Theory Evaluation Paper: Community Empowerment

Theory Evaluation Paper: Community Empowerment

NU 500-7A Theoretical Foundations of Nursing

Non-emergent use of the emergency department (ED) continues to plague area hospitals. 44.5% of Medicaid recipients visited the ED in the preceding 12-months (Kim, McConnell, & Sun, 2017). Medicaid recipients are 7 times more likely to utilize the ED for low severity visits continued Kim, McConnell and Sun. Although non-emergent care can be provided at a lower cost in the community, the patient states at the ED there is no waiting days for an appointment, there is no co-pay and they can go whenever they want (Department of Health and Human Services Office of the Inspector General, 1992). Back in 1992, the belief was to return non-emergent visits to a community clinic so there could be a savings in federal dollars, the report continued. If it were only that simple it would not continue to be a problem today. Much needs to be accomplished before we can return medical visits back to the community. Public health nurses need to reach out in the community to listen and hear what the community needs. It is not the place of the nurse to fix this problem, more importantly the public health nurse needs to guide the community to developing their own solutions. The Theory of Community Empowerment does just that, it empowers the lay community to take charge and construct the pathways to better health (Smith & Liehr, 2008). Persily and Hildebrandt’s design of the theory builds partnerships to reach common goals. Public health nursing is about partnerships and addressing the needs of the community for reciprocal health (Smith & Liehr, 2008). There are plethora’s of nursing theories that address a multitude of concerns, but it is the Community Empowerment theory that addresses the community and the demographic that truly aligns with public health nursing. It is a marriage of sorts, what one partner may be strong in, the other will learn. In return, the educated concepts are then shared with the community family. Many theories influence the Community Empowerment theory, most notably is Orem’s Self-Care Theory. The self-care theory works to facilitate community improvement of health and self-care strategies (Orem, 1991). As in Community Empowerment, self-care is a driving component to the success of Orem’s theory. This paper will examine Persily and Hildebrandt’s Community Empowerment theory and its application to public health nursing. The focus will be on the social relationships, which bring about buy-in from the population served within the community, leading to their self-care.

Theory Description


Hildebrandt’s Community Empowerment Theory was developed to facilitate effective interventions at both the individual and community level (Smith & Liehr, 2008). It requires the nurse to provide her knowledge and expertise to the community members to improve health. The theorist sought to garner the community involvement in order to improve their knowledge as a result of engaging with a nurse in order to take ownership. Hildebrandt felt these engagements would lead to better health care decisions.


In 2000, Higgins and Moore presented the general concepts of a middle range theory as including being considerably specific with engagements with small groups of distinct concepts that are related to the world we live in. The theory of community empowerment is a middle range theory that consists of three concepts


  1. Involvement
  2. Lay workers
  3. Reciprocal health (Persily & Hildebrandt 1996).

The community empowerment theory’s involvement in specific community health, while bridging the health care gap with lay members educated by professionals for their own health

Improvement is itself a specific definition for a middle range theory. The achievement of community empowerment is seen when community-based lay-workers involve themselves with seeking knowledge to obtaining reciprocal health. These concepts are the foundational in developing and providing care to the community. The key concepts of the community empowerment theory are specific to the theory itself and include:


  1. Involvement – willingness to investigate and promote change
  2. Lay workers – community individuals willing to learn and participate in change
  3. Reciprocal health – interactions with lay workers and health providers for better community health (Smith & Liehr, 2008).

The community empowerment theory is rooted in involvement with the community while motivating members to seek the change they feel is important. When relationships are forged to address the concerns and community members desire to participate, a sharing of knowledge occurs and reciprocal health begins. In public health nursing, the relationships the nurse establishes with the specific population are foundational to change. When the community invests in their health, change will occur. In 1989 Dean warned that is important to remember that even if a professional teaches health behaviors, the performance still requires the acceptance, motivation and ability of the individual to apply the knowledge. Dean went onto say that self-care is one of the most widespread and oldest behaviors we have in health. A major determinant of health is self-care adaptation. Relationship building within the community is a substantial determinant to success of this theory.


The Community Empowerment Theory takes its roots from the Community Involvement

in Health program developed by Hildebrandt in 1994. Driven by the need for the community to take ownership or at least a partnership for better care. In essence the Community Empowerment Theory starts with the identification of a need, the public health nurse makes contact to discuss the need of the community from the community. Resources are identified to meet possible deficits. The community has a voice in the problems and makes suggestions for pathways to solve or at least address the need. The supportive asset representatives are solicited for assistance and those who may be barriers to the selected plan are only asked to understand process. Work groups are set up, the plans and goals are developed. Tasks include many jobs including transfer of knowledge, social medial, outreach and more. Deadlines are tentatively set and frequently reviewed. Nurturing the program is imperative to its success. Frequently, the successes are measured against the goals, adjustments made to achieve unmet goals. Maintaining communication with both the supporters and those who simply provided acceptance. Continually evaluate the program for appropriate outcomes and need for change, continue to solicit the support from those who simply provided acceptance (Hildebrandt, 1994).

Hildebrandt stressed the most important step within this structure was the importance of asking for ideas and talking with people and not at them. Hettema, Steel and Miller continue that through the process it is important to remember it is their problem and the when they complete the process of creating a solution they are more invested in the outcomes (Hettema. Steel & Miller, 2005; Hildebrandt, 1994). If community members express an interest it is important to get them involved in the structure of the process (Hildebrandt, 1994) Hildebrandt continues that it is important to diffuse negativity and seek tolerance for the ideas or be willing to make modifications to gain acceptance. When needed the community lay worker can inquire for more knowledge to continue on the path of solving its identified problem says Hildebrandt. This theory requires a substantial investment from both the community and the health care provider.

Community Empowerment Flow Chart

Figure 1 Community Empowerment conceptual flow chart (Smith & Liehr, 2008).


The proposition of this theory is that when the community identifies its own needs and takes the steps to meet those needs, there will be positive outcomes from their investment. The theory elicits community participation with the lay worker to promote reciprocal health using different and unconventional ways to garner health (Smith & Liehr, 2008).

Theory Analysis

Theory’s Origin

The Community Empowerment Theory is a modified extension of Hildebrandt’s Community in Health Empowerment model. Hildebrandt did considerable work with the vulnerable Black population in South Africa and that became the basis for research that correlated with the vulnerable populations in the United States (Smith & Liehr, 2008).

Persily had a history of 20-years work in the area of women’s health and childbearing. Though her research she discovered that mothers sought help from a variety of caregivers. It was that discovery that led to the idea that a nurse need not impart all health interventions (Persily, 1995).

Needing more, Persily and Hildebrandt combined their efforts to create the Community Empowerment Theory.

Unique Focus

Persily and Hildebrandt believe that community health has the capacity to be the first line in the addressing public health issues (Smith & Liehr, 2008). That focus was formally presented in the Healthy People 2010 goals asking communities, organizations and the general public to achieve the set goals by 2010 (U.S. Department of Health and Human Services, 2000).

The theory is unique in using lay workers to impart the education to the community, unlike the public health nurse the lay worker is indigenous to the community and is often

times more readily accepted (Smith & Liehr, 2008). The use of lay workers is seen to be successful in other areas of home visitation and is the reason behind the increase in services being sought (McFarlane & Wriist, 1997).


The four nursing metaparadigms include person, environment, health and nursing (Branch, Deak, Hiner & Holzwart, 2000). The Community Empowerment Theory was designed to encompass each component of the nursing metaparadigm. The person is the community lay worker and community member, the environment is the vulnerable neighborhoods, health is the perceived problem within the community and nursing is the public health nurse. Together with the sharing of knowledge, interest and dedication the community is critical in addressing the problems before them.

Theory Evaluation


This theory‘s potential continues to be the reduction of the negative effect of limited access to health care resources needed to care for the at-risk populations with using a non-traditional approach with lay-workers (Smith & Liehr, 2008). This allows the community to reach outcomes concerning their health otherwise non-attainable.


Considering the public health lens of this theory it has significant importance in addressing the needs of the vulnerable communities. The buy-in of community partners is essential to the ultimate success of the theory, without the resource support some avenues will remain non-existent. Each community has specific issues that will be necessary to address, however it is the problem that the community feels is of utmost importance that should be addressed (Hildebrandt, 1994).

Logical Congruence

Referencing to the theory is consistent through out the literature. Persily’s dissertation work on health care seeking interventions left her short of key components for theory development and she sought Hildebrandt’s Model for Community Involvement in Health Program (Hildebrandt, 1996). Through discussion the Community Empower Theory was adapted to address the community participation in its healthcare (Smith & Liehr, 2008).


Hildebrandt (1996) stated, the validity and reliability of the interview process was monitored with a number of checks to assure the responses were authentic. She indicated that training was provided and the importance of the interview was thoroughly explained. Additionally, there were a variety of internal checks for validity of the responses including random checks, repeat friendly visits to discuss results or separate retest with different interviewer

Contribution to Nursing

The Community Empowerment Theory is vital to public health nursing with supported interventions and buy-in form the community members. The theory develops social relationships with community participation as lay workers to promote reciprocal health. It addresses the needs within the vulnerable areas of communities and helps address the meeting of mounting needs in those communities (Smith & Liehr, 2008). The theory works to promote a united front led by the community for the community to achieve healthy outcomes.


Branch, C., Deak, H., Hiner, C., & Holzwart, T. (2000). Four Nursing Metaparadigms. Nursing, 132-132. Retrieved from

Dean, K. (1989). Self-care components of lifestyles: the importance of gender, attitudes and the social situations. Social Science Medicine 29, 137-151

Department of Health and Human Services Office of the Inspector General. (1992). Use of the emergency room by Medicaid recipients (OEI-06-90 00180). Retrieved from

Higgins, P. A., & Moore, S. M. (2000). Levels of theoretical thinking in nursing. Nursing Outlook, 48(4), 179–183.

Hildebrandt, E. (1994). A model for community involvement in health (CIH) program development. Social Medicine, 39, 247-254.

Hildebrandt, E. (1996). Survey data collection: Operationalizing the research design. Public Health Nursing, 13(2), 135-140.

Hildebrandt, E. (1996). Building Community Participation in Health Care: A Model and Example from South Africa. Image: the Journal of Nursing Scholarship, 28(2), 155-159. doi:10.1111/j.1547-5069.1996.tb01209.x

Kim, H., McConnell, K. J., & Sun, B. C. (2017). Comparing Emergency Department Use Among Medicaid and Commercial Patients Using All-Payer All-Claims Data. Population Health Management, 20(4), 271-277. doi:10.1089/pop.2016.0075

McFarlane, J., & Wriist, W. (1997). Preventing abuse to pregnant women: Implementation of a mentor mother advocacy model. Journal of Community Health Nursing, 14, 234-249.

Orem, D. (1991). Nursing: Concepts of Practice (4th ed.). New York, NY: McGraw-Hill.

Smith, M., & Liehr, P. (2008). Theory of Community Empowerment. In Middle Range Theory for Nursing, Second Edition (pp. 131-144). New York, NY: Springer Publishing Company.

United States Department of Health and Human Services. (2000). Healthy People 2010. Retrieved from