Community Empowerment Theory

Exemplar

Health care providers such as nurses come across patients that come from different socio-economic, cultural, and educational background. Among the many healthcare providers, nurses spend tremendous amount of time with their patients have earned the greatest amount of trust. This amount of time and close contact with patients is a great opportunity to inform, educate and empower clients.

Patients come to hospitals seeking health care for different kinds of health-related problems. Providers then help resolve the health-related issues that clients might have with different level of services. These services provided primarily fall under primary, secondary, and tertiary health care categories. According to world health organization (2011), “while primary health care mainly focusses on health equity producing social policy beyond the traditional health care system, secondary healthcare is provided by medical specialists. The third category, tertiary health care is concerned with advanced medical investigation and treatment”.

The area that needs improvement in this hierarchy is, primary health care that focusses on health equity and social policy beyond the traditional health care system. This arm of health care service could be utilized more in empowering nurses, patients, and family members.  Using the great deal of patient contact and trust nurses have, this opportunity could be used to influence healthcare related policies, laws, and ethical issues for the advancement of community health. When patients are equipped with socio-economic, cultural, and political knowledge, they can make the right decision when it comes to social concerns such as health care coverage law votes that affect their health.

At University and Metro Hospitals, patients come to my assigned floor with late stage cancer, heart disease, and other chronic and acute illnesses. These diseases processes took place over time and intervention at the source of the disease process before it had happened would have saved these patients lives. These patients could benefit from community empowerment programs that addresses the root cause of their illnesses. These root causes of health issues include lack of affordable fitness centers, lack of affordable health insurance, lack of access to fresh fruits and vegetables in their neighborhoods, and lack of strong advocacy group that could exert influence on health care policy makers among many others as well as patient education outside hospital setting. For these interventions to work, we need affordable health care insurance, strong policies that promote communities’ health, strong organized patient advocacy group, and other supportive infrastructures. And these changes are dependent up on well informed community with voting power and nurse advocacy group that exerts influence on our policy makers.

I chose this situation because I realized that we are focused too much on treating symptoms and not the underlying problem that caused the disease or illness. We need strong organized Nurse group that works to educate patients as well as exercise authority on elected officials to bring a positive change geared towards health care system in the USA. Such community empowerment and Nurse organization could address the root cause of chronic and acute illnesses in a community. I chose this situation is because the root cause of health problems associated with policies, laws, and legislations that affect our patient’s health. Bringing social awareness and having influential community organization would be the expected outcome of this proposed nurse and community organization

I would like to see systemic changes that benefit the greater good of society in building strong healthy society. I would like to see a strong nurse advocacy group that stands for a community and fend off any faulty social policy in our health care system that put people’s lives at risk. I would like us to address chronic and acute illnesses at the grass root level before they get worse or even before they start to develop.

The outcome of such social change could be a well-informed society that is literate enough to be able to vote on the right health care reforms that brings positive outcome to the community. This outcome will be achieved with the help of a strong nurse advocacy group that lobby and exerts influence on policy makers to have the public’s best interest and not those of corporations or profit. This way, we expect to see less patients with late stage diseases and complications on our hospital floors.

Criteria

The criteria used in this paper to evaluate the theories used broad questions under the umbrella of significance, internal consistency, empirical adequacy, and pragmatic adequacy. Within each category, specific pertinent questions are also used to evaluate the theories. The source for the set of criteria used to evaluate the theories is Fawcett’s criteria for evaluation of nursing theories and pertinent questions. Faucett’s (2005) criteria are the following:

The first criteria used to evaluate the empowerment and emancipatory nursing praxis theories were the significance of the theories in utility in practice. The pertinent questions asked to evaluate these theories include whether the metaparadigm concepts, the philosophical claims, the conceptual model, and propositions are explicit. After looking at the significance of the theories, the internal consistency of the theories was evaluated for utility practice by asking questions such, as are the context and the content of the theory congruent? Do the concepts reflect semantic clarity and semantic consistency? Do the propositions reflect structural consistency? The next pertinent questions asked to evaluate the two theories with regards to the parsimony were; is the theory content stated clearly and concisely? Next, Testability of the middle-range theory was evaluated using pertinent question such as, does the research methodology reflect the middle-range theory? Are the middle-range theories concepts observable through instruments that are appropriate empirical indicators of those concepts? Do the data analysis techniques permit measurement of the middle-range theory propositions?  Finally, the two theories were evaluated based on empirical and pragmatic adequacy by asking questions like, are theoretical assertions congruent with empirical evidence? Are education and special skill training required before application of the theory in nursing practice?

Table 1: Faucett’s criteria for selection

Are the metaparadigm concepts and propositions addressed by the theory explicit?

Are the philosophical claims on which the theory is based explicit?

Is the conceptual model from which the theory was derived explicit?

Are the authors of antecedent knowledge from nursing and adjunctive disciplines acknowledged and are bibliographical citations given?

Are the context (philosophical claims and conceptual model) and the content (concepts and propositions) of the theory congruent?

Do the concepts reflect semantic clarity and semantic consistency?

Are the theories content stated clearly and concisely?

Is the theory content stated clearly and concisely?

does the research methodology reflect the middle-range theory? Are the middle-range theories concepts observable through instruments that are appropriate empirical indicators of those concepts?

Are theoretical assertions congruent with empirical evidence?

Are education and special skill training required before application of the theory?

Has the theory been applied in the real world of nursing practice?

Is it generally feasible to implement practice derived from the theory?

Does the practitioner have the legal ability to implement and measure the effectiveness of theory-based nursing actions?

Are the theory-based nursing actions compatible with expectations for nursing practice?

Do the theory-based nursing actions lead to favorable outcomes?

Is the application of theory-based nursing actions designed so that comparisons can be made between outcomes of use of the theory and outcomes in the same situation when the theory was not used?

Are outcomes measured in terms of the problem-solving effectiveness of the theory?

(Fawcett, 2005)

Theories considered

Theory of community empowerment was developed by Eugenie Hildebrandt and Cynthia Armstrong Persily. Caerse et al. (2011) stated that, “this theory was developed to give direction to improving health in communities.” The first conceptualization of the theory came out of participatory action research using an exploratory design. The mid-range theory is a merging of empowerment and community development theory for promoting health by building relationships both at individual and community levels. Persily and Hildebrandt (2008) states that “The theory is mid-range theory built on empowerment and creates a community involvement approach. With this theory, members of the community take responsibility for increasing their knowledge and decision making abilities.”

According to Persely & Hildebrandt, 2008, “The three main concepts in this theory include involvement, lay workers and reciprocal health.” Vargas et al. (2011) explained that involvement means when people in the community create support groups to identify their mutual needs, resources, and barriers to ultimately respond to a problem the community is facing done through planning, implementing, and intervening as a group.

Liehr and Smith (2008) stated that “the purpose of the theory is to provide a framework for research and practice through development of effective interventions at individual and community levels” (p.111). Caerse et al. (2011) found that empowerment theory  developing problem-solving capacity and competence that allows individuals and communities to gain mastery over their lives. When community development and empowerment are considered together, they demonstrate the potential for empowerment of community people through the involvement of lay workers in promoting reciprocal health.

Liehr and Smith (2008) also stated that “the lay worker concept involves trained persons indigenous to the community to which they live in and work in. These trained persons such as nurses reach out to families in the community. They know the community’s cultural values and they encourage preventative services, healthy behaviors, and assist with access to social services (p.113).

Here is where we can expand on the theory and add a new concept of empowering and informing the community. For example, informing a community about health care bill which is outside of the immediate health care needs of the community but directly affects the community. According to Caerse et al. (2011), the reciprocal aspect of the theory is concerned with the “actualization of inherent and acquired human potential. This occurs when professionals and community residents work together, respecting, and sharing what each other should offer”.

The reciprocal health is a concept where the community and professionals engage to promote proactive healthy behavior.

According to Fitzpatrick and Wallace (2006), “The theory was designed to structure a community involvement approach that enables community people to increase their knowledge and health care decision making capabilities. The desired outcome of community empowerment as community members participate proactively in ways to attach their highest potential” (p.343).

According to Caerse et al. (2011), “The community empowerment theory clearly addresses the metaparadigm of person, the environment, health, and nursing goals / processes and the theory explicitly states the members of the community who will receive the care/ intervention.”

The philosophical claims of this theory are also explicitly stated. Caerse et al. (2011), states that “the environment is mentioned as community’s social construct, as well as the neighborhoods, and the economy of the community. The theory also raises health issues identified by the community as important to address. The theory also mentions empowerment of members of the community to promote changes that will address the needs and issues identified by the community.”

In this theory, Caerse et al. (2011) states, “the metaparadigm propositions addressed include: life processes, patterns of human environment interaction, process that affect health, and interactions between health and environment.”

In this regard, empowering a community with information and involving strong nurse advocacy group could bring a profound change in society and bring about drastic health improvement among the community member.

My second theory choice is the emancipatory nursing praxis (ENP): a theory of social justice in nursing. According to National Institute of Health, “emancipatory nursing praxis (ENP): a theory of social justice in nursing is a middle-range nursing theory of social justice developed from an international, grounded theory study of the critical factors influencing nurses’ perceptions of their role in social justice.” (National Institute of Health, 2016).

According to Walter (2016), “the ENP theory implements processes such as becoming, awakening, engaging, and transforming. And the two conditional contexts the theory presents relational and reflexive, provide an in-depth understanding of the transformative learning process that determines nurse engagement in social justice.”

The relational context consisted of the numerous relational states for engaging in social justice.

These compartments of engagement include individual, group, organization/institutional, community, national, and international context. The emancipatory reflection promoted praxis and the ability to envision and act toward the possibility of individual and collective self-determination. The interpretive findings of this theory include the voice of privilege primarily informed ENP theory, the lack of nursing educational and organizational support in social justice role development, and the advocate role should expand to include the role of an ally. Health and disparities and inequality are socioeconomically constructed. The theory encourages nurses to engage in social justice to identify and redress the social conditions that negatively impact individual and public health (Walter 2016).

Professional awareness and involvement may increase if a theoretical framework is developed and this theory could be used in addressing the root cause of public and individual health concerns. For example, using this theory, the health problems that we are witnessing in our community today such as diabetes associated with sugary beverages could be addressed by implementing the ENP theory.

Table: 2 Theories considered

	Community empowerment theory	Emancipatory nursing praxis theory
Overview	Developed to give direction to improving health in communities.	Developed to involve nurse in social justice.
Origin	Swider and McElmurry and colleagues (1995) developed community empowerment intervention.	A middle-range nursing theory of social justice developed from an international, grounded theory study of the critical factors influencing nurses’ perceptions of their role in social justice
purpose	Seeks to provide framework for research and practice through development of effective interventions at the individual and community levels.	to explain the nurse professional’s role in social justice at a time when health disparities and inequities continue to be persistent nationally and globally.
assumptions	Empowerment can be learned, experiencing the process best accomplishes learning it, and broad based leadership from the community is more likely successful.	Becoming, awakening, engaging, and transforming) and 2 conditional contexts (relational and reflexive) provide an in-depth understanding to determines nurse engagement in social justice.
outcomes	Enhanced health through enhanced empowerment	According to Walter (2016),   “Emancipatory Nursing Praxis was the basic social process co-constructed from the voices of nurses internationally who engaged in social justice.”

Evaluation

Both the theory of community empowering and the theory of emancipatory nursing praxis put the community at the fore front and devise a way to bring desirable change for the community. The theory of community empowerment is more practical for my clinical situation of addressing the root cause of health care complications.

Table 3: Evaluation

http://www.authorstream.com/Presentation/bcawrse-1246362-community-empowerment-presentation-1/

Criteria-significance	Theory of community empowerment	Emancipatory Nursing Praxis theory, ENP
Are the metaparadigm concepts and propositions addressed by the theory explicit?	Accroding to Caerse et al. (2011) states “The theory clearly addresses the metaparadigm concepts of the person, the environment, health and nursing goals.”	Emancipatory nursing praxis is a theory based on the human-environment as an integral whole, where praxis (reflection-in-action and action in-reflection) is the facilitator for emancipatory human-environment (systemic) change.
Are the philosophical claims on which the theory is based explicit?	Caerse et al. (2011) also states that “the philosophical basis and the foundation of this theory is that through empowerment, change is possible.”	The philosophical claims on which the theory is based are explicit.
Is the conceptual model from which the theory was derived explicit?	The theory’s conceptual model up on which the community empowerment is built shows explicitly the intertwined nature of individual and community forces, individual and community health through involvement, lay worker, and reciprocal health model.	The theory is meaningful and useable. The theory is fit with other conceptual and philosophical perspectives already framing social justice engagement and inquiry in nursing.
Are the authors of antecedent knowledge from nursing and adjunctive disciplines acknowledged and are bibliographical citations given?	In their presentation, Caerse et al. (2011) states that the theory is derived from “a merging of the empowerment theory and the community development theory, the theory suggests that individuals and groups grow through community participant interaction and achievement of identified goals.”   Bibliographical citations are acknowledged.	Scholars have argued before that health and its attendant disparities and inequities are socio-culturally constructed.
Criteria–Internal Consistency
Are the context (philosophical claims and conceptual model) and the content (concepts and propositions) of the theory congruent?	Caerse et al. (2011) states that “Context includes both change through empowerment and the change must come within oneself or the community. The content includes identification of problems by the community and education of lay persons who will then educate others in the community, thus empowering them to change.”	The content emphasizes acting on a critical awareness of social structures and processes that systematically disadvantage the health of people, with the context of changing those structures and processes to promote health.
Do the concepts reflect semantic clarity and semantic consistency?	The content is semantically clear and consistent   https://www.slideshare.net/bcawrse/community-empowerment-presentation	ENP theory clearly and consistently endeavor to identify, redress, and change the socially constructed conditions that preclude full human expression and flourishing for all.
Criteria-Testability
does the research methodology reflect the middle-range theory?	Middle-range theories are useful in addressing the problems of nursing, especially among vulnerable populations. Although middle-range theories address specific phenomena within nursing practice, this theory is broad enough to be applied to a variety of patient populations, and across many practice settings.	Although broad, the theory of social justice grounded in the personal meanings and contextual social interactions influencing community, reflects mid-rage theory.
Are the middle-range theories concepts observable through instruments that are appropriate empirical indicators of those concepts?	The methods used to obtain practical answers to questions about reality are concrete and specific.	The concept is nonrepresentational and not easily quantifiable.
Criteria-Empirical Adequacy
Are theoretical assertions congruent with empirical evidence?	Caerse et al. (2011) argues that “The theory assertions appear to be well supported by empirical evidence.”	The theory claims and methods employed in the study were consistently supported with empirical evidence.
Criteria–Pragmatic Adequacy
Are education and special skill training required before application of the theory in nursing practice? (Nelson, Cook, & Ingram, 2013; Russo, Buonocore, & Ferrara, 2015)	Special training and skills may be required.	Special training and skills may not be required. http://www.authorstream.com/Presentation/bcawrse-1246362-community-empowerment-presentation-1/
Has the theory been applied in the real world of nursing practice?	Yes, theory has been applied in real world through public health nursing practices and other specialty areas.	The theory’s conceptual and philosophical perspectives already framing social justice engagement and inquiry in nursing has been applied.
Is it generally feasible to implement practice derived from the theory?	Caerse et al. (2011) states  argues that “Implementing the theory primarily be limited by the motivation of the community.”	Emancipatory Nursing Praxis was the basic social process co-constructed from the voices of nurses internationally who engaged in social justice. The implementing processes—becoming, awakening, engaging, and transforming is social process that is practical.
Does the practitioner have the legal ability to implement and measure the effectiveness of theory-based nursing actions?	On their presentartion Caerse et al. (2011) stated that “Legally, the nurse will likely be practicing within the scope of practice when providing health education to the lay persons and measuring its effectiveness within the community.”	Yes, the nurse will likely be practicing within the scope of practice when providing social justice engagement which is a professional expectation.
Are the theory-based nursing actions compatible with expectations for nursing practice?	Yes, theory based nursing is compatible with expectations for nursing practice.	The theoretical framework constructed from this study can be used to guide nursing education, research, and practice of social justice, thereby strengthening the profession’s ability to identify and redress the societal conditions that negatively impact individual and public health.
Do the theory-based nursing actions lead to favorable outcomes?	Yes, with community empowerment theory based nursing actions could lead to favorable outcome	Walter (2016) states that “there is a notable absence of professional nursing education and organizational support in the development of the nurse’s role in social justice.” Emancipatory Nursing Praxis is characterized by reflection-in action. Walter (2016) also states that “The advocacy role in nursing practice is expanded to include the social justice role of ally.”
Is the application of theory-based nursing actions designed so that comparisons can be made between outcomes of use of the theory and outcomes in the same situation when the theory was not used? http://www.authorstream.com/Presentation/bcawrse-1246362-community-empowerment-presentation-1/	Caerse et al. (2011) states that “Comparisons could be made between a community in which this theory was applied and a community in which the theory was not used.”	Comparison can be made and the theory holds several implications for nursing research.
Are outcomes measured in terms of the problem-solving effectiveness of the theory?	Caerse et al. (2011) states that “Outcomes to be measured would depend upon the problems identified by the community.”	Outcomes to be measured would depend upon the problems identified by the community.   https://www.slideshare.net/bcawrse/community-empowerment-presentation

(Fawcett, 2005)

If applied to nursing practice, both theories would bring about the desired change to address the root cause of a community’s health problems. However, the community empowerment theory can directly be applied and relates to my clinical situation. The emancipatory nursing praxis theory’s concepts are a bit far off from direct health care concerns in my clinical situation.

Community empowerment theory can empower a community to prevent health care problems while the emancipatory nursing praxis leans towards more abstract social engagement.

Plan

In the planning stage of the application of the theory we will use the involvement concepts from the theory. Persily and Hildebrandt (2008) states that “People in the community create support groups or coalitions to identify their mutual needs, resources and barriers to ultimately respond to a problem the community is facing.”

There are two approaches to apply the theory in clinical situation.

One of the plan would include going back to the idea of social health determinants and engaging patients in a conversation. This will help to see how well clients understand and can connect the effects of socio-political and economic decisions made by public office representatives affect their health. A good example would be to talk about the soda tax bill that could reduce the rate of diabetes spread among youth. According to Friedman (2016), “Educating is not enough to change our drinking habits and help the country lose weight.”

So, I would engage in a conversation with patients about having a possibility to have a discussion with their representatives. “To give consumers a nudge by taxing sugary drinks.” Friedman (2016)

I would explain the simple idea behind the plan as follows: According to Friedman (2016), “raise the prices of sugary beverages and people will buy and drink fewer of them, reduce their calorie intake and lose weight; use the revenue raised to pay for obesity prevention programs, and we have a win-win situation.”

The other plan would involve approaching individual nurses or nurse organizations and recommend the need to having a strong organized nurse advocacy group. An organization that can facilitate the empowerment of a community as well as influence the socio-economic and legislative environment that concerns health of the community. According to Community-Based Participatory Research, “The complexity of many of today’s health and social problems—environmental injustice, obesity, HIV/AIDS, and pronounced racial/ethnic health disparities—often renders them poorly suited to traditional academically driven research and the sometimes-disappointing intervention programs it spawns. Increasingly, too, there is a realization that to effect change, research in public health and related fields must be policy relevant.” (School of Public Health, UC Berkeley, 2008). Therefore, the organized public advocacy needs to study and address their issues and concerns, and collaboratively use the findings to influence policy and promote health equity. Siting a case study of empowering New Mexico’s Young people in public policy making, similar empowerment action could take place in nursing as well.

The first task of a nurse advocacy group in public policy making would be to identify potential health problem the community is facing. For example, let us say the advocacy group is concerned about the rampant diabetes among youth. The next step would be to secure a partnership for funding with organizations that support the cause. After securing funding to run the project, the advocacy group makes a thorough research the community’s problem and analyze policy issues that affected the community via surveys and other research methods. Evaluation methods would be designed to assess the effectiveness of the research. The next step would be to get involved in town hall meetings to identify actions areas on which to work on for policy and other systems change. The next step would be to translate the recommendations into action such as developing bills for the state legislature involving the health department of the community.

In addition, the advocacy group could get involved with different public offices such as the mayor’s office in persuading the office to support their cause.  Nurse organization advocacy group can influence health related bills for the greater good of society. Also, having an organized nurse media group that aims at educating the public about health care policies, bills, advocacy groups, and health care decisions that are made by political groups is crucial in reducing chronic and acute illnesses. Furthermore, a reform in the scope of Nursing practice is also expected if we were to empower patients and to have influence on the health outcomes that depend on governments and non-government organization’s decisions.

Similarly, we can make changes in nursing education curriculum to produce effective leaders in this regard. One recent activity that serves as a reminder how we badly we need to think outside the box is the recent poverty simulation practice that was held at the school of nursing. During the simulation, we were exposed to the different institutional services provided to clients and the bureaucratic ups and downs. While the exposure shade light to issues patients face when seeking help, the actual contributing factors were over looked and never discussed. Yes, addressing empathy, one of the core value nurses, is important.  But then, we would just be dealing with continued effort to fix the aftermath of failed health care policies and other social-economic factors if we continue to miss the big picture. Why don’t we go beyond and address the sources and make a real change?

Implementation

During one of my clinical practice days, I approached three of my patients. To my first patient I asked if she knew what the affordable care act is and what had happened to it recently. She knew what it was but she does not know details of what happened during the recent voting process on the act. At first, she did not show much interest in the conversation but as I explained the further, she got very curious. Here is what I said to the patient siting the recent New York Times article.

No too many people know that the affordable care act that was up for repeal in the US congress survived the repeal because the 3-dozen house freedom caucus secretive members of the republicans’ party voted against it. They did so because they wanted the complete repeal of the affordable care act. According to recent New York Times article, “they dismiss the bill’s subsidies to help middle-income Americans buy insurance as an entitlement program. And they want the bill’s cuts to Medicaid funding to kick in right away, instead of in 2020. They were not happy with trump’s partial repeal of law.” (New York Times, 2017).

After this information, my patient was very interested in knowing further how politicians affect her health. Due to time constraints, I did not go further in empowering the patient but we get the idea. In another implementation practice, I approached a nurse I was paired with and told her the same New York Times article story and added the what I wrote below.

Had Nurses had an influential organized body that advocates for patients in this regard, we would have made a real change by educating patients to get in touch with their representatives to alter the outcome of any such voting in favor of the general health of society. Nurses should also be able to engage with their patients in educating, informing, and empowering patients about health policies, laws and legislations. Nurses should realize that they have tremendous power collectively to address the root cause of these socioeconomic problems that make people sick. We talk about how our care is holistic and that we look at the person and a whole. We are also considered advocates for patients. But I noticed that we are not doing much to address the root causes of health disparity that emanate from poverty, bad policies, laws, socio-economic factors that contribute negatively to the community’s health.

Again, the reaction I got from the nurse was positive and supportive of the idea of having strong nurse advocacy group.

With the last patient and nurse, I asked if the patient is familiar with the story of soda tax bill. My patient did not know what the bill was. Here is what I told patient number two and nurse number two:

A strong organized nurse community that empowers and advocates for patients is needed to contest the negative health effect of for profit corporations. For example, health experts believe that soda taxes reduce consumption, particularly by young people who are unable to afford the additional expense.  In the fight against obesity, a new University of California, Berkeley study shows that http://news.berkeley.edu/2016/08/23/sodadrinking/

 “A 21% drop in the drinking of soda and other sugary beverages in Berkeley’s low-income neighborhoods after the city levied a penny-per-ounce tax on sugar-sweetened beverages.” (UC Berkeley, 2016). “While Berkeley, the first U.S. city to pass a “soda tax,” saw a substantial decline in the consumption of sugar-sweetened drinks in the months following implementation of the tax in March 2015, neighboring San Francisco, where a soda-tax measure was defeated, and Oakland, saw a 4 percent increase, according to the study”. (UC Berkeley, 2016) . The measure, AB 2782 in California to levy soda tax, as with similar proposals in the past, a bill such as this is expected to face strong opposition from Californians for Food and Beverage Choice, the political arm of the California Beverage Association (CalBev). Having a strong influential nurse organization as well as empowering our patients would enable society to bring about positive change with similar campaigns as the soda tax bill. By addressing the root cause of socio-economic and political dependent health care disparities, we nurse could influence the health care environment and contribute positively in a revolutionary way. Some of my patients that suffer from high blood pressure, Diabetes, chronic kidney disease, and heart disease could benefit from such community empowerment and an organized nurse advocacy group.

Following this, I asked if they would support any initiative to levy tax on sugary drinks. The answer was yes from both the nurse and the patient.

I shared the story of Affordable Care Act with my patient and I was able to get an understanding of how much my patient knew what was going on.

With regards to my patients, I asked them how they feel if there an organized advocacy group of nurses that exert influence on social and health related policies and undertakes educational role to patients. All the patient I exchanged the idea with were more than happy to see an organization like this created. I also asked nurses how willing they are to participate in a nurse advocacy group that has strong influence on social and health care policy matters. All the four nurses were happy to participate in such organization siting the benefit to our patients before they become sick.

Through Community empowerment theory, addressing the root cause of vulnerable community’s acute and chronic diseases is possible. Nurse could play a big advocacy role within the macro and micro environment in the community they serve. Political, economic, and social decisions made by public officials have huge consequences on communities and their health. Therefore, educating patients and professionals to bring change is important.

References

(2016). Emancipatory Nursing Praxis: A Theory of Social Justice in Nursing. National Institute  of Health. Retrieved from. https://www.ncbi.nlm.nih.gov/pubmed/27798438

(2011). Essential Packages of Health Services. World Health Organization. Retrieved from http://apps.who.int/medicinedocs/documents/s19420en/s19420en.pdf

Caerse, S., Hatcher, J., Lehil, S., & Vargas, J. (2011). Application of community empowerment to practice: Philosophical, theoretical, and ethical bases for nurses. Health and medicine technology. Retrieved from https://www.slideshare.net/woikekc/health-promotion-model

Fawcett, C. (2005). issue 2 Criteria for Evaluation of Theory. Nursing Science Quarterly, 18. Retrieved from. http://journals.sagepub.com/doi/pdf/10.1177/0894318405274823

(2017). House Republican Plan to Vote on the Obamacare Replacement. The New York Times. Retrieved from https://www.nytimes.com/interactive/2017/03/20/us/politics/health-care-whip-count.html

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Persily, C. A., & Hildebrandt, E. (2003). Community empowerment theory Middle range theory for nursing. New York: Springer Publishing Company

Persily , C. A. & Hildebrant , E. (2008). Theory of community empowerment. In Smith, M. J. & Lierhr , P. R. Middle Range Theories for Nursing (2nd Eds.).  New York, NY: Springer Publishing Company.

(2008). Promoting Healthy Public Policy Through Community-Based Participatory Research. University of California, Berkeley. Retrieved from. https://depts.washington.edu/ccph/pdf_files/CBPR_final.pdf

Fitzpatrick, J., Wallace, M. (2006). Encyclopedia of Nursing Research. New York. Springer Publishing Company.

Friedman, R. (2016). A Soda Tax- Will it Change Anything? Obesity Action Coalition. Retrieved from http://www.obesityaction.org/educational-resources/resource-articles-2/nutrition/a-soda-tax-will-it-change-anything.

(2016). Soda Tax Linked to Drop in Sugary Beverage Drinking. University of California  Berkeley. Retrieved From. http://news.berkeley.edu/2016/08/23/sodadrinking/

Walter, R. (2016). Emancipatory Nursing Praxis: A Theory of Social Justice in Nursing. Advances in Nursing Science Journal. Retrieved from http://journals.lww.com/advancesinnursingscience/fulltext/9000/00000/Emancipatory_Nursing_Praxis__A_Theory_of_Social.99932.aspx

Walter, R. (2016). Emancipatory Nursing Praxis: A Theory of Social Justice in Nursing. The Honor Society of Nursing, Sigma Theta Tau International. Retrieved from http://www.nursinglibrary.org/vhl/handle/10755/603781

Walter, R. (2016). Emancipatory Nursing Praxis: A Theory of Social Justice in Nursing.
Lenoir-Rhyne University. Retrieved from https://stti.confex.com/stti/nln16/webprogram/Paper78373.html

Appendix A

Figure 1: Emancipatory Nursing Praxis Theory Model

Adapted from Walter, R. (2016). Emancipatory Nursing Praxis: A Theory of Social Justice in

Nursing. Advances in Nursing Science Journal.

Appendix B

Figure 2: Community Empowerment Theory Model

Adapted from. Persily, C. A., & Hildebrandt, E. (2003). Community empowerment theory

Middle range theory for nursing. New York: Springer Publishing Company