Exploring Nursing Strategies to Engage Community in Cardiovascular Care

Abstract

Purpose of Review

This review aims to highlight some of the strategies nurses use to engage community members in cardiovascular care. We also elaborate on opportunities for improving community engagement.

Recent Findings

Community engagement occurs across a continuum of progressive levels of community involvement, impact, trust, and flow of communication. Successful community engagement has been shown to improve both patient-centered care and intervention design, implementation, and dissemination. Nurse strategies used for engaging community in cardiovascular care included more examples of outreach, consult, and involvement than collaboration and shared leadership.

Summary

More attention is needed toward strategies that embrace collaboration and enhance trusting relationships to advance to shared leadership. Nurses must intentionally work in partnership with communities to improve cardiovascular health for all. Furthermore, assessing meaningful community engagement is necessary to achieve the desired outcomes, including optimal cardiovascular health and thriving communities.

Introduction

Community engagement is essential for remediating the staggering racial, ethnic, gender, and economic inequities in cardiovascular outcomes [1, 2, 3•]. Communities are groups of people connected by some shared characteristic or element of their environment. By engaging with communities, healthcare professionals invite the voices, perspectives, and experiences of the people and groups most affected by cardiovascular inequities to be integral parts of constructing interventions and other solutions [1, 3•]. Nurses are essential care team members, providing care across various settings. Therefore, examining how nurses can engage with communities to promote cardiovascular health is essential.

Recently, the American Heart Association set a goal of increasing healthy years of life from 66 to 68 for every person in the USA and 64 to 67 worldwide by 2030 [4]. Achieving this lofty and essential goal of reducing and eliminating disparities in cardiovascular health outcomes must be shared by all members of the healthcare team, including nurses. At over 4 million individuals, nurses comprise the largest segment of the healthcare workforce and are consistently recognized as the most trusted profession [5, 6]. The discipline of nursing centers on the complex relationships between the individual, their environment, health, and the nurse as a partner in their healthcare, and this paradigm grounds all of nursing education [7]. Nurses can leverage their training to approach health holistically and deliver on the nation’s trust in the nursing profession to help actualize the goal of equity in cardiovascular health, leading to more healthy years of life for all communities. Achieving the goal of cardiovascular health equity also requires engaging communities as partners in this shared goal.

Community engagement is “working collaboratively with and through groups of people affiliated by geographic proximity, special interest, or similar situations” to improve their health and well-being [8]. The degree of community involvement exists on a continuum, beginning with outreach as the lowest level of community involvement and extending to shared leadership with its hallmarks of bi-directionality and community as the final decision makers (Fig. 1). Nurses must consider how to better engage with communities in our shared goal of reducing and eliminating inequities in cardiovascular outcomes. Although 55% of nurses work in acute care settings, nurses are employed in various settings, including ambulatory care, home health, schools, and public and community health settings [5]. With the rise in cardiovascular-related risk factors (e.g., obesity, sedentary behavior) and cardiovascular disease, nurses in most practice settings care for patients with diagnosed or undiagnosed cardiovascular disease or significant cardiovascular risk factors.

Fig. 1.

Continuum of community engagement

Cardiovascular care is a broad term encompassing all organized efforts to preserve cardiovascular health. These efforts include preventing the initial development of cardiovascular risk factors (primordial prevention), identifying and intervening on existing risk factors (primary and secondary prevention), or providing knowledge and skills to manage disease and restore optimal cardiovascular health (tertiary prevention). Abundant research makes clear the harms of structural and social factors on essential cardiovascular health behaviors and biomarkers [9–11]. Structural determinants of health are foundational factors that provide the necessary context to understand how social determinants constrain people’s choices and opportunities (e.g., access to nutritious foods and safe spaces for physical activity) and their access to health care services [9, 10, 12]. Historically social drivers of cardiovascular health have been underappreciated and underrepresented in cardiovascular care and research. This lack of attention is evidenced by extant publications decrying the insufficient research on these social drivers and, even more recently, a boon in the spotlight on social and structural factors [10, 11, 13]. In case there was still doubt about the influence of social and structural factors on health, including cardiovascular health, the COVID-19 pandemic illuminated this relationship in undeniable ways [14–17]. Now, nurses, other clinicians, and health workers must focus on these social factors. We aim to summarize strategies nursing professionals use to engage communities in cardiovascular care and identify gaps along the community engagement continuum. We conclude with recommendations for prioritizing community engagement in cardiovascular care, research, and suggestions for evaluating meaningful community engagement.

Community Engagement Continuum in Cardiovascular Care

Community engagement is a powerful tool for catalyzing the behavioral, social, and environmental change necessary to improve communities’ cardiovascular health and overall well-being. The Centers for Disease Control (CDC) describes community engagement as a continuum of community involvement, spanning from outreach, with less community interaction, to shared leadership which typically evolves out of partnerships and invested time in building relationships with community stakeholders (Fig. 1) [8]. “At each successive level of engagement, community members move closer to being change agents themselves rather than targets for change, and collaboration increases, as does community empowerment” p. 23 (CDC, 2011, p. 23) [8]. In consultation with a research librarian (informationist), we identified published articles describing strategies nurses use along this continuum to provide cardiovascular care and to restore power to communities to improve cardiovascular outcomes. While we discuss these levels as distinct steppingstones leading to shared leadership, in practice, there are often degrees of overlap, and a singular intervention could exemplify elements of outreach, consult, or collaborate.

Outreach

Community outreach is the first step in the community engagement continuum and typically includes little involvement from the community. Nursing strategies commonly used at the outreach level of community engagement include the following: (a) providing health education in the home or other community-based venues, (b) screening for cardiovascular risk factors (e.g., hypertension) in schools, churches, and other community settings, and (c) supporting care transitions from the hospital to the community [18–22]. Nurses are skilled at extending healthcare care beyond traditional healthcare settings. In the tradition of Lillian Wald, a noted nurse, and social worker from the early twentieth century who practiced nursing in the homes of immigrants, community outreach often situates nurses in the homes of patients recovering from acute cardiovascular events or patients with uncontrolled cardiovascular disease risk factors [23]. For example, participants in a 4-week nurse-led stroke self-management support program that included a home visit, group session at a community center, and follow-up telephone support saw significant improvements in self-efficacy and performance of self-management behaviors compared with the usual care group [20].

Another example is faith community nurses who are naturally embedded in community settings and are available for blood pressure screenings. A network of faith community nurses implemented a monthly blood pressure screening protocol and provided education and referrals for untreated community members. They noted opportunities for improving the referral process and communication with the healthcare system, especially for those already treated for hypertension, although not at goal [18].

A hallmark of community engagement at the outreach level is the unidirectional flow of communication from the nurse to the community to inform or educate. A nurse-led randomized control trial compared transitional care delivery of nurse practitioners, nurse practitioners combined with health coaches and usual care on post-stroke rehospitalization and blood pressure [21]. The NP provided in-home and telephone support, yet no statistical differences were observed in either outcome. The authors concluded that more research should focus on how to optimize usual care services; however, it is also plausible that future research could obtain perspectives from the community on intervention design, including wrap-around support to address social risks (e.g., food insecurity) and preferences for video over telephone support. Engaging community resources and creating an intervention from the community perspective may have yielded a different outcome. Community outreach alone is insufficient to achieve the transformation needed to eliminate the persistent inequities in cardiovascular health outcomes.

Consult

Consultation in the community is a reciprocal process involving a genuine partnership between the community and a service provider [8]. Nursing strategies to complete these consults are similar to outreach, although with more community involvement. For example, home visits, telephone follow-ups, patient education, and one-on-one coaching are combined with a participant evaluation of the intervention. Instead of the unidirectional communication flow that occurs in outreach, at the consult stage, communication is more transactional. In the post-stroke intervention described previously, they included semi-structured interviews after the intervention to obtain participant feedback [24]. The participants expressed enhanced confidence in their ability to perform self-management activities. They also appreciated emotional support from the nurse, and many participants wished for more nurse visits, suggesting modifications that could be made in future iterations [24]. The ENABLE CHF-PC program asked patient-caregiver dyads to be “consultants” to the study team by participating in translating an oncology palliative care intervention for use with clients with class III/IV heart failure [25]. Advanced practice nurses provided weekly telehealth coaching sessions and led dyads through a guidebook. After participants experienced the intervention, they were asked to give specific feedback about the ENABLE CHF-PC intervention, including suggestions for tailoring the content. This patient and family caregiver input early in the design process before a larger clinical trial was an essential part of the formative work to improve the intervention for future heart failure patients.

Involve

Community engagement should be a continuous and iterative process with community members deeply involved in all aspects of the planning and implementation of change. Involvement, collaboration, and true shared leadership foster the partnerships needed to address the longstanding inequities in cardiovascular disease. Beginning at the involve stage of community engagement and beyond, there are fewer and fewer examples of nurses engaging with communities in this type of authentic manner [26•]. Recently, Alvarez and colleagues [27•] detailed their process of developing and implementing an interprofessional training program for community health workers and nurse case managers in collaboration with community health centers to address hypertension disparities. Participatory communication, an essential component of involved community engagement, was evident in the descriptions of the community advisory board that helped to prepare for the training, including developing job descriptions for the new roles and input on curricular content [27•]. Pairing nurses with community health workers is an innovative way to leverage the medical and health expertise of nursing staff and combine it with the shared experience and emic perspective of community members who often share more commonalities with patients and can provide needed support and address social risks such as housing instability [26•, 27•]. Notably, the preparation for the intervention included interprofessional training on the different roles, best practices for communication and patient engagement, and content on cardiovascular disease and risk factors.

Collaborate

Collaborate features community members in an active role at each stage of the intervention, including identifying the problem, supporting the development of the intervention or activity, and participating in the implementation and evaluation. An example is the adaptation of the NHLBI With Every Heartbeat is Life (WEHL) program done in collaboration with a faith-based community [28]. The nurse collaborated with local churches and pastors to provide education, support, and implement community health programs such as the WEHL program. One of the keys to success was the pastor’s role in tailoring the intervention to the local congregation [28].

At the collaboration level of community engagement, communication becomes interactive rather than transactional. An example is a community-academic partnership born from community members identifying a need and nurse educators integrating community voices into nursing education [29]. The Critical Service-Learning project was a collaboration between nursing educators, students, and community stakeholders (e.g., a nurse practitioner and parish nurse) to respond to the need for improved early cardiovascular disease screening. Community members participated in class discussions and co-teaching, which provided the “insider” perspective and information useful in linking to root causes of health inequities. An essential distinction for critical service-learning projects is the intentional consideration of the inequities that have led to the need for the project. Moreover, critical interrogation of the why and history behind the problem is necessary for partnerships to continue evolving into shared leadership.

Shared Leadership

Shared leadership is the ultimate stage of community involvement and must be utilized more by nurses and other health researchers. Many community initiatives may begin as something other than a shared leadership format yet evolve over time into solid partnerships. These partnerships recognize and support community members as decision-makers and ultimately can produce a broader community impact. In 2020, Nolan and colleagues were preparing to implement a project to increase the representation of Black men in cardiovascular clinical trials when the COVID-19 pandemic halted most activities [30•]. The academic and community partners had been working together throughout the study design process and applying principles of community-based participatory research (CBPR) to reckon with the complex origins of medical mistrust. The foundation of trust and partnership permitted them to nimbly modify the plans and focus on responding to the COVID-19 pandemic. Ultimately, the community participants took the lead in transforming channels of communication to include virtual small group sessions to provide support and information sharing during the crisis. Although the researchers’ focus was on the retention of research participants, their openness to shared leadership was transformative and resulted in a broader impact. Notably, the team still retained 74% of the research participants. Although virtual community engagement was necessary during the COVID-19 pandemic, many partnerships were formed from in-person dialogue and team building that pre-dated the pandemic. Looking ahead, nurses will need to remain in conversation with community members to determine when virtual community engagement is preferred and be aware of potential limitations, such as excluding individuals with poor internet access.

Expanding Nursing Strategies for Community Engagement in Cardiovascular Care

The future of nursing 2020–2030 report calls for strengthening nursing capacity and expertise to support the imperative to achieve health equity [31]. Part of the expanded capacity and expertise should focus on principles of community engagement. Current nursing education is heavily weighted toward acute care practice, although more than a third of nurses practice in non-acute settings [5]. Clearly, focused training is needed to increase the knowledge and skills needed to engage with communities effectively to address cardiovascular health. A recent curriculum that was used to prepare nurses to implement a hypertension focused intervention is an example that could be adapted to fit other disease processes [27•]. The Preventive Cardiovascular Nurses Association (https://pcna.net) has online certificates available in behavior change and cardiovascular nursing, and there is room for expanding the content to include developing and implementing community-engaged cardiovascular interventions.

Nurses can advocate for and lead the expansion of co-creation of interventions with the intended end users from the community [27•, 32, 33•]. Voorberg [32] distinguishes co-creation as an active process versus participation which is more passive. There are many nursing studies with end users participating by providing feedback on an intervention [24, 26•], but fewer with community members as co-designers [32]. Ramos and colleagues [33•] detail their use of intervention mapping, a structured, six-step process, to guide the co-creation of an intervention for cardiovascular disease prevention with Black and Latinx sexual minority men with HIV. Co-implementation of an intervention can be used alone or paired with co-creation to extend the involvement of community members and stakeholders (Fig. 2). For example, working with a community advisory board to co-create the intervention and partnering nurses and community health workers as co-implementers [27•, 34]. It is worth noting that understanding the research process and restrictions imposed by funders or institutions is a common challenge when co-producing research with community advisors [35]. In addition to investing the time to develop a strong partnership with a community advisory board, another innovative approach is developing a community science academy to introduce the research process to community members and foster more citizen science [36, 37]. An organizational community advisory board in Arkansas suggested the idea of a community science academy and were partners in co-creating the program to increase research participation from communities typically underrepresented in research [36].

Fig. 2.

Strategies to engage communities in cardiovascular care

Evaluating Meaningful Community Engagement in Cardiovascular Care

Evaluating community engagement processes should be incorporated into future nursing strategies. Recently, the National Academy of Medicine (NAM) identified four domains of measurable outcomes for meaningful engagement: strengthened partnerships and alliances, expanded knowledge, improved health and health care, and thriving communities [38]. Health outcomes are the most included category to evaluate the effectiveness of the research or quality improvement project, as they are often the focus of externally funded research. However, the published research should also include detailed descriptions of the community partners, assessments of the partnerships, and/or assessments of the impact on the larger community. The partnership self-assessment tool (PSAT) is one example of a tool designed for measuring the synergy between community partners but has been used to evaluate community engagement [39, 40]. Of note, partnership synergy as used by this tool, is much more akin to engagement than the passive partnership that is representative of the lower levels of community engagement (e.g., consult, involve). Another example is the partnership readiness for community-based participatory research (CBPR) model. Nurse researchers in South Carolina defined major dimensions and key indicators of partnership readiness and designed a toolkit that included individual partner assessments and team assessments to guide follow-up discussions for action plans [41]. There is a need for continued instrument refinement specifically for assessing community engagement from the perspective of multiple stakeholders and to complement the existing qualitative descriptions of community engagement. This is a priority for researchers and practitioners.

Incorporating process and formal evaluation measures into the intervention’s objectives will support nurses engaged with communities to move from solely measuring individual level health-outcomes to assessing broader impacts such as community connectivity and community measures of well-being. The NAM conceptual model includes expected outcomes of meaningful community engagement, such as improved health and healthcare programs, strengthened partnerships, and culminating with thriving communities [38]. Figure 2 includes the expected outcomes of meaningful community engagement, with each advance on the continuum accompanied by a broader community impact. Nurses must be committed to growing partnerships over time and remain committed to nurturing these essential relationships if we are to reach the goal of thriving communities. Indicators of thriving communities include community connectivity, power, and well-being; more guidance on measuring these indicators will be forthcoming per the NAM publication.

Challenges Ahead

Multiple gaps and challenges remain for nurses to continue making progress toward providing community-engaged cardiovascular care (Table 1). Nurses need a solid understanding of the structural and social determinants of health as the foundation for understanding the need for community-engaged care and research. Nursing educators have incorporated service learning and other community-based learning experiences to scaffold knowledge and understanding of social determinants [29, 42]. Some nurses advocate for a structural competency to be integrated into nursing education to foster an understanding of the upstream factors that lead to the social needs and risks (e.g., food insecurity) experienced by some community members [14, 43].

Table 1.

Opportunities to enhance community-engaged cardiovascular care

Educational	Clinical	Research
Structural competency	Innovative, community-informed models of nursing care	Evaluating meaningful engagement
Community engagement principles	Enhanced knowledge of primordial—tertiary CVD prevention	Interventions to address social factors Community-engaged health policy development Multisectoral research teams Identifying and eliminating barriers to shared leadership

Clinical training to enhance nurses’ knowledge of primordial—tertiary prevention of cardiovascular disease is needed to prepare nurses to build capacity in lay members as interventionists. Interventions that engage community members in the delivery of the intervention are more effective than interventions where community members are consulted but not part of the implementation [2]. However, lay community interventionists, such as community health workers, need accessible clinical experts, such as nurses, available to answer questions and provide clinical guidance. There is a great opportunity to develop innovative nurse models of care that pair nurses in community settings with community health workers or navigators.

Some nursing research priorities for community-engaged cardiovascular care include co-creating interventions to address the continuum of social risks, social needs, and social determinants of health (SDOH), engaging communities in health policy development, and identifying barriers to shared leadership. Multisectoral research teams are needed for community-engaged research that will identify and address social risks and unmet social needs. Multisectoral research teams bring together diverse stakeholders to co-create change and may include legislators, city and local government leaders, faith leaders, social service professionals, nurses, physicians, pharmacists, behavioral health clinicians, and patients. While more interdisciplinary collaboration and shared leadership are needed, multisectoral teams represent an intentional progression beyond the health profession disciplines. This progression reflects an awareness that other contributing factors of cardiovascular health outcomes include equitable access to education, nurturing relationships, and social systems that support thriving and not merely surviving. Multisectoral partnerships are well-positioned to promote cardiovascular health equity by addressing the continuum of SDOH, social risks, and social needs [44].

Often research that is identified as community-based or community-engaged needs more details about how communities were involved in the design process. Community involvement in every stage of the creation process, including implementation, is key. Notably, as depicted in Fig. 2, the community engagement process continues after implementation. For example, it should continue with the dissemination of findings back to the community, and the creation process should begin anew based on the research findings and lessons learned from the current project. Through this process of designing interventions or initiatives together, implementing the plan, reporting the results, and evaluating the process, the relationships between the community and nursing professionals are nurtured and evolve into shared leadership.

Conclusion

Achieving optimal cardiovascular health for all will require community-engaged cardiovascular care. Many nursing interventions used outreach, consultative, or passive involvement of community members. However, we also identified examples of nurse-led interventions that are collaborative and co-designed with community members, an essential step in the progression toward mutual trust and shared leadership. Incorporating methods to evaluate the community engagement process meaningfully may aid more teams in reaching the shared leadership stage. Additionally, social risk factors, social needs, and determinants of health must be a high priority for future interventions and must be done in collaboration with communities to identify and prioritize needs and to co-create interventions. Nurses are encouraged to seize the current momentum spurred by the COVID-19 pandemic to develop partnerships for lasting change that can lead to cardiovascular health equity.

Data Availability

The authors confirm that all data underlying the results are included in this published article and no additional source data are required. Furthermore, data supporting the findings of this article were all publicly available at the time of submission.