N • I • N • E
Building Relationships and Engaging Communities Through Collaboration
Barbara A. Benjamin
One silver bracelet does not make much jingle.
—African proverb
Let us consider this adage when we think community health assessment (CHA). The primary purpose of building relationships and engaging communities through collaboration is to facilitate a dialog to aid in the assessment, planning, action, and evaluation of challenging care-based issues through program design and development. By working with the community, healthcare professionals have the opportunity to collaborate on issues relevant to the community to ensure sustainability and long-term success of community-based programs. This type of collaboration fosters bidirectional communication, understanding, and knowledge in the quest to ensure compassionate, quality, and culturally sensitive interventions.
MATRIX FOR COMMUNITY PRACTICE
Four determinants are especially relevant to this chapter. They are the American Association of Colleges of Nursing (AACN), the Affordable Care Act (ACA), community-based advanced practice registered nurse (APRN) competencies, and the Quad Council Practice Competencies for Public Health Nurses.
American Association of Colleges of Nursing
Elizabeth Lenz (2005), in an article “The Practice Doctorate in Nursing: An Idea Whose Time Has Come,” includes management of care for individuals and populations, administration of nursing and healthcare organizations, and health policy formulation and evaluation in her definition of doctoral-level advanced practice nursing. The practice-focused doctorate is an important alternative to research-focused doctorates in nursing. The choice to use a second approach was based, in part, on a long-standing conceptualization of nursing practice as having two related domains: the direct and the indirect, with the latter defined as activities that are carried out in support of the provision of direct care. Furthermore, Lenz felt that the decision to define nursing practice more inclusively than hands-on care is based on the recognition of the authority and responsibility to make decisions that influence nursing and healthcare. In addition, ultimately, patient outcomes often reside at the system level (e.g., with nursing administrators and policy makers). According to Lenz, there is an increasing need for insightful and visionary nursing leadership in practice; there must be a place at the decision-making table for the nurse. To paraphrase Lenz, the ability to make decisions at the community level requires that the APRN who works in the community (prepared at the doctoral level) be part of the higher level of care management and policy decision making in concert with the community-based consortium of healthcare policy makers. Lenz (2005) states, “It [doctor of nursing practice degree] is increasingly the credential that is needed for credibility in leadership positions” (para. 24).
The AACN (2006) published “The Essentials of Doctoral Education for Advanced Practice Nurses.” According to this document, doctoral programs prepare experts in specialized advanced nursing practice and focus heavily on practice that is innovative and evidenced based. AACN defines advanced nursing practice as “any form of nursing intervention that influences healthcare outcomes for individuals or populations, including the direct care of individual patients, management of care for individuals and populations, administration of nursing and healthcare organizations and the development and implementation of health policy” (AACN, 2006, p. 3). Building relationships and engaging communities through collaborations address these AACN criteria as they incorporate many of the principles suggested by this definition. AACN further states that the Doctor of Nursing Practice (DNP) program prepares the graduate to “[c]onduct a comprehensive and systematic assessment of health and illness parameters in complex situations, incorporating diverse and culturally sensitive approaches” (AACN, 2006, p. 16).
Darlyne Bailey (1992) defines a community-based consortium as “a partnership of organizations and individuals representing consumers, service providers, and local agencies or groups who identify themselves with a particular community, neighborhood, or locale and who unite in an effort to collectively apply their resources to the implementation of a common strategy for the achievement of a common goal within that community” (p. 72). It is necessary for community-based APRNs to know the community and to work with its leaders toward a common healthcare goal when making healthcare decisions at the community level.
In order for the APRN to practice at the level inclusive of all of the particulars described by Lenz, that nurse must know the community. The CHA is the most effective and efficient method used to develop that knowledge. Shuster and Goeppinger (2008) state that “[c]ommunity assessment is one of the three core functions of public health nursing” (p. 351). The objective of a CHA is to determine the healthcare needs of the community and to address those needs by developing a comprehensive plan for the community. The Affordable Care Act includes a mandate for many hospitals to conduct CHAs.
The Affordable Care Act
The Affordable Care Act was passed by Congress and then signed into law by President Barack Obama on March 23, 2010. The purpose of this act is to provide quality, affordable care to all Americans. It reduces what families will have to pay for healthcare by capping out-of-pocket expenses and requiring preventive care to be fully covered without any out-of-pocket expense. Americans without insurance coverage are able to choose the insurance coverage that works best for them (U.S. Department of Health and Human Services, [HHS], 2014a).
The ACA created several additional requirements, one of which is that organizations that operate one or more hospitals seeking to maintain or achieve 501(c)(3) tax-exempt status regularly perform a community needs health assessment. Note: A 501(c)(3) hospital is one that qualifies for exemption from federal income tax as it is organized and operated exclusively as a charitable organization (National Association of County and City Health Officials, 2014).
The Internal Revenue Service (IRS) is responsible for the tax provisions of the ACA that are implemented. The IRS published New Requirements for 501(c)(3) Hospitals Under the Affordable Care Act. IRS Section 501(r)(3) of the New Requirements for 501(c)(3) Hospitals Under the Affordable Care Act requires that hospital organizations conduct a community health needs assessment (CHNA) every 3 years and adopt and implement strategies to meet the community health needs identified through the assessment. The CHNA must take into account input from persons who represent the broad interests of the community/communities served by healthcare facilities, including those with special knowledge of, or expertise in, public health. This document further defines persons who represent the broad interests of the community/communities as (a) persons with special knowledge of or expertise in public health; (b) federal, tribal, regional, state, or local health or other departments or agencies, with current data or other information relevant to the health needs of the community served by the hospital facility; and (c) leaders, representatives, or medically underserved, low-income, and minority populations, and populations with chronic disease needs, in the community served by the hospital facility (Internal Revenue Service, 2014).
Compliance With the Affordable Care Act
In many states, nonprofit hospitals have joined with local health departments to fulfill their requirement to conduct a CHA because health departments are also required to conduct community assessments on a regular basis and have the expertise to do so. In Wake County, North Carolina, the Wake County Health Department (WCHD) joined with WakeMed, Rex, and Duke Raleigh hospitals to comply with the ACA. Involved parties included the resources of the various hospitals, the United Way, the WCHD, Community Care of North Carolina (CCNC), and the local federally qualified health center (FQHC). FQHCs include all organizations receiving grants under Section 330 of the Public Health Service (PHS) Act. FQHCs qualify for enhanced reimbursement from Medicare and Medicaid, as well as other benefits. FQHCs must serve an underserved area or population, offer a sliding-fee scale, provide comprehensive services, have an ongoing quality-assurance program, and have a governing board of directors (U.S. Department of Health and Human Services, Health Resources and Services Administration, 2014b). The WCHD led the process as they had experience doing CHAs. Data were gathered using focus groups and surveys. A full report was generated and a priority list of care needs of the community was generated. Sue Lynn Ledford, division director of WCHD stated, “We cannot treat the patient until we have the chart; so, as the community is the patient, we must triage the issues of concern that are bleeding out first in order to treat the community” (S. L. Ledford, personal communication, June 2014).
Often, in more rural areas the assessment is regional. In one such instance in western North Carolina, a regional collaboration was involved in an area assessment. The Western North Carolina Network (WNCN) collaborated with the local not-for-profit hospitals to do an area wide assessment, thereby pooling resources for the assessment. A steering committee that included the WNCN and the hospitals was formed to determine strategies for working together and methodologies for data collection. The data were collected using a random sample telephone survey across the counties. Health issues requiring intervention by both the hospitals and the WNCN were prioritized and addressed (H. K. Gates, personal communication, July 2014).
Health departments and hospital professionals have the opportunity to collaborate on health issues relevant to the community to ensure sustainability and long-term success of both hospital- and community-based programs. This type of collaboration fosters building relationships and engaging communities through collaborations, thus ensuring relevant, quality, and culturally sensitive interventions. Collaboration also facilitates compliance with the IRS New Requirements for 501(c)(3) hospitals under the Affordable Care Act.
Competencies Related to APRN Practice in Public/Community Health
The National Clinical Nurse Specialist Competency Task Force met at the American Nurses Association (ANA) headquarters in May 2008. Their charge was to develop a set of competencies for the clinical nurse specialist (CNS) on identified and valued behaviors. By the end of the meeting, the task force achieved the final listing of eight core competencies and the behaviors needed to accomplish each competency; these competencies and their behaviors were accepted and published. The eight competencies are (a) direct care, (b) consultation, (c) systems leadership, (d) collaboration, (e) coaching, (f) research, (g) evaluation of clinical practice, and (h) ethical decision making. Each competency contains a clarification and behavior statements (National Association of Clinical Nurse Specialists, National CNS Competency Task Force, 2013).
APRNs utilize every competency in this list; however, the collaboration competency is especially valuable. This competency provides a matrix for the establishment of relationships within and across all aspects of the CHA, including data collection, planning, delivery of care, and outcomes evaluation. One of the behavioral statements is “Provides leadership in promoting interdisciplinary collaboration to implement outcome-focused patient care programs meeting the clinical needs of patents, families, groups, and communities” (National Association of Clinical Nurse Specialists, National CNS Competency Task Force, 2013, C.6). Within the community we can conceptualize collegiality to include hospitals, health departments, religious congregations, community leaders, strategic services, focus groups, and any other aggregate group within the community.
Another competency that has especially strong meaning to the APRN within the community is the research competency. According to Bruce Leonard (2010), participatory research is one way to empower communities. He suggests that this approach can be carried out through collaboration between healthcare professionals and community leaders; thus, these two competencies are especially relevant to the CHA.
Quad Council of Public Health Nursing Organizations Practice Competencies for Public Health Nurses
Although the CNS core competencies are relevant to all APRNs, they are especially relevant to the APRN practicing in the community (K. Qureshi, personal communication, July 2014). The Quad Council of Public Health Nursing Organizations (Quad Council) is a coalition of four nursing organizations with a focus on public health nursing. Its competencies are based on a set of competencies developed by the Council on Linkages for public health professionals that were developed in 2011. The goal of the council was to ensure that public health nursing fits into the domain of public health science and practice (Quad Council of Public Health Nursing Organizations, 2011).
The Quad Council competencies are defined as observable and measurable knowledge and performance indicators that contribute to improving population health. These competencies ensure that public health practitioners achieve a certain level of competence in their practice to both safeguard the public and enhance practitioners’ effectiveness at achieving optimal population health outcomes (The Quad Council of Public Health Nursing Organizations, 2011).
The Quad Council lists eight practice domains for public health nursing: (a) analytic and assessment skills, (b) policy development/program planning skills, (c) communication skills, (d) cultural competency skills, (e) community dimensions of practice skills, (f) public health science skills, (g) financial management and planning skills, and (h) leadership and systems thinking skills. Each domain has multiple applications attached that interpret the domain. These domains are divided into tiers; each tier has implications for a level of practice in public health nursing. Tier 1 applies to the generalist, and tier 2 applies to the APRN with an array of responsibilities such as supervisory or program implementation. Tier 3 applies to PHNs (public health nurses) at an executive or leadership position in public health organizations (The Quad Council of Public Health Nursing Organizations, 2011). A copy of the competencies can be found on the Quad Council’s website (quadcouncilphn.org/).
The work of the AACN, National CNS Competency Task Force, and Quad Council provides a comprehensive foundation for APRN practice in population-based nursing. In order to build relationships with communities and to be successful in population health endeavors, APRNs require skills in leadership, management, research, and policy making. Through interdisciplinary teamwork and by collaborating with community leaders and other aggregate groups within the community, APRNs can engage communities in activities to improve health outcomes.
IDENTIFYING COMMUNITY NEEDS
Why Assess the Community?
Community assessment and analysis is a cornerstone of effective care and is the first step in community practice. There is an essential incentive for conducting a community assessment. A thorough assessment should identify the community needs by recognizing the diversity of the community and understanding the community’s goals and listening to its priorities. Assessment can help to identify what works and what does not work and can help to address perceived advantages and disadvantages by both parties, thus meeting the needs of that community.
Any plan to meet the needs of the community that is derived from a CHA may truly be considered an evidence-based practice plan. According to the Centers for Disease Control and Prevention (CDC), addressing health improvement is a shared responsibility of federal, state, and local governments, policy makers, business, healthcare providers, professionals, educators, community leaders, and the American public (Centers for Disease Control and Prevention, 2014a). Therefore, if health improvement is the goal, all segments of the community must be involved in a CHS. It must be a collaborative effort.
A CHA may focus on a community as defined by its geopolitical boundaries (e.g., towns, cities, counties) or on a defined population or an aggregate of a community. Aggregates are subpopulations within the larger population, a collection of individuals having one or more characteristics in common (Stanhope & Lancaster, 2013). CHAs are most often conducted for geographical communities. These assessments can be used to identify populations that need more intensive study of specific problems that require an aggregate assessment. A comprehensive community assessment addresses the characteristics of the community’s physical environment, infrastructure, and population characteristics. It is through this type of assessment that the APRN can begin to identify the strengths and weaknesses of a community. This information will be required when the time comes to work with community members to achieve mutually agreed-upon goals for improvement in targeted outcomes.
Conducting the Assessment
The APRN who works in the community in collaboration with the principal players in the healthcare environment of the community has many options when deciding what method is best to use for the community that is being assessed. Assessment can be done by any number of methodologies and can include assessment tools, surveys, focus groups, and windshield surveys. Information found in online databases and on websites (an excellent way to begin is by accessing county and municipal home pages on the Internet) is an invaluable resource for every community-based APRN. Online databases can provide a plethora of information, including, but not limited to, the following:
FIGURE 9.1 • Symphony Used to Achieve a Comprehensive Community Assessment
Graphic Courtesy of Ariel Adams (2011).
• Geographical composition of the community
• Vital statistics such as births, deaths
• Morbidity, mortality, communicable diseases
• Housing, migration, population density
• Education, employment
• Marriages, divorces, adoptions
• Health services provided
• Insurance companies, accidents, police, and fire reports
The experienced APRN will use a combination of methods to conduct an evidence-based CHA. Using research from online resources, as well as a combination of quantitative methods (e.g., searching databases), or qualitative methods (e.g., focus groups and surveys), the APRN can accomplish a fuller, richer, more powerful CHA (see Figure 9.1) (Hanchett, 1988).
No one should attempt to assess a community alone. The APRN should involve many people in the assessment because all stakeholders within a community have something to offer. The APRN who can mobilize an interdisciplinary team of administrators, policy makers, and members in public service, such as police and fire departments, educational facilities, and health departments, will have diverse resources of knowledge to access for a CHA. And by working together on the assessment, the initial steps taken toward an early collaboration will improve the chances of achieving targeted outcomes (AACN, Task Force on the Clinical Doctorate, 2004).
During the analysis and evaluation phase of the assessment data, the APRN may discover that further information is needed. The scope of the data collected may be large but certain parts may be missing. For example, if the APRN is interested in childhood obesity and needs more information on the scope of the problem in the community, it may be essential to assemble a group of parents within the community to better assess the problem. This subgroup of the population can meet using an open discussion methodology, in which the parents discuss their concerns about childhood obesity in their own community. Qualitative information derived from community members can be as valuable as, or in some cases more valuable than, quantitative information. An additional benefit is by allowing parents to derive their own conclusions about the root of the problem, this may yield a significant amount of insight into this community’s values and needs. This may also lead parents to consider solutions that work best for their own family and communities, which is more likely to ensure long-term buy in and success.
Assessment Tools
Most community health textbooks contain examples of CHA tools. Angeline Bushy, in her textbook Orientation to Nursing in the Rural Community (2000), details a comprehensive plan for a CHA, inclusive of phases of assessment with objectives and activities for completion of the assessment. Bushy’s community assessment design emphasizes the importance of forming community partnerships and using and understanding community data as well as evaluating the outcomes of the community health plan.
For the process phase, she lists the types of assessment as well as primary and secondary sources. She stresses the importance of engaging partners in the CHA process and having the community take responsibility for planning, implementing, and evaluating the action plans that are developed to deal with the community’s health-related concerns. For Bushy, the CHA goes well beyond collecting data. Importance is placed on bringing communities together to solve local problems (Bushy, 2000).
For three decades, the Healthy People initiative has provided a comprehensive set of national 10-year health-promotion and disease prevention objectives aimed at improving the health of all Americans (see Chapter 2 for more background). It is grounded on the notion that establishing objectives and providing benchmarks to track and monitor progress over time can motivate, guide, and focus action. Healthy People 2020 will continue in the tradition of its predecessors to define the vision and strategy for building a healthier nation with a focus on reducing disparities. According to Healthy People 2020, the determinants of health are individual biology and behavior, physical and social environments, policies and interventions, and access to quality healthcare. These determinants have a profound effect on the health of individuals, communities, and the nation. An evaluation of these determinants is an important part of developing any strategy to improve health (U.S. Department of Health and Human Services, 2008).
In their text Public Health Nursing: Practicing Population-Based Care (2012), Truglio-Londrigan and Lewenson used a systematic approach to design the Public Health Nurse Assessment Tool (PHNAT). The PHNAT is thorough and inclusive. The authors feel that their tool provides a systematic method for community assessment and “offers a kaleidoscope way to view the individual, family, community system and population.” The authors further suggest that the use of the online versions of their tool “further facilitates the use of this tool because it can be more easily manipulated and implemented in that format” (Truglio-Londrigan & Lewenson, 2012, p. 56).
Healthy People 2020 updates this concept to include “a feedback loop of intervention, assessment, and dissemination of evidence and best practices that would enable achievement of Healthy People 2020 goals” (U.S. Department of Health and Human Services, 2008, p. 7). This updated model adds monitoring and evaluation to the graphic. Assessment is considered by both the nursing profession and Healthy People 2020 to be the cornerstone of effective care. Collaboration was also considered invaluable in the development of this action model (Figure 9.2) “The Healthy People process is inclusive; and its strength is directly tied to collaboration” (CDC, 2014b, Strength in Collaboration section, para. 1). This assessment tool, similar to the others mentioned earlier, stresses community collaboration as necessary for a successful community assessment.
ASSESSMENT METHODOLOGIES
Focus Groups
CHA can be enhanced through the use of focus groups. Through the focus-group format, community members can provide inputs about what they feel their community needs. Sometimes, specific stakeholders in a community, such as members of government, designees from police or fire departments, clergy, and representatives from senior or youth groups, form the focus group. More often the focus groups are open meetings to which all members of a community are invited. Several community destinations, such as churches or public libraries, provide appropriate settings, and a variety of meeting times optimize the opportunities for community members to participate.
FIGURE 9.2 • Action Model to Achieve Healthy People 2020. Overarching Goals
Source: HHS (2008, p. 7).
A focus group should have a well-prepared moderator to lead the group. The moderator should guide the group so that it does not stray from the issues or topics being addressed, and the moderator should ask explicit questions that are specifically worded to elicit public input. Without an experienced moderator, focus can be lost and the discussion may become tangential and too diffuse to extract useful information. An experienced moderator can actually prompt or cue the members in a way that elicits innovative and constructive ideas with creative solutions. It may be helpful to record meetings to avoid missing any thoughts and ideas or nuances from the discussion. During focus-group discussions, it can sometimes become apparent that the project that has been targeted by the APRN may not be important to, or a high priority for the community; this often leads to a change in project focus, which should not be considered a negative outcome of a focus group but a success, as it is important for the community to buy into the project in order to have long-term sustainability. It is appropriate for community members to prioritize their needs.
Butler, Dephelps, and Howell (1995) suggest that selective community members who have relevant knowledge can provide the needed information through a focus-group approach. Focus-group leaders should be selected from the community. Often pastors of community churches, members of service groups, such as the Rotary Club or the Elks, or local politicians are asked to lead focus groups as they have some experience leading groups and can relate to community members. These leaders can be schooled in the topic of the focus group, and the outcomes of the discussions will be productive.
Surveys
Surveys form an excellent matrix for the collection of information about a population. In a CHA survey, questions are usually asked of a sample of the community’s population, and the responses generate information that is either numeric (quantitative) or written (qualitative) about the topics under examination. Surveys can be distributed to community members via face-to-face interaction, e-mail, telephone, and/or mail. They can also be distributed through schools and churches, and in some cases through the local newspaper. An excellent site for survey development is SurveyMonkey (www.surveymonkey.com).
Lundy and Janes (2009), in their text Community Health Nursing: Caring for the Public’s Health, discuss the use of a survey to discover the rates of drug use among long-haul truck drivers and the influence of the drugs on truck accidents and fatigue. Thirty-five truck drivers were surveyed at truck stops and loading facilities across cities and towns in Queensland, Australia. Truck drivers reported high rates of usage of prescription medications, over-the-counter drugs, and amphetamines. They also reported that they were motivated to use drugs because of peer pressure, socialization, and the need for relaxation, in addition to wanting to fit the image of a truck driver. The data collected through the survey identified those social factors that must be considered when developing drug prevention and treatment programs for truck drivers. This is an example of how surveys can be useful for describing the characteristics of a population. Surveys, however, are not useful when trying to establish a cause-and-effect relationship. In this case, there are three potential variables—peer pressure, socialization, and the need for relaxation—that cannot be easily controlled. If an APRN wants to explore how these variables may be related to drug usage among truck drivers, a literature review may be performed. If no relationship is evident in the literature, additional studies may need to be designed to establish the impact of these variables on drug usage among truck drivers. Regardless, the use of surveys can establish a pattern of behaviors and attitudes that may need to be addressed in the assessment phase. By carefully reviewing the literature and history of similar population-based interventions, the experienced APRN can approach this problem with evidence-based solutions or establish new solutions using the information obtained in the assessment.
Windshield Survey
A windshield survey refers to that information that can be obtained about a community by driving through it. It is an excellent tool for getting an overall feel or impression of a community. The APRN can use a windshield survey to view the amount of open space, the number and types of retail stores and commercial developments, and the type and condition of housing in a community. Walking through the community can yield similar results (Stanhope & Lancaster, 2013). The PHNAT tool of Truglio-Londrigan and Lewenson (2012) is useful when conducting a windshield survey as it provides a comprehensive matrix for describing the physical environment of the community.
One CHA windshield survey that undergraduate students conducted in a small industrial town revealed a large number of taverns. On visiting the taverns, the students discovered that many of the men who patronized them smoked cigarettes. They learned that it was the usual custom for the men in this community to stop at these places on their way home after work in the local industries to enjoy some socialization. A review of local health department data also revealed a high incidence of oral cancer in this town. This is an example of how a windshield survey, combined with health-related data, can be used to identify potential areas for intervention in a community. The interventions that ensued included an oral screening clinic and a smoking-cessation program that targeted the tavern patrons.
Internet Sites
The CHA is further enhanced when data are collected from a variety of sources. Essential #3 of the AACN Position Statement on the Practice Doctorate in Nursing (2004) states that graduates of DNP programs should be able to use information technology and research methods to collect appropriate and accurate data to generate evidence for nursing. A comprehensive discussion for locating population data is presented in Chapter 2 of this text.
Census Data
As required by the U.S. Constitution, the U.S. Census Bureau conducts a census of the entire population every 10 years. Although basic data are collected on everyone, a selected sample of the population is surveyed in greater detail using the “long form.” This extensive form gathers more detailed information about the population such as income, housing, employment, language spoken, ancestry, education, poverty, monthly rent/mortgage, commute to work, and so on. The census data provide a plethora of community characteristics (e.g., age, sex, race, education, employment, income) and better describe the makeup of communities. The information gathered is compiled and analyzed and reported to the nation. It should be noted that low-income and migratory populations are often underrepresented in the data. Ervin (2001) writes that the importance of census data as a source of information is invaluable. She notes that the census is a rich source of information and can provide details that will help identify important community characteristics (e.g., culture, socioeconomic characteristics). Census information is available at www.census.gov.
Health Department Vital Statistics
Vital statistics are an excellent source of information about a community and are easily obtainable. Although considered “dry” by many community assessors, data on births, deaths, marriages, and divorces are vital statistics within a community and are collected on an ongoing basis. There is also a wide spectrum of quantitative information on populations available on the Internet. Information from health departments, in combination with information gleaned from other sources such as surveys or focus groups, provides solid data for the development of specific interventions (e.g., high mortality rates due to breast cancer in a community might suggest the need for an increase in breast screening and improved access to mammography) (Ervin, 2001). This information is also useful for comparing data before and after interventions to determine whether a community intervention is successful (Ervin, 2001). As described in an earlier example, college students combined data from a windshield survey, discussions with residents, and morbidity statistics. By combining quantitative data from databases with more personal and qualitative CHA methods, the students were able to capture a more comprehensive view of the community and able to better identify community needs.
Disease Reports
The CDC publishes the Morbidity and Mortality Weekly Report (www.cdc.gov). The APRN may want to subscribe to this free publication. The data within these reports are often not available elsewhere and can be invaluable sources of health information. Morbidity and mortality data are also available from the HHS and CDC websites. Information on notifiable diseases and specific topics, such as registries, adverse drug reactions, injury surveillance, occupational health, and birth defects, is available from these two government agencies. Most of this information is useful for an APRN’s community assessment and is provided at little or no cost. It can also help the APRN generate new and innovative ideas in survey design or development of a focus-group questionnaire.
BUILDING RELATIONSHIPS
Collaboration: Community Partnership
Although one musical note may have no meaning, add a few notes and then a few more and it becomes a melody that can be sung and enjoyed. A community is made of many people, and the APRN must have a comprehensive understanding of those people in order to build a trusting relationship. Understanding a community’s culture is essential to program success.
Traditionally, a “community” has been defined as a group of interacting people living in a common location. The word is often used to refer to a group that is organized around common values and is attributed with social cohesion within a shared geographical location, generally in social units larger than a household. The word community is derived from the Old French communite, which is derived from the Latin communitas (cum, “with/together” + munus, “gift”), a broad term for fellowship or organized society (Editors of The American Heritage Dictionaries, 2002); For more information on defining populations and subgroups, refer to Chapter 1.
Community involvement is the foundation of a successful CHA. The members of the community, including the people, the government, the health department, the churches, the local businesses, to name a few, all need to be involved. Who are the leaders in the community? Who are the people who are respected and trusted and can engage community members? This is not always a political leader but can be a church member, a parent, a community advocate, and so on. Many communities do not have an inherent trust in “outsiders” who come into their community. There may be a history of people who have started programs only to leave without providing community members with the tools (financial or otherwise) to sustain programs after they are gone. The APRN will have the most success in building programs by working with and being guided by a trusted member of the community than by starting programs without first seeking the input and trust of the community.
It is also imperative that communities are not viewed as having a “problem” that needs to be fixed. Communities want to feel they are productive and cohesive and do not want someone to tell them how to fix their problems. They want partnership and understanding of who they are and what they stand for. When approaching a community, it is essential that you identify the community’s strengths and weaknesses. By knowing the strengths, you can establish more trust from community members because they do not want to be defined only by their problems. This mutual understanding can build trust and cooperation. It requires listening by both parties and should provide the community and its members with the tools to sustain programs on their own. A sense of independence and self-sufficiency is important for long-term success. This is the ultimate form of involvement. Education and learning should be bidirectional. APRN partnerships should be built on trust, cooperation, and communication. Methodologies for using data to improve healthcare in the community are presented in Chapters 6, 7, and 10.
Building Relationships and Engaging Communities Through Collaboration: An Example
The concept of community collaboration can be illustrated by using an example taken from Lee County, North Carolina. As has been discussed earlier, there are many methods for creating a community profile. In Lee County, a CHA was implemented using a survey. First, a general overview of the community was ascertained by using a combination of geographical information and vital statistics. Lee County is located in the geographical center of the state, covering 259 square miles, and it is one of the smallest counties in North Carolina. The county comprises eight townships and has had a population increase of 13.2% since April 2000. It continues to grow at a steady rate. According to the U.S. Census, the 2005 population of Lee County was 55,704. The per capita income, although slightly lower than the North Carolina average, has been increasing since 2000. Lee County has maintained an unemployment rate slightly higher than the rest of the state since 2000. Employment opportunities are a concern among all groups, especially Hispanics. This collection of vital statistics from the U.S. Census provided a snapshot of the strengths of the community, as well as some areas that could be targeted for intervention. To create a truly comprehensive CHA (a variety of methodologies were needed to fully assess and address the community’s needs), a task force was created.
The CHA Task Force
The lead in this CHA was a task force composed of the members of the Health Department, the supervisor of school nurses for Lee County, and the members of the Healthy Carolinians Partnership in Lee County, known as the Community Action Network (LeeCAN). The LeeCAN is a partnership with representation from government agencies, civic groups, citizen groups, and members from the faith-based communities. The mission of the LeeCAN is “to increase awareness and resources to effectively address health and safety issues in Lee County through a collaborative community effort” (S. Oates, personal communication, September 2010).
Lee County
To ensure adequate community participation, primary data for the CHA were collected using a community survey that was distributed and made available in a variety of modalities: online, paper/pencil, local newspaper, and through “open house” and “community forum”-type events. Local churches, volunteer fire departments, and local businesses also distributed information about the survey.
Members of the CHA team first looked for an appropriate instrument for collecting information. A CHA should measure the variables of interest consistently, dependably, and accurately. The survey selected was originally used in three other North Carolina counties—Montgomery, Moore, and Richmond—as the tool for their CHA. The survey was validated for use as a health assessment data-collection tool. It included a total of 28 questions. Demographic questions included age, gender, race/ethnicity, zip code of residence, marital status, number of people living in the household, number of children in the home aged 18 years or younger, education levels, and employment status. In addition to demographic questions, the survey also included questions that ask respondents their perceptions about community problems or issues, specific health-related issues, access to healthcare and insurance, and prevalence of diseases and disability.
Based on the innovative model of the Northeastern NC Partnership for Public Health, the North Carolina Public Health Incubator Collaboratives (NC PHICs) is a collaborative of local health departments working together voluntarily to address pressing public health issues (The North Carolina Public Health Incubator Collaboratives, 2014). The state is divided into several geographical incubator groups. Lee, Montgomery, Moore, and Richmond Counties are all located in the south central incubator group and data are compared within incubator groups.
Lee County Community Health Opinion Survey
“This survey is in the public domain. Community health assessment is the process of learning about the health status of our community. We use this information to identify needs/concerns about our community and then develop ways to address those needs” (see Exhibit 9.1) (S. Oates, personal communication, September 2010).
Survey results
The data were analyzed and reviewed by an advisory team from Lee County Public Health Department and members of the LeeCAN. Health-related concerns in Lee County were identified during this process. According to Oates (personal communication, September 2010), the survey respondents believed the most prevalent health-related problems for the county were the following:
• Access to mental health services
• Access to dental care
• Teen pregnancy
• Crime
• Poverty
• Migrant children whose parents are no longer in seasonal migrant jobs
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