Assessing the Educational and Support Needs of Nursing Staff Serving Older Adults: A Case Study of a Community Coalition/ University Partnership

Abstract

Given expected changes in demography and dependent care ratios, communities are preparing for the needs of older populations. Sometimes communities form coalitions to address health care needs. This case study evaluates a coalition/university partnership formed to assess the educational and support needs of nursing staff who are taking care of older adults across all service settings in one geographically defined community. A community-based coalition of 17 service providers contracted with researchers from an external university to determine the perceptions of three key stakeholder groups: older adults and their families; all levels of nursing staff; and agency administrators. By applying principles of Participatory Action Research (PAR) this case study presents the challenges faced in the community-based coalition/university research team partnership. This community/research partnership is unique, differing from most academic examples of PAR because nursing professionals as community members initiated the partnership.

Introduction

By 2030, older Americans age 65 and above are projected to comprise 19% of the U.S. population (Administration on Aging, 2010). Communities around the country are preparing for the impact of such unprecedented growth on affected sectors. As communities plan for this growing older population, it is important to understand the potential for community coalitions to address the needs of older adults. The potential service needs for this population are multi-faceted, including inpatient and outpatient treatment of acute and chronic health problems, residential care for persons of varying needs and care for persons choosing to remain in their homes. Scholars have argued that awareness of services in one's community also affects decisions older adults make about their housing choices (Tang & Pickard, 2008). Service providers are creating plans and models incorporating a spectrum of housing and service needs, working together to meet the needs of their constituents (Peck, 2010).

This case study reports the experiences of researchers working with one such collaboration of service providers in an innovative county-wide community coalition (“Promoting Excellent Nursing Care of Elders”; PENCE) organized to promote quality nursing services for older persons, across all care settings. This coalition framed their activities according to a logic model that outlined strategic actions targeting improved support for nursing staff as the key step to improving health outcomes for older adults. PENCE garnered a great deal of support in a short time, and, with its second year of operation, joined with a research university to conduct a county-wide needs assessment of the educational and support needs of nursing staff in all settings serving older adults. The primary focus of this paper is to analyze the coalition/university partnership and the challenges arising from it according to Whyte (1991)'s principles of Participatory Action Research (PAR).

An Innovative Coalition

In 2008, a group of nursing care providers in one county in Michigan, USA, formed a coalition to promote excellent nursing care for elders. A retired parish nurse founded the coalition. Parish nurses typically assist parishioners with navigating the health-care system and visiting them wherever they are receiving care (Dyess et al., 2010). In this role, the coalition founder witnessed many gaps in the quality of nursing services and approached clinical nurse specialists at the local hospital to discuss the situation. This led to the formation of a leadership team of nurses from the more visible sectors of the aging services network: community colleges that trained licensed nurses and nurse aides, hospital and home-care nursing administrators, and nursing home personnel. The leadership team then expanded the coalition to include others in the community. The parish nurse acted as the coalition facilitator, often bringing in stakeholders by personal invitation. Her reputation in the community fueled member agencies’ sustained interest in the project, as many viewed her experience as key to understanding the community and demonstrating a proven commitment to it. The coalition, Promoting Excellent Nursing Care of Elders, or PENCE, aimed to address the nursing needs of older adults in its community. Because of the fluid nature of health needs in later life, older adults may transition through many different health-care settings (e.g., clinics, hospitals, nursing homes, rehabilitation programs, home care). The coalition valued the potential of well-educated and supported nursing staff as key to promoting quality care throughout these transitions. Through working together across settings, PENCE planned to share resources, to facilitate communication, as well as to optimize continuity of care.

The coalition was unique in two ways. First, the quality of nursing services throughout the continuum of care was the focus, transcending historical service-provider boundaries. While there are initiatives to assess and improve the quality of services to older adults (e.g., Consumer Assessment of Healthcare Providers and Systems, Agency for Health Care Research and Quality, 2011), these are typically focused on one setting at a time, and not all service settings are included in the suite of assessment tools. The coalition emphasized the value that EVERY stakeholder was responsible for the overall quality of nursing care in the county. Second, the coalition defined the nursing team broadly. This coalition purposely and adamantly made it clear that direct-care workers (e.g., certified nursing assistants, home care aides, personal care attendants) were part of the team providing nursing care. Retention and recruitment issues, particularly in long-term care settings, have driven attention toward the work conditions of nurses’ aides (Institute of Medicine, 2008), the largest employee group in the long-term care field. Poor relationships between licensed nurses (Registered Nurses [RNs] and Licensed Practical Nurses [LPNs]) and nurse aides have often been cited as a leading cause of nurse-aide dissatisfaction (Stott et al., 2007). To address the needs of both older adults and their nursing-care providers, a unifying disciplinary perspective was needed to bridge the knowledge and support gaps between licensed and unlicensed nursing staff.

The coalition included representatives from 17 different agencies, settings or services, which spanned the continuum of care from home care to hospitals, nursing homes, and clinics, and included educational nursing programs and other stakeholders, such as women’s cooperatives and job-retraining agencies. Participating organizations designated representatives to attend coalition meetings, and most of the coalition participants were licensed nurses holding leadership positions in those organizations. However, coalition membership was not limited to representatives from formal organizations. The coalition also grew by adding community members at large.

Early in its formation, the coalition had success in securing funding from the Battle Creek Community Foundation to underwrite ten nurses from the county to complete the nationally recognized continuing education program known as “Nursing Interventions and Care of Health System Elders, (NICHE)” developed by the Hartford Foundation to increase knowledge and skills of health-care providers working with seniors (NICHE, 2011). This major step set the groundwork for future success and also integrated planning for new projects such as workforce training (Homan, 1999).

Before deciding on more specific goals for activities, the coalition determined that it wanted to obtain perspectives from various county stakeholders about the delivery and receipt of nursing care. Three stakeholder groups were identified: older adults and their families; nursing staff; and nursing administrators. The coalition anticipated collecting survey information from each stakeholder group, and holding focus groups with older adults, family caregivers, and licensed and unlicensed nursing staff. PENCE also wanted information that would be deemed credible by local stakeholders from many sources, rather than being seen as acting upon the beliefs and opinions of only coalition members. Therefore, members of the coalition contacted the University of Michigan School of Nursing and agreed to work with a faculty member (BLINDED FOR REVIEW) interested in gerontology and community-based practice and research. The coalition and faculty member successfully submitted a grant application to the Battle Creek Foundation, identified by the coalition as a potential supporter. Additional members of the university research team were BLINDED FOR REVIEW (a doctoral student in Social Work), and three research assistants hired by the principal investigator.

Case Study Method

As this project was initiated by the coalition and its members had contacts with many health care providers in the county, the research team, working with members, applied a Participatory Action Research approach to involve the community members in the design and implementation of research. Eschewing traditional roles in research, e.g., researcher as expert, Participatory Action Research (PAR) is an approach that views practitioners as co-researchers as well as research subjects (Whyte, 1991, p. 86). PAR has been utilized in needs assessments (Simonson, 1993). Booth and colleagues (2007) argue that nurses feel more “personally responsible” for developing solutions to identified problems if they are engaged in the process through action research. Additionally, practitioners contribute much to PAR research projects as they “often bring the pursuit of irrelevant or ill-conceived lines of inquiry to a rapid halt, correcting or refining the questions” (1991, p. 54).

Throughout the partnership with university researchers, coalition members displayed their engagement by permitting staff time to be allocated to attending design meetings, recruiting research participants through or at their agencies, in addition to participating in meetings about the results and implications of the needs assessment.

In a review of the evolving definitions of community health, Baisch argues that PAR approaches have been more evident in planning community health programs since the late 1990s where the community members “define the needed professional partners” (2009, p.2468). In this case study, the coalition members decided which research professionals they would partner with at the beginning of the project and throughout the needs assessment process.

Nursing researchers have also found that utilizing a collaborative approach better ensures that a unique definition of “community health” will be established locally and democratically (Baisch, 2009). While we applied principles of conducting research, we were not seeking to fill a gap in the literature by asking specific research questions. In fact, the coalition was clear that they were far more interested in what their own citizens had to say about needs and services, even in areas where there was ample existing literature upon which to base interventions (e.g., recruitment and retention of direct care workers).

Coalition members were involved in almost every detail of the needs assessment design. Before meeting with the researchers, the coalition had decided that the needs assessment would include focus groups and surveys of older adults, families, and nursing staff and administrators. The researchers then conducted group work sessions with coalition leaders to explicate the questions or topic areas of greatest importance to the coalition. The research team proposed several possible strategies, listing advantages and limitations of each, from which the coalition leaders made the final choice of methods. Following approval from the coalition, the research team then constructed drafts of methods and protocols for the coalition to critique and modify.

This community/research partnership differs from most of the instances of engaged research in the literature in that the community members initiated the partnership. The coalition leaders decided which research professionals they would partner with at the beginning of the project and throughout the needs assessment process. Before meeting with the researchers, the organization had already defined the desired methods.

In applying the framework of PAR the coalition/university partnership encountered challenges. Table One summarizes the seven challenges faced by the coalition/research partnership. The table also includes the implications for the partnership and the strategy the partnership used. In the next section, we describe in detail the challenges that emerged and how they were addressed.

Challenges

The goal of the needs assessment was to understand the support and educational needs of nursing staff taking care of older adults. The findings presented below are an evaluation of key challenges encountered in this coalition/university partnership. We apply the Participatory Action Research as the framework for analyzing the challenges faced by the partnership. The challenges were:

1. Challenge of defining the community

As the coalition desired geographically specific data, one challenge was to work with members to define the community to be assessed. Given the PAR perspective of the importance of beginning with problems people are facing rather than reviewing the literature (Whyte, 1991, p. 40) and the coalition's desire to know unique needs of the community, there were complications in defining the community to be examined. Depending on the definition and scope of the community, different perspectives of service provision and service use may emerge. It is also crucial that partners reach agreement on how to define a community.

In our project, the coalition wanted specific data about nursing services within their county limits. This guideline affected our understanding of service use in two ways. In some cases, service users may have been county residents, but used nursing services in neighboring counties. In other examples, older adults lived outside the county, but used nursing services within it. Thus, the research team had to assess carefully for residency and location of services used in forming focus groups and choosing survey recipients.

2. Challenges of being an outsider

In this example of a coalition/university partnership, the coalition initiated the research partnership. As the university research team became involved, the partners held to another challenge of using PAR as an approach. Whyte writes, “In PAR, the researcher is constantly challenged by events and by ideas, information, and arguments posed by the project participants” (1991, p. 42). Thus, the different perspectives of the partners, both insiders and outsiders, could be seen as a strength that worked toward a “Continuous Mutual Learning Strategy” (1991, p. 42). However, with these strengths, there are accompanying challenges.

In order to understand how the partnership evolved, details about the characteristics of the research team are important. First, the research team commuted over an hour to attend meetings. Accordingly, it was clear that the research team members were outsiders, not only because they were not from the geographically defined community and did not use their health care services, but also because they were invited to be involved for their technical research expertise. Labonte (2005) has offered a typology of three types of outsider interactions: consultation, involvement, and participation. According to Labonte's definitions, the research team functioned most probably in a participation framework. While consultation seeks information without ongoing dialogue and involvement contains dialogue which is controlled by external organizations, a participation approach “involves negotiated relationships with citizens, who are treated as constituencies and take part in naming the problem or selecting the issue” (2005, p. 93). Coalition members drove the design of the needs assessment during every phase of the project.

The challenge of being an outsider, due to both geography and academic training, led to negotiations in several areas. They were: 1) localized knowledge generated for the community vs. generalizable knowledge; 2) subject recruitment; and 3) the scope and focus of the project.

Before approaching researchers, the coalition leaders had already decided that they wanted to collect information through focus groups and surveys, but had numerous drafts and opinions about what specifically to ask. Some questions had been selected or adapted from published research articles, and other questions were based on personal observations and experience. It was difficult for the researchers to reconcile all of the different approaches in the absence of a selected theory or framework. The ultimate goal of the needs assessment was to create locally specific knowledge of the health-care needs of older adults. This led to tension for the research team because of the different process required to generate “new” local knowledge rather than apply existing findings. To resolve the tension, the researchers conducted group-work sessions with coalition leaders to explicate the questions or topic areas of greatest importance. Following approval from the coalition, the research team then constructed drafts of methods and protocols for the coalition to critique and modify.

The outsider status of the research team was beneficial however, for the conduct of focus groups, by providing an opportunity for participants to discuss concerns without their opinions being linked with their identities. The research team had to rely on coalition members to recruit participants. The coalition provided services in that county, whereas the researchers did not have ties there. However, the research team provided guidance about confidentiality in focus groups and anonymity in survey distribution and collection. Members of the research team facilitated the focus groups and deleted identifying characteristics from the results shared with the coalition, so the team was able to offer assurances of confidentiality to focus group participants. This decreased the risks of the vulnerability of research participants and fostered a more open environment.

Despite the aforementioned challenges, the coalition believed that partnering with faculty from such a well-regarded research university would lend greater credence and importance to the needs assessment. For example, in designing the recruitment flyers, the coalition wanted the university's logo featured prominently, thus making it more likely potential participants would regard the needs assessment as a serious endeavor, and be more likely to participate and act upon the results. Members also seemed to benefit from being engaged with “outsiders” and were excited about partnering with external allies who would present their community's concerns and accomplishments to others around the country who were interested in the well-being of older adults (e.g. Gerontological Society of America conference) as well as those involved in community organizing efforts. Involving an outside group also lent a feeling of neutrality, while also demonstrating there was support and interest for the project beyond the county. This support and interest indicated the multiple audiences interested in the “continuous mutual learning” (Whyte, 1991, p.42).

The coalition's inclusive approach to all settings in which care was provided and the desire to obtain information from so many different stakeholder groups greatly expanded the scope of the project and led to challenges to the research team due to practical restraints of time and resources. The researchers wanted to satisfy the requests of the coalition but needed to set limits. Boundaries were identified through negotiating with coalition leadership and the larger membership to illuminate priorities (described more in the next section).

3. Challenge of inclusion

The coalition's emphasis on broad inclusion of settings and stakeholders created several challenges to fulfill PAR's perspective that the “consultant/facilitator acts less as a disciplinary expert and more as a coach in team building and in seeing to it that as much of the relevant expertise as possible from all over the organization is mobilized” (1991, p. 40). While many of Whyte's original case studies were applied to single organizations, the same challenge can be applied to working with a seventeen-member coalition. The number of organizations provided challenges of inclusion developed over the course of the project. In recognizing the resources within the community, the coalition members had tremendous networks of service providers that could help recruitment for focus groups. Also, the surveys could be distributed at a wide variety of agency and hospital sites.

However, while such opportunities for data collection which could be seen as a strength, the partnership faced challenges of inclusion. It was difficult to incorporate an assessment of each and every setting serving older adults, given the current hybrid nature of many long-term care options (e.g., adult foster care, home care, adult day care, nursing home care, assisted-living residences) and the many different ways to provide acute-care or primary-care services (e.g., house calls, office visits, hospitals, sub-acute rehabilitation care, Programs for All-Inclusive Care for the Elderly[PACE]), especially since project funding constraints limited the scope. In addition, the taxonomy or nomenclature of long-term care systems is not understood by the general public. In the design of the survey, some coalition members also wanted to avoid the use of more familiar terms such as “nursing home” in favor of less stigmatized terms such as “rehabilitation center”. The partners settled on restricting the needs assessment to those settings wherein a licensed nurse provided supervision to direct-care workers, and using nomenclature most familiar to the public.

In the data analysis phases, challenges of inclusion also emerged. The coalition envisioned creating a positive, helpful exchange of resources and assistance and did not want the results of the needs assessment to sound like “finger pointing” or presenting findings that reflected negatively on settings or providers. County agencies and providers were likewise fearful that results of the needs assessment might damage their public images. Consequently, while hospitals, nursing homes, home care and hospice agencies participated in the needs assessment, the coalition later required that the results could NOT be linked by setting. This was consistent with the coalition's goal to unify, standardize and share accountability for the quality of nursing care for the elderly. However, for the research team, it was counter-intuitive to collect information about different settings for the purpose of identifying needs and yet ultimately obscure differences that could identify and localize gaps in the service continuum or highlight the areas in greatest need for improvement. In the end, the partners agreed to publish general findings, rather than highlight specific types of services that needed more support in the community. While the needs assessment presented comprehensive data, it lacked specificity to accommodate concerns of service providers, and a desire not to alienate some.

4. Challenge of differing timelines

Since “continuous learning is more efficient than learning concentrated at the initial and final stages of the project” and “learning is enhanced when members of the organization under study have active ownership in the project” (Whyte, 1991, p. 42), the availability of coalition members and research team members was a consideration in the project. Timeline expectations for coalition members and university researchers had to be negotiated. Other scholars have noted the challenges of differing timelines for university/community organization partnerships (Eng, et al., 2005). This project's timeline was affected by the calendar of research assistants who were on semester schedules and had periods of availability and then periods during which course work and school projects took precedent. Also, the need to allow time for approval of the needs assessment by the University's Institutional Review Board (HUM00038965) meant that distribution of surveys had to wait until approval. Since a dozen different institutions took part in staff recruitment for focus groups and surveys, the process became even more complex. University involvement also led to systematic negotiation of ethical considerations (e.g., approval of design by the Institutional Review Board). So, while university involvement brought technical assistance and legitimacy, it also added challenges, and the timeline of the project was extended twice by the Battle Creek Community Foundation, which, understanding the delays, proved to be flexible.

5. Challenge of revolving members

Whyte writes that “when involved in a PAR process with many team members contributing to the enterprise, it is often far easier to escape the limitations of theoretically imposed logics that constrain observation and thought” (1991, p. 54). The benefit of being open to emerging ideas of non-researchers accompanies working with many team members. Whyte suggests that, “Practitioners often bring the pursuit of irrelevant or ill-conceived lines of inquiry to a rapid halt” (1991, p. 54) and help refine the research questions. However, in this needs assessment, the challenge was not in recruiting members to participate in setting and reaching goals, but rather on how to accomplish these goals when the members of agencies participating changed over time. While working with researchers to design and implement the needs assessment, the coalition was also trying to recruit new coalition members. This situation resulted in an ever-changing group of members at meetings in which decisions about the needs assessment were made. Also, changes in agency staffing, administration, or ownership, meant different staff members would attend meetings. Consequently, it became clear that persons with little knowledge of the origin and history of the coalition were offering feedback on the purpose and the design of the needs assessment.

To address this challenge, the research team decided to meet for approval only with the smaller core group of the founding members of the coalition, designated the “leadership team,” made up of those who had deeper understanding of the 5-year goals. This group met monthly, designing a mission, vision and steps to achieve goals in line with their interests.

Another facet of a leadership team is that individuals are designated to represent an organization publicly (Minieri & Getsos, 2007). In a model where power-sharing is valued, it is complicated to build an understanding of who is authorized to contribute ideas and make decisions. Erving Goffman's work on participant roles in speech is especially salient here. He argues that in some cases, some may “author” the ideas while others may be given the tasks to “animate” or talk on behalf of the group to various audiences (Goffman, 1981). He considers the author as “someone who has selected the sentiments that are being expressed and the words in which they are encoded” and the animator as the “talking machine” or mouthpiece for such sentiments (1981, p. 144). In coalition work, which by its very nature means there are many members, the articulation of the mission and goals of a group can be affected by individuals' personalities, professional agendas and even the ability of “animators” to articulate the intended message. In this case study, members of the “leadership team” may be considered the key “authors” of the words or perspectives of the group, while others may be given the job of explaining or “animating” the purposes of the group while recruiting participants for attending focus groups or completing surveys. Making sure the group's message remained consistent as the partnership recruited participants for the needs assessment was a challenge of revolving member involvement.

6. Challenge of communicating the results of the needs assessment

After the needs assessment was completed, communicating the findings to stakeholders was another important component of the project.

The needs assessment revealed four major needs of nursing staff caring for older adults: 1) need for communication, information, and coordination; 2) need for initial and ongoing education; 3) need for support and recognition of nursing care in the work setting; and 4) need for emotional and relational support. PENCE has created an action plan to address these needs by creating a speakers bureau and consultation service by nurses who received training specifically in the care of older adults, and planning and implementing a “bridge” program that supports new, direct-nursing-care providers (CNA, nurse aides) transitioning from training into the workforce. To recognize nursing care, PENCE is planning to implement an Excellence in Elder Nursing Care Program. For the coalition, this applied for both written and oral communication of the findings. During the preparation of the final report, the research team frequently consulted the coalition as to format and contents. The research team was charged with condensing a great deal of information into a 20-page report that was accessible to a diverse audience.

Whyte writes, “In participatory action research, this means that the researcher must be willing to relinquish unilateral control that the professional researcher has traditionally maintained over the research process” (1991, p. 241). The presentation of the needs assessment also provided occasion to use PAR values. As the written product was being finalized, the coalition planned on ways to disseminate it. The coalition planned a community forum luncheon, with a three-part presentation; 1) welcome address by the coalition facilitator, which included the history of the coalition; 2) presentation of findings by the research team; and 3) presentation of future initiatives by a member of the coalition leadership. The program was designed to begin and end with the voices of coalition members, rather than of the research team. Representatives from member agencies, county officials, local pastors and reporters attended.

The four original members of the leadership team, who had actively worked from the inception of the coalition, were introduced. Because each of them represented large health-care systems, these introductions sent a clear message to everyone in the audience that the major players in the county supported the mission and goals.

Eng and colleagues (2005) argue that, in community forums, it is important to highlight needs, as well as articulating strengths of a community. The findings reflected the elders and caregivers’ compassion and empathy for nursing staff, highlighted as a strength of the community. Also, the list of member agencies, printed on each brochure and report, demonstrated the social cohesion and motivation of the community (Mattesich & Monsey, 2001). The overall tone of the forum demonstrated a “vision of a better future made more possible by the determination of purposeful actions” (Homan, 1999, p. 178). Throughout the presentation, audience members could sense the motivation and clarity of next steps.

7. The challenge of sustainability

Whyte suggests that PAR is beneficial to both researchers and practitioners. For practitioners, he suggests that PAR “extends the researchers’ learning far beyond the termination of particular projects” (1991, p. 42). He also suggests that PAR projects contribute to the advancement of social theories as researchers are presented with new problems and ways of considering them. In the coalition, however, achieving this principle was daunting. This project was initiated by the coalition and in the press release announcing the needs assessment the coalition members included their next steps: training and support for county health-care workers. At that time, conducting further research was not a priority. Thus, the priorities set by the coalition did not sustain our participation in their subsequent activities. However, the experience of partnering with the research team, within a framework of PAR, built knowledge and networking capacities among coalition members. The coalition continued to strive to meet the health-care needs of older adults in their community by strengthening the knowledge and effectiveness of nursing staff.

Discussion

The challenges outlined above clearly and dramatically show that there are lessons to be learned from community coalition/university partnerships centered around aging concerns. Analyzing these difficulties through a lens of values of Participatory Action Research leads to a better understanding of the partnerships between coalitions of service providers and researchers. As coalition building for advocacy is now the predominant type of community organizing (Sites et al., 2007), it is important to understand the different ways communities are working with researchers to plan for the needs of their aging populations by providing support for the largest group of care providers—nursing staff. The members of the research team benefited greatly from being involved with such an effective and successful coalition. It was an honor to work with such a motivated coalition who sincerely wanted to obtain a comprehensive picture of the learning and support needs of nursing staff serving older adults in their county.

Implications for future coalition action

Beyond those already expressed, there were other formidable barriers to success. While the daunting issues of inclusion were successfully resolved in terms of decisions about the scope of service providers and recipients to survey, another aspect was not addressed. The coalition did not include direct-care workers such as personal care aides and certified nursing assistants (defined as “unlicensed nursing staff” by the coalition). Some community organizing efforts prioritize gathering the voices of those affected (Marti-Costa & Serrano-Garcia, 2001; Henderson, et al. 2002). Input from direct care workers in the design of the survey and focus group questions may have been a valuable contribution. However, one of the key challenges faced by nursing administrators in the county was the difficulty in arranging substitutions that enable workers to attend trainings (Blinded for Review, 2011), let alone leadership activities such as being a representative to a county-wide coalition. While participation in coalition activities might even be encouraged by supervisors, the logistical challenge of dealing with their workload remains.

Future partnerships might include a plan to develop leaders from different backgrounds, further capturing and acknowledging the variability of support and learning needs for unlicensed nursing staff. The relevance of diverse leadership to coalition/university partnerships can be thought about in two ways: first, much of the communication and work was done between one coalition member and the team of researchers. If more leaders had been able to work with the research team, the burden would have been more equally distributed. Second, by having a senior licensed nurse in a leadership position without the participation of direct-care workers, the survey and focus group questions may have unintentionally overlooked other key concerns of frontline workers.

Another future direction for these types of community/university partnerships might be to identify allies not directly related to providing health care for the elderly. As the coalition reported on here is geographically specific, a map of service providers might have been useful, especially for the research team members from a university outside the county. In much of the community organizing literature, community groups make maps of resources (Henderson et al., 2002; Goldsmith, 2002; Murphy & Cunningham, 2003). Such mapping techniques are often taught at community organizing trainings (Bobo & Kendall, 2011). Sites et al. (2007), suggest that future community mobilizing efforts might include churches, foundations and universities. Interestingly, PENCE had not directly engaged churches, yet religious entities have been heavily involved in activities to assist elderly parishioners such as parish nursing services. In fact, a map of services and a map of faith-based organizations in the community might be useful to identify areas of overlap and areas where there are service gaps. A needs assessment which does not involve faith-based organizations may not discover activities already occurring within the community and may overlook potential allies who might join the coalition.

Because the interdisciplinary research team included a clinical nursing professor and social work doctoral student, the partnership in the design, implementation and analysis of the needs assessment provided an important feedback loop to curriculum planning for future practitioners serving older adults in both fields. While community organizing literature captures efforts of youth and marginalized groups, social-work students, as well as others interested in community organizing techniques, (e.g., urban planners) can benefit from understanding this case study describing how a community coalition functions, as well a way to involve universities, particularly for issues affecting older adults. This project was also a lesson in how to bridge academic disciplines, especially evident when the social work member facilitated the focus groups of nurses. Language needs to bridge sectors, and research needs to be tailored for health-care consumers and providers.

The nursing profession can benefit in many ways from the manner in which this unique coalition envisioned nursing practice targeting older adults. First, clear inclusion of direct-care workers as nursing staff bridges gaps between levels of nursing practice, and potentially elevates the overall quality of nursing services for older adults by improving communication, collaboration and career development among staff of various entry levels. Second, community-wide recognition of the value of nursing services in and of itself increases the amount of support felt for those engaged in a difficult job in often under-resourced settings. Third, joining forces and sharing resources can help alleviate disparities and close gaps in the service continuum that could undo even the best of care received in one setting. Last, by giving voice to consumers, service providers, and administrators, faulty assumptions driving community education programs or resource allocation can be corrected. The nursing profession can benefit from a deeper understanding of the needs of both licensed and unlicensed nursing staff for knowledge development specific to the care of older adults, and gain a better understanding of the ways nursing professionals can work together with other community members to address community needs.

Conclusion

In this case study, dynamic leaders undertook the task of involving researchers in community organizing efforts. With Participatory Action Research as a theoretical and methodological framework, the partners designed and implemented a needs assessment to better understand the support and education needs of nurses serving older adults in their community.

This case study highlights the challenges of coalition/university partnerships in assessing nursing service needs related to older adults in a geographically specific context. But the partnership also helped the coalition reach the next stage of their goals: to incorporate findings from the needs assessment into the design of trainings to help professionals address the varied needs of older adults.

The partnership also resulted in knowledge and experience for the interdisciplinary research team highlighting the interdependent and reciprocal nature of work in the community. Understanding coalitions will continue to be important, as many funders require coalition work as part of funding stipulations (Wandersman et al., 2005). In the future, coalition/university partnerships can work together to address the aging concerns of communities.

Table 1.

Application of PAR Principles to Challenges in the Case Study

Challenges	PAR Principle	Implication for Partnership	Strategy to Address Implications
Defining the community to be assessed	Research begins with the community's problems.	COMMUNITY DEFINED AS RECEIVING SERVICES ONLY WITHIN THE COUNTY AND BY RESIDENTS OF THE COUNTY	Inclusion criteria: requested zip code of elder/family residences and zip codes of where services are delivered.
Researchers as outsiders due to GEOGRAPHY & ACADEMIC TRAINING	Continuous Mutual Learning Strategy	Localized vs. generalizable knowledge Empowerment of community: Outsider researchers hired for skill set, university “brand name,” and objectivity. Status of the research university conveyed the importance of the work of the coalition.	Procedures to ensure confidentiality or anonymity of respondents (e.g., focus groups led by researchers; no identifiers on surveys; surveys returned by mail to research team). University logo on materials.
Challenge of inclusion	Mobilization of expertise: Researcher acts as coach in team building	Researchers required to frame results without identifying weak sectors. Broad scope desired which increased variety of settings in terms of size, staffing, purpose, etc.	Negotiation to limit scope & focus of needs assessment. Inclusion criteria reduced to settings where RNs/LPNs supervised CNAs. Findings aggregated across settings.
Competing Timelines & values	Learning enhanced when those under study take active part throughout the process.	VARIETY OF IRBS ACROSS SETTINGS; MANY COALITION MEMBERS NOT AWARE OF PROCEDURES FOR PROTECTION OF HUMAN SUBJECTS.	Anticipate extensive time for IRB approvals, education of coalition members, and monitoring of data collection according to IRB criteria.
Challenge of Revolving members	Research not constrained by theoretical logics only: Practitioners help define research questions	Group membership always in flux. Meetings with coalition meant different people attending & new agencies or settings to include. Difficult to narrow scope of surveys & focus groups.	Core leadership group from coalition made decisions throughout the process.
Communicating the results	Researcher without unilateral control over the research process.	Coalition planned public presentation.	Coalition presented next steps as part of the dissemination of results.
Challenge of sustainability	Research interest beyond the project	Research team involved for needs assessment only. Coalition carries forward with increased capacity for addressing community needs.	Coalition utilized findings to plan next steps.