Interdisciplinary assignment

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1. Read Schoon, Porta, & Schaffer (2019) Chapter 8

2. Identify an interdisciplinary team [or collaborative meeting] in your community that addresses a
public health need in your community (i.e. smoking, alcohol, obesity, wellness, homeless, domestic
violence, youth/senior issue, etc.). Please note that this interdisciplinary/collaborative meeting
should NOT be a patient specific (case management, discharge planning, etc.) meeting in a
healthcare setting (i.e. hospital, clinic).

Agenda 1/19/23
Notes taken by Tere Parsley Starne from MICAH

1. Welcome & Introductions
2. Team Updates

● Policy
● Communications
● Engagement

3. January 25th Launch Updates

● Event on Wednesday, January 25th from 10am- 11:15am
● Register here:

4. Announcements & Organizational Updates
5. Adjournment

Team Updates
Policy – Annie. Session is going. Lay of land. MN House has hurry up and wait attitude. Lots of hearings
happening now. We have to have a balanced budget. We need to know how much there is in bank. Will know
by Feb. $17 billion in surplus is what it looks like now. Hearings are starting.
Committees that impact housing

MN House Committees

MN Senate Committees

Annie wants to do a 101 to answer questions about this structure
Sue posted this in the chat: Excellent Policy Training: Legislature101

presented by
Dan Kitzberger, Policy Director, MN Housing

( begins at 18 minutes 44 seconds, about a 35 minutes presentation)

Annie listed the House and Senate Committees that H4A bills will move through

Confusing this year. She is planning to put together a document explaining more.

Gov. introduces Budget on Tues. They released Children and Family Budget last Tues. Focused on ending
childhood poverty. Will send out information about what will be in the budget. Hearing a lot of positive things
about it.
H4A Policy Agenda link

Yesterday in the Housing Committee a Bill that will provide funding for first generation home buyers was heard.
HF12 Link in chat
HF 12= DownPayment Assistance,

HF 11= Bring it Home,

HF 444 =

Today at 1pm in Health human services finance HF444 Pathway Home Bill that includes emergency services
program for people experiencing homelessness. Homeless Youth program Homeless Youth Act. Funding for
funding program from CloseKnit. Placed in home with chosen family. Transitional housing. Building shelters.
HF444 and here’s a link w/more info:

Lots of hearings that have been informational have been held. Now having first ones on specific bills. Our
agenda is progressing well.

Pathway home bill. MICAH supports. Concerns about some of the funding for data collection rather than
helping people with needs.
Data collections services required by HUD

We will send out information about Gov Budget and about the next hearings.

Hearing on Tenant Legislation will be coming on Tues. Annie will check to see when Bill will be heard.

Annie will put links in chat

Question is there a master list of which comm are the comm for different bills? Annie is working on that. She
hopes to have done by Monday Policy meeting. And will talk through because it is complicated.
Training. Annie hopes to do 101 training for H4A folks at the beginning of Feb.
Link to Policy meeting

Excellent Covid provider monthly meeting Excellent Policy Training: Legislature101
presented by
Dan Kitzberger, Policy Director, MN Housing

( begins at 18 minutes 44 seconds, about a 35 minutes presentation)

Communication team Mary – trying to get up to date. Considering adjusting their meeting time. Will post these
changes. Policy team will be available on website. Continuing to share out info on Launch. People can join
their committee

Engagement Matt – If haven’t registered for launch yet, need to do that. Link in chat.
Launch Jan 25 10 am
90 registered so far. Not bad for virtual launch

If you can blast promotion to increase registration.
Speakers will give overview of what the agenda is. Not like a rally. Engagement team has been working on

January 25th Launch Updates

● Event on Wednesday, January 25th from 10am- 11:15am
● Register here:

Announcements and organizational updates

MCH homeless day on the hill March 8 in person. 8am go on website there is a register here button on main
home page. Program 9 – 10. Legislative visits scheduled if you registered.

Sue – MICAH is supporting rallies and putting out information through our email lists. Having Policy Breakfasts
through Feb and March. See information on MICAH website. Excited to see energy in this session. Working on
Lead Safe Homes to protect children. Try to move this bill early in the session

Linda – two things. I am on a panel for Nat Coal for the Homeless. Mental healthcare on demand and wil
lcover medicaid and recertificaltion today on panel Link in chat
NCH Town Hall Meeting

Thursday, January 19th, 2022
2:00 PM CT
Topic: Medicaid coverage
Registration Link:

From the grassroots. She lives on a housing voucher. She wants to get housing insecure people to be on a
speaker’s bureau. This is coming. Offers her experience to be a speaker. [email protected] grassroots
speakers bureau

Ann asks a question. If anyone has advice on a community development block grant. Working with economic
development director on her board is this good? CDB could apply through HRH. Can County Board take on the
funds? If she works with county it should clear it up.

Dave – Manufactured Housing proposals. Have authors in House. Opportunity to purchase, rent reform and
utilities consumer protection issues. Have all three authored on House side.

What is link to track bills? Link in chat.

Linda – question/problem in the transition back to in-person people in rural Minnesota going to have to ask for
hybrid options or phone in options. Feels cut off in rural Minnesota. MCH has been advocating for this. House
doesn’t have the technology like the Senate does. House is only taking in-person testimony. There are rooms
in Capitol that have the capacity for Zoom. They could change rooms. Meeting resistance. Feels like
discrimination for rural people. If we all started phoning in with a well polished presentation.


Interdisciplinary Team/Collaborative Meeting Paper


School of Nursing, Minnesota State University, Mankato

NURS 482 01- Population and Focused Care for RNs

Dr. XXX (faculty name)


DISCLAIMER: This sample paper is intended to be a resource to better understand how key

content may be addressed in a paper for this assignment. The sample paper is not intended to be

used as a guide for formatting, as the assignment grading criteria and/or APA format

requirements may differ from current requirements; or used to obtain content for your individual

paper. This sample paper may not reflect a paper that received a 100% grade.


Interdisciplinary Team/Collaborative Meeting Paper

On September 22, 2020, a virtual Zoom meeting was held with members of Healthy

Communities, which is part of a larger organization called the Health Equity Coalition. During

the course of this two-hour meeting, ten members were present that contributed ideas, comments,

opinions, and suggestions to one another regarding present public health concerns in their

communities. This paper will discuss what the Health Equity Coalition is and what they do, the

current public health issues within their communities, and a reflection elaborating upon this

program and its impact on public health and how it can be enhanced to better the outcomes of

community members.

Collaboration Overview

The Healthy Communities team is made-up of three counties in rural Minnesota, which

include Meeker, McLeod, and Sibley County. This group, according to the Meeker, McLeod, and

Sibley Healthy Communities (MMS HC) (2020) website, “is a collaboration of organizations and

individuals partnering together to promote health and well-being within our communities” (para.

1). The group was created in January of 1995 with the same vision and goal as they abide by to

this day, which is “to partner with communities to encourage and support efforts to impact

environmental change and enhance healthful living” (MSS HC, 2020, para. 3). Heathy

Communities mission is “to advance healthy living within our three counties” (MSS HC, 2020,

para. 2). Their mission strives to identify health gaps within their communities and provide

education and awareness about health inequity that may contribute to the health outcomes of

individuals (V. Gladis, personal communication, September 22, 2020). According to Savage

(2020), “Health inequity describes avoidable gaps in health outcomes” (p. 158). By educating

their communities and spreading awareness of the current public health concerns they are facing,


they are not only making individuals aware of the issues, but they are actively working to engage

community members in realizing their potential in achieving the highest health outcomes for

themselves and all community members (MMS HC, 2020).

Prior to learning more about this group, Vlada Gladis, the program lead, was contacted

through email and asked about the Healthy Communities team. She then agreed to allow the

student nurse to participate in their monthly virtual team meetings that discuss various public

health issues occurring within the three counties. During the virtual meeting, the members within

the group, those who attended the meeting and those who did not, held various occupations. The

members represent nurses, lawyers, health educators, police officers, social workers, teachers,

emergency preparedness community health members, food shelf directors, and members of the

McLeod Alliance for Victims of Domestic Violence. However, Vlada expressed that due to the

current COVID-19 pandemic, many members have quit as their priorities have been shifted to

their occupations.

Public Health Issues

Within this coalition, many public health issues are addressed. These issues vary from

mental health to health disparities within the Hispanic community to obesity. Each year the

group strives to identify at least two public health concerns that are identified within their

communities, and this year the focus is on mental health and the Hispanic community. During

the meeting, the topic of COVID-19 was brought up in several contexts, all of which revolved

around the increasing mental health crisis and the health inequities of Hispanic individuals.

Vlada stated during the meeting that over 40 percent of Hispanic individuals within Minnesota

are experiencing an increase in stress, anxiety, depression, and other mental health concerns

(personal communication, September 22, 2020). This is a crucial topic for the health coalition to


address as Hispanics make-up a large portion of the population in McLeod, Meeker, and Sibley

County. Since many of the Hispanic individuals in the area speak little to no English, there is a

growing concern that they are not being properly educated on health resources that are available

to help them during this challenging time.

Collaborative Planning

Healthy Communities focuses their education and awareness programs based on

evidence-based data collected from credible sources like the Centers for Disease Control and

Prevention (CDC), the World Health Organization (WHO), and the Minnesota Department of

Health (MDH). They rely on credible data to determine areas of concern throughout the United

States, Minnesota, and their counties. Their website relies on data and statistics from these

sources for community members to view and interpret. Once the information is collected and

analyzed, the team then determines if the public health concern needs to be addressed within

their communities, and if so, then the team gathers further information and educational resources

to assist in their community involvements of the issue. Some of the data collected from this past

year includes national, state, and county statistics on COVID-19, Hispanic behavior health

surveys, and mental health surveys within the communities.

Additional data that may be useful for the team to utilize would be additional surveys

mailed out to individuals residing in the three counties. These surveys could consist of health

questions varying from physical to mental to emotional health. Another survey that could be

conducted could consist of question relating to health inequities and disparities within the

communities and determining what individuals are at highest risk based on the survey question

answers. However, the challenge with collecting this data is the chance that county residents will

not mail the surveys back. Another barrier is the cost of mailing out surveys. The team has a


budget and finance group that determines how much money to spend each year and what to

spend it on, so the cost of postage to mail-out surveys may be an expenditure that they do not

deem necessary.


The Health Coalition team has 19 partners within the organization. Vlada explained that

the partners are currently word of mouth, so there is no buy-in from these partners. They promote

their group by contacting agencies, organizations, and companies in the local areas and ask them

if they are willing to participate in their health coalition to promote the health and well-being of

community members. The primary reason that these community partners have joined the

coalition is to further promote their mission and goals of achieving positive health outcomes and

eliminating health disparities among community members. Most of the partners work with the

team to receive feedback on current and ongoing public health concerns, and they also provide

the coalition with evidence-based data and resources to be able to share with community

members, which is needed for the team to be successful.

Collaborative Outcomes

The Healthy Communities group has made several positive contributions to their

communities over the past 25 years. Some of these accomplishments include educational

trainings and seminars focusing on various health conditions and illnesses, creating a community

awareness program about health inequities and disparities, starting a Hispanic organization that

addresses health in the Spanish language, and partnering with the Statewide Health Improvement

Partnership (SHIP). The goal of SHIP is “to help Minnesotans live longer, healthier, better lives

by preventing risk factors that lead to chronic disease” (MMS HC, 2020, para. 1). When the

coalition partnered with SHIP, it was a special accomplishment. They are now able to provide


more resources to community members to improve their health and save money (MMS HC,



After participating in the virtual meeting, interviewing the coalition team leader, and

researching the program, it was very evident that this group is working hard to ensure that the

counties of Meeker, McLeod, and Sibley are working together to bring unity and health to

individuals, however, as a community member, I had never heard of this group before. Of course,

they partner with many other healthcare organizations and non-profit groups within the

communities that I am aware of, so through this project I was able to learn about the different

seminars and awareness and educational programs this group has implemented that I have also

heard of or participated in. I believe that this organization is well received by the community as

many individuals participate in their events, but due to the current pandemic, the group is afraid

that their message and various programs is not adequately reaching individuals, which poses a

barrier to their progress and mission.

The coalition has many partnerships that provide additional resources, education, and

donations. An additional partner that would be beneficial to the group is United Way. This

organization is a non-profit group that “is dedicated to advancing the common good. It’s less

about helping one person at a time and more about changing systems to help all of us” (United

Way, 2020, para. 2). This group works individually with a variety of community members, some

of which are struggling with health and well-being. Adding United Way as a partner with the

coalition would not only assist in spreading the word about the group but could identify more

individuals that may benefit from the coalition’s resources.


During this unique time of a global pandemic, Healthy Communities is facing many

challenges that were not an issue before the days of social distancing and limited capacity in

buildings and rooms. The coalition continues to promote their mission of advancing health equity

and promoting the well-being of individuals in a virtual platform instead. However, not every

community member has access to these virtual resources, so an additional way that would still

meet the groups mission and goals would be to make educational flyers and brochures to place in

the buildings of their partners, such as Hutchinson Health, McLeod County Public Health, and

Tri-Valley Migrant Head Start. These are organizations that allow individuals to seek care in-

person, so having handouts that people can physically take home and learn from would be


Another way to promote their mission within their communities would be to host small

events that discuss the current public health concerns, such as mental health and COVID-19.

These events could be small and follow the current COVID-19 guidelines, such as enforcing

social distancing and wearing a mask. This would be a way to continue to engage individuals

through health promotion and education in the form of lectures, videos, PowerPoints, and


Lastly, as this group focuses on the public health concerns that are present with McLeod,

Meeker, and Sibley County, having nurses as coalition members strengthens the programs

missions and goals as the nurses are able to bring additional data, education, and insights to the

group. There were many public health nurses who either attended the virtual meeting or were

mentioned by other group members, so their contribution to the coalition is greatly noticed and

received by coalition members. Nurses are able to use the educational resources provided by the

coalition to further educate their own patients and spread awareness of these public health


concerns, such as health inequity and mental health. Schoon et al. (2019) explains that “PHNs

must recognize and emphasize community assets in planning interventions to promote public

health” (p. 176). Through recognizing community assets, nurses are able to bring further insight

to ongoing community issues and assist the Healthy Communities team in identifying ways to

address and resolve the current issues.



Meeker, McLeod, Sibley Healthy Communities. (2020). About us. Retrieved from

Savage, C. L. (2020). Public/community health and nursing practice: Caring for populations (2nd

ed.). Philadelphia, PA: F. A. Davis.

Schoon, P. M., Porta, C. M., & Schaffer, M. A. (2019). Population-based public health clinical

manual: The Henry Street Model for nurses (3rd ed.). Indianapolis, IN: Sigma Theta Tau


United Way. (2020). What is united way? Retrieved from

Contact Person

Person Interviewed:

Vlada Gladis


[email protected]


Sibley County Public Health and Human Services
111 8th St., P.O. Box 237
Gaylord, MN 55334



Utilizes Collaboration to
Achieve Public Health Goals

n  Marjorie A. Schaffer 
with Melissa L. Horning and Carol J. Roth



Jake is a public health nursing student who has 10 years of experience in the acute care setting as an
associate degree nurse. His expertise has been in the area of cardiac care, working in the Coronary Care
Unit at a local hospital. Jake has returned to school to complete a baccalaureate degree in nursing. The
community surrounding the university that Jake attends has identified a need to address healthcare
access for the homeless population. A local church approached the university to work with it to develop a
clinic for the homeless by using resources in the community and students for the delivery of care for this
underserved population. Jake’s preceptor, Linda, a public health nurse (PHN), is representing the local
public health department at planning meetings. Jake will have the opportunity to learn how professionals,
community members, and organizations collaborate to contribute to the development of a community
clinic that serves a vulnerable population. Jake has many questions, such as: Whom would he collaborate
with to contribute to this goal? Whom should be invited to be partners in the collaboration? How does such
a diverse group work together? What is the PHN’s responsibility in collaborative work?

Before Jake attends the first planning meeting with Linda, he picks up his notebook to review the
population-based public health nursing competency list and concentrates on Competency #6, which
focuses on collaborative practice.

COMPETENCY #6 Utilizes Collaboration to Achieve Public Health Goals

A. Demonstrates effective participation on interprofessional teams

B. Develops relationships and builds partnership with communities, systems, individuals, and families

C. Utilizes community assets and community engagement to empower communities, systems, individuals,
and families

Source: Henry Street Consortium, 2017


Collaboration: Working together “to achieve a common goal through enhancing the capacity of one or more of
the members to promote and protect health” (Keller, Strohschein, Lia-Hoagberg, & Schaffer, 2004, p. 456).

Community Asset: “Anything that can be used to improve the quality of community life,” including peo-
ple, physical structures, community services, and businesses (KU Center for Community Health and
Development, 2017).

Community Engagement: Collaborating with community members or community organizations to mutually
participate in problem-solving to address issues that affect their well-being (National Institutes of Health, 2011).

Interprofessional Collaboration: Creating collective action to address the complexity of client needs and cre-
ating a team culture that integrates the perspectives of each professional and facilitates mutual team member
respect and trust (D’Amour, Ferrada-Videla, Rodriguez, & Beaulieu, 2005).

Partnership: Individuals or organizations sharing ideas, experiences, skills, and resources to address problems
through mutual decision-making and action (Wilson & Mabhala, 2009).





























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for Nurses
Account: s4200124.main.ehost

168 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

Accomplishing More by
Working Together
PHNs work with many individuals and community orga-
nizations. Collaboration can be between two or more indi-
viduals or between organizations. PHNs collaborate with
representatives of the population, other professionals, and
organizations to contribute to healthcare planning and pro-
mote health (American Nurses Association [ANA], 2013).

A study about public health nursing practice analyzed
how PHNs collaborated with individuals, communities, and
systems. At the individual level, PHNs said their goal was
to make a difference in the lives of their clients by focus-
ing on “doing with” rather than on “doing for” (Aston,
Meagher-Stewart, Edwards, & Young, 2009). They wanted
to empower their clients to take responsibility and owner-
ship for health decisions. The PHNs identified several strat-
egies for empowering their clients: begin with the client’s
perspective, tune into the readiness of the client, assess
holistically (refer to Public Health Nursing Competency #9
in Chapter 11), and build rapport with the client.

At the community level, Aston et al. (2009) suggested
strategies to encourage community member participation
in health programs and initiatives. The PHNs involved com-
munity members in decision-making groups, focused on
community assets, and gave positive feedback and encour-
agement by affirming what was working well. The PHNs
involved people who normally might not have the opportu-
nity to participate in decision-making groups, such as youth
living in poverty and mothers who were isolated. At every
group meeting, the PHNs asked, “So who is missing and
who needs to be here?” PHNs often initiate the process of
uniting people around a problem they all care about. PHNs
encourage group ownership and often look for community
members to take the lead in problem solving. PHNs can
assist with the group process, but ideally community mem-
bers should control the flow and process toward finding and
implementing solutions. Collaboration works best when
everyone has the opportunity to share thoughts and ideas.
One PHN in the study used the word catalyst to describe an
approach that draws the voices and participation of com-
munity members. This means that someone needs to initiate
the collaborative process, which then continues to develop
with the input of the people who contribute their perspec-
tives and skills to the collaboration.

At the systems level, the PHNs in the study connected
community members and groups to existing social net-
works, including neighborhood groups; community orga-
nizations, such as churches; or programs that provide food.
These connections helped to create a participatory infra-
structure. The PHNs linked people and community organi-
zations that were working on similar goals but had not yet
worked together. As a result, partnerships were built that
advocated for clients and linked agencies, contributing to

better services for clients. One PHN talked about finding
“the movers and shakers” in the community through reach-
ing out to community groups, such as men’s or women’s
groups, church groups, and community health boards.
These strategies encourage the collective voice of commu-
nity members and foster citizen participation. PHNs can
also bring their expertise in health promotion to existing
collaborative groups that are already established in commu-
nities (Aston et al., 2009).

Consider how PHNs collaborate with individuals and
families, community groups, and systems in the collabora-
tion example in Table 8.1. A local church hosts a Wellness
Center to serve the needs of people living in the community
who have health needs and difficulty accessing healthcare.
Many clients need dental care, so PHNs collaborate at all
levels of practice and across professions to respond to this
need. Figure 8.1 also elaborates on how PHNs collaborate
with individuals and families, communities, and systems.

FIGURE 8.1 How PHNs Work With Individuals, Communities, 
and Systems

Empowered their clients to take
responsibility and ownership
for health decisions

Involved community
members in decision-
making groups, focused
on community assets,
and gave positive
feedback and
by affirming
what was
working well

Connected community members
and groups to existing social
networks, including neighborhood
groups; community organizations,
such as churches; and programs
that provided food

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169CHAPTER 8  n  Competency #6

Collaboration With Other
Professionals and Communities
Depending on their practice setting, PHNs work with a
variety of other professionals, groups, and organizations.
For example, a PHN working in a school collaborates with
teachers, families, students, school administration, pri-
mary care providers, other health and special education
professionals, social workers, and groups that address such
health needs as chronic illness and mental health services.
The following are possible partners in public health nursing

Education collaborators:
n Childcare programs and providers
n Colleges and universities
n Early childhood development programs
n Head Start
n Literacy programs/English as a second language

learner programs
n Schools
n Special education

Holistic healthcare team members:
n Alcoholics Anonymous
n Audiologists
n Chemical dependency programs
n Clinical nurse specialists
n Complementary/alternative therapy programs
n Dental care providers (dentists, dental hygienists,

dental assistants)
n Home care agencies
n Mental health centers and providers
n Nutritionists
n Occupational therapists
n Physical therapists
n Planned Parenthood
n Primary care providers (physicians, nurse practitioners,

physician assistants)
n Psychologists
n Services for children with special needs
n Services for vision and hearing impaired
n Speech therapists
n Traditional/Native healers

Housing and food collaborators:
n Battered women’s shelters
n Congregate dining
n Food shelves
n Free and reduced-price school meal programs
n Homeless shelters
n Housing programs
n Meals on Wheels
n Supplemental Nutrition Assistance Programs (SNAP)
n Women, Infants, and Children (WIC)

Best Practices for Collaboration
With the input of several stakeholders (individuals and
organizations), the pooling of expertise and resources (e.g.,
knowledge, expertise, lived experience, money) can lead to
expanded ideas and strategies for improving population
health outcomes. Together with community partners and
other professionals, PHNs strive to identify mutual goals
and expected outcomes for the collaboration. See Table 8.2
for a summary of best practices for effective collaborative

TABLE 8.1 Collaboration Example

Level of Practice Example

Individual When clients at the Wellness Center
complain of toothaches, PHNs refer
them to low-cost dental care and
arrange transportation to the commu-
nity site where dental care is provided.

Community PHNs collect information on agencies
and organizations that provide low-
cost dental care and create a pamphlet
to communicate that information to
potential clients and other community
locations where people in need can
learn about resources. In addition,
PHNs could provide social marketing
to local schools about resources for
dental care.

Systems PHNs advocate for policy change to
include dental care in health pro-
grams that serve individuals and
families without employer-provided

TABLE 8.2 Best Practices for Collaboration

n Effective leadership
n Commitment of the participants
n Shared values and a sense of purpose
n Mutual respect for team members
n Linkages between groups and individuals
n Identification of strategies and resources to achieve the

goals, and a structure to support the collaborative work
n Internal systems to support the structure (e.g., commu-

nication mechanisms, a place to meet, time available in
assigned workload)

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170 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

Interprofessional education occurs when the various pro-
fessions “learn about, from, and with each other to enable
effective collaboration and improve health outcomes”
(WHO, 2010, p. 7). However, because professionals from dif-
ferent professions have different perspectives, practices, and
terminology, they may encounter barriers to effective team-
work. How can you anticipate and reduce potential barriers
to effective teamwork in interprofessional collaboration?

n Work to understand differences among team members’
culture, language, lifestyles, and beliefs

n Listen, be fully attentive, and truly hear
n Acknowledge and express appreciation
n Exhibit empathy and understanding
n Display courtesy and consideration
n Be accountable and professional
n Abide by the organizational professional code of

Source: Brewer, 2012, p. 33

PHNs work with many people who have different edu-
cational backgrounds, different experiences, and different
philosophies of life from their own and from each other.
They encounter different perspectives about which issues
are most important and what should be done to address
specific health concerns. It is important to become famil-
iar with common differences to avoid making assumptions
about the viewpoints of community partners and members
of the community. Sometimes tension and conflict occur as
collaborators work through different perspectives and ideas
about how to respond to a problem. Constructive conflict
may help move the group toward change. In most cases,
the accomplishments of the collaboration are far more
than what one individual or one professional group could

Legal collaborators:
n Law enforcement
n Legal aid
n Ombudsmen

Social Service collaborators:
n Child protection and welfare programs
n Energy assistance
n Financial assistance
n Jobs and training services
n Social services
n Transportation services
n Vulnerable adult programs

Community collaborators:
n Artists
n Businesses
n City councils/county boards
n Clergy and religious/faith leaders
n Community action programs
n Community residents
n Community service organizations (Rotary, Lions)
n Environmental health programs
n Extension agents
n Musicians
n Volunteers

Interprofessional collaboration is essential for developing
effective partnerships that improve health outcomes in pub-
lic health nursing practice. Interprofessional collaborative
practice engages communities and populations. Teamwork
and team-based care involve engaging other health pro-
fessionals, specific to the care environment, to participate
in client-centered problem solving. The Interprofessional
Education Collaborative Expert Panel (2011) identified four
domains or competencies of interprofessional practice (see
Table 8.3).

The values/ethics competency means that collaborators
take on a “community/population orientation, grounded
in a sense of shared purpose to support the common good
in healthcare, and reflect a shared commitment to creating
safer, more efficient, and more effective systems of care”
(Interprofessional Education Collaborative Expert Panel,
2011, p. 170). For roles and responsibilities, PHNs need to
understand their own professional role and responsibili-
ties as well as those of other professions. To communicate
effectively on interprofessional teams, PHNs need to avoid
professional jargon and demonstrate a readiness to work
together by being available, showing interest, and actively
listening. A consideration for effective teamwork is having
respect for the professional expertise among diverse mem-
bers of the team while staying focused on the goal of the
collaboration (Interprofessional Education Collaborative
Expert Panel, 2011).

The “professional” part of interprofessional collaboration
refers to individuals who have specific knowledge and skills
that they can use to contribute to community well-being.

TABLE 8.3 Domains and Actions Consistent
With Interprofessional Collaboration

Domain Action Example

Values/ethics for

Acting with honesty and integrity
in all relationships and modeling
respect, confidentiality, and dig-
nity for clients and team members

Roles and
responsibilities for
collaborative practice

Communicating one’s role and
responsibilities to clients/families,
community groups, and other


Actively participating in timely,
sensitive, and instructive sharing/

Teamwork and
team-based practice

Engaging other professionals
in shared problem solving and

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171CHAPTER 8  n  Competency #6

ask about their perspectives. Differences can be as basic
as using different terminology for similar work, practices,
or interventions. What you call an assessment might be
called something different in another profession. Also, take
enough time to communicate and make sure that all collab-
orators are on the same page. Time limitations and a sense

accomplish alone. Conflict that can be worked through has
the potential to lead to effective collaboration and positive

As you begin your practice, ask questions of people with
different educational preparation and roles about what
they think about a situation. Many will be pleased that you

Interprofessional Collaboration

As you read through these examples of interprofessional col-
laboration, think about your community and how you could
collaborate with other professionals to improve the health of
the population.

n Eckstrom and colleagues (2016) described a fall risk
reduction project that involved an interprofessional col-
laboration approach. An interprofessional teaching team
provided education to an interprofessional clinical team
about how to implement the American Geriatrics Society
and British Geriatrics Society guidelines to reduce the fall
risk for older adults in Oregon. The clinical teams included
representatives from medicine, nursing, pharmacy, and
social work in ambulatory, long-term care, hospital, and
home health settings. The project increased fall risk reduc-
tion activities of professionals in these settings.

n A study by Clancy, Gressnes, and Svensson (2012) found
that interpersonal and relationship skills were viewed as
most important for interprofessional collaboration in a
survey of PHNs, physicians, midwives, and child protection
workers from Norwegian municipalities and social ser-
vices. All participants ranked trust, respect, and collabo-
rative competence as most important in interprofessional
collaboration. Thirty percent of participants reported that
conflict among professionals was common. The authors
suggested that structural changes—such as co-locating
professionals, which could increase the potential for face-
to-face communication—would likely decrease territorial
thinking based on professional expertise.

Normative Group Development

To collaborate effectively with people representing different
organizations, an understanding of group dynamics is use-
ful. Tuckman developed a theory that explains the norms for
group development (1965). PHNs can apply this theory to
new situations of working with interprofessional teams. See
Table 8.4. The stages of normative group development pre-
dict how a collaborative group develops its relationships and
interaction patterns for working on a common public health
goal. There are four stages: forming, storming, norming, and
performing. After the forming phase, most groups will move

through a storming phase. Conflict-management skills can be
helpful in the storming phase to identify participant interests
and positions, create new options through brainstorming, and
negotiate a plan for moving forward (Bazarman, 2005). In the
norming phase, group members begin to unify as a group. After
moving through the norming phase into the performing phase,
the group aims to work together collaboratively to achieve an
agreed-upon goal. A healthy, functioning group creates energy
that moves the group toward goal accomplishment.

TABLE 8.4 Normative Group Development

Forming Storming Norming Performing

n Members work to
understand one another.

n The group determines its
boundaries and focus.

n Group leaders emerge.

n Conflict emerges.
n Some members may be

resistant to following
group direction.

n People express concern
about the right way to
do things.

n Trust develops.
n Members identify as a

n The group experiences

cohesion in choosing
a goal.

n The group focuses on
accomplishing tasks.

n Members establish rules
for working together.

Source: Tuckman, 1965

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172 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies


phase. After about 10 meetings, a core group of community
members have been identified through their commitment
and attendance at meetings. Jake observes that this smaller
group more easily comes to a consensus about the project’s
vision and purpose and that the members begin to trust
each other and understand their roles in the group.

Each group member is focused on the delivery of ser-
vices to assist the homeless. Each member brings unique
gifts and contributions to the table. Jake is excited to be a
part of this collaborative endeavor. He is asked to develop
a flyer to promote and advertise the wellness clinic, which
will be open on Wednesday evenings.

n Identify the forming, storming, norming, and performing 

stages in the preceding scenario.

n Discuss actions members of the group might take to reduce 
potential barriers to effective interprofessional collaboration.

Building Partnerships With Communities,
Systems, Individuals, and Families
Partnerships are needed to implement many public health
strategies to improve population health. In organizational
and systems-level partnerships, many factors need to be
addressed, including use of resources, personnel, and
power-related factors that influence decision-making. There
are often challenges when creating and maintaining part-
nerships; however, the benefits of working together are often
very rewarding (Wilson & Mabhala, 2009).

Effectively collaborating and developing partner-
ships requires equality among the partners (Casey, 2008;
Drahota et al., 2016). Equality in collaborative relationships
is promoted through listening, being respectful, shared
decision-making, appreciating differences and mutual
goals, and developing trust. To encourage effective collabo-
rative relationships with communities, professionals need to
give up control and recognize that all members bring diverse
and valuable expertise, lived experiences, and skillsets to the
partnership (Campbell, Whitcomb, Culver, & McClanahan,
2015; Casey, 2008). Collaborative relationships work best if
they are nonhierarchical in nature. Partnership roles are
determined based on knowledge or expertise rather than on
professional role, function, or education level (Casey, 2008).
Ineffective relationships result from power or control ineq-
uities (Casey, 2008; Drahota et al., 2016). To reduce power
and control inequities, you need to pay attention to how the
partnership is structured, who directs resources, and how
much time participants are expected to commit to partner-
ship work.

of urgency in responding to a public health problem can
sometimes create barriers to collaboration. However, time
spent getting to know one another can help to establish trust
among the collaborators and prevent tension and conflict,
which would likely take more time to resolve at a later point
or even result in the collaboration’s failure.

The first planning meeting Jake attends includes 31 other
people (the pastor, the assistant pastor, a police liaison,
two social workers, four nurses from various clinical back-
grounds, two alternative healers, two chiropractors, two
community members, two people from the church’s board
of directors, a director from a local clinic, a block nurse
coordinator, three homeless persons, two faculty from the
university Jake is attending, two staff members from the
surrounding homeless shelters, an insurance representa-
tive, a local physician, a musician, and two other nursing
students). The group meets early in the evening to accom-
modate the participants’ different schedules. It takes most
of the first meeting to introduce everyone and to allow each
person to share an opinion of what the wellness clinic’s
vision would be.

Jake is shocked to realize that for such a large group to
come to a consensus about a vision, at least six meetings
would be needed. He realizes the group members needed
time to talk so that they could determine their goals and
how they were going to work together. During the initial
meeting, the police liaison, who is also a social worker and
a member of the church, emerges as the natural leader of
the project. His skills and experiences have prepared him
for a leadership role. He also has experience working with
the homeless population in the neighborhood. After the
meeting, Jake asks his preceptor, Linda, several questions.
He wonders how a group of people with such a variety of
backgrounds and experiences could create one plan. What
will the group do if everyone has different ideas about how
to develop the clinic? Which services does the clinic need to
provide to meet the needs of the homeless population?

As the meetings progress, some community members
drop out of the group, feeling frustrated as they perceive
that their ideas are not being considered. As Jake con-
tinues to work on the planning team, he realizes that
conflict-management skills and leadership skills are essen-
tial to work with such a large group. Jake marvels at the
ability of the police liaison to create calm in a tense situ-
ation and focus on the group’s vision to serve the home-
less population through this community outreach project.
Decision- making involves negotiation and compromise
among the group members.

New members will sometimes come to one meeting and
then be gone at the next. This spotty attendance means that
at each meeting, time is needed to introduce new members
and explain the vision and review the group’s planning

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173CHAPTER 8  n  Competency #6

The Culture of Health action areas consist of the following:
n Making health a shared value is critical for govern-

ment, business, communities, and all individuals to
thrive, as we all are interdependent upon one another.
As Paul Wellstone once said, “We all do better, when we
all do better” (, 1999, para. 7). Taking steps
to make health a shared value requires working within
the social environment and shifting mindsets to focus
on health as a collective, fostering a sense of commu-
nity and promoting civic engagement through activities
like voting and volunteering (RWJF, 2015; Trujillo &
Plough, 2016).

n Fostering cross-sector collaborations is necessary to
create a Culture of Health. If PHNs work alone or even
with others within public health or healthcare sectors,
they will not have the resources or power to create the
necessary changes to foster a culture where all people
can be healthy. Thus, cross-sector collaborations are
critical to bringing diverse groups and interests together,
like government, businesses/industry, education, health-
care and public health, and community organizations.
By incorporating each group’s knowledge, resources,
and strengths, cross-sector collaborations can have
greater influence and impact on the policies and envi-
ronments that influence population health, well-being,
and equity to build a Culture of Health (RWJF, 2015).

Factors found to facilitate effective partnerships include
the following (Campbell et al., 2015; Casey, 2008; Drahota
et al., 2016):
n Establishing trust, commitment, and respectful

relationships among partners
n Having mutually shared values, goals, and outcomes
n Sharing resources and balancing power and control
n Having effective, clear, and open communication and

n Establishing clearly defined roles and a conflict-

resolution plan together
n Recognizing and building on strengths and assets of the

partners and individuals and communities


  The Healthy People 2020 website offers  
  suggestions useful for collaboration and  
  building partnerships. On the website: 1) click 
“Healthy People in Action,” 2) click “Stories from the Field,” 
3) click two or three map points to read the featured story, and 
4) identify the role of partnership in the success story. Then 
consider how PHNs could use Healthy People 2020 goals, 
tools, and resources as they collaborate with professionals and 

Building a Culture of Health:
Partnership and Collaboration
An important skill for PHNs is learning how to develop
collaborative community partnerships to bring about com-
munity and systems change for improving health (Fawcett,
Schultz, Watson-Thompson, Fox, & Bremby, 2010; Towne &
Valedes, 2017). Collaborating to establish effective partner-
ships is essential for building a “Culture of Health.”

What is a Culture of Health? The Culture of Health is a
systems-level initiative that brings together all stakeholders
who aim to improve health outcomes. As coined by Robert
Wood Johnson Foundation (RWJF, 2015), a Culture of
Health is where all individuals, communities, and societies
can enjoy good health to grow, live, work, and play. Through
an extensive research process, RWJF developed the Cul-
ture of Health Action Framework, shown in Figure 8.2, as a
guide for how governments, organizations, and health pro-
fessionals can work together to build a culture that increases
population health, well-being, and equity. The four action
areas overlap and are interconnected; one action area in
particular focuses on collaboration and partnership (RWJF,
2015; Trujillo & Plough, 2016). As you read about each of the
four RWJF action areas, consider how important collabora-
tion and partnership is for each action area.

FIGURE 8.2 Culture of Health Action Framework
Source: © 2015, Robert Wood Johnson Foundation.

Used with permission.

















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174 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

Consider who the cross-sector collaborators are with whom 
PHNs work to build a Culture of Health.

n Creating healthier more equitable communities focuses
on ensuring all people and communities have equitable
opportunities and resources in their neighborhoods to
achieve health and well-being. To create healthier, more
equitable communities, a PHN must work through
policies and systems to impact the built, social, and eco-
nomic environments by decreasing residential segrega-
tion and increasing access to affordable housing, healthy
foods, safe communities, and quality education at all
levels (RWJF, 2015).

n Strengthening the integration of health services and
systems emphasizes that to improve health outcomes for
all and reduce healthcare costs, all individuals need to
both be able to access affordable, holistic healthcare ser-
vices across the spectrum of medical, dental, and mental
healthcare services and receive needed social and public
health services. When working together, integrated
healthcare, public health, and social services can best
facilitate health promotion, disease prevention, and
chronic disease management through effective primary,
secondary, and tertiary prevention (RWJF, 2015).
Cross-sector collaboration requires the support of qual-

ity partnerships, investments, and policies (RWJF, 2015).
While each of these four action areas is critical for working
toward building a Culture of Health and increasing health
equity, well-being, and population health, cross-sector col-
laboration is critical to moving much of the work forward.
Factors that can facilitate success of cross-sector collabo-
ration and partnerships include ( Libbey & Miyahara, 2011;
Mattessich & Rausch, 2014):
n Clear, shared vision with common goals that are consid-

erate of the culture, backgrounds, and environments of
each partner in the cross-sector collaboration

n Skilled, devoted leadership with defined roles of

n An understanding of each of the partner organiza-
tions and mutual respect for what each brings to the

n Financial incentives from both government and
corporate businesses to support the partnership
You likely have already noticed that there are many

similarities between these factors that facilitate success of
cross-sector collaborations to build a Culture of Health and
those that facilitate successful partnerships at individual,
community and systems levels. Just like successful part-
nerships at the individual, community, and systems levels,
developing and sustaining quality cross-sector partnerships
for collective action is not easy. Yet, the outcomes of success-
ful cross-sector collaborations propel PHNs toward creating
a Culture of Health. Successful cross-sector collaboration
outcomes include improvements to services provided, policy
change, and improvements to and awareness of how social,
built, and economic environments (e.g., transportation
availability, safety of neighborhoods, availability of afford-
able housing) influence health (Mattessich & Rausch, 2014).

Cross-Sector Collaboration in Action

n The Twin Cities Mobile Market is a “grocery store
on wheels” that works to increase access to afford-
able healthy foods by bringing them to the doorsteps
of under-resourced communities. Led by a skilled,
devoted leader, Ms. Porter, the Twin Cities Mobile
Market is possible because of the successfully devel-
oped cross-sector collaboration and partnerships
with wholesalers, grocery stores, local farmers, local
government (including public health departments
and nurses), public and private housing agencies,
healthcare systems and insurance companies, com-
munity organizations and partners, philanthropic and
government funders, SNAP-Ed programs, legislation,
and researchers. This cross-sector collaboration
makes it possible for the Twin Cities Mobile Market to
serve under-resourced community sites each month,
and currently, 50% of all Twin Cities Mobile Market
sales are for fruits and vegetables (Twin Cities Mobile
Market, 2017).

n An exemplar of cross-sector collaboration is Commu-
nity of Care in rural Cass County, North Dakota, which
started as a pilot project of the Good Samaritan Society
to help older residents remain in their homes as long as
safely possible. Today, Community of Care is supported
by human service funds, grants, and other commu-
nity financial sources. Staffing includes an executive
director, a faith community nurse, a care coordinator,
a part-time bookkeeper, a volunteer coordinator, and a
cadre of community volunteers. Cross-sector collabo-
ration has resulted in expansion of services to commu-
nity members, including transportation to healthcare
appointments, referrals to state health insurance
counseling, yard work, minor home repairs, low-impact
exercise classes, blood pressure screening, music and
memory programs, a health newsletter, and health edu-
cation activities. Community wellness fairs are offered
in partnership with local university nursing students.
The outreach activities include home visits to residents
who are living in the rural parts of the county, as well
as providing referral assistance to the family mem-
bers of the residents. A goal of one of the grants that
helps support Community of Care is to reduce hospital
readmission rates through the efforts of collaboration
(Community of Care, 2017).

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175CHAPTER 8  n  Competency #6

In comparison, community engagement activities with
the greatest levels of community involvement are those
rooted in collaboration with shared leadership between
partners and the highest levels of trust, information sharing,
communication, and impact (Bagnall, White, & South, 2017;
National Institutes of Health, 2011). Community engage-
ment is best developed locally by drawing on the knowledge
and experience of community and volunteer organizations
to find and locate people from the community to take on
peer and lay roles in health initiatives (Bagnall et al., 2017).

There is not a “one size fits all” approach to engaging
communities. Public Health England and National Health
Service England identified four different options to choose
from to fit with the community context and type of health
initiative for doing community engagement work (Bagnall
et al. 2017). These options include:

1. Strengthening communities by building on com-
munity capacities to act together on health and the
social determinants of health

2. Developing volunteer and peer roles that focus on
enhancing individuals’ capabilities to provide advice,
information, and support or organize health activi-
ties in their own or other communities

3. Building collaborations and partnerships to involve
communities and local services working together
at any stage of the planning cycle, from identifying
needs through to implementation and evaluation

4. Increasing access to community resources by con-
necting people to community resources, practical
help, group activities, and volunteer opportunities to
meet health needs and increase social participation

PHNs strive for strong collaborations and partnerships
with community agencies and members. Therefore, you
should always aim to increase the level at which the com-
munity is involved in community engagement work, which
is an advocacy intervention. Within your public health
nursing clinical experience, you may become involved in
community engagement activities. Ultimately, the services
and interventions you provide should empower and engage

In the following activity, find an example of how PHNs
could actively participate in cross-cultural collaboration
with other stakeholders to promote health in a population.

Online Activity
    Visit the Community Tool Box website (http:// compiled by the KU Center for Community 
Health and Development at the University of Kansas, a des-
ignated World Health Organization Collaborating Centre for 
Community Health and Development. Check out the tool box 
resources that can be used to support and guide collaborative 
public health nursing actions and work with partners at individ-
ual, community, and systems levels. Which resources would be 
useful to you and the PHNs you work with during your public 
health clinical experience? Which resources on this website do 
you think are helpful for PHNs to stay up-to-date on the best 
practices of collaboration and partnership?

Collaborating Through
Community Engagement
Community engagement involves collaborating with a com-
munity agency, a community safety-net organization, or
community members to meet mutual needs that empower
the community and the target population. It is important to
acknowledge that community engagement work can involve
the community at different levels, from very little commu-
nity involvement to full community involvement (National
Institutes of Health, 2011; Potter & Willis, 2013). For exam-
ple, community engagement activities with less community
involvement include outreach and consultation, in which
information is often provided to the community. These
activities may be the start of long-term and lasting com-
munity partnerships and collaborations; however, at these
lower levels of community involvement, there is often less
trust, flow of information, and communication, and thus
there is less potential for impact.

Rural Nursing in South Africa

GOAL 17 In South Africa, there is a shortage of doctors and nurses in rural areas and a greater need
for access to healthcare. Healthcare needs include contraception and antenatal care, immunizations,
and reducing the spread of tuberculosis and HIV. Guin Lourens, along with eight fellow nurses, estab-
lished an organization called Rural Nursing of South Africa to increase nursing leadership in responding
to identified healthcare needs. This organization partners with the Rural Health Advocacy Project, the
Rural Doctors Association of South Africa, and Rural Rehab South Africa to respond to gaps in rural
healthcare (International Council of Nurses, 2017).

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176 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies



those you are working with, enrich the healthcare abilities
of the agency/community partner, and build organizational
capacity. By acknowledging and building on the strengths
that already exist, you are adding to the community’s assets
and strengthening its ability to manage its own healthcare
needs. Public health nursing advocacy through community
engagement involves empowering vulnerable populations
and their communities through capacity-building, collab-
orations, and partnerships. Table 8.5 provides a checklist
of key steps to take to ensure community engagement work
will be successful.

Jake realizes that the tone of the meetings has changed
to a collaborative relationship of listening to each other,
respecting differences, and valuing each other’s input in
the process—traits representative of an effective partner-
ship. The members who are homeless are key partners and
helpful in identifying needs and offering suggestions for
delivery of services. Jake feels the strength of the bond of
the collaborative partnership team in a shared vision. Jake
observes that the team members are sharing resources and
ideas with the group and striving for positive outcomes for
the wellness clinic.

When Jake’s preceptor, Linda, asks him which charac-
teristics and skills he thinks are needed for partnerships
to be effective in planning such a challenging project, he
answers that being committed, tactful, and persistent are
important. He comments that it was really hard when peo-
ple dropped out of the planning group in the early stage.
However, the people who stayed with the project demon-
strated they are committed and persistent. Jake also says
that he thinks it is very important to have people in the
group who have some influence in the community.

Using Community Assets to Empower
Communities, Systems, Individuals,
and Families
To be effective collaborators, PHNs must recognize and
emphasize community assets in planning interventions
to promote public health. PHNs along with community
groups and organizations, such as churches, social service
agencies, and neighborhoods, can identify assets within the
community that provide building blocks for public health
initiatives. An intervention that builds on a foundation of
community assets is sometimes referred to as a strength-
based intervention, which means that an intervention is
selected and/or enhanced because it is already a resource or
strength that exists within the community.

TABLE 8.5 Checklist for Successful
Community Engagement

❑ Learn about the community, the community safety-net
organization, and at-risk populations.

❑ Develop trusting relationships with the community and
diverse at-risk populations.

❑ Identify public health nursing activities beneficial to the
organization, at-risk populations, and students.

❑ Collaborate with and engage the community agency in the
planning, implementation, and evaluation of public health
nursing activities.

❑ Develop culturally sensitive public health nursing services
that are respectful of diverse populations.

❑ Create public health nursing services that are asset based,
building on the strengths of the community agency, com-
munity resources, and at-risk populations.

❑ Be flexible in developing and implementing public health
nursing services.

❑ Provide public health nursing services that strengthen an
ongoing relationship with the community agency.

Sources: Builds on work of Broussard, 2011; Schoon, Champlin, & Hunt,

Asset Mapping: A Tool for 
Strengthening Communities
Karen Goldman and Kathleen Schmalz (2005) contrast
a needs-based assessment approach with an asset-based
assessment approach. Looking for the community’s needs
results in assessing what is wrong with the community
and determining how “to fix” the problems, while looking
for assets results in building on community strengths and
mobilizing resources within the community to promote
community health (see Table 8.6).

Assessing community assets means listening carefully
to the voices of community members through interviews,
meetings, focus groups, and asset-based inventories. Asset-
based inventories identify strengths of individuals, commu-
nity groups, and community organizations. Strategies to
conduct an inventory may also include conducting a walk-
ing or windshield survey in which community strengths
are noted, and using maps to document assets with a Geo-
graphic Information System (GIS). Additionally, other
sources of information might include community websites;
town directories; bulletin boards; and listings of business,
organizations, and institutions (KU Center for Community
Health and Development, 2017).

Asset mapping can benefit the community in several
ways. This approach empowers people to think more pos-
itively and encourages them to discover their abilities and
resources to contribute to their own health and meeting

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177CHAPTER 8  n  Competency #6



TABLE 8.6 Needs Assessment vs.
Asset Mapping

Needs Assessment Asset Mapping

n Community need is based
on deficiency or problem.

n Looks at what is wrong
with the community and
how to fix it.

n Leads community to seek
assistance rather than
using in-house skills and
change agents.

n Discourages community

n Community assets include
people, places, businesses,
and organizations that
can be mobilized for

n Focuses on positive
aspects (strengths).

n Leads community to
look within for solutions
and resources to solve

Source: Goldman & Schmalz, 2005

TABLE 8.7 Questions for Community Groups
to Promote Thinking About Assets

Category Questions

Physical What are two or three physical assets in your
community (neighborhood, buildings, parks,
space, land, natural resources)?

Individual What are your talents, experience,
perspectives, and skills?

What do you care about?

What do you know about?

Whom do you know?

Associations What is your participation in formal or
informal voluntary groups, networks, and
organizations of individuals who gather to do
or enjoy something they cannot do alone?

Which groups are you part of?

Which groups do you know about?

Institutions Which institutions (such organizations as
businesses, nonprofit agencies, government,
and schools) are located in your community?

What do these organizations contribute to
your community?

Economic What is something you spend money on?

What is something you make or do that
people would pay you for?

Where do you invest your money?

What are unique economic assets in your

Sources: Hamerlinck, 2013; Snow, 2004

their goals for the future. They also learn to listen and value
the contributions of others. Asset mapping is an inclusive
process, which results in highlighting information and
resources that can be used to mobilize individual and com-
munity assets (Kretzmann & McKnight, 1993; Morgan &
Ziglio, 2010).

John Kretzmann and John McKnight (1993) have identi-
fied five categories of community assets: physical, individ-
ual, associations, institutions, and economic. Luther Snow
(2004) and John Hamerlinck (2013) propose asset-mapping
questions, which can be adapted to help community groups
explore their assets (see Table 8.7).

Once the community group has identified its assets, the
next step is to review and consider how these assets can be
tapped. In a group exercise, group members can list assets
on pieces of paper or sticky notes and talk about how they
are connected and can be used to improve the health and
well-being of the community (Snow, 2004).

An asset-based approach to working with communities
brings both strengths and challenges. Whiting, Kendall,
and Wills (2012) discuss assets from a health promotion
perspective. They identify categories of health assets and
development assets (individual level) and public health
asset frameworks (generally focus on community assets).
Table  8.8 describes both strengths and challenges of the
asset-based approach for individuals and communities.

Jake realizes the importance of knowing community assets
and working with other professionals. The pastor knows
the neighborhood and community well and has space and
people resources for serving the meal on Wednesday eve-
nings to the homeless. The social worker has experience
with chemical dependency patients and the skills needed
to address drug-abuse issues or concerns among the home-
less. Another nurse is a mental health specialist who knows
about useful referrals for homeless people. The police liai-
son knows many people who are homeless and is very well
respected in the community. The insurance representa-
tive can help find resources to increase people’s access to
healthcare by identifying funding options and programs.
The PHN knows about social service resources and possible
sources of healthcare funding. Jake, as a nursing student,
brings his gifts of delivery of care by doing blood pressure
screenings, health teaching, and foot care at the wellness
clinic. The programs planned at the wellness clinic are ser-
vices the collaborative community members can offer or
find others to come in and provide.

Jake is present the first night the wellness clinic opens. As
he sits down to share a meal with some of the individuals
who visited the wellness clinic, he realizes the value in this
statement: “It takes a community to take care of its own.”
The strengths of each collaborative partner are needed to
develop the wellness clinic.

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178 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

TABLE 8.8 Strengths and Challenges of an Asset-Based Approach

Strengths Challenges

n Helps people think positively about their circumstances
n Helps to obtain a common view of what is important
n Can be fun for the clients/participants involved
n Is realistic because it identifies what is already available
n Is inclusive
n Is a form of discovery
n Facilitates interdependencies
n Centers on effectiveness
n Facilitates hearing and valuing others
n Provides the information necessary for the mobilization

of assets
n Promotes the population as a producer of health, rather than

as a service user
n Encourages people to realize their ability to contribute to

the development of health
n Facilitates the identification of a range of health-promotion

n Helps to develop more sustainable initiatives
n Seeks to empower people
n Helps to identify ways for individuals to use their talents

n Requires financial investment
n Is initially time-consuming
n May be challenging emotionally and physically
n May be resisted if current practice is viewed as effective
n May identify assets that are not useable
n May highlight assets identified by various stakeholders,

rather than by communities or individuals
n Proves difficult to sustain, particularly within the current

political and socioeconomic climate

Source: Whiting, Kendall, & Wills, 2012, pp. 27–28

Asset Mapping

n The University of Chicago launched an initiative that
employed local youth to conduct a block-by-block census
of community assets on the South Side of Chicago. The
population of the geographic area was primarily African
American and Hispanic, with 32% living at poverty level
and a 22% unemployment rate. Partnerships included
three community-development organizations. College-age
adults mentored and supervised 54 high school youth
participants. Over 8,000 assets in 28 sectors or catego-
ries were identified in the census. The largest sectors were
food, trade services, and religious worship. The project
provided data about local assets that can be tapped to
help build a Culture of Health by sharing language and
principles (Lindau et al., 2016).

n An initiative to address childhood obesity used asset
mapping to identify individual and community strengths in
the targeted population, a public school district in upstate
New York. The goal was to reduce television viewing time.

Partners in the initiative included childcare staff, school
and college staff and faculty, primary healthcare staff,
local businesses, social and faith-based organizations,
the local library, and students from all educational levels.
Partners networked to involve others in the community;
community groups offered 40 different after-school and
weekend activities in 11 public locations for preschool chil-
dren and their families in a sponsored “TV turn off week.”
Community groups collaborated on a variety of family
activities, such as sports, lessons, music, dancing, and arts
and crafts. Outcomes based on feedback from question-
naires and partner debriefing sessions indicated that:
1) more parents enrolled their children in programs, which
promoted physical activity (individual/family level); 2) the
library decided to continue to offer storytelling hours
(community level); and 3) childcare providers changed
their policies for viewing media (systems level) (Baker et
al., 2007).

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179CHAPTER 8  n  Competency #6



When Jake first started the community health course, he
believed that, although important, the delivery of services
to persons who were homeless was someone else’s con-
cern, not his. He also wondered why individuals who were
homeless were included in the planning group. In the early
meetings, he observed that the participants who repre-
sented the homeless population were very quiet, so many
other members of the group were talking about what they
thought homeless people wanted. In the third meeting, the
police liaison who had emerged as the group’s leader asked
the members who represented the homeless population to
offer their opinions on some of the ideas that had been
expressed. He explained that they were “experts” on what
it meant to be homeless and would therefore have good
ideas about which services and resources would best help
meet their health needs. The police liaison also did not back
away from conflict but continued to emphasize the com-
mon goal of the group. In later meetings, participants who
represented the homeless population began to share more
about their experiences.

After being a part of the project and actually spending
time with individuals who were homeless, Jake now under-
stands why it is important to include people who have expe-
rienced homelessness in planning the clinic. The planning
group empowers the group members who are homeless to
participate as equal partners and take a leadership role in
creating solutions.

As Jake provides foot care for a middle-age man one
evening, the man shares his story of how he worked for a
big company, lost his job as the company downsized, coped
by drinking, lost his house and his family, and finally lost
his sense of self-respect. As Jake reflects on this story, he
concludes that each of us could find ourselves in a simi-
lar situation. Through collaboration, Jake realizes that a
community can use its strengths and resources to make a

Acknowledgment: Chapter narrative development by Joyce Bredesen,

Ethical Application
When PHNs collaborate with other professionals, commu-
nity members, and community organizations, ethical con-
cerns often center on selecting interventions that promote
social justice for vulnerable populations that have fewer
resources for improving their health. However, as PHNs
work to promote a healthier life for community members,
they must also consider how community members are going
to view and experience the interventions they develop. In
addition, collaboration often requires courage to work
with others who have different views and persistence to
keep working together even amid disagreements and ten-
sion about the right way to proceed. All voices need to be
heard in the decision-making process. In collaboration, an
emphasis on community assets leads to inclusion, diversity,
empowerment, and advocacy. See Table 8.9 for the applica-
tion of ethical perspectives to collaboration.

TABLE 8.9 Ethical Action in Collaboration

Ethical Perspective Application

Rule Ethics (principles) n The goal is beneficence or pro-
moting good (improvement in
health status) for the commu-
nity and community members.

n Encourage autonomy of com-
munity members by ensuring
that their perspectives contrib-
ute to determining interven-
tions to improve health.

Virtue Ethics

n Be courageous in working with
those with different views and

n Be persistent in working
through disagreements and
tension in collaboration with

Feminist Ethics
(reducing oppression)

n Encourage including the
voices of all stakeholders in the

n Respect everyone.
n Strive for equality in the provi-

sion of programs and services.
n Emphasize community

n Advocate for individuals and

community groups who have
less power.

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180 PART II  n  Entry-Level Population-Based Public Health Nursing Competencies

n Partnership development requires trust between part-
ners and a commitment to spend the time needed to
develop that trust.

n Collaborative partnerships for promoting the Culture
of Health and health of the public should work to have
high levels of community engagement

n Collaborative partnerships should integrate community
assets that contribute to the identification and design of
intervention strategies in collaboration with community

n Tools for identifying community assets include commu-
nity engagement and asset mapping.


n PHNs collaborate with many partners, including other
nurses, health professionals, lay workers, community
members, healthcare and community organizations,
businesses, and government organizations.

n When building interprofessional collaboration rela-
tionships, pay attention to the following: teamwork,
communication practices, roles and responsibilities,
and values.

n Effective partnerships share a common goal and require
respect for and equality among partners.


Developing a clinic for the homeless is a complex project that
involves many stakeholders and community organizations.
Before partners begin to collaborate, reflecting on the goals
of the collaborative project is essential. When partners are
gathered together, they need to reach consensus on a shared
goal. Now that you have learned about collaboration and the
knowledge and skills needed to collaborate effectively, con-
sider the following questions:

 1.  What does Jake need to consider about effective part-
nerships before collaborating to develop a clinic for the

 2.  Consider strategies for overcoming barriers to inter-
professional collaboration. For the scenario about the
clinic for the homeless, what do you see as possible
barriers the team might encounter? What can they do
to effectively manage those barriers?

 3.  What information about the population and commu-
nity organizations will be needed for planning? What is
an effective way to gather the information?

 4.  What would be important to include on the agenda for
the first planning meeting?

 5.  What actions will support cross-sector collaboration?
 6.  How can the group explore individual and community

assets that can be mobilized?
 7.  Which additional questions will you need to ask to

partner effectively in developing a clinic for the home-
less population? How will the group meaningfully
engage all partners?

 8.  Refer to the Cornerstones of Public Health Nursing in
Chapter 1. Which of the Cornerstones are consistent
with and support the development of a clinic for indi-
viduals and families who are homeless?

After you have worked through these questions, develop
an outline of possible partners and collaborative strategies.
Propose relevant Public Health Intervention Wheel inter-
ventions and the level of each intervention that may be part
of the expected outcome and action plan.


 1.  Which responses would you expect from the planning
group based on Tuckman’s Theory of Normative Group
Development (Tuckman, 1965)?

 2.  Which partnership guidelines would you apply to
increase the likelihood of partnership success?

 3.  How could you use asset mapping or community
engagement to achieve partnership goals?

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181CHAPTER 8  n  Competency #6

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