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Community nursing

Exploring an asset-based approach to nursing

The first of two articles on asset-based thinking focuses on what the profession might learn from asset-based approaches to community development

In this article…

  • A discussion of asset-based community development (ABCD)
  • Applying ABCD to nursing
  • How nurses and managers could form equal partnerships to create solutions

Author

Heather Henry is a freelance nurse and management consultant at Brightness Management Ltd, Manchester and a member of the national executive committee of the NHS Alliance.

Abstract

Henry H (2013) Community development part 1: exploring an asset-based approach to nursing. Nursing Times; 109: 3, 15-17.

This article explores a different perspective on perceived “failings” in the nursing profession. It takes learning from an asset-based community development approach called Connecting Communities to find out whether the problems and solutions that we observe in vulnerable communities can help us better understand what might be happening in the nursing community. The ideas presented are evidence-based community development theories that are currently used across the world and are now influencing the commissioning for health improvement/health inequalities.

  • This article has been double-blind peer reviewed
  • Figures and tables can be seen in the attached print-friendly PDF file of the complete article in the ‘Files’ section of this page

5 key points

  1. Asset-based community development (ABCD) is an approach that builds on the strengths of communities and engages citizens in taking action
  2. Communities that are not listened to display “locked in behaviour”
  3. The essence of ABCD is to listen, build relationships and make connections between residents themselves and between residents and agencies
  4. Residents have the lived experience of their community
  5. This approach sees nurses as assets who work in partnership with their organisations to lead change

Today’s nurses are under massive pressure. There is increasing scrutiny following allegations of care failings, they face a rising tide of demand and have more to do with fewer resources. It is no wonder that England’s chief nursing officer Jane Cummings and the Department of Health’s director of nursing Viv Bennett have been tasked with finding solutions - and quickly.

An asset-based approach to nursing might be described simply as a “glass half full” approach. It is concerned with how we can use each other, our talents, skills and experience - often described as the assets of heart, head and hand - to address the perceived ills in nursing. This article aims to start a debate with fellow nurses and nurse leaders to see whether, together, we can develop these ideas further. This is not yet another initiative; rather it is an opportunity to view the world in a different way (paradigm shift) and to give a potential explanation for what might be happening in our profession.

A tale of two health visitors

Back in the 1990s, two health visitors, Hazel Stuteley and Phillip Trenoweth, worked in Cornwall with a vulnerable population called the Beacon Estate, built up the hill from the picturesque seaside town of Falmouth. Beacon residents described the estate as the “Beirut of Cornwall”. It was dominated by drug gangs and crime rates were high. The agencies - housing, council and police - increasingly saw the Beacon as a no-go zone and the police only came onto the estate to arrest people (Jackson, 2000).

One day the health visitors, whose caseload was becoming uncontrollable, reached breaking point. They invited 20 residents from their caseload to a meeting to plan what to do. Of those 20, only five turned up. Together with Ms Stuteley and Mr Trenoweth they knocked on every door on the estate and asked residents to come to a public meeting with Carrick District Council, Carrick Housing Trust and the police.

The residents vented years of anger that night, but at the end of the meeting, it was agreed to try a new approach: to form an equal partnership between the residents and local agencies to tackle residents’ concerns. Crucially, the residents led the process because they knew what would work - they had the “lived experience”.

They started by redesigning a traffic-calming scheme, with the residents undertaking their own traffic survey, then applied for and won a £1.2m housing grant. Beacon residents oversaw the housing improvements themselves, with the backing of Carrick Housing. This transformed the lives of these tenants, and crime, health and education statistics vastly improved. The estate continues to thrive today.

What happened on the Beacon Estate is echoed across the world, where the evidence base for asset-based community development is expanding (Morgan et al, 2010; Foot, 2009; Kretzmann and McKnight, 1993).

Asset-based community development

Ms Stuteley thought long and hard about not only what had happened to transform the Beacon, but also why and how it happened. She now makes regular presentations and her story has been written about extensively (Foot, 2012; NHS Alliance et al, 2011; Jackson, 2000).

Researchers at Exeter University Medical School’s Health Complexity Group have put a theory behind the health visitors’ actions. Ms Stuteley and Mr Trenoweth, they said, had created the “enabling conditions for change” by creating a space where those agencies would listen to what the residents said.

The agencies realised that their needs-based, top-down approach to “fixing” the problems in that community had disempowered the residents. The two health visitors, on the other hand, had built upon the community’s lived experience. So for example, the former local drug-dealer

set up a plastering business employing local people and began policing the community for drugs rather than selling them. The residents became the solution and not the problem. Capacity was not “built”, it was “released”: the capabilities were already there - they just had to be drawn out. This is the essence of an asset-based approach.

Ms Stuteley explains that at first, residents demonstrated “locked-in behaviour”, which could have been interpreted as apathy. They were so used to being consulted but not listened to that few of them would bother to attend community meetings. However, once they felt they were being heard, they resorted to anger. As one resident of the Beacon said: “If you kick a dog it will turn round and bite you won’t it?” This anger, far from being feared or avoided, can be used as energy for change.

Complexity theory

Exeter University researchers said much of what happened on the Beacon Estate was an example of complexity theory (Health Complexity Group, online resource). In simple terms, when faced with a complex problem, a community can begin to organise itself to meet its own needs in the way it thinks best. This can feel threatening for organisations like the NHS and local councils, which are used to being in control, so it requires a lot of trust and the rebuilding of relationships.

The agencies learnt to share power and decision-making with the residents. The council and its partners formed an equal partnership with community leaders and took action by listening to what most residents said was important - “wants” rather than “needs”. Ms Stuteley took these ideas and formed Connecting Communities, also known as C2 - a seven-step approach that encapsulates this learning.

Today the C2 method is being used to transform 20 vulnerable communities across England and Scotland, by permanently changing the culture and relationships between public services and the residents they serve. Asset-based thinking is now influencing commissioning for health improvement and health inequalities (International Association for Community Development and Carnegie Trust, 2011; NHS Alliance, 2011; NHS North West, 2011).

Are nurses becoming “locked in”?

Concerning the debate about the perceived deficits within nursing, a number of parallels can be made between what is happening within our most vulnerable communities and the “community” of nursing.

In the media, nurses are portrayed as no longer seeming to care, and predominantly deficit-based language is used to describe the profession. Stories abound of nurses failing to look after patients’ basic needs and maintain their dignity, even though this is only a partial picture and elsewhere there are many excellent examples of skilled and compassionate care.

Looking at nursingtimes.net there is a similarity between residents in vulnerable communities and nurses on the frontline in that they display anger at not being respected or listened to:

“Wouldn’t it be good if the trusts cared about their staff instead of turning a blind eye to the rock bottom morale caused by an unappreciated overworked workforce… Never any recognition for hard work, only fault finding.” (Anonymous, nursingtimes.net, 25 June 2012)

Recently, hospital nurses were required to implement intentional rounding. Some nurses were indignant at the imposition of a solution, no matter how well-intentioned:

“How is an hourly round going to work? Patients don’t just sit there waiting for one of us to come along and ask about their needs. Caring for them is an ongoing process, some needing more time than others. Patients should dictate the needs not another chart that needs to be ticked every hour.” (Anonymous, nursingtimes.net, 4 May, 2012)

The chief nursing officers’ new nursing strategy, identifying six Cs: care, compassion, competence, commitment, communication and courage attracted adverse comments from some nurses:

“Here’s one C for you: Cobblers.” (@Redpaddys12, Nursing Times, 7 August 2012, page 9).

Are nurses demonstrating the same locked in behaviour as residents in vulnerable communities? Are they, after being kicked like dogs, now biting back? Are nurses in fact becoming alienated from their own leaders because they do not feel that their priorities are listened to and acted upon? Can managers form equal partnerships with nurses to co-create solutions?

Box 1. Evidence of a turning tide

Nurses as assets

The Energise for Excellence vision is for at least 200,000 nurses, midwives and heath visitors to sign up to take action and tell others their quality and cost-saving stories. This initiative encourages nurses and midwives to be proud of our many achievements as practitioners, partners and leaders. E4E is a call to action to all nurses and midwives aimed at harnessing our collective energy, commitment and expertise.

Pride in nursing

The Olympic opening ceremony ignited the debate about pride in nursing and in our health service. For the first time in a long while, nurses began to speak up about what they did, despite some cynicism. Now is not the time to be modest. If we do not speak up for our profession, who will?

RCN Congress

The 2012 RCN Congress was a good example of how nurses can and do support each other. Debates allowed “listening” and demonstrated self-organising - with the suggested subjects coming from branches across the UK. It highlighted all three of Hothi et al’s (2009) 3Cs: control (of the agenda by members); unparalleled opportunities to contact other members, from student to general secretary; and a huge opportunity to boost one’s confidence.

Empowering nurses for change

Most people agree, however, that these 6Cs are crucial to nursing. But there are three more Cs to add to the list that would support the wellbeing of nurses so they can deliver this new vision. These come from a report published in 2009 by the Young Foundation (Hothi et al, 2009), who looked at the things that improved wellbeing and happiness. They studied findings from three very different communities across England. The key elements that improved wellbeing and happiness were:

  • Control: by giving people greater opportunities to influence decisions, through participative and direct democracy rather than formal consultation exercises;
  • Contact: by setting up social networks and regular contact with neighbours;
  • Confidence: by enabling people to have confidence in their capacity to control their own circumstances.

Control

Reflecting on these findings, the debate about how much nurses feel in control of what is happening in their working lives is very moot. (There will be more about control, being able to make sense of your environment and the biological effects it has on the body, in the second article in this series.) There seems to be an underlying feeling that nurses find it hard to speak out when they see care failings:

“Nursing has… little actual power to change or influence in reality. Until that changes, and power structures are reconfigured, we will continue to pedal round in familiar circles” (Anonymous, Nursing Times, 7 August 2012, page 8).

“We are too busy bitching and moaning and stabbing each other in the back. We had a chance to stand up and fight, not only for our pensions, but our pay, our working conditions and even the future of the NHS itself, yet what did we do? Nothing.” (Anonymous, nursingtimes.net, 8 August, 2012).

Contact

In a recent Nursing Times article on the rising use of social media by nurses, Teresa Chinn explained that in the past, nurses used to live and socialise together, but now social media is increasingly becoming the way that busy nurses can overcome professional isolation and share knowledge, ideas and expertise (Chinn, 2012).

This is an example of the C “contact”, with nurses clearly using each other as assets. “Twitchats” (Twitter discussions organised at a given time around a given subject) are another example of complexity theory’s self-organising principle. New nurse twitchat opportunities, including #NTTwitchat, #wenurses, #nurchat and #nurseshift are appearing, around subjects identified by participants themselves.

McCrea (2012) notes, however, in Health Service Journal that, while individuals self-organise and share assets, on the whole, organisations such as the NHS use social media more as a tool to broadcast information than to engage, listen, respond and support. What a fantastic opportunity NHS employers have to become as McCrea calls it “communitarians” and to use social media to harness the views and knowledge of nurses and patients.

Confidence

Rarely do we tell each other what we are good at. So one technique I use to boost confidence is talent-spotting. This means approaching nurse colleagues and saying things like: “Hey, you would make a great clinical commissioner. Can I introduce you to the chair of the clinical commissioning group?” At first they tend to demur, but it sets them thinking and if you get it right, it becomes a self-fulfilling prophecy. Bright Diamonds, a podcast of district nurse John Wharton’s commissioning work (available free on iTunes) is an example of an “asset” spotted this way.

Starting the debate

As members of the nursing community, our future is in our own hands. We can make a start through discussion on forums and among colleagues. Consider the following questions:

  • How can we/are we starting to move the culture of our organisations from one where nurses are seen as the problem to one where they are seen as the solution?
  • How can/are nurses being supported to be more in control of their own practice?
  • What other mechanisms can we/are we using to put nurses in contact with each other?
  • How can we/are we building nurses’ confidence to work in partnership with employers to improve care?

And remember that anger is good - it is an energy for change, but should always be directed at the problem and not each other.

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