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 seven 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 saving 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 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 in developing their 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 connections 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. The Community Empowerment theory addresses the community and the demographic that truly aligns with public health nursing. It is a marriage of sorts, what one partner may be reliable in, the other will learn. In return, the lay worker shares the education concepts 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 social relationships, which bring about buy-in from the population served within the community, leading to their self-care.
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 to enhance their experience as a result of engaging with a nurse to take ownership. Hildebrandt felt these engagements would lead to better health care decisions.
In 2000, Higgins and Moore presented the general ideas of a middle-range theory as including being considerably specific with engagements with small groups of distinct concepts that are related to our living environments. The method of community empowerment is a middle-range theory that consists of three concepts
- Lay workers
- Reciprocal health (Smith & Liehr, 2008).
The community empowerment theory’s involvement in specific community health, while bridging the health care gap with lay members educated by professionals for their health
Improvement is itself a particular definition for a middle-range theory. The achievement of community empowerment is when community-based lay-workers involve themselves with seeking knowledge to obtaining reciprocal health. These concepts are foundational in developing and providing care to the community. The fundamental concepts of the community empowerment theory are specific to the theory itself and include:
- Involvement – willingness to investigate and promote change
- Lay workers – community individuals willing to learn and participate in change
- 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 essential. 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 it is essential 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 significant determinant of health is self-care adaptation. Relationship building within the community is a substantial determinant to the success of this theory.
The Community Empowerment Theory takes its roots from the Community Involvement
in Health program developed in 1994 by Hildebrandt and driven by the need for the community to take ownership or a partnership in 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 address the need. The solicitation of supportive asset representatives for assistance, and those who may be barriers to the selected plan are only asked to understand the process. Workgroups are set up, with the devlopment of plans and goals. Tasks include many jobs, including the transfer of knowledge, social medial, outreach, and more. Deadlines are tentatively set and frequently reviewed. Nurturing the program is imperative to its success and growth. Oftentimes, the measure of success is an evaluation of processes that ocurr to meet unmet goals. Maintaining communication with both the supporters and those who provided acceptance is essential. Continually evaluate the program for appropriate outcomes and need for change and continue to solicit the support from those who provided approval (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, it is important to remember that it is the community’s problem and when they complete the process of creating a solution they are more invested in the outcomes (Hettema. Steel & Miller, 2005). If community members express interest, it is important to get them involved in 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).
This theory proposes that when the community identifies its own needs and takes steps to meet those needs, there will be positive outcomes from their investment. The method elicits community participation with the lay worker to promote reciprocal health using different and unconventional ways to garner health (Smith & Liehr, 2008).
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. Through 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.
Persily and Hildebrandt believe that community health can be the first line in 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 a public health nurse, the lay worker is indigenous to the community and is
frequently 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 (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 has a sense of empowerment in addressing the problems before them.
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 use of a non-traditional approach with lay-workers (Smith & Liehr, 2008). The theory 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 a need that the community feels is important and should be addressed (Hildebrandt, 1994).
Referencing to the theory is consistent throughout the literature. Persily’s dissertation work on patients seeking useful interventions left her short of critical components for theory development. She found Hildebrandt’s Model for Community Involvement in Health Program as a completing component (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 for the theory development were monitored with several checks to assure all responses were authentic. Additionally, there were a variety of internal checks for the validity of the responses including random checks, repeat friendly visits to discuss results or separate retests with a 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 (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 https://scholarworks.iu.edu/journals/index.php/iusburj/article/download/22199/28143/
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 https://oig.hhs.gov/oei/reports/oei-06-90-00180.pdf
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 https://www.cdc.gov/nchs/healthy_people/hp2010.htm
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