Abstract
On 21 November 1986, the World Health Organization formally adopted the Ottawa Charter for Health Promotion, reframing health not merely as the absence of disease but as a resource for everyday life and locating its determinants in the social, economic, and environmental conditions in which people live, work, and age. 1 The fortieth anniversary of the Ottawa Charter prompts some uncomfortable but necessary questions: Has health promotion truly come of age? And has nursing, the largest health workforce in the world, fully embraced the ethical responsibilities this vision demands, or has its ethical centre of gravity remained at the bedside, rather than shifting upstream to the population-level determinants of health? If the twentieth century positioned nurses as custodians of recovery, the twenty-first century increasingly demands that they become custodians of the conditions that make recovery possible. Yet much of nursing practice, education, and institutional recognition still rewards the management of illness more than its prevention. The public as well as politicians readily celebrate the nurse who saves a deteriorating patient in intensive care, while paying far less attention to the nurse who advocates against upstream forces that impact health and its deterioration: unsafe housing, pollution, food insecurity, political neglect, and the escalating health threats posed by climate change and extreme heat.
The moral value of health promotion
These questions matter because health promotion is not ethically neutral. 2 Health is a precondition for human flourishing, social participation, and collective development. The moral value of health promotion therefore lies in expanding people’s real opportunities to live healthy lives, to make informed decisions, and to exercise agency in ways that matter to them and their communities. Illness is rarely distributed randomly; it typically follows patterns related to poverty and housing. Examples of insecurity, such as job loss, environmental degradation like deforestation, discrimination based on race or gender, pandemics, political conflicts, food insecurity affecting families, and instances of unequal access to education and healthcare, illustrate these challenges. To promote health ethically is to confront these structural conditions that continuously thwart human possibilities. A nurse caring for a child repeatedly admitted with bronchial asthma linked to urban pollution is confronting more than an isolated clinical event. A community nurse supporting a patient with uncontrolled diabetes who cannot afford nutritious food is confronting more than ‘noncompliance’. A mental health nurse caring for displaced migrants affected by precarity and unstable housing is engaging not only with illness but also with the social architecture that produces vulnerability.
The ethical challenge is that healthcare systems worldwide often individualise what are fundamentally collective failures. Professionals ask patients to ‘adhere’ while ignoring the determinants that make adherence nearly impossible. Professionals teach lifestyle modification in communities where healthy choices are economically inaccessible and structurally out of reach, often discharging patients back into the very environments that made them sick. Nurses stand at this intersection every day, witnessing how structural injustice becomes biologically embodied. In such situations, nursing ethics cannot focus on competent bedside care alone. It must also account for the social conditions that made these illnesses predictable from the outset, and recognise when social determinants of health become so ethically salient that they shift into what Berwick calls moral determinants of health. 3
Health promotion as nursing’s normative ambition
The International Council of Nurses’ (ICN) Code of Ethics for Nurses identifies the promotion of health as the first of nurses’ four fundamental responsibilities. 4 The 2025 ICN Definition of Nursing and a nurse goes even further, describing nursing as a profession dedicated to ‘upholding everyone’s right to enjoy the highest attainable standard of health’ and one that ‘acts and advocates for people’s equitable access to health and healthcare and safe, sustainable environments’. 5 Health promotion and a public-health orientation are thereby positioned as constitutive of professional identity, not as optional add-ons to bedside care. Yet this is precisely where the discomfort begins. The new definition is rights-based, climate-responsive, and socially conscious, but it collides with a professional reality marked by workforce shortages, unsafe staffing, inequitable migration patterns, and healthcare systems that reward acute intervention more readily than prevention. Nurses are increasingly expected to address climate change, social inequities, and population health challenges while simultaneously struggling under exhausting workloads that leave little room for advocacy or structural engagement. The question, then, is not whether nursing’s self-definition has caught up with the Ottawa Charter 1 – by 2025, it clearly has – but whether the profession’s working conditions, education, and political voice allow nurses to act on it. There is a profound irony here: the profession repeatedly described as the ‘backbone’ of healthcare is too often denied the political, institutional, and economic power necessary to shape the systems it sustains. Nurses are expected to absorb moral distress quietly, to compensate for failing systems through personal sacrifice, and to continue caring even when the conditions for ethical practice are steadily eroded.
Nursing: The backbone of public health – yet strained and vulnerable
The aspirational horizon of nursing’s ethical self-definition has never been wider, yet the material conditions that would allow nurses to enact it remain deeply constrained. Between ‘public’ health and ‘person-based’ health care, Solberg highlights an enduring tension: health systems often swing between population-level priorities and the immediate care needs of individuals. 6 Nursing, however, occupies a unique ethical and practical position at this intersection. Through advocacy, nurses mediate between structural public health goals and the lived realities of individuals, families, and communities. In this sense, nurses do not only deliver care; they translate public health ideals into relational, context-sensitive actions. This mediating role is especially evident when they advocate for health, where they navigate institutional systems, social inequities, and individual vulnerabilities to promote collective well-being and person-centred justice. 7
Part of the challenge is conceptual. Solberg distinguishes between the ethics of public health, which focuses on populations and structural determinants, and the ethics of healthcare, which traditionally centres on individuals, autonomy, and therapeutic relationships. 6 The Ottawa Charter is often interpreted primarily through a public health lens, emphasising policy, prevention, and social transformation beyond the clinic. Solberg, however, argues that empowerment offers a bridge between these domains. Health promotion is not limited to public health campaigns or government policies; it is also enacted within everyday clinical encounters that strengthen individuals’ capacities to understand, decide, and act in relation to their health. 6 This insight is especially important for nursing. Nurses occupy a unique position between systems and individuals, between public health priorities and intimate care relationships. They are often the professionals closest to people’s lived realities. 2 Yet nursing’s ethical imagination has historically been shaped by what Norman Daniels describes as the ethics of ‘identified sufferers’. The immediate and visible suffering of individuals whose faces, names, and stories are known. 8 By contrast, structural health promotion concerns those whose suffering is statistical, dispersed, or prevented before it becomes visible. Never would a nurse be blamed when caring for a patient gasping for breath and evoking immediate moral urgency. However, the thousands whose illnesses could have been prevented through cleaner environments, fairer policies, or stronger social protections remain largely invisible. Healthcare institutions are structurally designed to respond to crises once bodies break down, not to confront the conditions that quietly break them over time. Nursing, perhaps more than any other profession, stands uneasily between these two moral worlds. The ethical pull toward the identified patient is understandably powerful. The patient in pain before the nurse demands urgent attention; the future patient prevented from becoming ill does not. But when nursing ethics becomes confined exclusively to proximal bedside suffering, broader structural injustices risk becoming morally invisible. The result is a profession extraordinarily skilled at responding to illness yet insufficiently empowered to challenge the conditions that produce illness at scale.
Global health and the ethical horizon of nursing
Reclaiming nursing’s ethical role in global health promotion requires more than adding ‘health promotion’ to curricula or policy documents. It calls for a fundamental reorientation of nursing’s ethical horizon from the sharp edge of bedside care toward the wider social, political, and ecological conditions that shape health long before patients enter hospitals. This is not a call to ‘abandon’ bedside care but to recognise it as only one site, although a profoundly important one, for ethical nursing practice. When nurses advocate for healthier housing, equitable healthcare access, food security, climate justice, or safer working environments, they are not stepping outside the boundaries of nursing. They are fulfilling the profession’s deepest ethical commitments. The central question is no longer whether nurses should engage in global health promotion but whether nursing can remain ethically credible if it does not. A profession that witnesses the human consequences of inequality every day cannot ethically remain silent about the structures producing them. The anniversary of the Ottawa Charter, read alongside the ICN’s renewed definition of nursing, offers a timely opportunity to reaffirm that health promotion is not peripheral to nursing ethics, but integral to it. It also demands uncomfortable honesty: this vision will remain rhetorical unless nursing education, regulation, leadership structures, and working conditions are transformed in ways that make structural, political, and ecological engagement not only thinkable but also genuinely possible for nurses on the ground. Otherwise, health promotion risks becoming another aspirational slogan attached to a profession already carrying impossible expectations. For the future, the ethical role of nursing in promoting health may ultimately rely on the profession’s ability and willingness to both responding to human suffering ‘at the bedside' of clinical care and embrace its wider role in shaping the social, global, and planetary conditions that sustain human health.