Online Journal of Rural Nursing and Health Care, 2(2) 31 Hope at the Community Level According to Rural-Based Public Health Nurses Judith C. Kulig, RN, DNSc1 1 Associate Professor, School of Health Sciences, University of Lethbridge, kulig@uleth.ca Abstract The purpose of this exploratory, descriptive study was to generate the meaning of hope for 10 public health nurses in their rural-based practice. Ultimately, the study sought to answer if hope is a significant concept for communities rather than just individuals or aggregates. Analysis included coding of the transcripts and use of an auditor. Hope is identifiable at the community level and serves in part to confirm the residents’ collective status. In order to have hope, certain conditions such as the presence of hopeful people and resources (i.e., education) need to be present. Communities that are hopeful have specific characteristics such as a diverse economy and agreed upon community goals as well as the presence of community leaders. There are also indicators of community hope such as a sense of optimism and flexibility. Hope is an important element of the practice of the public health nurses included in this study. Keywords: hope, community/public health, rural communities, concepts, descriptive analysis Online Journal of Rural Nursing and Health Care, 2(2) 32 Hope at the Community Level According to Rural-Based Public Health Nurses I think a community definitely does have hope...and if they’re planning for the future...I mean that’s why they have a Parent Council up at the school to plan a future for their children. Hope has been recognized as important for nursing practice, particularly in the care of individual clients. A number of research studies on this topic have been conducted with cancer patients (Bunston, Mings, Mackie, & Jones, 1995; Dufault & Martocchio, 1988; Herth, 1989; Owen, 1989; Thompson, 1994) as well as the elderly (Farran & McCann, 1989; Gaskins, 1995; Zorn, 1997), youth (Hinds, 1984), and homeless families (Herth, 1996) and children (Herth, 1998a; Herth, 1998b). Despite the usefulness of the information generated from these studies, there are limitations in applying the results by public health nurses who work with communities as collective units. This article discusses a recently completed study that addressed hope beyond the confines of the individual. Available definitions of hope see it as a positive aspect that is necessary for human life. It is more often considered future-oriented and can be a motivating factor (Brumbach, 1994) therefore implying action in order to achieve that for which one hopes. Some definitions specifically emphasize the relationship between hope and goal attainment (see Stotland, 1969). There are also links between spirituality and hope. For example, hope is thought to be at least interconnected, or part of the process (Farran, Herth, & Popovich, 1995), in the search for the meaning of life (Ersk, 1992, as cited in Kylmä & Vehuiläinen-Julkunen, 1997) and therefore suggestive of a belief in a higher power or being (Brumbach, 1994; Gewe, 1994; LePeau, 1996; Thompson, 1994). Comments made by community-based workers indicated their perception that even at the community level, hope is linked with spirituality (Kulig, 1998). A recent concept Online Journal of Rural Nursing and Health Care, 2(2) 33 analysis of hope acknowledged it as having a future-orientation. It was postulated that research is needed to determine if positive events can stimulate hope (Benzein & Saveman, 1998). Theory construction in relation to hope has commenced but thus far is limited to individuals (Haas, Britt, Coward, Leidy, & Penn, 1992; Morse & Dobemick, 1995; Morse & Penrod, 1999). Different frameworks have been used to understand the meaning of hope but all of these emphasize the individual level (Dufault & Martocchio, 1988; Thompson, 1994). Other authors have postulated that there are four attributes to hope: 1) it has meaning for the person, 2) it is a process that involves thought and relationships, 3) it has a sense of anticipation, and 4) it holds a positive future outlook (Stephenson, 1991). There is also some suggestion that there are specific antecedents of hope such as a crisis, which can act as a catalyst to hope (Stephenson, 1991). Stephenson also believes that there are varying degrees of hope and describe individuals as either having low hope or high hope (Stephenson, 1991). However, the usefulness of placing hope on a continuum that ranges from hope to hopelessness is considered questionable (Dufault & Martocchio, 1988). Several instruments have been developed to measure hope but all have focused on individuals such as the chronically ill (Raleigh & Boehm, 1994), cancer patients (Herth, 1989), young psychiatric patients (Erickson, Post, & Paige, 1975 as cited in Raleigh & Boehm, 1994), the non-institutionalized elderly (Miller & Powers, 1988; Zorn, 1997), inner city adolescents (Canty, 1993) or well adults (Herth, 1996; Snyder et al. 1991). Although each of these scales has merits, all were developed for use among individuals with none of them being useful in understanding hope at the community level. The study discussed here attempts to generate information about hope at the collective rather than the aggregate level. Online Journal of Rural Nursing and Health Care, 2(2) 34 There has been some work assessing the impact of hope on an individual client’s response to nursing interventions (Miller & Powers, 1988) and only a few articles that discuss how nursing practice has an impact on hope (see for example Cutcliffe, 1995). O’Connor (1996) discusses the importance of hope for home care nurses while they conduct their practice but the ideas are not based upon research findings. In a survey of home health nurses, Brumbach (1994) asked them to describe a time when they felt hopeful about their nursing practice. In this study, the participants felt hopeful when they had made a difference in the lives of patients through the use of their nursing skills, had experienced positive relationships, including one with God, and had received affirmation from their coworkers and the patients’ family members about the work they had done. Palliative care clients were asked about the relationship between their perceptions of hope and the health care professionals who provided their care (Koopmeiners et al. 1997). The authors concluded that health care professionals both positively and negatively influenced hope among the clientele studied. The specific ways in which this was accomplished include the health care professional being present and giving information. Another way in which nurses can assist individual patients to become hopeful includes links to spirituality (Lange, 1978; Miller, 1985 as cited in O’Connor, 1996; Nowotney, 1991). Stimulating hope through being encouraging and using good communication (Thompson, 1994), seeking relevant information about the situation (Lange, 1978), analyzing the past for successes (Gewe, 1994), establishing a support system (Hickey, 1986; O’Connor, 1996), ensuring that the client has control (Gewe, 1994) and helping the individual patient develop realistic goals (Farran et al. 1995; Farran, Wilken, & Popovich, 1992; Gewe, 1994; Hickey, 1986; Lange, 1978) have also been suggested. Online Journal of Rural Nursing and Health Care, 2(2) 35 In summary, although research has been completed that addresses the concept of hope, there is still a lack of clarity about its meaning for nursing practice, more specifically for public health practice in a rural setting. As well, the studies that have been conducted include individuals; there is no information about how a community as a collective unit exhibits hope. Thus, the purpose of this exploratory, descriptive study was to explore the meaning of hope for public health nurses (PHN) in their rural-based practice, generate information about how PHN determine if hope is present in rural communities, and identify how PHN instill hope in the rural communities within which they practice. Methods An exploratory, descriptive study was the most appropriate method because there is no information available on the meaning of hope at the community level. For this study rural-based public health nurses were those nurses who delivered care to individuals, families or groups within rural communities by focusing on health promotion, prevention, and communicable disease control. All of the participants worked in a provincially funded health region and thus clients had universal access to care. An initial guiding definition of community was “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, p. 333). Interviews were conducted with 10 practicing PHN who were working either full or part- time in rural communities. Open-ended interviews were conducted until data saturation occurred. Purposeful sampling was used to select the participants, consequently individuals who had knowledge related to the concept (i.e., hope in rural-based public health practice) were recruited (Morse, 1989; Streubert, 1995). Online Journal of Rural Nursing and Health Care, 2(2) 36 Each participant was interviewed twice by the author. The initial individual interviews took 45-80 minutes and began with the collection of demographic information and then proceeded with questions from a research guide. Questions included asking the participant to describe well functioning communities, a typical day in their life as a PHN, what has helped them deal with the difficult days they encounter and specific questions such as their definitions of hope, was it significant in their practice and what are the characteristics of communities that have hope. Additional questions were also asked based upon the answers provided by the participant. For example, clarification questions were used to determine size of communities, specific information about issues communities had dealt with or their role as a PHN with communities that were not functioning well. Because data analysis and collection occurred simultaneously, questions derived from the earlier interviews were developed for use with subsequent participants. The interviews were tape-recorded and confidentially transcribed verbatim for simultaneous analysis with the data collection. Data analysis included frequent reading of the transcripts, focusing on identifying similarities and differences within the data and using creative thinking in interpreting the data. More specifically, after reading the transcripts several times, tentative categories such as the classification of hope were identified. The data were also analyzed in order to identify themes such as the identification of characteristics of hope within rural communities. Any differences (i.e., in definitions or beliefs) in these categories or themes noted by the participants were also identified for further discussion with all of the participants during a follow-up interview. Analytic memos, or notes describing the emerging theoretical ideas in relation to the concept (Schatzman & Strauss, 1973), were also written on the actual transcripts. Online Journal of Rural Nursing and Health Care, 2(2) 37 After an initial analysis of the data as outlined above was completed, a summary of the tentative categories and themes was distributed by mail to each of the participants in preparation for the follow-up interview. This provided opportunities to “check” the investigator’s understanding and analysis of the data that was generated. In addition, questions that arose while reading the interviews and during the initial data analysis stage were clarified with the participants. For example, clarification was sought about the definition of a tragedy at the community level, how a community illustrates it is optimistic, and individual characteristics of hope that can be exemplified at the community level. The second interview, which lasted from 45-65 minutes, was conducted over the telephone and also tape-recorded for later transcription. The participants agreed with the preliminary data analysis and offered additional insights. This manner of providing opportunities for the participants to give feedback had been used in two previous studies and resulted in a greater understanding of the research topic and an increase in the trustworthiness of the data (Kulig, 1996; Kulig, 1998). The transcripts from both interviews were analyzed and are reported here. Two additional steps were undertaken to ensure the accuracy of the data analysis and to increase rigor. First, an auditor was used to check the data analysis and findings for accuracy. The auditor was a Master’s prepared PHN who had experience in research and rural communities. Copies of two transcripts, one from the first interview and one from the second, and the generated categories and themes were sent to this individual for review. The auditor responded in writing to specific questions identified by the author. Second, after the data analysis was completed, a summary of the preliminary findings was distributed to three rural- based PHN at another health region for their review. These individuals responded in writing and indicated their agreement as well as rationale for any disagreement. Changes in the data analysis Online Journal of Rural Nursing and Health Care, 2(2) 38 were made as necessary and appropriate based upon the feedback of the auditor and the other PHN. An example is the clarification of terms such as indicators and characteristics when describing hope. Findings All of the PHN who were interviewed were female. Eight had baccalaureate degrees with one holding a public health diploma and one other with either a baccalaureate degree or diploma. In regards to the participant’s age, there were one each in the 21-25, 26-30, 31-35, 51- 55 and 56-60 year categories, 3 in the 36-40 year category and 2 in the 41-45 year category. The six full-time PHN had been in their positions from 1.5 to 26 years with an average of 14 years. The four part-time PHN had been in their positions from 6 months to 6 years with an average of 2.2 years. As a group, they had worked in rural areas from 3 months to 27 years with an average of 11.2 years. Six of the participants both lived and worked in the same rural community. All of them worked in agricultural-based communities that ranged in size from 150-3500 people. The Meaning of Community At the beginning of the interviews, detailed discussions were held with the PHN about their definition of community. Two types of communities emerged from their comments: 1. A social community, which is not dependent upon physical closeness but instead, relies upon the shared values, beliefs and relationships between people. Words such as “togetherness,” “sense of community,” and “attachments” were used to express this notion. 2. A physical community, which is defined by boundaries, that is sometimes imposed by the regional health authority but can also be reinforced by the presence of buildings Online Journal of Rural Nursing and Health Care, 2(2) 39 such as churches and schools. One other characteristic of this type of community is a connection to the land that is often noted in natural resource-based communities. Most of the participants commented about the “sense of community” they perceived in the rural communities within which they worked. This was defined as a sense of belonging or being part of the whole and having shared goals, interests and responsibilities in relation to one another. The presence of a sense of community was a necessary base upon which other aspects of the community are built. Other characteristics identified by the participants emphasized the quality of relationships and interactions between community members. Examples include a sense of inclusivity, cohesiveness, personal connections between residents, and the presence of community spirit and pride. These characteristics are particularly evident in rural communities during tragedies as well as community celebrations. Even if communities are doing well, the participants indicated that they needed to invest a substantial amount of energy into working with the community as a collective. In order to accomplish this, the PHN said that they needed to work with individuals in the community. Consequently, the PHN built and maintained trust and assisted in the building of community. The latter is accomplished by the PHN encouraging community gatherings, building their trust with community members and establishing credibility in the community. When asked, most of the participants agreed that the subtle way of working with individual community members could be described as “gentle persuasion.” This refers to the manner in which the PHN interacts with the client in order to introduce new ideas or behaviors. The PHN will provide information and continually address the issue over time in hopes that the client will incorporate the knowledge or change into their or their family’s lives. Only one participant responded that she worked from an empowerment model (i.e., working with clients in a manner that ensures their Online Journal of Rural Nursing and Health Care, 2(2) 40 full input while providing the opportunity for them to take increased control of their lives) and thus used this phrase to more accurately describe her work. The others also recognized and worked from an empowerment model within their work, but believed that a variety of methods, including “gentle persuasion” were necessary. The Meaning of Hope The PHN saw hope as a forward-looking perspective and as a positive feeling about the future or as a wish or dream. One of the participants defined it as “an expectation that something will be different” (i.e., better) whereas another said it was “a positive behavior-based action.” Because hope is set in the future it can act as a form of motivation. It was also seen as fluctuating over time due to changing circumstances and experiences. Most of the participants believed it was active in nature. In comparing faith and hope, all but one participant saw them as separate entities. Moreover, faith was described as intangible and associated with the present whereas hope was associated with the future. However, faith was seen as a precursor to hope. The participants also discussed the differences between spirit, attitude, mentality/outlook, and hope. Not all agreed on the finite details between these concepts but there was considerable overlap in their answers. Spirit was predominately seen as active. It was exemplified through levels of enthusiasm within the community. One participant defined it as the inward drive that results in outlook. Spirit was something that was inherent to the individual rather than something that can be instilled. For some of the participants spirit was equivalent to mentality or outlook. Attitude was seen as active by most of the participants. Some saw this concept as the core of hope but also as the internal aspect of self that could change. Attitude was seen as linked to the individual’s spirit. Some of the participants commented that a hopeful attitude can be seen as a positive spirit. For Online Journal of Rural Nursing and Health Care, 2(2) 41 others, mentality or outlook was seen as an internal process that is passive in nature. Outlook can vary daily but hope can remain as an overall goal due to changing circumstances. Hope in Communities The community level of hope was seen as incrementally related to the individual level of hope. The participants believed that with a greater number of hopeful individuals present, the community as a collective is more hopeful. One participant stated, “The obvious relationship would be the more individuals that were hopeful in a community, the greater the hope in a community would be.” There were also a number of external influences on hope including economic issues (loss of industry, loss of employment, having outside owners who make decisions that negatively affect the local residents), politics (polices and decisions such as highway location changes, school closures), media (reporting of tragedy), loss of infrastructure (health care restructuring), migration patterns (loss of population or increase of population), poor health status (substance abuse, addictions), social conditions (discrimination, poverty, crime, religious atmosphere), and weather and acts of nature (droughts). In order for hope to occur at the community level, specific conditions needed to be present. These included having access to resources, the presence of hopeful people, the presence of leaders, team work, having future plans, having trust/faith in others, a belief that positives can come from negatives, flexibility, past experiences with hope, any signs or indicators of improvement, livable conditions, healthy people within the community, and a need or issue that can stimulate hope. One participant stated that a hopeful community is one that “is more sensitive and caring and is involved a little bit more in the service end of things.” A few of the participants stated that conditions were necessities whereas resources were things that would be nice to have, but were not necessary. This conclusion was drawn from their experiences of Online Journal of Rural Nursing and Health Care, 2(2) 42 working with individuals in communities in developing and implementing programs—the individuals themselves were able to identify what was lacking or present in their community and hence worked at accessing resources from outside the community if necessary. For the participants, people were both resources and a condition. For those who believed that resources were necessary, they listed the following: money or at least access to it or to an “in-kind” contribution that would be considered an equivalent of money; social support; education; health care; and, infrastructure (i.e., community centre). There was a relationship between hope and resources, i.e., both having and not having resources stimulated hope. Finally, there was no attempt to identify the most important resource for hope but more often the participants automatically stated “people” first when resources were discussed. A community can have indicators of hope including being optimistic, flexible and having a positive outlook. For example, the condition of tidy yards with gardens and the presence of businesses in the community exude an optimistic, positive feeling. One other positive sign was community celebrations. Flexibility is inter-related with community leadership. However, temporarily strained circumstances within a community do not necessarily mean that people feel hopeless. Therefore boarded-up buildings and physical deterioration are not always signs of losing hope. The participants were not always sure that “hopeless” communities necessarily die. Some traits of hopeless communities include an increase in apathy and a decrease in cohesion among the community members and a loss of regular community activities such as sports events. The latter would mean that the opportunity for networks, social support and positive interactions would be decreased. The PHN identified that communities with hope had specific characteristics for which they assessed including infrastructure characteristics and social characteristics. Infrastructure Online Journal of Rural Nursing and Health Care, 2(2) 43 characteristics included: economic diversity; financial stability; access to education; increase in population; well tended yards, houses, streets and businesses; and, an increase in the population. Social characteristics included: having community champions or leaders present, people who both live and work in the community, community residents as volunteers, community celebrations, community involvement, active community clubs and service agencies, political activities, evidence of a vision or direction as a community, goals for the future of the community’s children, community pride and spirit, presence of community support, having a positive outlook and attitude, and, interactions between community members. In general, a thriving community was seen as a hopeful one. Hope and Empowerment Hope and empowerment were seen as intricately linked in part because they are both internal processes. In this instance, empowerment is “the possibilities for people to control their lives” (Rappaport, 1981, p. 15). The participants stated that when people felt hopeful, they felt empowered which in turn could empower others. One participant stated, “People that have hope, they are very powerful people. And they can empower others.” Furthermore, having hope provides the impetus to act in ways through which empowerment is increased. Being empowered helps people to feel more hopeful. Finally, empowerment helps people to realize their vision and build toward becoming more hopeful. Although these comments focus on individual empowerment, there was a belief that individual empowerment was inter-related with community empowerment. Instilling hope was also seen as having a symbiotic relationship with empowerment. Hopeful people were seen as empowered to move towards a vision or goal. The higher the level of individual empowerment, the more hope would be experienced by the individual. PHN have Online Journal of Rural Nursing and Health Care, 2(2) 44 opportunities to empower people through positive reinforcement, connecting community members to resources, boosting morale, and providing educational opportunities for the community. The Creation of Hope Most of the participants believed that a critical mass, per se, was not needed to build hope and that in fact often only one person was required. One of the participants made the insightful comment that the numbers were not so important as the characteristics of the individuals. Hence, if you had the “right” kind of individuals, hope could easily be built in a community. One of the participants stated that you need to have someone who is “a good communicator, friendly, good listener, well connected and positive.” Others noted that you could start with one, but in order to sustain the feeling of hope, more individuals would need to become involved. Daily interactions within the community helps residents feel as though they are valuable members of the community, which also instills hope among them. In communities where respect and dignity are present among the members, it was generally considered to be an environment within which hope could be instilled. The PHN noted specific activities they did in their work and through the roles they played (i.e., advocate, resource person, facilitator) that instilled hope for the individuals and communities with which they worked. One participant noted that when working with community members, it was important to be supportive of people and encourage them to get together with the professionals to make things happen. They also firmly believed, in relation to the notions of empowerment that individuals needed to be involved in creating health within their own communities. The participants also identified that they needed to be hopeful themselves as they saw their own attitude as instrumental to their work with community Online Journal of Rural Nursing and Health Care, 2(2) 45 members. This was further supported when they stated the need to continually look for the good in every situation and have a positive attitude. They also believed that with time and patience small investments in terms of activities or interactions would culminate in larger benefits for the whole community. Encouraging clients by being supportive of their ideas and health behaviors were also part of the PHN’s routine. Hope was also instilled when the PHN became part of committees within their assigned communities. Specific programs were seen as important in instilling hope in families including community kitchens and programs for high-risk families. The PHN believed that helping families and other community members through such programs would positively influence the entire community thereby giving hope to all. Ultimately, the PHN needed to have trust and credibility within the community in order to enhance or instill hope. Finally, it was important to encourage community members to care about one another because this was believed to be the basis for all other relationships within this setting. The PHN had goals for hope for the communities within which they worked. One participant noted that her communities were hopeful and hence she worked on maintaining it. She described her communities as “positive, stable, supportive, enthusiastic and wanting to do things for the community.” Among other participants, comments were made about goals at both the individual and community level in regards to hope. For those who emphasized goals in relation to hope for individuals, they believed that hope would carry over to the community level. One example was having a goal of healthy children within the school system. Those with goals for hope that related to the community as a collective talked about having smoking bylaws for their entire community or working on decreasing the level of poverty. The participants therefore believed that hope was important for their work in public health. Online Journal of Rural Nursing and Health Care, 2(2) 46 The PHN were also asked questions about the basis of their hope. Although religious beliefs played a part, it was not crucial for every participant. For those however who identified the importance of religion, they indicated that faith, belief in God, and support from prayers and other individuals of the same religious affiliation made a significant difference in their lives. Others indicated a reliance upon a belief in spirituality rather than organized religion. Sometimes this included a belief in God or a higher being that oversaw daily life events. However, one participant did not necessarily believe in God but acknowledged that “something” was looking after her life and its path. The other participants talked about their upbringing and its relationship to their feelings of hopefulness indicating the links between past experiences and their current level of hope. They elaborated by stating that their parents and other family members were hopeful, positive people. These feelings were reinforced by other significant individuals such as teachers, classmates or fellow workers. Regardless of how their own hope was created, the participants believed in looking to the future and that they could make a difference in the lives of others. In essence, the work they did reinforced their hope and further enhanced it. Discussion The findings generated from this study need to be considered in light of the small sample size and limitation to one health region. Despite this, the comments and ideas generated about hope from a community perspective add to the growing knowledge base about this concept. For example, Stephenson’s (1991) attributes of hope for individuals (it has meaning for the person; it is a process involving relationships; it has a sense of anticipation; and, it holds a positive future outlook) are also noted in the information generated in this study. Hope had significant meaning for the PHN in their practice, they saw it as a positive, forward moving process that involved Online Journal of Rural Nursing and Health Care, 2(2) 47 relationships with individuals as well as the community in its entirety. The participants talked about hope as having meaning for the community as a whole because activities are held which further confirm their status as a collective unit through the building of cohesiveness and unity. Hope in rural communities is illustrated at celebrations and as reactions to tragedy and are based upon relationships within the community. There is a sense of anticipation as community members look forward to coming together as a group at celebrations. Finally, community members hold a future outlook when they plan events and set goals for themselves. The findings also showed that like individuals, communities have indicators and characteristics of hope including both physical and social characteristics. Furthermore, inter- relationships between concepts such as spirit, mentality/outlook, attitude, and hope were noted with hope being an active state that can stimulate spirit and attitude even at the community level. Additional information about these links, as well as that between hope and empowerment would assist in further understanding the significance of hope for PHN and the rural communities within which they work. Like other concepts, it is difficult to determine the exact relationship between individual and community hope. Most of the participants believed that one person who was hopeful in a community could make a difference and there are case examples to support this notion (see Hinsdale, Lewis & Waller, 1995; Nozick, 1992). However, it is unclear whether a critical mass is needed or if it is the characteristics of the individual that are key to the further creation of hope at the community level. In all likelihood, the relationship is probably linked to the level of empowerment and the community’s history and ability to deal with adversity as well as the presence of community champions and reaffirmation of their success through community stories. Online Journal of Rural Nursing and Health Care, 2(2) 48 The PHN who were interviewed believed that hope was important to their practice and that what they did for individuals helped in the creation of hope at the community level. Unlike the literature, not all of the PHN who were interviewed indicated that their personal level of hope was related to organized religion or spirituality. Instead, they emphasized relationships, including those with parents, teachers and the like, as significant in this regard. This finding alone calls attention to the need to examine the personal basis of hope from different perspectives. More information needs to be generated about the models through which PHN provide care within communities and the transformation through which hope is generated at the community level. Acknowledgment A heartfelt thank you is extended to the public health nurses and all other individuals who participated and contributed to this study. This research was, in part, financially supported by a grant provided by The Hope Foundation, Edmonton, Alberta. Online Journal of Rural Nursing and Health Care, 2(2) 49 References Bellah, R.N., Madsen, R., Sullivan, W.M., Swidler, A., & Tipton, S.M. (1996). 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