept is evaluated if it is appropriately
and consistently used in the context (Penrod & Hupcey,
2005).
Nursing uses the concept of health in the literature to
reflect the perceived health status of the clients (e.g.,
nurses, persons, and patients). It is applied in different con-
texts and in individuals, families, and communities. In addi-
tion, health-related concepts are widely used in nursing
literature. For example, health promotion, health beliefs,
health needs, health care, and health education, etc.
Based on the four criteria mentioned above, health
concept is still immature in both interdisciplinary and
intradisciplinary features.
Discussion
Although there is a large body of literature that
addresses the concept of health, there is no consistency in
the definition and operationalization of health. Health
concept was evaluated based on Morse et al.’s (1996) prin-
ciples of level of maturity of the concept. There was con-
sistency in describing the health concept as dynamic and
subjective and varies according to the context, individuals,
and cultures (Hwu et al., 2001; Johansson et al., 2009; Lyon,
2012b). Nevertheless, health concept was defined using dif-
ferent terminology and definitions. For example, health was
defined as objective state, subjective state, and value (Lyon,
2012b). Health concept is considered as multidimensional,
complex, and difficult to be measured. It was measured
using different instruments based on the population,
context, and the purpose. Therefore, further concept devel-
opment and clarification are needed. Nurses and other
health professionals should work on the definition of health
concept and reach global consistency regarding the con-
ceptualization and operationalization of health. Nurses
should reach consensus regarding the definition of health in
order to be appropriately operationalized. Health in nursing
discipline must be defined in a manner that is consistent
with its philosophical presuppositions, should be measur-
able, empirically based, and capture outcomes that are sen-
sitive to nursing interventions (Lyon, 2012b).
Conclusion
Although health is a central concept in nursing, health is
defined inconsistently in nursing and other disciplines. Addi-
tional concept development and clarification is needed.
Health should be defined in a consistent manner in order to
help nurses and other healthcare professionals provide
healthcare services and interventions. How health is
defined can help the nurse with assessing the patient’s
health and identifying health problems and patient’s needs.
In addition, the nurse will be able to develop nursing diag-
nosis that provides the basis for nursing intervention to
achieve health outcome.
Acknowledgments. This paper was partially funded by the
University of Jordan.
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