a nursing model of community organization for change

A Nursing Model of CommunityOrganization for Change

Diane Anderson, R.N., M.N., M.P.H.Teresa Guthrie, R.N., M.N., and

Rebecca Schirle, R.N., M.N., M.P.H.

Abstract Community health nursing has the potential to reachbeyond the individual and create interventions that a�ect thecommunity as a whole. The Nursing Model of Community

Organization for Change presented in this article describes therelationships among the concepts of empowerment, partnership,participation, cultural responsiveness, and community compet-ence within a community organizing context. These concepts are

implemented through the use of the Nursing Model ofCommunity Organization for Change, which consists of fourphases: assessment/reassessment, planning/design, implementa-

tion, and evaluation/dissemination. This nursing model providesa theoretical framework for community health professionalswhen creating community health interventions in partnership

with community members.

Key words: community health nursing, community organizing,nursing model, community competence, community partner-

ship, empowerment, cultural responsiveness.

Community health nursing is developing relationshipswith and among individual community members andcommunity organizations with the goal of facilitating theempowerment of individuals and the community as anorganized whole, thereby increasing community compet-ence. ``Community health nursing combines the know-ledge and skills of nursing with those of public healthscience to maintain, protect, and promote the health ofspeci®c populations, or aggregates'' (Spradley, 1991, p. 83).

Communities are comprised of individuals who share acommon goal and are bonded by locale, interdependentsocial groups, interpersonal relationships, and culture.The culture of the community gives rise to values, norms,beliefs, and a sense of connectedness for its members(Thompson & Kinne, 1990). Communities possess capa-city, skills, and assets that when recognized and utilizedcan serve as a springboard to action toward communitychange. Through the process of identifying and utilizingresources within the community, the community membersbecome empowered to recognize and understand health-related issues of concern within the community and tomobilize community assets to improve community health(El-Askari et al., 1998).

Community organizing has its roots in social work andgrassroots social movements, such as the labor movementand the civil rights movement (Minkler & Wallerstein,1997). Community organization is ``the process of pur-posefully stimulating conditions for change and mobil-izing citizens and communities for health action'' (Bracht& Kingsbury, 1990, p. 66). Minkler and Wallersteindescribe community organization as ``the process bywhich community groups are helped to identify commonproblems or goals, mobilize resources, and in other ways,develop and implement strategies for reaching the goalsthey collectively have set'' (p. 241).

Diane Anderson, Teresa Guthrie, and Rebecca Schirle are all graduates

of the Community Health Nursing Program & School of Nursing,

University of Washington, Seattle, Washington.

Address correspondence to Rebecca Schirle, 237 NE 139th Seattle, WA

98125. E-mail: [email protected]

Public Health Nursing Vol. 19 No. 1, pp. 40±46

0737-1209/02/$15.00

Ó Blackwell Science, Inc.

40

THEORETICAL BASIS

The Nursing Model of Community Organization forChange combines the nursing process with communityorganizing principles (Fig. 1). The theoretical underpin-nings of the model are derived from a combination ofsystems theory, social learning theory, di�usion theory,and social support theory. These theories were chosenbecause of their emphasis on communities as systems ofchange, environmental e�ects on individual learning,information dissemination at the community level, andthe importance of social relationships to individual andcommunity health.

Systems theory provides a way of regarding a com-munity as a system composed of various subsystems,such as schools, churches, families, and individualcommunity members. In fact, the community systemitself is a subsystem of its various suprasystems, such asthe environment. These systems, subsystems, and supra-systems are each surrounded by boundaries, which havevarying degrees of permeability. The degree of permeab-ility of these boundaries establishes the norms ofinteraction between the system, its component subsys-tems, and the surrounding suprasystems. The boundariesallow for the exchange of information. Feedback loopsby which a system receives its own output as inputserves to maintain stability or promote change (Sills &Hall, 1977).

Important systems theory concepts include ecology,dynamics, interrelatedness, and holism. Ecology refersto a system that is in an interactive relationship with itsgeographic and social environment. Dynamics refers toa system and its component subsystems that areconstantly adjusting and adapting to changes withinthe system or to information received as input. Inter-relatedness describes how system components are inter-related and how a change in one component will causechange within the entire system. Holism refers to theconcept that the system as a whole is greater than thesum of its parts. These system qualities are what makecommunities as systems responsive to community or-ganizing methods of promoting change (Thompson &Kinne, 1990).

Bandura's social learning theory addresses the notionthat behavior, environment, and person constantly inter-act. An in¯uence or change in one leads to a change inanother. However, merely exposing individuals to newinformation is insu�cient to execute behavioral change.The attitudes and behavior of the community can exertsigni®cant in¯uence to facilitate change at the individuallevel. Social norms or pressures are a critical in¯uence inlearning and behavioral change. Utilizing the sociallearning approach, behavior change can be a�ectedthrough use of community members as role models, massmedia, and existing social networks (Baranowski, Perry,& Parcel, 1997; Lexau, Kingsbury, Lenz, Nelson, &Voehl, 1993).

Di�usion theory de®nes di�usion as the process bywhich information, goals, and objectives are communi-cated through certain channels over time among membersof a social system. Information disseminated at theindividual level is ine�ective in promoting community-wide change. Disseminating program components, goals,and evaluation results to the community involves the useof multiple forms of communication, including formal(e.g., media, town meetings) and informal (e.g., ¯yers,posters, focus groups) communication channels. Theultimate goal is not merely dissemination of knowledge,but also the adoption and maintenance of healthierpractices throughout the community (Oldenburg, Hard-castle, & Kok, 1997).

Social support theory describes how aid and assistanceis exchanged through social relationships and interper-sonal transactions. ``An understanding of the impact ofsocial relationships on health status, health behaviors,and health decision making contributes to the design ofe�ective interventions for preventing the onset or redu-cing the negative consequences of a wide array ofdiseases'' (Heaney & Israel, 1997, p. 179).

There are four broad types of supportive behavior oracts included in this theory. They are emotional support

Figure 1. A Nursing Model of Community Organization forChange.

Anderson et al.: Community Organization for Change 41

(expressions of empathy, love, trust, and caring), instru-mental support (tangible aid and service), informationalsupport (advice, suggestions, and information), andappraisal support (information that is useful for self-evaluation). Social support is always intended to behelpful, although the recipients do not always perceivethese intentions as helpful. Social support is providedconsciously by the sender, and although the provision ofsocial support is often an attempt to in¯uence thethoughts and behaviors of the receiver, the support isprovided in the context of caring, trust, and respect foreach person's right to self-determination (Heaney &Israel, 1997).

PURPOSE OF THE MODEL

A nursing model serves a variety of functions: to de®ne ordescribe something, to assist with the analysis of systems,to specify relationships and processes, and to representsituations in symbolic terms that may be manipulated toderive predictions. The purpose of this model is todescribe the relationships among the concepts of empow-erment, partnership, participation, cultural responsive-ness, and community competence within a communityorganizing context (Fig. 1).

KEY CONCEPTS AND RELATIONSHIPS INCOMMUNITY ORGANIZING

Empowerment is viewed as a process whereby communitymembers take control over their own lives and environ-ment. This process builds on the inherent strengths andabilities that already exist within the community. Anempowered community is a competent community. InWebster's New World Dictionary (Neufeldt et al., 1988),competence is de®ned as having su�cient resources totake care of one's needs. This implies the ability to deale�ectively with unexpected problems or threats to well-being. On the other hand, powerlessness is an inability toa�ect one's destiny. This powerlessness is not just asubjective feeling of a lack of power or control over one'sown destiny but also an objective lack of social, political,and economic power to e�ect change in a complex andoften forbidding society. Powerlessness has been found tobe a strong risk factor for illness and disease (El-Askariet al., 1998; Wallerstein, 1992). It follows that empower-ment would be a strong protective factor against diseaseand illness.

In order to increase community competence, it isnecessary to facilitate the empowerment of the individualcommunity members as well as the empowerment of thecommunity as a social unit. It is important to make thedistinction between empowerment of the individual,which focuses on gaining skills and increasing self-esteem,

thereby increasing control over one's life, and empower-ment of the community, which focuses on increasingcitizen participation, strengthening social networks, andincreasing a sense of community identity (Israel, Checko-way, Schulz, & Zimmerman, 1994; Wallerstein, 1992). Itis possible to have a community full of empoweredindividuals and still not have an empowered community.Only by working as a social unit will the community beable to achieve the broad changes needed to addressmajor determinants of health such as socioeconomicconditions, physical environment, and access to qualityhealth care (Washington State Department of Health,1996).

Participation in shared problem solving is one methodof increasing community competence through empower-ment. With each success as a problem-solving unit, thecommunity increases its sense of shared identity and itsproblem-solving ability (Eng, Hatch, & Callan, 1985).Community participation is an essential ingredient ineach phase of the Nursing Model of Community Organ-ization for Change. According to Arnstein (1969),``Citizen participation is citizen power'' (p. 216). Arnsteinvisualizes participation as multileveled with true partici-pation at the levels of partnership, delegation of power,and citizen control. It is at these levels of participationthat citizens are responsible for program management,policy setting, and decision making. In the NursingModel of Community Organization for Change, commu-nity members are given the opportunity to discover thatthrough participation they can promote change and thatby working together they will increase their power asindividuals and as a community.

Community partnership requires a sharing of powerand responsibility, not simply getting people to do whathealth professionals think they should be doing. ``Onlywhen issues are selected by the community itself can a realsense of `ownership' emerge, and this sense of ownershipof the organization is critical to empowerment and to theultimate development of competent communities'' (Min-kler, 1990, p. 271). Community competence refers to theability of the community to engage in e�ective problemsolving. Collective analysis of the community's strengthsand needs is of paramount importance if the communityis to reach its current objectives and future goals.

Cultural responsiveness plays a key role in communityorganization. In order to develop good working relation-ships based on trust, the community health nurse (CHN)must take the time to understand the cultural factors(beliefs, values, and customs) that a�ect interpersonalrelationships. He or she must ®nd out about the culturalmake up of the community and must learn about thehistory of the di�erent ethnic groups in the community(Gonzalez, Gonzalez, Freeman, & Howard-Pitney, 1991).

42 Public Health Nursing Volume 19 Number 1 January/February 2002

In addition, when working with communities, it isimportant to be aware of the cultural factors thatin¯uence the meanings of health and illness from theperspective of the community members. Cultural in¯uen-ces a�ect health-seeking behaviors (Chrisman, 1977) and,therefore, will have a direct e�ect on community healthand on the acceptance by community members of anyhealth promotion project.

Although speci®c health-seeking behaviors are uniqueto each individual, there are patterns that can beidenti®ed based on common ®ndings in the explanatorymodels (Kleinman, Eisenberg, & Good, 1978) and illnessbelief systems of a given culture. Care should be taken tobe sure that the various cultures in the community arerepresented among the community volunteers working onprogram planning. Because these community memberswill be designing the interventions for any given healthissue, the hope is that the interventions will then beculturally relevant and appropriate. Cultural factors willalso have an e�ect on the acceptance of the principles ofself-help, felt needs, and participation. These principlesare not necessarily valued or even viewed as desirable inall cultures (Stone, 1989).

DEFINITIONS OF CONCEPTS

The concepts and de®nitions that are associated with theNursing Model of Community Organization for Changeare shown in Table 1.

ASSUMPTIONS

Identifying the assumptions that are inherent in a theoryor model is necessary to improve understanding ofthe model and its applications among readers. Theassumptions identi®ed in this model include the following:(1) Increased community competence will lead to improve-ments in community health. (2) Participation promoteslearning. (3) Community participation increases the prob-ability of program success. (4) Culture in¯uences commu-nity health-seeking and health-promoting behaviors. (5)Sustainability depends on community participation.

PHASES OF COMMUNITY ORGANIZATION

The four phases of community organization are commu-nity assessment/reassessment, planning/design, imple-mentation, and evaluation/dissemination. The phases donot occur in a linear fashion but overlap and interminglethroughout the community organization process. Stringer(1996) describes this process as ``a continually recyclingset of activities'' (p. 17). For example, there will be theneed to evaluate at each stage of the process. This enablesthe planners to make necessary changes at the time theyare needed. A brief description of each phase of thecommunity organizing process integrated with the con-cepts of empowerment, participation, partnership, com-munity competence, and cultural responsiveness follows.

Community Assessment/Reassessment

Assessment is ongoing throughout the community organ-ization process. Initially, it involves gathering historicaland current information about the community. Data-gathering methods include analysis of vital statistics andcommunity health pro®les, performing a windshieldsurvey, talking with community members, studying thehistory of the community, and learning about the culturesrepresented in the community (Gonzalez et al., 1991).After these information-gathering activities, the CHNshould be able to de®ne the community of interest.De®ning the community ``is a necessary step in deter-mining where community members are and how to reachand organize them'' (Kinne, Thompson, Chrisman, &Hanley, 1989, p. 226).

Once the community is clearly de®ned, the assessmentprocess will be one of increasing community involve-ment. It is necessary to identify key organizations suchas churches, service clubs, local health care providers,schools, and social groups. Attending meetings andother community events will help to identify communityleaders. These resources will be the building blocksfor increasing community competency (McKnight &Kretzmann, 1997). Participation in voluntary associ-ations and strengthening social networks through

TABLE 1. Major Concepts in the Nursing Model of Community Organization for Change

Empowerment The process by which individuals and communities develop an awareness of their inherent problem

solving skills and resources.Partnership A working relationship built on mutual respect, exchange of ideas, and shared power.Participation The community members are engaged in all phases of community organization and have decision-

making authority.

Cultural responsiveness The ability to adapt methods and plans to incorporate the cultural factors that in¯uence themeanings of health from the perspective of the community members.

Community competence The ability of the community to collaborate e�ectively to manage threats to well-being and move

toward the goal of improved health.


partnership are two additional means of empoweringcommunities (McKnight, 1987).

At this point in the process, it is time to form acommunity advisory group (Kinne et al., 1989). Thisgroup should be composed of community members whohave shown an interest in being involved and arerepresentative of the community as a whole. The assess-ment now becomes their assessment of the community'sneeds and assets. This process should involve the entirecommunity through community meetings, surveys,in-depth interviews, and focus groups. Assessment ofthe community's assets allows community members torecognize the potential contributions of each individual(McKnight & Kretzmann, 1997). It allows communitymembers to see themselves in terms of what they haveinstead of what they do not have. Assessment of thecommunity's ``felt needs'' helps to establish trust betweenthe CHN and the community (Gonzalez et al., 1991) andis the ®rst step in establishing community ownership ofthe program. Once assets and needs are identi®ed by thecommunity members then planning can begin.

Planning/Design

Planning is the process of setting goals and objectives andthen designing the interventions necessary to meet theobjectives and reach the goals. Part of the CHN's job is tohelp the community select goals that are ``winnable andspeci®c'' (Minkler, 1990, p. 271). This will promote earlysuccesses, which in turn will promote an increased senseof community. If the community sets the goals anddesigns the interventions, then the program will be theirs.This gives the individual community members a sense ofpower and control over their environment, which are twoimportant factors in empowerment (Wallerstein, 1992).

The community advisory group should coordinate theplanning process with technical assistance from the CHN.This is an essential part of ensuring that the program willbe maintained when the CHN leaves. The CHN acts as atechnical advisor and catalyst. The temporary nature ofthe role of the CHN in this process is an essential aspectof community organization (Kinne et al., 1989). Speci®cplans for sustainment of the program should be includedduring the planning phase. Plans for program evaluationshould also be developed at this time. Careful planning ofgoals and measurable objectives will facilitate the evalu-ation process later (Stringer, 1996). The CHN's role isalso one of resource person. He or she will need to be ableto provide information about fundraising, methods ofhealth promotion, goal setting, and other technical adviceas needed. The CHN should also help to arrange for anyneeded training of community volunteers in whateverhealth issues are going to be addressed.

Implementation

Implementation involves preparing a timeline for com-pletion of each program objective, obtaining the neces-sary funding, collaborating with agencies outside thecommunity as needed, recruiting additional communityvolunteers needed for program implementation (Gonzalezet al., 1991), and actually putting into action the inter-ventions designed during the planning phase. Theseactivities provide many opportunities for communitymembers to develop or improve skills in leadership andteam building, to increase their understanding of thepolitics involved in implementing a community wide plan,and to learn about grant writing and other methods offunds acquisition. Development of leadership skills isvital to the sustainability of the program (Minkler, 1990).The CHN should serve as a support person by facilitatingcommunication among volunteers and encouraging use ofthe networks identi®ed during the assessment phase.

Evaluation/Dissemination

The evaluation phase of community organizing is criticalin identifying both successful and unsuccessful aspects ofcommunity-level projects. E�ective evaluation capturesthe short- and long-term changes that occur as a result ofthe community organizing e�orts. Short-term changesinclude community collaboration, participation, andaction toward health change; long-term changes relateto health outcomes (Minkler & Wallerstein, 1997).

Two methods of evaluating community-organizingprojects are process evaluation and outcome evaluation(Francisco, Paine, & Fawcett, 1993; Gonzalez et al., 1991).Process evaluation begins when the community organizingbegins and is a means of evaluating what is working andwhat is not working throughout the organization process.This is an important element because identifying what isnot working is crucial to the success of the program.Identifying what is working is necessary to point out earlysuccesses to the community members. Process evaluationis especially important in community organizing, wherethe process itself serves as a means of increasing commu-nity competence by ``development of local initiative,individual and community self-reliance, self-con®dence,and a cooperative spirit'' (Foster, 1982, p. 187).

Outcome evaluation is examining what has beenaccomplished as a result of the program (Gonzalez et al.,1991; Pirie, 1990). How e�ective were the interventions?Did the program meet its stated objectives? Were thereany unexpected outcomes? Has community competenceincreased? This information can be obtained throughfocus groups, outcome surveys or specially designedmeasurement instruments (Israel et al., 1994). Dependingon the type of program and the program objectives, there


may be quantitative as well as qualitative data to analyze.Process and outcome evaluations should be performed bythe community advisory group as well as by an inde-pendent evaluator (Francisco et al., 1993). The use of anindependent evaluator provides objective data for com-parison with the advisory group's data.

The information gained from evaluation of communityorganizing outcomes must be disseminated throughoutthe community. This information serves to guide thecommunity in the development of strategies to sustainprograms or pursue di�erent directions in programdevelopment.

Communication of such information can be accom-plished in a variety of ways. Di�usion of information viaoral andwritten reports to key groupswith a vested interestand commitment to the community organization processis vital. Key groups include program leaders and partic-ipants, media representatives, potential support sources,and other organizations (Bracht & Kingsbury, 1990).

CONCLUSION

Community health nursing reaches beyond the individualand creates interventions that a�ect the community as awhole. Through community organizing techniques, theCHN has the potential to mobilize citizens and commu-nities into action to a�ect community health positively.Community members need to be involved and invested inevery phase of the community organizing process in orderto assure community ownership and sustainability of theprogram once the CHN leaves.

This Nursing Model of Community Organizing forChange demonstrates how incorporating the conceptsof empowerment, partnership, participation, culturalresponsiveness, and community competence throughoutall phases of the organizing process can lead to lastingimprovements in a community's health-promotingbehaviors and overall health status.

ACKNOWLEDGMENTS

Two of the authors of this journal article were partiallysupported by Training Grant No. T42/CCT010418-07from the Centers for Disease Control and the Prevention/National Institute for Occupational Safety and Health.The contents are solely the responsibility of the authorsand do not necessarily represent the o�cial views of theNational Institute for Occupational Safety and Health.

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