T • E • N The role of the nurse in healing includes compassionate and quality care not only for the individual but also for the family and the community. Advanced practice registered nurses (APRNs) seek to improve the circumstances that contribute to poor population health by working with community members to modify or change the behaviors that may contribute to poor health outcomes. This type of collaboration has the potential to make or facilitate changes that improve health and reduce morbidity and mortality. The APRN should approach communities with an open mind and a focus on a comprehensive community health assessment (CHA; see Chapter 9). A CHA helps the APRN to gain an understanding of the community, its residents, their diversity, their goals, their aspirations for healthier lives, and the barriers to achieving these goals. People want a better life. They want to be healthier and they want to live longer, happier, and more productive lives. The challenge lies in changing the behaviors and attitudes of individuals and communities. For many, change is uncomfortable or difficult, but is a necessary process for communities that want to make improvements. But a process of change is unlikely to be smooth if community members do not buy into this change and are not willing to take a risk or make a sacrifice for the unknown. Lewin’s Three-Stage Model of Change provides a brief but profound approach to change at the aggregate or community level (Allender, Rector, & Warner, 2013). In the role of a change agent, the APRN begins by destabilizing the group or community by asking questions to generate hope and visions of something different, something possibly better. Perhaps the group or community is already experiencing a desire for something different. Disequilibrium in the current moment underscores the relevance and potential of change and of moving out of the current comfort zone. The first stage of change is unfreezing, and may arise from the community’s own self-assessment or it may be activated by the APRN through motivation, health education, advocacy, or other strategies (Allender et al., 2013; Connelly, 2014). An APRN may initiate unfreezing during the course of usual practice. For example, as part of a primary care practice, an APRN may find that many adult patients want to increase their physical activity, but the lack of designated walking or biking trails is a barrier that prevents this change. The APRN initiates a conversation with the head of the local farmers’ cooperative and with the director of the county’s agricultural extension office. A community meeting is planned, with broad attendance by local residents and representatives of other community organizations. Many express interest in increased physical activity, but doubt their ability to make changes to their community that will make it more “walker friendly.” This meeting is the first of many opportunities to present the problem to the community and address possible solutions, and begin to build a bridge of confidence between the community and the healthcare provider. Focus groups (see Chapter 9) can also further this goal and provide more individual attention to potential barriers while proposing possible solutions to address those concerns. The second stage in Lewin’s model reflects an understanding that change is not a timed event but an ongoing process that can be facilitated by the actions of the APRN. This stage is known variously as changing, moving, or transition (Allender et al., 2013; Connelly, 2014). Community members begin as individuals and as a group to transition to new attitudes and behaviors as they acquire new skills and perspectives. The combination of destabilizing the present state and the challenge of questioning the status quo of behaviors and attitudes can make the second stage the most difficult. The support role of the APRN is very important, as the nurse must accept the community’s attempts at change against the risk of early failures. The APRN cannot necessarily direct community change, as community residents benefit from developing their own new patterns of behavior as these emerge from who they are and their past experiences. The APRN can motivate and guide community members and help them build on their experiences to make the changes necessary for success. Using the earlier example, the APRN should provide encouragement about the value of change (e.g., an improvement in residents’ physical activity levels leads to improved health and less need for medications), implement strategies to reduce fears (e.g., educate residents about other successful programs), develop skills to unlock new behaviors (e.g., encourage residents to work together as peer support), provide prompts underscoring the importance of change attempts (e.g., use simple outcome measures for residents [i.e., step counters] to track progress and set goals), and remind residents about the benefits of the community’s goal (e.g., a healthier community is a more productive community) (Allender et al., 2013; Connelly, 2014). As a result of regular community meetings, the rural community raises funds and constructs new walking trails on public land. A park with a picnic shelter is also built to provide families and groups a place to gather after walking. The third stage of change is refreezing (or freezing), which reflects the restabilization of the community that follows after making change. This stage can require a period of time, as the change or transition that community members experience can lead to a change in their relationships and in their daily lives as they internalize what is now different. The system adapts to the impact of the change, and the community integrates the change into a newly stable and rebalanced present state. For example, the walking trails that were once seen as improbable are now embraced and accepted by the community. The APRN can provide the community with additional tools to stabilize the change and to reinforce and maintain new community behaviors. Families are encouraged to try out the new walking trail and to use the new picnic area for a healthy meal. Neighborhood events can center on the use of the park so as to introduce other community members to the benefits of the community space. Periodic reminders to area residents about the walking trails can be included in local print and visual media. The success of the change process can lead to an enhanced partnership between the nurse and the community with the potential for further collaboration. Ideally, over time, the rural community will increase its physical activity and may seek additional consultation, for example, on how to select and prepare nutritional meals. Two-way communication can identify and address resistance or barriers to change. The APRN needs to identify potential problems or doubts and reinforce the benefits and values of the changed behaviors. The emergence of a new equilibrium signals a potential exit point for the APRN’s engagement with the community (Allender et al., 2013; Connelly, 2014). APRNs are more likely to succeed in addressing community concerns when communities are prepared to engage in the process of change. Engagement is different from wishing or acknowledging that “something” needs to change in order to improve. According to the CDC (Centers for Disease Control and Prevention), community engagement is “the process of working collaboratively with and through groups of people affiliated by geographic proximity, special interest, or similar situations to address issues affecting the well-being of those people” (McCloskey et al., 2011, p. 7). Before beginning a community engagement effort, the APRN must carefully consider the target community/population. What are the results of the CHA, and what is known about the community? What has been the history of this community during and following previous change and engagement efforts? How are the community and its various groups likely to perceive the APRN, and what is the potential for a successful engagement of community members (Centers for Disease Control and Prevention/Agency for Toxic Substances and Diseases Registry [CDC/ATSDR] Committee on Community Engagement, 1997)? Is the community prepared to engage in change? Would the community’s social or physical environment facilitate or impede change? During this assessment and initial contact, the APRN needs to recognize the core principle of community self-determination and the limits of professional action. It is critical that the APRN clearly recognize the principle that “[n]o external entity should assume it can bestow to a community the power to act in its own self-interest” (CDC/ATSDR Committee, 1997, Principle 4). Community members will find their own power when they seek it in themselves and take action for themselves, their families, and their community. Involving the community is a second important and necessary step in assessing the potential for engagement. The APRN needs to establish relationships and build trust through contacts with community leaders and community organizations. As mentioned in earlier chapters, the community leaders are not always the political leaders, but rather can include leaders in the church, schools, charitable foundations, or any member of the community who is trusted as a leader. The successful engagement with the community will depend on developing relationships with these community leaders. Each community is distinctively unique; engaging with a community will require acknowledgment and inclusion of the cultures and diversity of that community in all steps of the engagement. Only by taking these steps can the APRN fully identify and mobilize community assets and resources and lay the groundwork for building long-term change in the community. With that said, healthcare professionals must recognize the limits of professional control and the need and/or cost of making a long-term commitment with the community and its residents (CDC/ATSDR, 2011; Table 10.1). When working with a community, population, or aggregate, the APRN must include strategies to initiate, develop, and sustain trust among the APRN and community leaders, community members, and stakeholders. Trust requires mutual intention and is characterized by reciprocity (Lynn-McHale & Deatrick, 2000). As a key element in social interaction, trust facilitates communication and mutual understanding. Trust is a basis for change, a constant connection that provides support when the change process destabilizes a known situation in favor of an unknown outcome. A focus on developing trust begins with the initial contact with community members (Macali, Galanowsky, Wagner, & Truglio-Londrigan, 2011). The resulting nurse–community relationship is a critical prerequisite to population intervention. Through a trusting relationship, the community member gains the security of the APRN’s stable presence as a prerequisite to risking the unknown. Four categories of trust have been described: calculative, competence, relational, and integrated. In calculative trust, potential members of the community initiative estimate the balance of benefits and costs to be derived from a potential collaboration as well as each member’s assets and linkages. Competence trust hinges on whether group members are capable of doing what they commit to do; this type of trust also underlies the development of mutual respect among the participants. Relational trust reflects the personal relationships that quickly arise among members of any group. Members may express the value of mutual exchanges and develop a sense of commitment to mutual goals. Taken together, these three categories of trust constitute integrated trust, the foundation of an ongoing partnership (Logan, Davis, & Parker, 2010). TABLE 10.1 • Principles of Community Engagement
Challenges in Program Implementation
Janna L. Dieckmann
LEWIN’S STAGES OF CHANGE
Unfreezing
Changing, Moving, or Transition
Refreezing
COMMUNITY ENGAGEMENT
Engagement
Gaining the Trust of the Community
Before starting a community engagement effort: • Be clear about the purposes or goals of the engagement effort and the populations and/or communities you want to engage. • Become knowledgeable about the community in terms of its economic conditions, political structures, norms and values, demographic trends, history, and experience with engagement efforts. Learn about the community’s perceptions of those initiating the engagement activities. |
For engagement to occur, it is necessary to: • Go into the community, establish relationships, build trust, work with the formal and informal leadership, and seek commitment from community organizations and leaders to create processes for mobilizing the community. • Remember and accept that community self-determination is the responsibility and right of all people who constitute a community. No external entity should assume it can bestow to a community the power to act in its own self-interest. |
For engagement to succeed: • Partnering with the community is necessary to create change and improve health. • All aspects of community engagement must recognize and respect community diversity. Awareness of the various cultures and other factors of diversity must be paramount in designing and implementing community engagement approaches. • Community engagement can only be sustained by identifying and mobilizing community assets and by developing capacities and resources for community health decisions and actions. • An engaging organization or individual change agent must be prepared to release control of actions or interventions to the community and be flexible enough to meet the changing needs of the community. • Community collaboration requires long-term commitment by the engaging organization and its partners. |
Source: Centers for Disease Control and Prevention/Agency for Toxic Substances and Diseases Registry Committee on Community Engagement. National Institutes of Health (2011).
Initiating trust is an essential first step in building a bond between the nurse and the community. The nurse’s presence in the community is qualitative evidence of the intent to develop a professional relationship with the community and its members. The community’s willingness to view this presence positively will hinge on the APRN’s clear communication of his or her role with the community. The APRN should seek to frame his or her presence within the broader outlines of the consensus needs or goals of the community, to the extent that these are known.
Processes of Developing and Sustaining Trust
The process of developing trust between the APRN and the community will likely emerge from early collaborative efforts. In most cases, selecting small, achievable goals that can be met swiftly is recommended. The success of early visible outcomes enhances the nurse’s credibility and increases the community’s willingness and openness to trust. Increasing the breadth and depth of community participation with these goals will also increase the proportion of community members who have had contact with the APRN and will be an advantage as the nurse–community collaboration continues. It is likely that the community will embark on testing or probing the nurse’s knowledge, behavior, and character for the sake of better understanding and will withhold open trust until the community’s needs begin to be met. As the nature of the nurse–community relationship is constructed and evolves during this period of role negotiation, the APRN must maintain commitment to the initial shared goals, demonstrate professional openness to engagement with the community, and continue visible and concrete participation in the community. As APRNs share a community presence with the public health nurse, it is relevant to consider that “[t]he less experience people have with trusting relationships and the less sense of personal power and control they have, the more time public health nurses must spend developing trust and strength” (Zerwekh, 1993, p. 1676).
Sustaining the community’s trust is built on a record of commitment and ongoing interaction with the community and its members. The nurse’s continuing presence within the community establishes a sort of continuity that is reinforced by reliable actions. Decisions by APRNs that become predictable to the community build the community’s independence in self-management. When community members can predict “what the nurse would do,” they are well on their way to independent decision making for their health. As community members gain independence, the importance of the APRN’s leadership becomes less necessary. With increased community competence, the APRN may face new challenges in sustaining the community’s trust, and the APRN’s role as a leader will change. As a community gains self-efficacy and confidence in self-determination and in its individual perspectives, conflicts become more likely. Mutual participation in thoughtful resolution is essential. Sustaining the community’s continued trust will depend on the APRN’s personal and professional skills and willingness to modify relationships with the community and its members and accept a new role as defined by a strengthened community.
Building Partnerships
If trust is an essential prerequisite for change, then partnerships are the essential underpinning for negotiating, planning, and implementing change. The long-lasting relationships that characterize some partnerships build on existing strengths even as new capacities are forged and developed. Themes of engagement, autonomy, and self-determination have shaped contemporary ideas of partnership since the mid-20th century. The Alma-Ata Declaration (1978) proposed a social model of health that underscored the need for “citizen’s greater self-reliance and decisional control over their own health” (Gallant, Beaulieu, & Carnevale, 2002, p. 152), and alerted national health systems to more formally involve citizens in healthcare decisions (Gallant, Beaulieu, & Carnevale, 2002). This is even more salient when addressing 21st-century healthcare demands that require individual and community initiatives to address and improve health promotion and disease prevention (Courtney, Ballard, Fauver, Gariota, & Holland, 1996).
Agency–Academic Partnerships
One long-standing approach to partnership is the bridging of health agencies and academic institutions through joint ventures. An early example occurred in Ohio in which the University Public Health Nursing District (in Cleveland, Ohio, 1917–1962) linked local schools of nursing with an independent nursing agency that provided clinic services, public health services, and nurse home visiting (Farnham, 1964). Nursing students were assigned to the district for their public health nursing experiences. Assignments for diploma school students tended more to observation of activities during a brief few weeks, compared to collegiate nursing students, who became fully engaged over a semester in the breadth of public health nursing work. The key structural element was the public health nursing staff of the district, who served as clinical educators for students as well as direct care providers.
As effective and contributory as such programs are, the agency–academic partnership model of collaboration between a health agency or primary care practice and an academic institution has a limited impact when community residents and the wider service-resource network remain uninvolved, and when services are delivered outside of a collaborative planning process that includes community participants at the table from the beginning. Agency–academic partnership programs that focus on delivering services and improving health, but do not address the critical underlying barriers to improving health, are too limited in scope. Changes in the community—both change that benefits community members and change that transforms the community’s health—are more likely to occur successfully with the participation of community representatives, both community members and leaders. One promising approach for successful academic–community partnerships uses the community-oriented primary care model to address the structural inequalities underpinning these challenges by placing a community-based organization in the central coordinating role for the partnership (Cherry & Shefner, 2004). An example of one such partnership is the one between Rush University and a community located in Chicago. The Rush University Colleges of Nursing, Medicine, and Health Sciences formed an academic partnership with Marillac House, an existing and trusted social service agency. The goal of the partnership was to provide interdisciplinary and primary healthcare services to a medically underserved neighborhood in Chicago. This partnership benefits both the community and the university as it provides much needed medical services to community residents, and the university uses the clinical site for its students, who gain valuable experience working with a diverse and underserved population (McCann, 2010). The university fostered engagement with the community by partnering with an established agency within the neighborhood and working with community members.
This discussion of agency–academic partnerships highlights the contrast between the APRN as advocate or as catalyst when engaging with a community for health changes. In both the advocate and catalyst roles, the APRN respects the community and its self-determination as a basis for developing strategies to assist or complement the community’s efforts for improved health. The advocate understands “the world view, life circumstances, and priorities of those requesting or receiving care and exploring the possible options with them in light of their preferences” (Walker, 2011, p. 75). While recognizing the community partner’s individuality and self-determination, the nurse advocate takes action on behalf of a community to raise awareness in community members or make change in policy, economic, or social systems affecting the community (Walker, 2011). This advocate approach is closest to the APRN role in the agency–academic partnership. In contrast, the APRN as catalyst understands the community as containing “all the necessary qualities and resources for change” and focuses on providing “the spark that will initiate change, as desired by the community and on its terms” (Walker, 2011, p. 75). The “nurse as advocate” role provides the framework for APRN practice in sustainable partnerships and coalitions.
Sustainable Partnerships
Developing long-term relationships between the APRN and community representatives and organizations is a necessary component for preparing communities for long-term change. Sustainable partnerships are characterized by a relationship process through which the nurse and partners “work and interact together” (Gallant et al., 2002, p. 153). Power is shared in a “power-with” approach “emphasizing the positive force created between partners and how this force sustains and propels a relationship forward” (Gallant et al., 2002, p. 154). Win–win negotiation models are recommended in the clinical nursing context (Roberts & Krouse, 1990), and have value in the APRN’s collaborations with community leaders and members. Not only are all parties’ views heard and valued, but also the power to make decisions is shared, leading to “a sense of responsibility and power” (Roberts & Krouse, 1990, p. 33). This is particularly important when establishing a context for the emergence of an empowered community.
Sustainable partnerships are supported by public participation that enhances decision making by reflecting the interests and concerns of partnership members and by highlighting the underlying values guiding partnership operation. The community that is affected by a decision should be able to participate in influencing the decision and should be included in a way that enables their full participation. Including community members in decision-making committees is an important part of community engagement. Decisions are likely to be more sustainable when the needs, concerns, and interests of all parties are communicated. Communication strategies themselves should be open and negotiated to accommodate representative styles and approaches. Finally, feedback must be provided to all participants and the public about how the decision was made and the role of their input in making the decision (International Association for Public Participation, 2014; Rippke, Briske, Keller, & Strohschein, 2001).
Partnerships can only be characterized as such when certain conditions exist: Each partner must be recognized as having his or her own power and legitimacy, own purpose and goals, and own connection to that locale or community. At the same time, the work of the partnership itself must be or become more than any one partner’s own goals. This is reflected in clear partnership objectives and mutual expectations. Regular patterns of feedback from and among all parties should be planned and shared. And finally, all partners should strive for open-mindedness, patience, and respect for others’ views (Labonte, 2012).
Working With Community Leaders and Members: Building Coalitions
A coalition-building strategy can establish the groundwork and/or initiate intracommunity relationships that contribute to an effective, sustained effort to identify and respond to community challenges and needs. Coalition building “promotes and develops alliances among organizations or constituencies for a common purpose. It builds linkages, solves problems, and/or enhances local leadership to address health concerns” (Keller, Strohschein, & Briske, 2008, p. 204). Coalitions bridge sectors, organizations, and constituencies to provide a benefit to the wider community.
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