37 DISCUSSING HOPE WITH RURAL PUBLIC HEALTH NURSES AND COMMUNITY MEMBERS Judith C. Kulig, RN, DNSc1 1 Professor, School of Health Sciences, University of Lethbridge, kulig@uleth.ca Keywords: Hope, Rural, Public Health, Nurse, Community ABSTRACT The aim of this exploratory, descriptive study was to understand the meaning of hope for rural communities, in particular how community members and public health nurses understand this concept, and how they work together to create hope within rural communities. Qualitative interviews were conducted with nine community members and five public health nurses using an open-ended interview guide. The participants saw hope as a positive element of life that could be recognizable at the community level. The community members spoke about how they, as individuals, could help create and instill hope within their communities. Public health nurses were seen as resources for such communities and could add to the sense of hope being experienced there. However, the two groups did not work together to create hope. Recommendations include providing more opportunities for community members and public health nurses to work together on community issues. INTRODUCTION As a concept, hope has been explored among individuals and families, but only recently has it been addressed within a community setting (Kulig, 1999, 2002). Most of the nursing studies on hope have been descriptive in nature and have focused on individual participants who were unwell (Kylmä & Vehuiläinen-Julkunen, 1997). Examples include research studies that have been conducted with cancer patients (Dufault & Martocchio, 1988; Herth, 1989; Owen, 1989; Thompson, 1994; Bunston, Mings, Mackie & Jones, 1995; Herth, 2000; Rustoen & Wiklund, 2000; Chen, 2003) and people living with HIV/AIDS (Akinsola, 2001; Kylmä, Vehuiläinen-Julkunen, & Lahdevirta, 2001). There is similar research that focuses on groups such as the elderly (Farran & McCann, 1989; Gaskins, 1995; Zorn, 1997; Cutcliffe & Grant, 2001), youth (Hinds, 1984), homeless families (Herth, 1996), children (Herth, 1998), and specific religious groups (Benzein & Saveman, 1998). Hope has been defined as a positive and necessary aspect of human life that is a future-oriented, motivating factor (Brumbach, 1994). Links have been made between spirituality and hope, with suggestions of a need for a belief in a higher power or being (Brumbach, 1994; Gewe, 1994; Thompson, 1994; LePeau, 1996). Hope has also been discussed as being a process (Snyder et al. 1991) in which activity on the individual’s part is essential (Stephenson, 1991). Individuals have been described as either having low hope or high hope (Snyder et al. 1991). However, the usefulness of placing hope on a continuum that ranges from hope to hopelessness is questionable (Dufault & Martocchio, 1988). Online Journal of Rural Nursing and Health Care, vol. 4, no. 1, Spring 2004 http://www.uleth.ca/hlsc/ mailto:kulig@uleth.ca 38 The image of the nurse as being hopeful and providing hope for clients is a common one. However, an understanding of the process through which this is achieved has not been developed. Some suggestions for stimulating hope include encouraging individual patients to focus on their past achievements, creating an atmosphere that allows individuals to think about their goals and readjust their plans accordingly (Dufault & Martocchio, 1988), or simply creating an atmosphere of hope (Lange, 1978). Hope can also be stimulated through the nurse being encouraging and using good communication (Thompson, 1994), seeking relevant information about the situation (Lange, 1978), establishing a support system (Hickey, 1986; O’Connor, 1996), helping the individual patient develop realistic goals (Lange, 1978; Hickey, 1986), and assisting the individual to renew their spiritual life (Lange, 1978; Nowotney, 1991; Miller 1985 in O’Connor, 1996). The concept of hope is particularly relevant to rural communities in Canada, which comprise 22% of the total population (duPlessis, Beshiri & Bollman, 2001). Rural residence negatively impacts on life expectancy and health status (Pampalon, 1991). In addition, rural communities have been facing depopulation, youth out-migration, and erosion of health care services and other resources. The result has been increased levels of stress and mental health problems. For these reasons, more research is needed on hope for rural communities stimulating the author to pursue the research reported here. One recent exploratory, descriptive study focused on the meaning of hope for public health nurses (PHNs) in their rural-based practice (Kulig, 1999, 2002). The 10 PHNs in the study identified hope as a forward-looking perspective that was significant in their work with individuals, families and communities. The participants believed that communities, as collectives, could also be considered hopeful and that there were conditions (for example, access to resources, hopeful people), as well as characteristics (such as financial stability) and indicators (for instance, being optimistic) for hope at that level. The PHNs identified that working with individuals or within community-level programs gave hope to the entire community. The findings of this research were used as the basis for the study reported here, in particular to address the research question: What is the meaning of hope for rural PHNs and community members, and how do these two groups create hope in rural communities? Due to the paucity of literature on hope within communities, the research discussed here is intended to address such a gap and offer insights unique to rural communities that may be useful when considering sustainability issues. In particular, the findings are useful for rural PHNs who can positively impact communities on multiple levels. BACKGROUND For the purposes of this research, hope was defined as the inner belief that helps one deal with difficult circumstances (Lynch, 1965; McGee, 1984). Community was defined as "a group of people who are socially interdependent, who participate together in discussion and decision making, and who share practices that both define the community and are nurtured by it" (Bellah, Madsen, Sullivan, Swidler & Tipton, 1996). The study focused on rural communities, defined as communities outside the commuting zones of larger urban centers with 10,000 or more population (duPlessis, Beshiri & Bollman, 2001). Online Journal of Rural Nursing and Health Care, vol. 4, no. 1, Spring 2004 39 The aim of this exploratory, descriptive research was to: 1) explore the meaning of hope for public health nurses (PHNs) in their rural-based practice and for community members who reside in rural communities; 2) generate information about how PHNs and community members determine if hope is present in rural communities; and 3) identify how PHNs and community members instil hope in rural communities. This study allows us to begin to understand the relationship between community members’ sense of hope and the viability and sustainability of their community. These issues are particularly significant to rural communities because of the changes that are occurring within them, for example, depopulation, and loss of employment opportunities for youth (Beshiri & Bollman, 2001). In order to understand concepts such as hope at the community level, it is necessary to conduct interviews with individuals to ascertain their perceptions and then, through the analysis process, hypothesise the meaning at the community level (Brown & Kulig, 1996/7; Kulig 2000). METHODS Design An exploratory, descriptive design was used to pursue the research question, What is the meaning of hope for rural PHNs and community members, and how do these two groups create hope in rural communities? Exploratory, descriptive studies are intended to generate information about poorly understood concepts (Burns & Grove, 2001). Variables can then be examined in detail to determine differences or similarities but not causation (Lo-Biondo-Wood & Haber, 1998). Due to the nature of the study, purposeful and snowball sampling are commonly used. Purposeful sampling allows for participants to be included who have knowledge about the matter under study (Morse, 1989; Streubert, 1995) while snowball sampling includes the participants making referrals to other potential participants (Haber, 1998). Like other qualitative designs, exploratory, descriptive studies focus on generating perspectives and ideas from participants through the use of open-ended questions. Additional probes are used to clarify and expand upon the participant’s answers. Interviews are conducted until data saturation, or when no additional data is generated, occurs. Setting Interviews with both PHNs and community members were conducted within a predominantly agricultural-based regional health authority in southern Alberta, Canada from 2000-2001. PHNs are those nurses who deliver care to individuals, families or groups within the community by focusing on health promotion, prevention, and communicable disease control. PHNs provided this type of care in rural communities and settings scattered throughout the health authority, which serves approximately 88,584 residents in a geographic area of 44,000 square kilometres. In this health region, there is one small city of 51,000 and a number of rural communities that range in size from 150 to 10,000 residents. The second group interviewed were residents within these rural communities and were 18 years of age and older. Online Journal of Rural Nursing and Health Care, vol. 4, no. 1, Spring 2004 40 Data collection Data collection commenced after human subject, or ethical, approval was granted from the author’s university. Open-ended interviews were conducted until data saturation, occurred. The researcher individually interviewed a total of five PHNs and nine community members. Purposeful sampling was used initially and hence a summary sheet explaining the study was prepared and given to the public health supervisor to circulate to the PHNs. Interested individuals then called the author. The interviews occurred in a mutually convenient time and location, often in the PHNs’ offices. After informed consent was obtained, demographic information was collected and the interview was audiotaped for later transcription. Most interviews took an average of 50 minutes, with the range from 45 to 90 minutes. Snowball sampling was also used to locate the community members and hence suggestions for recruiting further participants were made by the PHNs and the community members themselves. The author contacted these individuals directly to explain the study and set up an interview. Informed consent was obtained at the beginning of the interview. After this, demographic information was collected and the interview was also audiotaped for later transcription. These interviews usually lasted from 45 to 75 minutes, with the average being 55 minutes. Data analysis included using reflection, creativity and comparison (Mariano, 1995). The transcripts were read to identify similarities and differences within the data while using creative thinking to interpret the data. More specifically, after reading the transcripts several times, tentative categories in relation to hope were identified. The data was also analyzed in order to identify themes (Schatzman & Strauss, 1973), or the ideas shared in common by the participants in each of the groups and between the two groups. Constant comparison was also used in the data analysis process (Glaser & Strauss, 1967). Consequently, the transcripts were read to identify the themes regarding the characteristics of hope within rural communities, such as the antecedents and the attributes of hope, as well as how PHNs and community members instill hope in their communities. Any differences noted by the individual participants regarding the categories and themes were identified for further discussion with all of the participants during the follow-up interview. The responses to the specific questions allow for understanding of hope at a community level, a feature of analyzing qualitative data. After the initial analysis of the data was completed, a summary of the tentative categories and themes was distributed by mail to the participants in preparation for the second, follow-up interview. Questions that arose in the interviews and during the initial data analysis stage were clarified. A second interview was conducted with four participants who wished to provide further information. The remaining participants indicated that they did not feel they needed to be interviewed again because the summaries reflected their perceptions of the topic and they had no additional comments. The second interview was conducted over the telephone and took approximately 45 to 60 minutes. The interview was also audiotaped for later transcription, and the transcripts were then analyzed with the initial interviews to further understanding of the themes and categories. In this qualitative research, trustworthiness (Guba & Lincoln, 1981; Lincoln & Guba, 1985; Lincoln & Guba, 1986) was established by asking the participants to review Online Journal of Rural Nursing and Health Care, vol. 4, no. 1, Spring 2004 41 and validate the initial data analysis, including sufficient detail so that others can follow the decision trail, and ensuring that the findings were generated from the data itself. There are limitations of the research, including that the information generated may only be applicable to PHNs who practice in rural areas in southern Alberta, Canada. However, given the paucity of theoretical development in this field of nursing (Kulig, 2002), the findings, although limited, contribute to expanding the baseline of knowledge related to community health and public health nursing. RESULTS The demographic information indicated that there were seven female and two male community members interviewed, five of which had lived in the same rural area their entire lives. Seven of the community members ranged in age from 31 to 45 years. For the five PHNs who were interviewed, the average length of time working in a rural area was ten years with the range from 2.5 to 20 years. Three had bachelor’s degrees, and three worked full-time. The five PHNs were all experienced in their roles and spoke at length about the type of activities they routinely performed within that role. Hence, all were involved with families, schools and seniors in various rural communities and in farm and ranch settings. Some of their activities included giving immunizations, conducting postpartum visits, providing health education at school sites and attending inter-agency community committee meetings. They all noted that over time, and with the erosion of the funding to public health, there were many activities, such as community development, to which they could not devote as much time as they would like. They were clearly dedicated to their work, keenly interested in rural communities and concerned about the health and well- being of the communities within which they worked. The nine community members represented a range of individuals who were active in their communities at different, but significant levels. Although only a few identified themselves as community leaders, all could have been described in this way because each performed leadership roles in one way or another. Consciously, or unconsciously, they initiated community activities that distinguished their locales in a positive way. Some examples included developing a museum, mobilizing a community in relation to an intensive livestock operation, and developing a community-based food industry. Other activities included membership in school-based economic committees, coaching high school sports, and organizing community fairs and suppers. All spoke of the importance of working within one’s own community and passing this value on to their children. Initially, the data were analyzed according to the two groups who were included in the sample. However, careful review of the transcripts illustrated that despite the demographic and role variations between the two groups, there were few, if any differences between them regarding their perceptions and understanding of hope within communities. For example, both the community members and the PHNs described community as a place where people come together to accomplish something; and hope for both groups was seen as a positive aspect of life. Thus, the following sections discuss the themes regarding the topic under study from both groups simultaneously. The lack of differences may be due to the small sample size and perhaps another contributing factor Online Journal of Rural Nursing and Health Care, vol. 4, no. 1, Spring 2004 42 is that both groups had spent significant time in rural communities leading to more similarities in their perspectives about the topic under study. Perceptions of Community When asked to define community, the basic element noted by the 14 participants was that community consisted of a group of people who have a common purpose. In addition, the participants made it clear that communities needed to have cohesion among their members, who in turn would feel as though they "belonged." One participant indicated that communities are about relationships that can be developed at different levels and between different kinds of people. The majority of participants emphasized the social aspect of communities, commenting that in communities, people pull together, get along and interact with one another in a positive way. One community member stated, "community is kind of like extension of the family." Communities, however, were not seen only as ideal. One participant stated that a community is a bunch of people who get together and make something, either positive or negative happen. Geography also influenced the meaning of community because natural boundaries, such as rivers, could determine the community’s boundaries. Finally, one participant commented that there are communities within communities, or smaller groups of individuals within the larger community. These smaller groups have their own common goals and ideas but also interact with the larger community. The participants acknowledged that both economics and politics influenced communities. Other influencing factors included the sense of cohesiveness in the community, the networking with others in the community, and the involvement of people within the community. The physical size and geographic location of communities can also be considered an influence; those communities that are not doing well (for example, they lack leadership, cohesiveness, or a history of working together) and are within a reasonable commuting distance of 30 to 45 minutes by vehicle to a larger centre can potentially decline even further. In their experience, communities that have a history of successfully working together, have sufficient resources for their residents, and are situated a sufficient distance outside a larger centre, will be more successful at maintaining themselves as a community. The exact distance outside a larger centre is difficult to determine, particularly because rural residents commute so frequently, but an estimate would be 45 minutes by vehicle. What is Hope? Lengthy discussions were held with each participant about the meaning, indicators and characteristics of hope. The participants saw hope as something positive that was related to a future outcome. For example, hope was described as "knowing tomorrow is going to be a better day," a basic requirement for survival, and a reason to live. However, it was not passive because the individual needed to be actively involved in being hopeful and creating outcomes. Hope gave people the courage to move ahead and work toward something that they desired. Hope was also a spiritual issue; one participant considered hope as promises from God. Although hope was active, it included a passive aspect that things will work out the Online Journal of Rural Nursing and Health Care, vol. 4, no. 1, Spring 2004 43 way they should. In further discussion with the participants, it was determined that there were relationships between faith, hope and spirit. The participants expressed that faith is a precursor to hope. In this instance, faith was not necessarily being described from the perspective of a church-based religion. The participants acknowledged that individuals can have faith and hope without a formal religion, but they were unsure about the mechanisms for this to occur. Several participants further stated that individuals might be agnostic or atheist and still have hope. Hope was described as more tangible, whereas faith was described as more abstract. One community member said that “faith brings you back to the hopeful stage.” Both faith and hope deal with the future. Furthermore, hope is an element of spirit. The latter is the emotional aspect of one’s faith. For some of the participants, spirit is the active component that brings people together. It can mobilize hope because hope itself is fluid. At the core of all of these concepts is the soul from which spirit and hope emerge. Soul is the essence of one’s being, but communities could also have a soul. Hopeful Communities The participants indicated that communities could also be hopeful, in part, because of the presence of hopeful people, which meant that there would be more community involvement and participation. Although it was perceived that some individuals were needed to ensure the community was hopeful, there were differing opinions about the exact number. Some participants believed that only one hopeful individual was needed in order to stimulate the community but for sustainability, more than one hopeful individual was required. Other participants believed that hope was not related to the number of individuals, but to the kind of people present. People who displayed leadership qualities, had ideas and were willing to work were more important than a specific number of people. Leaders brought people together to develop a shared goal and demonstrated tolerance for a wide variety of ideas. Overall, it was easier for the community when there were enthusiastic people willing to share the workload. Some participants acknowledged that getting involved in the community was a choice and some people did not want to contribute to the community. Another concern was the decreased numbers of individuals in rural areas because farms and ranches are becoming larger in order to economically survive, which leads to fewer neighbors and decreased availability of individuals to become involved in the community. The participants perceived hope as important for rural communities to prevent apathy. A final concern was the notion that, as a society, we are becoming more individual-focused; hence, in general, there is a decrease in interest and enthusiasm regarding involvement in community activities. Characteristics of Hope. A hopeful community is thriving, and contains hopeful people who feel safe living there; not just one age group, but also all ranges of ages, including children, are visible in the community. There were a number of characteristics evident in hopeful communities that can be separated into two categories: physical characteristics and social characteristics. Physical characteristics include having: homes with neat yards and well maintained buildings throughout the community; schools and community halls; services; a range of interests among the community members; and an economic base. Social characteristics include having: leadership; volunteers; resource Online Journal of Rural Nursing and Health Care, vol. 4, no. 1, Spring 2004 44 people, such as health professionals; plans for regular activities; participation in various activities and functions; goals; groups and organizations; and cohesiveness during a crisis. Hopeful communities have a history of facing stressors and challenges, but enact an effective problem solving style that brings the community together as one cohesive unit. Indicators of Hope. Besides characteristics of hope, there are indicators of hope, which refer to the way in which hope can be measured within the community. In this study, the participants stated that an indicator of hope was the number of annual events and the number of people participating in them. Other indicators would be new people moving in, and the development of industry and economic opportunities for the residents. Not all communities were always seen as entirely hopeful. The participants remarked that a sense of hopelessness was probably related to timing, as all communities will have some hopelessness depending upon what is happening. Communities with a number of boarded up buildings were displaying hopelessness; some communities die because they are not economically successful. It was perceived that communities with high suicide rates, alcoholism and unemployment were likely showing signs of hopelessness. It was easy to begin to feel hopeless when communities started to lose services such as schools and stores. The participants indicated it takes a great deal of energy to work to maintain such services, and if they are lost after such a struggle, the community can lose more energy and become more hopeless. Threats to Hope. There were several threats to hope, including the loss of services such as grain elevators and schools, which exemplified economic instability. Another threat to hope was the loss of a meeting place, such as a community hall or school. Some participants noted that the loss of the school signified the beginning of the end for the community because it was a central part of the community. A number of the participants emphasized that communities existed because of interactions between their members. Without a specific meeting area, there would be decreased opportunities for interaction and the potential for the decline of community. Another threat to hope was natural disasters and weather patterns, which for farmers most often meant droughts that threaten their existence. Fear threatens hope because it immobilizes individuals such that they are not able to move forward with new ideas or make changes. A final threat to hope was the loss of community spirit. The participants were also asked about hopelessness. Several participants felt that it was difficult to think that total hopelessness existed. These individuals described themselves as "eternal optimists," and although they could understand that one’s circumstances could make life difficult, they believed that each individual held a grain of hope within them. However, the participants believed that hopelessness was present when the individual could not be involved in changes. Depression and alcoholism were seen as symptoms of hopelessness. Finally, what represents hope to one individual may be hopelessness to another. For example, others may see a new baby as a source of hope, but the baby’s mother may see the child as hopelessness if she does not have sufficient resources and support. Personal Sources of Hope When the participants were asked about their own personal source of hope, they noted personal participation in organized religions or a personal sense of spirituality. For Online Journal of Rural Nursing and Health Care, vol. 4, no. 1, Spring 2004 45 the latter, the individual may believe in a higher power, but not attend a formal church service on a regular basis. There were also comments that the individual participant’s hope stemmed from a sense of belonging in the community, working with other hopeful people, or personal/familial experiences with volunteerism in their community. Some also commented that being involved in successfully addressing a particular issue gave them more hope. Comments included an inherent belief that things would get better or that there is a plan for everyone’s life and that it will work out the way it should, and that this knowledge gave hope. Community Members, Health Care Professionals and the Creation of Hope All the participants acknowledged the importance of hope for rural communities. One comment was that "hope is who public health nurses are." PHNs create hope through the various health programs, which are bridges that illustrate hope. There was a belief that when PHNs worked with one family there was a positive impact on the entire community. However, hope can only be encouraged; the participants noted that the individuals with whom PHNs work must want to be hopeful. In order for the PHNs to instill hope, they must have established trust with the individual or family and lead by example. Furthermore, the PHN must be willing to help and participate in the rural community in order for hope to be enhanced. Finally, empowering people in the community would lead to hope and was seen as a significant part of the PHN’s role. Community members also had their own role to play in creating hope in rural communities. They did so by being active volunteers, by instigating initiatives that addressed community needs and supporting those who were trying to do their best. Community members created hope by working at winning issues that were important for the community. Finally, it was noted that community members chose to be hopeful people and were encouraged to do so in order to create hope in communities. In fact, comments were made that the more hopeful people that were present, the more that can be accomplished in the community. Despite the acknowledgement that PHNs and community members created hope in communities, there was little evidence that these two groups worked together to create hope. Outside groups, such as PHNs, were noted as bringing hope to the communities in which they worked. However, for the specific issues that community members worked on, there was little or no interaction with PHNs regarding those specific issues. The work of PHNs was seen as providing individual care to those who needed it, not to larger community issues. DISCUSSIONS Understanding communities is a challenging task given the complexity and inter- relationships of variables such as history, geographic size, personality differences among community members, and negative and positive influences on communities, such as politics, economics, and policy. Exploring the concept of hope at the collective level is a new way to understand the dynamics and internal processes of communities. Online Journal of Rural Nursing and Health Care, vol. 4, no. 1, Spring 2004 46 For the participants, hope was seen as a positive force in their lives and in the workings of the rural community. It was described as something that gave them courage to go on and therefore, as Brumbach (1994) points out, can be a motivating factor. Repeatedly, they emphasized that hope was not passive and that individuals had to be actively involved in being hopeful. Although it is difficult to ascertain how many hopeful individuals it takes to make a hopeful community, the sense was that even one person could stimulate hope. However, for sustainability of hope, more than one hopeful individual was required. Similar to what has been described in the literature (Brumbach, 1994; Gewe, 1994; Thompson, 1994; LePeau, 1996), the participants described hope as having a spiritual aspect that was not necessarily connected to a formal religion. Hopeful communities were noted as places where there were leaders who brought people together with common goals, physical resources such as meeting places, inclusion of all age groups, cohesion among the residents, and a history of successfully overcoming challenges. Indicators of hope included participation in regular and special events within the community, development of new industry, and the location of new people in the community, at least in part, because the community is known as a hopeful place. Rural communities can have their hope threatened by natural disasters, loss of services, presence of fear in the community, loss of meeting places and loss of community spirit. Due to the challenges that rural communities are already facing, such as depopulation, these additional threats place the sense of hope in rural communities at a more precarious level. There is a limited discussion in the literature regarding the impact of PHNs on the collective (Kulig, 2000). In this study, PHNs were seen as having the ability and position to create and enhance hope at the community level. This was accomplished by establishing trust with the community members and working within specific health programs (such as home care services for the elderly). The PHN’s role in empowering the rural community also enhanced hope and thus this concept needs to be the basis for the work done when interacting with the community. Community members also had a large role to play in creating hope in their communities by supporting community activities, choosing to be hopeful people and instigating community initiatives. Interestingly, these two groups (PHNs and community members) do not often work together in creating hope. More often this is due to the workload of the PHN, who now works almost exclusively with individuals in the health region, rather than with communities as a collective. A concerted effort needs to be made by health regions to ensure that health care professionals such as PHNs are able to work with rural communities as collective units, and not just with the individual families within them. In addition, PHNs need to be supported by their health region to be involved in community-based initiatives, such as collaborating with community members to plan agricultural shows that could include health information booths. There are many examples in the literature that discuss collaborative initiatives between PHNs and community members illustrating the opportunity for such endeavours in the case of creating hope at the community level. All of the participants talked about hope as something they could "see" at the community level. Credence needs to be given to these observations so that they may be discussed and incorporated within the community assessment tools used by the health Online Journal of Rural Nursing and Health Care, vol. 4, no. 1, Spring 2004 47 region. For example, questions that focus on the physical and social characteristics from a hope perspective could be included in existing community assessment tools. Community members may want to enhance hope in their own rural communities by focusing attention on the physical appearance of their community as well as implementing activities that support social networks and build leadership. Once again, PHNs could be involved in these initiatives. Finally, community members need to work on maintaining their own hope by ensuring they have their own support network intact, which can be used to bolster one another when circumstances become difficult. CONCLUSION The current study suggests that hope is applicable at the collective level but points to the need for additional exploration in a variety of rural communities. Further study in communities that have been less successful in addressing problems and difficulties would also be informative regarding perceptions of hope. Such studies when combined with the findings from the present study could be used by community members and public health nurses to instil and enhance hope. Consequently, the development of social support networks in rural communities is an important activity in order to achieve hope. Finally, opportunities for collaborative work between public health nurses and community members are essential to create hope in communities as collectives. ACKNOWLEDGMENTS A heartfelt thank you is expressed to the participants who so willingly gave their time during this study—thanks for sharing your many interesting stories with me about rural communities! 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