International Journal of Nursing Practice 2000; 6: 168–173

INTRODUCTIONA decision to use the Ottawa Charter for Health Promo-tion as a framework for the delivery of nursing serviceswithin an organization specializing in the area of alcohol

and other drugs had its origins in both the national andinternational literature.

International contextIn recent years international emphasis has been placed onthe strategies of the Ottawa Charter as a means by whichhealth for all could be achieved.1 The Ottawa Charteroriginated from the first International Conference onHealth Promotion held in Ottawa, Canada, in November

✠ S C H O L A R L Y P A P E R ✠

The Ottawa Charter—from nursing theory to

practice: Insights from the area of alcohol and

other drugs

Morgan Smith RN, BN, MEDLecturer, Nursing, University of South Australia, Australia

Lynette Cusack RN, BN, MH Admin, MRCNDirector, Nursing and Intervention Services, Drug and Alcohol Services Council, Parkside, South Australia, Australia

Accepted for publication June 1999

Smith M, Cusack L. International Journal of Nursing Practice 2000: 6: 168–173The Ottawa Charter—from nursing theory to practice: Insights from the area of alcohol and other drugs

This article aims to assist nursing services to use the Ottawa Charter as a framework for nursing practice. Incorporationof the Ottawa Charter for Health Promotion into a nursing structure constitutes an innovation in nursing practice thatwas evaluated as a quality improvement exercise in a health-care organization responsible for providing services in thearea of alcohol and other drugs. The evaluation consisted of two stages and sought to identify the degree to which theframework was effective in practice. This involved identifying issues surrounding the implementation of the OttawaCharter as a framework for nursing practice as well as identifying the means by which quality improvements could occur.The evaluation involved an initial questionnaire to all nursing staff, followed by a series of focus groups. The data col-lected was both informative and enlightening and revealed a range of pertinent issues such as staff understanding andinterpretation of the Ottawa Charter, expansion of the nurse’s role and suggestions for organizational change.The OttawaCharter strategies are discussed in relation to their relevance to the organization under evaluation and also expanded intorecommendations to assist those contemplating using the Ottawa Charter as a framework for nursing practice.There wasconsiderable agreement among the respondents that the Ottawa Charter provided a useful framework for nursing prac-tice, but was on occasions problematic.

Key words: alcohol and other drugs nursing, organizational change, Ottawa Charter.

Correspondence: Morgan Smith, Lecturer, University of South Australia,

Division of Health Sciences, School of Nursing and Midwifery,City East

Campus, North Terrace, Adelaide, South Australia 5000, Australia.

Fax: 83022579; Email: morgan.smith@unisa.ed.au

The Ottawa Charter and nursing practice 169

1986 and built on progress made through the Declarationof Primary Health Care at Alma Ata.2 The Ottawa Chartercomprises five key strategies that lay the foundations fora truly international framework.Together these strategiesseek to address the broader determinants of health. Thisis significant because it shifts the focus from the individ-ual, a traditional medical and nursing approach, to onethat considers the individual within the environment.

The five strategies suggested by the Ottawa Charterwere reinforced by the Jakarta Declaration3 as necessaryfor positive long-term changes to the health of popula-tions. The Jakarta declaration3 restates the five OttawaCharter strategies as:

• building healthy public policy;

• creating supportive environments;

• strengthening community action;

• developing personal skills; and

• re-orienting services in the interest of health.These strategies, used in combination, aim to address

factors that affect health and wellbeing at both the indi-vidual and community level. The Ottawa Charter wasdeveloped to address a broad range of health issues, andso it was considered useful in the alcohol and other drugsfield.

National contextIn Australia the Ottawa Charter strategies were acknowl-edged as significant for the management of alcohol andother drug issues by the Australian National Drug Strat-egy.4 The direction of the Australian National Drug Strat-egy 1993 reflects strongly the principles and philosophyof primary health care, and uses the language of theOttawa Charter. The aim of the National Drug Strategywas to minimize the harmful effects of drug use on Aus-tralian society, with a particular emphasis on the OttawaCharter strategy of building healthy public policy acrossall sectors of the community.

A recent review of the Australian National Drug Strat-egy5 confirmed the value of the general direction of theAustralian National Drug Strategy, thus supporting theframework of the Ottawa Charter. Greater emphasis,however, is now placed on the need to build partnershipsacross the health, welfare and education sectors to reduceharms related to alcohol and other drug use.

South Australian contextThese broad national directions, which reflect the OttawaCharter strategies, form the blue print for the goals of the

Drug and Alcohol Services Council of South Australia(DASC).The Drug and Alcohol Services Council’s missionis to prevent and minimize the harm related to alcohol andother drug use through the activities of a range of pro-grams. The organization consists of a number of inde-pendent units/programs across a wide geographical area.While all units/programs follow a corporate plan, theirindividual activities and responsibilities are often differ-ent. Some staff work in relative isolation while others arepart of a small multidisciplinary team.

Given the goals of the Drug and Alcohol ServicesCouncil the senior nurses within the organization devel-oped the Ottawa Charter framework into a model toguide nursing practice in the alcohol and other drug area.This model has been used since 1994 and:

Involves a collaborative and integrated systems approach to

client/community-centred care.The nurse interacts with individuals

and the community to facilitate a supportive environment through

the provision of personal care, education, advocacy and support for

community action.The nurse assists in developing and implement-

ing healthy public policy to minimize the harmful effects of alcohol

and other drugs in the community.6

The means by which this model has been translated intospecific nursing actions is discussed elsewhere.7

Following a period of implementation, and consistentwith best practice principles, the initiative was evaluated.The purposes of the evaluation were to identify issues sur-rounding the use of the Ottawa Charter as a frameworkfor nursing practice and highlight activities that could leadto improvement in the use of this framework. There is alack of literature focused on the use and evaluation of the Ottawa Charter strategies across all areas of nursingservice provision.7Therefore this evaluation is particularlysignificant.

EVALUATION METHODThe evaluation comprised two stages. The first stageinvolved a survey and the second stage a series of focusgroups.A survey method was chosen as it provided oppor-tunities for all staff to voice their opinion anonymously.It also allowed for the collection of a wide range of infor-mation.The focus group approach was chosen so that in-depth information could be obtained about issues raisedin the questionnaire that required greater clarification.Theevaluation method was approved as a quality improvementactivity by senior management.

170 M. Smith and L. Cusack

Stage one was a survey that took the form of a ques-tionnaire using a Likert Scale with provision for qualita-tive comment.The questionnaire sought to identify issuessurrounding the use of the Ottawa Charter as a frameworkfor nursing practice, nurses’ understanding of the OttawaCharter, as well as benefits, problems and barriers toimplementation. A covering letter accompanying thequestionnaire invited staff to participate and emphasizedthat participation was voluntary and anonymous.Attachedto the questionnaire was a tear-off returnable slip invitingnurses to participate in a focus group. Nurses were askedto return the slip independently of the questionnaire ifthey were interested in participating in a group.

Stage two comprised a series of focus groups. Datafrom the questionnaires were used to identify issues thatwarranted further discussion. These issues included theparticipants’ perceptions of staff understanding of theOttawa Charter, expansion of the nurses’ role, use of the Ottawa Charter across departments, organizationalbarriers to change and suggestions for change.

In stage one of the evaluation 71 questionnaires weresent to nurses within the Drug and Alcohol Services

Council. Twenty-nine were returned. Of the nurses who responded, 26 were registered nurses and three wereenrolled nurses. Twenty of the registered nurses whoresponded had tertiary education.

Findings of the questionnaireThe responses to the Likert Scales are summarised in Table 1. No statistical analysis was undertaken because thenumber of responses was less than 30. As stated earlier,qualitative data was collected as part of the questionnaireand in the focus groups. This data is incorporated in thenext section as it adds a depth and richness not providedby the quantitative data alone.

Stage 2 comprised three focus groups that involved atotal of seven nurses. Participation was voluntary and eachgroup discussion was of approximately 2 hours duration.A person who was independent of the organization con-ducted the groups. The discussions were documented and later transcribed by a skilled assistant. Transcriptswere returned to participating staff for comment and revi-sion as necessary.

Table 1 Findings of the questionnaire: Summary of the responses to the Likert Scales

Question Strongly Agree Unsure Disagree Strongly Other

agree disagree

(a) The Ottawa Charter is a useful framework 9 (31%) 17 (59%) 2 (7%) 1 (3%) 0

for my practice/ work in this organisation

(b) The Ottawa Charter has changed the way 3 (10%) 16 (55%) 3 (10%) 3 (10%) 2 (7%) 2 blanks

I approach my practice

(c) The Ottawa Charter has given me an 2 (7%) 14 (48%) 3 (10%) 7 (24%) 1 (3%) 1 ambiguous

opportunity to expand my role 1 blank

(d) The Ottawa Charter is inappropriate for 2 (7%) 1 (3%) 1 (3%) 14 (48%) 11 (38%)

my area of practice

(e) There are many barriers to implementing 1 (3%) 7 (24%) 4 (14%) 14 (48%) 3 (10%)

the Ottawa Charter in my work

(f) The culture of this organisation makes it 2 (7%) 3 (10%) 4 (14%) 16 (55%) 4 (14%)

difficult to use the Ottawa Charter in practice

(g) I have difficulties understanding the 0 1 (3%) 1 (3%) 21 (72%) 6 (21%)

strategies of the Ottawa Charter

(h) The Ottawa Charter is only useful for 0 4 (14%) 2 (7%) 17 (59%) 6 (21%)

specific projects

No statistical analysis was undertaken because the number of responses was less than 30.

The Ottawa Charter and nursing practice 171

ISSUES AND DISCUSSION ARISINGFROM THE EVALUATION

A number of key themes emerged during the evaluation.These themes related to the nurses’ understanding andinterpretation of the Ottawa Charter, enhancement andexpansion of the nursing role and suggestions for organi-zational change.

Understanding and interpretation of theOttawa Charter

The nurses’ depth of knowledge of the strategies of theOttawa Charter. and their ability to transfer this knowl-edge into practice, varied. While responses to the LikertScale indicated that nurses had little difficulty understand-ing the Strategies of the Ottawa Charter, this understand-ing was thrown into some doubt by qualitative comments.Further clarification was sought in focus groups. It becameevident that some nurses indicated a sound theoreticalunderstanding of the Ottawa Charter strategies and theability to apply this knowledge to their practice setting.Other nurses had a sound theoretical understanding butfound it difficult to link the theory to their everyday prac-tice.A small number of nurses lacked understanding of therelevance of the strategies to their practice.

The concepts of the Ottawa Charter are expressed inabstract form. Lack of precedence in the application of thestrategies to nursing practice in the field of alcohol andother drugs often made it difficult for nurses to translatethe concepts into practice.This situation was exacerbatedin programs that were structured to reflect the medicalmodel and the demands of traditional nursing practice.Data from the focus groups, however, indicated acknowl-edgement that the strategies had the potential to broadenthe nurses’ approach to their role.

There was evidence that the Ottawa Charter provideda focus and structure, but qualitative comments from boththe questionnaire and the focus group indicated that it wasmore applicable, and thus better supported, in some areasof the organization than in others. Community outreach,education and training, and project work were perceivedto be areas where the Ottawa Charter strategies could beused most effectively. The relevance for in-patient unitswas less clear.

Qualitative comments from the focus groups in par-ticular indicated that the extent to which the five strate-gies were incorporated into program planning and nursingpractice depended on a number of factors. These werecommitment and values of staff, traditional work prac-

tices, focus of the service area and professional profile ofstaff. In some areas nurses perceived that their non-nursing colleagues did not understand the framework ofthe Ottawa Charter, creating a further barrier to imple-menting changes within their unit/programs.

Some nurses indicated a degree of cynicism, boththrough the questionnaire and later in focus groups.Theyperceived the Ottawa Charter to be a short-term initia-tive that would soon be replaced and thus warranted littleattention. Other nurses considered the Ottawa Charterinterchangeable with a number of other possible modelsof care provision.

The difficulties outlined above are not easily resolved.They have significant implications for organizations utiliz-ing or considering implementing the Ottawa Charter as aframework for nursing practice. Despite the difficulties,staff had many suggestions as to how change could be facilitated.These suggestions are discussed at length under‘strategies for organizational change’.

Enhancement and expansion of thenursing role

Responses to the Likert Scale indicated that for a numberof nurses the Ottawa Charter changed the way theyapproached their practice. Developing knowledge of theOttawa Charter enabled them to advance their role byproviding a broader framework than the traditional task-based approach.

Qualitative data indicated that for many nurses theOttawa Charter enabled them to expand the nursing role in only small ways. For example, nurses had becomeincreasingly aware of the need to network with otherorganizations and some indicated they had been able tovisit other services. This link was beneficial in helping tocreate a supportive environment for clients on discharge.

For some nurses their practice did not change but theframework of the Ottawa Charter enabled them to artic-ulate their current role differently. Nurses placed theircurrent tasks into the thinking of the Ottawa Charter, butfailed to consider avenues for expansion. The nurses’inability to consider avenues for expansion were attrib-uted to an already full workload. During a focus group itwas suggested that:

We have a full unit of clients and it is very demanding work with

backup telephone counselling plus other projects that people do as

well. It is hard to say I need to do this and that, hard to plan.The

workload is unpredictable.

172 M. Smith and L. Cusack

A view was also expressed that role expansion was not feasible because the tight economic environmentrestricted the resources necessary to implement thestrategies effectively.

While it might have been reasonable to expect that theframework of the Ottawa Charter would expand nursingroles, this was generally not the case.Traditional thinking,practices and resource restrictions inhibited the expansionof the nurses’ role.

Suggestions for organizational changeIn qualitative responses to the questionnaire, and duringfocus groups, nursing staff provided many suggestions for organizational change. Suggestions raised through thequestionnaire were put to the focus groups for further discussion. These fell into the categories of staff develop-ment, organizational structure and communication.

Initiatives suggested in the area of staff developmentincluded education for individuals relating to specificstrategies where knowledge was lacking, increased oppor-tunities for discussion about the Ottawa Charter at a unit level and education sessions for members of otherdisciplines.

Initiatives suggested in relation to organization struc-ture included a range of activities to facilitate dischargeplanning consistent with the Ottawa Charter strategiesand the development of quality assurance processes thatreflected the Ottawa Charter strategies.

Initiatives to improve communication across the or-ganization included changes to the content and distribu-tion of the organization’s newsletter and improvements tothe orientation of new staff induction to encompass allareas of the organization. It was suggested that this wouldenable staff to understand better the structure and impli-cations of organizational decision making.

RECOMMENDATIONS TOORGANIZATIONS

The following recommendations have been formulated to assist organizations introducing the Ottawa Charter asa framework for nursing service provision. These recom-mendations relate to staff development, organizationalpractice and communication.

Staff developmentIt is suggested that organizations review current literatureon the Ottawa Charter to determine existing initiatives intheir specific area of service provision. In this way they

develop a greater understanding of how concepts can beutilized within the specific context of a given organiza-tion. As highlighted earlier, theoretical concepts of thiscomplexity are not always readily translated into nursing practice.

Opportunities should be made available to assist nursesto identify their own learning needs in relation to theOttawa Charter. Nurses have different levels of under-standing due to their experience and exposure to the concepts. It is necessary to develop some common under-standing of the strategies for change to be effective at theunit level.

In choosing to adopt the Ottawa Charter as a frame-work for service provision, it is essential to provide oppor-tunities for nursing staff and other health professionals todiscuss the relevance and practical application of OttawaCharter strategies at a departmental level. As the natureof the work within each area may vary, a greater or lesseremphasis on each of the strategies may be required.

Organizational practiceAny genuine attempt to use the Ottawa Charter as aframework for service provision should address the roleand extent of participation of community members andagencies who use or are involved with the organization.The level of community/agency participation and theirrole should be endorsed by the organization and clearlycommunicated to staff.

Nurses may perceive difficulties with community/agency participation through lack of confidence and expe-rience in involving them in organizational planning anddecision making. Staff may have difficulties dealing withcomments they perceive to be negative, or may incor-rectly assume that community members/agencies do notwant to participate. Given this situation, staff will needopportunities to work through their own concerns andissues in a constructive and supportive environment sothat any conflicts that may arise as a result of this processmay be effectively managed.

It is very important to have the Ottawa Charter embed-ded within the organizational or divisional strategic plan.All staff must be clear about the vision and direction ofthe organization. It is necessary to support the strategicdirection with organizationally endorsed policies andguidelines that reflect the Ottawa Charter in practice.These policies and guidelines are used as the foundationfor units/programs to develop their goals, objectives andoperational policies. It is important to recognise that the

The Ottawa Charter and nursing practice 173

actual application of the policies to nursing practice is adifficult and challenging task.

CommunicationEffective communication is particularly important inbringing about the massive changes suggested by theOttawa Charter. It is desirable to increase informationsharing about how the Ottawa Charter is used in all areasof the service. Sharing of ideas across the organizationcould assist individual units/programs to expand theirthinking on ways to translate the Ottawa Charter strat-egies into practice.

The organization should seek to inform serviceproviders, clients, community members and local agen-cies of changes in strategic direction and policies. Adop-tion of the Ottawa Charter strategies may alter existingrelationships with other agencies. Clients and communitymembers must be informed of opportunities for increasedinvolvement. They must also be assisted to develop thenecessary skills to be confident and effective in their con-tribution to improving service delivery.

CONCLUSIONMany of the respondents to the questionnaire and par-ticipants in the focus groups indicated that the OttawaCharter was a good framework for nursing practicealthough some nurses, for a number of reasons, remainedsceptical. More work must be done before the OttawaCharter can be either accepted or rejected conclusively as

a framework for nursing practice. There are indicationsthat it can be used more effectively in some areas, althoughthere are considerable possibilities for the strategies to bestrengthened in all areas.These considerations are impor-tant for organizations planning to use the Ottawa Charteras a framework for nursing practice.

ACKNOWLEDGEMENTSMany nurses within the Drug and Alcohol ServicesCouncil of South Australia contributed to this evaluation,and without their commitment and support the evaluationwould not have been possible.

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World Health 1988; August/September: 16–17.3 World Health Organization. The Jakarta Declaration on

leading health into the 21st century. Health Promotion Interna-

tional 1997; 12: 261–4.4 National Drug Strategy Committee. National Drug Strategic

Plan, 1993–1997. Canberra:Australian Government PrintingService, 1993.

5 Single E, Rohl T.The National Drug Strategy:Mapping the future,

1997.Canberra: Ministerial Council on Drug Strategy, 1997.6 Cusack L. Nursing Services, 1995. Adelaide: Drug and Alcohol

Services Council, 1995.7 Cusack L, Smith M, Byrnes T. Innovations in Community

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