1. Introduction

The nursing profession continues to struggle with the delivery of health care to patients within communities affected by high rates of morbidity and mortality. One of the primary functions of nursing is to give care with quality and awareness, promoting an atmosphere of education and disease prevention. However, this function can only be effectively accomplished if special attention is given to patients’ socioeconomic, cultural, and community backgrounds[1]. Researchers such as Byerly & Stein[2] discuss the potentially negative influence of income, education, culture, and gender on positive health outcomes and encourage health care providers (e.g. nurses) to develop education and treatments that meet the specific needs of the community population.

Community-based approaches to health promotion remain important to nursing practice and provide an effective basis for the inclusion of primary prevention methods in the delivery of nursing care[3]. These approaches offer greater understanding of the relationships between individuals, the environment, culture, and administrative constraints and the impact on health decisions. However, the manner in which prelicensure nurses are introduced to these concepts can vary and may not include practical opportunities toward understanding these methods. Although schools of nursing (SON) around the world are required to teach some elements of population health and community-based health promotion (CBHP), the depth of education and training varies and are influenced by the availability of multiple resources. These variations and challenges potentially deliver a nurse unable to provide the most effective care management to a population with the greatest need.

2. Background

2.1. Community-Based Health Promotion and Improvement of Health Outcomes

Primary prevention approaches to health care are recognized as one the most effective methods used to reduce the rates of disease in community populations[4]. These methods include the provision of health specific education toward the reduction or removal of risk factors (environmental and personal). The use of primary prevention in CBHP allows nurses the ability to better understand the determinants of community health and design quality health promotion programs for improved health outcomes[5]. Although, this method is a proven process for supporting health promotion and community education, it does not always include the direct involvement of the community-at-large. Therefore, other principles such as community engagement and collaboration must be included in all efforts by health care personnel when planning health care programs.

2.2. Nurses and Community-Based Health Promotion

Traditionally nurses are one of the primary tools by which health education is delivered[6]. However, the education predominately occurs in the acute clinical setting after the onset of disease. Thereby, missing the opportunity to utilize concepts of primary prevention and reduce or remove risk factors for disease development[3]. This encourages the patient to address health conditions after their occurrence versus managing the risk factors that lead to the advance of disease. As a result, the nursing profession worldwide has acknowledged the need to move nursing’s focus from the inpatient setting to the community setting in an effort to meet the needs of the population where they live, work and play[7]. Consequently, allowing for increased understanding of community, social, economical, and cultural influences on health outcomes. Additionally, nurses have begun to explore concepts of community empowerment, engagement, and equitable sharing of knowledge between patients, families, and health care personnel.

These concepts of community-health are included in numerous research methodologies (i.e. community-based participatory research and participatory action research) but may not be present in more basic nurse-led community-based health promotion programs or projects. Therefore, the impact of these efforts may be minimal, lack community engagement, and may have little impact on improving health outcomes. Nurses are educated in community-health concepts but may not receive educational focus on the collaborative connection and buy-in of all community stakeholders.

2.3. Nursing Education in the U.S.

In the United States all Registered Nurses must pass a national council licensure examination (NCLEX) to determine readiness for practice. This test evaluates all prelicensure nursing school graduates on content related to: (1) Safe and effective care environment. (2) Health promotion and maintenance, (3) Psychosocial integrity, and (4) Physiological integrity[8]. The area of health promotion and maintenance includes community health education, collaborative partnerships, health promotion, wellness, and screening. The licensure exam evaluates a students knowledge of health care risks related to a variety of community populations, planning and delivery of community education opportunities, and assessing the effects of environmental influences on health[8].

In 1986, a document (hereafter called The BSN Essentials) was created as a guideline to all Registered Nursing pre-licensure educational programs in an effort to streamline, define, and support the basic knowledge, values, and skills of nurses. To date, The BSN Essential serves as a blueprint for baccalaureate nursing schools throughout the nation in developing, maintaining, and revising nursing curricula[9]. In 1998 the authors recognized that a major trend toward population-based care would need to be not only addressed by nurses but also introduced to students early in their nursing education. The American Association of Colleges of Nursing (AACN)[9] recognized that health promotion; risk reduction and disease prevention was a core component to the body of nursing knowledge. Two specific types of knowledge required of nursing curricula are[9]:

● Fostering of “strategies for health promotion, risk reduction, and disease prevention across the life span”.

● Initiation of “community partnerships to establish health promotion goals and implement strategies to meet those goals”.

Both of these concepts support the focus of other researchers in encouraging efforts toward primary prevention[5]. The concept of primary prevention being ideal for health promotion is not lost on the nursing profession. The guidelines above show this core idea as being a required key component in nursing education.

Accrediting agencies within the U.S. has several core competencies listed as being required for any level of nursing education (Practical, Diploma, Associate, Bachelor, and Graduate). Nursing competencies are defined as a minimally acceptable level of expertise in a given area of practice[8]. As nurses are theoretically and clinically trained in health care, they are required to be minimally competent in actions of patient care on completion of the nursing program[9]. The idea of community partnership, collaborative management of disease processes, and population-based health is required to be present in all forms of nursing education.

The first competency requires that nurses should demonstrate their caring for the community’s health and wellbeing[8]. It requires nurses to:

● Have broad understanding of determinants of health (i.e. environment, socioeconomic conditions, behaviour, genetics)

● Be able to work with others in the community to integrate a range of services and activities that promote, protect, and improve health

● Take as the unit of analysis the whole population (apply the concepts and tools of epidemiology to a variety to contexts ranging from individual patient encounters to the management of complex systems)

● Apply knowledge of the new sciences

● Advocate for public policy that promotes and protects the health of the public

The restricted involvement of nursing students in CBHP not only limits the students’ exposure to culturally sensitive health care but also potentially stunts the students’ sense of social responsibility and civic duty.

2.4. Nursing Education and Community Partnerships

Many SON may be located within or near communities that have higher than average disease states. These nursing programs include practicing nurses and scholars who, in conjunction with community partners, could address many community-health issues with faculty research, program development and active use of prelicensure nursing students to deliver health education programs to the public. The nursing programs are in a unique position to not only educate new nurses for the workforce but also support the community by active display of engagement and promotion of social change[10].

Nurses are expected to use concepts of empowerment, support and inclusion when providing care and education to the public. These participatory methods promote active stakeholder/ patient involvement in assessing personal health and development of a treatment plan. Failure of nurses (and student nurses) to understand concepts of participatory action inhibits the promotion of patient centeredness and community engagement[11]. Additionally, this has the potential to alienate the very person or groups for whom the education or treatment interventions are designed and ultimately restricts the promotion of primary preventive health care.

Some nursing programs and other academic settings have acknowledged the need to improve their community collaborative efforts and are participating in numerous activities to support these actions and promote their degree of community engagement. Designations such as the Carnegie Community-Engagement Classification[12] acknowledge the efforts of local universities in community engagement efforts and mutual partnerships to prepare educated students and promote the public good. In order to implement and measure the degree of engagement, many schools participate in required service learning activities designed to not only introduce a student to the community setting but to deliver a service or product to the community-at-large. However, the focus of the activity may be one-sided and have minimal (if any) participatory components to their design and may not be effective in improving overall community health outcomes.

Amerson[13] discussed the impact service learning had on students’ perception of civic responsibility and cultural awareness. The author recognized the mutually positive impact the community-based service-learning activities had on student growth and overall health. Community health researchers[14] discuss the process of involving students in mentoring programs designed to promote community-based health. The authors recognized the synergistic learning that takes place between the students and program participants in terms of promoting overall health for residents and socializing students into the profession. Other researchers such as Shoultz et al.[15] described the positive outcome Another example is the use of nursing and dental students in collaborative partnerships with four different community health centers aimed at studying Intimate Partner Violence (IPV) disclosure. In addition to evaluating the rate and occurrence of IPV, the researchers also identified methods for improving education and reporting instances of violence. Both examples utilized nursing students (as well as other health professions education units) to evaluate a problem and implement an intervention. The use of students offers an opportunity for learning within the context of the situation and delivery of a product tailored to a community in need.

2.5. Culturally Sensitive Care

The provision of culturally sensitive and competent nursing care is an important concept in the nursing profession. Leininger and McFarland[1] acknowledge that healthcare is informed by an understanding of how culture, family, environment, and socioeconomic status affect health outcomes and decision-making. The theory encourages health professionals to seek out the input and concerns directly affecting members of the community, from the community, before creating complex medical regimes. Transcultural theory encourages cultural sensitivity for all nursing actions that include patient care and administrative activities. This sensitivity may not be effectively translated to nursing students and is potentially missing when nursing schools lack participatory community-based partnerships and activities with local agencies and members.

3. Community-Based Health Promotion Improving the Health of the Community

The ability of health care personnel to use community-based health promotion methods offers a promising insight into what are considered the missing components of effective disease prevention and health promotion[16]. These authors acknowledge the need for health personnel (e.g., nurses) to consider the social context impacting health outcomes and include the community as a partner in not only identifying health issues but also determining methods for addressing the concerns. Understanding the complexities of community health problems is considered to be a key aspect in improving the state of health for communities. However, health care leaders often resort to more traditional approaches when they plan health promotion projects. A traditional approach frequently leaves the community outside of the decision-making process and encourages a feeling of community isolation and non-involvement[17].

The use of community-based approaches to primary prevention (e.g. CBHP) allows health care professionals to better understand the determinants of health—of the community and the individual—and how to research issues and design educational programs that best meet the needs of those individuals and communities. The primary function of a nurse, with regard to health promotion and protection, is to act as an advocate, care manager, consultant, deliverer-of-services, educator, and healer[5]. This role responsibility and the methods for identifying community-based problems are both foundational and vital in nursing education.

Pommier, Guevel, & Jourdan[18] completed a study that evaluated the effectiveness of a community-based health promotion project directed with local schools. The authors used a mixed approach in identifying the methods and factors that allow for development of health promotion in schools by evaluating the strategies that influence teachers, the school’s environment and influence of the health promotion project on children’s perceived life skills. Pommier, Guevel, & Jourdan[18] used a combination of quantitative and qualitative research methods to answer the following research questions:

1. What are the mechanisms and the contextual factors that allow the school community to develop an HP (health promotion) approach?

2. How do the strategies developed through the program influence the development of teachers’ HP practices and the schools’ health promoting environment?

3. How do these practices affect well-being in the schools?

4. What is the influence of the program on the children’s perceived life skills?

The use of surveys and interviews assisted these researchers in obtaining a clearer understanding of the collected data and the overall effectiveness of the project. Traditional methods were noted to be less than adequate in the management of disease symptoms and quality of life. The authors used effective methods for identifying the importance of this research and the methodology was very appropriate to the variables being evaluated offering a good example of the impact peers can have on health awareness and promotion.

Members of the community often view nurses as a form of community peers[19]. Therefore, nurses have an opportunity to use this relationship to educate the public on their level. The language used was clear and unbiased and properly supported by recent and relevant references. However, the authors failed to consider some variables related to the students that might impact the results. Some of the variables include race/ethnicity, socioeconomic background and initial level of disease education. These factors should have also been considered to be additional variables and could have been included in the list of confounders.

3.1. Barriers to Action

Educators report the lack of student involvement in CBHP activities is a result of the lack of time, resources, and personnel[20]. These constraints reduce the ability of nursing students to understand community-health concepts and the delivery of culturally sensitive and competent nursing care. Even if nursing educators can move beyond these constraints and involve students in CBHP, they will often face other challenges to collaboration such as resistance to change, power structure struggles, ineffective communication, and lack of knowledge about other health care disciplines[21].

Although SON might engage in community-based practicum activities, the focus and depth of those activities may limit active stakeholder partnerships. Educators frequently report joint efforts toward promoting community health with local community agencies[21]. However, the activities may lack full involvement and receipt of mutual benefits from all participants. Additionally, educators might find the barriers listed to be too challenging to overcome. Nursing education representatives agree that students require knowledge and awareness of community based health promotion, but the reported challenges (time, resources, personnel) minimize the potential impact to the community [20].

3.2. Community Stakeholders

Community partners are eager to develop existing and create new SON collaborations[20]. The continued development of these partnerships has the potential to grow to levels that far exceed current national reporting. Unfortunately, this is hindered when SON allow stated barriers to limit or impede their progress.

A study performed by Shannon[20] interviewed local community members and leaders about ways in which community-heath education theory and practice might be strengthened in community-based nursing programs. The study participants (N=10) reported that they wanted to see an:

● Increased presence of nursing students at local community agencies

● Improvement in the student’s sense of value and responsibility toward the delivery of community health

● Improvements and expansion in the development of SON relationships with community partners.

The participants reported feelings of discontent with some of the methods chosen by local SON to deliver community-health and teach these concepts to new nurses. For example, when asked about their thoughts regarding current SON and community relationships and what measures would they like to see implemented, one community member key informant replied:

●“… I would like for it (the practicum rotation) to be more of an encompassing experience than just learning technical skills, I want social skills as well. It would be really nice for them to obtain that exposure.”

Another community leader offered a similar response:

●“…I think that many times they are not able to really see what community health is because of its time constraint but even that little bit will help to give them a better understanding of the role of the community health nurse…”

Additionally, some respondents voiced a desire for extensive faculty-community partner relationship development. The respondents recommended SON work with local agencies to identify ways to increase the level of “buy-in” on behalf of the students when learning about and delivering community health. Community stakeholders were reported to be very eager when discussing and sharing ideas of relationship building with local nursing programs[20]. Shannon[20] reported that most community members became visibly excited when they received the study information was offered. Study participants also reported they believed local nursing schools and community agency collaborations were significant to promoting the health of the community, required to serve the needs of the community and was a natural process that should be explored.

4. Implications for Nursing Education

Nursing educators worldwide are often required to balance student educational experiences with the provision of culturally sensitive, safe and effective nursing care to patients, families and communities[22]. This balance frequently necessitates the use of personalized approaches to student learning, research, and patient care. However, this balance can suffer when scarce time, resources, and personnel block the expansion of CBHP to students and communities. Therefore, nurse educators are encouraged to work together with not only local community members and agencies but also other nursing educators toward identifying specific participatory projects designed to meet the needs of the students and the agencies[23].

This collaboration can encourage active stakeholder communication, partnership and relationship development that initiates dialogue between the faculty, students, community members, community agencies and even other regional SON. Nursing educators should find opportunities to expand nursing education into the community setting[25]. These opportunities could involve the development of regional alliances, in which SON use research modalities such as participatory action research, which encourages local community stakeholders to share and discuss the issues most important to them.

Nurse educators have reported feelings of pride and accomplishment when engaging students in CBHP-type activities[20]. However, the greater impact of these activities might be short-lived and one-sided. The types of community-based experiences designed for the nursing practicums potentially only focuses on the practicum and the student. Therefore, reducing the potential growth opportunities between SON and local partners.

4.1. Obligation of Nurses for Community Health Promotion

The American Nurses Association Code of Ethics[26] establishes the focus of the nursing profession (and preliminary education) as one centered on the education of individuals, families and communities in the quest for healthy outcomes. The professional obligation toward community health should not simply be introduced to entry-level, prelicensure nurses. There is an additional obligation of nursing educators to continue to foster and develop these values of service among student populations from the earliest development of nursing education.

Riley & Beal[27] evaluated the processes by which nurses developed their sense of serving the public. The authors discovered that most experienced nurses used their own personal perceptions of altruism, practice improvement, and giving back to guide their nursing practice. These perceptions did not come from their educational backgrounds but instead developed as a result of their professional experience and on average took approximately three (3) years to result in active community-based participation. The lack of foundational educational focus on community health limits the scope of practice for nurses.

Various nursing pioneers and theorists[28] identified the responsibility of the profession to use culturally and holistically focused methods of education, treatment, and support for populations affected by ever-rising disease rates. The delivery of holistic care requires that patients be supported within the context of where and how they live[29]. This may be taught to prelicensure nursing students in didactic terms but failure to include practical, community-based, community-focused, and culturally competent experiences potentially reduces this concept of holism to a page in a textbook.

The important component of responsibility for promoting community-health is potentially lost on new nurses until well into their active practice[27]. Thus, reducing the impact of the overall profession and total number of people that can and should be helped. Many communities may potentially benefit from the active presence and involvement of experienced nursing faculty and prelicensure students. However, failure of community-based nursing schools to identify this connection potentially diminishes the concept of service upon which the profession was founded.

5. Global Health Nursing

Nurses around the world are exposed to the effects of poverty and disease. In many communities, nurses are the only available healthcare provider and this necessitates the establishment of not only a therapeutic relationship but also an awareness of community responsibility. Leininger and McFarland[1] discuss the ethical and moral implications of globalization on developing nursing practice. The authors identify the need for nurses to consider a renewed focus on the concept of a worldwide community. This requires the profession to take a broader approach toward community-based care, education, and support.

The International Council of Nurses (ICN)[30] acknowledges health promotion as a diverse process that moves beyond the provision of simple health services. The council encourages nurses from all areas of the world to consider their approach toward the promotion of global health. This includes: advancing nursing core values, influencing health policy, and using innovation to develop community partnerships.

5.1. Global Nursing Education

Nurses and other health care workers remain in great demand throughout the world. Although the Unites States reports an increase in the number of prelicensure nursing students and practicing nurses; a shortage remains worldwide. Higher rates of morbidity and mortality strain the already overtaxed resources of health professionals[31]. This requires educational units to place definitive focus on recruitment and training.

Agencies such as the ICN[30] acknowledge the need for nursing education programs to place increased focus on the needs of global populations. This includes providing effective global student learning opportunities and curriculums that support:

● Human rights, social justice, solidarity, and access to health care

● Ethical, legal, and decision-making abilities

● Social action and professional values

The values required to deliver global nursing care are the same values required to support healthy communities at home. However, lack of practical student engagement minimizes the overall impact nurses might have on reducing the impact of disease.

5.2. Global Influences on Nursing Education

Some nursing programs are taking an active approach toward working in tandem with global communities. Vanderbilt University developed an Institute for Global Health and a Global Health Nurse Program[32]. The focus of these programs was to educate developing practioners in methods (patient care, community education, health promotion, health care training) to improve the state of health for international communities. Additionally, nurses (and other health care providers) were taught methods of participatory collaboration, utilization of limited resources, and policy analysis for the goal of promoting social change. This encourages nursing educators and practioners to consider a wider reach in terms of educating others within their own social context. Furthermore, the active collaborative nature of the program supports communities with vulnerable populations.

6. Recommendations for Nursing Educators

Nursing educators worldwide are encouraged to develop active partnerships with local stakeholders. This will open a dialogue for the development of open communication in which education and community seek and receive equal benefits. Nursing educators are also encouraged to expand their own knowledge into public health, policy development, and global support.

Nursing programs have the ability to create an alliance of regional and international SON that are devoted to promoting participatory community health concepts. This potentially reduces the impact of the stated challenges to community collaboration with a sharing of knowledge, resources and support. These measures can be performed locally or on international scale. For example, the American Association of Colleges of Nursing has established an alliance with the Global Alliance for Leadership in Nursing Education to support global efforts for pre and post licensure nursing education[31]. Additionally, the development of memorandums of understanding (MOUs) will allow for a sharing of skills and expectations. This will ultimately support a partnership-synergy[14] that has the potential to not only develop the social responsibility of new nurses but also promote community health.

7. Conclusions

The active incorporation of CBHP and participatory concepts in prelicensure nursing education will provide a foundation for the new nurse’s practice. Inclusion of these concepts is consistent with national guidelines for nursing education (e.g., health promotion, collaboration, and maintenance) but may be outside the general practice of nursing educators[7]. Despite this, these concepts allow the profession to better serve populations that suffer high rates of morbidity and mortality. The barriers that influence CBHP (cost of resources, personnel and time) are often overwhelming for community-based agencies and nursing education alike. Yet, active, participatory collaboration between the SON and community agencies potentially minimizes the impact of these challenges. This supports an educational environment with a focus on service learning and community support. Additionally, it demonstrates a level of community responsibility that is ever-present in the theoretical foundation of nursing education and ethical nursing practice.