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It all starts here: integrating the role of nursing education and community health promotion

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https://www.eduzhai.net International Journal of Nursing Science 2013, 3(1): 15-21 DOI: 10.5923/j.nursing.20130301.03 It All Starts Here: Merging the Role of Nursing Education and Community-Based Heath Promotion Crystal Shannon School of Nursing, Indiana University Northwest, Gary, 46410, United States Abstract Many communit ies continue to have high levels of morb idity and mortality and co mmunity-based health promotion is recognized as one of the most important factors in pro mot ing positive health outcomes. Nurses remain one of the primary resources for the delivery of co mmun ity-based health but the manner in wh ich nurses are educated about community-based health greatly influences their ability to deliver culturally appropriate and socially responsible care. Globally, nurses are one of the primary sources for guidance, education, and support. Communities rely on the profession to not only deliver culturally appropriate, quality, safe, and effective nursing care; but to work together with the co mmunity to develop solutions to various health problems. Nursing education is responsible for educating new nurses on these concepts, but lack of practical educational opportunities can impact a student’s understanding of community-health concepts. Students are potentially unprepared and unable to support positive health outcomes for populations with the greatest need. Presented here is a review of the role of nursing education in preparing prelicensure nurses, the responsibility of the profession for co mmunity health pro motion, the barriers reported by local nursing schools, and possible recommendations to improve the efforts of co mmunity-based health promotion. Keywords Nursing Education, Co mmun ity-Based, Nursing Schools, Health Pro motion 1. Introduction The nursing profession continues to struggle with the delivery of health care to patients within co mmunities affected by high rates of morbid ity and mo rtality. One of the primary functions of nursing is to g ive care with quality and awareness, promoting an at mosphere of education and disease prevention. However, this function can only be effectively acco mp lished if special attention is given to patients’ socioeconomic, cultural, and co mmunity backgrounds[1]. Researchers such as Byerly & Stein[2] discuss the potentially negative influence of income, education, culture, and gender on positive health outcomes and encourage health care providers (e.g. nurses) to develop education and treatments that meet the specific needs of the community population. Co mmu n ity -b ased app ro aches t o h ealth p ro mot io n remain impo rtan t to nu rs ing p ract ice and p rov ide an effect ive basis for the inclusion of p rimary prevent ion met h o ds in th e deliv ery o f nu rs in g care[3]. Th ese approaches offer greater understanding of the relat ionships b et ween in d iv idu als , th e en v iron men t , cu lt u re, and ad min ist rat iv e const raints and the imp act o n h ealth * Corresponding author: crshanno@iun.edu (Crystal Shannon) Published online at https://www.eduzhai.net Copyright © 2013 Scientific & Academic Publishing. All Rights Reserved decisions. However, the manner in which prelicensure nurses are introduced to these concepts can vary and may not include practical opportunities toward understanding these methods. Although schools of nursing (SON) around the world are required to teach some elements of population health and community-based health promotion (CBHP), the depth of education and training varies and are influenced by the availability of mult iple resources. These variations and challenges potentially deliver a nurse unable to provide the most effective care management to a population with the greatest need. 2. Background 2.1. Community-B ased Heal th Promotion and Improvement of Health Outcomes Primary prevention approaches to health care are recognized as one the most effective methods used to reduce the rates of disease in community populations[4]. These methods include the provision of health specific education toward the reduction or removal of risk factors (environ mental and personal). The use of primary prevention in CBHP allows nurses the ability to better understand the determinants of community health and design quality health promotion programs for imp roved health outcomes[5]. A lthough, this method is a proven process for supporting health promotion and community 16 Crystal Shannon: It All Starts Here: M erging the Role of Nursing Education and Community-Based Heath Promotion education, it does not always include the direct involvement of the community-at-large. Therefore, other princip les such as community engagement and co llaboration must be included in all efforts by health care personnel when planning health care programs. 2.2. Nurses and Community-B ased Health Promoti on Traditionally nurses are one of the primary tools by which health education is delivered[6]. Ho wever, the education predominately occurs in the acute clinical setting after the onset of disease. Thereby, missing the opportunity to utilize concepts of primary prevention and reduce or remove risk factors for disease development[3]. This encourages the patient to address health conditions after their occurrence versus managing the risk factors that lead to the advance of disease. As a result, the nursing profession worldwide has acknowledged the need to move nursing’s focus fro m the inpatient setting to the commun ity setting in an effort to meet the needs of the population where they live, wo rk and play[7]. Consequently, allo wing fo r increased understanding of community, social, economical, and cultural influences on health outcomes. Additionally, nurses have begun to explo re concepts of community empowerment, engagement, and equitable sharing of knowledge between patients, families, and health care personnel. These concepts of community-health are included in numerous research methodologies (i.e. co mmunity-based participatory research and participatory action research) but may not be present in more basic nurse-led community-based health promotion programs or projects. Therefore, the impact of these efforts may be minimal, lack community engagement, and may have little impact on improving health outcomes. Nurses are educated in community-health concepts but may not receive educational focus on the collaborative connection and buy-in of all community stakeholders. 2.3. Nursing Educati on in the U.S. In the Un ited States all Reg istered Nurses must pass a national council licensure examination (NCLEX) to determine read iness for practice. This test evaluates all prelicensure nursing school graduates on content related to: (1) Safe and effective care environ ment. (2) Health promotion and maintenance, (3) Psychosocial integrity, and (4) Physiological integrity[8]. The area of health promotion and maintenance includes community health education, collaborative partnerships, health promotion, wellness, and screening. The licensure exam evaluates a students knowledge of health care risks related to a variety of community populations, planning and delivery of community education opportunities, and assessing the effects of environmental in fluences on health[8]. In 1986, a document (hereafter called The BSN Essentials) was created as a guideline to all Reg istered Nursing pre-licensure educational programs in an effort to streamline, define, and support the basic knowledge, values, and skills of nurses. To date, The BSN Essential serves as a blueprint for baccalaureate nursing schools throughout the nation in developing, maintain ing, and revising nursing curricula[9]. In 1998 the authors recognized that a major trend toward population-based care would need to be not only addressed by nurses but also introduced to students early in their nursing education. The American Association of Colleges of Nursing (AACN)[9] recognized that health pro motion; risk reduction and disease prevention was a core co mponent to the body of nursing knowledge. Two specific types of knowledge required of nursing curricula are[9]: ● Fostering of “strategies for health promotion, risk reduction, and disease prevention across the life span”. ● Init iation of “co mmunity partnerships to establish health promotion goals and imp lement strategies to meet those g o als ”. Both of these concepts support the focus of other researchers in encouraging efforts toward primary prevention[5]. The concept of primary p revention being ideal for health pro motion is not lost on the nursing profession. The guidelines above show this core idea as being a required key co mponent in nursing education. Accrediting agencies within the U.S. has several core competencies listed as being required for any level of nursing education (Practical, Dip lo ma, Associate, Bachelor, and Graduate). Nursing co mpetencies are defined as a minimally acceptable level of expertise in a given area of practice[8]. As nurses are theoretically and clinically t rained in health care, they are required to be minimally co mpetent in actions of patient care on completion of the nursing program[9]. The idea of commun ity partnership, collaborative management of disease processes, and population-based health is required to be present in all forms of nursing education. The first competency requires that nurses should demonstrate their caring for the co mmun ity’s health and wellbeing[8]. It requires nurses to: ● Have broad understanding of determinants of health (i.e. environment, socioeconomic conditions, behaviour, g en etics ) ● Be ab le to work with others in the community to integrate a range of services and activities that promote, protect, and improve health ● Take as the unit of analysis the whole population (apply the concepts and tools of epidemiology to a variety to contexts ranging fro m ind ividual patient encounters to the management of co mplex systems) ● Apply knowledge of the new sciences ● Advocate for public policy that promotes and protects the health of the public The restricted involvement of nursing students in CBHP not only limits the students’ exposure to culturally sensitive health care but also potentially stunts the students’ sense of social responsibility and civic duty. 2.4. Nursing Educati on and Community Partnerships Many SON may be located within or near co mmun ities that have higher than average disease states. These nursing International Journal of Nursing Science 2013, 3(1): 15-21 17 programs include practicing nurses and scholars who, in conjunction with community partners, could address many community-health issues with facu lty research, program development and active use of prelicensure nursing students to deliver health education programs to the public. The nursing programs are in a unique position to not only educate new nurses for the workforce but also support the community by active display of engagement and promotion of social change[10]. Nurses are expected to use concepts of empowerment, support and inclusion when provid ing care and education to the public. These participatory methods promote active stakeholder/ patient involvement in assessing personal health and development of a treat ment p lan. Failure of nurses (and student nurses) to understand concepts of participatory action inhibits the promotion of patient centeredness and community engagement[11]. Additionally, this has the potential to alienate the very person or groups for who m the education or treatment interventions are designed and ultimately restricts the promotion of primary preventive health care. Some nursing programs and other academic settings have acknowledged the need to imp rove their co mmunity collaborative efforts and are participating in nu merous activities to support these actions and promote their degree of commun ity engagement. Designations such as the Carnegie Co mmunity-Engagement Classification[12] acknowledge the effo rts of local universities in co mmunity engagement efforts and mutual partnerships to prepare educated students and promote the public good. In order to implement and measure the degree of engagement, many schools participate in required service learning activities designed to not only introduce a student to the community setting but to deliver a service or product to the community-at-large. However, the focus of the activ ity may be one-sided and have minimal (if any) part icipatory components to their design and may not be effective in improving overall co mmun ity health outcomes. Amerson[13] discussed the impact service learning had on students’ perception of civic responsibility and cultural awareness. The author recognized the mutually positive impact the community-based service-learning activ ities had on student growth and overall health. Co mmunity health researchers[14] d iscuss the process of involving students in mentoring programs designed to promote community-based health. The authors recognized the synergistic learning that takes place between the students and program participants in terms of pro moting overall health fo r residents and socializing students into the profession. Other researchers such as Shoultz et al.[15] described the positive outcome Another e xa mple is the use of nursing and dental students in collaborative partnerships with four different co mmunity health centers aimed at studying Intimate Partner Vio lence (IPV) disclosure. In addition to evaluating the rate and occurrence of IPV, the researchers also identified methods for improving education and reporting instances of violence. Both examp les utilized nursing students (as well as other health professions education units) to evaluate a problem and implement an intervention. The use of students offers an opportunity for learn ing within the context of the situation and delivery of a product tailo red to a commun ity in need. 2.5. Cul turally Sensitive Care The provision of culturally sensitive and competent nursing care is an important concept in the nursing profession. Lein inger and McFarland[1] acknowledge that healthcare is informed by an understanding of how culture, family, environ ment, and socioeconomic status affect health outcomes and decision-making. The theory encourages health professionals to seek out the input and concerns directly affecting members of the commun ity, fro m the community, before creating co mplex med ical reg imes. Transcultural theory encourages cultural sensitivity for all nursing actions that include patient care and administrative activities. This sensitivity may not be effectively translated to nursing students and is potentially missing when nursing schools lack participatory co mmunity-based partnerships and activities with local agencies and me mbers. 3. Community-Based Health Promotion Improving the Health of the Community The ability of health care personnel to use community-based health promotion methods offers a promising insight into what are considered the missing components of effective disease prevention and health promotion[16]. These authors acknowledge the need for health personnel (e.g., nurses) to consider the social conte xt impacting health outcomes and include the community as a partner in not only identifying health issues but also determining methods for addressing the concerns. Understanding the complexit ies of commun ity health problems is considered to be a key aspect in imp roving the state of health for co mmun ities. Ho wever, health care leaders often resort to mo re t raditional approaches when they plan health pro motion pro jects. A tradit ional approach frequently leaves the commun ity outside of the decision-making process and encourages a feeling of community isolation and non-involvement[17]. The use of commun ity-based approaches to primary prevention (e.g. CBHP) allows health care professionals to better understand the determinants of health—of the community and the individual—and how to research issues and design educational programs that best meet the needs of those individuals and commun ities. The primary function of a nurse, with regard to health promotion and protection, is to act as an advocate, care manager, consultant, deliverer-of-services, educator, and healer[5]. Th is role responsibility and the methods for identifying community-based problems are both foundational and vital in nursing education. Pommier, Guevel, & Jourdan[18] co mpleted a study that evaluated the effectiveness of a co mmunity-based health 18 Crystal Shannon: It All Starts Here: M erging the Role of Nursing Education and Community-Based Heath Promotion promotion project directed with local schools. The authors used a mixed approach in identify ing the methods and factors that allow for development of health promotion in schools by evaluating the strategies that influence teachers, the school’s environment and influence of the health promotion project on children’s perceived life skills. Pommier, Guevel, & Jourdan[18] used a comb ination of quantitative and qualitative research methods to answer the following research questions: 1. What are the mechanisms and the contextual factors that allow the school commun ity to develop an HP (health promotion) approach? 2. Ho w do the strategies developed through the program influence the development of teachers’ HP p ractices and the schools’ health promoting environ ment? 3. How do these practices affect we ll-being in the schools? 4. What is the influence of the program on the children’s perceived life skills? The use of surveys and interviews assisted these researchers in obtaining a clearer understanding of the collected data and the overall effectiveness of the project. Traditional methods were noted to be less than adequate in the manage ment of disease symptoms and quality of life. The authors used effective methods for identifying the importance of th is research and the methodology was very appropriate to the variables being evaluated offering a good example of the impact peers can have on health awareness and promotion. Members of the community often view nurses as a form of community peers[19]. Therefore, nurses have an opportunity to use this relationship to educate the public on their level. The language used was clear and unbiased and properly supported by recent and relevant references. However, the authors failed to consider some variab les related to the students that might impact the results. So me of the variables include race/ethnicity, socioeconomic background and init ial level of d isease education. These factors should have also been considered to be additional variables and could have been included in the list of confounders. 3.1. Barriers to Action Educators report the lack of student involvement in CBHP activities is a result of the lack of time, resources, and personnel[20]. These constraints reduce the ability of nursing students to understand community-health concepts and the delivery of cu lturally sensitive and competent nursing care. Even if nursing educators can move beyond these constraints and involve students in CBHP, they will often face other challenges to collaboration such as resistance to change, power structure struggles, ineffective communicat ion, and lack of knowledge about other health care disciplines[21]. Although SON might engage in co mmunity-based practicum activit ies, the focus and depth of those activities may limit active stakeholder partnerships. Educators frequently report joint efforts toward promoting community health with local co mmunity agencies[21]. However, the activities may lack full involvement and receipt of mutual benefits fro m all participants. Additionally, educators might find the barriers listed to be too challenging to overcome. Nursing education representatives agree that students require knowledge and awareness of community based health promotion, but the reported challenges (time, resources, personnel) minimize the potential impact to the community [20]. 3.2. Community Stakehol ders Co mmunity partners are eager to develop existing and create new SON collaborations[20]. The continued development of these partnerships has the potential to grow to levels that far exceed current national reporting. Unfortunately, this is hindered when SON allo w stated barriers to limit or impede their progress. A study performed by Shannon[20] interviewed local community members and leaders about ways in which community-heath education theory and practice might be strengthened in co mmunity-based nursing programs. The study participants (N=10) reported that they wanted to see an: ● Increased presence of nursing students at local community agencies ● Improvement in the student’s sense of value and responsibility toward the delivery of co mmun ity health ● Improvements and expansion in the development of SON relationships with co mmunity partners. The participants reported feelings of discontent with some of the methods chosen by local SON to deliver community-health and teach these concepts to new nurses. For example, when asked about their thoughts regarding current SON and co mmunity relationships and what measures would they like to see imp lemented, one community member key in formant replied: ●“… I would like for it (the pract icu m rotation) to be more of an encompassing experience than just learn ing technical skills, I want social skills as well. It would be really n ice for them to obtain that expos ure.” Another community leader offered a similar response: ●“…I think that many times they are not able to really see what community health is because of its time constraint but even that little bit will help to give them a better understanding of the role of the commun ity health nurse…” Additionally, so me respondents voiced a desire for extensive faculty-community partner relationship development. The respondents recommended SON work with local agencies to identify ways to increase the level of “buy-in” on behalf of the students when learning about and delivering commun ity health. Co mmunity stakeholders were reported to be very eager when d iscussing and sharing ideas of relationship building with local nursing programs[20]. Shannon[20] reported that most commun ity members became visib ly excited when they received the study informat ion was offered. Study participants also reported International Journal of Nursing Science 2013, 3(1): 15-21 19 they believed local nursing schools and community agency collaborations were significant to p ro moting the health of the community, required to serve the needs of the community and was a natural process that should be exp lored. 4. Implications for Nursing Education Nursing educators worldwide a re often required to ba lance student educational experiences with the provision of culturally sensitive, safe and effective nursing care to patients, families and communit ies[22]. This balance frequently necessitates the use of personalized approaches to student learning, research, and patient care. However, this balance can suffer when scarce time, resources, and personnel block the expansion of CBHP to students and communit ies. Therefore, nurse educators are encouraged to work together with not only local co mmunity members and agencies but also other nursing educators toward identifying specific part icipatory projects designed to meet the needs of the students and the agencies[23]. This collaboration can encourage active stakeholder communicat ion, partnership and relationship development that initiates dialogue between the faculty, students, community members, commun ity agencies and even other regional SON. Nu rsing educators should find opportunities to expand nursing education into the community setting[25]. These opportunities could involve the development of regional alliances, in which SON use research modalities such as participatory action research, which encourages local community stakeholders to share and discuss the issues most important to them. Nurse educators have reported feelings of pride and accomplishment when engaging students in CBHP-type activities[20]. Ho wever, the greater impact of these activities might be short-lived and one-sided. The types of community-based experiences designed for the nursing practicums potentially only focuses on the practicum and the student. Therefore, reducing the potential growth opportunities between SON and local partners. 4.1. Obligati on of Nurses for Community Health Promotion The A merican Nurses Association Code of Ethics[26] establishes the focus of the nursing profession (and preliminary education) as one centered on the education of individuals, families and communit ies in the quest for healthy outcomes. The professional obligation toward community health should not simply be introduced to entry-level, prelicensure nurses. There is an addit ional obligation of nursing educators to continue to foster and develop these values of service among student populations fro m the earliest development of nursing education. Riley & Beal[27] evaluated the processes by which nurses developed their sense of serving the public. The authors discovered that most experienced nurses used their own personal perceptions of altru ism, pract ice improvement, and giving back to guide their nursing practice. These perceptions did not come fro m their educational backgrounds but instead developed as a result of their professional experience and on average took approximately three (3) years to result in act ive co mmunity-based participation. The lack of foundational educational focus on community health limits the scope of practice for nurses. Various nursing pioneers and theorists[28] identified the responsibility o f the pro fession to use culturally and holistically focused methods of education, treatment, and support for populations affected by ever-rising disease rates. The delivery of holistic care requires that patients be supported within the context of where and how they live[29]. This may be taught to prelicensure nursing students in didactic terms but failure to include pract ical, community-based, commun ity-focused, and culturally competent experiences potentially reduces this concept of holism to a page in a textbook. The important co mponent of responsibility for pro moting community-health is potentially lost on new nurses until well into their active practice[27]. Thus, reducing the impact of the overall profession and total number of people that can and should be helped. Many communities may potentially benefit fro m the act ive presence and involvement of experienced nursing faculty and prelicensure students. However, failu re of co mmun ity-based nursing schools to identify this connection potentially d iminishes the concept of service upon which the profession was founded. 5. Global Health Nursing Nurses around the world are exposed to the effects of poverty and disease. In many commun ities, nurses are the only availab le healthcare provider and this necessitates the establishment of not only a therapeutic relat ionship but also an awareness of community responsibility. Lein inger and McFarland[1] d iscuss the ethical and moral imp lications of globalization on developing nursing practice. The authors identify the need for nurses to consider a renewed focus on the concept of a worldwide co mmunity. This requires the profession to take a broader approach toward community-based care, education, and support. The International Council of Nu rses (ICN)[30] acknowledges health promotion as a diverse process that moves beyond the provision of simp le health services. The council encourages nurses from all areas of the world to consider their approach toward the promotion of g lobal health. This includes: advancing nursing core values, influencing health policy, and using innovation to develop community partnerships. 5.1. Global Nursing Educati on Nurses and other health care workers remain in g reat demand throughout the world. Although the Unites States reports an increase in the nu mber of prelicensure nursing students and practicing nurses; a shortage remains 20 Crystal Shannon: It All Starts Here: M erging the Role of Nursing Education and Community-Based Heath Promotion world wide. Higher rates of morb idity and mo rtality strain the already overtaxed resources of health professionals[31]. This requires educational units to place definitive focus on recruit ment and train ing. Agencies such as the ICN[30] acknowledge the need for nursing education programs to place increased focus on the needs of global populations. This includes providing effective global student learning opportunities and curriculu ms that support: ● Hu man rights, social justice, solidarity, and access to health care ● Ethical, legal, and decision-making abilities ● Socia l action and professional values The values required to deliver global nursing care are the same values required to support healthy communit ies at home. However, lack of pract ical student engagement minimizes the overall impact nurses might have on reducing the impact of disease. 5.2. Global Influences on Nursing Education Some nursing programs are taking an active approach toward working in tandem with global co mmun ities. Vanderbilt Un iversity developed an Institute for Global Health and a Global Hea lth Nurse Progra m[32]. The focus of these programs was to educate developing practioners in methods (patient care, co mmunity education, health promotion, health care training) to improve the state of health for international commun ities. Additionally, nurses (and other health care providers) were taught methods of participatory collaboration, ut ilization of limited resources, and policy analysis for the goal of pro mot ing social change. This encourages nursing educators and practioners to consider a wider reach in terms of educating others within their own social context. Furthermore, the active collaborative nature of the program supports communities with vulnerable populations. Education to support global efforts for pre and post licensure nursing education[31]. Additionally, the development of memo randums of understanding (MOUs) will allo w for a sharing of skills and expectations. This will u ltimately support a partnership-synergy[14] that has the potential to not only develop the social responsibility of new nurses but also promote co mmunity health. 7. Conclusions The active incorporation of CBHP and participatory concepts in prelicensure nursing education will provide a foundation for the new nurse’s practice. Inclusion of these concepts is consistent with national guidelines for nursing education (e.g., health pro motion, collaboration, and maintenance) but may be outside the general practice of nursing educators[7]. Despite this, these concepts allow the profession to better serve populations that suffer high rates of morb idity and mo rtality. The barriers that influence CBHP (cost of resources, personnel and time) are often overwhelming for co mmun ity-based agencies and nursing education alike. Yet, active, participatory collaboration between the SON and co mmun ity agencies potentially minimizes the impact of these challenges. This supports an educational environment with a focus on service learning and community support. Additionally, it demonstrates a level of co mmunity responsibility that is ever-present in the theoretical foundation of nursing education and ethical nursing practice. REFERENCES [1] Leininger, M ., & M cFarland, M . R. (2002). Transcultural nursing: Concepts, theories, research & practice (3rd ed.). New York, NY: M cGraw-Hill M edical Publishing Division. 6. Recommendations for Nursing Educators [2] Byerly, A., & Stein, R. (2003). Fostering nursing student’s cultural sensitivity to diverse community health clients. Journal of M ulticultural Nursing and Health, 9(1), 68-74. Nursing educators worldwide are encouraged to develop [3] Pender, N., M urdaugh, C., & Parsons, M . (2006). Health active partnerships with local stakeholders. Th is will open a dialogue for the develop ment of open co mmunication in promotion in nursing practice, 5th ed. NJ: Pearson, Prentice Hall. which education and co mmun ity seek and receive equal [4] Banerjee, D., Perry, M .S., Slentz, M .S., Tran, D., & Arafat, benefits. Nursing educators are also encouraged to expand their own knowledge into public health, policy development, and global support. R.A. (2007). Health promotion in the inner city: Process of implementing a community based participatory project. TPHA Journal; 59(2): 43-46. Nursing programs have the ability to create an alliance of [5] Edelman, C., & M andle C. (2010). 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[15] Shoultz, J., Oneha, M ., M agnussen, L., Hla, M ., Brees-Saunders, Z., Dela Cruz, M., & Douglas, M . (2006). Finding solutions to challenges faced in community-based participatory research between academic and community organizations. Journal of Interprofessional Care, 20(2), 133-144. Retrieved from EBSCOHost Database. [16] Leung, M ., Yen, I., & M inkler, M . (2004). Community-based participatory research: A promising approach for increasing epidemiology’s relevance in the 21st century. International Epidemiological Association; 55(3) 499-506. doi:10.1093/i je/dy h010 [17] Schwab, M . Neuhauser, L., M argen, S., Syme, S.L., Ogar, D. Roppel, C., & Elite, A. (1992). The wellness guide: towards a new model for community participation in health promotion. Health Promotion International, 7(1), 27-36. doi:10.1093/ heap ro/7.1.27 [22] Seifer, S., & Calleson, D. Health professional faculty perspectives on community-based research: Implications for policy and practice. Journal of Interprofessional Care. 2004; 18(4). doi:10.1080/13561820400011719 [23] Community-Campus Partnerships for Health (2010). Transforming Communities & Higher Education. Retrieved from http://www.ccph.info [24] Adams, C., Browning, M . & Woodward, R. (2012). The future of nursing: Community-health’s network approach. Journal of Nursing Administration; 42(7/8): 347-349. [25] Center for the Advancement of Collaborative Strategies in Health (2002). Pathways to Collaboration. Retrieved from ht tp ://www.cacsh.org [26] American Nurses Association. (2010). Code of ethics for nurses with interpretive statements. Washington, D.C. [27] Riley, J. & Beal, J. (2010). Public service: Experienced nurses’ views on civic and social responsibility. Nursing Outlook 58 (3), 142-147, doi:10.1016. [28] Kelley, M . A., Connor, A., Kun, K. E., & Salmon, M . E. (2008). Social responsibility: Conceptualization and embodiment in a school of nursing. International Journal of Nursing Education Scholarship, 5(1), Article 28. [29] Wald, L. D. (1991). The House on Henry Street. New Brunswick: NJ; Transaction Publishers. [30] International Council of Nurses (2012). The ICN code of ethics for nurses. Jean-M arteau, Switzerland. [31] Callister, L. Clark (2012). Issues in global nursing education. M aternal Child Nursing, 37(6), November/December 2012. [18] Pommier, J., Guével, M ., & Jourdan, D. (2010). Evaluation of health promotion in schools: a realistic evaluation approach using mixed methods. BM C Public Health, 1043. Retrieved [32] Vanderbilt University (2013). Vanderbilt Institute for Global Health. Global Health Nurse Program. Retrieved from ht tp ://globa lhea lt h.vanderbilt .edu/p rogr ams/nurse-in-r esiden ce/

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