Interdisciplinary assignment

167

CHAPTER

8COMPETENCY #6 Utilizes Collaboration to Achieve Public Health Goals

n  Marjorie A. Schaffer  with Melissa L. Horning and Carol J. Roth

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Jake is a public health nursing student who has 10 years of experience in the acute care setting as an associate degree nurse. His expertise has been in the area of cardiac care, working in the Coronary Care Unit at a local hospital. Jake has returned to school to complete a baccalaureate degree in nursing. The community surrounding the university that Jake attends has identified a need to address healthcare access for the homeless population. A local church approached the university to work with it to develop a clinic for the homeless by using resources in the community and students for the delivery of care for this underserved population. Jake’s preceptor, Linda, a public health nurse (PHN), is representing the local public health department at planning meetings. Jake will have the opportunity to learn how professionals, community members, and organizations collaborate to contribute to the development of a community clinic that serves a vulnerable population. Jake has many questions, such as: Whom would he collaborate with to contribute to this goal? Whom should be invited to be partners in the collaboration? How does such a diverse group work together? What is the PHN’s responsibility in collaborative work?

Before Jake attends the first planning meeting with Linda, he picks up his notebook to review the population-based public health nursing competency list and concentrates on Competency #6, which focuses on collaborative practice.

JAKE’S NOTEBOOK COMPETENCY #6 Utilizes Collaboration to Achieve Public Health Goals

A. Demonstrates effective participation on interprofessional teams

B. Develops relationships and builds partnership with communities, systems, individuals, and families

C. Utilizes community assets and community engagement to empower communities, systems, individuals, and families

Source: Henry Street Consortium, 2017

USEFUL DEFINITIONS

Collaboration: Working together “to achieve a common goal through enhancing the capacity of one or more of the members to promote and protect health” (Keller, Strohschein, Lia-Hoagberg, & Schaffer, 2004, p. 456).

Community Asset: “Anything that can be used to improve the quality of community life,” including peo- ple, physical structures, community services, and businesses (KU Center for Community Health and Development, 2017).

Community Engagement: Collaborating with community members or community organizations to mutually participate in problem-solving to address issues that affect their well-being (National Institutes of Health, 2011).

Interprofessional Collaboration: Creating collective action to address the complexity of client needs and cre- ating a team culture that integrates the perspectives of each professional and facilitates mutual team member respect and trust (D’Amour, Ferrada-Videla, Rodriguez, & Beaulieu, 2005).

Partnership: Individuals or organizations sharing ideas, experiences, skills, and resources to address problems through mutual decision-making and action (Wilson & Mabhala, 2009).

C o p y r i g h t 2 0 1 8 . S i g m a .

A l l r i g h t s r e s e r v e d . M a y n o t b e r e p r o d u c e d i n a n y f o r m w i t h o u t p e r m i s s i o n f r o m t h e p u b l i s h e r , e x c e p t f a i r u s e s p e r m i t t e d u n d e r U . S . o r a p p l i c a b l e c o p y r i g h t l a w .

EBSCO Publishing : eBook Collection (EBSCOhost) - printed on 2/1/2023 1:14 AM via MINNESOTA STATE UNIVERSITY - MANKATO AN: 1917387 ; Patricia M. Schoon, Carolyn M. Porta, Marjorie A. Schaffer.; Population-Based Public Health Clinical Manual, Third Edition: The Henry Street Model for Nurses Account: s4200124.main.ehost

168 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

Accomplishing More by Working Together PHNs work with many individuals and community orga- nizations. Collaboration can be between two or more indi- viduals or between organizations. PHNs collaborate with representatives of the population, other professionals, and organizations to contribute to healthcare planning and pro- mote health (American Nurses Association [ANA], 2013).

A study about public health nursing practice analyzed how PHNs collaborated with individuals, communities, and systems. At the individual level, PHNs said their goal was to make a difference in the lives of their clients by focus- ing on “doing with” rather than on “doing for” (Aston, Meagher-Stewart, Edwards, & Young, 2009). They wanted to empower their clients to take responsibility and owner- ship for health decisions. The PHNs identified several strat- egies for empowering their clients: begin with the client’s perspective, tune into the readiness of the client, assess holistically (refer to Public Health Nursing Competency #9 in Chapter 11), and build rapport with the client.

At the community level, Aston et al. (2009) suggested strategies to encourage community member participation in health programs and initiatives. The PHNs involved com- munity members in decision-making groups, focused on community assets, and gave positive feedback and encour- agement by affirming what was working well. The PHNs involved people who normally might not have the opportu- nity to participate in decision-making groups, such as youth living in poverty and mothers who were isolated. At every group meeting, the PHNs asked, “So who is missing and who needs to be here?” PHNs often initiate the process of uniting people around a problem they all care about. PHNs encourage group ownership and often look for community members to take the lead in problem solving. PHNs can assist with the group process, but ideally community mem- bers should control the flow and process toward finding and implementing solutions. Collaboration works best when everyone has the opportunity to share thoughts and ideas. One PHN in the study used the word catalyst to describe an approach that draws the voices and participation of com- munity members. This means that someone needs to initiate the collaborative process, which then continues to develop with the input of the people who contribute their perspec- tives and skills to the collaboration.

At the systems level, the PHNs in the study connected community members and groups to existing social net- works, including neighborhood groups; community orga- nizations, such as churches; or programs that provide food. These connections helped to create a participatory infra- structure. The PHNs linked people and community organi- zations that were working on similar goals but had not yet worked together. As a result, partnerships were built that advocated for clients and linked agencies, contributing to

better services for clients. One PHN talked about finding “the movers and shakers” in the community through reach- ing out to community groups, such as men’s or women’s groups, church groups, and community health boards. These strategies encourage the collective voice of commu- nity members and foster citizen participation. PHNs can also bring their expertise in health promotion to existing collaborative groups that are already established in commu- nities (Aston et al., 2009).

Consider how PHNs collaborate with individuals and families, community groups, and systems in the collabora- tion example in Table 8.1. A local church hosts a Wellness Center to serve the needs of people living in the community who have health needs and difficulty accessing healthcare. Many clients need dental care, so PHNs collaborate at all levels of practice and across professions to respond to this need. Figure 8.1 also elaborates on how PHNs collaborate with individuals and families, communities, and systems.

FIGURE 8.1 How PHNs Work With Individuals, Communities,  and Systems

Individual/Family Empowered their clients to take responsibility and ownership for health decisions

Community Involved community members in decision- making groups, focused on community assets, and gave positive feedback and encouragement by affirming what was working well

System Connected community members and groups to existing social networks, including neighborhood groups; community organizations, such as churches; and programs that provided food

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169CHAPTER 8  n  Competency #6

Collaboration With Other Professionals and Communities Depending on their practice setting, PHNs work with a variety of other professionals, groups, and organizations. For example, a PHN working in a school collaborates with teachers, families, students, school administration, pri- mary care providers, other health and special education professionals, social workers, and groups that address such health needs as chronic illness and mental health services. The following are possible partners in public health nursing networks:

Education collaborators: n Childcare programs and providers n Colleges and universities n Early childhood development programs n Head Start n Literacy programs/English as a second language

learner programs n Schools n Special education

Holistic healthcare team members: n Alcoholics Anonymous n Audiologists n Chemical dependency programs n Clinical nurse specialists n Complementary/alternative therapy programs n Dental care providers (dentists, dental hygienists,

dental assistants) n Home care agencies n Mental health centers and providers n Nutritionists n Occupational therapists n Physical therapists n Planned Parenthood n Primary care providers (physicians, nurse practitioners,

physician assistants) n Psychologists n Services for children with special needs n Services for vision and hearing impaired n Speech therapists n Traditional/Native healers

Housing and food collaborators: n Battered women’s shelters n Congregate dining n Food shelves n Free and reduced-price school meal programs n Homeless shelters n Housing programs n Meals on Wheels n Supplemental Nutrition Assistance Programs (SNAP) n Women, Infants, and Children (WIC)

Best Practices for Collaboration With the input of several stakeholders (individuals and organizations), the pooling of expertise and resources (e.g., knowledge, expertise, lived experience, money) can lead to expanded ideas and strategies for improving population health outcomes. Together with community partners and other professionals, PHNs strive to identify mutual goals and expected outcomes for the collaboration. See Table 8.2 for a summary of best practices for effective collaborative action.

TABLE 8.1 Collaboration Example

Level of Practice Example

Individual When clients at the Wellness Center complain of toothaches, PHNs refer them to low-cost dental care and arrange transportation to the commu- nity site where dental care is provided.

Community PHNs collect information on agencies and organizations that provide low- cost dental care and create a pamphlet to communicate that information to potential clients and other community locations where people in need can learn about resources. In addition, PHNs could provide social marketing to local schools about resources for dental care.

Systems PHNs advocate for policy change to include dental care in health pro- grams that serve individuals and families without employer-provided insurance.

TABLE 8.2 Best Practices for Collaboration

n Effective leadership n Commitment of the participants n Shared values and a sense of purpose n Mutual respect for team members n Linkages between groups and individuals n Identification of strategies and resources to achieve the

goals, and a structure to support the collaborative work n Internal systems to support the structure (e.g., commu-

nication mechanisms, a place to meet, time available in assigned workload)

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170 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

Interprofessional education occurs when the various pro- fessions “learn about, from, and with each other to enable effective collaboration and improve health outcomes” (WHO, 2010, p. 7). However, because professionals from dif- ferent professions have different perspectives, practices, and terminology, they may encounter barriers to effective team- work. How can you anticipate and reduce potential barriers to effective teamwork in interprofessional collaboration?

n Work to understand differences among team members’ culture, language, lifestyles, and beliefs

n Listen, be fully attentive, and truly hear n Acknowledge and express appreciation n Exhibit empathy and understanding n Display courtesy and consideration n Be accountable and professional n Abide by the organizational professional code of

conduct Source: Brewer, 2012, p. 33

PHNs work with many people who have different edu- cational backgrounds, different experiences, and different philosophies of life from their own and from each other. They encounter different perspectives about which issues are most important and what should be done to address specific health concerns. It is important to become famil- iar with common differences to avoid making assumptions about the viewpoints of community partners and members of the community. Sometimes tension and conflict occur as collaborators work through different perspectives and ideas about how to respond to a problem. Constructive conflict may help move the group toward change. In most cases, the accomplishments of the collaboration are far more than what one individual or one professional group could

Legal collaborators: n Law enforcement n Legal aid n Ombudsmen

Social Service collaborators: n Child protection and welfare programs n Energy assistance n Financial assistance n Jobs and training services n Social services n Transportation services n Vulnerable adult programs

Community collaborators: n Artists n Businesses n City councils/county boards n Clergy and religious/faith leaders n Community action programs n Community residents n Community service organizations (Rotary, Lions) n Environmental health programs n Extension agents n Musicians n Volunteers

Interprofessional collaboration is essential for developing effective partnerships that improve health outcomes in pub- lic health nursing practice. Interprofessional collaborative practice engages communities and populations. Teamwork and team-based care involve engaging other health pro- fessionals, specific to the care environment, to participate in client-centered problem solving. The Interprofessional Education Collaborative Expert Panel (2011) identified four domains or competencies of interprofessional practice (see Table 8.3).

The values/ethics competency means that collaborators take on a “community/population orientation, grounded in a sense of shared purpose to support the common good in healthcare, and reflect a shared commitment to creating safer, more efficient, and more effective systems of care” (Interprofessional Education Collaborative Expert Panel, 2011, p. 170). For roles and responsibilities, PHNs need to understand their own professional role and responsibili- ties as well as those of other professions. To communicate effectively on interprofessional teams, PHNs need to avoid professional jargon and demonstrate a readiness to work together by being available, showing interest, and actively listening. A consideration for effective teamwork is having respect for the professional expertise among diverse mem- bers of the team while staying focused on the goal of the collaboration (Interprofessional Education Collaborative Expert Panel, 2011).

The “professional” part of interprofessional collaboration refers to individuals who have specific knowledge and skills that they can use to contribute to community well-being.

TABLE 8.3 Domains and Actions Consistent With Interprofessional Collaboration

Domain Action Example

Values/ethics for interprofessional practice

Acting with honesty and integrity in all relationships and modeling respect, confidentiality, and dig- nity for clients and team members

Roles and responsibilities for collaborative practice

Communicating one’s role and responsibilities to clients/families, community groups, and other professionals

Interprofessional communication practices

Actively participating in timely, sensitive, and instructive sharing/ feedback

Teamwork and team-based practice

Engaging other professionals in shared problem solving and decision-making

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171CHAPTER 8  n  Competency #6

ask about their perspectives. Differences can be as basic as using different terminology for similar work, practices, or interventions. What you call an assessment might be called something different in another profession. Also, take enough time to communicate and make sure that all collab- orators are on the same page. Time limitations and a sense

accomplish alone. Conflict that can be worked through has the potential to lead to effective collaboration and positive change.

As you begin your practice, ask questions of people with different educational preparation and roles about what they think about a situation. Many will be pleased that you

EVIDENCE EXAMPLE 8.1 Interprofessional Collaboration

As you read through these examples of interprofessional col- laboration, think about your community and how you could collaborate with other professionals to improve the health of the population.

n Eckstrom and colleagues (2016) described a fall risk reduction project that involved an interprofessional col- laboration approach. An interprofessional teaching team provided education to an interprofessional clinical team about how to implement the American Geriatrics Society and British Geriatrics Society guidelines to reduce the fall risk for older adults in Oregon. The clinical teams included representatives from medicine, nursing, pharmacy, and social work in ambulatory, long-term care, hospital, and home health settings. The project increased fall risk reduc- tion activities of professionals in these settings.

n A study by Clancy, Gressnes, and Svensson (2012) found that interpersonal and relationship skills were viewed as most important for interprofessional collaboration in a survey of PHNs, physicians, midwives, and child protection workers from Norwegian municipalities and social ser- vices. All participants ranked trust, respect, and collabo- rative competence as most important in interprofessional collaboration. Thirty percent of participants reported that conflict among professionals was common. The authors suggested that structural changes—such as co-locating professionals, which could increase the potential for face- to-face communication—would likely decrease territorial thinking based on professional expertise.

THEORY APPLICATION Normative Group Development

To collaborate effectively with people representing different organizations, an understanding of group dynamics is use- ful. Tuckman developed a theory that explains the norms for group development (1965). PHNs can apply this theory to new situations of working with interprofessional teams. See Table 8.4. The stages of normative group development pre- dict how a collaborative group develops its relationships and interaction patterns for working on a common public health goal. There are four stages: forming, storming, norming, and performing. After the forming phase, most groups will move

through a storming phase. Conflict-management skills can be helpful in the storming phase to identify participant interests and positions, create new options through brainstorming, and negotiate a plan for moving forward (Bazarman, 2005). In the norming phase, group members begin to unify as a group. After moving through the norming phase into the performing phase, the group aims to work together collaboratively to achieve an agreed-upon goal. A healthy, functioning group creates energy that moves the group toward goal accomplishment.

TABLE 8.4 Normative Group Development

Forming Storming Norming Performing

n Members work to understand one another.

n The group determines its boundaries and focus.

n Group leaders emerge.

n Conflict emerges. n Some members may be

resistant to following group direction.

n People express concern about the right way to do things.

n Trust develops. n Members identify as a

group. n The group experiences

cohesion in choosing a goal.

n The group focuses on accomplishing tasks.

n Members establish rules for working together.

Source: Tuckman, 1965

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172 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

’’ ‘‘

phase. After about 10 meetings, a core group of community members have been identified through their commitment and attendance at meetings. Jake observes that this smaller group more easily comes to a consensus about the project’s vision and purpose and that the members begin to trust each other and understand their roles in the group.

Each group member is focused on the delivery of ser- vices to assist the homeless. Each member brings unique gifts and contributions to the table. Jake is excited to be a part of this collaborative endeavor. He is asked to develop a flyer to promote and advertise the wellness clinic, which will be open on Wednesday evenings.

Activity n Identify the forming, storming, norming, and performing 

stages in the preceding scenario.

n Discuss actions members of the group might take to reduce  potential barriers to effective interprofessional collaboration.

Building Partnerships With Communities, Systems, Individuals, and Families Partnerships are needed to implement many public health strategies to improve population health. In organizational and systems-level partnerships, many factors need to be addressed, including use of resources, personnel, and power-related factors that influence decision-making. There are often challenges when creating and maintaining part- nerships; however, the benefits of working together are often very rewarding (Wilson & Mabhala, 2009).

Effectively collaborating and developing partner- ships requires equality among the partners (Casey, 2008; Drahota et al., 2016). Equality in collaborative relationships is promoted through listening, being respectful, shared decision-making, appreciating differences and mutual goals, and developing trust. To encourage effective collabo- rative relationships with communities, professionals need to give up control and recognize that all members bring diverse and valuable expertise, lived experiences, and skillsets to the partnership (Campbell, Whitcomb, Culver, & McClanahan, 2015; Casey, 2008). Collaborative relationships work best if they are nonhierarchical in nature. Partnership roles are determined based on knowledge or expertise rather than on professional role, function, or education level (Casey, 2008). Ineffective relationships result from power or control ineq- uities (Casey, 2008; Drahota et al., 2016). To reduce power and control inequities, you need to pay attention to how the partnership is structured, who directs resources, and how much time participants are expected to commit to partner- ship work.

of urgency in responding to a public health problem can sometimes create barriers to collaboration. However, time spent getting to know one another can help to establish trust among the collaborators and prevent tension and conflict, which would likely take more time to resolve at a later point or even result in the collaboration’s failure.

The first planning meeting Jake attends includes 31 other people (the pastor, the assistant pastor, a police liaison, two social workers, four nurses from various clinical back- grounds, two alternative healers, two chiropractors, two community members, two people from the church’s board of directors, a director from a local clinic, a block nurse coordinator, three homeless persons, two faculty from the university Jake is attending, two staff members from the surrounding homeless shelters, an insurance representa- tive, a local physician, a musician, and two other nursing students). The group meets early in the evening to accom- modate the participants’ different schedules. It takes most of the first meeting to introduce everyone and to allow each person to share an opinion of what the wellness clinic’s vision would be.

Jake is shocked to realize that for such a large group to come to a consensus about a vision, at least six meetings would be needed. He realizes the group members needed time to talk so that they could determine their goals and how they were going to work together. During the initial meeting, the police liaison, who is also a social worker and a member of the church, emerges as the natural leader of the project. His skills and experiences have prepared him for a leadership role. He also has experience working with the homeless population in the neighborhood. After the meeting, Jake asks his preceptor, Linda, several questions. He wonders how a group of people with such a variety of backgrounds and experiences could create one plan. What will the group do if everyone has different ideas about how to develop the clinic? Which services does the clinic need to provide to meet the needs of the homeless population?

As the meetings progress, some community members drop out of the group, feeling frustrated as they perceive that their ideas are not being considered. As Jake con- tinues to work on the planning team, he realizes that conflict-management skills and leadership skills are essen- tial to work with such a large group. Jake marvels at the ability of the police liaison to create calm in a tense situ- ation and focus on the group’s vision to serve the home- less population through this community outreach project. Decision- making involves negotiation and compromise among the group members.

New members will sometimes come to one meeting and then be gone at the next. This spotty attendance means that at each meeting, time is needed to introduce new members and explain the vision and review the group’s planning

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173CHAPTER 8  n  Competency #6

The Culture of Health action areas consist of the following: n Making health a shared value is critical for govern-

ment, business, communities, and all individuals to thrive, as we all are interdependent upon one another. As Paul Wellstone once said, “We all do better, when we all do better” (Wellstone.org, 1999, para. 7). Taking steps to make health a shared value requires working within the social environment and shifting mindsets to focus on health as a collective, fostering a sense of commu- nity and promoting civic engagement through activities like voting and volunteering (RWJF, 2015; Trujillo & Plough, 2016).

n Fostering cross-sector collaborations is necessary to create a Culture of Health. If PHNs work alone or even with others within public health or healthcare sectors, they will not have the resources or power to create the necessary changes to foster a culture where all people can be healthy. Thus, cross-sector collaborations are critical to bringing diverse groups and interests together, like government, businesses/industry, education, health- care and public health, and community organizations. By incorporating each group’s knowledge, resources, and strengths, cross-sector collaborations can have greater influence and impact on the policies and envi- ronments that influence population health, well-being, and equity to build a Culture of Health (RWJF, 2015).

Factors found to facilitate effective partnerships include the following (Campbell et al., 2015; Casey, 2008; Drahota et al., 2016): n Establishing trust, commitment, and respectful

relationships among partners n Having mutually shared values, goals, and outcomes n Sharing resources and balancing power and control n Having effective, clear, and open communication and

decision-making n Establishing clearly defined roles and a conflict-

resolution plan together n Recognizing and building on strengths and assets of the

partners and individuals and communities

healthypeople.gov

Healthy  People

  The Healthy People 2020 website offers     suggestions useful for collaboration and     building partnerships. On the website: 1) click  “Healthy People in Action,” 2) click “Stories from the Field,”  3) click two or three map points to read the featured story, and  4) identify the role of partnership in the success story. Then  consider how PHNs could use Healthy People 2020 goals,  tools, and resources as they collaborate with professionals and  communities. 

Building a Culture of Health: Partnership and Collaboration An important skill for PHNs is learning how to develop collaborative community partnerships to bring about com- munity and systems change for improving health (Fawcett, Schultz, Watson-Thompson, Fox, & Bremby, 2010; Towne & Valedes, 2017). Collaborating to establish effective partner- ships is essential for building a “Culture of Health.”

What is a Culture of Health? The Culture of Health is a systems-level initiative that brings together all stakeholders who aim to improve health outcomes. As coined by Robert Wood Johnson Foundation (RWJF, 2015), a Culture of Health is where all individuals, communities, and societies can enjoy good health to grow, live, work, and play. Through an extensive research process, RWJF developed the Cul- ture of Health Action Framework, shown in Figure 8.2, as a guide for how governments, organizations, and health pro- fessionals can work together to build a culture that increases population health, well-being, and equity. The four action areas overlap and are interconnected; one action area in particular focuses on collaboration and partnership (RWJF, 2015; Trujillo & Plough, 2016). As you read about each of the four RWJF action areas, consider how important collabora- tion and partnership is for each action area.

FIGURE 8.2 Culture of Health Action Framework Source: © 2015, Robert Wood Johnson Foundation.

Used with permission.

EQUITY

EQUITY

ACTION AREA 2

FOSTERING CROSS-SECTOR

COLLABORATION TO IMPROVE WELL-BEING

ACTION AREA 1

MAKING HEALTH A

SHARED VALUE

OUTCOME IMPROVED

POPULATION HEALTH, WELL-BEING, AND EQUITY

ACTION AREA 4

STRENGTHENING INTEGRATION OF HEALTH SERVICES

AND SYSTEMS

ACTION AREA 3

CREATING HEALTHIER, MORE EQUITABLE

COMMUNITIES

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174 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

Activity Consider who the cross-sector collaborators are with whom  PHNs work to build a Culture of Health.

n Creating healthier more equitable communities focuses on ensuring all people and communities have equitable opportunities and resources in their neighborhoods to achieve health and well-being. To create healthier, more equitable communities, a PHN must work through policies and systems to impact the built, social, and eco- nomic environments by decreasing residential segrega- tion and increasing access to affordable housing, healthy foods, safe communities, and quality education at all levels (RWJF, 2015).

n Strengthening the integration of health services and systems emphasizes that to improve health outcomes for all and reduce healthcare costs, all individuals need to both be able to access affordable, holistic healthcare ser- vices across the spectrum of medical, dental, and mental healthcare services and receive needed social and public health services. When working together, integrated healthcare, public health, and social services can best facilitate health promotion, disease prevention, and chronic disease management through effective primary, secondary, and tertiary prevention (RWJF, 2015). Cross-sector collaboration requires the support of qual-

ity partnerships, investments, and policies (RWJF, 2015). While each of these four action areas is critical for working toward building a Culture of Health and increasing health equity, well-being, and population health, cross-sector col- laboration is critical to moving much of the work forward. Factors that can facilitate success of cross-sector collabo- ration and partnerships include ( Libbey & Miyahara, 2011; Mattessich & Rausch, 2014): n Clear, shared vision with common goals that are consid-

erate of the culture, backgrounds, and environments of each partner in the cross-sector collaboration

n Skilled, devoted leadership with defined roles of responsibility

n An understanding of each of the partner organiza- tions and mutual respect for what each brings to the partnership

n Financial incentives from both government and corporate businesses to support the partnership You likely have already noticed that there are many

similarities between these factors that facilitate success of cross-sector collaborations to build a Culture of Health and those that facilitate successful partnerships at individual, community and systems levels. Just like successful part- nerships at the individual, community, and systems levels, developing and sustaining quality cross-sector partnerships for collective action is not easy. Yet, the outcomes of success- ful cross-sector collaborations propel PHNs toward creating a Culture of Health. Successful cross-sector collaboration outcomes include improvements to services provided, policy change, and improvements to and awareness of how social, built, and economic environments (e.g., transportation availability, safety of neighborhoods, availability of afford- able housing) influence health (Mattessich & Rausch, 2014).

EVIDENCE EXAMPLE 8.2 Cross-Sector Collaboration in Action

n The Twin Cities Mobile Market is a “grocery store on wheels” that works to increase access to afford- able healthy foods by bringing them to the doorsteps of under-resourced communities. Led by a skilled, devoted leader, Ms. Porter, the Twin Cities Mobile Market is possible because of the successfully devel- oped cross-sector collaboration and partnerships with wholesalers, grocery stores, local farmers, local government (including public health departments and nurses), public and private housing agencies, healthcare systems and insurance companies, com- munity organizations and partners, philanthropic and government funders, SNAP-Ed programs, legislation, and researchers. This cross-sector collaboration makes it possible for the Twin Cities Mobile Market to serve under-resourced community sites each month, and currently, 50% of all Twin Cities Mobile Market sales are for fruits and vegetables (Twin Cities Mobile Market, 2017).

n An exemplar of cross-sector collaboration is Commu- nity of Care in rural Cass County, North Dakota, which started as a pilot project of the Good Samaritan Society to help older residents remain in their homes as long as safely possible. Today, Community of Care is supported by human service funds, grants, and other commu- nity financial sources. Staffing includes an executive director, a faith community nurse, a care coordinator, a part-time bookkeeper, a volunteer coordinator, and a cadre of community volunteers. Cross-sector collabo- ration has resulted in expansion of services to commu- nity members, including transportation to healthcare appointments, referrals to state health insurance counseling, yard work, minor home repairs, low-impact exercise classes, blood pressure screening, music and memory programs, a health newsletter, and health edu- cation activities. Community wellness fairs are offered in partnership with local university nursing students. The outreach activities include home visits to residents who are living in the rural parts of the county, as well as providing referral assistance to the family mem- bers of the residents. A goal of one of the grants that helps support Community of Care is to reduce hospital readmission rates through the efforts of collaboration (Community of Care, 2017).

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175CHAPTER 8  n  Competency #6

In comparison, community engagement activities with the greatest levels of community involvement are those rooted in collaboration with shared leadership between partners and the highest levels of trust, information sharing, communication, and impact (Bagnall, White, & South, 2017; National Institutes of Health, 2011). Community engage- ment is best developed locally by drawing on the knowledge and experience of community and volunteer organizations to find and locate people from the community to take on peer and lay roles in health initiatives (Bagnall et al., 2017).

There is not a “one size fits all” approach to engaging communities. Public Health England and National Health Service England identified four different options to choose from to fit with the community context and type of health initiative for doing community engagement work (Bagnall et al. 2017). These options include:

1. Strengthening communities by building on com- munity capacities to act together on health and the social determinants of health

2. Developing volunteer and peer roles that focus on enhancing individuals’ capabilities to provide advice, information, and support or organize health activi- ties in their own or other communities

3. Building collaborations and partnerships to involve communities and local services working together at any stage of the planning cycle, from identifying needs through to implementation and evaluation

4. Increasing access to community resources by con- necting people to community resources, practical help, group activities, and volunteer opportunities to meet health needs and increase social participation

PHNs strive for strong collaborations and partnerships with community agencies and members. Therefore, you should always aim to increase the level at which the com- munity is involved in community engagement work, which is an advocacy intervention. Within your public health nursing clinical experience, you may become involved in community engagement activities. Ultimately, the services and interventions you provide should empower and engage

In the following activity, find an example of how PHNs could actively participate in cross-cultural collaboration with other stakeholders to promote health in a population.

Online Activity     Visit the Community Tool Box website (http://  ctb.ku.edu/en) compiled by the KU Center for Community  Health and Development at the University of Kansas, a des- ignated World Health Organization Collaborating Centre for  Community Health and Development. Check out the tool box  resources that can be used to support and guide collaborative  public health nursing actions and work with partners at individ- ual, community, and systems levels. Which resources would be  useful to you and the PHNs you work with during your public  health clinical experience? Which resources on this website do  you think are helpful for PHNs to stay up-to-date on the best  practices of collaboration and partnership?

Collaborating Through Community Engagement Community engagement involves collaborating with a com- munity agency, a community safety-net organization, or community members to meet mutual needs that empower the community and the target population. It is important to acknowledge that community engagement work can involve the community at different levels, from very little commu- nity involvement to full community involvement (National Institutes of Health, 2011; Potter & Willis, 2013). For exam- ple, community engagement activities with less community involvement include outreach and consultation, in which information is often provided to the community. These activities may be the start of long-term and lasting com- munity partnerships and collaborations; however, at these lower levels of community involvement, there is often less trust, flow of information, and communication, and thus there is less potential for impact.

Rural Nursing in South Africa

GOAL 17 In South Africa, there is a shortage of doctors and nurses in rural areas and a greater need for access to healthcare. Healthcare needs include contraception and antenatal care, immunizations, and reducing the spread of tuberculosis and HIV. Guin Lourens, along with eight fellow nurses, estab- lished an organization called Rural Nursing of South Africa to increase nursing leadership in responding to identified healthcare needs. This organization partners with the Rural Health Advocacy Project, the Rural Doctors Association of South Africa, and Rural Rehab South Africa to respond to gaps in rural healthcare (International Council of Nurses, 2017).

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176 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

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those you are working with, enrich the healthcare abilities of the agency/community partner, and build organizational capacity. By acknowledging and building on the strengths that already exist, you are adding to the community’s assets and strengthening its ability to manage its own healthcare needs. Public health nursing advocacy through community engagement involves empowering vulnerable populations and their communities through capacity-building, collab- orations, and partnerships. Table 8.5 provides a checklist of key steps to take to ensure community engagement work will be successful.

Jake realizes that the tone of the meetings has changed to a collaborative relationship of listening to each other, respecting differences, and valuing each other’s input in the process—traits representative of an effective partner- ship. The members who are homeless are key partners and helpful in identifying needs and offering suggestions for delivery of services. Jake feels the strength of the bond of the collaborative partnership team in a shared vision. Jake observes that the team members are sharing resources and ideas with the group and striving for positive outcomes for the wellness clinic.

When Jake’s preceptor, Linda, asks him which charac- teristics and skills he thinks are needed for partnerships to be effective in planning such a challenging project, he answers that being committed, tactful, and persistent are important. He comments that it was really hard when peo- ple dropped out of the planning group in the early stage. However, the people who stayed with the project demon- strated they are committed and persistent. Jake also says that he thinks it is very important to have people in the group who have some influence in the community.

Using Community Assets to Empower Communities, Systems, Individuals, and Families To be effective collaborators, PHNs must recognize and emphasize community assets in planning interventions to promote public health. PHNs along with community groups and organizations, such as churches, social service agencies, and neighborhoods, can identify assets within the community that provide building blocks for public health initiatives. An intervention that builds on a foundation of community assets is sometimes referred to as a strength- based intervention, which means that an intervention is selected and/or enhanced because it is already a resource or strength that exists within the community.

TABLE 8.5 Checklist for Successful Community Engagement

❑ Learn about the community, the community safety-net organization, and at-risk populations.

❑ Develop trusting relationships with the community and diverse at-risk populations.

❑ Identify public health nursing activities beneficial to the organization, at-risk populations, and students.

❑ Collaborate with and engage the community agency in the planning, implementation, and evaluation of public health nursing activities.

❑ Develop culturally sensitive public health nursing services that are respectful of diverse populations.

❑ Create public health nursing services that are asset based, building on the strengths of the community agency, com- munity resources, and at-risk populations.

❑ Be flexible in developing and implementing public health nursing services.

❑ Provide public health nursing services that strengthen an ongoing relationship with the community agency.

Sources: Builds on work of Broussard, 2011; Schoon, Champlin, & Hunt, 2012

Asset Mapping: A Tool for  Strengthening Communities Karen Goldman and Kathleen Schmalz (2005) contrast a needs-based assessment approach with an asset-based assessment approach. Looking for the community’s needs results in assessing what is wrong with the community and determining how “to fix” the problems, while looking for assets results in building on community strengths and mobilizing resources within the community to promote community health (see Table 8.6).

Assessing community assets means listening carefully to the voices of community members through interviews, meetings, focus groups, and asset-based inventories. Asset- based inventories identify strengths of individuals, commu- nity groups, and community organizations. Strategies to conduct an inventory may also include conducting a walk- ing or windshield survey in which community strengths are noted, and using maps to document assets with a Geo- graphic Information System (GIS). Additionally, other sources of information might include community websites; town directories; bulletin boards; and listings of business, organizations, and institutions (KU Center for Community Health and Development, 2017).

Asset mapping can benefit the community in several ways. This approach empowers people to think more pos- itively and encourages them to discover their abilities and resources to contribute to their own health and meeting

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177CHAPTER 8  n  Competency #6

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TABLE 8.6 Needs Assessment vs. Asset Mapping

Needs Assessment Asset Mapping

n Community need is based on deficiency or problem.

n Looks at what is wrong with the community and how to fix it.

n Leads community to seek assistance rather than using in-house skills and change agents.

n Discourages community members.

n Community assets include people, places, businesses, and organizations that can be mobilized for improvement.

n Focuses on positive aspects (strengths).

n Leads community to look within for solutions and resources to solve problems.

Source: Goldman & Schmalz, 2005

TABLE 8.7 Questions for Community Groups to Promote Thinking About Assets

Asset Category Questions

Physical What are two or three physical assets in your community (neighborhood, buildings, parks, space, land, natural resources)?

Individual What are your talents, experience, perspectives, and skills?

What do you care about?

What do you know about?

Whom do you know?

Associations What is your participation in formal or informal voluntary groups, networks, and organizations of individuals who gather to do or enjoy something they cannot do alone?

Which groups are you part of?

Which groups do you know about?

Institutions Which institutions (such organizations as businesses, nonprofit agencies, government, and schools) are located in your community?

What do these organizations contribute to your community?

Economic What is something you spend money on?

What is something you make or do that people would pay you for?

Where do you invest your money?

What are unique economic assets in your community?

Sources: Hamerlinck, 2013; Snow, 2004

their goals for the future. They also learn to listen and value the contributions of others. Asset mapping is an inclusive process, which results in highlighting information and resources that can be used to mobilize individual and com- munity assets (Kretzmann & McKnight, 1993; Morgan & Ziglio, 2010).

John Kretzmann and John McKnight (1993) have identi- fied five categories of community assets: physical, individ- ual, associations, institutions, and economic. Luther Snow (2004) and John Hamerlinck (2013) propose asset-mapping questions, which can be adapted to help community groups explore their assets (see Table 8.7).

Once the community group has identified its assets, the next step is to review and consider how these assets can be tapped. In a group exercise, group members can list assets on pieces of paper or sticky notes and talk about how they are connected and can be used to improve the health and well-being of the community (Snow, 2004).

An asset-based approach to working with communities brings both strengths and challenges. Whiting, Kendall, and Wills (2012) discuss assets from a health promotion perspective. They identify categories of health assets and development assets (individual level) and public health asset frameworks (generally focus on community assets). Table  8.8 describes both strengths and challenges of the asset-based approach for individuals and communities.

Jake realizes the importance of knowing community assets and working with other professionals. The pastor knows the neighborhood and community well and has space and people resources for serving the meal on Wednesday eve- nings to the homeless. The social worker has experience with chemical dependency patients and the skills needed to address drug-abuse issues or concerns among the home- less. Another nurse is a mental health specialist who knows about useful referrals for homeless people. The police liai- son knows many people who are homeless and is very well respected in the community. The insurance representa- tive can help find resources to increase people’s access to healthcare by identifying funding options and programs. The PHN knows about social service resources and possible sources of healthcare funding. Jake, as a nursing student, brings his gifts of delivery of care by doing blood pressure screenings, health teaching, and foot care at the wellness clinic. The programs planned at the wellness clinic are ser- vices the collaborative community members can offer or find others to come in and provide.

Jake is present the first night the wellness clinic opens. As he sits down to share a meal with some of the individuals who visited the wellness clinic, he realizes the value in this statement: “It takes a community to take care of its own.” The strengths of each collaborative partner are needed to develop the wellness clinic.

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178 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

TABLE 8.8 Strengths and Challenges of an Asset-Based Approach

Strengths Challenges

n Helps people think positively about their circumstances n Helps to obtain a common view of what is important n Can be fun for the clients/participants involved n Is realistic because it identifies what is already available n Is inclusive n Is a form of discovery n Facilitates interdependencies n Centers on effectiveness n Facilitates hearing and valuing others n Provides the information necessary for the mobilization

of assets n Promotes the population as a producer of health, rather than

as a service user n Encourages people to realize their ability to contribute to

the development of health n Facilitates the identification of a range of health-promotion

factors n Helps to develop more sustainable initiatives n Seeks to empower people n Helps to identify ways for individuals to use their talents

n Requires financial investment n Is initially time-consuming n May be challenging emotionally and physically n May be resisted if current practice is viewed as effective n May identify assets that are not useable n May highlight assets identified by various stakeholders,

rather than by communities or individuals n Proves difficult to sustain, particularly within the current

political and socioeconomic climate

Source: Whiting, Kendall, & Wills, 2012, pp. 27–28

EVIDENCE EXAMPLE 8.3 Asset Mapping

n The University of Chicago launched an initiative that employed local youth to conduct a block-by-block census of community assets on the South Side of Chicago. The population of the geographic area was primarily African American and Hispanic, with 32% living at poverty level and a 22% unemployment rate. Partnerships included three community-development organizations. College-age adults mentored and supervised 54 high school youth participants. Over 8,000 assets in 28 sectors or catego- ries were identified in the census. The largest sectors were food, trade services, and religious worship. The project provided data about local assets that can be tapped to help build a Culture of Health by sharing language and principles (Lindau et al., 2016).

n An initiative to address childhood obesity used asset mapping to identify individual and community strengths in the targeted population, a public school district in upstate New York. The goal was to reduce television viewing time.

Partners in the initiative included childcare staff, school and college staff and faculty, primary healthcare staff, local businesses, social and faith-based organizations, the local library, and students from all educational levels. Partners networked to involve others in the community; community groups offered 40 different after-school and weekend activities in 11 public locations for preschool chil- dren and their families in a sponsored “TV turn off week.” Community groups collaborated on a variety of family activities, such as sports, lessons, music, dancing, and arts and crafts. Outcomes based on feedback from question- naires and partner debriefing sessions indicated that: 1) more parents enrolled their children in programs, which promoted physical activity (individual/family level); 2) the library decided to continue to offer storytelling hours (community level); and 3) childcare providers changed their policies for viewing media (systems level) (Baker et al., 2007).

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179CHAPTER 8  n  Competency #6

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When Jake first started the community health course, he believed that, although important, the delivery of services to persons who were homeless was someone else’s con- cern, not his. He also wondered why individuals who were homeless were included in the planning group. In the early meetings, he observed that the participants who repre- sented the homeless population were very quiet, so many other members of the group were talking about what they thought homeless people wanted. In the third meeting, the police liaison who had emerged as the group’s leader asked the members who represented the homeless population to offer their opinions on some of the ideas that had been expressed. He explained that they were “experts” on what it meant to be homeless and would therefore have good ideas about which services and resources would best help meet their health needs. The police liaison also did not back away from conflict but continued to emphasize the com- mon goal of the group. In later meetings, participants who represented the homeless population began to share more about their experiences.

After being a part of the project and actually spending time with individuals who were homeless, Jake now under- stands why it is important to include people who have expe- rienced homelessness in planning the clinic. The planning group empowers the group members who are homeless to participate as equal partners and take a leadership role in creating solutions.

As Jake provides foot care for a middle-age man one evening, the man shares his story of how he worked for a big company, lost his job as the company downsized, coped by drinking, lost his house and his family, and finally lost his sense of self-respect. As Jake reflects on this story, he concludes that each of us could find ourselves in a simi- lar situation. Through collaboration, Jake realizes that a community can use its strengths and resources to make a difference.

Acknowledgment: Chapter narrative development by Joyce Bredesen, DNP, RN, PHN

Ethical Application When PHNs collaborate with other professionals, commu- nity members, and community organizations, ethical con- cerns often center on selecting interventions that promote social justice for vulnerable populations that have fewer resources for improving their health. However, as PHNs work to promote a healthier life for community members, they must also consider how community members are going to view and experience the interventions they develop. In addition, collaboration often requires courage to work with others who have different views and persistence to keep working together even amid disagreements and ten- sion about the right way to proceed. All voices need to be heard in the decision-making process. In collaboration, an emphasis on community assets leads to inclusion, diversity, empowerment, and advocacy. See Table 8.9 for the applica- tion of ethical perspectives to collaboration.

TABLE 8.9 Ethical Action in Collaboration

Ethical Perspective Application

Rule Ethics (principles) n The goal is beneficence or pro- moting good (improvement in health status) for the commu- nity and community members.

n Encourage autonomy of com- munity members by ensuring that their perspectives contrib- ute to determining interven- tions to improve health.

Virtue Ethics (character)

n Be courageous in working with those with different views and perspectives.

n Be persistent in working through disagreements and tension in collaboration with others.

Feminist Ethics (reducing oppression)

n Encourage including the voices of all stakeholders in the collaboration.

n Respect everyone. n Strive for equality in the provi-

sion of programs and services. n Emphasize community

strengths. n Advocate for individuals and

community groups who have less power.

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180 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

n Partnership development requires trust between part- ners and a commitment to spend the time needed to develop that trust.

n Collaborative partnerships for promoting the Culture of Health and health of the public should work to have high levels of community engagement

n Collaborative partnerships should integrate community assets that contribute to the identification and design of intervention strategies in collaboration with community members.

n Tools for identifying community assets include commu- nity engagement and asset mapping.

KEY POINTS

n PHNs collaborate with many partners, including other nurses, health professionals, lay workers, community members, healthcare and community organizations, businesses, and government organizations.

n When building interprofessional collaboration rela- tionships, pay attention to the following: teamwork, communication practices, roles and responsibilities, and values.

n Effective partnerships share a common goal and require respect for and equality among partners.

REFLECTIVE PRACTICE

Developing a clinic for the homeless is a complex project that involves many stakeholders and community organizations. Before partners begin to collaborate, reflecting on the goals of the collaborative project is essential. When partners are gathered together, they need to reach consensus on a shared goal. Now that you have learned about collaboration and the knowledge and skills needed to collaborate effectively, con- sider the following questions:

 1.  What does Jake need to consider about effective part- nerships before collaborating to develop a clinic for the homeless?

 2.  Consider strategies for overcoming barriers to inter- professional collaboration. For the scenario about the clinic for the homeless, what do you see as possible barriers the team might encounter? What can they do to effectively manage those barriers?

 3.  What information about the population and commu- nity organizations will be needed for planning? What is an effective way to gather the information?

 4.  What would be important to include on the agenda for the first planning meeting?

 5.  What actions will support cross-sector collaboration?  6.  How can the group explore individual and community

assets that can be mobilized?  7.  Which additional questions will you need to ask to

partner effectively in developing a clinic for the home- less population? How will the group meaningfully engage all partners?

 8.  Refer to the Cornerstones of Public Health Nursing in Chapter 1. Which of the Cornerstones are consistent with and support the development of a clinic for indi- viduals and families who are homeless?

After you have worked through these questions, develop an outline of possible partners and collaborative strategies. Propose relevant Public Health Intervention Wheel inter- ventions and the level of each intervention that may be part of the expected outcome and action plan.

APPLICATION OF EVIDENCE

 1.  Which responses would you expect from the planning group based on Tuckman’s Theory of Normative Group Development (Tuckman, 1965)?

 2.  Which partnership guidelines would you apply to increase the likelihood of partnership success?

 3.  How could you use asset mapping or community engagement to achieve partnership goals?

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181CHAPTER 8  n  Competency #6

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