Keywords

FormalPara The Key Points of the Chapter Are the Following

  • To understand social innovation in the context of nursing.

  • To characterise the two branches of population-based nursing involved in social innovation.

  • To identify principal concepts relating to healthcare inequity found in population-based nursing.

  • To summarise basic findings on the status of social innovation in population-based nursing.

  • To delineate the three primary pillars of a social innovation exemplar in population-based nursing.

1 Introduction

The global Covid-19 pandemic, which began early in the year 2020, revealed the importance of population-based nursing services in the community not solely to dispense vaccinations, but also to provide care and assistance to at-risk population groups (Salvage and White 2020). Nurses understand that effective population-based interventions are only possible with community partnerships. This integrative review examines the current state of the art of social innovations used in population-based nursing.

Social innovation has been defined in many ways, but the consensus is that social innovation signifies enlisting community involvement to assist with an intervention or project that either improves personal capacity such as knowledge on self-care, develops new formal structures such as healthcare services for un- or under-served populations, or alters national systems such as changing social or healthcare practices to ensure more effective and culturally-appropriate care (Grimm et al. 2013). Social innovations are complex and require a multi-disciplinary approach to intentionally create or improve the capacity for tackling societal challenges in healthcare and other areas; social innovations by design must possess the “soft” infrastructure of community input, know-how and expertise (Grimm et al. 2013; Ziegler 2017). The Vienna Declaration, the first document delineating the topics and priorities of social innovations, notes that higher education institutions (HEIs) are ideally situated to promote social innovations (Hochgernet et al. 2011).

In HEIs, nursing departments encompass practice, education and research, and all three dimensions strive to improve healthcare services (Kaya et al., 2015). Nursing education includes didactic, classroom courses on subjects such as physiology, pharmacology, psychology, sociology and communication that provides nursing students with a broad knowledge-base, which is essential for good clinical practice. Nursing education also includes “real-life” clinical experiences in hospitals, clinics and the community where nursing students learn to apply principles from classroom education to their clinical practice. At all degree levels (bachelor’s master’s and doctoral), nursing students learn about research, as it is through research that the interventions, services and procedures that improve healthcare outcomes are identified, infused into clinical practice, and documented into evidence-based practice (EBP) guidelines (Mackey and Bassendowski, 2017). At the centre of EBP is the patient (Mackey and Bassendowski, 2017), and the best method of ensuring that new practices are culturally appropriate and meet the needs of diverse patient populations is by inviting input from representatives of the patient population (Madjar et al. 2019; Zlotnick 2021). Thus, the creation of social innovations by mobilising collaborations with community representatives is vital (Dil et al., 2012; McSherry & Douglas, 2011) to improve the quality of healthcare delivery and the quality of life in the community (Kara, 2015).

2 Social Innovation and Nursing

2.1 A Slice of Nursing History

Social innovations are collaborations or partnerships with the community that create interventions designed to remedy unmet societal needs such as inequities in healthcare or social welfare services (Pulford and Social Innovation eXchange (SIX), 2010). The practice of social innovations is not new to nursing, as the leaders of the nursing profession in the late 19th and early 20th centuries sought to promote health and well-being among disenfranchised and vulnerable populations by working in partnership with representatives from those communities (Curley 2020; Fee and Bu 2010; Thurman and Pfitzinger-Lippe 2017).

This population-based nursing approach underwent a dramatic change during the twentieth century when industrialisation and urbanisation created new technologies that introduced many new and sophisticated hospital-based diagnostic tests, instruments, and treatments for acutely and chronically ill patients, enticing nurses to move from working in the community to working in hospitals (Grimm et al. 2013; Kub et al. 2015). Nursing education, following these trends, revised their curricula to concentrate on inpatient care.

By the late 20th and early 21st centuries, however, a cadre of nursing leaders revived the emphasis on population-based nursing and the need for social innovations (Sela-Vilensky et al. 2020). This focus was not only supported by nurses, but also by the World Health Organization and the Institute of Medicine (Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing 2011; World Health Organization 2013).

2.2 Global Nursing Citizen

Population-based nursing embraces the concept of the global nurse citizen, nurses dedicated to initiating and collaborating with others to develop interventions and programs that reduce inequity in healthcare access, utilisation and status (World Health Organization 2017). The World Health Organization (WHO) has coalesced a wide array of geographical, social, physical and economical concerns that are sources of worldwide inequity, called Sustainable Development Goals or SDGs, including “Good Health and Well-being” (SDG-3) (World Health Organization 2021).

Devising effective interventions or programs that effectively address the SDG-3 of Good Health and Well-being requires input from professionals with diverse backgrounds as well as the expertise of representatives from at-risk populations. It means nurses must participate in changing public policy so it promotes healthcare access and utilisation among all population groups (Scott and Scott 2020); but healthcare professionals do not have all the answers. While they may understand the contributions of their scientific disciplines, only members from at-risk population groups have the cultural knowledge to: (1) judge culturally appropriate approaches that will promote use and access to healthcare services, and (2) identify barriers erected by discrimination and racism that reduce access to healthcare resources, knowledge and services.

For example, an institutionalised barrier could be making healthcare services available only between the day hours of 9 am and 5 pm, reducing service utilisation by people who work during the day and would lose a day’s pay if not at work. Some healthcare policies add to existing vulnerabilities by ignoring differences that exist in certain population groups due to culture, language, socio-economic status or geographical location. An example is a policy allocating each individual ten mental health visits per year when ample epidemiologic evidence suggests that individuals living in impoverished, high crime areas require many times more mental healthcare services than those living in middle to high income, low crime areas. Equality means distributing the same amount of resources to all members of the population; equity indicates distributing resources according to the need of the members of the population (World Health Organization (WHO) 2021). The global nurse citizen is dedicated toward developing social innovations and interventions that promote societal equity in every aspect of life, as is noted in the SDGs (Clark et al. 2017; Rosa et al. 2019).

Nursing, as a caring profession, is committed to the provision of high quality, respectful patient care for all people, regardless of their socioeconomic status (International Council of Nurses (ICN) 2020; Scott and Scott 2020). Population-based care includes working different groups (may be defined by gender, culture, socioeconomic status, religion, geography or other characteristics) to advocate for equitable healthcare service access (International Council of Nurses (ICN) 2018). The importance of social justice and healthcare service equity is documented within the standards of professional population-based nursing practice (called competencies) (Nursing and Midwifery Board of Ireland 2016; Torres-Alzate 2019).

The first step of launching a population-based intervention or program, according to the standards of professional population-based nursing practice, begins with a community assessment, which is the identification of the community culture, supports and resources, and challenges (Campbell et al. 2020). This assessment is only possible when nursing students or professionals actively listen to community members, recognise their own biases, and check their community assessments with individuals from those same communities (Quinn et al. 2019; Shahzad et al. 2019). Accordingly, nursing curricula for population-based nursing include skills on being inclusive and developing healthcare social innovations (Grimm et al. 2013).

2.3 Population-Based Nursing: Community and Public Health Nursing

Two branches of nursing practice in population-based care are community health and public health nursing. Both branches are similar in that nurses work with population and community groups; however, while community health nurses focus on treating chronic and acute illnesses, public health nurses focus on disease prevention and health promotion (Issel and Bekemeier 2010; Molloy and Caraher 2000). Community health nurses, therefore, provide the bridge for supporting and coordinating care for discharged hospital patients, and other chronically and acutely ill individuals recuperating in the community. They assess health indicators and can implement or adjust treatments. Public health nurses support and encourage behaviours that prevent disease and promote health and well-being such as vaccinations, well-baby care, coordinating resources and presenting educational seminars that promote healthy behaviours for targeted populations at risk. Some countries have both types of population-based nurses, while others combine the role (Schober et al. 2020).

Both branches of population-based nurses face many challenges. Healthcare funding for nurses has focused mostly on inpatient nursing care, resulting in inadequate staffing and lack of advancements in community and public health infrastructures (Issel and Bekemeier 2010). Migration has added to the complexities of working in the community, as many societies are comprised of individuals with different cultures, languages, and needs. Divisions based on socioeconomic status may further increase the inaccessibility to health and social welfare services. Thus, to ensure healthcare equity, community and public health nurses must devise creative and unique strategies that optimise resources, and facilitate effective delivery of culturally appropriate healthcare services to a variety of population groups (Dupin et al. 2020).

2.4 Community Members: Populations at Risk and their Needs

Being at-risk is often related to social disadvantage and based on characteristics such as age, gender, ethnicity/race, ability/disability, and socioeconomic status (called intersectionality (Daftary 2018)), and those with more characteristics or layers of social disadvantage are at greater risk for having decreased health status, access, utilisation, and outcomes. Not surprisingly, socioeconomic status is central to social disadvantage as low socioeconomic status is more common among women, ethnic/racial minorities, the unemployed and the elderly (or very young).

Other health indicators also may contribute to being at-risk, such as body mass index (BMI), activity level, and history of chronic diseases such as diabetes (World Health Organization 2013). Population groups with characteristics that are associated with greater social disadvantage are more at risk of chronic diseases (Stringhini et al. 2017). Accordingly, population-based nursing academic partnerships target disadvantaged and underserved populations as determined by intersectionality or health indicators (Ezhova et al. 2020).

3 Methods

The best methodology to cull information from a body of literature is to conduct a review. However, there are several types of review and each type of review achieves a different goal. The most common types of reviews are systematic reviews, scoping reviews and integrative reviews. Systematic reviews are designed to uncover evidence on treatments or procedures with the goal of guiding decision-making on the treatment or procedure under study (Munn et al. 2018). Scoping reviews are used to map the evidence and key concepts for exploratory questions on a particular topic with the goal of identifying knowledge gaps and determining future research directions (Colquhoun et al. 2014). The integrative review focuses on a specific concept and is used to synthesise existing literature and gain a clear understanding of a phenomenon or issue with the goal of advancing practice, informing research, and promoting policy (Broome 2000; Whittemore and Knafl 2005; Whittemore 2007).

For the goal of identifying the principles for successful social innovations developed via academic population-based nursing partnerships, this study will use an integrative review methodology. The integrative review uses a five-step methodology (Hopia et al. 2016; Whittemore 2007):

  1. 1.

    identify the purpose,

  2. 2.

    provide a PRISMA diagram indicating article inclusion and exclusion,

  3. 3.

    describe the method of evaluating articles and provide summaries of the articles,

  4. 4.

    conduct analyses delineating the most important concepts/themes including a table listing the articles on which the analyses were based, and

  5. 5.

    present the results.

Identify the Purpose

The aim of this integrative review is to examine social innovations created by non-hospital/non-clinic partnerships with academic, population-based nurses. This review will focus on the nurses’ and nursing students’ roles, the partnership strategy, and the highlights of social innovation. The research question is: what are the principals for successful social innovations created through partnerships comprising non-hospital/non-clinical organisations and academic population-based nurses?

Provide a PRISMA Diagram Indicating Article Inclusion and Exclusion

Most nursing literature is found in the databases of the Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, and PsychInfo. The following keywords were included: “academic partnerships”, “interventions or therapy or treatment or strategy” and “community” and “nursing”. Inclusion criteria were articles that were: (1) English-language and (2) published in journals. No year limits were used. The PRISMA figure illustrates the details of the search (see Fig. 12.1).

Fig. 12.1
A flowchart of the PRISMA with labels Identification, Screening, Eligibility, and Included, from top to bottom, respectively. The flow starts with selection criteria with Bibliographic databases and ends at full text articles included through records after duplicates removed, records screened by title and abstract, and full text articles assessed for eligibility.

PRISMA figure of study search

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Describe the Method of Evaluating Articles and Provide Summaries of the Articles

Of the 351 records of article abstracts obtained, duplicate records were removed prior to abstract evaluation. Next, abstracts of the records were reviewed. Exclusions were made based on the omission of: nursing (n = 116), a community group (n = 40), and/or program/intervention (n = 22). Also excluded were records of abstracts referring to hospital- or clinic-based interventions (n = 23), review articles (n = 35), editorials/book evaluations (n = 10) and a single study describing the economic situation rather than the intervention/program (n = 1). Of the records remaining (n = 31), the full articles were read resulting in additional exclusions (n = 13) due to: hospital- or clinic-based interventions, the absence of program/intervention, and the finding of a duplicate study not previously identified. The final sample of articles (n = 19) were summarised in a table, organised by author and year, study purpose, methods and results, the nursing role in primary care, the academic-community partnership, and highlights (see Table 12.1).

Table 12.1 Description of Selected Articles (n = 19)
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Conduct Analyses Delineating the Most Important Concepts/Themes

Content analysis was used on the final sample of articles (n = 19) to identify patterns, themes and subthemes. In the first step, each author reviewed the articles and created the table describing basic characteristics of the interventions and identifying common themes. Next, both authors compared their findings and discussed any questions, indecisions and ambiguities, eventually reaching consensus.

4 Results

Three primary themes arose from the partnerships presented in the articles (n = 19): (1) the methodology to obtain community input; (2) the need for mutual benefits among partners; and (3) sustainability and its link to the focus and types of projects.

4.1 Methodology to Obtain Community Input

The methodologies used to create a partnership varied, as 48% (n = 9) reported a specific partnership framework: 26% (n = 5) used a service-learning framework, 11% (n = 2) used the community-based participatory research (CBPR) approach with a community advisory board, and the remaining 11% (n = 2) used advisory boards, memoranda of understanding or contracts.

The methodology to obtain community input was linked to funding support and the type of project. For example, two of the three projects that reported funding support had advisory boards (Knight et al. 2020; Sullivan-Marx et al. 2010). Only community health projects used CBPR, an approach that requires input from the representatives of the target population (Friedman et al. 2012; Stacciarini et al. 2011). In contrast, the service-learning paradigm was found in articles reporting both public health and community health social innovations (Alexander 2020; Alexander et al. 2014; Breen and Robinson 2019; Gresh et al. 2020; Tyndall et al. 2020).

The community partners varied by project and included agencies, schools, the public health department, and interested individuals; and by definition, the nursing academician was among the partners. The number of members within the partnerships also varied. Many partnerships comprised only an academic institution and a single community partner, while one grew to include a myriad of agencies (Wilson et al. 2000). Another became a multi-million-dollar government funded businesses (Sullivan-Marx et al. 2010).

4.2 The Need for Mutual Benefits among Partners

Most articles identified mutual benefits when they initiated the partnership, and some conducted surveys or interviews to assess satisfaction with their partnerships and activities (Breen and Robinson 2019; Knight et al. 2020; Lashley 2008; Schaffer et al. 2017; Tyndall et al. 2020). Others measured either the provision of services or the attainment of outcomes (Alexander 2020; Alexander et al. 2014; Davis and Travers Gustafson 2015; Eddy et al. 2008; Gresh et al. 2020; Hildebrandt et al. 2003; Marcus 2000; Northrup et al. 2008; Singh et al. 2017; Stacciarini et al. 2011; Sullivan-Marx et al. 2010; Wilson et al. 2000).

From the articles, it was clear that the nursing academic partner held many roles: originator of the innovation, provider of services, evaluator, fundraiser and researcher. Almost all articles indicated that the nursing academic partners were the originators of the innovation project (n = 16) and most indicated that either the nursing academic partner’s faculty or students were among the providers of the social innovation (n = 15). The role as evaluators was noted in about half the articles (n = 11). Even less common among the nursing academic partners were the roles of fundraiser (n = 3) and researcher (n = 3).

The majority of partnerships included nursing students; however, almost a quarter of the articles (n = 5) reported no student involvement. Articles describing interventions without students included: research studies (Eddy et al. 2008; Northrup et al. 2008; Stacciarini et al. 2011), the development of new nursing specialties such as the Oncology Nurse Navigator (Friedman et al. 2012), and simulations of disaster preparedness comprising a variety of multi-disciplinary health professionals (Burke et al. 2015).

Among the articles reporting nursing student participation (n = 14), the majority initiated the partnership for the purpose of teaching nursing students about the social determinants of health and the consequences of inequities (Alexander 2020; Alexander et al. 2014; Breen and Robinson 2019; Davis and Travers Gustafson 2015; Gresh et al. 2020; Knight et al. 2020; Lashley 2008; Marcus 2000; Schaffer et al. 2017; Sullivan-Marx et al. 2010; Tyndall et al. 2020; Wilson et al. 2000). One launched the partnership to address inequities in the nursing workforce (Singh et al. 2017) and another sought to illustrate the utility of nurse-operated community centres (Hildebrandt et al. 2003).

4.3 Sustainability and its Link to the Focus and Types of Projects

Among the total sample of articles (n = 19), most reported public health (n = 13) rather than community health (n = 5) nursing projects, although one article was not categorised in either branch of population-based nursing as it described efforts to increase college recruitment of Hispanic high school pupils into the field of nursing by having nursing students provide presentations on their college experiences (Singh et al., 2017). Public health programs targeted drug-exposed infants, school children, new mothers, and older persons; and they provided health education on oral health (Lashley 2008), cancer prevention (Friedman et al. 2012), healthy eating (Alexander 2020; Northrup et al. 2008), maternal-child preventive healthcare (Knight et al. 2020; Marcus 2000), intimate partner violence (Eddy et al. 2008), disposal of unused prescription medication (Alexander et al. 2014), and disaster preparedness (Burke et al. 2015). Some projects conducted assorted interventions based on a community assessment (Davis and Travers Gustafson 2015; Gresh et al. 2020; Schaffer et al. 2017). One article described a project in which nursing students learned to provide education on health-related topics in an under-resourced country (Tyndall et al. 2020).

In contrast, community health partnerships (providing acute and chronic illness care) (n = 5) focused on a wide spectrum of mental health treatment and services (Stacciarini et al. 2011) or working with various agencies to provide screening and treatment (Breen and Robinson 2019). The target populations were individuals living in low-income communities (Hildebrandt et al. 2003) or older persons (Sullivan-Marx et al. 2010) or migrants (Wilson et al. 2000). The vast majority (80%) of community health partnerships reported multiple collaborators (Breen and Robinson 2019; Hildebrandt et al. 2003; Sullivan-Marx et al. 2010; Wilson et al. 2000). Two of the five community health nursing partnerships reported project sustainability for more than a decade (Hildebrandt et al. 2003; Sullivan-Marx et al. 2010), and a third sustained their project for more than six years (Wilson et al. 2000).

In summary, community health, compared to public health, programs were more likely to report sustaining the partnership for long durations of time, most often with the support of external funding (Hildebrandt et al. 2003; Sullivan-Marx et al. 2010; Wilson et al. 2000), while public health partnerships contained fewer partners, were smaller in scale, and rarely reported sustaining the partnership over time.

5 Discussion

Population-based social innovations implemented through academic nursing-community partnerships varied by population group, methodology and goals; nevertheless, this integrative review found that all partnerships adhered to the ideal of working in partnership to decrease inequities in healthcare access, utilisation or outcomes (Grimm et al. 2013) in both branches of population-based nursing (i.e., community health and public health nursing). Nursing academic partners frequently held multiple roles including as project initiators, providers and evaluators of the social innovations. The nursing academic frequently was the initiator of the partnerships and used a systematic approach that not only ensured that community representatives provided input, but also that the community input was incorporated into the social innovation project. Moreover, most social innovations had identified benefits for both partners (i.e., the nursing academicians and the community members); however, in contrast, very few social innovations had successfully developed a formal feedback loop ensuring sustainability of the partnership or the project.

This integrative review found that the exemplars of nursing academic-community partnerships were characterised by three basic elements: (1) the approach that the partnership requires ongoing input from community representatives; (2) the goal that both partners receive a priori identified benefits from the partnership; (3) sustainability of the partnership by devising a method to ensure project continuation (see Fig. 12.2).

Fig. 12.2
A model of population based, social innovations from nursing academic community partnerships, community health nursing, and public health nursing working on 3 principles, approach, goal, and sustainability.

Principles for population-based nursing-academic community partnerships

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Engaging the community in a consistent and systematic way was a priority for the success of the social innovations, and nursing academicians demonstrated their commitment for obtaining systematic and ongoing input from the community by using approaches such as community-based participatory research (CBPR). CBPR is a methodological approach that requires an active and representative community advisory board to ensure the use of culturally-appropriate instrumentation, procedures and recruitment for at-risk and vulnerable populations (Wallerstein and Duran 2010); and the social innovations indeed included various vulnerable populations such as ethnic minorities, migrants, older persons, new-borns of mothers with substance abuse problems, and youth with few resources.

Most nursing academic-community partnerships identified benefits for both partners. Community members received services, information, and connections to healthcare services and resources, and academic nurses obtained placements to provide ‘real world’ experiences for nursing students. The benefits also extended to students, the next generation of health professionals, who saw the consequences of the unequal distribution of healthcare resources. Nurses are considered healthcare resources and this point was made when a social innovation engaged nursing students to speak with high school pupils of a minority ethnic group (the ethnic group was under-represented in the nursing profession) to encourage them to become university nursing students and enter the nursing profession. Such efforts show the commitment to reducing inequities even in the nursing workforce (Murray 2019).

Sustainability was found in some academic nursing-community partnerships exemplars but lacking in most. The few social innovations reporting sustainability efforts tended to be partnerships in which the nursing academic partner was tied to community nursing’s efforts for providing individuals treatment and follow-up of acute and chronic illness rather than public health nursing’s efforts for providing health promotion and disease prevention. While public health partnerships were more plentiful, they were smaller, mostly unfunded, and less likely to report mechanisms for sustainability compared to community health partnerships (providing treatment for acute and chronic illnesses). This finding may result from the almost universal healthcare orientation for disease treatment rather than disease prevention, a problematic orientation that academic nursing faculty are working to change in their curricula and in their nursing students (Dupin et al. 2020; Issel and Bekemeier 2010; Sela-Vilensky et al. 2020). The World Health Organization is similarly dedicated to changing this orientation worldwide (World Health Organization 2013).

A primary goal of social innovations is to improve society and address inequities. In healthcare, inequities are characterised by increased morbidity and early mortality. While all social innovations in this integrative review met the first criteria of launching an intervention and making efforts to decrease society inequities, few academic nursing-community partnerships provided documentation that their social innovations had successfully attained outcomes that systematically decreased societal inequities. Most noted the number of services provided or satisfaction with services. Only a single well-established social innovation noted outcomes of decreasing hospitalisation and emergency room visits; this academic nursing-community partnership provided older persons with chronic illnesses assistance in the community health, supported by substantial funding (Sullivan-Marx et al. 2010).

Most often community health programs (i.e., providing treatment for chronic illnesses) rather than public health programs reported successfully obtaining external funding (Hildebrandt et al. 2003; Sullivan-Marx et al. 2010; Wilson et al. 2000). Unfortunately, many government health systems fund curative programs, particularly those using new technology, rather than disease prevention or health promotion programs (Issel and Bekemeier 2010; Shern et al. 2016). Yet, initiating more targeted, public health social innovations that promote health and prevent illness could reduce the incidence of disease thereby reducing inequities in serious health problems that occur later in life and result in early mortality; it is for this reason that public health nursing community partnerships are vital (Institute of Medicine (US) Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing 2011; World Health Organization 2017). Clearly, health professionals and healthcare systems must lead the change in orientation that focuses primarily on disease prevention and health promotion, before the lay population can be persuaded to follow suit, as it is through these efforts that health status inequities can be reduced (Madjar et al. 2019). This change of orientation already has the support of the World Health Organization, which has declared that preventing illness and promoting health is the cornerstone of healthcare systems in the European region (World Health Organization 2013).

6 Conclusion

Nurses, the largest healthcare labour force in the world, will play a key role in providing population-based healthcare services in the community (World Health Organization 2013). Nurses of all levels advocate for their clients, whether the client is an individual, community or population group, to promote policy changes that contribute to reducing existing inequities for at-risk population groups (Ellenbecker et al. 2017; O’Connor 2017; Taft and Nanna 2008). When appropriate interventions are lacking, nurse academicians need to model the role of a global nurse citizen, a nurse who becomes a change agent and initiates social innovations that promoting efficient, equitable, accessible population-based services with oversight and feedback from the community (Clark et al. 2017; Rosa et al. 2019). Nursing academicians not only must respect the values, knowledge, perspectives, and ideologies of community partners but also instil those values into nursing students through the curricula. That is, social innovation must have the dual role of benefiting the community and contributing to student learning. Equally importantly, the social innovation must be sustainable so it can realise its goal to promote healthcare equity.