Discussion: Program Implementation in Health Care and Community Settings

Journal of Community Health Nursing, 26:24–34, 2009
Copyright © Taylor & Francis Group, LLC
ISSN: 0737-0016 print/1532-7655 online
DOI: 10.1080/07370010802605762
Public Health Nurses’ Primary Health Care Practice:
Strategies for Fostering Citizen Participation
Megan Aston and Donna Meagher-Stewart
School of Nursing, Dalhousie University, Canada
Nancy Edwards
School of Nursing and Department of Epidemiology and Community Medicine,
University of Ottawa, Canada; CHSRF/CIHR Nursing Chair Director,
Community Health Research Unit, Canada
Linda M. Young
Public Health Services, Capital District Health Authority, Canada
Citizen participation is heralded as a critical element of community health programs that emphasize
empowerment and health promotion strategies. Although there is a growing body of research on public health nurses’ primary health care practice, few studies have described how public health nurses
foster citizen participation. This article presents findings from an interpretive qualitative study of public health nurses’ perceptions of their role in fostering citizen participation in an eastern Canadian
province at a time of significant health care restructuring. The findings from this study clearly profile
public health nurses as integral to the practice of fostering citizen participation.
Citizen participation is a critical element of health programs. Full citizen participation attends to
client values, interests, and concerns, with citizens having the right and duty to actively participate
in and be in control of assessing, planning, implementing, and evaluating their health and health
care both individually and collectively (World Health Organization [WHO], 2003). In Canada, citizen participation has been recognized as a key component of frameworks to guide community
nursing practice (Community Health Nurses Association of Canada, 2003).
Public health professionals in Canada have historically been concerned with establishing public policies that address the social and environmental conditions that deny access to health care/
services (Canadian Public Health Association [CPHA], 2001). From the late 1970s to the early
1990s, public and professional rhetoric called for a new public health that included a move toward
primary health care with greater citizen participation and an expanded community development
approach to health care practice (CPHA, 2001; Epp, 1986; Ottawa Charter on Health Promotion,
Correspondence should be addressed to Megan Aston, RN, Ph.D., Assistant Professor, Dalhousie University, School
of Nursing, 5869 University Ave Halifax, Nova Scotia, Canada B3H 3J5. E-mail: megan.aston@dal.ca
FOSTERING CITIZEN PARTICIPATION
25
1986). Although there is a growing body of research on public health nurses’ primary health care
practice, fewer studies have described how public health nurses foster citizen participation
(Health Canada, 2002; Rodger & Gallagher, 2000). This article presents findings from an interpretive qualitative study of public health nurses’ perceptions of their role in fostering citizen participation. These findings are part of a larger study that examined public health nurses’ primary
health care practice at a time of significant health care restructuring (Meagher-Stewart, Aston, Edwards, Young, & Smith, 2007).
LITERATURE REVIEW
Public health nurses have more than a century-long legacy of addressing broad inequities in health
and building capacity with people who are disadvantaged by their life circumstances (Reutter &
Ford, 1998). Their practice focuses on vulnerable populations, issues of social justice, and empowerment (Aston, Meagher-Stewart, Sheppard-Lemoine, Vukic, & Chircop, 2006; Edwards &
Davison, 2008). Services delivered by front-line community health nurses and social service professionals can be empowering to disadvantaged groups and communities who often mobilize
around lack of health and/or social services or access to them (Sadan & Churchman, 1997). Citizen participation is one of the five principles of primary health care—accessibility, citizen participation, intersectoral cooperation, health promotion, and appropriate technology (WHO, 1978)—
and therefore needs to be understood within this guiding frame. The central tenants of primary
health care support a provider-as-partner role with lay persons and other health professionals,
characterized by reciprocity and equality in the levels of status, control, and responsibility between the professional and the lay person (Stewart, 1990). In her review of Canadian and U.S. literature, Hardina (2003) examined the relationship between citizen participation and empowerment that developed from the 1960’s to 2000. She submitted that “Empowerment activities
include engagement and dialogue with constituents, leadership development, and the creation of
organization structures that encourage decision making by program beneficiaries” (p. 33). However, she acknowledged that including citizens who would provide a representative point of view
is a challenge, but deemed to be important and integral to the self-help, coproduction of services,
and peer support processes. Abelson (2001) also concluded that it is important to understand community values and context when involving the public in local health care decision making
processes.
Other important concepts related to citizen participation and empowerment can be found in
Kretzman and McKnight’s (1993) discussion of asset-based community development that focuses on strengths of communities as well as Freire’s (1970) ideas on critical consciousness and
trusting relationships. Similarly, Jackson, Cleverly, Poland, Burman, Edwards, and Robertson
(2003) developed a model that focused on strengths and assets of community members within
a socio environmental context. Sadan and Churchman (1997) offered an empowerment model
of process-focused community planning and professional practice that focused on individual
and community assets and strengths. They noted that the empowering process is contingent on
the attitudes of professionals toward local knowledge and experience, and the quality of community involvement that the professional encourages. Furthermore, overcoming disempowerment includes professionals’ ability to understand and shift their power relationships in
their communities.
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ASTON ET AL.
According to Charles and DeMaio’s (1993) framework, citizen participation is an essential aspect of the decentralization of health care decision-making with provincial or state governments
moving away from a “professionally dominated decision making process and toward a more participatory process that includes local communities” (p. 884). The framework includes three domains of participation; level of participation, role perspective, and decision making. Charles and
DeMaio proposed that the restructuring of health decision-making provides an unprecedented opportunity for the advancement of citizen concerns and ideas. Recent growth in the consumer-control movement has led to increasing citizen demands to have choice and participation in decisions
that affect their health (Stewart & Reutter, 2001).
There is a paucity of research highlighting the practice of empowerment and citizen participation by public health nurses and other health professionals. Byrne (1998) conducted research with
nurses who facilitated an empowerment group with people experiencing mental illness and noted
that there was a shift in the nurses’ practice from doing to to working with. Falk-Rafael (2001), in
her qualitative study of public health nurses, identified a client-centered approach that included a
relationship of mutuality and trust as central to their practice and consistent with an empowerment
process. A pilot study conducted by Aston et al. (2006) reported how public health nurses and new
mothers experienced empowering relationships during home visits.
Action research conducted by Moyer, Coristine, MacLean and Meyer (1999) with frail and isolated older adults enabled them to develop a capacity building model for communities. Elements
in the model included capacity building, citizen participation, working cooperatively, working in
partnership with a community agent, and working across different sectors of the community.
Westbrook and Schultz (2000) described the work of a public health district multidisciplinary
team approach. They specifically cited the nurses’ role as strengthening agency within groups and
communities to cocreate health through partnership, and intervening in the environment to support collective agency.
There appears to be strong support for the concepts of citizen participation and empowerment
from many sectors. Few would dispute the philosophical and practical benefits of incorporating
the voice and strengths of citizens into a mutually beneficial relationship with health professionals, institutions, and government. However, the question still remains: How is citizen participation
effectively carried out in the daily lives of Canadian citizens between individuals, families, communities, and health care professionals? With a focus on public health nurses as front line workers,
we set out to research this important question.
METHODS
Through an interpretive qualitative study, the following research questions were explored: (a)
What is the nature of public health nurse practice in fostering citizen participation and healthy
public policy? (b) What are facilitators and barriers to this practice?
Study Setting
The study was conducted in a province in eastern Canada with less than one million residents (Statistics Canada, 2005). At the time of the study, there were approximately 147 public health nurses
in the province, with the majority (76%) practicing in three mandatory programs: family health,
FOSTERING CITIZEN PARTICIPATION
27
school health, and communicable disease control. The other nurses (24%), who worked in more
rural areas, practiced in a generalist model.
Recruitment and Data Collection Procedures
Ethical approval was obtained from the University’s ethics board and the District Health Authority’s ethics boards. Potential participants for individual interviews were identified randomly from
a roster of nurses who had worked in their positions for at least 3 years. Purposeful sampling
(Patton, 2002) was used to augment the randomly selected participants, ensuring the inclusion of
nurses with diverse experiences, including rural and urban practice; and representation from all
focused program areas and generalist practice. A semistructured interview guide was used for
90-min face-to-face interviews (n = 44). Nurses were asked to describe their primary health care
practices. A copy of the audiotaped interview was mailed to each participant, with a 30-min follow-up telephone interview conducted 2 to 3 weeks later for verification and elaboration of transcript content. Five 90-min focus groups were conducted, by the principal investigators and research coordinator, with 31 nurses. These included many nurses who had participated in the
individual interviews, as well as other public health nurses, who met the inclusion criterion. The
participants discussed emergent themes from the individual interviews, provided feedback, and
identified strategies to enhance public health nurses’ practice. Demographic data was collected
from all participants.
Data Analysis
Transcribed interviews were thematically analyzed using established procedures (Lincoln &
Guba, 1985; Miles & Huberman, 1994). The principal investigators and the research coordinator
independently coded the interviews, identified emergent themes, and arrived at the final coding
and thematic structure by consensus. The QSR’s N6 qualitative analysis software was used to assist with data management and thematic analysis. Several strategies were used to establish trustworthiness in the research process: random and purposeful sampling, member checking through
return of taped interviews and telephone follow-up interviews, and in-depth descriptions from all
participants.
FINDINGS AND INTERPRETATION
Participants in both the individual interviews (n = 43; one drop out) and focus groups (n = 31) had
worked an average of 14.5 years (range = 4) as public health nurses. The majority were baccalaureate-prepared (72%) with 16% masters-prepared and 12% with a public health diploma; 91%
worked full time; 78% practiced in program focus; and the majority described their practice as rural (46%) or combined rural/urban (42%).
Building capacity for partnership and citizen control emerged as a meta-theme from descriptions of the nurses’ practice with individuals, groups, and communities. Many of the nurses talked
about the importance of making a difference in their clients’ lives that focused on doing with rather
than doing for, so the clients themselves felt empowered to take ownership of their health decisions. Several subthemes reflected how the nurses built capacity for partnerships and citizen con-
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trol: (a) working within a population health promotion perspective, (b) building trusting relationships and rapport, (c) building personal confidence and skills, (d) engaging in empowering
educational strategies, (e) connecting to a broader social network, and (f) facilitators and constraints to their practice.
Working Within a Population Health Promotion Perspective
All participants spoke about how their role had shifted in the last decade from a more singular focus on individuals to a population-focused approach. This required a shift in thinking by the
nurses, as well as by the clients and institutions with whom they worked. The nurses described trying to encourage teachers and students, to think from a population-focused health perspective in
contrast to the historical one–on-one interactions. To illustrate:
You try lots of different ways to get that message out, and if it means being involved in community
group things, for instance, on an advisory committee for the teen health centre and making it so that
they don’t call it a “teen clinic,” they call it a teen health centre because we don’t do any band-aid stuff
[anymore].
Many nurses described how working with individuals and families required attending to social
determinants of health. One nurse stated,
Using the whole population health approach, our job has really shifted from doing sessions with
classes on sexual health primarily, to working more with partners to look at the curriculum and identifying the gaps and doing in-services with teachers. … The paradigm has shifted.
With a focus on citizen participation and authentic partnerships, all nurses noted that they used
strategies such as starting from the client’s perspective, tuning into client readiness and implementing a holistic assessment.
Building Trusting Relationships and Rapport
All the nurses repeatedly stated that building an individual’s or group’s capacity to take control
over their health and the health of their community starts with a mutually trusting and respectful
relationship between the client and the health care professional. Most of the nurses spoke of the
need for a balance of power in this relationship, one in which the nurse saw herself as taking a
more egalitarian approach and strove to shift the balance of power away from the nurse as expert
and include the clients’ voice, perspectives, and ideas. They used several strategies in exercising a
provider-as-partner role: engaging in respectful dialogue and active listening; believing in clients’
capabilities and focusing on their strengths; and creating a safe, welcoming and accessible environment. As one nurse stated, “The important thing is trust. Trust is incremental. It comes in little
waves. If [a] mum’s having a challenge with her breastfeeding, you just build gradually upon it.
But it works only if you have trust.”
Many nurses across all programs stated that it was important to establish a partnership where
the nurse truly believed that the client could make their own informed decisions, as well as acknowledge the hierarchy between expert and client that often exists and work to reduce the traditional power imbalance in the relationship between client and health care professional.
FOSTERING CITIZEN PARTICIPATION
29
Most of the nurses maintained a long-term relationship with several of their clients, and many
stated the importance of their ability to build rapport with their clients. These were the basis for
strong trusting relationships and allowed them to probe beyond the surface of a client’s situation.
As one nurse stated: “But you know the day to day work with clientele [injection drug users] and
establishing the relationship with them and gaining their trust, all those things take time.” Many
nurses established collaborative relationships with the schools by getting to know the teachers and
promoting themselves as resource people and partners at staff meetings.
Building Personal Confidence and Skills
The nurses identified confidence and skills as two key outcomes of building relationships with individuals and groups, which then had the potential to lead to empowering citizen participation.
Strategies included supporting people from marginalized populations to participate in various decision making groups, starting with the clients’ strengths, and giving positive feedback, or affirmation, on what was working well.
Most nurses, in all program areas, expressed a need to seek out the voices of vulnerable individuals and groups who had previously been excluded from decision-making processes. They sought
input from the less empowered populations, encouraging them to have a say in setting directions
and make decisions about their own issues and health concerns. Youth, those living in poverty, and
isolated moms were examples offered. Several nurses spoke of the need to take these voices seriously throughout decision making processes. Many nurses noted that they were conscious of who
was sitting at decision-making tables and who was not. “We continually ask those questions at
each committee that we’re at. So who’s missing? Who needs to be here?” Most nurses started with
the client’s strengths, encouraged them to voice their concerns, and gave positive reinforcement.
All of these helped to build confidence, as illustrated by the following.
And self-esteem, giving them feedback that they are doing a good job … If I’m visiting a new mother
I’ll point out things like, “Oh, aren’t you a great mom?” I’ll say, “Oh, your baby’s so lucky because
you’re singing to them,” or “You’re really attentive; you handle them securely.”
The public health nurses described how their roles continuously changed as they helped to
build a self-help group’s capacity, skills, and confidence. They sensed opportunities for more
group ownership, and they stepped back from the process, giving space for clients to take the lead
Engaging in Empowering Educational Strategies
Public health nurses’ educational roles unfolded in two ways, either as a more traditional consultant or as a process-focused, empowerment-focused educator. As consultants, all nurses spoke
about sharing information related to health promotion, health protection, and illness and injury
prevention in numerous ways. They did this verbally, or by using print material and videos in a variety of settings. For example, one nurse stated “We went into all of our elementary and junior high
schools, not to deliver the program, but to talk to all the teachers and bring the resources out and
give them an up-to-date orientation on the revised manuals.”
A more prominent educational role was revealed in the nurses’ use of process-focused methods. This approach included asking questions, providing information, and discussing possible
next steps as a way of building the client’s decision-making capacity. For example, as stated by
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two nurses,“[We were] trying to spark their interest in the program again, even though it’s been
around for a long time.” and “Getting back to that issue of being a catalyst to sort of getting people
a little bit more vocal and active in their own care of themselves”
The nurses described starting where the client was at, creating open dialogue, and listening to
client needs. To illustrate,
If they don’t have an interest in what you’re doing, that whole adult education type of thing, or if
you’re not coming from where they are, then they’re not going to learn anything. They’re just not going to come, or not going to be there. They’re not going to take advantage of the information that you
have.
Connecting to a Broader Social Network
All of the nurses reported actively connecting individuals and groups to broader social networks.
This was more obvious among nurses in rural settings, who were key community players. Participants in our study gave numerous examples of creating participatory infrastructure by building
partnerships among clients, establishing self-help groups, advocating for clients by connecting
them to other agencies, and linking together agencies to provide the best possible service for clients. To accomplish this, many nurses indicated that it was important to know community needs,
as well as available programs and services. For example, they had established relations with community services and family resource centers. This enabled them to tap into client strengths and
concerns and link them to appropriate services. Tapping into the strengths of clients was a common thread throughout many of the subthemes, that was understood to be empowering, client focused, and located in a population health promotion framework.
Many public health nurses developed partnerships with local organizations that were working
on similar health topics. “Ours would be more partnering with [an organization] if there was a project or something going on that we would actually involve a community member to be part of”.
Several nurses worked collaboratively with agencies from many sectors of their community to
build skills and create participatory infrastructures. In one example, teens from youth health centers were encouraged to have a say in broader community activities. The role of a public health
nurse in these organizational relationships varied from collaborator, skill builder, and enabler to
resource person and educator. These supportive roles were integral to bringing people and agencies together.
Most public health nurses described their knowledge and ability to make connections happen
for their clients as a significant skill. They saw part of their role as going to bat for their clients,
particularly those who were more vulnerable.
So you have to go to your community, to the grassroots, to be able to get community support. So that
means going to the women’s groups, going to the men’s groups, going to church groups, going to your
community health boards, and the people who are the movers and shakers in your community.
Facilitators and Constraints to Fostering Greater Citizen Participation
All the nurses discussed facilitators and constraints to their practice. Most indicated that they felt
understood and supported by their public health managers, and all stated that they were supported
FOSTERING CITIZEN PARTICIPATION
31
by peers. A few participants spoke about support from other agencies, providers, and the general
public.
The nurses identified many constraints to their practice of fostering citizen participation. Dominant among these were lack of funding for health promotion and prevention programs, and misunderstanding of public health nurses’ roles by politicians, the general public, and managers. Others included lack of visibility, increased multiple demands, and reduced presence at provincial
planning tables. One nurse stated:
Most people in my area, they’re still a lot of people that don’t know we’re not coming in to put a
band-aid on, and they really only understand nursing as that. And that, all by itself, is a bit of a barrier.
Education isn’t seen or valued, as the real value is to care, in caring for the sick as opposed to helping
people learn how to keep themselves well. So education on all levels: from population to the
government.
Managers who did not fully understand the role of public health nurses were not always able to
provide appropriate guidance and direction when organizing workload and health programs, creating inconsistency in the role nurses played and confusion over health priorities.
Several nurses spoke of being overwhelmed by the workload. Doing more community driven
activities that fostered citizen participation pulled them in many directions and created conflicted
loyalties with mandated programs such as immunization clinics.
The only thing I can think that has changed, a few years ago I think were were in the community,
maybe about 80% of our day was spent in the community. Now I would say no more than 30% of my
time is spent in the community, because the rest of the time we spend on paperwork.
DISCUSSION
Public health nurses in this study demonstrated their commitment to primary health care and population-focused health beginning with citizen participation. The relational work between clients
and public health nurses created empowering processes whereby citizens were supported to participate in assessing, planning, implementing, and evaluating their health and health care. Framing
their practice within a population health perspective supported an inclusive and holistic use of social determinants of health (Hamilton & Bhatti, 1996; Population Health Template, 2001). There
were many examples of how nurses supported marginalized and vulnerable populations to feel
more confident with their health choices by connecting them with broader social networks to
share strengths, build individual and community capacity, and promote citizen voice within community groups. This focus on empowerment and accessibility exemplifies how public health
nurses worked from a position of social justice and equity. The work of social justice is supported
by the code of conduct for nurses in Canada (Davison, Edwards, Webber, & Robinson, 2006).
Stevens and Hall (1992) described citizen participation as an egalitarian partnership between professionals and lay persons, groups, and communities that consider issues of social justice and equity that are inherent in primary health care. In their reflective article, Drevdahl, Kneipp, Canales
and Dorcy (2001) reminded readers that public health nurses’ historical practice has been to advocate for a healthy society through social justice.
Building trusting relationships, confidence, and skills was integral to the empowerment process. Other authors similarly concluded that nurses’ empowering practices occur within nurturing
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ASTON ET AL.
nurse-client relationships through trust, support, encouragement, and building capacity
(Falk-Rafael, 2001). Carin

References:

Nursing Standards

Nursing and Midwifery Board of Australia. (2018). Code of conduct for midwives. https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx

Clinical Guidelines

Guideline Adaption Committee. (2016). Clinical practice guidelines and principles of care for people with dementia. NHMRC Partnership Centre for Dealing with Cognitive and Related Function Decline in Older People. https://cdpc.sydney.edu.au/wp-content/uploads/2019/06/CDPC-Dementia-Guidelines_WEB.pdf

Living Guideline

Stroke Foundation. (2022). Australian and New Zealand living clinical guidelines for stroke management – chapter 1 of 8: Pre-hospital care. https://app.magicapp.org/#/guideline/NnV76E

Evidence-based practice

BMJ Best Practice

Goldfarb, S., & Josephson, M. (2020). Cystic fibrosis. BMJ Best Practice. https://bestpractice.bmj.com/

Schub, T., & Cabrera, G. (2018). Bites: Head lice [Evidence-based care sheet]. Cinahl Information Systems. https://www.ebscohost.com

Beyea, S. C., & Slattery, M. J. (2006). Evidence-based practice in nursing: A guide to successful implementation. http://www.hcmarketplace.com/supplemental/3737_browse.pdf

JBI: Evidence summary

Swe, K. K. (2022). Blood glucose levels: Self-monitoring [Evidence summary]. JBI EBP Database. https://jbi.global

JBI: Best practice information sheet

Bellman, S. (2022). Experiences of living with juvenile idiopathic arthritis [Best practice information sheet]. JBI EBP Database, 24(1), 1-4.

Cochrane Database of Systematic Reviews

Srijithesh, P. R., Aghoram, R., Goel, A., & Dhanya, J. (2019). Positional therapy for obstructive sleep apnoea. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD010990.pub2

Drug Information

Codeine. (2023, January). In Australian medicines handbook. Retrieved February 2, 2023, from https://amhonline.amh.net.au

Colorado State University. (2011). Why assign WID tasks? http://wac.colostate.edu/intro/com6a1.cfm

 

Dartmouth Writing Program. (2005). Writing in the social sciences. http://www.dartmouth.edu/~writing/materials/student/soc_sciences/write.shtml

Rutherford, M. (2008). Standardized nursing language: What does it mean for nursing practice? [Abstract]. Online Journal of Issues in Nursing, 13(1). http://ojin.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/Health-IT/StandardizedNursingLanguage.html

Wagner, D. (n.d.). Why writing matters in nursing. https://www.svsu.edu/nursing/programs/bsn/programrequirements/whywritingmatters/

Writing in nursing: Examples. (n.d.). http://www.technorhetoric.net/7.2/sectionone/inman/examples.html

Perth Children’s Hospital. (2022, April). Appendicitis [Emergency Department Guidelines]. Child and Adolescent Health Service. https://www.pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Appendicitis

Department of Health. (n.d.). Who is being active in Western Australia? https://ww2.health.wa.gov.au/Articles/U_Z/Who-is-being-active-in-Western-Australia

Donaldson, L. (Ed.). (2017, May 1). Healthier, fairer, safer: The global health journey 2007-2017. World Health Organisation. https://www.who.int/publications/i/item/9789241512367

NCBI Bookshelf

Rodriguez Ziccardi, M., Goyal, G., & Maani, C. V. (2020, August 10). Atrial flutter. In Statpearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK540985/

Royal Perth Hospital. (2016). Procedural management: Pre and post (24-48 hours) NPS. Canvas. https://courses.ecu.edu.au

 

 

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