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Community Empowerment

Bruce Leonard

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Learning Objectives

Community empowerment provides a foundation for community health nurses to build partnerships with communities. This chapter provides an overview of how community health nurses may apply the theoretical components of empowerment in practice.

After studying this chapter, you will be able to:

1. Understand a framework for empowering communities through building partnerships with community members.

2. Develop an understanding of empowerment as an important concept in the development of community partnerships to resolve problems, create change, and increase community action to address health and social issues.

3. Apply a bottom-up and/or top-down approach through participatory research as a pathway to community empowerment for improved community health status.

Partnerships between community members and health care professionals are critical for collaborative decisions that promote awareness and understanding of a community's health needs. Community health nursing has the potential to create relationships beyond the individual and develop program interventions that affect the community as a whole. Nurses have long been at the forefront of integrating health resources by forming partnerships with clients, families, and communities. Through the application and use of relationship building concepts such as empowerment, we can influence and reshape the environment to address health disparities among those who are the most vulnerable in our society. The process by which nurses develop positive relationships in the community reflects interactions among the four major constructs of the nursing paradigm: health, environment, client, and nurse.

Community health nurses serve a vital function in developing relationships that promote health and empower others to engage community members in collaborative efforts, partnerships, and coalitions. These concepts are congruent with the World Health Organization's 1986 Ottawa Charter that identifies community empowerment as a central construct for health promotion. Health promotion is fundamental to professional nursing practice. Nurses routinely interact with people in all community settings to promote health by developing positive collaborative relationships.

Community health nursing focuses on health, caring, and relationship building among community members. Community involvement is one of the critical elements of successful problem solving with communities. A basic component of community empowerment is that the community defines its own agenda. The role of the community health nurse involves collaboration and forming partnerships to address problems related to health and social issues. Community participation is a crucial element to engage community members to develop agendas that serve as a cohesive force to mobilize the community toward a process of change. For social change to be long term and relevant to the needs of a community, it must come from the community members themselves. Community empowerment works like a catalyst in creating a sense of readiness to mobilize forces among community members or groups to engage in active community interventions to build relationships.

Perspectives on Community Health Partnerships

Community partnership programs have not always been equitably distributed, nor thought of as essential to community members. Many community health programs of the 1960s emphasized processes of community participation led by academic experts who were in control of health programs and who set the agenda for the types of programs offered within communities. These programs often failed because they lacked true community commitment and involvement. A major lesson learned from failures in the past has been that effective partnerships require active community participation, community ownership and control of programs, and continual relationship building.

More recently, community health professionals have placed a new emphasis on having communities solve their own problems with guidance from experts by forming partnership alliances. Through partnerships, communities can promote health and decrease health disparities to create equitable social, economic, and political conditions. The ideas of community participation as a model for community health initiatives in the 1960s and 1970s now focus on ideas of partnership, collaboration, community empowerment, and community capacity. Rather than allowing self-interests of experts to guide a community, partnerships work by integrating the community's ideas, people, and resources in both the development and implementation processes. A community's level of commitment and involvement may be increased by capacity-building in allowing them to gain knowledge, learn skills, and gain confidence to improve their health through partnerships. The act of creating partnerships is a complex process of bringing together academics, community leaders, and health care providers to accomplish change. Effective partnerships require a sharing of power and decision making along with feedback mechanisms to assure understanding among all parties for successful implementation of community health promotion programs. We will examine how nurses might use these concepts to expand on nursing interventions for initiating social change.

Partnerships are not only important in implementing community-based programs, but must also be culturally sensitive to ensure success. When implementing a program, we need to assist communities in ways that match their perception of health problems. Partnership programs often fail if there is a conflict between the health care provider's and the community's belief systems. We define our own health and illness beliefs based on our cultural and ethnic backgrounds, and on our own perceptions of how to be healthy or recognize illness.

Historically, nurses have had a rich practice in the community, transforming both individual and public health for the poor and the disenfranchised through political advocacy., who coined the term public health nurse in 1893, probably provides our prime example of working with communities to improve health. During the latter half of the 20th century, however, nurses have primarily been employed in hospitals rather than in communities. Our historical focus of nursing in the community has been replaced by"site-managed care systems" such as hospitals and primary care clinics that require the client to come to a facility rather than the nurse providing care within the community.

Today, although many nurses are employed by organizations that provide home health care, community health nursing is more than just providing health care to an individual, but focuses on the aggregate population in providing primary health care as opposed to primary care. The concept of primary health care, as defined in Chapter 1, embraces the ideals of the World Health Organization's Alma-Ata declaration of providing essential health care based on the needs of the community emphasizing health and well-being as a fundamental right for all.

Modern health care emphasizes individualized medical care as opposed to providing aggregate community-based health care. Our present "system" of health care has not served our profession well, and this has resulted in fragmented programs and limited return on improving the overall health in communities. In many respects, modern-day nurses who work for large hospital-based institutions, whose focus of care has been on the individual, have lost their unique voice, innovation, and drive to be proactive in community affairs. Nurses frequently remain silent to what is going on around them in the community; however, what goes on in the community is really the pulse that drives our health care needs. Our challenge as community health nurses is to transform our health care system into one that reflects the values and needs of our communities based on the concepts of primary health care.

Community nurses may transform our fragmented system of individualized health care by reformulating a vision for the future. We must look beyond our past and explore new avenues aimed at improvement of health for all. Rather than focusing on disease-specific problems, we should explore developing new programs with a community focus on providing primary health care.

People in communities deserve comprehensive nursing care aimed at improvement of health and quality of life. Health in this country cannot be improved just by providing health services, but needs to be based on principles of equity, participation, and involvement of communities in making decisions about health care. Successful participation implies negotiation without manipulation and equity in relationships between community members and health care workers who embrace common goals in providing health care with accessible programs and service for all that which relate to the central constructs outlined in the World Health Organization's 1986.

Empowerment Through Community Participation

Community participation is a social process involving people from specific geographic localities who share common values in identifying their needs. Participation in formulating the framework for primary health care in a community may lead not only to better services but also to services based on existing socioeconomic conditions. Rifkin (1986) described three approaches to community participation in health programs commonly used by different countries (Fig. 6.1). One is the medical approach, which is focused on curing diseases and is controlled by the medical profession. The second is a health services approach, which mobilizes people to take an active role in the delivery of services based on modifying unhealthy behaviors.

: Figure 6.1 summary: A diagram illustrating three approaches to community participation in health care. The medical approach and health services approach both feed into a triangle representing top-down approaches that emphasize primary care. Separately, the community development approach leads to a box stating that the community determines the health care services. The figure contrasts top-down primary care strategies with a community-driven approach to health service determination.

The third is a community development approach in which people are involved in the decision-making process to improve health. The first two approaches to health care are top-down approaches, where experts prescribe their values of health care for the public. The third approach is a grassroots approach. approach in which members within the community determine what health care services should be provided. It is more consistent with the principles of primary health care.

Essential components for community participation include the following: (1) a framework to define the community; (2) shared awareness by members of the community; and (3) mechanisms to mobilize the community to recognize its needs and develop a culture of participation. Through empowerment, community health nurses can empower people to make decisions and to act on issues they believe are essential to their health or well-being.

Empowerment through participation has three essential components to which nurses must be sensitive for community transformations to occur (Box 6.1). First, participation is an active process, not a process where one group or organization imposes its values on the community, but a process of mutuality where all have a voice. Second, participation involves choice, implying people have the right and the power to make decisions that affect their lives. Third, the decisions made through participation must have the possibility of being effective, and there are social systems to allow decisions to be implemented. Community participation, according to Rifkin, Muller, and Bichmann (1988),"is a social process whereby specific groups with shared needs living in a defined geographical area actively pursue identification of their needs, make decisions and establish mechanisms to meet these needs" (p. 933).

The role of the nurse in community empowerment is to build effective partnerships through community participation. Only our imagination, vision, and moral or ethical values limit the climate of empowerment we create. Central to professional nursing is building human relationships that preserve human dignity of human-to-human caring.

Box 6.1 Essential Elements of Community Empowerment

- Active process (one that is nonjudgmental and characterized by mutuality)

- Choice (right to make decisions)

- Effective participation (decisions are implemented)

Developing Right-Relationships

Nurses relate to clients, communities, and families on many psychosocial levels. In the development of a nurse-client relationship, nurses interact with clients and communities. For true relationships to develop, there must be a balance of unconditional acceptance between the nurse and the client as a whole person.

The transformation of becoming whole is what identifies as the right-relationship among one or more levels of the human system. Right-relationship is defined"as any pattern of organization within the system that supports, encourages, allows, or generates actualization and self-transcendence—at any and all levels". Nurses play a critical role in the process of assisting communities, families, and individuals in the process of becoming whole as they facilitate right-relationships. The development of the right-relationship is not an ethical or moral judgment, but a pattern of organization that generates self-transcendence or self-actualization.

Communities are composed of many core groups and subsystems in the community-as-a-partner model. Community health nurses assist community members by transforming relationships. If relationships are limited or confined to the elements where “academic experts” maintain control of the health care resources through either medical or health care services approaches, as identified earlier by Rifkin (1986), that emphasize primary care, communities may not be able to maximize their human potentials to become proactive for positive outcomes to occur. Although the “primary care model” of health care strives for predictable outcomes in curing disease, people may be left out in the process. If nurses do not develop right-relationships with communities, community members may not be able to maximize their potential to become empowered.

In the traditional “primary care” approach to health care, community health care workers viewed community members as sources for data gathering or recipients of care. The conventional approach to health care has resulted in fragmented or unwanted programs, with community members as passive participants. Community health partnerships, by contrast, emphasize active participation by community members and health care workers not only from a variety of disciplines, but from every relevant segment of the society. The goal for community health care workers, then, should be to empower community members to visualize their needs and actively participate in planning and implementing the needed change—the tenets of primary health care.

Transforming Communities Through Empowerment

How can nurses assist communities to expand their resources? Empowerment means different things to different people and depends on the context. Community participation exists on many levels that may range from passive compliance by acceptance of the status quo to true shared decision making. Empowerment is an avenue for communities to gain control of resources and transform inequities of power through social change.

Only through the ability to organize and mobilize community forces can individuals, groups, and communities achieve social and political change necessary to rectify their powerlessness. Empowerment enables people to take control of their lives and community resources. Nurses work to empower communities not for domination or control of people, but rather to facilitate the development of others to promote change.

Dialogue is a critical element for community transformations to occur. All voices in a community are important., a Brazilian educator, contributed philosophical and theoretical writings on empowering people through education to reverse the dehumanization and objectification of oppressed people. His concerns deal primarily with class oppression, but his philosophies have been applied to empowerment of professions such as nurses, feminist theory, and vulnerable populations among communities at risk for poor health. In more recent times, broader conceptualizations of Freire's ideas after his death have evolved into concepts related to “popular education”. Popular education has exerted a strong influence on social movements for creating “just societies,” where people who have historically been marginalized can learn and expand their knowledge to help eliminate social inequities.

Community partnerships develop through a process of empowerment. Four characteristics of an empowered community follow:

Faith in people

Trust established through dialogue

Hope in positive transformations benefiting the community as a whole

Discussions grounded in critical thinking without fear of repercussions by those who are in power

Freire (1997) hypothesizes that dialogue or communication between people is the key to empowerment. Each of the empowerment characteristics has been discussed in the following.

Faith in people implies that all people have the potential to provide a voice in community affairs. Faith in humanity encourages a commitment between community members to create and transform the bonds of human communities and interconnect those who live on the fringes or are the most vulnerable to the whole of the society. Vulnerability includes individuals or communities who are camouflaged in our society, such as the homeless, chronically disabled, immigrants, or low-income single parents.

Vulnerable populations are at a great risk in a society for harm to occur and are often those with the least social capital. The risk encountered by the vulnerable is generally not voluntary or under their control. The more risk encountered, the more vulnerable the person or population becomes.

Vulnerability leads to symptoms of victimization, alienation, helplessness, or powerlessness, all approaches opposite to empowerment.

Freire (1997) believes that faith in people through dialogue is a primary component in transforming those who are most vulnerable to be empowered, but we cannot have dialogue without trust. Trust in people is founded on the principles of truth and integrity in our words. Many well-intentioned community projects have failed through false leadership of people saying one thing or designing projects for their own personal reality, ignoring those the project is intended to serve, or performing actions not congruent with their behaviors. Trust occurs when people meet in cooperation to transform ideas into a reality and are committed to making a difference or create change.

Hope is another vital component of empowerment. Hope engenders a sense of inner strength that propels people to act, mobilize forces, and envision a better tomorrow. Hope is all encompassing in providing people protection against despair, and gives them strength, as well as determination to live, when misfortunes in life occur. Empowerment through hope inspires an ability to move beyond the present difficulties and see a future with possibilities.

Empowerment through hope is not an entity of imagination acquired while sitting still, but rather a transformational process fought for with conviction. Empowerment is not an instant transformation, but a slow process of weaving thin threads of society together through dialogue like a spider weaves a web.

Trust, faith, and hope are significant concepts that relate closely to developing relationships, but it is through the process of critical thinking and evaluation that people are ultimately empowered. For empowerment and communication to be successful, people must engage in critical thinking, continually evaluating and reevaluating the premises behind their thoughts. People need to be free to exchange ideas, weighing the positive and negative impacts of change on themselves or their communities. As new realities emerge, people must critically evaluate their world and not remain blind or naive to those who are most vulnerable in our communities. Naive thinking justifies maintaining the “status quo” or the continual oppression of those who are at the greatest risk for harm to occur. For social inequalities to change, we must develop new abilities through education to influence others and transform our communities.

Empowerment is gained through critical dialogue and reflection of critical thought, not necessarily from what is known. It is a process of going from the known to the unknown and reflecting on the possible, with the hope for a better tomorrow. Without critical dialogue, true learning ceases. to exist and only knowledge—not wisdom—is passed between the empowered and the oppressed. Critical thinking encourages the transformation of knowledge into wisdom for those who are most vulnerable. The wisdom gained through critical thought, faith, trust, and hope in humanity may transform social structures from ones of oppression to powerful communities with a voice (Fig. 6.2).

Figure 6.2 summary: A diagram illustrating a model for community empowerment. The top section shows a cyclical process of assessment, analysis, community nursing diagnosis, and intervention—categorized into primary, secondary, and tertiary prevention—which feeds back into assessment. This cycle is linked to the role of community nurses, who assist communities in becoming whole and transform them through empowerment. The model contrasts a "No Right-Relationship" path, leading to a sick-cure primary care model with predictable outcomes, against a "Right-Relationships" path characterized by connectedness and self-actualization, which leads to community empowerment through diversity and participatory processes. The point is that fostering right-relationships enables a shift from a restrictive primary care model to one of creative and multidimensional community empowerment.

Empowering Communities

Community health nurses are responsible for caring for and supporting communities, families, and individuals as they respond to health, violence, or dissonance within a society. Nurses are skilled in compassionate caring and the application of scientific knowledge and technology. We are also skillful at humanistic universal-psychosocial-spiritual interactions that support our clients and empower them in the change process. The nurse's role does not directly create change in others, but creates the processes or conditions for change to occur. For compassionate care to be sustained, the communities we work with must be willing and able to care for themselves.

Today, communities are often faced with horrific acts of violence and senseless loss of life by extremists on the fringes of the society. The psychological scars communities face as the result of sudden acts of violence may persist unless the causes of the social imbalances are resolved. As health care professionals, community nurses have the potential to facilitate this change.

Nurses need to be aware of the ways to help others during times of tragedy to facilitate the process of caring for others. We also need to care for ourselves as human beings, balancing our commitment to practice with the need to help others. Nurses can inspire community members by making changes in their lives that will contribute to the well-being of others. Nurses, as universal-psychosocial-spiritual beings, have the unique capacity to look beyond the symptomatic causes of disharmony in our communities, placing nursing in a unique position to empower communities to make positive changes.

Empowerment of Consciousness

The process of empowerment through dialogue enables communities to see their inequities and transform their environment. “The spirit of dialogue involves an openness to new ideas”. This spirit of openness implies people are willing to listen to others and negotiate with an understanding of opposing viewpoints. Empowerment is a process of hope, trust, faith, and critical thinking based on mutual concerns and love for all human beings. Empowerment is a dualistic interactive process involving investment in understanding yourself and others and a willingness to impact change for the betterment of humanity.

The process of promoting an empowerment of consciousness in communities parallels process of human liberation of oppression through education. Education, according to Freire, should provide a human awakening of consciousness or what he calls conscientizacao. The awakening of the spirit develops through processes of reflection and critical thinking between the teacher and the students (Fig. 6.3). The open exchange of ideas through dialogue does more than just pass old knowledge in justifying the inequities in communities; it provides new insight into the understanding of political, social, and economic forces of oppression.

Figure 6.3 summary: A flow diagram illustrating the process of empowerment. Empowerment components, consisting of hope, trust, and faith, combine with critical thinking to lead into right-relationship based on mutual concerns, which then progresses through dialogue to achieve empowerment. The diagram depicts a sequential path where psychological and cognitive precursors are necessary to reach a state of empowerment.

In the modern Western paradigm of the world, “a person is merely in the world, not with the world or with others; the individual is spectator, not re-creator”. In the postmodern paradigm of community health nursing, only our imaginations and our own fears limit reality. Empowerment is essential to the nursing process. Nursing is a profession based on mutual understanding of clients, families, and communities.

Empowerment provides the force of liberation for communities to reconcile forces of oppression and transform the human consciousness to awaken our capacities for humility, love, and cooperation. For empowerment to emerge as a new consciousness, community health nurses must engage in active, critical dialogue that promotes understanding, cooperation, and critical reflection of community aspirations. Nurses may institute global change through the application of the concept of empowerment and help our communities achieve their hopes and dreams.

Transformation of the Global Community

The transformative process of empowering a community through the integration of humanistic relationships by community health nurses has the potential to change the global environment of health care and promote healthy environments for all. The community development approach to health care involves empowerment participation by all members of a society regardless of culture, social status, gender, or ethnicity. As the world shrinks through instantaneous global communication, we are exposed, through the news media, to inequities in our global environment daily. We are able to witness firsthand the adversities of war, famine, drug abuse, unemployment, genocide, murder, and lack of health care worldwide. Community health nurses must not remain blind to these inequities, but advocate transforming our societies into communities based on principles of trust, hope, love, and faith in humanity.

Our unique vantage point as nurses is our ability to communicate, dialogue, and form partnerships with clients, families, and communities. Nurses are in a prime position to chart a new course for the delivery of health care and resolve many of the social injustices for the world's disenfranchised through empowerment.

Empowering a Community Through Participatory Action Research

One method community health nurses may use in empowering a community to focus on health problems is participatory research. This is performed through collaboration between health professionals and community members. Participatory research is problem-focused or context-specific research centered on a particular problem involving all participants.

Participatory research is similar to action research in which each person or group engaged in the process is committed to improvement through continuous interaction among dialogue, research, action, reflection, and evaluation. Individuals are active participants in change and are not passive objects. Through participatory research, community members can gain skills to critically think and analyze the health concerns of their community.

Participatory research is a form of emancipatory inquiry that addresses inequities and injustices in health and society. This is a research method community health nurses may use in empowering a community to focus on health problems. It incorporates conversations that produce both collaboration and self-awareness between nurses and their community. The methods of participatory research incorporate scientific research, education, and political action developed primarily out of the works of Freire (1997). Critical theory and feminist theory underlie the emancipatory process.

Critical theory emphasizes a critical analytic approach to discussing social problems by active reflection and synthesis through continuous dialogue. In understanding the social and political patterns of oppression, community members may be able to facilitate change using processes of engagement, collaboration, cooperation, reflection, and evaluation. Feminist theory shares many of the humanistic values of nursing based on concepts of caring, intuitiveness, and valuing others' worldviews and experiences. A feminist perspective provides a powerful language to enhance our understanding or to provide insights for social change.

Wallerstein (1999) identifies six core principles of participatory and action research. These include (1) the participants in the research project are the ones who determine the research agenda; (2) the research project should be one that benefits the community as a whole, and allows community members to make informed decisions and act collectively; (3) the relationship between health care experts and community members should be a collaborative effort based on the principles of shared dialogue; (4) community members should have access to all information and knowledge from which they might normally be excluded; (5) the process should be democratic and empower the participation of a wide range of community members; and (6) community members and the researchers should strive to achieve mutual goals.

The goal of participatory research is social change, not just the advancement of new scientific knowledge. Emancipatory inquiry is designed to have a direct effect on the lives of all participants in the research process, not just the life of the researcher. Individuals involved in participatory nursing research are able to explore how inequities in society are linked to their own health and, therefore, are enabled to act on this knowledge through empowerment.

The Nurse's Role in Participatory Research Programs

In instituting participatory research programs, nurses help communities identify, understand, find solutions, and determine common goals in resolving community problems. The problems examined through emancipatory inquiry are those that community members believe are important, and not necessarily those identified by health professionals in the community. Nurses are challenged to awaken the spirit of social change among those who are most vulnerable in our communities. Emancipatory inquiry provides a framework to expand the political consciousness of the disenfranchised in a community. As Henderson (1995) reminds us, “The goal of emancipatory inquiry is neither prediction nor understanding, but emancipation, both within the research process and within society” (p. 64).

Community health nurses can be the eyes and ears of a community. We have considerable credibility in the community as health professionals. Our clinical and educational experiences guide us in assessing the pulse of our surroundings. We have numerous tools for implementing change in the community environment based on theory and experience.

Nurses have strong interpersonal communication skills, understand the importance of client–nurse relationships, are willing to learn from others, and know how to maximize the health resources of a community. Through our professional encounters with clients, we learn to solve problems almost intuitively and attempt to fix them before harm occurs. Our solutions are not always the right answer if the end result is not congruent with the views or beliefs of those affected. A better solution is to empower the community to resolve its problems while expanding their resources.

Participatory research is an excellent method for nurses to implement change, even on a small scale.

Developing a Participatory Research Program

An example of participatory research by the community health nurse might be your recognition of the importance of informing clients of influenza vaccines for seniors during the flu season while working at a senior center checking blood pressures in a low-income, African American neighborhood. In talking with clients, you may find that very few in this community have had flu shots, but many have friends who died last year or were seriously ill from influenza. The seniors seem very concerned in light of many news broadcasts predicting a major flu epidemic. You assess that this may be an important health issue to bring up at the monthly board of directors of the senior center meeting next week.

On the way back to the local public health department, you decide to stop by the epidemiology department to examine the community statistics related to influenza over the past few years. In analyzing the data, it is evident that low-income seniors in the county had a death rate 50% higher than those with higher income. The death rate for seniors living near the senior center where you were taking blood pressures was significantly higher than that in the rest of the city.

The data also indicate that there is an overall higher death rate for senior African Americans within the county. You feel compelled to act because this is a significant health problem where nursing might make a difference.

Over the next week, you carry out a literature search and put together a proposal to present to the senior center's executive board members to develop a participatory research influenza immunization program with the support of the public health department. You reflect on how to make your proposal successful, knowing there are several barriers. A potential barrier identified is to make the program culturally sensitive to the African American community. Many seniors around this senior center have limited access to health care, lack transportation, and have minimal understanding of the importance of influenza vaccinations. Your literature search, as well as the experience of your practice, reveals some key issues related to the African American communities. Religion is central in their lives; cultural beliefs and health practices are often underutilized, regardless of their impact on well-being; and family support networks and informal health care systems play important roles in maintaining health during periods of stress or crises. The community health diagnosis for this proposal might be decreased influenza immunization rate of senior African Americans living in this community related to (1) cultural barriers, (2) low socioeconomic status, (3) attitudes, and (4) lack of resources for health promotion and disease prevention, as manifested by statistical evidence of high mortality rates and low immunization rates.

Your proposal includes a conceptual framework for increasing the effectiveness of an immunization program for the senior center based on the components of the community-as-partner model. The plan incorporates African American cultural values relating to health and illness practices. The strategies include three main components.

One involves increasing the active participation of community members from the senior center in the program design, implementation, and evaluation process. The second includes strategies to tap into the established formal and informal community networks, and the third is structuring the plan to be culturally sensitive with the assistance of the executive board of the senior center as well as religious leaders in the community.

A fundamental component of your proposal is how to empower senior African Americans to receive their flu immunizations through health promotion. Health promotion entails motivating the community, families, and individuals toward obtaining their optimum state of well-being, health, or happiness. The strategies should encourage the best quality of life, with goals toward continuous improvement in the overall health of the community. The health status of a community is directly related to the individual health-related behaviors and environmental conditions, and is indirectly affected by environmental factors, which influence health behaviors. Communities can directly influence their health status by targeting individual health-related behaviors and can change health-damaging environments into health-promoting environments. Brown (1991) states,"The ultimate objective of community action for health promotion must be to empower people to improve their individual and collective health" (p. 455).

Three essential elements of health promotion identified by Brown (1991) involve (1) encouraging individuals to change and sustain personal behaviors that prevent disease and promote healthy lifestyles, (2) encouraging health-promoting behaviors that discourage health-damaging behaviors of individuals, and (3) creating an environment that promotes health by eliminating health hazards from the physical environment. According to Brown, most health promotion programs focus on encouraging individuals to change their health behaviors, but seldom look at empowering people to change the lifestyle or environment that shapes their behavior and influences their lifestyle. The goal is to increase the number of seniors immunized against the flu, and the objectives are to assist seniors to overcome their fears of immunizations, increase seniors' knowledge about the flu, increase their political power, and improve their physical health. The community-as-partner model, the concepts outlined for developing a participatory action research plan, and Brown's theory of health promotion are several tools community health nurses can use to promote change.

With the approval of the executive board of the senior center, the nursing interventions to meet the objectives of the immunization project are focused on participatory research emphasizing education and focus group community interaction. The strategies addressed in the focus groups to make the program successful highlight clarification of information on flu immunizations, stressing healthy outcomes, keeping the message culturally sensitive, and decreasing fears of the vaccine.

The missing component in our discussion on developing a participatory research program for our immunization project is the ethic of connectedness or developing the right-relationship with the senior African American community members. We have mentioned the critical component of cultural sensitivity, but we need to focus our energies on building relationships in the process of participatory research. The relationships nurses develop in the processes of human interactions are critical to the success of all community programs.

We cannot ignore the political, social, environmental, cultural, and economic relationships among all community members. How we interact with communities on all social levels has an impact on our ability to provide a voice to those who are most vulnerable in our society. Community health nurses are morally responsible to provide a voice that maintains a dialogue of caring and builds a dynamic of empowered connectedness within the community-as-partner model.

Summary

Community nurses can provide the critical voice to raise awareness of health disparities in a community. As a group, nurses can provide the bonding capital and bridging capital for community members to work together effectively to achieve common goals for improved community health and quality of life. Empowerment requires active community participation by community members and formal organizations to work together to achieve mutually agreed on outcomes based on trust. Empowerment is not just a program nurses create, but a process enabled by community health nurses to transform thinking through dialogue. Only through continued activism can nurses expose the social injustices that continue to contribute to powerless communities. Through community empowerment, nurses can provide a moral voice to inspire change to regain our historical roots as vanguards of the community.

Critical Thinking Questions

1. How might you apply empowerment in your community nursing practice?

2. What are the essential processes for empowerment to occur within a community?

3. As a nurse, how might you describe empowerment as a transformational process?

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