1. APPLICATION OF COMMUNITYEMPOWERMENT TO PRACTICENR.110.500 Philosophical, Theoretical, and Ethical Basis forNursingSara Cawrse, Jamie Hatcher, Sandeep Lehil, & Jessica Vargas

2. INTRODUCTIONApply the CommunityEmpowerment theoryto socio-economicallydisadvantaged, urbanAfrican Americans withuncontrolled type 2diabetes 3. PROBLEM & SIGNIFICANCE According to ADA, African Americans (AA) are athigh risk for diabetes due to: Genetics High rates of obesity Low levels of physical activity In 2005, more than 18 million adults had diabetes in the United States AA accounted for a disproportionate amount (Green, McClellan,Gardner, & Larson, 2006). AA are 1.6 times more likely to develop diabetesthan non-Latino Whites 4. PROBLEM & SIGNIFICANCE AA have higher rates of diabetes than their whitecounterparts, and tend to have poorer outcomes. Social, economic, and environmental factorscontribute to health disparities (Green, McClellan, Gardner, & Larson,2006). Differences in glucose control persist between AAand Whites even after adjusting for socioeconomicstatus, access to health care, and severity ofdisease (Marshall, 2005). 5. PROBLEM & SIGNIFICANCE AA increased rates ofdiabetic sequelaeincluding retinopathy, microalbuminuria, end stage renal disease, lower extremity amputation mortality(Green, McClellan, Gardner, & Larson, 2006;Marshall, 2005). 6. PROBLEM & SIGNIFICANCE AA less likely to attain glucose control Possible reasons: Poor compliance with self-monitoring Poor adherence to treatment Cost of test strips and drugs Literacy rates Lack of diabetic education Sociocultural components Physician related factors 7. PROBLEM & SIGNIFICANCE Patients who are able to control their diabetes, (Green,McClellan, Gardner, & Larson, 2006; Austin & Claiborne, 2011): Often have friends or family with diabetes Seek out information about the disease Evidence-based self-management strategies Accurate perceptions of their own diabetes control Experience turning point events 8. PROBLEM & SIGNIFICANCE Further focus needed on: Preventing and controlling diabetes in this population Alternative interventions to traditional primary care Peer support and education Community Empowerment Theory 9. N U R S I N G T H E O RY: C O M M U N I T YEMPOWERMENT Developed by Eugenie Hildebrandt and CynthiaArmstrong Persily (Persily & Hildebrandt, 2008) Middle range nursing theory Built off both empowerment and the communitydevelopment theories Creates a community involvement approach Members of the community take responsibility forincreasing their knowledge and decision-makingabilities. 10. N U R S I N G T H E O RY: C O M M U N I T Y EMPOWERMENT Three main concepts:InvolvementLay WorkersReciprocal Health Involvement: People in the community create support groups orcoalitions to identify their mutual needs, resources, andbarriers to ultimately respond to a problem thecommunity is facing. Done through planning, implementing, and interveningas a group (Persily & Hildebrandt, 2008) 11. N U R S I N G T H E O RY: C O M M U N I T YEMPOWERMENT Lay Workers (Persily & Hildebrandt, 2008): Trained persons indigenous to the community to which they live in and work in. Reach out to families in the community Know community cultural values firsthand Encourage preventative services, healthy behaviors, and assist with access to social services 12. N U R S I N G T H E O RY: C O M M U N I T YEMPOWERMENT Reciprocal Health (Persily &Hildebrandt, 2008): Actualization of inherent and acquired human potential. Occurs when professionals and community residents work together, respecting, and sharing what each other has to offer. Desired outcome of community empowerment as community members participate proactively in ways to attain their highest potential. 13. N U R S I N G T H E O RY: C O M M U N I T YEMPOWERMENT(Smith & Lierhr, 2008) 14. E VA L U AT I O N : S I G N I F I C A N C E Clearly addresses the metaparadigm concepts of theperson, the environment, health, and nursinggoals/processes. Person: members of the community (these are theindividuals who will receive the care/intervention) Environment: community itself as well as thecommunitys social constructs, the neighborhood, andthe economy of the community Health: issues identified by the community as importantto address Nursing goals/processes: empowerment of membersof the community (lay persons and other communitymembers) in order to promote changes that will addressthe needs and issues identified by the community 15. E VA L U AT I O N : S I G N I F I C A N C E The metaparadigm propositions addressed include: life processes patterns of human-environment interaction processes that affect health interaction between health and environment Philosophical basis: the foundation of this theory isthat through empowerment change is possible. 16. E VA L U AT I O N : S I G N I F I C A N C E Derived from a merging of the empowerment theory and the communitydevelopment theory. Posits that individuals and groups "grow through community participantinteraction and achievement of identified goals." Guided by models that advocate for supporting individuals andcommunities to develop while working together on commonly identifiedproblems. Empowerment involves developing problem-solving capacity andcompetence that allows individuals and communities to gain masteryover their lives. Critical in primary health care Part of the nurse-individual dyad Vital for linking health care providers and communities. When community development and empowerment are consideredtogether, they demonstrate the "potential for empowerment of communitypeople through the involvement of lay workers in promoting reciprocalhealth (Persily & Hildebrant, 2008). It does not appear that the theory acknowledges use of adjunct orantecedent theories. 17. E VA L U AT I O N :CONSISTENCY & CLARITY Congruency between context and content Context: includes both change through empowermentand that change must come from within (oneself or thecommunity). Content: includes identification of problems by thecommunity and education of lay persons (members ofthe community) who will then educate others in thecommunity, thus empowering them to change. The content is semantically clear and consistent. 18. E VA L U AT I O N : A D E Q U A C Y The theory assertions appear to be fairly wellsupported by empirical evidence. The theory itself was developed based on theexperiences and observations of the two theoristsand has been applied by them in their research. 19. E VA L U AT I O N : F E A S I B I L I T Y Pragmatic adequacy: Special training and skills may be required Implementing the theory primarily be limited by the motivation ofthe community Cost may or may not be a factor Legally, the nurse will likely be practicing within her scope ofpractice when providing health education to the lay persons andmeasuring its effectiveness within the community. Education and empowerment and key components of nursing practice,The theory is organized in such a way that, should one want to, Comparisons could be made between a community in which thistheory was applied and a community in which the theory was notused Outcomes to be measured would depend upon the problemsidentified by the community Measurement of such outcomes should accurately indicate theeffectiveness of the theory. 20. RATIONALE FOR THEORY SELECTION Significant disparities exist between AA and whites withregards to diabetes management and the rates ofassociated morbidity and mortality, AA face several barriers: including poor access to care,limited resources for physical activity due to residentialbarriers, and interference of care due to other life eventsor stressors (Samuel-Hodge, et al., 2000). Can address barriers by: Bringing the care to the patient through lay-educators, Altering the care so that it is appropriate and reasonable for the patients lifestyle and culture. For diabetes management to be effective, it must beapproached with an understanding of the populationssocial, cultural, and familial influence (Chesla, et al., 2004; Samuel-Hodge, et al., 2000; Two Feathers, et al., 2005) 21. POSSIBLE SOLUTION Community health worker (CHW) programs haveshown promise in improving health behaviors andhealth outcomes Particularly for racial and ethnic minoritycommunities and for those who have disparateaccess to health care (Spencer, Rosland, Kieffer, Sinco, Valero, Palmisano, &Anderson, 2011). CHWs can provide comprehensive care regarding socialand some medical needs at a less expensive cost (Gary,Bone, Hill, Levine, McGuire, Saudek, & Brancati, 2003). 22. POSSIBLE SOLUTION CHWs use their ethnic,cultural, or geographicbackgrounds to promotehealth within their owncommunities. They are a bridge for those with disparities to accessiblehealthcare Become part of the patients support system Can also provide resources, transportation, andcoordinate case management. 23. EXAMPLE OF THEORY IN USE In Heisler, Spencer, Forman, et al. (2009), participantsfelt CHWs gave them clear and specific strategies onmanaging diabetes care, nonjudgmental assistance toincrease confidence in maintaining diabetic care, andsocial and peer support. CHW programs that provide both one-on-one supportand group self-management training sessions may beeffective in promoting more effective diabetes care andpatientdoctor relationships among African-Americanadults with diabetes than without CHW support (Heisler,Spencer, Forman, et al., 2009). 24. POTENTIAL PROBLEMS WITHIMPLEMENTING Most studies on community health workers havenot used a randomized controlled trial design. Studies have small samples in a localizedneighborhood and therefore have threats toexternal validity. Potential problems may arise with training andretaining community health workers whenimplementing programs (Hill-Briggs, Batts-Turner, Gary, Brancati, Hill, Levine, Bone, 2007). 25. REFERENCESAustin, S. A., Claiborne, N. (2011). Faith wellness collaboration: A community-based approach toaddress type II diabetes disparities in an African-American community. Social Work HealthCare, 50(5), 360-375.Chesla, C. A., Fisher, L., Mullan, J. T., Skaff, M. M., Gardiner, P., Chun, K., & Kanter, R. (2004).Family and disease management in African-American patients with type 2 diabetes. DiabetesCare, 27: 2850-2855.Fawcett, J. (2005). Criteria for evaluation of theory. Nursing Science Quarterly, 18(2), 131-135.Gary, T. L., Bone, L. R., Hill, M. N., Levine, D. M., McGuire, M. Saudek, C., and Brancati, F. L.(2003). Randomized controlled trial of the effects of nurse case manager and community healthworker interventions on risk factors for diabetes related complications in urban AfricanAmericans., 37 (1), 2332.Greene, C., McClellan, L., Gardner, T., & Larson, C. O. (2006). Diabetes management among low-income African Americans: A description of a pilot strategy for empowerment. Journal ofAmbulatory Care Management, 29(2), 162-166.Heisler, M., Spencer, M., Forman, J., Robinson, C., Shultz, G., Graddy Dansby, G., Kieffer, E.(2009). Participants assessments of the effects of a community health worker Intervention ontheir diabetes self-management and interactions with healthcare providers. American Journal ofPreventive Medicine, 37(6, 1), S270-S279.Hill-Briggs, F. Batts-Turner, M., Gary, T. L., Brancati, F. L., Hill, M. N., Levine, D. M., Bone, L. R.(2007). Training community health workers as diabetes educators for urban African Americans:Value added using participatory methods. Progress in Community Health Partnerships:Research, Education, and Action, 1(2), 185-194. 26. REFERENCESMadden, M. H., Tomsik, P., Tercheck, J., Navracruz, L., Reichsman, A., Clarck, T. C., & Werner, J. J. (2011). Keys to successful diabetes self-management for uninsured patients: Social support, observational learning, and turning points. 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