Rural Landscapes of Community Health: The Community Health Assessment Sustainable Education (CHASE) Model in Action (Global Perspectives on Health Geography) 3031432002, 9783031432002

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Global Perspectives on Health Geography

Jean Ross Samuel Mann Keith Whiddon  Editors

Rural Landscapes of Community Health The Community Health Assessment Sustainable Education (CHASE) Model in Action

Global Perspectives on Health Geography Series Editor Valorie Crooks Department of Geography Simon Fraser University Burnaby, BC, Canada

Global Perspectives on Health Geography showcases cutting-edge health geography research that addresses pressing, contemporary aspects of the health-place interface. The bi-directional influence between health and place has been acknowledged for centuries, and understanding traditional and contemporary aspects of this connection is at the core of the discipline of health geography. Health geographers, for example, have: shown the complex ways in which places influence and directly impact our health; documented how and why we seek specific spaces to improve our wellbeing; and revealed how policies and practices across multiple scales affect health care delivery and receipt. The series publishes a comprehensive portfolio of monographs and edited volumes that document the latest research in this important discipline. Proposals are accepted across a broad and ever-developing swath of topics as diverse as the discipline of health geography itself, including transnational health mobilities, experiential accounts of health and wellbeing, global-local health policies and practices, mHealth, environmental health (in)equity, theoretical approaches, and emerging spatial technologies as they relate to health and health services. Volumes in this series draw forth new methods, ways of thinking, and approaches to examining spatial and place-based aspects of health and health care across scales. They also weave together connections between health geography and other health and social science disciplines, and in doing so highlight the importance of spatial thinking. Dr. Valorie Crooks (Simon Fraser University, [email protected]) is the Series Editor of Global Perspectives on Health Geography. An author/editor questionnaire and book proposal form can be obtained from Publishing Editor Zachary Romano ([email protected]).

Jean Ross • Samuel Mann • Keith Whiddon Editors

Rural Landscapes of Community Health The Community Health Assessment Sustainable Education (CHASE) Model in Action

Editors Jean Ross Otago Polytechnic Dunedin, New Zealand

Samuel Mann Otago Polytechnic Dunedin, New Zealand

Keith Whiddon Bishop’s Castle, Shropshire, UK, Community Partnership Shropshire, UK

ISSN 2522-8005     ISSN 2522-8013 (electronic) Global Perspectives on Health Geography ISBN 978-3-031-43200-2    ISBN 978-3-031-43201-9 (eBook) https://doi.org/10.1007/978-3-031-43201-9 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Paper in this product is recyclable.

Fig. 1  Global map. Produced by Suzanne Thornton with permission from Editors. Globe images: Roy Wylam/Alamy Stock Vector

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This book is dedicated to the graduate nurses for their contribution to rural communities globally.

Preface

Rural Landscapes of Community Health: The CHASE Model in Action is at the intersection of nursing, education, community development, research and rural. In its broadest level, this book will engage with numerous disciplines who participate with community development. The rural is a key lens discussed throughout this book as we highlight the challenges of enhancing the health of rural spaces. The purpose of the book is to engage and offer discussion and critical debate on the praxis of community health and nursing education. We emphasise the importance of rural communities and the people who reside, visit or engage with this space. The rural population internationally accounts for almost half of the total global population, and they are confronted with reduced access to healthcare which contributes to increased health disparities. We acknowledge here the differences between rural communities locally, nationally and internationally. However, rurality highlights the numerous commonalities that unite these dynamic and significant locations. In this book, we consider rural communities and community health, and the integrated concerns for the health of indigenous, minority and vulnerable populations in rural contexts. The goal is to bring about positive social change, enhance healthcare and improve social determinants of health through engaging in the practice of community development. Community development is the means to improve the health of community residents. Together, community stakeholders and multidisciplinary teams partner to fulfil this goal. While nurses are positioned to navigate the holistic landscapes of health that integrate the socio-political, cultural, sustainable, economic and environmental aspects related to the uniqueness of rural communities, they require models to guide their practice. The Community Health Assessment Sustainable Education (CHASE) model is one such model that guides practice and can be engaged with by all health disciplines and a variety of wider fields such as engineers, planners, geographers and environmentalists as they focus on sustainable health. So, while the book focusses on nursing, it is our intention that it will be useful for other fields. This model is a starting point that does not set out to impose a single understanding – it is adapted in practice to rural communities’ requirements. This book is distinctive; it engages with social geography, rural, research, community, design, ix

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Preface

pedagogy, decolonisation, impact and future rural landscapes. Nurse learners are exemplified as a case in point, capturing how tertiary health providers have engaged in the CHASE model as a learning and teaching pedagogy. This way of practice examines spatial and place-based aspects of health and weaves together connections between disciplines and communities, highlighting the importance of spatial thinking. Health and place are highlighted within this rural space demonstrating how places influence on health and wellbeing. How to engage and read this book? This book sits at the nexus of rural community health, design, education and evaluation. There are seven chapters in this book; they each stand alone with reference to these distinctive elements and have been connected pulling through themes and directing the reader to ongoing connections and referring to previous chapters. The first four chapters position the book with a rural focus on the challenges of providing health services to people who live, work or visit rural communities while positioning the rural as a central concept of this book. Chapter 1 contributes to this discussion of the importance of understanding and conceptualising the rural as it relates to health care provision while providing the bases in which Chap. 2 is positioned. This second chapter introduces the original CHASE model and presents its many iterations providing the rationale for these adaptations as nurse learners’ have engaged with the model to undertake community development projects, as a component of the Bachelor of Nursing programme at Otago Polytechnic, Dunedin, New Zealand, with the aim to reduce rural health disparities. Chapter 3 extends the CHASE model into the design thinking world, as nurse learners engage with problem-­solving processes and employ systems and design thinking principles, illustrated in all six phases of the CHASE model. Design thinking is a vehicle for the creation of health promotion messages and resources to promote change and reduce health disparities. Chapter 4 encounters a new pedagogical space while engaging with the CHASE model as pedagogy and nurse education. The last three chapters take an analytical approach – an open-ended normative style. Chapter 5 describes through storytelling how the CHASE model can be used as a vehicle for de-colonised rural health by and for Indigenous people. Chapter 6 takes an evaluative approach. It explores health disparities and (in)equity related to rural health, which are analysed and evaluated. Chapter 7 reflects on the previous six chapters’ contributions linked to rural community development while engaging with CHASE.  An imaginary Bishop’s Castle, Shropshire, England, UK CHASE 2033 positions the future through an education design fiction approach, positioning five narratives to use the hypothetical futures to illustrate and inform the ongoing development of CHASE. The CHASE model ‘in action’ is illustrative in the case studies presented throughout this book. Exemplified in each of the five case studies showcase rural communities, cultural topography, demography and specific rural community assessments. These lead to the identification of population health needs and health inequities facing Indigenous peoples, minority groups or environmental and community sustainability. The manner in which nurse learners engage with design thinking, the creation of resources and the impact on health disparities reveal

Preface

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community and the learners’ reflections that conclude each case study. To assist the reader with this international landscape, Fig. 1 displays each of the case study locations across the globe. Dunedin, New Zealand  Jean Ross Dunedin, New Zealand  Samuel Mann  Shropshire, UK  Keith Whiddon June 2023

Acknowledgements

Rural Landscapes of Community Health: The CHASE Model in Action would not have been written without the commitment of many people over several years. The CHASE approach was developed as a collaboration between Josie Crawley, Laurie Mahoney and Jean Ross. From us seeing the learners struggling with the complexity of community development, to our plotting out stages on a whiteboard and then stepping back, CHASE emerged and so began a journey of collaboration and discovery. We are indebted to the registered nurses who have been fellow travellers on this journey. They have supported the development and use of CHASE to assist in their practice as they facilitate learning. Thank you Raelene Thompson, Cynthia Mullens, Anna Askerud, Amy Simons and Rachel Sayers. Thank you to the wider Te Kura Tapuhi School of Nursing at Te Pūkenga, Otago Polytechnic, Dunedin, which supported this initiative as we have progressed community development within the Bachelor of Nursing programme. The CHASE model has been guided and developed under the direction of Mereana Rapata-Hanning (Ngati Kurī, Te Aupouri, Ngāpuhi) and the Office of Kaitohutohu for their guidance in the cultural and ethical aspects of CHASE. We are also grateful to Scott Klenner (Kāi Tahu), Ron Bull (Waitaha, Kati Mamoe, Kai Tahu) and the whole of the Office of Kaitohutohu with their guidance in the production of this book – any remaining errors are ours. Ngā mihi nui ki a koutou. To the nurse learners who have contributed to the success of these community development projects as part of your Bachelor of Nursing programme. Thank you also for your generous engagement in providing reflective evidence on your professional practice as graduate nurses and how engaging with the community development projects has influenced your practice. We are indebted to the Research and Postgraduate Office at Otago Polytechnic, Te Pūkenga for your support of research funding that has enabled the deep dives and evidence of impact in the case studies described in this book. Similarly, we are grateful for the support and attention of the Otago Polytechnic Ethics Committee – thank you for keeping us all safe.

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Acknowledgements

This book came from an opportunistic meeting with Zachary Romano from Springer Publishers at the Royal Geographical Society Conference in 2019. The importance of such conversations in progressing academic understanding and practice cannot be understated. We are thankful for that impromptu meeting, for supporting and guiding us, and what has eventuated. Thank you to Springer Publishers for supporting this initiative and believing in us. Thank you Suzanne Thornton for your expertise in design imagery and your patience as these images have been refined on numerous occasions and for compiling the book as a whole. And thank you to Courtney Taylor and Wendy Aiken for your assistance with the research. We are overwhelmed by the support of the highly skilled contributors who agreed to participate in this publication. Your expertise and insights have made this publication possible, and we will continue to see improvements in community health and learning into the future because of your mahi (work). All contributors have taken time from their already busy lives to contribute to a chapter. This book has been a collaborative experience and is true to its philosophy about community development. We are grateful for the peer reviewers who have provided their insightful comments that have made the final draft of this book a success. We are grateful to our work colleagues who have supported this book in immeasurable ways; their feedback and insightful comments have assisted in the quality of this book. There are two communities at the heart of this book – the rural communities and the nurse learners. The rural communities across Aotearoa New Zealand, the Pacific and beyond are the key to sustainable thriving futures. The nurse learners are beginning their careers as insightful, caring, knowledgeable practitioners who are making a difference. You are all community development practitioners, no matter where you practise. This book couldn’t have been made without you, and we present it to you with aroha. With gratitude from the Editors, June 2023 Further recognition goes to co-editors Samuel Mann (my academic colleague and mentor) and Keith Whiddon (my inspiration and ‘big brother’) for believing in this vision. With respect Jean.

Contents

1

 Rural Community Landscapes of Health��������������������������������������������������  1 Jesse Whitehead, Jean Ross, Cynthia Mullens, and Samuel Mann

2

Progressive Rural Community Collaboration: A Vehicle for Rural Encounters – The CHASE Model in Action ��������������������������  21 Jean Ross, Laurie Mahoney, and Josie Crawley

3

Creative Designs: Health Promotion Resources Aligned with Rural Community Health ����������������������������������������������������������������  67 Laurie Mahoney, Phil Osborne, and Jean Ross

4

Rural Community Health – Encountering a New Pedagogical Space������������������������������������������������������������������������������������  113 Caroline McCaw, Claire Goode, and Cynthia Mullens

5

 CHASE as a Vehicle for Decolonised Rural Health������������������������������  149 Mawera Karetai and Samuel Mann

6

 Impact Evaluation on Rural Community Health ��������������������������������  181 Samuel Mann and Jean Ross

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Future Landscapes of Collaborative Rural Community Development ��������������������������������������������������������������������������������������������  211 Samuel Mann, Keith Whiddon, and Jean Ross

Index������������������������������������������������������������������������������������������������������������������  235

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Contributors

Josie  Crawley Associate Professor  Otago Polytechnic | Te Pūkenga, Dunedin, New Zealand Te Kura Tapuhi | School of Nursing, Dunedin, New Zealand Claire Goode  Otago Polytechnic | Te Pūkenga, Dunedin, New Zealand Learning and Teaching Development & Te Kura Tapuhi | School of Nursing, Dunedin, New Zealand Mawera  Karetai  University of Otago | Te Whare Wānanga o Otāgo, Dunedin, New Zealand Te Whare Wananga o Awanuiarangi & Management | Te Mātauranga Whakahaere, Dunedin, New Zealand Caro McCaw Professor  Otago Polytechnic | Te Pūkenga, Dunedin, New Zealand Te Maru Pumanawa | College of Creative Practice and Enterprise, Dunedin, New Zealand Laurie  Mahoney  Te Kura Tapuhi | School of Nursing, Otago Polytechnic | Te Pūkenga, Dunedin, New Zealand Samuel Mann Professor  Otago Polytechnic | Te Pūkenga, Dunedin, New Zealand College of Work Based Learning, Dunedin, New Zealand Cynthia Mullens  Otago Polytechnic | Te Pūkenga, Dunedin, New Zealand Te Kura Tapuhi | School of Nursing, Dunedin, New Zealand Phil Osborne  Otago Polytechnic | Te Pūkenga, Dunedin, New Zealand Te Maru Pumanawa | College of Creative Practice and Enterprise, Dunedin, New Zealand

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Contributors

Jean Ross Professor  Otago Polytechnic | Te Pūkenga, Dunedin, New Zealand Te Kura Tapuhi | School of Nursing, Dunedin, New Zealand Keith Whiddon  Bishop’s Castle, Community Partnership, Shropshire, UK Jesse  Whitehead  Te Ngira: Institute for Population Research, University of Waikato, Hamilton, New Zealand

About the Editors

Jean Ross’s background in nursing, rural health, sustainability, community development and geography is originally from Wales, UK, and has lived in Aotearoa New Zealand since 1991. The cumulation of her work associated with rural nursing includes activism, research and education. Jean’s initial work with rural health commenced in Wales and continued in 1994 with the establishment of the first Centre for Rural Health in New Zealand and in 1999 the National Centre for Rural Health of which she was co-director. Jean is also an advocate for sustainable rural community development and nurse education. Her book Rural Nursing: Aspects of Practice dedicates a space for rural research to be presented, while being the first rural textbook published in New Zealand. Stories of Nursing in Rural Aotearoa: A Landscape of Care promotes rural health and in particular rural nursing practice. Equally, Growing Rural Health Tipu Haere Tuawhenua Hauora: 30 Years of Advocacy and Support in Aotearoa has captured rural activism amongst health professionals and the support of rural communities. Samuel  Mann’s background in geography, sustainability, computing and botany has enabled him to dedicate his career to developing frameworks to allow professionals to deliver on this promise of socioecological good which encompasses community development. His book The Green Graduate: Educating Every Student as a Sustainable Practitioner outlines a framework for integrating sustainability into every course of study. This framework was successfully adopted by all polytechnic computing programmes in New Zealand, following its transformation of education at Otago Polytechnic, Dunedin. Sam has been working with indigenous groups to better understand the potential and urgency of de-colonising computing, and how we can ensure that computing serves the needs of all members of society. Sam’s book Sustainable Lens: A Visual Guide explores the visual narrative of sustainability.

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About the Editors

Keith Whiddon’s background in geography was formerly a teacher and Educational Inspector/Adviser and a passionate advocate for how new technologies may transform learning and teaching. He moved to Shropshire to become a full-time musician and community activist and founded the Bishop’s Castle Community Partnership; chaired the town’s Michaelmas Fair; and is a school governor. Keith has instigated many innovative community projects, including the development of an online platform designed to improve community mental health and wellbeing. He is an enthusiastic explorer, capturing wild and forgotten places on camera, both over- and underground.

List of Figures

Fig. 1

Global map. Produced by Suzanne Thornton with permission from Editors. Globe images: Roy Wylam/Alamy Stock Vector��������   v

Fig. 1.1 Community Development Research Framework. (Adapted from original Scope: Contemporary Research Topics: Health and Wellbeing 5, Collaboration (2020, p. 61) by Ross, Mann and Whiddon with permission from Jean Ross)��������������������������������������������������������������������������������  14 Fig. 2.1 CHASE Model 2017. (Adapted from Scope: Contemporary Research Topics: Learning and Teaching 4 (2017, p. 12) by Ross, Crawley and Mahoney with permission from Samuel Mann)��������������������������������������������������������������������������  29 Fig. 2.2 CHASE model 2018. (Produced by Ross and Mahoney with permission from authors)����������������������������������������������������������  35 Fig. 2.3 CHASE Model 2019. (Produced by Ross and Mahoney with permission from Authors) ��������������������������������������������������������  37 Fig. 2.4 CHASE model 2020. (Produced by Ross and Mahoney with permission from authors)����������������������������������������������������������  37 Fig. 2.5 CHASE model 2021. (Produced by Ross and Mahoney with permission from authors)����������������������������������������������������������  39 Fig. 2.6 CHASE model 2022. (Produced by Ross and Mann with permission from authors)����������������������������������������������������������  40 Fig. 2.7 CHASE model 2023. (Produced by Ross with permission from authors)������������������������������������������������������������������������������������  41 Fig. 2.8 Map of New Zealand highlighting Heratini/Geraldine. (Produced by Suzanne Thornton with permission from authors)������������������������������������������������������������������������������������  42 Fig. 2.9 CHASE model 2017. (Adapted from original Scope: Contemporary Research Topics: Learning and Teaching 4 (2017, p. 12) by Ross, Crawley, and Mahoney with permission from Samuel Mann)��������������������������������������������������������������������������  43 xxi

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List of Figures

Fig. 2.10 Dairy Cows in the Distance. (Produced by Mahoney with permission from Authors) ��������������������������������������������������������  44 Fig. 2.11 Mountain range. (Produced by London with permission from London Photography)��������������������������������������������������������������  45 Fig. 2.12 Geraldine Community Gardens. (Produced by Ross with permission from Authors) ��������������������������������������������������������  46 Fig. 2.13 Health promotion resource – poster in English. (Reproduced from Community based health services for older people living in the Moeraki and Hampden areas by Armon et al. (2018) with permission from Authors) ��������������������������������������������������������  49 Fig. 2.14 Health promotion resource – poster in Tagalog. (Reproduced from Community based health services for older people living in the Moeraki and Hampden areas by Armon et al. (2018) with permission from Authors) ��������������������������������������������������������  49 Fig. 2.15 CHASE model 2018. (Produced by Ross and Mahoney with permission from authors)����������������������������������������������������������  51 Fig. 2.16 Map of New Zealand highlighting Moeraki. (Produced by Suzanne Thornton with permission from authors)����������������������  53 Fig. 2.17 CHASE model 2018. (Produced by Ross and Mahoney with permission from authors)����������������������������������������������������������  53 Fig. 2.18 Moeraki Boulders. (Produced by Ross with permission from Authors)������������������������������������������������������������������������������������  55 Fig. 2.19 Pounamu. (Produced by Ross with permission from Baumgartner Family) ��������������������������������������������������������������  55 Fig. 2.20 Moeraki Village. (Produced by Laurie Mahoney with permission from Authors) ��������������������������������������������������������  56 Fig. 2.21 Health promotion resource – invitation poster to community event. (Reproduced from Community-based health services for older people living in the Moeraki and Hampden areas by Armon et al. (2018) with permission from authors)��������������������  59 Fig. 2.22 CHASE model 2019. (Produced by Ross and Mahoney with permission from authors)����������������������������������������������������������  61 Fig. 3.1 Five steps of design thinking process. (Produced by Suzanne Thornton with permission from authors)������������������������������������������  71 Fig. 3.2 Double diamond thinking. (Produced by Suzanne Thornton with permission from authors after British Design Council (Design Council, n.d.))����������������������������������������������������������������������  71 Fig. 3.3 Design Thinking & Community Development the CHASE model in action. (Produced by Suzanne Thornton with permission from authors)����������������������������������������������������������  72 Fig. 3.4 Creative designs. (Produced by Suzanne Thornton with permission from authors)����������������������������������������������������������  77 Fig. 3.5 Map Tāhuna/Queenstown. (Produced by Suzanne Thornton with permission from authors)����������������������������������������������������������  78

List of Figures

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Fig. 3.6 Queenstown Lake. (Produced by Wilson with permission from Sarah Wilson) ��������������������������������������������������������������������������  79 Fig. 3.7 Health promotion resource – submission. (Produced by Suzanne Thornton with permission from authors)����������������������  80 Fig. 3.8 Map Rakiura/Stewart Island. (Produced by Suzanne Thornton with permission from authors)����������������������������������������������������������  81 Fig. 3.9 Rakiura Harbour. (Produced by Ross with permission from Jean Ross) ����������������������������������������������������������������������������������������  81 Fig. 3.10 Health promotion resource – Poster/Pamphlet. (Produced by Philips et al. (2021) with permission from Authors)��������������������  82 Fig. 3.11 Map Motupōhue/Bluff. (Produced by Suzanne Thornton with permission from authors)����������������������������������������������������������  82 Fig. 3.12 Shacklock oven. (Source: CC3 Clark Mills with permission from authors)������������������������������������������������������������������������������������  83 Fig. 3.13 Health promotion resource – fridge magnet. (Produced by Hesford et al. (2019) with permission from authors)������������������  83 Fig. 3.14 Map Warrington. (Produced by Suzanne Thornton with permission from authors)����������������������������������������������������������  84 Fig. 3.15 Warrington water tank. (Produced by Ross with permission from Jean Ross)��������������������������������������������������������������������������������  85 Fig. 3.16 Health promotion resource – fridge magnet. (Produced by Kilkelly et al. (2018) with permission from authors)������������������  85 Fig. 3.17 Health promotion resource – pamphlet. (Produced by Kilkelly et al. (2018) with permission from authors)������������������  85 Fig. 3.18 Map Tarras. (Produced by Suzanne Thornton with permission from authors)������������������������������������������������������������������������������������  86 Fig. 3.19 Tarras Plunket Rooms. (Produced by Ross with permission from Jean Ross)��������������������������������������������������������������������������������  86 Fig. 3.20 Health promotion resource – social media. (Produced by Wennekes et al. (2018) with permission from authors) ��������������  87 Fig. 3.21 Map Westport. (Produced by Suzanne Thornton with permission from authors)������������������������������������������������������������������  88 Fig. 3.22 West Coast Beach. (Produced by London with permission from London Photography)��������������������������������������������������������������  88 Fig. 3.23 Health promotion resource – safety vest. (Produced by Spence et al. (2020) with permission from authors)��������������������  89 Fig. 3.24 Map Milton. (Produced by Suzanne Thornton with permission from authors)������������������������������������������������������������������������������������  89 Fig. 3.25 Milton Primary School. (Produced by Mann with permission from Samuel Mann) ������������������������������������������������������������������������  89 Fig. 3.26 Health promotion resource – anxiety reducing. (Produced by Ward et al. (2018) with permission from authors) ����������������������  90 Fig. 3.27 Map Waitati. (Produced by Suzanne Thornton with permission from authors)������������������������������������������������������������������������������������  91

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List of Figures

Fig. 3.28 Waitati Beach. (Produced by Ross with permission from Jean Ross)��������������������������������������������������������������������������������  91 Fig. 3.29 Health promotion resource – book. (Produced by Suzanne Thornton with permission from authors)������������������������������������������  92 Fig. 3.30 Map Waikouaiti. (Produced by Suzanne Thornton with permission from authors)����������������������������������������������������������  92 Fig. 3.31 Waikouaiti main road. (Produced by Ross with permission from Jean Ross)��������������������������������������������������������������������������������  93 Fig. 3.32 Health promotion resource – fridge magnet. (Produced by Gilbert et al. (2018) with permission from authors)��������������������  94 Fig. 3.33 Map of New Zealand highlighting Maruawai/Gore. (Produced by Suzanne Thornton with permission from authors)����������������������  95 Fig. 3.34 CHASE model 2019. (Produced by Ross and Mahoney with permission from authors)����������������������������������������������������������  96 Fig. 3.35 State Highway 1. (Produced by Mann with permission from Samuel Mann)��������������������������������������������������������������������������  97 Fig. 3.36 Maruawai/Gore farmland. (Produced by Mann with permission from Samuel Mann) ������������������������������������������������������������������������  98 Fig. 3.37 Health promotion resource – drink holder. (Produced by Ferris et al. (2019a, b) with permission from author)������������������  102 Fig. 3.38 Health promotion resource – keychain. (Produced by Ferris et al. (2019a, b) with permission from author)������������������  103 Fig. 3.39 CHASE model 2020. (Produced by Ross and Mahoney with permission from authors)����������������������������������������������������������  106 Fig. 4.1 Map of Vanuatu, South Pacific highlighting Paama. (Produced by Suzanne Thornton with permission from the Author) ����������������  120 Fig. 4.2 CHASE 2020 Model. (Produced by Ross and Mahoney with permission from the Authors) ��������������������������������������������������  121 Fig. 4.3 Surgical and Maternity Ward. (Produced by Cynthia Mullens with permission from the Author)����������������������������������������������������  126 Fig. 4.4 Health Promotion Resource – Poster. (Produced by Benseman et al. (2021) with permission from the Authors)��������  129 Fig. 4.5 Health Promotion Resource – Poster. (Produced by Benseman et al. (2021) with permission from the Authors)��������  130 Fig. 4.6 Health Promotion Resource – Poster. (Produced by Benseman et al. (2021) with permission from the Authors)��������  131 Fig. 4.7 CHASE Model 2021. (Produced by Ross and Mahoney with permission from the Authors) ��������������������������������������������������  134 Fig. 5.1 Map of New Zealand highlighting Whakatāne ��������������������������������  163 Fig. 5.2 CHASE Model 2022. (Produced by Ross and Mann with permission from the Authors) ��������������������������������������������������  164 Fig. 5.3 Waimana River. (Produced by Dennis Turner with permission from Authors)������������������������������������������������������������������������������������  165

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Fig. 5.4 Rata Te Urewera. (Produced by Dennis Turner with permission from Authors)������������������������������������������������������������������������������������  166 Fig. 5.5 Health promotion resource – Banner Pen. (Reproduced from Sustainable community development through evidence-­based health promotion focusing on the Whakatāne community by Sullivan et al. (2022) with permission from the Authors)��������������������������������������������������������������������������������������������  170 Fig. 5.6 Health promotion resource – Information Card. (Reproduced from Sustainable community development through evidence-based health promotion focusing on the Whakatāne community by Sullivan et al. (2022) with permission from the Authors)������������������������������������������������������������������������������  170 Fig. 5.7 Health promotion resource – Information Card. (Reproduced from Sustainable community development through evidence-based health promotion focusing on the Whakatāne community by Sullivan et al. (2022) with permission from the Authors)������������������������������������������������������������������������������  171 Fig. 5.8 Health promotion resource – Fridge Magnet. (Reproduced from Sustainable community development through evidence-based health promotion focusing on the Whakatāne community by Sullivan et al. (2022) with permission from the Authors)������������������������������������������������������������������������������  172 Fig. 5.9 CHASE Model 2023. (Produced by Ross with permission from the Authors)������������������������������������������������������������������������������  174 Fig. 6.1 Mapped to phases of CHASE. (Produced by Suzanne Thornton with permission from the Authors) ��������������������������������������������������  185 Fig. 6.2 Impact evaluation. (Produced by the Authors)����������������������������������  197 Fig. 7.1 Map of United Kingdom highlighting Bishop’s Castle. (Produced by Suzanne Thornton with permission from Authors)��������������������������������������������������������������������������������������������  213 Fig. 7.2 Artist’s impression of the Bishop’s Castle circa 15 Century. (Illustrated by Drusilla Cole with permission)����������������������������������  214 Fig. 7.3 The Old Bull Inn dating from 1533. (Produced by Whiddon with permission from Authors) ��������������������������������������������������������  215 Fig. 7.4 Bishop’s Castle’s Response to the CHASE Model Study – Setting the Strategic Direction. (Produced by Whiddon with permission from the Authors)������������������������������������������������������������������������������  216 Fig. 7.5 The ‘March of the Elephants Artworks Trail’ Bishop’s Castle. (Produced by Whiddon with permission from Authors)������������������  218 Fig. 7.6 Bishop’s Castle Michaelmas fair. (Produced by Whiddon with permission from Authors) ��������������������������������������������������������  219 Fig. 7.7 Vegetable Box. (Produced by Daphne Page with permission from Authors)������������������������������������������������������������������������������������  221

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Fig. 7.8 The BCIRCLR Platform – In Crisis Urgent Help. (After BCIRCLR with permission from Authors)����������������������������  223 Fig. 7.9 Health promotion resource – poster mental health support. (Produced by Restieaux et al. (2020) with permission from the Authors)������������������������������������������������������������������������������  224 Fig. 7.10 Health promotion resource – community moodle platform. (Produced by Krueger et al. [2021] with permission from the Authors)������������������������������������������������������������������������������  224 Fig. 7.11 Bishop’s Castle Town. (Produced by Whiddon with permission from Authors)������������������������������������������������������������������������������������  227 Fig. 7.12 Health promotion resource – community-led plan. (Produced by Miller, et al. [2022] with permission from the Authors)��������������  230 Fig. 7.13 CHASE 2033. (Produced by Ross, Mann and Whiddon with permission from the Authors) ��������������������������������������������������  232

List of Tables

Table 2.1 Community Profile and Assessment Criteria. (Produced by Authors)����������������������������������������������������������������������  31 Table 2.2 Presentation plan������������������������������������������������������������������������������  32

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Chapter 1

Rural Community Landscapes of Health Jesse Whitehead, Jean Ross, Cynthia Mullens, and Samuel Mann

Abstract  The rural population accounts for almost half the total global population. It is in these rural communities people are confronted with numerous barriers and reduced access to health care which impacts on their health as defined by the social determinants of health. We acknowledge and discuss the opportunities and challenges for community health and how they relate to rurality, health geography, and place-based contexts. This includes a discussion of the importance of conceptualising and defining ‘rural’, considering community socio-cultural, demography, and unique rural encounters affecting vulnerable, minority, and Indigenous populations, situated in geographical rural landscapes including islands. We advocate the Community Health Assessment Sustainable Education model can identify and improve the health of diverse rural populations and communities. Keywords  Rural · Global · Classification · Health · Disparities · Populations

J. Whitehead (*) Te Ngira: Institute for Population Research, University of Waikato, Hamilton, New Zealand e-mail: [email protected] J. Ross · C. Mullens Te Kura Tapuhi | School of Nursing, Otago Polytechnic | Te Pūkenga, Dunedin, New Zealand e-mail: [email protected]; [email protected] S. Mann Te Kura Tapuhi | School of Nursing, Otago Polytechnic | Te Pūkenga, Dunedin, New Zealand College of Work Based Learning, Otago Polytechnic | Te Pūkenga, Dunedin, New Zealand e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. Ross et al. (eds.), Rural Landscapes of Community Health, Global Perspectives on Health Geography, https://doi.org/10.1007/978-3-031-43201-9_1

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Introduction The rural is a key lens in this chapter contributing to the discussion of the importance of conceptualising and defining ‘rural’ which has significant resource implications for the design, maintenance, and improvement of rural services. While these vary with rurality, and in many cases are correlated, they are not in and of themselves definitions of rurality. Global representations of the rural include the wilderness, the outback, a village, the bush, or an open space (Halfacree, 2006), and all connect with the notion of community. A thriving rural community is dependent on understanding the socio-cultural, demography, economic, and unique rural encounters. The purpose of this chapter is to capture these encounters as they relate to the health of vulnerable, minority, and Indigenous populations situated in geographical rural landscapes, including islands. Clearly the social determinants of health, including access to health-care services, are important factors that shape health outcomes including those community members participating in creative responses for community development. Nurse learners are one such participant engaged with community development whose creative endeavours are proving beneficial for rural communities. Their work is guided by the Community Health Assessment Sustainable Education (CHASE) model (Ross et al., 2017) which we refer to in this chapter but is more extensively discussed in Chapter 2.

Interpretations of the Rural ‘Rural’ is a contested space; Woods (2011a) eloquently sets the rural scene proclaiming it has different meanings to those who live in, visit, or romanticise this space. These fundamental meanings evoke a range of images dependent on how the world is viewed and our position within the world (World Bank, 2022). There are numerous representations of the rural, and these include engaging with nature; farm life, including animals; farmed space; and domesticated and wild space. Rural localities are understood as productive, for example, for producing food, fuel, and minerals. Agriculture and a simple healthy lifestyle, clean air (Thurston & Meadows, 2003), and isolation (Bushy, 2012) are equally interpreted as positive aspects of economic production associated with the land (Panelli, 2006). Family is another important focus as part of economic production with family members living and working close to each other (Panelli, 2006). Rural places have also become recreational areas, holiday venues, and a space to enjoy a slower pace of life (Central Otago a World of Difference, n.d.; Woods, 2011a). Ideas of adventure, recreation, and freedom are associated with the rural and are represented through adventure tourism (Woods, 2011a). These illustrations are associated with the open spaces situated outside of cities (Bunce, 2003) and are also identified with the term ‘countryside’ (Cloke, 2003). Positive aspects associated with the countryside include having a strong sense of community (Cloke, 2003;

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Liepins, 2000). Rural communities are constructed through their rural context, rural people, community meanings, community practice, and community space (Panelli, 2006). Rural places are more than geographical locations; they extend the social and human to non-human relationships. ‘Place’ is important because it is central to the social world. ‘Place’ occurs when meaning, naming, or the feeling of connection occurs with that ‘place’. Conceptualising place provides a meaningful understanding of our sense of connections to place and more importantly sense of belonging which is significantly related to rural residents’ sense of community and connectedness. Agnew’s (1987) three fundamental elements of ‘place’ comprised what he considered as a ‘place framework’. This ‘place framework’ takes account of ‘location’, ‘locale’, and a ‘sense of place’. ‘Location’ refers to physical settings or geographical contexts; ‘locale’ is associated with the development and maintenance of social relationships. These relations are effectively between people and their relationship to their specific geographical context(s) and cultural connections where meaning is made. Meaningful places assist people to make connections and to develop a sense of who they are in relation to a geographical location. Meaningful relationships can be further extended to encompass a ‘sense of place’ and social participation amongst rural residents who practice a sense of community through various social practices (Panelli, 2006).

Rural Communities Community and place are constantly intertwined (England, 2011). Communities involve and are based on social relations that occur continually in places and spaces as interactions develop and as social relations are enhanced between people. Social relations are linked through family, friends, functionality, and loyalty to each other, as well as community membership (England, 2011; Hughes, 2009). Social relationships are based on personal bonds of friendship and kinship, inter-generational stability, and a state of close proximity with associated beneficial interactions (Liepins, 2000). Place provides a positive image associated with the rural, and a sense of belonging and social cohesion in relation to residents’ communities based on where they live, [t]he very notion of community sits rather more comfortably in a rural rather than urban framework. One does not often hear the term ‘urban community’… (Hughes, 2009, p. 201). Communities are spaces of social networks where residents work, live, and play and are associated with each other through shared connections, obligations, and responsibilities (England, 2011; Hughes, 2009). Communities are also places where people, other than rural residents, live; rural communities are places non-rural people visit for holidays and recreation. The concept of community in general terms is linked to people who align with similar values and beliefs, which bond them together with a common cause. Rural communities comprise rural people as a social

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collective. A social collective does not mean all people share the same values as a variety of views exist amongst rural people; conflict as well as cohesion can occur. Rural communities are identified as having both negative and positive connotations as discussed by Woods (2011a) and Murray (2012), who reflect that the rural is sometimes considered as backward, in contrast to positive images related to the ‘rural idyll’, noting how the environment is an attractive and romanticised place to live in or visit, by outsiders. Positive characteristics include community cohesion, which Liepins (2000) associates with social collective and action with rural locations. Liepins (2000) notes there is a greater sense of cohesion as rural communities become more remote from urban centres. Physical remoteness builds resilience and self-reliance amongst rural residents (Bushy, 2000; Dillon, 2008; Leipert & Reutter, 2005) and promotes community sustainability (Panelli, 2006). It is timely to consider what is ‘rural’?

‘Rural’ The rural is not a simplistic concept as there is no one set of attributes that represent this complex space (Woods, 2011a). Instead, there are multiple ways of understanding the rural in which individuals and institutions, both within and beyond rural geographical and cultural boundaries, construct their own understandings. These understandings fall into two categories that the rural is both real (internal subjectivity) and imagined (external subjectivity). Halfacree (2006) studied the social constructions of the rural for many years and has noted a change in how the rural is represented and imagined while also being associated with many diverse meanings. Diverse meanings reveal that the rural is a contested space, according to Woods (2011a), who notes that a variety of different approaches are used to make sense of this space and describes these approaches as ‘imagination, representation, materialisation and contestation… taking on different forms in different contexts and from different perspectives’ (p. 30). These different and diverse understandings associated with the rural imply that there are multiple ways of knowing and understanding the rural. It is the essence of knowing the rural which is in question, as to how we can understand the rural, which requires the knower to have a sense of the rural. However, Woods (2011a) cautions that: [t]he rural is a messy and slippery idea that eludes easy definition and demarcation. We could probably all instinctively say whether any given place was rural to us, rather than urban, but explaining why it was rural, not urban, and drawing a boundary line between urban and rural space on a map are altogether more difficult tasks. (p. 1)

These multiple understandings hold similar, different, and relational meanings for rural and non-rural people, organisations, policymakers, educators, and regulators, and are all important aspects to take into consideration as we proceed throughout this chapter. Different meanings associated with the rural can lead to contesting what the rural space is and the practices which are performed in that space.

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According to Cloke (2006) “it is [through] the social distinction of rurality that the significant differences between the rural and urban remain” (p. 19). Rurality, therefore, is related to the countryside or an isolated geographical location and includes traditional ways of living and being in the rural. The division of rural and urban is one of the oldest ideas in geography according to Woods (2011a), which is now discussed in which a sense of difference between these two aspects is highlighted. Rural residents are aware they identify themselves as different to urban people (Strasser, 2003). Rural community connectedness is one such factor (Hughes, 2009) in rural areas, with a traditional belief that everyone generally knows everyone (England, 2011; Hughes, 2009). Woods (2011a) emphasises rural residents may feel a sense of belonging with each other. However, this social connection does not mean all rural residents think and act in the same manner; residents do have differing rural values and views (England, 2011) as discussed previously.

Defining Rural Defining rural internationally particularly as it relates to health care plays an integral, but background, element in this book and adds to the growing international debate. Rural is identified as a worldwide concept; despite this, there is no one unified international definition encapsulating the rural (Cloke, 1997; Hugo, 2002). However, there are a number of core characteristics encompassing the rural, which fall into three main categories and include descriptions, typologies or continuums, and indices (Bidwell, 2001; Bushy, 2000). Descriptions of the rural are associated with population density and distance (Bidwell, 2001). Distance is usually measured by kilometres from urban centres (Bushy, 2000), which provide services such as tertiary health care and employment for rural residents who commute from their rural locations (Statistics New Zealand, 2004). Typologies or continuums, according to Halfacree (1993), have been in use since the 1940s to measure the rural-urban divide. The aim of using a continuum is to measure the differences in size, population, and factors associated with the location from the remote through to urban contexts. According to Hugo (2002), typologies or continuums are valuable measures of defining rural. Measurements, whether distance, the nature of the population base, or access to health care, are associated in defining the concept of the rural. Indices are linked with measuring specific rural characteristics, which, collectively, can have the aim of developing a rurality index. A rurality index assists with the planning of health care, which takes into consideration the nature of rural communities and their health-care needs (Kulig et al., 2008). However, this approach has not served rural communities and health professionals well (Whitehead et al., 2022b; Crengle et al., 2022). Rurality may appear to be a straightforward concept. Everyone knows rural when they see it – or live it. However, it is important to understand that rural places are heterogeneous (Valentine, 2000) and rurality is an elusive concept that it is difficult to define in concrete terms. But how rurality is defined matters, both from a

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policy and service delivery perspective, and for rural populations and communities themselves (Nelson et al., 2021). This is particularly true in health contexts, where fit-for-purpose definitions allow the accurate monitoring of rural population health, potentially identifying disparities that provide impetus for targeted strategy, policy, and interventions for the equitable allocation of resources (Attanasio et al., 2004; Barnidge et  al., 2013; Grobler et  al., 2015; Humphreys & Wakerman, 2018). However, no internationally agreed definition of ‘rural’ exists. This is understandable, as national contexts greatly differ around the globe. In fact, the United Nations Statistics Division (2017) suggests that countries should establish their own definitions for their own needs. So how can this be done? Given the nuances of conceptualising and defining rurality, arguably what is more important is how rural is defined and for what purpose. This has become a particularly pertinent issue in Aotearoa New Zealand recently; the Labour Minister of Health, Andrew Little, noted, in his keynote address at the New Zealand National Rural Health Conference in 2021, the definition of rural is ‘not just semantic’ and has real implications in terms of policy decisions and resource allocation. Poorly defined rural-urban divisions lead to poorly defined and implemented policies (Nelson et al., 2021) and hence services. Geographers have long debated the best way to concretely define rurality (Halfacree, 1993). In general, the two main approaches to defining rurality are either (1) socio-cultural or (2) descriptive and data-driven (Woods, 2011b). Socio-cultural approaches asses the cultural characteristics of communities to define places as rural or urban (Bell, 2007). This is an attempt to capture interwoven aspects of rural society that relate to socio-cultural factors, occupation, and ecology (Howie, 2008). This can include cultural constructions of rurality such as a nostalgic rural idyll in the UK, ‘country-mindedness’ in Australia, and a ‘frontier life’ in the USA (Cloke, 2003; Smith, 2004; Valentine, 2000). While ideas of rural occupations are strongly linked to traditions of agriculture dominating rural life, this perception is being challenged, and there is a recognition that a large proportion of rural people work in service industries (Pomeroy, 2021). Since rural life is often associated with rural work, there is an orientation and affinity towards the land and natural environment, as well as a recognition that distance and isolation are key characteristics of rural ecology (Howie, 2008). The rural idyll constructs rurality as anti-urbanism or counter-urbanism while maintaining a nostalgic and romanticised idea of the rural played out in social, economic, and cultural structures with the intention to keep the rural image alive. Some people value and dream of the rural countryside, as a simpler way of life, which is lost in urban contexts, and they ‘seek to construct rurality in a certain way rather than representing the rural that actually exists’ (Woods, 2011b, p. 22). The concept of the rural idyll can have strong influences on policy development by non-rural people (Cloke, 2003) acknowledged in later chapters in this book. Likewise, Liepins (2000) states that people from beyond a rural community may be powerful in constructing or constraining understandings about it, including the governance of policymakers in core agencies who can shape resources, responsibilities, and relations within and beyond the community. A representation associated with the rural is

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linked with the concept of knowing the rural. Knowing the rural is discussed in Chapter 2 in relation to nursing practice and community development. Descriptive approaches employ technical and quantitative methods to empirically describe socio-spatial characteristics to classify places according to pre-­ defined criteria (Woods, 2011b). Both approaches have limitations, particularly when used alone. For instance, socio-cultural approaches assume that population density affects behaviour and that values and behaviours differ between rural and urban residents, despite contradictory evidence (Woods, 2011b). A striking example of this are communities in East London displaying many apparently ‘rural characteristics’ despite clearly living in an urban centre (Woods, 2011b). Conversely, descriptive approaches are critiqued as providing an inadequate view of the social construction that is rurality (Cloke, 1994; Nelson et al., 2021; Woods, 2009). These technical classifications also imply that a clear and quantifiable geographic distinction between rural and urban areas exists, when in fact borders are often blurred, contested, and subjective (Woods, 2009). Where exactly does the city fringe end and a rural region begin? As Howie (2008) explains, attempts to understand the rural context do use both socio-cultural descriptive are generally approached in four key ways. Firstly, narrative portrayals examine how rurality is represented. These have often focused on ideas of population scarcity, distance from urban centres, and an agricultural way of life (Bidwell, 2001). While descriptions of rural merely characterise, rather than define, it (Howie, 2008), it can be argued that rurality at its essence is a socially and culturally constructed phenomenon that needs to be understood through descriptions and narrative (Cloke, 2003). A second approach is that of dichotomies, where places are divided into opposing ‘rural’ and ‘urban’ classifications that are distinct and contrasting (Howie, 2008). While a clear and simple rural-urban binary is appealing, the challenge is around what criteria are used to define rurality and where to draw the line between what makes places urban or rural. Typologies of rurality can be used to overcome some of these challenges and limitations. In these typologies, rurality (or urbanicity) is usually considered on a continuum in terms of the population size, density, and location of communities in relation to larger urban centres (Howie, 2008). The rurality classifications produced by Statistics New Zealand are a good example of typologies based on census data. The 2004 Urban Rural Experimental Profile used population size and density to classify rural settlements as those with fewer than 10,000 residents. Commuting data was then used to classify places on a continuum from ‘Highly rural/remote areas’ through to ‘Main urban areas’ (Statistics New Zealand, 2004). While these typologies are readily accepted as approaches to defining rurality, they are not without their limitations. Finally, indices that use multiple variables in an attempt to quantify rural-urban differences are sometimes viewed as being more comprehensive and flexible than other approaches (Howie, 2008). There is also the potential to incorporate not only geographic and demographic variables such as distance and population size but also socio-cultural or economic

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characteristics. Modern advances in geospatial data analysis and the easy availability of a vast array of sociodemographic data have led some researchers to develop rurality classifications for health based on a complex combination of variables. However, this does not always improve the resulting classifications. For instance, Zhao et al. (2019) developed a classification of rurality for the northern region of Aotearoa New Zealand’s North Island that included variables related to population density, natural space, access to various service facilities, and the proportion of people employed in farming-related occupations. While the inclusion of such variables may be conceptually valid, it does result in some anomalies. For example, urban greenspace in Aotearoa New Zealand’s largest city can be classed as highly rural, while some areas on the city fringes are classified as less rural, possibly due to a misconception of ‘farming occupations’ that excludes horticulture and the relative dominance of tourism. Furthermore, considering ‘access to services’ to be a component of rurality can complicate matters. Clearly the social determinants of health, including access to health-care services, are important factors that shape health outcomes. While these vary with rurality, and in many cases are correlated, they are not in and of themselves definitions of rurality. It is often true that rural access to health services such as primary care or essential vaccinations is worse than in urban areas (Whitehead et al., 2020, 2022a). However, some rural places can have good access to services, while many urban neighbourhoods are underserved. Furthermore, including access to services in definitions of rurality considerably limits and confounds the end uses of such a classification. It becomes unclear whether any differences in health outcomes are associated with rurality or with service access. Furthermore, it makes it impossible to examine variations in the distribution of services or fairness of access to services in rural and urban areas, if a key part of the rurality definition is access to services. If rural communities successfully advocate for improved and expanded local services, would this mean that they are no longer rural? For this reason, parsimonious classifications are ideal (Humphreys, 1998). In fact, there are several other key concepts and criteria that help with the process of developing rurality classifications. These have been outlined in the international research literature and are summarised by Nixon et  al. (2021). A classification should have (1) clear objectives and purpose and measure something explicit and meaningful; (2) a clear and relevant framework, appropriate, simple, and high-­ quality indicators and data; (3) a consistent spatial unit that allows both examination of small area differences and aggregation into broader regions; and (4) categories that maximise internal homogeneity and external heterogeneity, as well as on-the-­ ground validity which aligns with heuristic understandings of rurality. While definitions are context-dependent, change over time, and have become increasingly blurred, the core concepts and measures of rurality – population size and proximity to metropolitan areas  – have remained consistent since the 1970s (Nelson et al., 2021). However, this has not resulted in national level agreement on the definition of rurality. In fact, there is often significant variation within countries around how rural should be defined. In the USA, there are five key measures of rurality for epidemiological studies, all based on a combination of population size, density, and distance or commuting patterns (Hall et al., 2006). Canada has at least

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four different rurality classifications used in health research – all based on a combination of population size, density, and distance (Muula, 2007). Having several different national level classifications can result in inconsistent categorisation of areas and populations. This impacts the results of epidemiological studies and health service research and has the potentially to mask rural-urban health differences (Berke et  al., 2009; Hawley et  al., 2002; Inagami et  al., 2016; Langlois et  al., 2010; Weissman et al., 2014; West et al., 2010). The influence of aggregation methods, (Schuurman et al., 2007) and the Modifiable Area Unit Problem (MAUP) means spatial units that are used (Openshaw & Taylor, 1979). Even when the same health outcome data is used, the choice of rurality classification influences results, as different classifications aggregate together different populations into rural or urban categories. Considering different rural populations and their geographical locations focuses our attention to the rurality of islands. Islands further extends these rural classifications and limited definitions of populations who reside not only within geographical isolated regions as described above but those contexts that are surrounded by water, small land mass, and boundedness (Royle, 2001). Islands are considered as distinct places. Climate and seasons have a direct bearing on island, rural culture, and economy. This brings demands on the services and supply industries and can also impact on resources highlighting dis-economies of scale, which raises costs of transport and goods (Dillon, 2008). While a consistent definition of rurality is important, exact thresholds cannot be universally applied. However, factors of population size, density, and distance are key considerations in international geographic classifications of rurality. There is also recognition of ‘rurality’ as a fluid, context-dependent, concept (Nelson et al., 2021) that is socially constructed and defined by discourse (Woods, 2011b). People construct themselves as being rural, and rurality is in the eye of the beholder (Woods, 2011b). For the purposes of this book then, a meaningful classification of rurality must therefore effectively balance both ‘technical’ and ‘discourse’ approaches. In Aotearoa New Zealand, the definition of rurality used in health research to date has been problematic. Research by Fearnley et al. (2016) suggests that the way rurality has usually been classified in Aotearoa New Zealand results in a significant underestimation of rural morbidity. Many small towns in remote areas have incorrectly been classified as urban, while ‘lifestyle residential’ zones on the edges of cities have been incorrectly classified as rural. Further to this, the fact that no fit-for-­ health purposes definition exists has meant that researchers and organisations have inevitably reworked generic definitions in different ways. It is estimated that between 2000 and 2020, rurality was classified in more than 30 different ways in Aotearoa New Zealand’s health research literature (Farrell & Fearnley, 2021). This has produced varying conclusions and prevented a clear picture of the state of rural health in Aotearoa New Zealand from being developed and is likely to have masked rural-urban differences in health outcomes. In the absence of clear and compelling evidence, the assumption from health administrators has often been that ‘all is well in rural’.

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Geographic Classification for Health The completion of recent research coming out of Aotearoa New Zealand with the development of the Geographic Classification for Health (GCH) has produced a robust, technically sound classification of rurality – that is also heuristically valid and makes sense on the ground (Whitehead et al., 2022b). This was an attempt to balance the differing approaches to classifying rurality for health purposes and avoid some of the pitfalls of purely technical approaches. It extended work by Statistics New Zealand (2020), who were developing a generic rurality classification, using the internationally recognised core components of population size density and distance using small statistical areas (SA1s). One of the key components of the GCH, which allowed the development of a classification that could synthesise ‘technical’ and ‘discourse’ approaches was co-­ design, consultation, and engagement with the health delivery, research, and policy sectors early on (Nixon et  al., 2021). The core technical approach to classifying rurality employed by Statistics New Zealand  – that of population size and travel time to major or large urban areas – was maintained. However, different population and travel time thresholds were explored, and feedback on these was sought from co-design partners and stakeholders in an iterative process. These modified thresholds were selected to reflect on-the-ground realities of rurality more accurately in health contexts and are a key point of difference to the generic Statistics New Zealand classifications. The final version of the GCH was consulted on extensively and quantitatively validated against health-care provider definitions of rurality using anonymised patient enrolment data. The result is a robust classification that was specifically designed for considering rurality in health contexts and makes sense on the ground. When the GCH was applied to routinely collected health data, and compared to two generic Statistics New Zealand rurality classifications, it was found that the generic classifications significantly underestimated the crude mortality rate in rural areas (Whitehead et al., 2022b) as well as a range of other health outcomes and health service utilisation (Whitehead et al., 2023). Furthermore, applying these classifications to health data resulted in incidence rate ratios for mortality that were between 7 percent to 33 percent lower in rural compared to urban areas. Using the more accurate and purpose-designed GCH with the same data resulted in incidence rate ratios that were 21 percent higher in rural compared to urban areas. These findings suggest that inappropriate use of rurality classifications has meant that clear inequalities have been hiding in plain sight for decades. While the GCH is not a ‘perfect’ classification for every scenario, it is important to remember that as statistician George Box (1979) notes ‘all models are wrong but some are useful’ (p. 202). The GCH is a significant improvement on other generic classifications used in Aotearoa New Zealand. It has been designed for the specific purpose of analysing routinely collected health datasets and developing health policy and will therefore, for the first time in Aotearoa New Zealand, lead to development of consistent evidence on health differences and health needs in rural communities. This evidence will then inform health policy to address rural-urban

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health differences and support rural communities. Confirmation supporting this claim is introduced later in this chapter and further discussed and exemplified in Chapter 2 endorsing nurse learners’ encounter with the CHASE model.

Health of Rural People The rural population accounts for almost half the total global population (United Nations n.d.). These rural communities are confronted with reduced access and quality of health care, including primary health-care services and difficulty accessing speciality services based within urban tertiary hospitals (Singh et  al., 2018). People in rural areas have an increase in heart disease, cancer, chronic lower respiratory disease, and stroke or die from unintentional adding injury (Singh et al., 2018; Smith, 2022). Indigenous populations tend to experience higher incidents of chronic illness including diabetes, asthma, hypertension, cardiovascular disease, obesity, and mental health management than urban populations (Hogarth & Rapata-Hanning, 2023; Singh et  al., 2018). Indigenous populations have a 20 percent lower life expectancy than their non-Indigenous counterparts (World Bank, 2022) which is compounded by lower socioeconomics, poverty, cultural imbalance, loss of land and reduced access to education (World Bank, 2022). Rural population health from Aotearoa New Zealand and the Pacific Islands are included in several case studies (showcasing the CHASE model in action) presented in this book (in Chapters 3, 4 and 5) further adding to this topic. Rural health disparities are found in the Aotearoa New Zealand population and are associated with socioeconomic deprivation. These include the incidence of mortality, hospitalisations, health risk factors, chronic disease and many acute conditions (Hogarth & Rapata-Hanning, 2023). There is a substantial difference in life expectancy between Indigenous Māori and non-Māori populations (Hogarth & Rapata-Hanning, 2023). Life expectancy for male Māori in 2021 was 73 years compared to 79 years for non-­ Māori and 77 years for female Māori compared to 83 years for non-Māori (Hogarth & Rapata-Hanning, 2023). Rural Māori have a shorter life expectancy than urban Māori with 1.2  years difference for women and 1.5  years difference for men (National Health Committee, 2010). Across the rural-urban spectrum, the mortality rates for both Māori and non-Māori mortality rates increasing as rurality intensify (Crengle et al., 2022). Māori experience a higher rate of cancer, a higher incidence of obesity, and higher rates of chronic illnesses stemming from obesity (Hogarth & Rapata-Hanning, 2023). Chronic illnesses such as diabetes mellitus, coronary heart disease, stroke, and high blood pressure are also more common amongst Māori (Hogarth & Rapata-Hanning, 2023). Similar factors also impact Pacific populations. For example, in 2002 65 percent of all deaths in Vanuatu were related to chronic diseases with an increase to 74 percent as reported in 2016 (WHO, 2019a). This matches the global trend of increase in non-­communicable disease impact on health for Pacific Island communities (WHO, 2019a). Vanuatu differs from some other island states in the Pacific, such as

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Tonga and Samoa which are facing epidemics of diabetes and obesity within their populations (WHO, 2019b). One factor that may contribute to this is the slower rate of change of traditional lifestyle of Ni-Vanuatu and the highly rural population distribution. Health disparities are also experienced by minority rural populations generally regarding access to health services or a lack of knowledge of services available in their communities (Mahoney & Ross, 2019). These rural populations include infants, children, pregnant and nursing mothers, senior adults, seasonal workers, and refugees and are discussed in more depth in Chapter 3.

Provision of Rural Health Care The provision of health-care services in rural locations is under threat. This threat is a global concern and has been recognised as such for the past two decades (Australian Institute of Health and Welfare, 2022; Hughes, 2009; Scheil-Adlung, 2015). According to Rural WONCA (an active network of rural family doctors and rural academics from each of the world’s regions) access to health care is the major issue in rural health around the world (Strasser et al., 2016). Chapman et al. (2014) recognise the many barriers that exist which reduce client access to health care. Barriers include limited access to transportation (Bushy, 2009; Jones et al., 2009) as well as experiencing poor road conditions (Wakerman & Lenthall, 2002) and limited communication (Hughes, 2009; Wakerman & Lenthall, 2002) including cell phone coverage and broadband internet  access (National Health Committee, 2010). Rural residents may experience all or some of these barriers in their attempts to access health-care services. Access to health-care services is compounded by a reduction of health-care practitioners and leads to the lack of experienced practitioners and a corresponding lack of rural planning and dedicated funding (Crooks, 2012; Hughes, 2009; O’Malley et al., 2009; Ross et al., 2022). Worldwide there is an uneven distribution of health professionals per capita of population in rural locations, when compared with urban areas (Hughes, 2009). The challenge for rural doctors, nurses, midwives, and pharmacists, who make up most of current practising rural professionals, is to improve access to health care and to highlight these issues to health planners, regulators, and governments, globally (Bushy, 2012; Hegney et al., 2014; Ministry of Health, 2001; Strasser, 2003). Health-care planners often assume health-care services and policies developed for urban environments can be easily adapted for rural areas, with the notion that the only difference is population distribution (Long & Weinert, 2010). Equally, Strasser (2003, 2016) expresses his concern that the health-care resources for rural residents are focused on urban environments and these realities raise significant concerns for rural health-care practitioners, who seek to promote the planning of rural health-­ care services, requiring the distribution of resources is aligned to individual rural communities’ health needs and associated barriers when accessing health care (Bushy, 2000; National Health Committee, 2010; Matsumoto, et al., 2013).

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One example of future proofing the health of rural communities is the CHASE model (refer to Chapter 2). CHASE underpins the preparation of nurse learners in the Bachelor of Nursing (BN) programme at Otago Polytechnic, Dunedin, Aotearoa New Zealand to carry out community development projects as a component of their undergraduate clinical experience. Community development enhances and brings together community stakeholder, residents, individuals, and collective groups and organisations who are committed to improve the health and wellbeing of people and their community. Engaging with community development projects prepares nurse learners for their future practice as registered nurses with the aim to identify and reduce rural health disparities. The CHASE model is embedded in a social model of health which integrates the principles of primary health care (PHC). These principles provide first-contact equitable, accessible, affordable, comprehensive health care to populations who reside in the community (McMurray & Clendon, 2015; Clendon & Munns, 2023). PHC is also focused on self-determination, social justice, and empowerment and recognises the impact of social determinants of health (SDH) have on the health and wellbeing of individuals and communities. The SDH include social support networks (community, physical, virtual or other) sustainable housing, and environmental factors such as work contexts and economic influences whether in paid or unpaid work. Equally important SDH include access to health services, support systems, health literacy and education (local and virtual), transportation, access to nutritious food, and awareness of addictions (Clendon & Munns, 2023). These factors can shape immediate and long-term detriments of the health and wellbeing outcomes for individuals and communities and raise awareness for empowerment and change. Challenges, coupled with limited financial resources and the ‘uneven geographical distribution of the… health care workforce’ (Hughes, 2009, p. 205), are evident, as rural areas become more isolated or remote over time. It is in these rural, geographically isolated locations that rural nurses form the majority of health-care practitioners (Hughes, 2009). Nurses make up the largest segment of the global health-care profession (WHO, 2022) and are in a position, especially in rural locations, to play a critical role improving health outcomes for rural populations (Ross, 2016; Ross et al., 2023; Smith, 2022). Nurses must also be capable of working with the rural community to gather and analyse population-level data; promote wellness and disease prevention; assist in adopting and disseminating best practices for population health; and identify patients who are at greater risk of disparities, necessitating greater outreach efforts. Examples related to this community development practice are showcased in the case studies guided by the CHASE model in the remaining chapters throughout this book. Further community development practice is aligned with an updated version of the Collaborative Research Framework (Fig. 1.1) developed by Ross et al. (2020). The image of the globe provides a central focus to this framework, representing collaborative global relationships with the sharing of hands around the globe. The framework’s six separate but interlinking components are included in chapter themes within the book. These include community development practitioners and the CHASE model (Chapter 2); creative design (Chapter 3); pedagogy (Chapter 4);

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Scope: Contemporary Research Topics: Health and Wellbeing 5, Collaboration (2020 p. 61) by Ross, Mann and Whiddon with permission from Jean Ross. Fig. 1.1 Community Development Research Framework. (Adapted from original Scope: Contemporary Research Topics: Health and Wellbeing 5, Collaboration (2020, p.  61) by Ross, Mann and Whiddon with permission from Jean Ross)

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Indigenous populations (Chapter 5); impact evaluation (Chapter 6); and future development as the framework is evaluated and is revisited in Chapter 7.

Conclusion In this chapter we have positioned rural as a complex concept to pin down, not least because there are multiple ‘rural’ realities, and the definition of rurality can therefore vary depending on the reason why it is being defined. Definitions of rural places and of rural society are therefore ever-evolving and context-dependent. However, despite these difficulties in concretely defining rurality, definitions are useful and important. They help to ensure the consistent, accurate, and meaningful analysis of health data, which can inform health and social policy. Throughout the remaining book chapters, we draw on several case studies developed using the CHASE model, engaging with the complex mix of socio-cultural, economic, and political constructions associated with the rural, which we present as cultural topography, people and their culture, and demography. These case studies demonstrate health issues and population groups from rural communities while showcasing the CHASE model in action, and we elaborate on its adaptation to maintain and improve health, aid in the decolonisation of rural health, the creation of resources to improve health, learning and teaching pedagogy, impact evaluation on health, and future encounters to reduce health disparities, meanwhile improving social justice.

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Weissman, S., Duffus, W. A., Vyavaharkar, M., Samantapudi, A. V., Shull, K. A., Stephens, T. G., & Chakraborty, H. (2014). Defining the rural HIV epidemic: Correlations of 3 definitions – South Carolina, 2005–2011. The Journal of Rural Health, 30(3), 275–283. West, A. N., Lee, R. E., Shambaugh-Miller, M. D., Bair, B. D., Mueller, K. J., Lilly, R. S., Kaboli, P. J., & Hawthorne, K. (2010). Defining “rural” for veterans’ health care planning. The Journal of Rural Health, 26(4), 301–309. Whitehead, J., Pearson, A. L., Lawrenson, R., & Atatoa Carr, P. (2020). “We’re trying to heal, you know?” A mixed methods analysis of the spatial equity of General Practitioner services in the Waikato District Health Board region. New Zealand Population Review, 46, 4–35. Whitehead, J., Atatoa Carr, P., Scott, N., & Lawrenson, R. (2022a). Structural disadvantage for priority populations: The spatial inequity of COVID-19 vaccination services in Aotearoa. The New Zealand Medical Journal, 135(1551), 54–67. Whitehead, J., Davie, G., de Graaf, B., Crengle, S., Fearnley, D., Smith, M., Lawrenson, R., & Nixon, G. (2022b). Defining rural in Aotearoa New Zealand: A novel geographic classification for health purposes. The New Zealand Medical Journal, 135(1559), 22–38. Whitehead, J., Davie, G., de Graaf, Crengle, S., Lawrenson, R., Miller, R., Nixon, G. (2023). Unmasking hidden disparities: A comparative observational study examining the impact of different rurality classifications for health research in Aotearoa New Zealand. BMJ Open, 13(4), https://doi.org/10.1136/bmjopen-­2022-­067927 Woods, M. (2009). Rural geography: Blurring boundaries and making connections. Progress in Human Geography, 33(6), 849–858. Woods, M. (2011a). Rural. Routledge. Woods, M. (2011b). Rural geography: Processes, responses and experiences in rural restructuring. Sage. World Bank. (2022). Indigenous peoples. https://www.worldbank.org/en/topic/indigenouspeoples World Health Organization. (2019a). Vanuatu: Health profile. https://www.who.int/countries/vut/en/ World Health Organization. (2019b). Addressing non-communicable diseases in the Pacific islands. https://www.who.int/westernpacific/activities/addressing-­ncds-­in-­the-­pacific World Health Organisation (2022). Nursing and midwifery key facts. https://www.who.int/ news-room/factsheets/detail/nursing-and-midwifery#:~:text=Key%20facts,of%20the%20 global%20health%20workforce Zhao, J., Ameratunga, S., Lee, A., Browne, M., & Exeter, D. J. (2019). Developing a new index of rurality for exploring variations in health outcomes in Auckland and Northland. Social Indicators Research, 144(2), 955–980.

Chapter 2

Progressive Rural Community Collaboration: A Vehicle for Rural Encounters – The CHASE Model in Action Jean Ross, Laurie Mahoney, and Josie Crawley

Abstract  Engagement in community development is the vehicle to progress rural community collaboration, identifying health needs and the rural encounters which can lead to health disparities. Rural encounters are experienced by community members who are faced with day-to-day environmental, cultural, physical, and individual features that are distinctive to that rural context. Community development is showcased throughout this chapter commencing with the original 2017 Community Health Assessment Sustainable Education model in action and adapted 2018 version as a suitable approach for highlighting rural encounters, rural population health aligned with two case studies from Aotearoa New Zealand; the rural communities of Heratini/Geraldine, South Canterbury; and Moeraki, North Otago, both situated in the South Island of Aotearoa New Zealand, highlight our purpose in which to progress rural population health. Population health is introduced as it pertains to the diversity of rural populations and rural contexts. The rural population accounts for almost half of the total global population, while rural communities are confronted with reduced access to health care contributing to increased health disparities. Nurses play a critical role in reducing these disparities around the globe but with limited community rural models to guide their practice. It is within this context the authors facilitate nurse learner’s theoretical and clinical practical engagement through rural community development underpinned with the Community Health Assessment Sustainable Education model, as a teaching and learning resource in preparation for nurse learners to advocate on behalf of and with (rural) communities as registered nurses.

J. Ross (*) · J. Crawley Te Kura Tapuhi | School of Nursing, Otago Polytechnic | Te Pūkenga, Dunedin, New Zealand e-mail: [email protected]; [email protected] L. Mahoney Te Whata Ora, Southern and Otago Polytechnic | Te Pūkenga, Dunedin, New Zealand e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. Ross et al. (eds.), Rural Landscapes of Community Health, Global Perspectives on Health Geography, https://doi.org/10.1007/978-3-031-43201-9_2

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Keywords  Community · Assessments · CHASE model · Rural · Health · Education

Introduction This chapter introduces the Community Health Assessment Sustainable Education (CHASE) model to engage with community development in rural localities. The CHASE model was originally developed in 2017 (Ross et al., 2017) with further iterations in 2018–2022 and is discussed in this chapter. Nurse learners engage with the CHASE model; how this eventuated and plays out as a component of their Bachelor of Nursing (BN) education is examined. Rural community development was introduced in Chap. 1 and is extended in this chapter as we focus on rural population disparities aligned with identified rural communities. These communities are exemplified in a total of five varied and diverse case studies which are showcased within this book; two are included in this chapter. The strength of this work relies on a combination of collaborative efforts between community stakeholders, registered nurses aligned with educational organisations, and nurse learners. The CHASE model includes assessment frameworks to assist in gathering secondary and primary data associated with rural communities. The aim is to progress nurse learners’ community development practice and navigate the holistic landscape of health that integrates the socio-political, epidemiological, cultural, sustainable, economic, and environmental aspects related to the uniqueness of rural communities and rural encounters. This relational model immerses nurse learners in community development while engaging them to be active in their own learning in partnership with their group peers, identified rural community, and educational facilitators. CHASE enables nurse learners to influence change and policy at local, national, and global levels, as demonstrated in the two case studies presented in this chapter, while community development aims to address nurses’ role in advocacy that requires them to act on behalf of communities, like Florence Nightingale, to remove health disparities for all and fulfil nurses’ commitment to social justice.

Community Development Community development is a practice-based profession and an academic discipline that promotes participative democracy, sustainable development, rights, economic opportunity, equality and social justice, through the organisation, education and empowerment of people within their communities, whether these be of locality, identity or interest, in urban and rural settings. (Clarke & Crickley, 2022, p. 31)

Community development focuses on accessing, creating, identifying, planning and improving individual/population health disparities and community/environmental health. Community health is a broad holistic concept where outcomes are

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measured across multiple factors. Community health encompasses the engagement of community residents and community stakeholders who together address health needs and work collaboratively to achieve a healthy social, environmental, cultural, and physical society (McMurray & Clendon, 2015). Community health involves participation by community members with community development practitioners, to collaborate, assess community assets and needs, discuss, plan, and implement agreed changes with the aim of improving health outcomes. Nurses working in and with communities can be community members, community stakeholders, and community development practitioners, offering their skills and knowledge to work with other community stakeholders to improve community health. Holding all three roles is common in rural nursing (Ross et al., 2023). Even if familiar with the rural community, a partnership between the nurse and multiple stakeholders is crucial to capture a range of perspectives through which stakeholders interpret community needs, resources, and shared past experiences. Assessment of community resources requires trust, and for implementation to ‘fit’ and empower the community, the nurse needs to be an expert at observing, seeking, and listening to the voices of the community. Community stakeholder voices must safely include those experiencing the poorest inequitable health outcomes. For example, in Aotearoa New Zealand, partnership with local Māori (the indigenous people of Aotearoa New Zealand) is paramount, with partners participating to promote and protect Māori health as both process and outcomes need to be valued by the local Māori community. This partnership avoids increasing pre-­­ existing inequities through inadvertent modern colonialism. Where there is no meaningful partnership, communities are dis-empowered, the opposite of what community development aims to achieve. The overall focus of community development is to enhance and bring together community stakeholders, residents, individuals, collective groups, and organisations, who are committed to improve the health and wellbeing of people and their community. This requires a multi-disciplinary approach including practitioners from health, education, environmental, and community sustainability (Clarke, 2022). This wealth of knowledge and the collaborative efforts of numerous practitioners are a powerful source for collective action when combined with community stakeholders, education organisations, students/leaners, researchers, planners, and analysts (Mullens & Mullens, 2019). We are guided by the International Association of Community Development (IACD) global association supporting community development (McConnell et al., 2022). As a global organisation, it is accredited with the United Nations (UN) as an international, non-governmental organisation and assists in aligning our efforts with the purpose to work alongside and with rural communities. IACD is a leader in this field promoting community development as a discipline centred on a practice-based profession. The aim of IACD is to uncover inequities and work in collaboration with vulnerable communities while sharing a commitment to community development. Community development practitioners include community activists, leaders, practitioners, and volunteers who are either in paid or un-paid work, equally claiming this title with the overall goal to assist in the success of human rights and social justice.

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Social Justice Social justice challenges inequities. Inequities such as poverty, ethnicity, housing, and discrimination require individuals and organisations to work towards a just society through collective action (Clarke & Crickley, 2022). Nurses who practice in communities appreciate the injustices populations face, first-hand. Groups perceived as ‘other’ experience reduced health outcomes related to poverty associated with social and educational disadvantage. Injustices reveal social and health inequalities in the provision of health care at local, national, and global levels. Nursing’s social mandate (Abu, 2020) focuses on collective change, to meet the health care needs of diverse populations. These people include the disadvantaged and vulnerable and incorporate indigenous, seniors, children, people living with chronic illness and disabilities and low income, and the homeless, in dynamic and complex environments including rural locations. Moving beyond these challenges, nurses engage with these diverse populations. This stresses the significance of social justice as a shared value, which underpins nursing practice (Abu, 2020; Matwick & Woodgate, 2017). Social injustice issues confront and shape nurses’ social responsibilities and underpin their everyday practice. The profession of nursing represents the largest group of health professionals globally (WHO, 2022). And the goal of nursing’s response to social injustice is to improve health outcomes which can be attributed to human rights (Abu, 2020). Human rights aligned with the nursing practice embrace both individuals and communities, with the aim to eliminate social barriers to negate the negative effects of the Social Determinants of Health (SDH).

Social Determinants of Health In Aotearoa New Zealand, the SDH that have the greatest influence on health outcomes are income and poverty, employment and occupation, education, housing, and culture and ethnicity (Ministry of Social Development, 2016). Indigenous and ethnic minority groups including migrants experience greater disparities in health (Curtis et  al., 2019) particularly Māori, Pasifika, and non-Māori (Stanley et  al., 2019). The terms ‘health inequalities’ and ‘inequities’ or ‘disparity’ have different meanings (Braveman 2006). Health inequality refers to the differences with mortality and morbidity between people from different socio-economic backgrounds, whereas inequity and disparity refer to unequal access or opportunity to health care (Braveman 2006). Globally, health disparities are synonymous with being unnecessary, avoidable, unfair, and unjust. Krieger (2001) states: … health disparities, within and between countries, that are judged to be unfair, unjust, avoidable, and unnecessary (meaning: are neither inevitable nor unremediable) and that systematically burden populations rendered vulnerable by underlying social structures and political, economic, and legal institutions. (p. 698)

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Social inequalities in health are defined as inequality in access to health care between and amongst populations and can be changed (Graham, 2009). Globally, indigenous population groups have the greatest inequalities in health outcomes, with poorer access and receiving high-quality health care (Curtis et  al., 2019; Stanley et al., 2019; Smith, 2022). Keating and Jaine (2016) found that when health practices correlate their own data that is ethnic-specific, individually they can develop quality techniques for improvement, based around specific cultural health and equity for vulnerable groups. Equally, nurse learners are introduced to social and health inequities in clinical placements in which they experience social (in)justices in action. This provides nurse learners the opportunity to critically analyse unfairness, injustice, and inequality as a result of social, political, and economic policies and systems. Therefore, clinical placements equip learners to be meaningful contributors within the health-­­ care sector, as they acknowledge that social, cultural, economic, and environmental challenges can hinder the provision of care for the people. This leads nurse learners to engage with community development as community development practitioners while revealing their compassionate and empathetic understanding and commitment for change.

Community Development Practitioners It is within the context of the SDH we facilitate nurse learner’s theoretical and practical engagement with rural community development. The traditional roles of nurses providing health care in the community continue, for example, nurses relate their practice to community development in Aotearoa New Zealand, such as Public Health and Tamariki Ora (Well Child), and approach client partnerships with a strength-based model of practice, establishing rapport, listening, and assessing strengths and vulnerabilities (Gottlieb & Laurie, 2012). These nurses assess the wider determinants of health and collaborate with communities to identify health needs, to shape and evaluate individualised responses. When the strength-based model is applied to communities, nurses actively engage with the community stakeholders. For example, a vaccination clinic in one community may be centred at a community health practice, another community at a local school or in a mobile bus at the farm gate. Sustainable partnerships for community intervention are reliant on the community feeling heard, its goals and values shared (Alves et al., 2018). Nurses in Aotearoa New Zealand work under national guidelines. Nurses are required to achieve and maintain Nursing Council of New Zealand Competencies which are underpinned by collaboration and explicitly require partnership with health consumers when evaluating progress towards expected outcomes (Nursing Council of New Zealand, 2016). Health consumers may comprise a mix of individuals, whānau, and communities depending on the nurse role. Melo and Odete (2019) found that nurses who work with the community as a client, while embedded (as paid health practitioners) within that community, resulted in community

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e­mpowerment. The processes necessary for community empowerment include identifying problems and assessment, creating solutions, and taking actions (Laverack, 2005). These processes align with the stages of nursing frameworks, assessment identifying need/problems, generating potential solutions, and acting and evaluating outcomes (Melo & Odete, 2019) positioning community nurses as community development practitioners. The CHASE model was developed for nurse learners in the BN programme through the School of Nursing at Otago Polytechnic, Dunedin, Aotearoa New Zealand. The BN programme has at its foundation a curriculum which aims to achieve practical principles of public health, community health, and wellbeing underpinned by the foundational knowledge of primary health care (PHC). To fulfil this curriculum’s aim and nurse learners’ experience, we focus on community development practice. This promotes nurses’ responsibilities for the provision of health while minimising potential health issues and health disparities. All nurse learners experience community nursing practice within this programme at levels 5, 6, and 7. Community clinical placement equates to 120 clinical hours and is based on the principles of PHC.

Community Development Practice Community development practice also known as project or project work includes community profiling, assessment, identification of health need aligned with population groups. Further, action, and the design and development of health promotion messages and resources, with the aim to improve the health of those identified population associated with the rural community concludes community development. Community practice can be experienced by nurse learners in traditional clinical placements. For example, they might be practising in general practice clinics with practice nurses as their mentor to the nurse learner; district nursing practice caring for residents in their own homes; school nursing practice; workplace environments as an occupational practitioner; and child health practice. Our particular interest is the nurse who practices in rural contexts, referred to as the rural nurse whose practice is a combination of all of these community practices (as mentioned above) including emergency health care (Ross, 2016). The community development work at the School of Nursing, Otago Polytechnic, was initially engaged with by Ross, Crawley, and Mahoney in the early 2010s in their capacity as nurse educators who guided nurse learners as they engaged in community development practice. Community development at this time was aligned with health promotion activities undertaken by two to three learners in collaboration with community organisations, for example, the local Cancer Society, the Disability sector and Women’s Refuge. Nurse learners worked under the direction of the organisations’ registered nurse which was no different to all other clinical placements. The remainder of learners worked under the direction of registered nurses practising in numerous community contexts (as mentioned above).

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However, from 2016 onwards, community development projects were extended to include all BN learners under direction of the academic nurse ­­educators/facilitators as a component of their clinical placement at level 7 of the BN programme. The rationale was to provide learners the opportunity for them all to experience community development practice and work collaboratively with an identified community. This was in meeting the aim to include this in the BN curriculum and prepare nurse learners to be aware of the importance of the role of nurses (fulfil nursing’s social mandate) in reducing health inequalities and in addressing issues and interventions that should be addressed at national, regional, and local levels by funders and providers (Ministry of Health, 2002). It was within this capacity the academic nurse educators listened to the nurse learners’ evaluations including their frustrations in relation to the process of engaging with community development and understood that these learners were apprehensive about commencing community development projects. There were several unknowns as learners progressed with the numerous stages necessary to complete these projects. Ross and colleagues agreed a systematic approach was required to support learners with their efforts as they engaged with this project work. This was the time the Community Health Assessment Sustainable Education model was created (Ross et al., 2017) and the CHASE model 2017 was established as a teaching and learning resource (Ross et al., 2017).

Community Health Assessment Sustainable Education Model The Community Health Assessment Sustainable Education (CHASE) model (Ross et al., 2017) comprises five concepts and when linked together is an approach to engage with community development practice aligned with nurse learner’s experience in clinical practice. The following is a brief outline of each concept: Community – a rural geographical location, a population, a group, or aggregate with a common goal or sense of connectedness associated with health. Health – a dynamic concept, ‘constantly changing as our biology and genetic predispositions interact with the psychological, social, cultural, spiritual and physical environments that we live in’ (McMurray & Clendon, 2011, p. 5). Assessment – the collection and analysis of data about a rural community, population, or aggregate with a view to identify and improve health and the sustainability of rural communities. Sustainable – a common commitment to work towards creating and sustaining the health of an identified population group or geographical location and environment. Education – involves active learning and engagement of nurse learners in the community development process, leading to innovative critical thinking, to identify and improve health. The CHASE model is a ‘model in action’. What we mean by ‘action’ is that the CHASE model was originally created to guide the nurse learners as they engage

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with community development. Equally the CHASE model can be engaged with learners from other health disciplines including medicine, midwifery, and ­occupational therapy and not limited to the health disciplines, for example, learners related to planning, social work, and social, human, and health geography. The CHASE model enables learners to influence and change policy at local, regional, and national levels. The community development aspect aims to address community development practitioner’s role in advocacy, reduce health disparities, and fulfil their commitment to social justice. For the purposes of this book, we focus on various rural communities and countries’ specific requirements while accommodating a global pandemic and significant country lockdowns. The application and adaptation of the CHASE model ‘in action’ is the focus of this book complemented by Aotearoa New Zealand (Chapters 2, 3, and 5) and international case studies (Chapters 4 and 7).

The CHASE Model ‘in Action’ The original CHASE 2017 model was engaged with by nurse learners to guide their community development practice and consisted of pre-orientation and orientation stages and six phases. The CHASE model has been further adapted based on impact evaluations between 2018 and 2022. The five adapted versions are included and discussed in the remainder of this chapter. Further, the adapted CHASE models are presented in the five rural national and international case studies. The five case studies have been included within this book in a systematic way to allow insight into the evolution of the CHASE model throughout the 2017–2022 periods. These case studies demonstrate learner-stakeholders engagement, project scope, and impact and are presented sequentially. We start with an introduction in the following section of the original composition of the CHASE model followed by its adaptations and the rationale for change. The CHASE model provides a consolidated structure that immerses nurse learners in community development and involves these learners to be active in their own learning in partnership with their group peers, community organisations, and educational facilitators. This model guides learners through ethical, cultural, epidemiological, professional, and critical thinking, verbal and written communication, and presentations. The CHASE model is a visual representation of the sequence of the community development individual stages and phases identified in Fig. 2.1 the original CHASE 2017 model.

The Original CHASE Model Stages and Phases The original 2017 CHASE model commences with two preparatory stages – a pre-­­ orientation and an orientation stage – and six subsequent phases. The X-axis represents these stages and phases of the model, while the Y-axis is illustrative of those

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Community Health Assessment Sustainable Education Model (Ross, Crawley & Mahoney, 2017). This work is licensed under a Creative Commons Attribution-NonCommercialNoDerivatives 4.0 International License

Adapted from Scope: Contemporary Research Topics: Learning and Teaching 4 (2017 p. 12) by Ross, Crawley and Mahoney with permission from Samuel Mann. Fig. 2.1  CHASE Model 2017. (Adapted from Scope: Contemporary Research Topics: Learning and Teaching 4 (2017, p. 12) by Ross, Crawley and Mahoney with permission from Samuel Mann)

individuals’ responsibility. The lecturer’s responsibility is identified by the orange-­­ dotted line, while the student responsibility is recognised by the green solid line. The pre-orientation stage of each project commences with the responsible nursing academic facilitator/lecturer initially engaging with potential community stakeholders to initiate collaborative partnerships. Nurse lecturers plan the project and collaborate with the Office of Kaitohutohu (KTO) guided by Te Rautaki Māori ki Te Kura Matatini ki Ōtāgo Maori Strategic Framework 2020–2022 (n.d.) to complete the ethics application and gain approval for the students (nurse learners) to proceed with the community development project. As a responsible tertiary education institution, Otago Polytechnic, Dunedin, in Aotearoa New Zealand has representatives for the indigenous people of Otago, Kai Tahu, and all research and consultation requests follow a process whereby potential impact on Māori is explored. The orientation stage provides the nurse learners to engage in collaborative practice. Collaboration is a skill to be learned, it is not innate, but culturally influenced (Johnston & Johnston, 2016). Equally, growing partnership skills between learners requires intensive facilitated time before approaching the community. To begin the 4-week project, nurse learners are encouraged to develop a trusting relationship between themselves which assists them to collaborate with each other and with the responsible nursing lecturer. Throughout this orientation phase, the

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lecturers facilitate the nurse learners to discover and share each other’s strengths and attributes that can be relied upon throughout the term of the project. Lecturers discuss the importance of nurse learners discussing, agreeing, and setting group core ground rules that highlight student inter-reliance and group membership. Lecturers support the process for nurse learners to become acquainted with each other and to the rural geographical location to which they have been assigned to conduct the community development project. Lecturers offer inside information that project process may seem muddied and the path forward uncertain for a period of time, but they will work closely with the students throughout the project. Phase one commences with the planning stage to undertake the community assessment associated with the identified rural geographical location. Learners engage with an adapted version of Anderson and McFarlane (2011) Community-as-­­ Partner Wheel which is a community assessment framework which enhances the collecting of both secondary and primary data. The original Community-as-Partner Wheel (Anderson & McFarlane, 2011) has been adapted by Ross and colleagues to include a further three subsystems which aligns this Community-as-Partner assessment to include social, political, and ecological issues evidenced in contemporary society. This data collection identifies the core of the community, the demographics of the community, and the community services by engaging with the original eight subsystems and include communication; safety and transportation; physical environment; health and social services; politics and government; economics; recreation; the physical environment; as well as education. The three additional subsystems include housing, COVID-19, and climate change (refer to Table 2.1). Secondary data is gathered initially through Internet websites and library sources. Any gaps revealed from the secondary data collection assists learners in compiling specific questions they will ask of the community stakeholders (primary data collection) to complete the community assessment. It is in phase two nurse learners start to take more responsibility for the project represented in the CHASE model in Fig. 2.1 by the increase in the solid line moving above the dotted line representing the lecturer’s responsibilities which decreases. Phase two identifies the health needs and population group(s) and takes into consideration ethical issues and cultural representations. This phase of the CHASE model includes a presentation by the learners to the community stakeholders, and in Aotearoa New Zealand, learners are guided by the principles of Te Rautaki Māori ki Te Kura Matatini ki Ōtāgo Maori Strategic Framework (n.d.) situated within the Otago Polytechnic, Office of Kaitohutohu, who guide all indigenous research projects at the institution that could represent or involve Māori learners and research. With engagement or the potential of engagement with the indigenous populations, learners must actively seek and include Māori statistics for the community population and identify potential resources and vulnerabilities, including recognition of the people of that place the tangata whenua in pre-colonial days. The differing health and socio-economic status of Māori and non-Māori are included in a presentation which is conveyed to the Office of Kaitohutohu, as students uncover potential community health needs. The presentation first occurs once assessment data is collected and health needs accessed and communicated back to the community

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Table 2.1  Community Profile and Assessment Criteria. (Produced by Authors)

stakeholders before definitive decisions are made about the community health challenge that will be explored. Phase two requires students to prepare the draft written report for verbal and visual presentation in consultation with the supervising lecturers and all stakeholders/community partners and Kaitohutohu who agree upon the two identified health needs and population groups. To achieve this, nurse learners present their analysis of the patterns and themes identified from phase one so the community stakeholders can include their input and direction. This collaboration forms the basis of phase three of the CHASE model (Table 2.2). Nurse learners in phase three work in smaller groups and progress with both identified health needs associated with the population groups. Additional consultation may occur with community members specific to the learners’ focus on the identified health needs. A detailed literature review is completed related to these health needs. Critique of the literature assists learners to consider whether these findings could potentially improve or remove the barriers to the health needs. The suitability of these findings or the need to adapt them are considered in response to

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Table 2.2  Presentation plan Introduction – geographical boundaries Mihi (Māori welcome and introductions) Māori History/Indigenous History Colonial History Demographics – Statistics/Census data Secondary data Community assessment – Primary data SWOT analysis Potential identified health need/population Consideration of Māori representation in the project Discussion Open for questions

Produced by authors the identified population groups and local rural community context analysed from the completed community assessment in phases one and two of the CHASE model. Learners are tasked to improve the identified health needs, as they develop solutions and engage with the literature from national and international sources including health-care documents and policies. Focusing on solutions of the identified health/needs, learners engage in phase four of the CHASE model beginning with engaging with the Ottawa Charter for Health Promotion which is a global charter for action (WHO, 1986). This charter suggests advocating, mediating, and enabling as processes to assist community residents to increase their control over and improve their health. Ideas to promote health may include shaping legislation; promoting healthy public policy; and creating environments that are sustainable and support health while empowering communities to own and control health choices, reorientate health services, and provide personal and social development to work together and improve health status (Clendon & Munns, 2023). Nurse learners continue to work collaboratively with community stakeholders to create resources that will communicate the health promotion messages to the identified populations while complementing the health need of the identified population groups. To convey the health promotion messages, several groups of learners write submissions or lobby-relevant government ministers including those responsible for health and education portfolios tackling the health concern at a national level. Other groups attempt to challenge the health issue at a local level by writing articles for newspapers, lobbying local governments, and producing pamphlets and posters, engaging with online platforms including social media or Internet webpages for agencies and considering other creative media for sharing health messages illustrated on keyrings, beer coolers, and others (exemplified in Chap. 3). All resources and reports align with the tertiary organisations’ policies, for example, appropriate signage and logos are approved for publication by the academic facilitator for wider distribution to the community.

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In phase five, learners compile all their data and analysis into a final written report and Power Point presentation of the community development project. The written report and presentation include the completed community profile, assessment, SWOT analysis, and identified health needs and literature reviews related to these needs (which were generated in phases one to three of the CHASE model). At completion of phase five, learners complete the Impact Assessment Template (refer to Chap. 6) with information that will be required for completing the impact assessment (evaluation) in phase six of CHASE. Phase six of the CHASE model is completed by the lecturing staff 6–12 months following completion of phase five when an impact assessment (evaluation) further analyses whether there has been any impact on the identified health need of the population as they have engaged with the health promotion message and resources completing the CHASE model stages and phases.

The CHASE Model Collaborative Relations The CHASE model comprises three individual collaborative relations that work in partnership; these include identified rural community stakeholders; the nurse learners (students); and the registered nurse academic lecturers/facilitators and are briefly described below: Identified rural community and stakeholders  – Rural communities are at the centre of the CHASE model and have initially been identified by the academic lecturer/facilitator as a community of interest. Interest may have been raised between the academic lecturer and a member of the community, and/or community stakeholder has approached an academic lecturer inviting engagement with their community. Nurse learners (students)  – Partnership in nursing practice is identified by the Aotearoa New Zealand professional body governing nurses as over-arching skill nurses are required to master as a component of their practice (Nursing Council of New Zealand [NCNZ], 2016). The opening statement of the competencies for registered nurses describes the scope of a registered nurse in New Zealand as a comprehensive process that ‘… occurs in a range of settings in partnership with individuals, families, whānau and communities’ (NCNZ, 2016, p. 2). The CHASE model encourages nurse learners to develop and work within four different partnerships: (1) to partner with communities to identify health needs and work together to create solutions within their learner team; (2) between their group and the academic lecturer; (3) with indigenous people’s representative (Office of Kaitohutohu); and (4) with the community stakeholders themselves. Nurse learners are required to build meaningful partnerships with the indigenous population and in Aotearoa New Zealand, Māori. Nurses have an ethical responsibility to provide culturally safe practice (Papps, 2002) working within the tenants of

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Te Triti o Waitangi (a founding document of 1840 between Māori and Queen Victoria’s representatives that promises protection, participation, and partnership in decisions that may affect Māori). In contemporary health terms, this means to reduce and not compound inequity with Māori health outcomes (Nursing Council of New Zealand, 2016). This requires ‘culturally safe’ practice, where nurses recognise and respect Māori world view, and safety is determined by the client (Francis et al., 2013; Papps, 2002). Academic lecturers also referred to as facilitator in the CHASE 2018–2022 models (see Fig.  2.3 and explanation below) working in the capacity as the ­Registered Nurse encourage the nurse learners to take responsibility to engage and complete phases one to five of the CHASE model. Facilitators help elevate uncertainties bringing together group core ground rules  – including group self-­ determination based on strengths, interests, and shared resources. Establishing communication routes, sharing resources, and developing group goals are all important group dynamics to shape an effective group that can produce an effective outcome in partnership with each other (Johnston & Johnston, 2016). Academic facilitators provide clear guidelines that outline each of the CHASE model phases of the process and possible ethical issues to consider. Facilitators need to be realistic about what they can offer while encouraging learners to extend their practice, teach each other, manage their time, and build their skills and capacity for community development practice. A role of the academic facilitator is the awareness of timelines who is aware that community development projects must be completed within a 4-week period. The project is divided up into four distinct steps: (1) community profiling and assessment; (2) identification of health need and literature review; (3) creation of health promotion resource; and (4) presentation and ­distribution.

Evaluating and Adapting the CHASE Model The original CHASE model was initially created in 2017 for the rural Otago, ­Aotearoa New Zealand context. However, throughout the proceeding years, opportunities were presented to work with communities within wider national and global landscapes including the rural geographical regions of Australia, the Pacific, and the UK (Ross et al., 2020b). These extensions have progressed nurse learners’ practice with rural communities internationally and through changing health-care contexts that includes the COVID-19 pandemic. The original CHASE 2017 model has been evaluated and adapted to accommodate these changes. The original developers Ross et al. (2017) evaluated the CHASE model annually. More recently Ross has been joined by Mann (Ross et al., 2023) and Mullens (n.d.). All evaluators have acknowledged the model’s contribution to the community development process and within the educational context but have agreed it has needed to be updated to maintain currency and effectiveness. The CHASE model iterations have accommodated these evaluations including virtual community

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development, recognition of nurse learners’ contribution, and expansion of academic facilitator (lecturer) responsibility. A brief explanation of the adaptations and rational are presented below, including diagrammatic representations of the CHASE models 2018–2022 in Figs. 2.2, 2.3, 2.4, 2.5, 2.6, and 2.7.

Evaluated and Adapted CHASE Model 2017 The evaluated CHASE model 2017 brings to light the CHASE 2018 version and draws attention in Fig. 2.2 to this adaptation. The CHASE model 2018 comprises two adaptations and include: 1. A change of title from Lecturer Responsibilities to Facilitator Responsibility (highlighted by the dotted line in Fig. 2.2) to accommodate relationship between the nurse learners and the academic nurse facilitator which removes the stigma of power relations between learner and lecturer and is keeping with the overall approach of collaboration and partnership (discussed earlier in this chapter). 2. In phase six, the impact assessment becomes the responsibility of nurse learners rather than the facilitator. This change was to continue the collaborative nature of the project and capture the commitment of learners to complete the

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Community Health Assessment Sustainable Education Model adapted by Ross & Mahoney (2018) published with permission from Ross, Crawley & Mahoney (2017). This work is licensed under a Creative Commons Attribution-NonCommercialNoDerivatives 4.0 International License

Fig. 2.2  CHASE model 2018. (Produced by Ross and Mahoney with permission from authors)

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project cycle, evaluating the impact the health promotion resources they created had on the health of the identified population. The rationale for these adaptations was to emphasise and enhance the importance of community engagement as well as ensuring the impact assessment was completed in a timely manner, 3–6  months following completion of phase five rather than 6–12  months as planned in the original CHASE model 2017. Because of time pressure, this had not been completed. Additionally, some community stakeholders were difficult to contact; some had left the organisation or community. Note the change to the CHASE model lines of responsibilities, the solid line representing the team of learners has been extended representing their responsibilities, and the dotted line representing the facilitator responsibility, has been reduced.

Evaluated and Adapted CHASE Model 2018 The evaluated CHASE model 2018 brings to light the CHASE 2019 version and draws attention in Fig.  2.3 to this adaptation. The CHASE model 2019 has one adaptation: 1. The impact assessment (in phase six of CHASE) had not been completed within a timely fashion by the nurse learners (students) during 2018. This meant we were not fulfilling our obligation to evaluate (test) health outcomes and whether identified health need had been in any way improved. To remedy this concern, the impact assessments in the CHASE model 2019 became the responsibility of nurse learners engaged with this model but was responsible to conduct and complete the 2018 impact assessment (phase six of the CHASE model) as they engaged with the CHASE model 2019 to conduct their community development project.

Evaluated and Adapted CHASE Model 2019 The evaluated CHASE model 2019 brings to light the CHASE 2020 version and draws attention in Fig.  2.4 to this adaptation. The CHASE model 2020 has five adaptations: 1. The rationale to promote learners’ teamwork rather than student group work. This rationale is in keeping with a focus on clinical practice and NCNZ competency that all nurse learners are required to demonstrate teamwork as a component of their clinical practice. 2. A new stage  – a pre-engagement physical community visit commences for some projects with an academic facilitator engaging either physically visiting the community or communicating by other means (virtually or email/phone). Engagement is made with community stakeholders to explain the aim of the

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3-6 months following Phase Five an impact assessment completed by the students in the following year

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Community Health Assessment Sustainable Education Model adapted by Ross & Mahoney (2019) published with permission from Ross, Crawley & Mahoney (2017). This work is licensed under a Creative Commons Attribution-NonCommercialNoDerivatives 4.0 International License

Fig. 2.3  CHASE Model 2019. (Produced by Ross and Mahoney with permission from Authors)

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Community Health Assessment Sustainable Education Model adapted by Ross & Mahoney (2020) published with permission from Ross, Crawley & Mahoney (2017).

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Fig. 2.4  CHASE model 2020. (Produced by Ross and Mahoney with permission from authors)

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project, discuss their involvement, and meet with further members of the ­community/organisation, and examples of previous projects are provided. A project plan and timeline are discussed along with including responsibilities of community stakeholders and academic facilitator and nurse learners. Opportunity to answer all questions prior to the commencement of the community development project is engaged with. 3. An additional member joined the CHASE team – a research assistant whose responsibility was to write up the completed 2017–2021 community d­ evelopment projects as case studies and complete all outstanding impact evaluations (representative as the dotted line in the model’s key and against phase six of the CHASE model). 4. A new phase – phase seven introduces nurse learners to the United Nations 17 Sustainable Development Goals (n.d.) and to comment whether the health promotion messages and resources they created could potentially meet one or more of these goals. 5. A new phase – phase eight acknowledges the changes to the teaching and learning, engaging, planning and delivery of course content, and completing the community development projects, in a time of significant disruption both in Aotearoa New Zealand and internationally. This disruption was a result of the COVID-19 pandemic requiring individual, group, and country isolation (Ross et  al., 2020a, b).

Evaluated and Adapted CHASE Model 2020 The evaluated CHASE model 2020 brings to light the CHASE 2021 version and draws attention in Fig.  2.5 to this adaptation. The CHASE model 2020 has four adaptations: 1. Nurse academic facilitator maintain relationships with community stakeholders from previous community development projects, acknowledge the identified health needs, and build on the impact of the health promotion messages and resources previous nurse learners had created, with a new team of nurse learners. 2. The initial engagement of the nurse learners with the CHASE model is at the orientation stage and in the 2021 is included in ELM (Extended Learning Module) and provides an opportunity for learners to introduce themselves with each other and become acquainted with the community project and its geographical location prior to commencing the clinical placement. 3. A new phase – phase nine benefits the nurse learners on successful completion of the clinical placement (course) with a micro-credential from the educational institution, endorsed in one of the United Nations Sustainable Development Goals (United Nations, n.d.). This work is underpinned by the CHASE model which acknowledges the nurse learner’s contribution to community development

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Community Health Assessment Sustainable Education Model adapted by Ross & Mahoney (2021) published with permission from Ross, Crawley & Mahoney (2017).

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License

Fig. 2.5  CHASE model 2021. (Produced by Ross and Mahoney with permission from authors)

and recognises the learner as a community development practitioner as stated by the IACD (McConnell, et al., 2022). IACD is a leader in community development as a discipline centred on a practice-based profession. 4. A written summary is presented to KTO (Māori ethical approval) prior to the presentation (phase two of the CHASE model) with the purpose to assist in the ongoing dialogue and collaborative relationship associated with the identified health needs.

Evaluated and Adapted CHASE Model 2021 The evaluated CHASE model 2021 brings to light the CHASE 2022 version and draws attention in Fig.  2.6 to this adaptation. The CHASE model 2022 has one adaptation: 1. Granting additional importance to complete the impact assessment (phase six of the CHASE model) has been expanded into phases seven, eight, and nine. Reviewing the potential impact, the health promotion message and resources developed in phase four of CHASE could benefit and reduce identified health disparities, analysed by a research assistant 3–6 months following completion of phase five of the CHASE model.

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Community Health Assessment Sustainable Education Model adapted by Ross & Mann (2022) published with permission from Ross, Crawley & Mahoney (2017).

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License

Fig. 2.6  CHASE model 2022. (Produced by Ross and Mann with permission from authors)

Evaluated and Adapted CHASE Model 2022 The evaluated CHASE model 2022 brings to light the CHASE 2023 version and draws attention in Fig. 2.7 to this adaptation. The CHASE model 2023 has three adaptations: 1. The impact assessment in phase six of the CHASE model engages back with academic nurse facilitator instead of the research assistant (related to inadequate research funds). 2. A new phase – phase ten focuses the academic facilitator to take responsibility and conclude each of the community development projects with a written case study. 3. A new phase – phase eleven aligns with a post planning discussion between all academic facilitators evaluating community development outcomes, identifying and theming the population health issues and disparities associated with the various community development projects. The aim being to identify – what has been learnt and how can the academic facilitators progress this valuable work as they engage with forward-looking reflections.

Summing up the CHASE Model ‘in Action’ The CHASE model has been evaluated annually and adapted to progress the stages and phases to ensure it is fit for purpose. The original CHASE model 2017 was an established guide to provide nurse learners to perfect their contributions

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Community Health Assessment Sustainable Education Model adapted by Ross (2023) published with permission from Ross, Crawley & Mahoney (2017).

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License

Fig. 2.7  CHASE model 2023. (Produced by Ross with permission from authors) Note: The CHASE model 2023 has not been evaluated

as community development practitioners through the process of community development. The CHASE model initially included two stages and six phases that included community engagement, assessment, identification of health need associated with population groups, creation of health promotion messages, and corresponding resources and impact assessment. There have been six iterations since the original CHASE 2017 model. We acknowledge there are both strengths and weaknesses associated with this model ‘in action’. The CHASE model’s stages and phases are aligned with responsibilities that are shared between what was originally termed lecturers to academic facilitator and from students’ responsibility to teams’ responsibility. A continued weakness throughout these years has been the timely engagement with the impact assessment related to evaluating health disparities. The inclusion of a new member, a research assistant of the CHASE team, with the availability of research funding was engaged with, whose responsibility (between 2020 and 2022) was to capture and complete all of the 2017–2022 impact assessments. In 2023 with insufficient research funds, the academic facilitators were granted allocated time to complete the research aspects of the community projects and continue to complete the impact assessments as part of their research performance. A significant adaptation occurred in 2020 when the CHASE model was updated due to disruptive issues related to COVID-19. The teaching and learning structure took into consideration working within a virtual platform, and the course content and delivery were updated to accommodate this disruption (discussed in Chap. 4).

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The CHASE Model ‘in Action’: Case Studies The CHASE model ‘in action’ is showcased in this chapter with the first case study demonstrating how the original CHASE model 2017 was initially engaged associated with the Heratini/ Geraldine rural community of South Canterbury, Aotearoa New Zealand.

 ASE STUDY 2017 – Rural Community, Heratini/Geraldine, C South Canterbury, Aotearoa New Zealand Compiled by Laurie Mahoney and Jean Ross (2023) Community development projects commence with the lecturer initially engaging with potential community stakeholders, plans the project, completes the ethical application, and gains approval for students to proceed with the project referred to as the pre-orientation stage of the CHASE model. The CHASE model 2017 ­community planning is associated with the rural community of Heratini/Geraldine situated in the South Canterbury region of the South Island highlighted in comparison to New Zealand in Fig. 2.8.

Heratini/Geraldine

Fig. 2.8  Map of New Zealand highlighting Heratini/Geraldine. (Produced by Suzanne Thornton with permission from authors)

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Community Health Assessment Sustainable Education Model (Ross, Crawley & Mahoney, 2017). This work is licensed under a Creative Commons Attribution-NonCommercialNoDerivatives 4.0 International License

Fig. 2.9  CHASE model 2017. (Adapted from original Scope: Contemporary Research Topics: Learning and Teaching 4 (2017, p.  12) by Ross, Crawley, and Mahoney with permission from Samuel Mann)

CHASE Model in Action 2017 Nurse learners engaged with the CHASE 2017 model to guide their community development practice of the rural community of Heratini/Geraldine, in the South Canterbury region of the South Island of New Zealand. CHASE 2017 (Fig.  2.9) comprises a pre-orientation, orientation, and six phases showcased in this case study.

Community Engagement Community engagement engages with Heratini/Geraldine’s cultural topography. Describing its land, people, their culture, and demography offers the opportunity to explore the relationship and connections between the people(s)’ past and present and the environmental and cultural influences of residing in Heratini/Geraldine and its peoples’ associations with this place. Learners define the cultural topography of this rural community by gathering information on the physical environment, the

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history, and demography which forms the bases of the community assessment in phases one and two of the CHASE model.

Cultural Topography Land Heratini/Geraldine is a rural township 140  km from Christchurch in the South Canterbury region of the South Island of New Zealand. It sits on the banks of Waihi River to the north, which is one of the major rivers in the Canterbury Plains, and the Four Peaks Mountain range in the Southern Alps and Talbot Forest to the west. It is surrounded by many small sub-communities that make up the Geraldine District of South Canterbury. The agricultural industry is the heart of the economy of Heratini/ Geraldine which has seen a substantial increase in dairy farms in the last 20 years throughout the region. The core types of agriculture involve agricultural crops, dairy farming, and rearing of livestock (Figs. 2.10 and 2.11).

Fig. 2.10  Dairy Cows in the Distance. (Produced by Mahoney with permission from Authors)

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Fig. 2.11  Mountain range. (Produced by London with permission from London Photography)

People and Their Culture South Canterbury is affiliated with the Māori iwi, Ngāi Tahu. The lines of earlier South Island iwi of Ngāiti Mamoe and Waitaha merged with Ngāi Tahu, but are especially strong in the region (Wilson, 2017). The Heratini area was a source of food gathering for Māori, including native birds such as kaka, tui, pigeons, ducks, quail, moa, and weka, and the Talbot Forest provided a source of hard woods for waka (canoes). There were very few Māori in South Canterbury at the time of European arrival (colonisation) – estimated at 100 and 200, who lived mainly in areas closer to the coast at Arowhenua and Waimate areas. Māori health and education facilities are now based in Arowhenua. Pakeha history post 1840 includes forestry as the main source of economy. With forestry came major roads and the subsequent establishment of small communities in South Canterbury in the 1860s–1870s. Following deforestation of the land, large sheep holdings were established. However, recent history (the 1990s onwards) has seen many large sheep farms converted into dairy farms which is reflected in the continued success and expansions of the Fonterra Dairy Factory (Fig. 2.12).

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Fig. 2.12  Geraldine Community Gardens. (Produced by Ross with permission from Authors)

Demography The population of Heratini/Geraldine at the 2013 New Zealand statistics was 2040 with an ethnic mix including European, Māori, Pacifica, Asian, and others (Statistics New Zealand, 2018). Asian ethnicity is the third most common population group living in Heratini/ Geraldine with Filipino making up most migrants (Immigration New Zealand, 2017). In 2015/2016, there were 1772 people who found employment as permanent migrants (Skilled Migrant Category principal applicants) in the Canterbury region (Immigration New Zealand, 2017). There were 7204 people approved for the ‘essential skills’ work visa in the wider Canterbury region, with the Philippines and India being the two most source countries, and livestock farmers the main occupation of ‘essential skills’ workers in Canterbury in 2015/2016 (Immigration New Zealand, 2017). Nurse learners connect community members and stakeholders in partnership and take collective action on issues identified through community profiling and assessment (Francis et al., 2013). A component of community engagement and assessment requires the learners to complete a SWOT and needs analyses of Heratini/ Geraldine and in partnership with community members, the stakeholders, and the presentation to the Kaitohutohu panel identified the migrant community and their health needs as a population of concern.

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Identified Population: Migrant Workers Migrant farm workers are employed in the rural dairy industry. They have immigrated to Aotearoa New Zealand as sponsored labour on a working visa for greater than 12 months as full-time permanent employees. They have satisfied trade-related qualifications required for entry into Aotearoa New Zealand. The main nationalities of migrants are Filipino and Indian, and they are often accompanied by family. The New Zealand government and the Ministry of Business Innovation and Employment (MBIE), through the Migrant Settlement and Integration Scheme, identified five outcomes that migrants desire to enable them to make Aotearoa New Zealand their home; these are employment; education and training; inclusion; English language; and health and wellbeing (Ministry of Business, Innovation, and Employment, 2015).

I dentified Health Needs: Migrant Workers Access to Primary Health-Care Services The Heratini/Geraldine community stakeholders identified the following health concerns for the migrants were in respect to access to primary health care and migrant workers being unfamiliar with navigating the New Zealand health system. These issues were as follows: a lack of enrolled population spaces in general practitioners services because the practices were fully enrolled, cost of appointments due to visa restrictions, and a lack of routine screening that all contribute to a lack of access to health services for migrants. Migrant workers were unfamiliar with New Zealand culture and health system, particularly the complexity of accessing primary health care, the limited access to resources, English language barriers, and employment protocols. These issues contributed to social, economic, and geographic isolation leading to physical and mental ill-health for migrant workers.

Identified Evidence-Based Review In phase three of the CHASE model, learners conduct a review of regional, national, and international evidence-based literature related to the identified population and health need. Critique of the literature assists learners to consider whether these findings could potentially improve the barriers to access and navigate the primary health-care system. The suitability of these findings or the need to adapt them is considered in response to the identified population and local rural community context identified as rural encounters. The literature review of the above issues futher collaborated the information identified by the community including a disconnection between the information

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presented by health providers and the health receivers; low uptake of health services and inconvenient time or place for migrants to access health care; limited health information resources that are distributed and available for migrants; reluctance of farmers to promote or make resources available; and barriers including language, access to technology and cultural divide, and apprehension of the immigration status for the immigrants (Migrant Community Social Services Report, 2013).

Identified Imaginative Resources Nurse learners respond to the critical analysis of the evidence-based literature completed in phase three of the CHASE model, and in phase four, learners develop an appropriate community health promotion message and resource(s) with the aim to improve health care of migrants connected to the Heratini/Geraldine community. It is in phase four that nurse learners engage with the Ottawa Charter for Health Promotion (World Health Organisation, 1986). The Charter has five key action areas and three health promotion strategies, and when employed together, it may envisage an improvement of the identified health need. Engagement of the Ottawa Charter has proven an effective platform for nurse learners to imagine and shape an appropriate health promotion message while co-creating a suitable resource, for the identified population and rural contextual encounters. Immigration New Zealand has recognised migrant labour vulnerability and has online resources including a guide for farmers’ legal and pastoral responsibilities (Ministry of Business and Innovation, n.d.). Information in this brochure includes immigration protocols, points of contact, health and safety information, and instructions and photographs to identify how to use machinery. However, in 2017, this booklet was only published in English. Therefore, the learners created a poster with information on how to contact emergency and other services to assist them and were translated into Tagalog (local dialogue) (Figs. 2.13 and 2.14).

Health Promotion Resources Learners’ Rationale and Consideration of Resources The key considerations in developing health promotion resources by the learners were to create visual resources to reduce health inequalities for migrants. The posters were designed as a guide to understand the complex nature of the New Zealand primary health system. Methods on how to communicate with health-care professionals were added including useful applications. Phone numbers of relevant services for migrant workers locally were included in the pamphlet. Tagalog is the most spoken language in the Philippines and translating into Tagalog aimed to address the language barrier.

2  Progressive Rural Community Collaboration… Fig. 2.13 Health promotion resource – poster in English. (Reproduced from Community based health services for older people living in the Moeraki and Hampden areas by Armon et al. (2018) with permission from Authors)

Fig. 2.14 Health promotion resource – poster in Tagalog. (Reproduced from Community based health services for older people living in the Moeraki and Hampden areas by Armon et al. (2018) with permission from Authors)

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Identified Impact Analysis Impact analysis related to the Heratini/Geraldine community development project is now presented in this section of the case study. Impact aligns with community stakeholders’ feedback; ethical cultural considerations nurse learners addressed, related to disparities for Māori presented to the Kaitohutohu Panel; teaching and learning pedagogy associated with the CHASE model; and graduate nurse professional practice reflections that concludes this case study as reported below. Impact Analysis: Community Feedback The 2017 case study was not evaluated until 4 years later, and the length of time from completion of the project to the impact analysis was found to be too long with many of the personnel and stakeholders that had changed and the resources had been lost. Despite a prolonged evaluation time that had lapsed, the professionals contacted in 2021 did identify that migrant worker health continued to be of concern for the community, and a team of learners returned to Heratini/Geraldine in 2021. The impact analysis found that many stakeholders had changed and no longer had copies of the resources created. However, 4  years later, the migrant workers’ access to health care remained a key issue by the present stakeholders within the community. Therefore in 2021, a second team of learners focused their community development project on migrant workers, rather than the general population of Heratini/Geraldine. Solutions require efforts on the part of both employers and health professionals. Immigration New Zealand has recognised migrant labour vulnerability and has online resources that include a guide for farmers as to their pastoral care and legal responsibilities (Immigration New Zealand, 2017). As for health professionals, Keating and Jaine (2016) found that when health practices collaborate with data that is ethnic-specific, individually they can develop quality improvement techniques based around specific cultural health needs of their migrant clients. Phase six of the CHASE model focuses directly on the impact of the creative designs associated with the health promotion messages and resources had on the identified community and the impact of the community development project on the community itself and stakeholders and impact on the learners’ professional nursing practice 1 or more years having completed their education. Impact Analysis: Ethical Cultural Considerations Phases two and five of the CHASE model is aimed at learners to address the disparities for Māori and present their findings from the community research and needs analysis to the Kaitohutohu Panel. The Office of Kaitohutohu are advisors within the educational institute who give support and advise on matters pertaining to

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Māori. The learners focused on answering four main questions, posed by the Kaitohutohu panel. This ensured that the learners approached constructing primary and secondary data with an emphasis on being culturally sensitive and maintaining a focus on the Māori population in Heratini/Geraldine to address and alleviate any inequities, demonstrating cultural sensitivity and understanding of Māori cultural protocol, values, and beliefs. Cultural respect is represented in the Code of Conduct regarding a person’s cultural, values, and beliefs of nursing practice in New Zealand (Nursing Council of New Zealand, 2012). Impact Analysis: CHASE Model in Action 2017 The original CHASE 2017 model was engaged with for this case study to guide learners’ community development practice (Fig. 2.9). The CHASE 2017 model was evaluated by the original developers who acknowledged its contribution but agreed the model needed to be updated to maintain effectiveness, and the CHASE model 2018 was created (refer to Fig. 2.15) for engagement by nurse learners in 2018. The evaluated version has two adaptations (highlighted in bold text); refer to Chap. 2 for details.

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Community Health Assessment Sustainable Education Model adapted by Ross & Mahoney (2018) published with permission from Ross, Crawley & Mahoney (2017). This work is licensed under a Creative Commons Attribution-NonCommercialNoDerivatives 4.0 International License

Fig. 2.15  CHASE model 2018. (Produced by Ross and Mahoney with permission from authors)

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Impact Analysis: Graduate Nurse Professional Practice Reflections Graduate nurses reflected (invited survey participation discussed in Chap. 6) on whether engaging with this Heratini/Geraldine community development project at an undergraduate level had any influence on their previous or current professional practice. This case study is an edited version of the community development project completed by nurse learners and facilitated by nurse academics, titled Community health project: Geraldine district. To review the full report, refer to Auld et al. (2017). We now draw on the second case study in this chapter which is representative of the CHASE model 2018 ‘in action’ related to the rural community of Moeraki, North Otago, Aotearoa New Zealand.

 ASE STUDY 2018: Rural Community, Moeraki, North C Otago, New Zealand Compiled by Laurie Mahoney and Jean Ross (2023)

Community Planning Community planning commences with the lecturer initially engaging with potential community stakeholders to gauge their interest in participating with a community development project, plans the project, completes the ethical application, and gains approval for students to proceed with the project. These activities are referred to as the pre-orientation stage of the CHASE model. At the orientation stage, nurse learners are introduced to the rural community of Moeraki situated in the North Otago region of the South Island (Fig. 2.16) and the CHASE 2018 model which guides their community development project (Fig. 2.17).

Chase Model in Action 2018 The CHASE model 2018 comprises a pre-orientation, orientation, and six phases showcased in this case study. Two adaptations (highlighted in bold) are comprised in the 2018 model. A change from the title Lecturer Responsibilities (highlighted by the dotted line) to Facilitator Responsibility and the impact assessment in phase six of CHASE becomes the responsibility of the student nurses during 2018 rather than the lecturer.

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Fig. 2.16  Map of New Zealand highlighting Moeraki. (Produced by Suzanne Thornton with permission from authors)

Moeraki

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Community Health Assessment Sustainable Education Model adapted by Ross & Mahoney (2018) published with permission from Ross, Crawley & Mahoney (2017). This work is licensed under a Creative Commons Attribution-NonCommercialNoDerivatives 4.0 International License

Fig. 2.17  CHASE model 2018. (Produced by Ross and Mahoney with permission from authors)

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Community Engagement Community engagement connects the learners with community stakeholders from Moeraki in phases one and two of the CHASE model. Learners define the cultural topography of this rural community by gathering information on the physical environment, the history, and demography which forms the bases of the community assessment. Learners describe its land, people, their culture, and demography which offers the opportunity to explore the relationship and connections between the people(s)’ past and present and the environmental and cultural influences of residing in Moeraki and its peoples’ associations with this place.

Cultural Topography Land Moeraki is small rural coastal/fishing community situated on a peninsula surrounded by steep hills and sloping cliffs, located an hour’s drive north of Dunedin (nearest urban city) in the Waitaki District, Otago, New Zealand. Native forest once covered the whole peninsula, but as colonisation progressed, it has been gradually cleared for farming. Local volunteers from Moeraki have partnered with the Department of Conservation since 1983, to manage a wildlife reserve at Katiki to encourage the endangered yellow-eyed and little blue penguins to nest and breed. Native vegetation has been planted to establish this breeding colony. Dogs are banned from the Katiki reserve to avoid disturbing the penguins and seals (Department of Conversation, n.d.). Moeraki is also known for the large spherical boulders on the Kohekohe Beach. These boulders originally started forming on the sea floor around 60 million years ago and became exposed through erosion from coastal cliffs (Fig. 2.18). According to Māori legend, these boulders are the scene of the loss of the Arai te uru canoe, during its voyage south searching for pounamu. “All pounamu is sourced from riverbeds and boulders in the South Island, especially the West Coast. The colour and markings of each stone vary according to its river source” (New Zealand Greenstone, n.d.) (Fig. 2.19). People and Their Culture Excavations of the southern Moeraki peninsula have identified an early Māori iwi Waitaha occupied the region in the thirteenth century, and carbon dating have confirmed a pā (village) with a small hapū (sub-tribe) occupied Moeraki in the late seventeenth and eighteenth centuries (Wikipedia, n.d.). Whalers established the European settlement in 1836. During the second whaling season, a company of Māori from Kaiapoi arrived in Moeraki by canoes and an old whale boat, settling

2  Progressive Rural Community Collaboration… Fig. 2.18 Moeraki Boulders. (Produced by Ross with permission from Authors)

Fig. 2.19 Pounamu. (Produced by Ross with permission from Baumgartner Family)

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Fig. 2.20  Moeraki Village. (Produced by Laurie Mahoney with permission from Authors)

about a mile from the European settlers, several of whom were employed by the whaling station (Pybus, 1954). Through the efforts of the Wesleyan missionaries of old Waikouaiti, Māori embraced Christianity. During the mid to late 1800s, the Māori population in Moeraki fluctuated frequently. In 1844 the population was 200, in 1861 it decreased to 64, then in 1869 it increased again to 100, and in 1907 the pā was abandoned, and Māori moved into the European fishing village (Taylor, n.d.) (Fig. 2.20). Demography According to New Zealand 2013 Statistics (Statistics New Zealand, 2013), there were 100 residents living in Moeraki, with a median age of residents being 60 years, compared with Dunedin City where the figure was 36.7 years. Thirty-six percent of residents living in Moeraki were over the age of 65 years. Twelve percent were under the age of 15 years. The number of individuals aged over 65 is significantly different to Dunedin city, where only 15% of residents are aged over 65 (Statistics New Zealand, 2013). The community is predominantly of European descent, with 10.5% identifying as Māori and 1.1% identifying as coming from one of the Pacific Islands (Statistics New Zealand, 2013). Community development is a process that nurse learners engage with to connect community members and stakeholders in partnership and take collective action on

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issues identified through community profiling and assessment (Francis et al., 2013). Following the community assessment, the learners completed a SWOT (strengths, weaknesses, opportunities, and threats) and needs analyses of Moeraki and in partnership with community members and stakeholders and KTO presentation identified the senior adults (elderly or older adults) as a population of concern.

Identified Population: Senior Adults of Moeraki Barriers preventing seniors from accessing health care in Moeraki situates them as a vulnerable group within this community.

I dentified Health Needs: Access to Health-Care Services for Senior Adults of Moeraki Access to health care: Many people who have multiple chronic conditions reported themselves as having a healthy and active health status despite many falling into the clinical category of moderate to serious health. Rural transport: Rural residents are often required to travel to different areas and usually long distances for health-care services and the facilities they need (Francis et  al., 2013). Similarly, health-care workers often need to travel long distances to access rural communities (Francis et al., 2013). If an elderly person cannot drive and have health issues that need attention from services that their community does not provide, the cost to travel out of town and the cost for the appointment can become an issue and, therefore, lead to poorer overall health (Syed et al., 2013). Rural isolation: Social isolation and loneliness result in higher risks of mortality in those over the age of 52 years (Bailey, 2017). Geographic isolation and distance from services are reasons that rural populations have health inequalities (Francis et al., 2013). If there are few or no health-care facilities in the residential area, then residents, especially seniors, often find it too difficult to travel to other areas or feel it’s a burden on health-care workers coming to them (McCann et al., 2005).

Identified Evidence-Based Review In phase three of the CHASE model, learners conducted a review of regional, national, and international evidence-based literature related to the identified population and health need. Critique of the literature assisted learners to consider whether these findings could potentially improve the access to health-care services for senior

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adults in Moeraki. The suitability of these findings or the need to adapt them is contemplated in response to the identified population and local rural community context. How nurse learners responded to this critical analysis is determined in phase four of the CHASE model.

Health Promotion Resources Nurse learners respond to the critical analysis of the evidence-based literature completed in phase three of the CHASE model, and in phase four, they developed an appropriate community health promotion message and resource(s) with the aim to improve access to health-care services for senior adults connected to the Moeraki community. It is in phase four, nurse learners engage with the Ottawa Charter for Health Promotion (World Health Organisation, 1986). The Charter has five key action areas and three health promotion strategies, and when employed together, it may envisage an improvement of the identified health need. Engagement of the Ottawa Charter has proven an effective platform for nurse learners to imagine and shape an appropriate health promotion message while co-designing a suitable resource, for the identified population and rural contextual encounters. Co-design Resources To increase knowledge of health services for the senior population in the Moeraki community, the learners created an information leaflet for publication in the local community newsletter which gives an overview of available health resources nearby the community. A plan was established to hold an information session in conjunction with community health providers. The aim was to provide an information about the availability of health-care services to community members in an informal way. Community stakeholders suggested that the event be held in the nearby District Memorial Centre in Hampden (near Moeraki). All members of the community were invited to attend. The second resource was an information leaflet submitted to the local community newsletter, outlining information on the available health-care services (Fig. 2.21). Learners’ Rationale and Consideration of Resources A leaflet with relevant information was designed to be visually appealing with the benefit of being able to reach residents who may not have Internet access. The leaflet included a tear-off section, so that interested residents could keep the

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Fig. 2.21  Health promotion resource – invitation poster to community event. (Reproduced from Community-based health services for older people living in the Moeraki and Hampden areas by Armon et al. (2018) with permission from authors)

information on hand after they had disposed of the newsletter. Publishing in local media such as newspapers is an effective way of communicating with the community to promote available health services. Community development and health promotion are understood to have a positive impact on communities as they empower the community to use the resources available and provide awareness of services.

Identified Impact Analysis The health promotion resources together with a written report inclusive of the Moeraki community profile, assessment, identified health needs of the identified population group, a critical analysis of the evidenced-based literature review, and community resources were presented back to the community stakeholders in phase five of the CHASE model, prior to the engagement with phase six which focused on the community impact analysis. Phase six of the CHASE model focused directly on the impact of the community development project and creative designs of the health promotion message and resources with feedback from the Moeraki community stakeholders. The impact of the creative designs associated with the health promotion messages and resources aligned with the 2018 case study was evaluated by the nurse learners 3-6 months following completion of phase five of the CHASE model. Learners evaluated the

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potential impact the health promotion message and resources developed in phase four of the CHASE model had on the identified population. Evaluation from stakeholders’ impression of engaging with the community project was also considered. Further ethical cultural considerations nurse learners addressed, related to disparities for Māori presented to the Kaitohutohu Panel; teaching and learning pedagogy associated with the CHASE model. Impact Analysis: Community Feedback The 2018 case study situates the identified barriers preventing seniors (the identified vulnerable population) from accessing health care in the rural community of Moeraki situated within the North Otago region of the South Island. Once the learners decided on the health promotion resource, they revisited and consulted community stakeholders to gather their feedback and ideas which was very positive. Most community stakeholders were very keen to implement the local information session immediately. The learners explained that for the project, they were in a position only to get the resources developed to the point where they were ready to be implemented; however, they needed to hand them over to the community and leave it up to them to decide if they wanted to make use of these ideas. These ideas ranged from an information session that could be held at the community church, but on consulting one of the stakeholders, it was recommended this session be held at the local community hall, to assist with parking and the safety of seniors. Additionally, they mentioned the local rural women’s group would be useful in facilitating the event. Also, due to targeting seniors, holding the session in the afternoon or morning would be preferred including the provision of a morning/ afternoon tea which is a way to attract people to the event. Overall, community members seemed enthusiastic about the resources developed and wanted to make use of them. Impact Analysis: Ethical Cultural Considerations Phase three of the CHASE model is aimed at learners to address the disparities for Māori and present their findings from the community research and needs analysis to the ethical cultural considerations  – the Kaitohutohu Panel. The Kaitohutohu are advisors within the educational institute who give support and advise on matters pertaining to Māori. The group focused on answering four main questions. This ensured that the learners approached constructing primary and secondary data with an emphasis on being culturally sensitive and maintaining a focus on the Māori population of Moeraki and address and alleviate any inequities, demonstrating cultural sensitivity and understanding of Māori cultural protocol, values, and beliefs.

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Cultural respect is represented in the Code of Conduct regarding a person’s cultural, values, and beliefs (Nursing Council of New Zealand, 2012). Impact Analysis: CHASE Model in Action 2018 The CHASE model 2018 guided the nurse learners as they engaged with the Moeraki community development project. The CHASE model 2018l was evaluated by the original developers who acknowledged its contribution but agreed the model needed to be updated to maintain effectiveness as a teaching and learning model and the CHASE model 2019 was created; refer to Fig. 2.22. The CHASE 2018 model was engaged with for this case study to guide learners’ community development practice (Fig. 2.17). The CHASE 2018 model was evaluated by the original developers who acknowledged its contribution but agreed the model needed to be updated to maintain effectiveness and the CHASE model 2019 was created (refer to Fig.  2.22) for engagement by nurse learners in 2019. The evaluated version has one adaptation (highlighted in bold text) discussed in this chapter.

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Community Health Assessment Sustainable Education Model adapted by Ross & Mahoney (2019) published with permission from Ross, Crawley & Mahoney (2017). This work is licensed under a Creative Commons Attribution-NonCommercialNoDerivatives 4.0 International License

Fig. 2.22  CHASE model 2019. (Produced by Ross and Mahoney with permission from authors)

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Impact Analysis: Graduate Nurse Professional Practice Reflections Graduate nurses reflected (invited survey participation discussed in Chap. 6) on whether engaging with this Moeraki community development project at an undergraduate level had any influence on their previous or current professional practice. This case study is an editored version of the community development project completed in 2018 by nurse learners and facilitated by nurse academics, titled Community based health services for older people living in the Moeraki and Hampden areas. To review the full report, refer to Armon et al. (2018). Further case studies demonstrate additional iterations to the CHASE model 2019–2022 and are presented in Chaps. 3, 4, and 5.

Conclusion The original CHASE model 2017 has been adapted to accommodate learners’ evaluations and change in community contexts and is responsive to progressing this model within the wider national and global landscapes including the rural geographical regions of the Pacific, the UK, and Australia (Ross et al., 2020b) to accommodate a changing health-care landscape that includes the COVID-19 pandemic. The CHASE model guides learners to engage with an identified rural community to complete a community profile and assessment while identifying its assets and services. Learners progress with this assessment and analyse the data and then complete a SWOT analysis to identify vulnerable population(s) and their health need(s) in collaboration with community stakeholder. Learners complete a literature review on the identified topic(s) which assists them to plan purposeful interventions which meet the identified population group and their health needs and create a purposeful health promotion message supported with meaningful resources that have been designed by the nurse learners and are appropriate to the population and community circumstances with the aim to improve health care and reduce health disparities (discussed in detail in the following chapter). The CHASE model has been adapted into several iterations to accommodate various rural communities and countries’ individual requirements and to apply it in practise. Initially, the CHASE model consisted of a pre orientation, an orientation, and six phases. As our work has progressed, these six phases have been extended to include an additional two five phases as the research and circumstances have evolved. The CHASE model raises nurse learners’ awareness of community development in rural contexts. What is important is demonstrating that this work can impact positively, on health outcomes, and reduce disparity with the creation of health promotion resources designed by nurse learners. Learners engage with a problem-solving process when they engage in system and design thinking. Design thinking enlightens nurse learners’ creativity, as they develop health promotion resources. It is because of this process we acknowledge nurse learners as designers, which we discuss in the following chapter (Chap. 3).

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Ross, J., Crawley, J., & Parmee, R. (2023). The rural way: Rural nurses’ contribution to new models of health care, reducing health disparities-stories from practice. In C. Rusangwa (Ed.), Rural health – Investment, research and implications. https://doi.org/10.5772/Intechopen.109768 Smith, J.  G. (2022). Rural nursing health services research: A strategy to improve rural health outcomes. Journal of Advanced Nursing, 78(8), 2257–2663. Stanley, J., Harris, R., Cormack, D., Waa, A., & Edwards, R. (2019). The impact of racism in the future health of adults: Protocols for a prospective cohort study. BMC Public Health, 19, 346. https://doi.org/10.1186/s12889-­­019-­­6664-­­x Statistics New Zealand. (2018). Geraldine. https://www.stats.govt.nz/tools/2018-­­census-­­place-­­ summaries/Geraldine#work Syed, S., Gerber, B., & Sharp, L. (2013). Traveling towards disease: Transportation barriers to health care access. Journal of Community Health, 38, 976–993. https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC4265215/ Taylor, W. L. (n.d.). History of the South Island Māori. Victoria University of Wellington. http:// nzetc.victoria.ac.nz/tm/scholarly/tei-­­TayLore-­­t1-­­body1-­­d12.html Te Rautaki Māori ki Te Kura Matatini ki Ōtāgo. (n.d.). Maori Strategic Framework 2020–2022 //efaidnbmnnnibpcajpcglclefindmkaj/, https://online.op.ac.nz/assets/K04298_2020-­­ MaoriStrategicFramework_WEB.pdf United Nations Sustainable Goals. (n.d.). http://www.un.org/sustainabledevelopment/news/ communications-­­material/ Wikipedia (n.d.). Moeraki. https://en.wikipedia.org/wiki/Moeraki#cite_note-­­McDonald-­­7 Wilson, J. (2017). South Canterbury region – Māori in South Canterbury. In Te Ara – The encyclopedia of New Zealand. http://www.TeAra.govt.nz/en/south-­­canterbury-­­region/page-­­4 World Health Organisation (1986). Ottawa Charter for health promotion. https://www.who.int/ healthpromotion/conferences/previous/ottawa/en/ World Health Organisation. (2022). https://www.who.int/news-­­room/fact-­­sheets/detail/nursing-­­ and-­­midwifery

Chapter 3

Creative Designs: Health Promotion Resources Aligned with Rural Community Health Laurie Mahoney, Phil Osborne, and Jean Ross

Abstract  The Community Health Assessment Sustainable Education model provides nurse learners with the knowledge and skills, a component of the Bachelor of Nursing programme in Aotearoa New Zealand, to accomplish a community development project. Community development projects are a vehicle for nurse learners to engage with population health. This clinical placement exposes learners to identify health disparities, as they analyse data associated with geographically rural communities and population groups. Population and community health are fundamental features of primary health care, in which learners become immersed in problem-­ solving principles including systems-thinking and human-centred design. In phases one-six of the Community Health Assessment Sustainable Education model, nurse learners employ design principles supported by the Ottawa Charter for Health Promotion to design appropriate health promotion resources and improve identified population health. Nurse learners are working within a design landscape, which we showcase in the case study and excerpts of creative health promotion resources, presented in this chapter. Nurses throughout history have and continue to reveal their capacity as designers, initially exemplified by Florence Nightingale who was considered a leading nurse designer. We acknowledge her work in this contemporary space affiliated with hospital health-care facilities and community public health environments.

L. Mahoney (*) Te Whata Ora, Southern and Otago Polytechnic | Te Pūkengad, Dunedin, New Zealand e-mail: [email protected] P. Osborne Te Maru Pumanawa | College of Creative Practice and Enterprise, Otago Polytechnic | Te Pūkenga, Dunedin, New Zealand e-mail: [email protected] J. Ross Te Kura Tapuhi | School of Nursing, Otago Polytechnic | Te Pūkenga, Dunedin, New Zealand e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. Ross et al. (eds.), Rural Landscapes of Community Health, Global Perspectives on Health Geography, https://doi.org/10.1007/978-3-031-43201-9_3

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Keywords  Design · Systems-Thinking · Resources · CHASE model · Health · Nurses

Introduction In this chapter, we extend our involvement with the Community Health Assessment Sustainable Education (CHASE) model (Ross et al., 2017) described in Chap. 2. Learners engage with a problem-solving process and employ systems and design thinking principles, illustrated in all six phases of the CHASE model. Design thinking incorporates human-centred design (HCD) (Norman & Spencer, 2019) and when applied with the principles of the Ottawa Charter for Health Promotion (World Health Organisation [WHO], 1986) with the aim of enlightening nurse learners’ creativity, as they develop health promotion resources. To accomplish this aim, we acknowledge nurse learners as designers, which we showcase in the case study and excerpts of creative health promotion resources developed by nurse learners, presented in this chapter. We are reflective of nurses as designers, paying tribute to Florence Nightingale, a leader improving the health of individuals, populations, and communities and the architectural design of hospitals. It is in this chapter we focus on the question, why is it important to acknowledge the nurse as designer, in the space of community development?

Problem-Solving Problem-solving is a fundamental principle underpinning the community development process (McConnell et al., 2022) with the aim to raise nurse learners’ awareness, of community health needs associated with identified population groups (Ross et  al., 2017). Nurse learners engage with problem-solving principles, systems-­ thinking, and design thinking. These principles enlighten nurse learners’ creativity, to assist in improving health outcomes with the production of health promotion resources, as a component of their clinical placement. This is underpinned by the CHASE model’s phases one-six. When a problem-solving process works succinctly with systems-thinking, they are powerful tools for understanding and addressing complex problems. Problems need to be identified and clarified with community stakeholders, goals developed with a plan of action and implemented, and outcomes evaluated. System-thinking has its roots in the early twentieth century, when a group of scientists and philosophers, including Ludwig von Bertalanffy, Norbert Wiener, and W. Ross Ashby, began to challenge the prevailing reductionist paradigm that had dominated scientific thinking since the enlightenment (Career Foundary, n.d.). These thinkers saw the world not as a collection of isolated parts, but as a complex web of interdependent systems. In the 1950s and 1960s, systems-thinking gained

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popularity in fields such as management, engineering, and social sciences. This was due in part to the work of Jay Forrester and his colleagues at the Massachusetts Institute of Technology, who developed the field of system dynamics to help understand complex systems like urban growth and industrial production. While systems-thinking is used in a wide variety of fields, from health care to education to environmental sustainability, nurses are system-thinkers by the pure nature of their clinical practice (Stalter et  al., 2018). Complexity is inherent in nurses’ practise as they interact with individuals, populations/groups, or communities. Nurses routinely navigate complex situations requiring them to uncover and dig deep to expose diverse problems, engage with evidence-based information, and create solutions to improve health outcomes, as these are implemented and tested. Nurses become aware of complex problems as part of their community practice. Engaging in systems-thinking, nurses can address the intricacies of community issues that may be multifaceted. Communities are made up of organisations and institutions which relate with each other in complex ways. People, organisations, and environments interact with each other, therefore raising awareness of external influences such as economic and political changes, natural disasters, and environmental factors which can have impact on community health. Systems-thinking looks for the connections and relationships and the effects between one thing and another, which highlights the complex nature of problem-solving (Philips et  al., 2018). This means that systems are interconnected and changes in one system can affect other systems. In community health nursing, it is important to be aware of the interdependence and changing systems. By collaborating with community stakeholders, nurses are able to understand how changes in one system can affect another; this will inform the community health nurse in the design of solutions and resources or interventions that may reduce health disparities and inequities. As nurses work as designers in complex situations, nurse learners need the opportunity to develop these skills.

Design Thinking Design thinking is considered a unique method of problem-solving; it puts people at the centre of its focus (IDEO, n.d.-a). The aim of this focus is to observe people in their own contexts with the intension to describe the problem as it is experienced by the people themselves in their own space and place. This information then provides the designer a comprehensive insight and opportunity to understand the problem in more detail. This extensive insight relies on developing a collaborative relationship between community partners and designer or in our case the nurse learners. These associations assist in building empathetic relationships. This empathetic relationship uses the observations to assist in developing creative solutions that are meaningful to the people they are being created for; they are then tested for applicability with the same people.

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Norman and Spencer (2019) explain that the four major phases of design thinking are human centred – it’s about the people. The goal is to expose the problem related to systems which are interrelated with other systems, creating a solution that is tested and refined and tested again. Design work is not left to only designers (IDEO, n.d.-a). This has led us to consider the role of nurses as designers and possible benefits of utilising human-centred design (HCD) frameworks and processes to improve the development of design and acknowledgement of nurses’ creative practice. Through the work of Tim Brown and his global design company IDEO, HCD has been democratised beyond the realm of classically trained designers (IDEO, n.d.-b). While this has caused consternation within the design industry, many disciplines including engineering and computing have adopted its principles with success (Stevens, 2021). Likewise, health disciplines are engaging with HCD (Richardson & Ash, 2010) but with less vigour than other disciplines, in particular nurses are not routinely supported to engage with HCD from their organisations (Zuber & Moody, 2018). Engaging with a problem-­ solving approach, nurses accentuate empathy with the identified population group or aggregate to apply a design process to the known health disparity. Brooks-­ Carthon et al. (2021) promote the engagement with a four-stage approach of design being discover, develop, design, and deliver, a traditional nursing process. We can use the four phases of design thinking as a framework to consider the CHASE model: 1. Ensuring the core of the problem (cause) is identified, not only what is presented – CHASE phases one and two 2. Having people at the core of thinking – all stages and phases associated with the CHASE model 3. Applying a systems lens to the issue, because there are often multiple parts that contribute to the issue – all phases associated with the CHASE model 4. Testing and refining and testing again until the issue for the people is resolved – CHASE phase six We use the original HCD image (IDEO Design Thinking, n.d.) and adapt it for a nursing context to fit more closely with the phases of the CHASE model. Refer to throughout this chapter in Figs. 3.1, 3.2, and 3.3 representing our engagement with the individual components of design thinking, into a practical method. The HCD principles include empathise, define, ideate, protype, and test (refer to Fig.  3.1). However, these steps are not lineal; rather they intertwine throughout the design process. The HCD principles can be simply aligned with the adaptation of the classic five steps of the Design Thinking Process (Leung, et al., 2020). Our adaptation engages with Double Diamond Thinking (DDT) in Fig.  3.2. The DDT is a versatile and powerful tool for problem-solving. It is a model used in design thinking that has been applied to computing, education, health care, and more. Initially developed by the British Design Council (Design Council, n.d.), this model engages with critical thinking and reflective practice with the aim of acknowledging a problem and developing a solution. This is where DDT is beneficial, offering a structured approach to problem-solving that combines both divergent and convergent thinking or in other

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5 STEPS OF THE DESIGN THINKING PROCESS

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words taking a broad and narrow method. By combining both divergent and convergent processes, individuals and teams can generate, develop, and implement creative and innovative solutions that better meet the needs of stakeholders and deliver desired outcomes in a collaborative and co-creation process as highlighted in Fig. 3.2. The second diamond tests the assumption of the first through prototyping solutions. Convergent or narrow approach focus on confining down options and creating the best possible solution and involves analysing and evaluating different ideas to determine the most effective one. This approach is often used in situations where

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CHASE Model 2019 Develop health C t promotion n enmessagesoand n g Initialvpresentation r resources ver er e with stakeholders, ge v ge i Kaitohutohu n(Mā oriD nt t and ethical approval) identify health needs

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there is a clear goal or objective, and the focus is on finding the most efficient and effective way to achieve it. Alternatively divergent or broad thinking involves generating a wide range of ideas and possibilities. It involves exploring multiple solutions and options, without evaluating or criticising them. This approach is often used in situations where creativity and innovation are important, and there is no clear solution to the problem. By combining these in a structured approach, the learners are encouraged to cycle through different perspectives (phase four of the CHASE model and the ideate HCD principle) allowing a wider and more diverse solution set to be developed, distributed, and tested (evaluated). The overall aim is to develop an appropriate health promotion message and resource and its ability to improve the health issue and reduce health disparities related to the identified population and health needs (aligned with the CHASE model, phases five and six, and the HCD test principle).

Design Application The following sections of the chapter expands on the problem-solving process, embedded within systems-thinking (Norman & Spencer, 2019; Stalter et al., 2018) while enhancing the design application in relation to the CHASE model. In Chap. 2,

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the stages and phases of the CHASE model were introduced in chronological order as the process of a community development project proceeds. It is in this chapter we revisit these phases to exemplify the design process. Given the plethora of attention of applying design in different contexts, we present a simple set of principles and tools based on HCD principles and DDT combined that can be used to connect the development of nursing practice with design. We apply these principles as we examine how design thinking has been applied in the formation of the community development process by the nurse learners as they engage with the CHASE model 2019 in Fig. 3.3. The HCD empathise component aligns well with nursing fundamentals to care, as holding the needs of the client/patient and community is paramount in any solution that provides strong connections to nursing theory and practice (Watson, 2005). Watson (2005) emphasises that ‘… when we include caring and love in our science, we discover our caring-healing professions and disciplines are much more than a detached scientific endeavour, but a life-giving and life-receiving endeavour for humanity’ (p. 3). While the empathise component of the HCD commences for nurse learners initially in phases one and two of the CHASE model and provides them an opportunity to understand and associate with the geographical area, cultural topography, the people and their history, the land/place, and demographics. It is in these phases learners complete the community profile and assessment. The CHASE model assists nurses in their mission to expose complex problems that impact on health in relation to specific community and population groups. Problems are identified through primary and secondary data collection, and with this information the team of nurse learners conclude phase two of the CHASE model with a strengths, weaknesses, opportunities, and threats (SWOT) analysis. This analysis helps to identify potential health problems aligned with an identified population group or rural community. Identifying health problems are a decisive phase of the community development project requiring learners to undertake the process of critical thinking in which to question, analyse, interpret, evaluate, and identify the community development project goals. Learners can recognise how real-life problems and disparities for minority groups leads to health issues and is reflective of rural communities which have specific needs that may not be found in more urban areas (discussed in Chap. 1). For the nurse learners, the rural communities can be seen as the ‘user group’, and design approaches prioritise identifying their needs during the ‘empathise’ and ‘define’ (the problem) HCD stages (Leung et  al., 2020) and that, with empathy in the design thinking process, will support vulnerable communities to develop resilience (Afroogh et al., 2021). Once the health issue and vulnerable population group(s) have been identified (in consultation with community stakeholders), the learners complete an evidence-­ based literature review (Whitehead, 2020) which leads onto engaging with phase three of the CHASE model and the HCD principle, ‘ideation’. This review enables nurse learners to critically analyse how this evidence could benefit population groups and improve health outcomes while putting the population group in the centre of the problem solving and system-thinking process. Complex problems or

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problems that are difficult to solve can be defined as ‘wicked’ (Stevens, 2021). This means that problems are: • • • • •

Unique and novel Difficult or impossible to solve Characterised by incomplete factors and complex interdependencies Subject to contradictory evidence Dependent on multiple stakeholders, often with conflicting interests

Nurse learners navigate the ‘wickedness’ of the problem in collaboration with community stakeholders, guided by the academic facilitator. Together they identify the distinctiveness of the identified problem which is unique to that community and its context and particular population group. The problem can be difficult to solve and may raise uncertainty amongst community stakeholders. However, nurse learners have a commitment to complete the community development project and keep the momentum flowing. Where the wickedness of the problem is apparent, the application of design thinking for nurse learners becomes more evident as the design development of a resource is created; refer back to Fig. 3.3 – ideate.

Design Development In the design process, learners focus on the target audience (population group or community problem) supported with the evidence they have critiqued and work towards designing a health promotion message and resource to improve health outcomes. During this process, learners acknowledge potential hazards, gaps in services, and/or lack of available resources. Nurse learners proceed with conception and prototyping and create the health promotion messages and resources for identified groups, phase four of the CHASE model. This process requires learners to work towards clarifying a solution that fits best for the identified group, for example, the geographical location, cultural otherness, the engagement of appropriate language, and ethnic makeup of the community including indigenous health needs and access to health-care services. Learners also take into consideration the ability of the intended audience to access and view the health promotion resources. The prototype or in our case the health promotion message and resource is developed by the nurse learners in a team approach with all team members sharing their thoughts and ideas. This process can take from hours to days to finalise the issue to be addressed, depending on the wickedness of the issue, and for the team of learners and community stakeholders to agree on the best approach of how they will share the knowledge that has been generated. Nurse learners apply the principles of the Ottawa Charter for Health Promotion (World Health Organisation [WHO], 1986) in association with the identified community’s asset or strengths and gaps (ascertained from the analysis of the community assessment phase one of the CHASE model) to assist them in developing appropriate community-focused health promotion messages related to the identified

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health need and population. The mission of the Ottawa Charter is to promote health at a global level while focusing health at the community level. Its goal is social justice, and it acknowledges the availability of local assets and identifies areas for improvement. The Ottawa Charter has five key action areas (included below) for health promotion which are aligned with the philosophy of public health activities. These activities are grounded in a ‘[primary health care] approach of grassroots community development and an ecological view of health’ (McMurray & Clendon, 2015, p. 64). The Ottawa Charter five action areas when employed together, with the three health promotion strategies, advocate, enable, and mediate, can envisage an improvement of identified health needs. The five action areas are: Building healthy public policy: Requires health professionals to advocate, enable, and mediate on behalf of communities to influence decision-makers, so they become aware that health needs to be a part of all public policies (intersectoral), so all decision-makers consider health as a significant aspect of policy development. Similarly, when health policy becomes ineffective, creating appropriate and beneficial public policies using evidence-based solutions can promote individual and population groups to achieve better health outcomes. Improved public health policies aim to create health awareness and community participation opportunities and build capacity (McMurry & Clendon, 2015). Create supportive environments: Requires health professionals to embrace the socio-ecological model to advocate, enable, and mediate on behalf of communities. The socio-ecological model encourages individuals and communities to focus on conserving environmental resources and capitalising on individual community assets. Respecting and valuing these resources can support individuals to maintain and preserve their health ‘including physical or social resources’ (McMurry & Clendon, 2015, p. 64). Strengthening community action: Requires health professionals to advocate, enable, and mediate on behalf of communities to ensure communities receive up-to-date information and resources. These resources support community people in the process of community action as decisions need to be considered and worked through. This can be guided by the SWOT analysis completed in the CHASE model phase two. As a community takes action, best evidence is required to plan and make informed decisions with the community’s best interests at heart. Develop personal skills: Requires health professionals to advocate, enable, and mediate on behalf of individuals and communities to ensure they are empowered to take control of their health including the social, ecological, economic, and environmental factors. To ensure this key area is successful, people in the community develop appropriate skills, so they can contribute to making informed decisions as to the best way to use resources effectively to benefit the community (McMurry & Clendon, 2015). Reorientate health services: Requires health professionals to advocate, enable, and mediate on behalf of individuals and communities to reorient health services towards engaging with best evidence that can improve the health of individuals. This requires the health sector to change from focusing primarily on clinical and

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curative services to an increased focus on health promotion and prevention (McMurry & Clendon, 2015). In this next section, we illustrate a range of health promotion resources developed by several teams of nurse learners between 2017 and 2022. These resources complement the resources included in the case studies throughout this book but are extended further in this chapter with examples of ‘minority groups’ considered as vulnerable populations who encounter health inequities. Engagement with the Ottawa Charter has proven to be an effective platform for nurse learners to shape appropriate health promotion messages and resources in phases four and five of the CHASE model.

Designing for Different Populations and Health Needs Nurse learners work together and with the nurse academic facilitator create suitable resources for the identified population group(s). Examples of resources in this section of the chapter demonstrate health issues equated with minority groups, including women, children, youth, migrants, and rural environments. Given these groups have different ability to access information (because of rural contextual encounters), the team of nurse learners is considerate to these needs in their design and creation of a collection of health promotion resources, meeting individual population, and environmental needs. As nurse learners progress with the community development projects, the CHASE model offers them an opportunity to release their creativity and curiosity which are core competencies of the design thinker. These are important skills for problem-solving and applying health promotion messages into creative resources. Traditionally for nurses, this entails the combination of ‘the art and science of nursing’, with knowledge and skills being typically considered the ‘art of nursing’ (Connett-Finfgeld, 2008; Henry, 2017). A more recent emphasis draws attention to the creativity as an aspect of nursing expertise. Cheraghi et al. (2021, p. 394) bring to our attention: [c]reativity in nursing care is a complex concept… Creativity has various meanings, such as creating, making, producing designs, product relationships and attributes, a new and useful set of operations, reconstruction of old ideas, and a problem-solving method. However, the implementation of creativity in nursing clinical settings is of particular importance.

Based on our practical and research experience, we agree with Cheraghi et  al.’s (2021) examination on the topic, and we contend that the ‘art’ of nursing incorporates the capacity for nurses to adapt their practice through the art of creative design using systems- and critical thinking.

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Design Examples In some cases, social media access has been created, for instance, for isolated young mothers to assist their communication together and to receive support from health professionals. Whereas pamphlets have been designed that can be taken away and read in private, posters have been designed for adults who may view them in a more public area or space. Some pamphlets and posters have been translated into people’s native languages, for instance, for migrant groups, while other health promotion resources have been designed to be a discussion or a talking point, for instance, beer coasters at the local public house. Yet other resources have been designed to be interactive, for instance, a stress ball for young children to use and respond to the message on it. And a book has been developed to be shared by teachers with young pupils. In some cases, a key gap in services addressing the health issue is the lack of services in a rural area, for example, maternity care, where a written submission has been developed with the purpose directed to the Minister of Health to address this need. The following designs have been selected to present a variety of health promotion resources representative of the target or intended audience at national, regional, local, and environmental levels within different Aotearoa New Zealand rural geographic locations. To organise the presentation of these resources, we have developed the following model; refer to Fig.  3.4. to illustrate the examples of health promotion messages and resources.

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Fig. 3.5  Map Tāhuna/ Queenstown. (Produced by Suzanne Thornton with permission from authors)

National Level Health promotion resources of the prototypes are created and aimed at the national and policy level to advocate for vulnerable minority populations. This includes writing submissions to government ministries and local body authorities providing them with evidence about the lack of services in a particular rural area. Queenstown-Lakes District of Central Otago, South Island, New Zealand In the Queenstown Lakes area of Central Otago, New Zealand, nurse learners identified that there were no maternity services available. Learners in 2017 identified that pregnant women were required to drive 3–4 hours to a regional hospital to give birth. For many women, this meant leaving their families including their children and their farm/occupation and support networks for a few days for them to safely deliver in a hospital, with some women needing to leave their home for several weeks prior to delivery. The learners wrote and presented a submission to the Minister of Health in New Zealand advocating for maternity services to be provided locally. Applying the principles of the Ottawa Charter for health promotion (WHO, 1986), this met two of the five principles, those being building healthy public policy and strengthening community action (Figs. 3.5, 3.6, and 3.7). This national example relates to the community development project titled Improvement and sustainability of maternity level care in the Lakes District. To review the full report, refer to van Stijn, et al. (2017).

Regional Level At the regional level, several teams of learners identified environmental issues as the topic or health need to explore exemplified in Rakiura/Stewart Island, Bluff and Warrington.

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Fig. 3.6 Queenstown Lake. (Produced by Wilson with permission from Sarah Wilson)

Rakiura/Stewart Island, New Zealand Rakiura/Stewart Island is the southernmost inhabited island in Aotearoa New Zealand. In 2021, nurse learners profiled this isolated coastal community and found that visitors and tourists had a lack of awareness about island life and the need for understanding of sustainability issues. The community stakeholders identified that there was a significant increase in New Zealander’s visiting because of international border closures caused by COVID-19 lockdown. As local tourism increased, so did an increase usage of local electricity. Electricity is generated on the island, and the increase of visitors was placing a strain on the local resources, both environmentally, economically, and sustainability. The health promotional resource created targeted visitors with a simple message, ‘Sustainability for Future Generations’ which was placed in accommodation venues to inform visitors. Applying the principles of the Ottawa Charter for Health Promotion (WHO, 1986), this met two of the five principles, those being creating supportive environments and strengthening community action (Figs. 3.8, 3.9, and 3.10). This regional environmental example relates to the community development project titled Te Punga o Te Waka a Māui (Rakiura/Stewart Island community assessment. To review the full report, refer to Philips et al. (2021). Bluff, South Island, New Zealand Motupōhue/Bluff is a small coastal rural community with a population of less than 2000 in the southernmost region of Aotearoa New Zealand. There, New Zealand’s only aluminium smelter, Tiwai Point, is the main employer for local and regional people and generates sales, and goods and services in the Southland region exceeding $1600 million, contributing heavily to the New Zealand economy Learners in 2019, examined the health risks to the community and found various attributing factors associated with respiratory illness including asthma and chronic obstructive pulmonary disease attributed to a coastal region and the burning of local coal in old Shacklock ovens in the homes. The learners developed a health promotion message to reduce indoor air pollution to promote healthier environments and reduce

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Fig. 3.7  Health promotion resource – submission. (Produced by Suzanne Thornton with permission from authors) (Refer to van Stijn et al. (2017))

exacerbation of respiratory illnesses. They designed an interactive fridge magnet to be the resource that supported the health promotion message. The information on this resource is intended to support the reduction in indoor air pollution from coal burner by reminding homeowners to sweep their chimneys annually. Applying the principles of the Ottawa Charter for Health Promotion (WHO, 1986), this met two

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Fig. 3.8  Map Rakiura/ Stewart Island. (Produced by Suzanne Thornton with permission from authors)

Fig. 3.9  Rakiura Harbour. (Produced by Ross with permission from Jean Ross)

of the five principles, those being creating supportive environments and strengthening community action (Figs. 3.11, 3.12, and 3.13). This regional environmental example relates to the community development project titled The impact of environmental air pollution on the wider community of Bluff: Looking at sustainable prevention. To review the full report, refer to Hesford et al. (2019). Warrington, Near Dunedin City, South Island, New Zealand The learners in 2018 identified that residents of the small rural community of Warrington were using water tanks for their water supply because they did not have access to the local body water supply. The learners targeted the whole community to raise awareness of the importance of water tank safety. Learners produced an informative pamphlet which was sent to residents with their local district council rates. It had information on how poor water storage can cause ill health, hazards commonly found in unmaintained water tanks, and tips on how to properly clean and maintain a water tank. Additionally, a fridge magnet was created as a constant reminder about the awareness of water tank health and maintenance. The learners

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Fig. 3.10  Health promotion resource – Poster/Pamphlet. (Produced by Philips et al. (2021) with permission from Authors)

Fig. 3.11 Map Motupōhue/Bluff. (Produced by Suzanne Thornton with permission from authors)

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Fig. 3.12  Shacklock oven. (Source: CC3 Clark Mills with permission from authors)

Fig. 3.13  Health promotion resource – fridge magnet. (Produced by Hesford et al. (2019) with permission from authors)

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also wrote an article that was published in the local newspaper on safe tank water to alert residents and provide information. Applying the principles of the Ottawa Charter for Health Promotion (WHO, 1986), this met two of the five principles, those being building healthy public policy and strengthening community action (Figs. 3.14, 3.15, 3.16, and 3.17). This regional example relates to the community development project titled Could your water tank be affecting your health? A sustainability project for the Warrington community. To review the full report, refer to Kilkelly et al. (2018).

Local Level At the local level, learners identified disadvantaged or minority groups at the personal level and mediate on behalf of these residents identified from Tarras and Westport and with children from Milton, Waitati, and Waikouaiti. Tarras, Central Otago, New Zealand Learners in 2018 found that pre-school infants in the rural town of Tarras in the Central Otago region were not receiving well-child checks. The learners created a Facebook page for the local well-child nurse to share information relevant to preschool children and their families. A fridge magnet was produced for distribution throughout Tarras, with the slogan ‘Rural Mothers Matter Too’. The magnet met the Ottawa Charter for Health Promotion (WHO, 1986) principle of reorientating health

Fig. 3.14 Map Warrington. (Produced by Suzanne Thornton with permission from authors)

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Fig. 3.15 Warrington water tank. (Produced by Ross with permission from Jean Ross)

Fig. 3.16 Health promotion resource – fridge magnet. (Produced by Kilkelly et al. (2018) with permission from authors)

Fig. 3.17  Health promotion resource – pamphlet. (Produced by Kilkelly et al. (2018) with permission from authors)

services, by creating a link to a social media platform named Rural Mothers where mothers can interact with the well-child nurse (Plunket), who was based approximately 70 kilometres away, and therefore not readily available for face-to-­face regular appointments. The Facebook page enabled mothers to engage with the nurse and ask questions and arrange meetings virtually (Figs. 3.18, 3.19, and 3.20).

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Fig. 3.18  Map Tarras. (Produced by Suzanne Thornton with permission from authors)

Fig. 3.19  Tarras Plunket Rooms. (Produced by Ross with permission from Jean Ross)

This local example relates to the community development project titled A sustainable community development project for the resident mothers & infants of Tarras. To review the full report, refer to Wennekes et al. (2018). Westport, West Coast, South Island, New Zealand In 2020, the nurse learners worked virtually due to COVID-19 pandemic lockdown in partnership with stakeholders on the Westcoast of the South Island. The community were concerned that in the small town of Westport, many children rode their

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Fig. 3.20 Health promotion resource – social media. (Produced by Wennekes et al. (2018) with permission from authors)

bikes to school on a major highway. The community were concerned about the children’s safety but wanted them to continue riding their bikes to school as this was a healthy alternative to parents/guardians driving them and also encouraged independence and resilience. To strengthen community action and meet one of the Ottawa Charter for Health Promotion (WHO, 1986) principles, the learners designed a high visibility vest that children could customise with their own designs and therefore encourage them to wear while riding their bikes. The aim was to increase the visibility of children who cycle to and from school by implementing a compulsory ‘hi-vis’ vest that all children wear (Figs. 3.21, 3.22, and 3.23). This local example relates to the community development project titled An analysis on the benefits of safer cycling in Westport. To review the full report, refer to Spence et al. (2020). Milton, South Otago, South Island, New Zealand In Milton, staff at the local junior school identified that anxiety was common amongst young children. The learners in 2018 created a stress ball for each child in the school in the shape of a lightbulb with relevant wording (1 2 3 4 5 Breathe). This was to encourage them to be self-aware and form the basis for acknowledgement and individual mindfulness. When they become anxious or stressed, the stress ball would remind the child to take some initial steps to de-escalate themselves and to seek further support from their teacher. Alongside this, instruction sheets were provided for each of the classroom teachers to teach the children mindfulness exercises using the stress ball. Applying the principles of the Ottawa Charter for Health Promotion (WHO, 1986), this met two of the five principles, those being creating supportive environments and strengthening community action (Figs.  3.24, 3.25, and 3.26). This local example relates to the community development project titled A health sustainability project for the communities of Milton, Otago, New Zealand. To review the full report, refer to Ward et al. (2018).

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Fig. 3.21  Map Westport. (Produced by Suzanne Thornton with permission from authors)

Fig. 3.22  West Coast Beach. (Produced by London with permission from London Photography)

Waitati, North Otago, South Island, New Zealand In Waitati, young children were identified as having high levels of anxiety. Research links school bullying with poor mental health; hence the leaners created a resource applicable for the school environment, which was engaging, visual, and easily accessible. The learners in 2018 chose to write a story and produce a picture book telling the story of Piglet experiencing feelings relating to anxiety. The story follows Piglet as he receives help from his friends reducing his anxiety. A copy of this book is available at the local Waitati primary school and the local library. Children can access this resource in a supported environment which meets the Ottawa Charter for Health Promotion (WHO, 1986) principle of building personal capacity (Figs. 3.27, 3.28, and 3.29). This local example relates to the community development project titled The improvement of youth mental health in Waitati: A sustainable community project. To review the full report, refer to Gilchrist et al. (2018).

3  Creative Designs: Health Promotion Resources Aligned with Rural Community Health Fig. 3.23 Health promotion resource – safety vest. (Produced by Spence et al. (2020) with permission from authors)

Fig. 3.24  Map Milton. (Produced by Suzanne Thornton with permission from authors)

Fig. 3.25  Milton Primary School. (Produced by Mann with permission from Samuel Mann)

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Fig. 3.26  Health promotion resource – anxiety reducing. (Produced by Ward et al. (2018) with permission from authors)

Waikouaiti, North Otago, South Island, New Zealand Learners focused on dementia in older adults in the rural community of Waikouaiti, in 2018. It was noted that some senior residents in the community were wandering around disoriented and confused. This poses a concern as both wandering and disorientation are some of the early signs of dementia. Learners concluded that a barrier to early detection of dementia is a lack of public awareness around the disease.

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Fig. 3.27  Map Waitati. (Produced by Suzanne Thornton with permission from authors)

Fig. 3.28  Waitati Beach. (Produced by Ross with permission from Jean Ross)

This led to deciding to target the whole of the Waikouaiti community in addressing the health need of dementia amongst the elderly. By making the community as a whole aware of the disease, the hope was they could help and offer support. Educating the public about signs and symptoms of dementia and early detection can increase their understanding about what cognitive impairment looks like, eliminate myths, and encourage individuals to talk with their health-care providers (Figs. 3.30 and 3.31).

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Fig. 3.29  Health promotion resource – book. (Produced by Suzanne Thornton with permission from authors) Fig. 3.30  Map Waikouaiti. (Produced by Suzanne Thornton with permission from authors)

The concept of a health promotion fridge magnet was created as a health promotion resource. Fridges are used in all households and are in a communal space where the magnets on them can be seen. People are less likely to throw away fridge magnets than brochures because they have somewhere to go. The plan was to place several magnets on fridges within the community, such as the local shops and cafes.

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Fig. 3.31  Waikouaiti main road. (Produced by Ross with permission from Jean Ross)

This way it can be seen by the wider community. The fridge magnet included information on early warning signs of dementia and services that can be contacted if the reader notices someone who needs support. Applying the principles of the Ottawa Charter for Health Promotion (WHO, 1986), this met three of the five principles, those being building healthy public policy, creating supportive environments, and strengthening community action (Figs. 3.32). This local example relates to the community development project titled Wandering in Waikouaiti: A sustainable support project. To review the full report, refer to Gilbert et al. (2018). The above images and descriptions of nurse learners’ design thinking has demonstrated that the CHASE model can be applied to all levels of decision-making, whether that is at the national, regional, local, or environmental levels. For further examples of identified health need and health promotion resources, refer to Mahoney and Ross (2019). These health promotion resources are tested, and testing requires rigorous attempts to determine whether the proposed solution is successful as they are tested in phase five and evaluated in phase six of the CHASE model. It is this iterative approach that develops confidence amongst nurse designers which further influences risk-taking and creativity of the nurse as designer and being confident to test the resources with the community stakeholder and adjust as required. Resources have a continued life once they have been handed to the community stakeholders, so they can reduce health disparities as the intended goal. We further showcase the design thinking process engagement and creation of health promotion resources in the following case study of the rural community Gore, Southland, Aotearoa New Zealand. This case study has drawn on the adapted CHASE model 2019 ‘in action’ in which nurse learners have engaged with the population of the rural community

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Fig. 3.32  Health promotion resource  – fridge magnet. (Produced by Gilbert et  al. (2018) with permission from authors)

Gore, Southland, Aotearoa New Zealand, to carry out a community development project. The case study illustrates the identified health issues at the beginning of the problem-solving process and design thinking in phases one and two of the CHASE model. Extended in phase three of the CHASE model as the research gathering approach is completed to inform the creative process in phase four of the CHASE model. Phase four demonstrates the innovative capabilities and extends the ability of the nurse as designer. The testing phase five and impact evaluation in phase six complete the design thinking process aligned with the CHASE model. Equally important is the engagement by nurse educators to facilitate the creative approaches to be explored and recognises this as legitimate components of nursing practice and pedagogy. This has been highlighted in the case studies introduced in the previous chapter which supplements the case study and excerpts of creative resources exhibited in this chapter.

 ASE STUDY 2019: Rural Community, Maruawai/Gore, C Southland, New Zealand Compiled by Jean Ross

Community Planning Community planning commences with the lecturer initially engaging with potential community stakeholders to gauge their interest in participating with a community development project, plans the project, completes the ethical application, and gains approval for students to proceed with the project. These activities are referred to as

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Fig. 3.33  Map of New Zealand highlighting Maruawai/Gore. (Produced by Suzanne Thornton with permission from authors)

Maruawai/Gore

the pre-orientation stage of the CHASE model. At the orientation stage, nurse learners are introduced to the rural community of Maruawai/Gore situated in the Southland region of the South Island in Aotearoa New Zealand (Fig. 3.3) and the CHASE 2019 model which guides their community development project (Figs. 3.4 and 3.33).

Chase Model in Action 2019 Nurse learners drew on CHASE 2019 model to guide their community development practice (Fig. 3.3) and comprises a pre-orientation, orientation, and six phases showcased in this case study. CHASE pre-orientation engages with ethical approval to conduct this community project, completed prior to the project commencing by the academic facilitator. Responsibilities and the impact assessment in phase six of the CHASE model becomes the responsibility of the student nurses during 2018 rather than the lecturer (identified in Fig. 3.4 highlighted in bold). During 2017 and 2018, these evaluations had not been completed within 6–12 months of the dedicated timeline. In 2019 a further change to evaluations of impact aligned learners to complete the 2018 impact assessment 3–6 months following phase five of CHASE (Fig. 3.34).

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Fig. 3.34  CHASE model 2019. (Produced by Ross and Mahoney with permission from authors)

Community Engagement Community engagement connects the learners with community stakeholders from Maruawai/Gore in phases one and two of the CHASE model. Learners define the cultural topography of this rural community by gathering information on the physical environment, the history, and demography which forms the bases of the community assessment. Learners describe its land, people’s culture, and demography which offers the opportunity to explore the relationship and connections between the people(s)’ past and present and the environmental and cultural influences of residing in Maruawai/Gore and its peoples’ associations with this place.

Cultural Topography Land The Maruawai/Gore district is situated within the plains of the Southland region between Dunedin and Invercargill. It is surrounded by the Hokonui Hills, Catlins Forest Park, Blue Mountains, Eyre Mountains, and Leithen Bush. The district covers a 1251  km2 area from Waikaka in the north to Wyndham in the south (Gore

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Fig. 3.35  State Highway 1. (Produced by Mann with permission from Samuel Mann)

District Council, 2013a). To the east, it extends to include Pukerau and to the west Waimumu. The Maruawai/Gore district is divided into four electoral wards: Maruawai/Gore, Mataura, Waikaka, and Waimumu/Kaiwera. This community health assessment focuses on the Maruawai/Gore ward, a town situated in the centre of the Maruawai/Gore district and surrounded by agricultural land. The topography is flat, and the Mataura River flows through the centre, separating East Gore from the rest of the town. State Highway 1 enters the town from the east, crosses the river, and runs southwards to Mataura, the next largest town within the district (Fig. 3.35). People and Their Culture Māori iwi Kati Mamoe and Waitaha were the original settlers who occupied the Southland region of the lower part of the South Island Kai Tahu iwi later moved south from Kaiapoi Pa in Canterbury and became absorbed into the whakapapa of Waitaha through a process of small incursions, intermarriage, and acquisition of tribal belief systems (Te Maire, 2017). The main Māori settlement established in the Southland plains was in Tuturau, near Mataura in the south of the now Maruawai/ Gore district. The site where the town of Maruawai/Gore now sits was an important route of travel for Māori, as the Mataura River was a rich source of food, and Māori named the area Maruawai – ‘Valley of Water’ (Gore District Council, 2013b). The site of Maruawai/Gore was not explored by Europeans until 1855 with the arrival of Alex McNab and Peter McKellar who established two large sheep farms

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Fig. 3.36  Maruawai/Gore farmland. (Produced by Mann with permission from Samuel Mann)

in the area (Beattie, 1962). During the gold rush of the 1860s, Maruawai/Gore served as a location of transit between Dunedin and Invercargill, when bridges, roads, and railway were developed. The fertile plains of Southland and booming agricultural industry ensured Maruawai/Gore continued to prosper, due to sheep production and the successful cereal mill that processed oats grown in the district. During the 1960s, Maruawai/Gore had New Zealand’s highest retail turnover per capita. However, following a downturn in farming and the closure of the cereal mill in 1976, business dropped, and the population declined (New Zealand Government, n.d.). However, since the 1970s, the Maruawai/Gore district has seen an increase in profits as several farms have converted to dairy production, and the district council has worked towards population growth (Gore District Council, 2013b) (Fig. 3.36). Demography According to the 2013 census, the population of the Maruawai/Gore district was 12,033, with 91% of the population identifying as European and 11 percent as Māori (Statistics New Zealand, 2013). In recent years, as Maruawai/Gore’s working population moves towards retirement and the population has declined due to urban drift, concern has been raised over the need to encourage growth in the district (Kelly, 2016; Newman, 2018). The district council is currently developing action plans as part of a new ‘ready for growth’ initiative aiming to increase the population by 1500 people by 2030 (Newman, 2018). For example, the 2013 rebranding project

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aims to raise the profile of the community, focus on a vibrant future, and create a cohesive framework for marketing and economic development (Gore District Council, 2013b; Newman, 2018). Nurse learners built on the cultural topography of Maruawai/Gore gathered in part one of this case study. Nurse learners connect community members and stakeholders in partnership and take collective action on issues identified through community profiling and assessment (Francis et  al., 2013) in phase two of CHASE.  Learners complete a SWOT and needs analyses of the Maruawai/Gore community which leads them to work in partnership with community stakeholders and at the Kaitohutohu presentation, to identify male farmers and their health needs as a population of concern.

I dentified Populations: Māori Families and Male Farmers from the Maruawai/Gore Region A community health assessment conducted by the researchers revealed that mental health and family violence were major health issues in the Maruawai/Gore community. Māori families and male farmers are groups that are particularly vulnerable to these health issues. Many of Maruawai/Gore’s farmers are geographically and socially isolated, often with poor Internet and mobile phone services. This, together with the stress of operating a farm, which is frequently dependent on external environmental factors such as weather and disease contributes to mental health issues amongst this population group. Working hours for farmers often do not coincide with the opening times of health services, so access to these services is limited. Additionally, the attitudes and stigma associated with mental health is also a barrier for men in seeking help and support. Furthermore, within Maruawai/Gore’s vulnerable families, women and children are overrepresented in presentations to Oranga Tamariki (New Zealand’s Child Protection Agency), and the Gore Women’s Refuge were concerned about emotional abuse, neglect, and gang affiliations. Contact with Māori representatives in the Maruawai/Gore community revealed concern for Māori youth mental health and family violence statistics. Approximately half of the presentations to Oranga Tamariki and Gore Women’s Refuge are Māori.

Identified Evidence-Based Review Nurse learners are further guided in phase three of CHASE to conduct a review of regional, national, and international evidence-based literature related to the identified population and health need and consider whether these findings could potentially improve the mental health of farmers and reduce family violence.

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I dentified Evidence-Based Review: Mental Health Amongst Male Farmers High incidence of mental illness and suicide are significant health issues for male farmers worldwide (Roy et al., 2013). Maruawai/Gore is no exception. In reviewing relevant literature, three primary drivers of poor mental health that may be applicable to farmers in Maruawai/Gore become apparent, these being: Adverse environmental conditions: Maruawai/Gore is in the Southland region, which experiences shorter days and less sunshine hours in the winter months than the rest of New Zealand, and decreased sun exposure can contribute to depression due to reduced vitamin D synthesis. Additionally, the Southland area is exposed to the cold southerly winds and snowstorms emanating from the Antarctic continent. Isolation: The stressor of isolation is a major factor contributing to mental illness of farm workers (Fraser et al., 2005). The effect of physical isolation on male farmers’ mental health and the financial burden of taking a day off work are major barriers to accessing health services (Edwards et al., 2001). Being socially connected is psychologically beneficial, while a lack of social networks and minimal close relationships is associated with depressive symptoms (Kawachi & Berkman, 2001). Attitudes and stigma: In New Zealand, and particularly in Southland, there is a stigma amongst many men that sharing thoughts and feelings is a weakness (Macdonald, 2017). It is because of this attitude that many contain their thoughts, leading to an increase in anxiety and depression. Men were found to be less open than women in acknowledging their mental health problems and seeking professional help. Stigma is a significant barrier to people seeking help or speaking out, and it diminishes self-esteem and reduces opportunities for social interaction (Hammer & Vogel, 2010). Family Violence Family violence has been recognised as a health issue due to the immediate and long-lasting harm it causes to individuals, families, and communities. In New Zealand, 39% of women in rural areas experience family violence, with isolation and infrequent accessing of health services making detection difficult (Rural Women New Zealand, 2018). The characteristics of rural culture in New Zealand are strength, hardiness, and self-reliance (Bales et al., 2006). Particularly for men in Southland, this often means they must live up to the ‘southern man’ persona that portrays strong masculinity and disdain for appearing vulnerable (Jackson et al., 2009). This concept normalises the dominance of men over women and creates a stigma of weakness around seeking help and addressing family violence. Living in a small town such as Maruawai/Gore is also a barrier to disclosure of family violence as there is a perception that in rural areas, everyone knows everyone else’s business.

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Approaches to prevent and reduce incidence of violence towards their partners have been found to be effective, including having sports figures as role models of healthy relationships to young men, teaching safe practices when relationship become strained, and forming peer support groups for men (Jaime et  al., 2018). However, reluctance remains in men participating in these programmes (Casey et al., 2017). How nurse learners respond to this critical analysis is determined in phase four of the CHASE model when they develop an appropriate community health promotion message and resource(s) with the aim to improve health care of youth, farmers, and Māori connected to the Maruawai/Gore community. Nurse learners engage with the Ottawa Charter for Health Promotion (World Health Organisation, 1986). The Charter has five key action areas and three health promotion strategies and, when employed together, may envisage an improvement of the identified health need. Engagement of the Ottawa Charter has proven an effective platform for nurse learners to imagine and shape an appropriate health promotion message while co-­ designing a suitable resource, for the identified population and rural contextual encounters.

Health Promotion Resources To increase knowledge of mental health needs of the farming community of Maruawai/Gore, and to raise awareness of the high rates of family violence in rural communities, the learners created several resources. The first team of learners’ research found from the literature review that farming is a very mentally taxing job with high stress and isolation contributing to an increase in mental illness. For male farmers who are often working in isolated places, sharing and talking about their thoughts and feelings can reduce the burden and can help people work through situations together. By using the common practice of having a drink with others as a social lubricant amongst male farmers, the learners hoped to reduce stigma and improve farmers’ mental health. This small keep’s sake is not only practical for them but can also help be the ice breaker for them to ‘crack on with the conversation’. The second group of learners identified the high incidence of family violence in rural areas and was prevalent in Maruawai/Gore particularly amongst Māori families. The learners aimed to effectively engage stakeholders and the wider public information on the prevention of family violence, and therefore the messages needed to be clear and consistent and utilise strategies for communicating to these groups. The key considerations in developing health promotion resources by the learners were to create visual resources to reduce health inequalities for male farmers and Māori families in Maruawai/Gore. The nurse learners were guided by the Ottawa Charter for Health Promotion as a framework and supported by the literature to design and develop all resources for this project. They aimed to address the lack of

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knowledge on available health-care services amongst the rural community of Maruawai/Gore and to help people to start having conversations that were meaningful about sharing resources and reducing harm in the community. The resources were shared with key stakeholders in Maruawai/Gore (Figs. 3.37 and 3.38). Learners’ Rationale and Consideration of Resources Health Promotion Resource: Drink Holder The use of social interaction and talking therapy to improve mental health were the main considerations for designing a drink holder as a health promotion resource for

Fig. 3.37  Health promotion resource – drink holder. (Produced by Ferris et al. (2019a, b) with permission from author)

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male farmers. The phrase ‘crack open a cold one and crack on with the conversation’ is printed on the side of the drink holder to encourage sharing a drink with mates as an opportunity to have a healthy conversation, therefore challenging the stigma of opening up to others. Phone numbers for existing help lines were printed on the drink holder to refer farmers to support services available for them. Consent was obtained from these organisations to print their details. Health Promotion Resource: Poster and Keychain For the second resources, a poster and keychain were developed as health promotion resources. The poster designed by the learners’ used language and imagery to incorporate Māori and male values and the values of the community of Maruawai/Gore. The poster aimed to encourage people to have conversations about family violence while raising awareness about the effect of family violence on individuals and the community. It challenges stigma and masculine ideology by stating ‘it is ok for men to feel stressed, frustrated, angry and vulnerable’. The barrier of isolation is targeted by emphasising the importance of seeking support and referring to ‘talking it out’. Use of the phrase ‘you are not alone’ in the centre of the poster also places the focus on support, making connections, and challenging stigma. Clear and simple words

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are used to signify the different types of abuse (hurt, control, intimidate, harm) to explain the meaning of family violence without focusing solely on physical abuse. The values of whānau and community are emphasised, and Māori imagery is used in the form of two koru which represent origins, growth, strength, and new life (Te Ahukaramū Charles Royal, 2005). The second resource was a keyring aimed at being more interactive, to accompany the poster and to act as a tool to promote ‘time-out’ and self-regulating strategies. Literature referred to men taking time out to go for a drive (Hayward et al., 2007); therefore the keychain with a traffic light image was developed to communicate a ‘stop, think, share’ strategy to aid in de-escalation and promote support seeking. Contact details for support services were included on the back of the keychain with consent from the organisations for the use of their details. The poster and keychain were sent to Gore Women’s Refuge and Oranga Tamariki as they are both organisations with interest in the project who are relevant to the health and social aspects of family violence.

Community Development Identified Impact Analysis Impact analysis related to the Maruawai/Gore community development project is now presented in this section of the case study. Impact aligns with community stakeholders’ feedback and ethical cultural considerations of nurse learners addressed related to disparities for Māori presented to the Kaitohutohu Panel; teaching and learning pedagogy associated with the CHASE model and graduate nurse professional practice reflections concludes this case study as reported below. Impact Analysis: Community Feedback Phase six of the CHASE model focuses directly on the impact of the creative designs associated with the health promotion messages and resources had on the identified community; the impact of the community development project on the community itself and stakeholders and impact on the learners one or more years having completed their education in their professional nursing practice. The Gore community were so impressed with the drink holder resource they mentioned to ‘Will I Am’, a national organisation who were visiting to hold a community dinner with local farmers to raise awareness of mental health issues and the availability of support services. We were contacted by the national organisation to supply 200 drink holders, one for each of the farmers attending the dinner we were also invited to attend the event. We sourced additional funding and presented all farmers with a drink holder; their feedback was positive, so positive the national organisation asked if they could produce 1000 drink holders for distribution nationally, which we agreed to.

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Community Impact This case study identified the mental health and family violence issues for isolated farmers in the Maruawai/Gore District of the Southland region in New Zealand. Nurse learners reviewed the Ottawa Charter for Health Promotion (World Health Organisation, 1986) which provides five action strategies and principles that enabled them to envisage a health promotion change in a community and a framework for potential strategies to alter health status. CHASE phase four provides nurse learners an opportunity of imagining and shaping how to improve the health of this identified population and together develop an appropriate health promotion message while co-designing a suitable (for the identified population and rural contextual encounters) resource showcasing the message.

Identified Impact Analysis The impact of the creative designs associated with the health promotion messages and resources aligned with the 2017 case study have been analysed as guided in phase six of the 2018 CHASE model. Nurse learners evaluated the potential impact the health promotion message and resources developed in phase four of CHASE by engaging with community stakeholders from Maruawai/Gore including their impression of engaging with the community project. Additional impact from graduate nurses’ reflection on professional practice, the academic teaching staff, and Kaitohutohu (indigenous ethical guide for the community project) has concluded this case study as reported below.

Identified Chase Model Adaptation The evaluated CHASE 2019 model was adapted from the original CHASE model 2017 to create CHASE 2020. CHASE 2020 version draws attention in Fig. 3.9 highlighting the adaptation of extending phase six the impact assessment into phases seven, eight, and nine (highlighted in bold). Twofold objectives include maintaining the established partnership with the Maruawai/Gore community and collaboration between community stakeholders and the nurse education facilitators at Otago Polytechnic education organisation; reviewing the potential impact the health promotion message and resources developed in phase four of the CHASE model could benefit and reduce identified health disparities, analysed by a research assistant 3–6 months following completion of phase five of CHASE. Phases two and five of the CHASE model are aimed at learners to address the disparities for Māori and present their findings from the community research and needs analysis to the Kaitohutohu Panel. The Kaitohutohu are advisors within the

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educational institute who give support and advice on matters pertaining to Māori. The group focused on answering four main questions. This ensured that the learners approached constructing primary and secondary data with an emphasis on being culturally sensitive and maintaining a focus on the Māori population in Maruawai/ Gore with the aim to address and alleviate any inequities, demonstrating cultural sensitivity and understanding of Māori cultural protocol, values, and beliefs. Cultural respect is represented in the code of conduct regarding a person’s cultural, values, and beliefs (Nursing Council of New Zealand, 2012). CHASE Model in Action 2020 The CHASE 2019 model was engaged with for this case study to guide learners’ community development practice (Fig. 3.4). The CHASE 2019 model was evaluated by the original developers who acknowledged its contribution but agreed the model needed to be updated to maintain effectiveness, and the CHASE model 2020 was created (refer to Fig. 3.9) for engagement by nurse learners in 2020. The evaluated version has five adaptations (highlighted in bold text); refer to Chap. 2 for details (Fig. 3.39). Graduate Nurse: Professional Practice Reflections

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PH

KEY

DISRUPTIVE

Graduate nurses reflected (invited survey participation discussed in Chap. 6) on whether engaging with this Maruawai/Gore community development project at an undergraduate level had any influence on their previous or current professional practice.

Community Health Assessment Sustainable Education Model adapted by Ross & Mahoney (2020) published with permission from Ross, Crawley & Mahoney (2017).

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License

Fig. 3.39  CHASE model 2020. (Produced by Ross and Mahoney with permission from authors)

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This case study is an edited version of the community development project completed in 2019 by nurse learners and facilitated by nurse academics, titled Sustainable Community Health: Evidence-based Health Promotion for Youth, Families and Farmers of the Gore/Maruawai Community a Focus on Mental Health and Family Violence. To review the full report, refer to Ferris et al. (2019a, b). Design Reflection At the commencement of this chapter, we positioned the nurse as designer, and we questioned this phenomenon. Why is it important to acknowledge the nurse as designer? We have provided a strong argument throughout this chapter, supported with a variety of creative examples of health promotion resources, based on the key principles of design thinking as necessary for the improvement of reducing health disparities in rural communities. Design thinking has been acknowledged as an accepted part of nursing practice since the days of Florence Nightingale. Ahead of her time, Nightingale is considered the founder of modern nursing (Karimi & Alavi Masoudi, 2015) and is credited with changing the health-care structure by using system thinking and a design lens. She considered nursing skills to be the ‘art’ of nursing practice as nursing skills and the ‘science’ of nursing as the public health approach to nursing practice. Examining the practice of Nightingale through a design thinking lens highlights that she observed her surroundings, for example, when Nightingale arrived at Scutari Barracks in 1854, she observed men sleeping in filthy straw beds and floors that were covered in excrement. Observation remains a critical skill underpinning nursing practice today and a significant component of phase one of the CHASE model the community profile and assessment. Nightingale identified that many of the deaths in the Scutari Barracks were preventable and, due to improved sanitation and hygiene which she advocated strongly for, is attributed to reducing the death rate of injured soldiers in the Crimean War from 33% to 2% (Hundt, 2020). A further link between Nightingale’s original contribution to health care and today’s nurse learners’ is the identification of health needs and disparities associated with population groups, as part of phase two of the CHASE model. Not only did Nightingale make effective changes to the soldiers’ care, but she addressed the external environment including the sewers that were blamed for the high death rate of the injured. This is one example of Nightingale’s systems-thinking and empathy which are both aspects of HCD and inherent to design thinking foundations (Buchanan, 1992) in nurses’ practice today. Nightingale recognised the disparities in health, for instance, amongst children, women, and people on low incomes and encouraged nursing care to consider the individual needs and safety of those people at risk of unnecessary ill-health and disease. In the current period of COVID-19, Nightingale’s relevance on space and hand hygiene are clear examples of her influence on public health philosophy of health promotion and disease prevention and systems-thinking of today (Ross et al., 2020).

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We have demonstrated how nurses and nurse learners continue in a similar vein to Nightingale’s work, and we acknowledge this for the contemporary nurse situated within a public health philosophy. Nurses continue to use creativity and critical thinking to create solutions in their everyday practice as they encounter unexpected situations with diverse communities, population groups, and health disparities (Cheraghi et  al., 2021). Like Nightingale, Brooks-Carthon et  al. (2021) call on nurses to use a problem-solving approach to reduce health disparities. Creative thinkers create critical solutions, and nurse educators/facilitators should encourage creative thinking in learners (Chan, 2012; Cheraghi et al., 2021) as is the case in the CHASE model. In Nightingale’s Notes on Nursing: What it is and what it is not (Nightingale, 1969), the importance of design in the health-care setting was described, particularly the importance of fresh air and ventilation, light, warmth, and patient-nurse interactions (Andrews, 2003). Nightingale was inspirational in hospital design recommending wide open wards and open windows and natural light to promote health and prevent the spread of disease. This was considered transformational promoting nurses’ efficiency and safety to health care (Lockey, 2021; McDonald, 2020). Nightingale did not limit her design advocacy to hospitals; rather she continued to advocate for the principles of health care throughout her life, and these are what we now know as the core principles of public health and disease prevention, those being promote, prevent, and protect (Ministry of Health, 2016). Equally, for today’s nurses, it is important for them to feel confident to engage in this design landscape and likewise for nurse educators to facilitate creative approaches to be explored and recognised as legitimate components of nursing practice and pedagogy (discussed further in Chap. 4).

Conclusion Creativity and design go hand in hand (Kim & Ryu, 2014), and it is at the nexus of creativity and design that the opportunity lies for developing nursing practice. The discipline of design thinking can allow rational minded thinkers grounded in science to break free and unleash their creativity (Kim & Ryu, 2014). It is in this chapter we have linked the ‘art and science of nursing’ (Henry, 2017) with design thinking. Nurses have had a part to play in health-care design historically, and viewing creative and critical thinking is not new in nursing, with Florence Nightingale having a critical role in hospital and community design. To adjust a health system invariably requires a degree of creativity, and creative health-care workers in the organisation are essential (Cheraghi et al., 2021). We have identified how the design thinking process has been integrated as a component of the CHASE model (Ross et al., 2017) as nurse learners undertake community development projects. In this chapter, we have revealed nurse learners as designers who engage with human-­ centred design, double diamond thinking, and systems-thinking with health frameworks, such as the Ottawa Charter for Health Promotion. Here is where nurse

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learners have applied empathy and engaged in design thinking, to develop numerous health promotion resources, imagined, critically considered, and crafted. We have provided several examples of these health promotion resources nurse learners have created, using collaborative design thinking in the case study and creative resources presented in this chapter. The teaching and learning pedagogy which extends our argument and further guides the CHASE model is discussed in the following chapter.

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3  Creative Designs: Health Promotion Resources Aligned with Rural Community Health 111 Lockey, S. (2021). What Florence Nightingale can teach us about architecture and health. Scientific American. https://www.scientificamerican.com/article/ what-­florence-­nightingale-­can-­teach-­us-­about-­architecture-­and-­health/ Macdonald, C. (2017). Women and men – Common ground: 1999–21st century. https://teara.govt. nz/en/ephemera/29266/southern-­man Mahoney, L., & Ross, J. (2019). Nurse learners’ educational interaction with communities as ‘living labs’ has proven to impact positively on the sustainability of rural community health-care outcomes. Scope Contemporary Research Topics, Health & Wellbeing, Rural, 4, 88–95. www. thescopes.org McConnell, C., Muia, D., & Clarke, A. (2022). International community development practice. In C. McConnell, D. Muia, & A. Clarke (Eds.), International community development practice (p. xxix). Routledge. McDonald, L. (2020). Florence Nightingale’s influence on hospital design, hospitalism, hospital diseases, and hospital architects. HERD, 13(3), 30–35. https://journals.sagepub.com/doi/ full/10.1177/1937586720931058 McMurray, A., & Clendon, J. (2015). Community health & wellness: Primary health care in practice (5th ed.). Churchill Livingstone/Elsevier. Ministry of Health. (2016). About public health. Available from https://www.health.govt.nz/ our-­work/public-­health-­workforce-­development/about-­public-­health New Zealand Government. (n.d.). New Zealand history: Gore. https://nzhistory.govt.nz/ keyword/gore Newman, T. (2018). Gore sets sights on new growth plan. Southland Times. https://www.stuff. co.nz/southland-­times/news/103165225/gore-­sets-­sights-­on-­new-­growth-­plan Nightingale, F. (1969). Notes on nursing, what it is and what it is not. Dover Publications. Norman, D., & Spencer, E. (2019). Community-based, human-centered design. Paper presented at the 2019 World Government Summit. https://jnd.org/community-­based-­human-­centered-­design/ Nursing Council of New Zealand. (2012). Competencies for registered nurses. Nursing Council of New Zealand. Phillips, J., Slater, A., Winegardner, S., Wiggs, C., & Jauch, A. (2018). Systems thinking and incivility in nursing practice: An integrative review. Nursing Forum: An Independent Voice for Nurses, 53(3), 286–296. Phillips, E., Riddle, A., Roger, M., Rohtmets, L., Sanders, S., Senelale, C., Turner, M., Yee, A., & Ross, J. (2021). Te Punga o Te Waka a Māui (Rakiura/Stewart Island) community assessment. Report available from the community and School of Nursing, Otago Polytechnic. Richardson, J., & Ash, J. (2010). The effects of hands-free communication device systems: Communication changes in hospital organization. Journal of the American Medical Informatics Association, 17(1), 91–98. https://doi.org/10.1197/jamia.M3307 Ross, J., Crawley, J., & Mahoney, L. (2017). Sustainable community development: Student nurses making a difference. Scope Contemporary Research Topics: Learning and Teaching, 4, 8–17. www.thescopes.org Ross, J., Mann, S., & Leonard, G. (2020) Rural nursing during the COVID-19 pandemic: A snapshot of nurses’ experiences from Aotearoa New Zealand. Journal of Nursing and Practice. ISSN: 2578-7071. Roy, P., Tremblay, G., Oliffe, J. L., Jbilou, J., & Robertson, S. (2013). Male farmers with mental health disorders: A scoping review. Australian Journal of Rural Health, 21(1), 3–7. Rural Women New Zealand. (2018). We are helping build safer communities. https://www.ruralwomen.org.nz/ok2help.html Spence, K., Matheson, L., Turner, K., Kaniki, & Mullens, C. (2020). An analysis on the benefits of safer cycling in Westport. Report available from the community and School of Nursing, Otago Polytechnic. Stalter, A., Phillips, J., Ruggiero, J., Scardaville, D., Merriam, D., Dolansky, M., Goldschmidt, K., Wiggs, C., & Winegardner, S. (2018). A concept analysis of systems thinking. Nursing Forum: An Independent Voice for Nurses, 52(4), 323–330.

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Statistics New Zealand. (2013). 2013 census quick stats about a place: Gore district. http:// archive.stats.govt.nz/Census/2013-­census/profile-­and-­summary-­reports/quickstats-­about-­a-­ place.aspx?request_value=15152&parent_id=15112&tabname=#15152 Stevens, E. (2021). The key principles and steps of the design thinking and process. https://careerfoundry.com/en/blog/ux-­design/design-­thinking-­process/ Te Ahukaramū Charles Royal. (2005). Māori creation traditions: Common threads in creation stories. In Te Ara: The encyclopedia of New Zealand. https://teara.govt.nz/en/photograph/2422/ the-­koru Te Maire, T. (2017). Ngai Tahu, Te Ara – The encyclopedia of New Zealand. https://teara.govt.nz/ en/ngai-­tahu, http://www.un.org/sustainabledevelopment/news/communications-­material/ van Stijn, K., Riddell, A., Wadham, L., Su’a, M., & Ross, J. (2017). Improvement and sustainability of maternity level care in the Lakes District. Report available from the community and School of Nursing, Otago Polytechnic. Ward, H., Woodford-Webb, T., Wyber, S., Wylie, E., Rogers, S., Saunders, S., Mills, Z. Scully, N., Yeritsyan, Y., Smith, J., & Ross, J. (2018). A health sustainability project for the communities of Milton, Otago, New Zealand. Report available from the community and School of Nursing, Otago Polytechnic. Watson, J. (2005). Caring science as sacred science. F. A. Davis. Wennekes, M.J., Watts, E., Robinson, A., Priddle, A., & Ross, J. (2018). A sustainable community development project for the resident mothers & infants of Tarras. Report available from the community and School of Nursing, Otago Polytechnic. Whitehead, D. (2020). Nursing and midwifery research methods and appraisal for evidence based practice (D. Whitehead, C. Ferguson, G. LoBiondo-Wood & J. Haber, Eds.) (6th ed., pp. 55–80). World Health Organisation. (1986). The Ottawa Charter for health promotion. https://www.who. int/healthpromotion/conferences/previous/ottawa/en/ Zuber, C., & Moody, L. (2018). Nursing Administration Quarterly, 42(1), 62–75. https://doi. org/10.1097/NAQ.0000000000000267

Chapter 4

Rural Community Health – Encountering a New Pedagogical Space Caroline McCaw, Claire Goode, and Cynthia Mullens

Abstract  In this chapter, we engage with the pedagogy behind both the Community Health Assessment Sustainable Education model and the networks which are forming through its use. Drawing on learning and teaching theories underpinning project-­ based learning, communities of practice and rural community development, we consider the importance of partnership and collaborative relationship building, in the contexts of health, research and education development in rural communities. We consider how research techniques, paired with experiential and relational learning, facilitated by nursing lecturers, and employing technology, can support learners and communities towards positive outcomes for both parties. A case study in the South Pacific nation of Vanuatu is used to illustrate and explore the Community Health Assessment Sustainable Education model in action, and to examine lessons learned from its implementation in these applied pedagogical spaces. We identify the stages of risk and potential transformation, both for learners and participating communities. We reflect on the frameworks required for partnerships to be able to evolve safely, and for learners and the communities to feel empowered through their engagement with learning projects, and the exposure of a community’s needs. Opportunities for implementing further strategies and for co-ownership of learning and teaching artefacts are considered. Keywords  Education · Pedagogy · CHASE Model · Learners · Nursing C. McCaw (*) Te Maru Pumanawa | College of Creative Practice and Enterprise, Otago Polytechnic | Te Pūkenga, Dunedin, New Zealand e-mail: [email protected] C. Goode Learning and Teaching Development & Te Kura Tapuhi | School of Nursing, Otago Polytechnic | Te Pūkenga, Dunedin, New Zealand e-mail: [email protected] C. Mullens Te Kura Tapuhi | School of Nursing, Otago Polytechnic | Te Pūkenga, Dunedin, New Zealand e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. Ross et al. (eds.), Rural Landscapes of Community Health, Global Perspectives on Health Geography, https://doi.org/10.1007/978-3-031-43201-9_4

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Introduction The original Community Health and Sustainable Education model (CHASE) was developed by Ross et al. (2017) as a way of managing the academic process associated with teaching, learning and assessment during primary healthcare clinical placements in their undergraduate nursing curriculum (as already seen in Chaps. 1 and 2). As part of the requirements to complete a Bachelor of Nursing (BN) degree in Aotearoa New Zealand, nurse learners must engage in a specific number of clinical hours to ensure they are prepared for the demands of nursing across various contexts of practice. Scarcity of clinical placements in rural community settings became a catalyst for lateral thinking in how to ensure learners attending Otago Polytechnic in Dunedin, Aotearoa New Zealand were able to meet course outcomes, while not able to resource the traditional community (primary healthcare) clinical placement model. Ways to effectively engage with teaching and learning that met clinical course outcomes and requirements meant a shift in thinking was required, as the traditional status quo approach was no longer viable (refer to Chap. 2). The CHASE model empowers learners to engage with aspects of population health through community collaboration that considers the health of the community, rather than health of the individual. Population and community health are pivotal aspects of primary healthcare, and the model encourages engagement focusing on enhancing knowledge around how to understand different communities’ needs, and to respond to these through health promotion outcomes and activities that are specific to each community. In this chapter, we explore pedagogies that underpin the CHASE model, drawing on pedagogical theories in project-based learning (PBL), communities of practice (CoP), and rural community development. We consider the importance of partnership and collaborative relationship building, in the multi-layered contexts of health, research and education development in rural communities. We identify the stages of risk and potential transformation, both for learners and participating communities.

Experiential Learning Nurse education, as with other forms of vocational education, can draw upon pedagogical roots that value experience. When ‘learning’ and ‘doing’ are connected, reflection and practice are similarly connected in iterative cycles as a form of knowing (Dewey, 1938; Schön, 1983). Bradley-Levine and Mosier (2014, para. 1) assert that, by ‘engaging students through exploring real-world issues and solving practical problems’, students develop their own questions, study concepts and information in order to propose and test possible answers. Learners apply their knowledge in an ongoing cycle, while taking more personal responsibility for their learning. There are a number of differing perspectives on how experiential learning takes on different meanings, depending on the lens through which it is viewed (Merriam et  al., 2007). Kolb’s (2015) theory of experiential learning divides the learning

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process into a cycle of four basic theoretical components: concrete experience, reflective observation, abstract conceptualisation and active experimentation. Kolb identifies different learning approaches with each of these processes and helps to identify how knowledge is created through experience. ‘Situated cognition’ (also known as ‘situated learning’) is another term used by Seely Brown et al. (1989) to describe learning design that makes direct connections when the context of learning is very similar to real-life situations. This is based on the premise that learning is influenced by the situation in which it occurs (Vygotsky, 1997). These approaches to experiential learning consider the direct social context in which learning takes place as playing a primary role in the construction of meaning from experience. Meaning is not simply constructed; it is co-constructed. In these situations, collaborative and co-operative learning contribute to a successful social experience for learners. Other instructional strategies commonly considered as ‘experiential learning’ include self-directed, kinaesthetic activities and workplace projects (Fenwick, 2001), as well as reflective practice, problem-based learning, project-based learning and apprenticeship (Ellmers & Foley, 2007). Experiential learning can be implemented in a multitude of contexts. More recently, service learning has been added to these, as ‘a pedagogy integrating academically relevant service activities that address human and community needs into a course’ (Suffolk University Boston, 2023, para 6). Though there are many documented advantages to experiential learning, some have questioned to what degree these projects should be either ‘live’ or ‘simulations’ of real-world problems (Zeydani et al., 2021). Nursing education draws upon a range of experiential learning strategies, ranging from authentic hospital placements to classroom-based simulations. Paige and Daley (2009) suggest that the advantages of employing experiential teaching strategies, alongside more traditional classroom-based approaches in nursing education, are that these experiences are able to contribute to the clinical competency of learners while also strengthening their clinical reasoning and reflective-thinking skills.

Project-Based Learning Through their engagement with the CHASE model, Otago Polytechnic’s nurse learners are engaging in project-based learning (PBL). PBL is a model that designs learning around real-world projects. Thomas (2000, p. 3) defines PBL as the organisation of: Complex tasks, based on challenging questions or problems, that involve students in the design, problem-solving, decision-making, or investigative activities; give students the opportunity to engage in work relatively autonomously over extended periods of time; and culminate in realistic products or presentations.

PBL offers opportunities for fostering an enduring curiosity, developing high levels of motivation, placing emphasis on collaboration, including co-operative ‘reflection’ and ‘building a connection to the world outside the classroom’ (Thomas, 2000,

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p.  5). In this form of interdisciplinary learning, students draw on competencies already acquired and spontaneously apply relevant conceptual and procedural knowledge, integrating these through problem-solving activities. Within nursing education, Arif and Putri identify that PBL for nurses allows for enhanced critical thinking and problem-solving (2022, p. 50). Anecdotally, educational organisations that integrate PBL into their programmes report that these projects unleash a contagious creative energy amongst both learners and teachers. The case studies throughout this book are clearly experiential and employ PBL approaches; they focus uniquely on live projects working with rural communities. Partnering with communities can offer broader perspectives for learners in  lockdown that are missing in emergency online delivery, experienced during some of the case studies identified in this book. As a result, students develop deep content knowledge as well as critical thinking, creativity, and communication skills in the context of doing an authentic, meaningful project (Bradley-Levine & Mosier, 2014). Zeydani et  al. (2021) conducted research on PBL within nursing education and concluded that: [i]n all studies, undergraduate nursing students’ skills were improved by participation in a community-based education program[me]. Community-based education enhances professional skills, communication skills, self-confidence, knowledge and awareness, and critical thinking skills and teamwork skills in undergraduate nursing students. (p. 233)

The benefits of PBL, then, should not be underestimated. In summary, PBL undertaken with a community can offer effective and engaging education, and can help nurse learners to understand the changing needs and contemporary problems of various local and distant communities. Furthermore, as opposed to an individual being a nurse’s client, the focus on a community and their needs shifts the emphasis towards more broadly sustainable healthcare solutions and innovations that align with the community’s contexts and practices.

Rural Communities and Health Education The focus of the CHASE model in rural communities and on the community’s health needs creates additional considerations for nurse learners. Hutchinson and East (2017) bring to our attention important considerations, for example, the provision and accessibility of healthcare in rural contexts, that influence the practice of rural nurses. Rural nursing practice requires nurses to offer a health service that is responsive, innovative and collaborative (Ross et  al., 2023). These values reflect many of those identified in our review of experiential learning such as the importance of context in the learning situation, where meaning is co-constructed. Furthermore, in many respects, the involvement of nurse learners in these rural community projects reconsiders the teacher as facilitator, in an equal partnership with the local Rural Nurse facilitators as community stakeholders.

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Communities of Practice Along with experiential and PBL, the CHASE projects invariably generate communities of practice (CoP). The learning and teaching theories underpinning CoP draw heavily on the work of Lave and Wenger (1991), who first used the term when studying the learning model of apprenticeships and the ‘community that acts as a living curriculum for the apprentice’ (Wenger-Trayner & Wenger-Trayner, 2015, p. 4). The subsequent work of Wenger (1998) expands on the predominantly constructivist concept and applies it in other areas, including organisational development. For these key theorists, learning is part of our everyday lives, relationships, and social participation (Bitterman, 2008; Squires & Van De Vanter, 2013; Padilla & Kreider, 2020) and, in fact, as Wenger (1998, p.  6) emphasises, CoP ‘are everywhere’. A much-cited definition of CoP describes them as ‘groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly’ (Wenger-Trayner & Wenger-Trayner, 2015, p. 1). Personal and professional development achieved through the ‘collective creation of knowledge’ (McGrath et al., 2020, p. 189) is one outcome of a CoP’s interactions. This building of knowledge through communities is considered by the critical education theorist Freire to be one way of empowering learners and liberating them from relying on a teacher’s knowledge (for example, Freire, 1970, 1973). In addition, it echoes elements of the theories of educational philosophers Vygotsky and Bruner around knowledge being socially constructed (Aubrey & Riley, 2016). Drawing on the ideas of Wenger (2002), CoP may include shared domains, communities and practices. CoP members through sharing a domain of knowledge or interest, learn with and from each other. They create common ground and common knowledge. CoP members may identify as a community and interact through joint discussions and activities. This builds relationships and enables collaborative learning. And CoP members may share a practice, which over time develops a shared repertoire of resources and solutions. Lave and Wenger (1991) coined the terms ‘situated learning’ for learning in context, and ‘legitimate peripheral participation’ for the initial role a newcomer takes on when first joining the group, as they learn from more experienced peers and gradually become full-fledged community members. Wenger (1998, p.  5) asserts that socially situated learning involves the development of ‘meaning (learning as experience), identity (learning as becoming), practice (learning as doing), and community (learning as belonging)’. Building on this, when writing about organisational innovation, Levin (2013, p. 280) highlights that such innovation is a ‘situated social learning process that depends on active involvement from members of the organisation’, and goes on to emphasise that ‘individual change is actually a situated collective social process where routines and relationships are transformed’. Similarly, Bitterman (2008, p. 319) argues that, in the context of adult education, ‘the social interaction or culture of how participants interact with each other’ will determine the success or otherwise of CoP.

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One significant advantage of CoP is that they are not bound by formal structures and can operate across organisational and/or geographic boundaries (Wenger-­ Trayner & Wenger-Trayner, 2015), as evidenced in the CHASE case studies (Chaps. 2, 3, and 5 and this chapter). Squires and Van De Vanter (2013) cite Wenger: [Learning in the] 21st century cannot be confined by the traditional separation between education, business, and civic domains. Nor can it assume that learning is confined to specific settings or moments in people’s lives. Learning has to be understood in the context of multi-scale social systems … dynamic constellations of communities of practice (pp. 303–304).

Perhaps, as a result of this, while the origins of CoP lie in learning theory and work-­ based learning in particular, the concept is also being applied in many other contexts including organisational design, government projects, professional associations and the social and civic realms (Squires & Van De Vanter, 2013; Wenger-Trayner & Wenger-Trayner, 2015). In the health sector, CoP have been used to help build resilience in healthcare teams (Delgado et  al., 2021a, b), learn with peers via online virtual CoP (Alali & Salim, 2013; Jiménez-Zarco et al., 2015), enhance the work environment (Moore & Waters, 2019) and contribute to nurse education (Cain, 2018; Haslam, 2020). Online virtual CoP is exemplified in the Liro, Paama, Vanuatu case study showcased in this chapter. Underpinning all of these examples is the importance of building relationships. Indeed, Higgs and Titchen (2001) propose a conceptual framework of professional practice which places an emphasis on ‘working with and for people’ (p.  6), and Goode (2021) identifies relationship building  – between teachers, learners, colleagues and peers  – as one of five overarching keys to teaching excellence. The CHASE model embraces the value of working with others and building strong networks, first through the nurse facilitator establishing a relationship with the community in question, and then by leveraging their existing relationships with their learners to introduce them into the community and empowering them to move forward with the community health investigation. Palmer (2017) writes that ‘good teachers possess a capacity for connectedness. They are able to weave a complex web of connections among themselves, their subjects, and their students so that students can learn to weave a world for themselves’ (p. 11, emphasis added). In the context of the CHASE model, it could be argued that it is not only the students but also the wider community who ‘learn to weave a world for themselves’. We move now to the case study of Liro, a small community in Paama, an island in the Vanuatu group, in the Southwest Pacific. Along with this case study, we refer to the doctoral research of Cynthia Mullens (third author), and her analysis developed from engaging in open-ended interviews with learners and stakeholders, both in Liro, Paama (in this chapter) and in Bishop’s Castle  (see Chap. 7). Mullens’s (n.d.) project-based research draws connections between this CHASE community-­ engaged PBL example and the ideas discussed above.

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 ASE STUDY 2020 – Island Community, Liro, Paama, C Vanuatu, South Pacific Ocean to the East of Australia Compiled by Cynthia Mullens (2022)

Community Planning Community planning commences prior to the nurse learners commencing the community project with the pre-engagement stage. An invitation was extended from the community elders and village chief from Liro, Paama, Vanuatu, situated in the South Pacific Ocean to the East of Australia highlighted in Fig. 4.1 to collaborate with nurse learners in 2020. This relationship evolved out of an ongoing pre-­existing collaborative community development relationship between the nurse facilitator and the village, dating back to 2011. In 2017 nurse facilitator Cynthia Mullens alongside a team of engineering students from the educational institution Otago Polytechnic, Dunedin, New Zealand were welcomed into the community and the homes and lives of the people of Liro, Paama, Vanuatu while on a field trip. Through this collaboration with the village school and health centre a strong level of trust and connection was formed and solidified these relationships with this community, and a further invitation from community elders and the village chief was extended to third-year nurse learners from the same educational institution. The aim was to complete their primary healthcare clinical placement onsite. Planning began for a return trip in July 2020 for what has traditionally been known as an International Service-Learning (ISL) opportunity, that forms part of the community development projects nurse learners are engaged with. CHASE 2020 commences with a pre-engagement and physical contact stage by a nurse facilitator (in this case Cynthia Mullens) who established a collaborative partnership with a team of nurse learners who identified their willingness to travel to Vanuatu. Due to COVID-19 pandemic and restrictions on international travel, the capacity to travel to the community was severely impacted and the fieldtrip had to be cancelled. In consideration of this, a virtual engagement was proposed, and learners and community stakeholders decided this would be an optimal outcome. Adaptions to the CHASE 2020 model were made to extend this into a virtual space and phase eight of CHASE was created. Cynthia Mullens completed an ethical application and approval, including project planning, referred to as the pre-orientation stage of the CHASE model. At the orientation stage, the nurse learners were introduced to each other and the island community of Liro, Paama, Vanuatu; the CHASE model 2020 guided the community development project.

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Fig. 4.1  Map of Vanuatu, South Pacific highlighting Paama. (Produced by Suzanne Thornton with permission from the Author)

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CHASE Model in Action 2020 Nurse learners drew on CHASE 2020 model to guide their community development practice in the island community of Liro, Paama. CHASE 2020 (Fig. 4.2) comprises a pre-engagement, pre-orientation, orientation and eight phases showcased in this case study. The evaluated CHASE 2019 model was adapted from the original CHASE model 2017 to create CHASE 2020 version and draws attention to three adaptations. Phase six, which is the impact assessment, has been extended into phases seven, eight and nine and the impact assessment becomes the responsibility of a new member of the CHASE team. A research assistant takes on this role (highlighted in bold text and included in the Model Key by the dotted line) with the sole purpose of completing all of the case studies and impact evaluations for 2017–2021. This change was to continue the collaborative nature of the project and to complete

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Community Health Assessment Sustainable Education Model adapted by Ross & Mahoney (2020) published with permission from Ross, Crawley & Mahoney (2017).

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Fig. 4.2  CHASE 2020 Model. (Produced by Ross and Mahoney with permission from the Authors)

the project cycle evaluating the impact the health promotion resources learners had created had on the health of the identified population. Phase seven invites learners to reflect on whether their created health promotion messages and/or resources could improve the identified health issues meeting one or more of the United Nations’ 17 Sustainable Development Goals (United Nations, n.d.). Through 2020, phase eight was aligned with COVID-19 pandemic which is referred to as  – ‘Distribution’ and a change to the learning and teaching pedagogy.

Community Engagement Community engagement connects the learners with community stakeholders from Liro, Paama, Vanuatu found within the province of Malampa in phases one and two of the CHASE model. Nurse learners engaged with the cultural topography describing the communities’ land, people, their culture and demography. This offered the opportunity to explore the relationship and connections between the people/s’ past and present and the environmental and cultural influences of residing in Liro, Paama, Vanuatu. Nurse learners defined the cultural topography of this island community by gathering information on the physical environment, the peoples’ history and demography. Community development is a method to connect community members and stakeholders to engage in partnership with nurse learners and take collective action on issues identified through community profiling and assessment.

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Cultural Topography Land Liro is a small village on the island of Paama, Vanuatu. Paama is a small volcanic island in the Malampa Province of Vanuatu. Vanuatu is an archipelago in the Melanesian group of islands located in the South Pacific Ocean to the northeast of Australia and comprises about eighty islands with a land area of 12,189 km2. It has a population of approximately 307,145 people. Paama is one of the eighty islands and is approximately 8 km long from north to south and 5 km at its widest point. The island is dominated by hills, rising to 550 m above sea level in the north. Paama island lies a short distance south of Ambrym, east of Malakula, west of the large active volcano Lopevi, and north of the island Epi. Most of the people living in Paama live in villages built close to the coast, with their gardens on the hillside about an hour’s walk from the village. People and Their Culture Many of the islands of Vanuatu have been inhabited for over 3000 years, with the oldest archaeological evidence dating to 2000  BC.  Oral tradition of storytelling, along with artefacts discovered in the 1980s, suggests that the people of Vanuatu traded with nearby Melanesian islands of Fiji, Papua New Guinea, New Caledonia and the Solomons. In 1605, the Portuguese explorer Pedro Fernández de Quirós was the first European to reach the islands, believing it to be part of Terra Australis. Europeans began settling there in the late eighteenth century after British explorer James Cook visited the islands on his second voyage and gave them the name New Hebrides. In 1887, the islands began to be administered by a French-British naval commission. In 1906, the French and British agreed to an Anglo-French Condominium on the New Hebrides. During World War II, the islands of Efate and Espiritu Santo were used as allied military bases. In the 1960s, the ni-Vanuatu people started to press for self-governance and later independence. Full sovereignty was finally granted by both European nations on July 30, 1980. It joined the United Nations in 1981 and the Non-Aligned Movement in 1983 (Government of Vanuatu, n.d.). The archipelago of Vanuatu has continued with a very traditional village way of life. Vanuatu is reliant on agriculture (coconut oil, kava, cocoa, coffee), fishing and tourism for much of the country’s income. Limited exposure to the economic and social changes that have occurred in larger communities, like Port Vila and other Pacific nations, through tourism, has had little impact on Paama Island. In a close-knit tribal community, the villagers live a very traditional subsistence lifestyle. Income generation is slowly evolving, with most of the population’s source of income coming from selling locally harvested food supplies. Many young people

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are absent from the village due to educational requirements, with many migrating for work in more urbanised areas to fund families at home. Demographics Given the remote nature of this island community, specific demographics around the villages located here are not readily available through online statistical databases. The people of this island rely on community stakeholder approximation, which fluctuates according to migratory income generation, that means many in the villages will leave at times for work or study, therefore the population is not static. For the purposes of this project, the total population of the island of Paama was considered due to access to health and municipal resources. In the 2020 census the population of the total island of Paama was recorded to be 1677 with an almost even split between males totalling 50.7% males and 49.3% females. The largest population group in 2016 was the 0–19 age group with 746 people being within this range; however, this changed to 56.8% being 19–65 years in the 2020 census (Area Council in Vanuatu, 2020). Nurse learners connect community members and stakeholders in partnership and take collective action on issues identified through community profiling and assessment (Francis et al., 2013). A component of community engagement and assessment requires the learners to complete a SWOT (strengths, weaknesses, opportunities and threats) and needs analyses of Liro, Paama. In partnership with community members and stakeholders, and following the Kaitohutohu presentation, the learners identified the whole population of concern. Identified Populations The following population aggregates in Liro, Paama, Vanuatu were identified by the nurse learners as having health disparities including: • Children • Older people • Whole community

Identified Health Needs Oral Health Oral health was identified as priority for the community of Paama, specifically in children up to the age of 12 years old. While consulting with an elder from the community, he reaffirmed that oral health is an issue for the community in Paama. In

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2019, the Rotary Club of Ballarat West conducted a study and found that 6-year-old children in Vanuatu start school with an average of 10 or more decayed teeth, and 35% of children in this age group had experienced toothache in the 12 months prior to the study, and 18.7% of these required urgent treatment (Rotary Club of Ballarat West, 2019). The survey also indicated that 68.9% of adults aged between 30 and 40 years had tooth decay, 60.5% had gum disease and 58.5% of adults experienced toothache in the past 12 months, of whom 31.8% required urgent treatment (Rotary Club of Ballarat West, 2019). Respiratory Health The traditional way of cooking in Paama is on an open fire in the family home, with the fuel used typically being coconut husks, wood and animal dung. Homes are made from a mix of traditional locally sourced materials, such as wood, coral, palm, dirt and western industrial materials, such as metal and concrete, with most homes being poorly ventilated (personal communication). Through the learner’s communication with community stakeholders from Paama in Vanuatu, it was identified that the local church has smoke-free as a goal for the community on their agenda, as they are aware of the complications it causes. They have been looking into smoke-free forms of cooking but are finding it difficult to initiate because it uses soil (personal communication). Learners identified reduction in smoke inhalation as a goal for health promotion in the community of Paama and set out to research the specific effects it has on health as well as possible solutions. Food Security Food security is a significant issue in many Small Island Developing States (SIDS), such as Paama. Natural disasters and climate change have significant effects on being able to produce a source of stable food. This is especially true for Paama, as Vanuatu is vulnerable to natural disasters, including cyclones, floods, droughts, earthquakes and volcanic eruptions (Food and Agriculture Organisation of the United Nations, 2020). Over the years, coastal resources have been exploited and while they do meet some needs, many are now close to extinction (Raubani, 2006). With a continuing increase in the ni-Vanuatu population, the need for sustainable and renewable food sources is even more paramount (Raubani, 2006). Diet is also a big issue in Vanuatu, with a stable nutritional diet being less and less available. A large factor for this is the influence and availability of Western foods changing the traditional diets. Western foods are commonly high in simple sugars and carbs, and low in protein and good fats. This has led to a double burden of disease, with burgeoning non-communicable diseases and consistent childhood nutritional deficiencies (Charlton et al., 2016).

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Identified Evidence-Based Review Nurse learners are further guided in phase three of the CHASE model to conduct a review of regional, national and international evidence-based literature related to the identified population and health needs. This assisted them to consider what sustainable measures could be implemented to enhance oral and respiratory health and food security within the identified population. The suitability of these findings or the need to adapt them are considered in response to the identified population and local rural community context. How nurse learners respond to this critical analysis is determined in phase four of the CHASE model when they develop an appropriate health promotion messages and resources with the aim of improving the identified disparities and health needs for the population groups of Paama.

Rural Encounters Economic viability, migration and sustainability are at the forefront of the health challenges faced by many Pacific Island communities. Globally, Vanuatu is one of the most at-risk countries in the world, with natural disasters including volcanic eruptions and cyclones that add to the burden of geographical isolation and the health of the people. The Ministry of Health is based in Port Vila with provincial offices based on the main islands. There are five levels of healthcare within Vanuatu: main hospitals in Port Vila and Espiritu Santo, provincial hospitals, health centres, dispensaries and aid posts (Ministry of Health, 2018). Paama Island has one health centre, one dispensary and two aid posts. In 2020, the health centre in Liro was fully staffed with a nurse practitioner, a midwife, a registered nurse and a nurse aide. Most of the staff are from other islands on 2-year contracts, that can be renewed up to three times (personal communication). The Lehili dispensary on Paama is located next to the Lehili school near Tavulai village and has one registered nurse and one nurse aid on site. The Luvil aid post is in Lulep and the Selusa aid post is in Tahi and are run by village healthcare workers. They can provide basic first aid, wound care services and paracetamol. There is an initiative to bring the village healthcare worker programme under the supervision of the registered nurse programme. The village healthcare workers receive around two months training prior to engaging in healthcare service provision. The maternity ward is located at the health centre and dispensary. Before the midwife was employed on the island, many women travelled to Norsup and the hospital in Port Vila to give birth. In 2020, many women felt comfortable to give birth on the island with availability of an experienced midwife (personal communication). A visit to see the registered nurse at the health centre for an adult is 100 Vatu (NZ$1.50) and 50 Vatu ($0.75) for children. This means that it is not viable for them

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Fig. 4.3  Surgical and Maternity Ward. (Produced by Cynthia Mullens with permission from the Author)

to make money for repairs on the clinic from within the community resources (Pacific Pathways, 2018) (Fig. 4.3). Impact of Climate Change Vanuatu is classified as an SIDS, a recognized group of 58 low-lying island nations across three geographical divisions (World Health Organization [WHO], 2017). The characteristics of SIDS include small land mass, geographical remoteness and susceptibility to natural disasters which makes them extremely vulnerable to climate change and increasing sea levels (Pacific Adaptation to Climate Change [PACC], n.d.; WHO, 2017). Due to the small area, dense population and reliance on local ecosystems for survival, climate change will disproportionately affect SIDS, including Vanuatu (Kim et al., 2015; Reti, 2007). There is ‘…compelling evidence that, by global standards, Vanuatu is one of the nation’s most vulnerable to climate change and sea-level rise’ (PACC, n.d., p. 8.). Vanuatu is extremely susceptible to most natural threats including tropical cyclones, flooding, droughts, earthquakes, tsunamis and volcanic eruptions. The impact of these events differs between islands (Reti, 2007). Climate-related events influence the nation’s economic, social and environmental structures (PACC, n.d.). Rising sea levels is an undeniable threat to the people living on islands in the Pacific. The Pacific region is experiencing increased sea levels faster than the global average, with those living in this region facing the stark choice of relocation or

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elevation. Due to geography and limited resources, Pacific Island nations are vulnerable to natural disasters, and can have damaging effects on the populations. For example, in 2015, cyclone Pam caused severe damage to many health facilities in Vanuatu (Kim et al., 2015). The impacts of climate change on plants grown in Vanuatu are not well understood but the probable impacts may be damaging to agricultural production and therefore decreased food security (Reti, 2007). Changes in rainfall could have major impacts on agricultural production in a region where water is a scarce resource (Reti, 2007). In recent years there have been numerous infectious disease outbreaks in the Pacific, most of which were climate-sensitive diseases including Dengue, Chikungunya and Zika virus (Kim et al., 2015). The WHO, along with Ministries of Health and other stakeholders in Pacific Island countries, have been working to construct climate-resilient health systems. ‘As recommended by WHO, this programme should address (i) health governance and policies tackling climate risks; (ii) health information, integrated surveillance and climate early warning systems; (iii) preventative and curative services …’ (Kim et al., 2015, p. 819). Vanuatu continues to develop and understand the effects of climate change and respond appropriately to the issue (Reti, 2007). The now uninhabited island of Lopevi dominates the view east from the village of Lulep on the northeast coast of Paama. This volcano is active, erupting reasonably regularly, every 2 years, which causes quite serious problems for those living in the villages of Lulep and Luli in the northeast side of Paama. The acidic volcanic ash falls onto gardens, ruining crops and onto the natangura thatched roofs, rotting them (Benseman et al., 2021; Vanuatu Tourism, 2020a, b). The most common mode of transport for those on the island is walking. Walking between Liro and South Paama takes about 2.5 h (about 8 km). Although there are three trucks on the island, they are often not used as they are expensive to run. There is one road along the west coast of the island. There are also seven speedboats which can be used for transporting people and produce to and from other islands and around the island, except for the western side which has no sea access. Speedboats are used more frequently than the trucks as they are cheaper to run. People also use their own canoes to travel around the coast of the island. There is a grass airstrip in the northern part of the island which serves as the island’s airport (Benseman et al., 2021; Positiveearth, 2015). A typical household on Paama has access to potable water via rainwater collection tanks with pipes that either run into housing or have communal access. There are two pump wells located in Liro, that are functioning but difficult for less physically able individuals to readily use and are less accessible than rainwater tanks. The main source of lighting for private houses are kerosene lamps and solar-powered lighting as electricity is fully dependent on a working generator with fuel to run. As of 2020, the community generator needed repair and was not being used at all. How nurse learners respond to this critical analysis is determined in phase four of the CHASE model.

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Health Promotion Resources Liro, Paama, Vanuatu, – the chosen case study for 2020 highlights oral health management and sustainability in relation to young people up to the age of 12 years old, respiratory health and food security. As nurse learners progressed with the community development project, in phase four of the CHASE model they engaged with the Ottawa Charter for Health Promotion (WHO, 1986) which provides five action strategies that, employed together, are most likely to envisage a health promotion change in a community and a framework for potential strategies to alter health status. CHASE phase four provides nurse learners an opportunity on how to improve the health of this identified population and together develop an appropriate health promotion message while co-designing a suitable resource (for the identified population and island contextual encounters) showcasing the message. The following are the designs developed: 1. Oral health needs (Fig. 4.4) 2. Respiratory health (Fig. 4.5) 3. Food security (Fig. 4.6) Learners’ Rationale and Consideration of Resources Resource (1). Learners found that the oral health services in Vanuatu are expensive and inadequate for the population needs, particularly in smaller outer islands like Paama. There was also lack of available and appropriate resources on oral health needs in the community. They recommended that a comprehensive approach involving primary, secondary and tertiary interventions to help combat poor oral health was needed. On discussion with a community health leader, they decided that resources written in Bislama would be more accessible and sustainable for the whole community. They therefore developed a poster on good oral health practices and the need to reduce sugar intake that was translated into Bislama and aimed to raise funds for health promotion that the community could undertake. Resource (2). The effects of inhaling smoke from cooking in indoor stoves were identified. The learners created a poster on the health effects of smoke inhalation. Further, they encountered a stove design through the Presbyterian Church of Vanuatu which uses less wood and produces less smoke than the traditional indoor stoves used in Paama. The stove consists of clay bricks that can be constructed from local materials such as clay, dirt and straw. The tools required to make the brick mould can be sourced on the island, and it is designed to be easily made following instructions and taught to members of the community. The design reduces the need for outside funding and maintenance and does not rely on transport (Bryden et al., 2005; PCV Health, n.d.). Not only will the stove design help to decrease indoor smoke inhalation, but it also decreases the amount of fuel required. Making the stove is a three-step process with step three being highlighted above.

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Fig. 4.4  Health Promotion Resource – Poster. (Produced by Benseman et al. (2021) with permission from the Authors)

Resource (3) was regarding the issue of food security in Paama, Vanuatu. Fish farming was found to influence diet, food security and sustainability. By supporting the continued fish farming efforts on Paama, better health outcomes could be achieved through increased access to protein and provision of a stable food source.

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Fig. 4.5  Health Promotion Resource – Poster. (Produced by Benseman et al. (2021) with permission from the Authors)

Promotional posters (to raise the profile of the fish farming efforts on Paama) and educational pamphlets (outlining the community benefits of fish farming) were developed as tools to empower the community to continue and expand upon current fish farming practices.

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Fig. 4.6  Health Promotion Resource – Poster. (Produced by Benseman et al. (2021) with permission from the Authors)

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Community Development Identified Impact Analysis Impact analysis related to Liro, Paama, Vanuatu situated in the South Pacific Ocean to the east of Australia community development project is now presented in this section of the case study. The impact aligns with the community stakeholders’ feedback; ethical cultural considerations nurse learners addressed related to disparities for Māori presented to the Kaitohutohu Panel; teaching and learning pedagogy associated with the CHASE model; United Nations’ 17 Sustainable Development Goals and graduate nurse professional practice reflections conclude this case study as reported below. Impact Analysis – Community Feedback The impact of the creative designs of the resources associated with the health promotion messages analysed by the stakeholders in Liro, Paama, Vanuatu indicated the most impactful to be the financial contribution that allowed for the early implementation of a locally sustainable oral health programme at the local school, with the posters adding to the knowledge base in an easy and relatable way. As initial engagement with this community changed due to COVID-19 and an inability to travel, funds raised by the learners to assist with travel costs were no longer required. As such these funds were requested on behalf of the learner to the Head of College for release to the community. This funding totalling 1300 NZD was used to support a local oral health project running out of Port Vila. Through the learner research and collaboration with community stakeholders, funds transferred to PCV Health in Port Vila were used to support the ‘Gudfala Tut Skul Program’ at the local school for 1 year. This was a simple solution to bridge the gap of time before the Vanuatu Ministry of Health would roll out the programme in Liro, Paama, Vanuatu. Connecting respiratory health with indoor cooking for the local population helped to increase awareness and provide resources to effect change. Further interest in alternative ways of cooking continues with exploration of solar ovens. The information around fish farming helped to generate more interest and there are now multiple fish farms across the community at various stages of growth and development. This continues to be a primary focus for the community. Impact Analysis – Ethical Cultural Considerations All resources were discussed with local stakeholders prior to researching and developing for approval. Considerations of language were paramount, as English was not the most appropriate version for development, and this required a different approach. As Bislama is not a primary language of the nurse learners nor the facilitator, connections in the community with a local registered nurse originally from Malekula

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enhanced language meaning and transfer into this medium. This consultation assisted with the technical and cultural aspects of translation and communication. Phase three of the CHASE model is aimed at learners to address the disparities for Māori and present their findings from the community research and needs analysis to the Kaitohutohu Panel. The Kaitohutohu are advisors within the educational institute who give support and advice on matters pertaining to Māori. This ensured that the learners approached constructing primary and secondary data with an emphasis on being culturally sensitive and maintaining a focus on the Māori population of Liro, Paama, Vanuatu (if relevant) were to highlight, address and alleviate any inequities, demonstrating cultural sensitivity and understanding of Māori cultural protocol, values, and beliefs. Cultural respect is represented in the Code of Conduct regarding a person’s cultural, values and beliefs (New Zealand Nursing Council, 2012). Impact Analysis – CHASE Model in Action 2021 For this case study the learners engaged with the CHASE 2020 model to guide the community development practice (Fig. 4.2). This model was evaluated by the facilitator (Mullens, n.d.) including independent researchers who acknowledged its contribution but agreed the model needed to be updated to maintain effectiveness as a teaching and learning model for offshore to New Zealand, international Island communities and the CHASE model 2021 was created (Fig. 4.7) for nurse learners to engage with and direct their community development projects. The evaluated version CHASE 2021 differentiates and highlights the varied aspects associated with community development project work, adding to CHASE four parts 2018–2019, an additional part in 2021 and a further part in 2022. The part six of CHASE represents a new phase nine in which nurse learners receive a micro-­ credential or Edubit on successful completion of the community development project. The CHASE model in 2021 is an adapted version of the original CHASE 2017 which consisted of the pre-orientation, orientation and nine phases. The CHASE model 2021 commences with the pre-engagement and physical contact stage by the nurse facilitators to make the initial encounter with the chosen rural geographical area and the identified community stakeholders to initiate collaborative partnerships, share ideas, discuss responsibilities and answer questions prior to the commencement of the community project. The original pre-orientation continues to engage with ethical approval for learners to conduct a community project (completed prior to the commencement of the project by the facilitator). The initial engagement of the nurse learners with the CHASE model is at the orientation stage and the 2021 version commences with what we term as ELM (Extended Learning Module) providing an opportunity for learners to introduce themselves to each other, team development, become acquainted with the community project and discuss this amongst themselves, which also offers time to think about the project and its geographical location prior to its

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Fig. 4.7  CHASE Model 2021. (Produced by Ross and Mahoney with permission from the Authors)

commencement. A research assistant continues to be contracted (research project funding) to complete the impact evaluations from the 2020 community projects and prepare this information for evaluation and dissemination. Impact Analysis – United Nations’ 17 Sustainable Development Goals At the completion of the Liro, Paama, Vanuatu community development project, nurse learners reflected on whether their health promotion message and resources could make a difference to one or more of the United Nations’ 17 Sustainable Development Goals (SDGs) as considered below. Goal 1 – No poverty – This involves ending global poverty by ensuring the poor and vulnerable have equal rights to economic resources. This can be done by building resilience to help reduce exposure to climatic, economic, social and environmental risks. Due to the global pandemic of COVID-19 and climate change, developments addressing this issue have been slowed, resulting in a high level of poverty and increase in conflict and food insecurity (United Nations, n.d.): • Paama is a small community which supports one another to ensure everyone’s basic needs are met. • Paama gains support from international volunteers who promote development, e.g. Otago Polytechnic helping produce funds to develop fish farms, improve oral health outcomes and respiratory health in the community.

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Goal 2 – Zero hunger – About 8.9% of the world’s population are hungry and suffer from undernourishment. The global aim is that the world’s population will have a sufficient food supply all year round and increase agriculture productivity to help maintain resilience and food security in all climate changes by 2030 (United Nations, n.d.): • Many families within the Paama community have crop fields on both ends of the island. This helps maintain food security to prevent hunger by increasing their chances of garden-survival during disasters, such as cyclones and volcanic eruptions. • The fish farm aims to address nutritional deficiencies by providing increased access to a stable protein source to increase food security. Goal 3 – Good health and well-being – This involves making sure all people are supported to have healthy lives and good well-being. The health promotion resources help to address this goal by: • Increasing access to quality oral healthcare services that are safe, affordable and effective • Providing education around the importance of oral hygiene and the effects of what you eat and drink on oral health Goal 4 – Quality education – This Goal promotes equitable and appropriate education opportunities for all people. This can lead to better job opportunities, higher incomes and greater country development: • This project provides education for all citizens on why it is important to look after oral health and how to properly undertake oral hygiene is important. • Effective education will ensure that the risk of developing non-communicable diseases directly related to poor oral health can be lowered. • Education at all levels will ensure the development of good hygiene practices from a young age and help to introduce new practices for older citizens. Goal 5 – Gender equality – The objective of this Goal is to empower women and girls to be involved in all areas of life and community. This helps to address disparities between genders and promote equity: • By implementing the health promotion projects in the community of Paama, the learners became aware of the traditional cultural gender roles. They ensured respect was shown to the community at the same time promoting and empowering women and girls in their health and quality of life. • A specific intervention aligning with this Goal was by implementing a fish farm for the community’s women to run, which would be enterprising and provide an income to the women and their families. Goal 6 – Clean water and sanitation – This supports sustainable access to clean water and sanitation processes for all people. This has a direct correlation with increased health and well-being along with decreased mortalities:

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• Paama has water and sanitation projects currently being worked out, including a new rainwater tank that has been installed and a toilet for the health centre that drains effectively into the ground. • The community also have solar water-sanitising devices to provide clean water for households. Goal 7 – Affordable and clean energy – This promotes access to energy that is sustainable and works towards decreasing the impact of global warming. This can look different in different places, and for Paama it includes: • Wood, charcoal and animal dung being used on open fires in homes. These are plentiful in this setting where access to electricity is difficult and unreliable. • This supplies light, heat, and a method for cooking. However, it also has negative effects on respiratory health. • Stoves built from locally sourced materials are an affordable alternative to open fires to help decrease health implications from smoke inhalation. Although the smoke will still contribute to negative respiratory health, the stove will allow for less smoke to be produced throughout the process of energy production. Goal 8 – Decent work and economic growth – This Goal promotes inclusive and sustainable economic growth, employment and decent work for all (United Nations, n.d.): • Industry in Paama includes small shops, textiles and handicraft production, fruit and vegetable growth and harvesting. • Many young adults leave Paama to seek work elsewhere due to the lack of opportunities in Paama, often sending money or food (e.g., rice) home to family members. • Peace Corps volunteers have worked alongside the local community to begin developing grassroots business opportunities (e.g., sewing machines for textiles to improve access to work for women). Goal 9 – Industry, innovation and infrastructure – This Goal aims to build resilient infrastructure, promote inclusive and sustainable industrialization and foster innovation (United Nations, n.d.): • Access to Internet and communication in Paama is commonly limited to mobile phone use. Many Ni-Van people own two phones due to differing mobile providers and coverage on Paama. • Low-smoke stoves offer an affordable, sustainable alternative to open fires. These stoves are long lasting and resilient in both indoor and outdoor conditions. Goal 10  – Reduced inequalities  – Reduced financial equality between first and second world nations is increasing. This SDG is concerned about the impact that financial/income inequality has and promotes the need for sound policies and

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global solutions. It promotes the empowerment of social, economic and political inclusion for all: • Many people in Vanuatu with chronic diseases, for instance COPD, may go unnoticed due to the overwhelmed health system and lack of qualified health professionals. Increasing health education amongst the community will lead to better health and therefore less stress on the health system, thereby improving the financial well-being of the community. • The training of health professionals and general first aid training across the population will also benefit the community. Goal 11 – Sustainable cities and communities – There is a rapid increase in global urbanisation in which adaptations need to be made to become sustainable in long term for human survival by focusing on reducing impacts on the environment including air quality and waste management (United Nations, n.d.): • Paama is a relatively self-sustainable island. The most common form of transport is walking, with only two vehicles on the whole island. This means air pollution is limited to fires used for cooking rather than due to transportation. • Most of the food supply is grown on the island, and the community is developing and improving projects like fish farms to increase sustainability and personal health. Goal 12 – Responsible consumption and production – Human consumption and use of nature’s resources is destructive and unsustainable. This Goal aims to reduce food and power wastage building on the three Rs reduce, reuse, recycle to effectively use nature’s resources (United Nations, n.d.): • Paama is an isolated community and therefore is heavily reliant on their own resources for survival and using as much of their produce as possible to avoid waste. • Food scraps are used to feed new and developing fish farms, which avoids waste and helps the growth of fish for consumption. Goal 13 – Climate action – This SDG aims to take action to combat climate change and its impact. This SDG is highly applicable to the community of Paama as they are subject to experiencing the effects of climate change such as extreme weather, cyclones and rising sea levels: • The learners were conscious to ensure that their interventions would not contribute to climate change, are sustainable long term and will withstand or be able to be rebuilt after cyclones. • The three areas of health promotion the learners focused on will help support the lifestyle and living practices already in place in the community. This is important rather than introducing new westernised practices and materials that need to be transported a great distance to the community, producing more carbon emissions and possibly contribute to waste issues on the island.

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• The intervention of improving stoves to low-smoke mud brick stoves aligns with this goal as the stove can be built from materials from the island, and community members can be taught how to build them, and to rebuild them if needed after a cyclone. These stoves are more efficient, producing less smoke and requiring less fuel and will reduce deforestation on the island. Goal 14 – Life below water – This Goal seeks to conserve use of the oceans, seas and marine resources for sustainable development. This goal is highly relatable to the community as the island is surrounded by water and the community has a lot of interaction with it: • The learners were mindful to ensure that the interventions developed would be sustainable long term in the community and not contribute to waste on the island as it could end up in the oceans. Goal 15 – Life on land – This Goal ensures the conservation, restoration and sustainable use of life on land as it is invaluable in the survival as a human race; providing food, oxygen pollination of crops and altering weather patterns (United Nations, n.d.): • Paama is heavily reliant on land life for living, producing and consuming their own crops as a majority of their food intake. As a community they are self-­ sustainable and continue to look at ways to improve this including fish farming. Goal 16 – Peace justice and strong institutions – This Goal aims at reducing all forms of violence globally, with a particular focus on abuse, trafficking and exploitation of children. This can be achieved by developing transparent institutions and inclusive decision-making at all levels globally (United Nations, n.d.): • Paama’s close community means they are more like family to each other. Violence rates are low in the community and any issues are usually sorted internally without the need for further action. Goal 17 – Partnership for the goals – This Goal requires a shared vision and goals to develop successful agendas globally, nationally, regionally and locally. Partnership is important for both developed and underdeveloped countries to make sure no one is left behind: • This goal is important in the learners’ work with the community of Paama, as they were conscious of the need to ensure their own health goals were in line with the needs of Paama community, and when looking at interventions the learners’ provided ideas that were practical and sustainable for an isolated community.

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Graduate Nurse Professional Practice Reflections Graduate nurses reflected (invited survey participation discussed in Chap. 6) on whether engaging with this Liro, Paama, Vanuatu community development project at an undergraduate level had any influence on their previous or current professional practice. This case study is an edited version of the community development project completed by nurse learners and facilitated by nurse academics, titled Evidence-Based Health Promotion and Sustainable Community Development – A Focus on Paama, Vanuatu. To review the full report, refer to Benseman et al. (2021).

Pedagogies of Compassion Mullens’s Doctor of Professional Practice (DPP) research employed the CHASE model to undertake research into pedagogies of compassion. In his work on Compassion in Philosophy and Education, White (2017) explores the philosophy of Arthur Schopenhauer in response to compassion as a fundamental, that without which, we would experience no sense of obligation to others at all. He concludes his work by proposing compassion for others in our personal lives is integral and extends into all relationships that we have including those with learners. He stresses not to become so focused on outcomes that we miss the inherent art of compassion in relation to the act of collaborating for knowledge formation (White, 2017). How to enact compassion in nursing education has been explored through the critical review of Younas and Maddigan (2019) on how to foster compassion in nurse learners. They propose a policy framework for curriculum design and suggest that compassion is expressed by nurses when there is authentic engagement to actively seek to understand suffering and become sensitive to the experiences of others to collaborate for health. Three areas for policy direction were identified: (1) an appropriate balance of teaching and learning strategies within nursing curriculum to target learning outcomes for compassion; (2) enhancing the use of reflection and reflective thinking in learners for integration of knowledge and proficiency; (3) giving voice to the act of compassion at various points within the curriculum progression. From this work, they recommended future research that contributes to the cultivation of compassion to develop guidelines for nursing education to integrate into curriculum design. We suggest that Mullens’s CHASE work is able to make such a contribution. Mullens (n.d.) research started first in a community of practice at Otago Polytechnic, Aotearoa New Zealand, bringing like-minded academic practitioners together around the potential for impact and capacity-building. The aim being to encourage graduate nurses to engage with global awareness and align learning projects with educational strategies promoting global connectivity. Mullens then developed a proposal for the integration of ISL opportunities for third-year nurse learners

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within the Bachelor of Nursing curriculum. Having herself studied nursing in the United States, Mullens reflected on the important role ISL had on her own development and felt strongly that global health  – a form of population and community health – was missing from the current nursing curriculum and that ISL provided a powerful way to address this gap. Conceptualising ISL as pedagogy, Bringle and Hatcher (2011) describe ISL as the intersection of service learning, study abroad, and international education: A structured academic experience in another country in which students (a) participate in an organised service activity that addresses identified community needs; (b) learn from direct interaction and cross-cultural dialogue with others; and (c) reflect on the experience in such a way as to gain further understanding of course content, a deeper understanding of global and intercultural issues, a broader appreciation of the host country and the discipline, and an enhanced sense of their own responsibility as citizens, locally and globally. (p. 19)

In this way, Mullens (n.d.) suggests that ISL incorporates much more than cultural exchange or study abroad as it identifies activities that addresses community needs through professional collaboration. This definition aligns closely with the aims and purpose of PBL with communities, such as those showcased in the case studies presented in this book. Following an invitation from a community with which Mullens (2019) had ties, the inaugural project was set out as working with the Liro, Paama community in Vanuatu, with twelve participating learners and four facilitating lecturers, with fundraising to travel to the islands planned for July 2020. However, with the onset of the global COVID-19 pandemic, and the closing of Aotearoa New Zealand’s international borders in February 2020, the ISL project needed to be rapidly re-designed in order to engage with the community project online. As Mullens (n.d.) had planned for onsite delivery, she needed to rapidly assess and evaluate the suitability of the CHASE model as an online tool for implementation of her project with this remote community in Paama. Mullens’s (n.d.) research provides a useful evaluation of the CHASE model in this context, and we consider the following findings useful for reflecting on the model itself and the networks which are forming through its use. These support a number of key ideas outlined through literature, and, by drawing upon practices and the experiences of participants, can provide insights for others. Although Mullens’s focus was on better understanding pedagogies of compassion, we believe the following observations are relevant for broader educational practices surrounding experiential and PBL.  Relevant to this analysis, we identified the following six observations from Mullens’s (n.d.) research: 1. Emotional experiences. The collaborative process for community stakeholders involved an emotional connection to the work. Stakeholders feedback suggested that this was a time for reflection and connection with the nurse learners. They noted feeling a sudden disconnect after the four weeks of engagement. Mullens notes that, in community-engaged projects, this emotional aspect of teaching and learning branches outside of a learner focus, resulting in an emotional responsibility on behalf of facilitating lecturers not to leave the participating

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community at arms-length and without a process of follow-through and potential reconnection. There is an ethical element to forming relationships of trust in any PBL encounter, and this is particularly true for remote communities. Mullens adds that facilitators need to be comfortable working outside of the model, and directly with people, including stakeholders, learners, and fellow facilitating lecturers, to ensure a sense of emotional safety is supported when relationships of trust are developed. Coimmunities of  Practice. The collaborative process for learners was also important, and this was enabled at a distance. Feedback from learner interviews identified a strong connection to their participating communities, and with this a sense that one did not need to be co-located to feel part of that community. Through the lens of the learner, the defining of community does not necessarily equate with that of being bound by geography but rather that of a community of practice. Learners acknowledged gaining a deeper understanding of the sense of this community, their values, beliefs and how they live their lives. This echoes Wenger’s (1998) assertion that socially situated learning involves meaning, identity, practice and community. It is particularly useful to note that this experience could be shared through online participation in an educational project, with people who may never meet face-to-face. Learner teamwork opens a space for collaboration with communities. Related to this was Mullens’s (n.d.) observations that through interviews conducted with learners, a specific community of practice was enabled through the use of learner teams. Learners observed that teamwork built better connections with others; Learners worked collaboratively  enhancing  team  connection, (Mullens, n.d.). This suggests that learners engaging in effective and meaningful teamwork are able to model productive dynamics which flow through to the work with community stakeholders and facilitating lecturers too. It emphasises the value of good relationships which can be learnt through active mentoring, but also through implicit behaviours demonstrated through community engagement. Longer engagement leads to integrated learning for all. Although this was already understood by facilitating lecturers employing CHASE, Mullens’s (n.d.) research highlighted the tangible benefits of establishing and maintaining community relationships over a number of years. This was identified first in Mullens’s test of CHASE as suitable for online delivery, employing research into the community of Bishops Castle, UK.  These  stakeholders  were concerned about the longevity of the project at the end of the nurse learners engagement. The stakeholders felt obliged to continue with the project goals and to improve the identified health issues that began with the nurse learners. These insights suggest that the time frame for the learners and the curriculum requirements do not necessarily match the expectations of the community. Mullens (n.d.) noted that the follow-through and continued conversation with community stakeholders is equally important as early engagement, and that this also falls to the facilitating lecturers to maintain. Mullens’s own identification. The roles of empathy and compassion describe empathy as the emotional tool that potentially allows us to identify with others,

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but that it is compassion that moves us to action (Mullens, n.d.). It became apparent that nurse learners were indeed able to perform and contextualise theoretical knowledge acquired earlier in their degree, but that the integrative educational projects also drew community stakeholders, and facilitating lecturers into the learning circle, and that a more prolonged relationship would benefit those project participants beyond the graduation of the nurse learners. Structures for ongoing relationship development need to be built into the model, requiring an investment of time and resource sharing beyond the structure of the course or curriculum. 6. Reflective practice draws all involved into an ongoing relationship. Another pedagogical tool that contributed to the development of CoP was the integration of reflective practice. In the second week of the student projects, facilitating lecturers engaged with the learners’ reflective journaling as a formative assessment tool. This approach allowed the facilitating lecturers to gain insight into the emotional experiences of the nurse learners, who often conveyed a range of sentiments through their reflective writing. As a result, the facilitating lecturers became active participants in the journey of the nurse learners. This potentially transformative experience of engaging in reflective practice highlights the importance of incorporating such pedagogical tools in community-based learning environments. The Liro, Paama, Vanuatu case study provided the community with a number of novel and timely community health resources. Addressing education for oral health of children, sharing resources to support low-smoke cooking – in turn, helping to address community respiratory illness  – and considering fishing and local food security were ways in which nurse learners, in partnership with the local community were able to discuss, research and innovate community health problems and potential solutions. However, there were also a number of pedagogical learning outcomes that are easily overlooked. First, it must be noted that delivery of this CHASE project online depended on pre-existing relationships that had been built by Mullens through previous work with the community, leading to the invitation for nurse learners to undertake project work. This project work was not initially planned for online delivery, but this was required due to COVID-19 travel restrictions. Unexpected benefits included the ability for nurse learners to donate funds raised for travel towards project implementation costs for the community in Liro, Paama, Vanuatu. Subsequent research by Mullens (n.d.) was able to identify the successful implementation of CHASE in this instance, but further research is required to find the right balance between in-person relationship building and successful online delivery in the future. Second, the process of learning in nursing is a transformative journey that has the potential to shift perspectives and instil a sense of compassion in learners. Mullens’s (n.d.) research project aimed to explore the impact of this shift in perspective on participants and how it can be harnessed to promote a pedagogy of compassion in nursing education. Central to this research was a desire to understand the experiences of participants and develop teaching that is compassionate, authentic and

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fosters an understanding of global health. Through this work, Mullens (n.d.) proposes the following definition of compassion in global health nursing education as ‘…the purposeful development of opportunities that connect communities globally with nurse learners, encouraging them to step outside traditional contexts of practice and perceive the interconnectedness of self within global health’ (n.p.). This definition contributes to the attributes required of registered nurses in Aotearoa New Zealand to work with individuals in culturally safe ways and broadens the curriculum to include population health, global health and community-focused approaches to nursing education. Through Mullens’s (n.d.) analysis, we can see clear links to the theories of teaching and learning highlighted earlier in this chapter. The facilitated exploration of genuine issues in rural communities, employing the CHASE model, enables nurse learners to connect learning, doing and reflecting in iterative cycles, and to apply their new knowledge gained through this experiential learning project with others. Higher levels of critical thinking, decision-making and problem-solving can help to prepare learners to become more autonomous in their practice, while also enhancing teamwork skills, and can contribute to increased confidence and resilience. Through the creation of, and engagement in authentic CoPs, nurse learners based in Aotearoa New Zealand are able to build and maintain relationships across significant distances and in radically different types of community. What begins as a group of potentially disparate individuals evolves into a team, working together towards a common goal. Having said all of this, it is important to acknowledge that there are limitations and challenges for facilitators, learners and communities. The Liro, Paama, Vanuatu project involved an invitation from the community, on the strength of an existing relationship with the facilitating lecturer. Working in such a different setting required a long lead-in for that lecturer and additional preparation of learners, in anticipation of spending time onsite. This necessitated time and effort outside of the ‘normal’ teaching block and needed extra time and resources on the part of the lecturer (refer to the CHASE model 2020 in Chap. 7 and the case study in this chapter). In this example, Mullens also brought a lifetime of experience regarding ISL with her, and it would be easy to imagine a less-experienced lecturer unintentionally triggering negative impacts or consequences for any of the community stakeholders. Four weeks is a very short period for learner encounter and a high level of engagement is required for all steps to be completed. We can imagine that communities do not all move at the same speed as the BN curriculum. While the nurse learners prepare to complete and move on to their next course, community stakeholders may need more time to consider remaining questions that they might have, and it seems important not to leave communities feeling at a loss, and to have steps that they can take to continue the work begun through this engagement. More work is also needed to ensure that health promotion resources can be genuinely owned by the community and are then able to be modified over time subject to recognition of Intellectual Property rights held by the learners. As well as the CHASE projects impacting learners and rural communities, the outcomes can in turn impact the CHASE model. Critical pedagogy provides a clear

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focus to guide the BN curriculum for nurse learners. This guidance establishes the most effective and meaningful approach of preparing to engage nurse learners in one of the core values associated with nursing, that of social justice identifying health disparities and social injustices (Thurman & Pfitzinger-Lippe, 2017). The CHASE model has endeavoured to ensure the BN curriculum engages with real-­ world authentic experiences as a component of one of their clinical placements. As discussed in Chap. 2, nurse learners identify and assess vulnerable populations resulting in health disparities, which is critically analysed as unfair, unjust and/or unequal. The CHASE model is a useful means to equip nurse learners to be meaningful contributors within the healthcare sector. This practical approach captured taught theoretical content and applied it in lived clinical practice experience allowing for integration of reflection, effective communication strategies, health promotion engagement, social context, social change and social justice. This can draw together history, social determinants of health, health disparities, indigenous population and economic and environmental factors, and enable community outreach, team building and collaborative project planning. As a result, public health theory and research and frameworks for practice are learned and applied in action. Together and supported, these can demonstrate nursing competencies as set out by the Nursing Council New Zealand (NCNZ, 2016).

Conclusion – Communities Empower Us We began this chapter by investigating literature that considered experiential learning and recognised the importance of learning contexts and co-constructed learning, through collaborative and co-operative practices. In turn, these contexts acknowledge others within the CoP that can be drawn together through live PBL activities. We have identified how the CHASE model repositions learners, where nurse learners and their participating community representatives learn from each other, creating CoP that enable the development of bespoke resources and solutions to current local problems. In the best cases, these resources and approaches are taken into and developed further by participating communities, empowering learners’ resources and community members alike. It is when these participatory relationships of mutual care actively learn together that nurse education moves well beyond meeting the prescribed outcomes and into the zones of potential transformation, for the learner and others. This reflects Dinsmore and Wenger’s (2006) claim that ‘individual change is actually a situated collective social process where routines and relationships are transformed’ (p. 60). While we acknowledge the need for ongoing and lively iteration of the CHASE model, reflecting the diversity of rural learning contexts and changing times, the case study discussed in this chapter demonstrates that community health and sustainable education do not need to be considered as separate domains, but that their confluence through structured learning projects can empower all.

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Chapter 5

CHASE as a Vehicle for Decolonised Rural Health Mawera Karetai and Samuel Mann

Abstract Mā te whakātu, ka mohio Mā te mohio ka marama Mā te marama ka matau Mā te matau ka ora

With discussion comes knowledge With knowledge comes light and understanding With light and understanding comes wisdom With wisdom comes wellness

Decolonised rural health is the theme for this chapter and advances on the notion of social justice as highlighted in Chap. 2. The chapter takes the form of an indigenous autoethnograpy. Specific recognition is given in this chapter as to how people and place have become consumed by urban and colonial dominance over centuries. This dominance has resulted in major consequences and implications to the health and well-being of both people and their land. These examples further acknowledge and showcase the connections between rurality, health and place and their engagement with the CHASE model as a strong vehicle in which to bring forward the issues identified and discussed in this chapter. Keywords  Decolonisation · Indigenous · Health · Disparities · CHASE Model · Narrative

M. Karetai (*) Te Whare Wānanga o Awanuiārangi & Management | Te Mātauranga Whakahaere University of Otago | Te Whare Wānanga o Otāgo, Dunedin, New Zealand e-mail: [email protected] S. Mann College of Work-Based Learning, Otago Polytechnic | Te Pūkenga, Dunedin, New Zealand e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. Ross et al. (eds.), Rural Landscapes of Community Health, Global Perspectives on Health Geography, https://doi.org/10.1007/978-3-031-43201-9_5

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Introduction In 2021, a group of Otago Polytechnic student nurses worked remotely with Mawera Karetai to conduct a CHASE community development project in Whakatāne, North Island, Aotearoa New Zealand. These are the stories she told them, followed by a critical reflection on the process. The chapter concludes with the case study produced by the nurse learners. In keeping with the principles of kaupapa Māori research, this chapter adopts indigenous autoethnography. This process of culturally informed research practice, Whitinui et al. (2013) state, makes ‘space for our desire to ground our sense of ‘self’ in what remains ‘sacred’ to us. As Indigenous people, that is in the world we live in, and in the way we choose to construct our identity, as Māori’ (p. 2). Whitinui’s work sees synergy between autoethnography and narrative enquiry as methodologies involving storytelling.

Story One ‘Shhhh, Boy, listen’, said Koro. ‘Can you hear them?’ Koro and the Boy lay amongst the forest understory, high in the ngahere (forest), in the Bay of Plenty, New Zealand. They were hunting red deer, an introduced pest species and a delicious addition to every local table. The Boy lay still, breathing as quietly as he could, lest he be heard by the stag and his hinds that were approaching them. He had been hunting with Koro (his grandfather) his whole life, from as soon as he could walk far enough, following Koro’s footsteps. His parents did not look after him properly when he was little; Koro said they had their own problems to deal with. He was brought to Koro when he was a baby and Koro had raised him in the bush. Growing, gathering and hunting their kai, living the old way, from what Papatūānuku (our Earth Mother) provided them. Right now it was ‘the roar’ – every hunter loves the roar. That is when the stags are most noisy and most careless, trying to attract hinds for mating. It is only once a year and it is only for a few weeks in March and April. If you are ever going to shoot a stag, this is the best time – the stags are fat! Koro and The Boy were hunting to fill the freezer with meat for winter. Last week they had gone for a good walk and shot a nice 10-pointer. The Boy had cut out the back steaks and the hind legs, as Koro had taught him. When he had finished, Koro had said, ‘Good enough, Boy!’ That was high praise, indeed. If it were a short walk, Koro would have carried out the whole carcass. But it was a long walk and so they only took what they could carry and left the rest for the pigs – they will be back for the pigs later in the year. On that walk, Koro had fallen over. That sometimes happens in the bush – you cannot always see what is around your feet and you get tripped up on roots, vines, old bones, your other foot and sometimes your imagination.

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A few weeks ago, Koro had tripped up on the root of an old kahikatea tree. He had twisted his ankle and got a good cut just above his boot. That has been happening quite a bit lately. He just needed to remember to lift his feet a bit higher when he walked. He gave The Boy the meat pack to carry and limped home using a strong stick as a crutch. When they got home Koro put his foot up and The Boy made poultice out of tūpākihi (a poisonous native tree), as Koro had taught him, to bring the swelling down. The Boy really loved learning about rongoā rākau (plant remedies) to help people and Koro knew so much about them. The Boy was worried though – this time, the rongoā was not working as it usually did and Koro seemed like he was still in a lot of pain. But he never complained. The Boy thought to himself he should probably mention he was worried to Aunty – she always knew what to do. The Boy stilled his mind and brought his attention back to the sound of the approaching deer. He could smell the stag and knew they were close. Suddenly, the herd stopped moving. The Boy looked up in time to see the stag lift his head and let out a thunderous roar that echoed all around them. The Boy slowly lifted his rifle to his shoulder, found his target, let out his breath and gently squeezed the trigger. BOOM! The sound of the shot rang out, and through his scope The Boy watched the stag drop. A perfect shot. The hinds, scared by the noise, turned as a group and ran. The stag stayed still. He was dinner for Koro, The Boy and their whanau. Lots of dinners. ‘Good’ said Koro. The Boy smiled. It was a long walk home and Koro was really struggling. The Boy carried the meat and his rifle. He was tired. When they got home, Koro went to sleep and The Boy rode his horse down the valley to Aunty’s house. ‘Aunty, I am worried about Koro’, said The Boy. He told Aunty what had happened with the ankle and the cut, and how Koro could not carry anything back from hunting. Aunty knew that something must be very wrong and said she would make an appointment with the nurse in town, when he next came to visit the valley. Before The Boy went home, Aunty logged into the Manage My Health app and booked an appointment with Nurse for Koro. Koro had no phone or Internet. He had no way of making the appointment for himself, so Aunty set up the app on her phone. She supposed that she should not be logging into the account as Koro, but how else could she get access to healthcare for him? He had never touched a computer and would not be happy that Nurse was coming; he would say he would be fine. ‘Kei te pai au – I am good.’ Aunty booked Nurse for a visit later in the week and let The Boy know the details. No one would tell Koro – he would disappear. Later that week the dogs started barking, letting Koro and The Boy know that someone was driving up the track to the house. Koro hobbled out to the front of the house, to see who was brave enough to drive the track. As Nurse’s Hilux came into view, Koro knew it was too late to hide – he had been seen. He shouted out to The Boy. ‘Boy, you and your bloody Aunty!’ Nurse got out of his truck and smiled at Koro. ‘It’s been a long time between visits, Matua,’ he said. ‘You didn’t need to visit now, e kare, it's a waste of your time. I’m fine!,’ said Koro. Nurse smiled again and said he had brought some milk from town so they could have a cup of tea, and might as well have a look at Koro’s leg since he was here, while The Boy made the tea.

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Koro sat down at the kitchen table and sipped his tea. Fresh milk was a treat. With no electricity in the house, there was no fridge. Everything that needed refrigeration was kept at Aunty’s house. Mmmm, it was good tea. While he enjoyed his tea, Nurse examined his leg. Koro knew something was wrong, but going to town to see Doctor was not for him. He did not like that place. He never understood what they were talking about and he knew too many others who had gone into the hospital and died there. He did not want to die there, away from his whanau and the whenua. He could see from the look on Nurse’s face that he was worried. ‘Koro,’ said Nurse, ‘I think we need to go into town and let Doctor have a look at your leg. What I am seeing here is troubling me. Have you been taking your diabetes medication?’ Koro told Nurse that he had not taken it and that he did not need that stuff. All his mates who had taken it had ended up ‘more crook’, so he was not taking it. And he was not going to Doctor either. ‘You aren't putting me in that hospital, e kare. I’m staying here with The Boy.’ Nurse looked at Koro. ‘Koro, you know about the gangrene? You know what that does?’ Koro knew. The Boy sat at the other end of the table, listening to the men talking. He was scared. He knew about the diabetes and the gangrene. He also knew that once Koro made up his mind, there was nothing anyone could do to change it. No one would get Koro to go to Doctor, no matter what they said to him. Nurse left without Koro, but The Boy knew he would go to Aunty’s and tell her what happened. They would make a plan and Koro would not have any more choices to make, except the one choice The Boy knew he would make – Koro would go into the bush and they would not find him until he wanted to be found. The Boy could feel the warm wetness of tears rolling down his cheeks. He loved his Koro so much.

Story Two Where to start? I could start with the facts, the stuff in Wikipedia – Whakatāne is the main town in the Eastern Bay of Plenty. Or I could start with the environment – it is an exciting but sometimes tragic story of explosions, earthquakes, floods and sunshine. But he tangata, he tangata, he tangata – it is people, it is people, it is people. Actually, it is a tree. The tree is called Taketakerau which means strong trunk supporting many leaves. Taketakerau is a sacred Puriri tree over 2000 years old and its longevity, fortitude and resilience in the face of many challenges and changes is a good model for the people of the Eastern Bay. If you were here, it would be one of the first places I would take you. There is a beautiful book by Marnie Anstis (Anstis & Howitt, 2011) that describes the world of Taketakerau, starting as a seedling in warm forest, just far enough away from disruptions of volcano and flood. Living alone in the forest with the birds for company, it was not until 1000 years ago that people arrived. These navigators from the Pacific settled in this new land. One of the first parts to be settled by Māori in Aotearoa was the Eastern Bay of Plenty.

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The second place I would take you is Kōhī Point. From there you can see the whole of the Bay of Plenty from Mayor Island to the west, the still steaming Whakaari (White Island) to the north and the coast past Ōpōtiki – regularly voted the best beach in New Zealand – to the east and inland to the summits of Pūtauaki and Tarawera. Behind you is the estuary of the Whakatāne River, Whakatāne itself, and the plains reaching into valleys, then into the rugged hills of Te Urewera and Tarawera. This is a beautiful place, but I said it is about people, so why are we at Kōhī Point? Just over there is Kaputerangi, one of the oldest known pā sites in New Zealand, associated with the ancestor Toi te huatahi (later Toi Kairakau). He landed at Whakatāne in around 1150, in search of his grandson, Whatonga. Failing to find Whatonga, he decided to settle in the locality and built a pa on the highest point of the headland. Around 600  years ago, the Mataatua waka landed after journeying from the homeland, Hawaiki. Mataatua was captained by the chief, Toroa, and accompanied by his younger brother Puhi, sister Muriwai and daughter Wairaka. The descendants of these ancestors are the Iwi, Te Whanau-a-Apanui, Te Whakatohea, Ngati Awa, Ngai Tuhoe, Ngaiterangi and Ngapuhi. These people are still here in the Whakatāne rohe. My friend Toi Kai Rakau Iti, son of activist Tame Iti, is a regional councillor, actor, television presenter, teacher and activist in his own right. He would tell you over a cup of tea that the plight of Māori in the Eastern Bay of Plenty is dire and the process to change that is difficult, especially when there is little willingness to enable the sort of social change we need here. This is not a new story. This story goes back to the beginning of colonisation, Te Tiriti o Waitangi, native schools, the Native Land Act, the Tohunga Suppression Act and a raft of other legislations that were designed to disempower Māori and enable the rule of the Crown. The design of colonisation was to rig the game in favour of the coloniser – it locked in these structural inequities – the remnants of those structures and the ongoing effects mean a lopsided health story in Whakatāne. This is a story of loss and suffering; however, it is also a story of resilience and determination. In 1854, the New Zealand Parliament was established. The system of government, based on the Westminster model, gave a vote for representation to men who individually possessed land. This excluded almost all of Māoridom, since Māori then, and to this day, communally own land. Because Māori were excluded from participating in the democratic system, the legislations passed by acts of parliament were based on the aspirations of the new settlers to Aotearoa. In order for the settlers to achieve their aspirations, the Māori must be dispossessed of land, rights and cultural identity – and so began the process of doing exactly that. In 1865, the Native Land Act was passed by the New Zealand Parliament with its primary purpose to make it easier for settlers and the government to obtain Māori land. The Eurocentric notion of land ‘ownership’ was very different from how Māori approached habitation and use of land. Each hapū – community of families that usually had close familial bonds and a common ancestor – collectively inhabited the land around them. For early Māori who were convinced to ‘sell’ land, there

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was no understanding of what selling meant. Under the Native Land Act, regardless of the size of the block, or the number of hapū members, a land sale only required 10 names to be listed as the owners, and those 10 were able to sign legal documents selling the land. There was no recourse. Hapū members were evicted from their ancestral land and effectively made homeless. The loss of home also meant the loss of resources, family, identity, traditional medicines, knowledge and cultural practice. The health of disenfranchised hapū members suffered, and that suffering has persisted. The effect, intended or not, was akin to genocide by stealth. In 1907, the Tohunga Suppression Act was passed, effectively making it illegal for Māori to practice traditional methods of healing. While the Act specified practices that included a spiritual or supernatural approach, what it actually sought to do was discredit traditional health practices and practitioners, much like the outlawing of witchcraft and other similar practices around the world (Hokowhitu et al., 2022). There were few prosecutions under the Act, but the damage was done in outlawing Tohunga practices. It was intended through this process that Māori would attend settler doctors and embrace Eurocentric health practices, but instead, Māori were further disenfranchised by the loss of cultural well-being practice, and were suspicious of the Western medicines. This is not difficult to understand when you consider that the same people who were offering health also brought disease. The impact of the Tohunga Suppression Act and the loss of culturally appropriate health practices is still felt today (McDonald, 2016). Māori health statistics paint a picture of inequity that is not improving in a way that indicates the problems are solved. In fact, in areas of mental health, addiction, obesity, diabetes and cancer, the situation for Māori is bleak. In Decolonising Methodologies, my friend and colleague Professor Linda Tuhiwai Smith wrote: ‘Our survival, our humanity, our worldview and language, our imagination and spirit, our very place in the world depends on our capacity to act for ourselves, to engage in the world and the actions of our colonizers, to face them head-on’ (Smith, 2013). It is through education that we are doing this. Education is one cultural area where we, as Māori, have begun to embrace our tino rangatiratanga, our self-determination and autonomy. It has not always been that way. Education is the solution to so many social issues, but for some time it was, by design, the pathway to inequity. The New Zealand Native School system was set in place by an act of parliament in 1867. The primary purpose of the system was to assimilate Māori children into the colonised society, and through instruction to create a serving class of skilled, low-paid workers (Simon & Smith, 2001). All teaching was done in English and children were punished for speaking te reo Māori. While Māori children attended the Native Schools, a mainstream school system was also established, for the settler’s children. In the 1960s the Native School system became part of the mainstream and Māori children attended whichever school was closest to their community. It is said that history is written by the victor; for Māori, history was written by the coloniser in English, painting themselves as the saviour of a stone-aged savage people who spent their time fighting and eating each other. The true story of Māori as global travellers, builders, astronomers and as educators, healers and traders was not taught in mainstream education until recently. Imagine

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the impact on your identity as an Indigenous child, being told the colonial version of your people and your history. The path to wellness for Māori depends on the restoration of a positive identity and the embracing of positive cultural practices that connect hapū members back to land and family. So, when we consider the health and well-being of our community today and the alarming statistics that represent Māori health, we must look a long way back to see where the problems began. But the answers are also found in the past and there is a strong movement towards the re-establishment of traditional cultural practice in maintaining the health and well-being of the wider community. While the Tohunga Suppression Act sought to completely eliminate Māori knowledge and practice in well-being from everyday life, in favour of a Eurocentric approach, it is now acknowledged that the two, when practised side by side, lead to better health outcomes for the community (Longmore, 2018). We have been standing on this headland for a while now. Let us head over to the other side of Whakatāne, beside the river. Alongside the Intermediate School and not far from the hospital, we will find the Awatapu lagoon. It is an ox-bow lake formed when the Whakatāne river was straightened for flood protection in the 1970s, cutting off the fresh water supply. By the early 2000s, the water was in a terrible condition, literally toxic; the banks  – while technically a reserve  – were a wasteland and the suburb on the inside of the bend was dominated by gangs. A report to the Whakatāne Council in 2013 listed ‘a history of burglary, disorder, littering, vandalism, drug, and alcohol-related charges’ (Opus, 2013, p. 2). The recommended solution was the removal of vegetation so as to limit opportunities for anti-social behaviour. But there is a different approach, and it took the initiative of Graeme Henton, the now-retired Environmental Science teacher at the Intermediate to make it happen, we can meet Graham there. The Wetlands Project has been a co-operative effort between the School, Te Papa Awawhai, the Bay of Plenty Regional Council, Whakatāne District Council and the Lions Club, for some time. All pupils attending Whakatāne Intermediate School participate in Enviro, an environmental science class. They pitch in to help maintain floating wetland pods of purei or pukio plants, as well as do regular clean-ups using kayaks, and even cranes to pull out old car bodies and other large items dumped in the waterway. Graham says the water quality of the lagoon fits in perfectly with the school’s long-term goal of making it a community resource. ‘Our students use the lagoon for their practical outworking of the principle of “Kaitiakitang” – showing care and respect for all that is around us. The lagoon is perfectly suited as a context for environmental learning, as it provides a multiplicity of ecosystems, all of which can be used to support student learning.’ Alongside the work on the lagoon, students are actively involved in restoring an adjacent wetland and native forest. They are growing native seedlings, planting tussock to restore a wetland and are out there on the wetland in their kayaks taking water samples and learning about the ecosystems and principles of kaitiakitanga. Students maintain the school worm farm, compost, vegetable gardens and fruit trees, feeding themselves and their families with what they have grown, and reaping the health benefits of fresh produce. As well as the Enviro class for all students,

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there is also a Green Team that operates during lunchtime, and an Enviro elective for students who show a commitment to the well-being of the environment. Those students take a week out of school to work on environmental projects that contribute to the well-being of the community. Through positive engagement in education, we have the opportunity to influence future health outcomes by strengthening cultural connections. Enabling students with the skills and knowledge to improve their environment, to grow their own food and to work with others, belonging and feeling valued will result in the change we need to address inequity in community health.

Story Three – Jack’s Birth Certificate ♪♫ If my words did glow with the gold of sunshine. And my tunes were played on a harp…♪♫ ‘Kia ora, Mawera speaking.’ ‘Oh, um, kee or-ra… Mar, um… Maaa, um… sorry, is this Jack’s caregiver?’ Asked the person on the phone. ‘Kia ora, this is Mawera, Jack’s mum. Who is this, please?’ ‘This is Whakatāne Hospital calling. I am calling about Jack’s referral to see the paediatrician.’ ‘Oh, cool, thanks. When can he see the doctor?’ ‘Well, Maa …, Mar …, well we don’t seem to have a birth certificate on file for Jack, and until we sight one, we are unable to make an appointment.’ ‘Excuse me? I think you have the wrong person.’ *Caller provides Jack’s full name and address. * ‘I think there must be some kind of mix up. Jack is Māori, was born in Whakatāne, has had one doctor his whole life and has been to the ED twice for falling off things. What do you mean you can’t make an appointment for him?’ ‘Well, um … there is a policy that we have to see the birth certificate before we can book an appointment.’ ‘Yes, you said that, but it still does not make sense. My son was born in Whakatāne, has a NHI number that is used in hospital and by his GP. He has only had one GP his whole life and I am his mum, also with a health number, also Māori, and also previously been to Whakatāne Hospital.’ ‘But the rules are the rules. If you don’t like them then you can choose to go to a private specialist and pay for private treatment.’ ‘I can’t afford that, and I want Jack seen in the public system. That is what it is there for.’ ‘Well, we need you to bring his birth certificate to the hospital, then once we sight it we can book his appointment.’ ‘Can you please explain why that is the policy?’ ‘Because there were too many people going to the hospital who are not New Zealand citizens.’

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‘Ok. Can you look at Jack’s health records and see he is a New Zealand citizen?’ ‘Well, yes, I suppose so.’ ‘So why do you need his birth certificate? Why can’t I just bring it when I bring him to his appointment?’ ‘BECAUSE IT’S THE POLICY!’ ‘Ok. So, I am not able to come to the hospital right now. What are my options for sending you a copy?’ ‘You are supposed to bring it down so we can see it.’ ‘What happens for families who don’t have a copy of their birth certificate?’ ‘WINZ (social welfare) will have a copy on file for them.’ ‘Hold on. Are you saying that if people don’t have a copy of their birth certificate they must be on a benefit?’ ‘No, that is not what I meant.’ ‘Maybe, but it is what you just said.’ *Silence* ‘Look, Jack needs this appointment. I have a birth certificate, but I can’t bring it down. What are my options for getting it to you?’ ‘You can bring it to the hospital, or you can post it.’ ‘So, in this digital age where you can already verify that Jack is a New Zealand-­ born indigenous child, born in Whakatāne to a New Zealand-born indigenous mother, you will only accept a physical copy of the birth certificate? Where does it say that in the policy?’ ‘You could take a photo and email it to me.’ ‘Fine, what is your email address?’

Story Four – Reflection on Process Let me start by saying I am not from Whakatāne, but I have lived here for a long time. Ko Pukekura te mauka, ko Owheo te awa, ko Takitimu te waka. Nō Ōtākou ahau! I left Ōtākou as a girl and through some amazing interventions in my life, I have found my way to Whakatāne. I am a fair-skinned, blue-eyed wahine mau moko, Indigenous ethnographer, living in a community where most of that is kind of weird. But, after having been here for more than 20 years, I feel like I am part of this community that I love – the people and the place. As I reflect on the opportunity to work with the Otago Polytechnic nurses, discussing the Whakatāne district, I feel so privileged to have had a seat at the virtual table. It was a conversation that made me happy, sad, mad, hopeful and led me to feel a myriad of other emotions as we explored this amazing place and all that is right and wrong about it. The cool thing about being an ethnographer is that I get to write and tell stories. My favourite way to tell stories is through fictionalised ethnography – the story is always based on something real, but the names, places and other identifying details are often made up. Since the stories, with their fictionalised parts, were based on real problems, they helped the nurses engage with the reality of life here in the

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Eastern Bay of Plenty. I purposely did not distract with detailed statistics as I wanted the nurses to focus first on the stories and then the stats – giving people a why often helps them to make a real commitment to a process. In this case the ‘why?’ was the inequity in health and well-being in our community. After all, people’s lives depend on those nurses giving a damn and willing to be part of change. So, why these stories? The story of Koro and The Boy is part of a series of fictional stories about The Boy, as he journeys through life, navigating systems that were designed to at best not include him, and at worst to oppress him. In this story, he and Koro have highlighted the difficulty in communicating with and accessing healthcare in our isolated rural communities. It also tells the story of the mistrust of the health system many Māori experience, particularly the kaumatua (older adults), who feel like the Western medicine happens to them, rather than works for them (Graham & Masters-Awatere, 2020). They see suffering in it  – Pākehā people, places and products to solve Pākehā problems that did not exist until Pākehā brought them here – none of it is designed by, or for Māori. Taiuru (2018) argues that ‘Māori are already suspicious of the government due to colonialism, oppression and intergenerational trauma, which makes Māori susceptible to belief in conspiracy theories’ (n.p.) – we see that in Koro – it is an ongoing challenge faced by our rural nurses. The brief explanation of land loss, education and healthcare gives insight into how long these problems have existed and how they came to be in the first place. Activists like Toi Kai Rakau Iti, Professor Linda Tuhiwai Smith and Graeme Henton are people who I see making a difference. By including them, I am honouring them and the work they do. And finally, the birth certificate story … well what sort of ethnographer would I be if I did not include something real from my own family life? Yes, I could have found some time to deliver Jack’s birth certificate to the hospital. But what about those families I work with who cannot do that, because of any number of barriers, such as cost, birth certificates being a symbol of an oppressive system, no access to technology or simply no idea on how to get a birth certificate and no one to ask. There is every danger that those would not talk about the problem or the impact of that problem – they just accept that it stops them from accessing healthcare for their children. It is those things that happen to me in my life that keep me doing this  – telling the stories  – trying to inspire enduring change through education. I have spent a long time thinking about this experience of being interviewed in this project, and the process of working with the nurse researchers. Sometimes when I reflect on it, I feel ‘othered’. A Māori working with a group that was predominantly non-Māori, on a process that was not designed by, or for Māori, but was directly or indirectly about Māori. Everyone else was in a room, sharing space, but I was on Zoom. Middle-aged me, working with a bunch of mostly young people. Living in the North Island, in a struggling rural community, working with people based in an affluent South Island city. Othered in my own mind? Perhaps. When you are othered a lot in life, you start seeing othering where it might not be there. But, in this instance it was my ‘otherness’ that added value, so it must have been there. Were it not for the differences, there would not have been a conversation. In

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reflection I see value in my otherness, as I saw value in the perspective of those who othered me. Oh, and there I go ‘othering’ the otherers. But, one might argue, surely most of nursing is independent of culture – is deliberately ‘othered’ to standards of care. But, taking a Freirean view (1985), this apparent lack of cultural integration exposes the normalisation of the oppressive culture. Artefacts are actively imbued with the political values held by those who created them (Winner, 1980); these values silence other values (Scheuermann et al., 2021) and knowledges are not innocent (Barad, 1997). Writing of industrial design, Torreta and Reitsma (2019) argue that it ‘emerged from a specific nature/culture and political situation; it is therefore a situated field that echoes the worldview of where it was created’ (p. 2). In the same way, we can see nursing is not culturally neutral but embedded with cultural, social and political values that often appear hidden through the normalisation process. My story has been about my experience of interacting with the learners on the CHASE project. I do so as a member of the Indigenous people, referred to as the tangata whenua, of Aotearoa New Zealand. While I can tell my version and my lived experience, I cannot presume that the experiences of those from Rakiura would be the same. And while my whakapapa of proud Polynesian sailors navigating the Pacific might resonate with Welsh notions of Cymru am Byth – of Welsh pride and patriotism – they should most certainly not be considered synonymous. So, it would be a mistake to interpret my story as representing all Indigenous peoples. And yet learners in CHASE need to be able to apply their skills to diverse peoples and environments – from high country farmers in semi-arid Central Otago to tiny islands in tropical Vanuatu where rather than ‘small-island states’, ‘large ocean states’ (Chan, 2018) is increasingly preferred – recognising the interconnectedness of the peoples and the long history of navigation. The core principles that are evident in person-centred practice, no matter where we work are empathy, hospitality, respect for people and place, respect for the long and complex intertwined histories, that explain the why and how of the present, and a willingness to accept that systems do not always act in the best interests of all people. Through this chapter we have talked about colonisation as the problem for rural health and education as the solution. But since colonisation has had a huge impact on education, perhaps we need to now talk about decolonising health education so that it actually fixes the problem rather than adding to it. There are three questions here – what does it mean to decolonise health? Then how do we decolonise health education? And finally, how does CHASE contribute as a positive force for decolonisation? Toyama (2015) wrote that technology amplifies human forces, and, we argue that nursing practice is an agent of technology and the dominant force in New Zealand was, and continues to be, colonialism. The almost romantic vision of settler families arriving in tall ships belies the establishment of systems to benefit the coloniser. Crucially, it involves a set of unequal relationships between the colonial power and the colony, and between the colonists – or colonisers – and the Indigenous population – or colonised. The systems are imposed that benefit the coloniser. And those

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forces and systems have continued (Smith 2013) and are amplified by education. In educating future nurses, CHASE must recognise this position. Mkansi et al. (2018) describe decolonising education as a ‘baffling endeavour’ for the sciences. This bafflement can be imagined in a perspective that things Māori have nothing to do with learning how to carry out the technical skills of nursing – dressing a wound for example. This systemic shortcoming is mostly not from a position of arrogance but a genuine bewilderment of how you could teach a thing that is seemingly culturally independent and abstract in ways that better align with Te Ao Māori (the Māori world). The New Zealand health practice has traditionally been underpinned by the Te Whare Tapa Wha model of care designed by Sir Mason Durie in 1984 (Durie, 1994). The understanding and commitment to providing a better standard of patient-centred care has grown since that model was released. And yet Te Whare Tapa Wha is still regarded as the standard for good practice. The lack of development since 1984 suggests the bar could be raised higher. While Durie (1994) provided a valuable model to support the process to decolonise New Zealand health practices it does not position these practices as decolonised on its own. So, what does it mean to decolonise health? Linda Smith (2013) describes a long-term process of change: ‘Decolonisation, once viewed as the formal process of handing over the instruments of government, is now recognized as a long-term process involving the bureaucratic, cultural, linguistic and psychological divesting of colonial power’ (Smith, p. 98). In The Waitangi Tribunal’s WAI 2575 Report: Implications for Decolonizing Health Systems, Came et al. (2020a) applaud the Waitangi Tribunal’s findings and identify the five most significant and impactful steps towards a transformed, decolonised health system: ‘(1) the adoption of Tiriti-compliant legislation and policy; (2) recognition of extant Māori political authority (tino rangatiratanga); (3) strengthening of accountability mechanisms; (4) investment in Māori health; and (5) embedding equity and anti-racism within the health sector’. (p. 209) This simple roadmap to transformation would directly address the barriers to health and the appalling Māori health and rural health statistics we continue to live and die with. And yet the change remains a discussion and an aspiration, rather than the plan we need to see. In Gorse to Ngahere, Came et al. (2020b) take Smith’s understanding and apply it to health using the allegory of changing perceptions of environmental management ‘which likens the colonial health system in Aotearoa to gorse, and a decolonised Māori-centric health system to a ngahere’. Gorse is an invasive spiky woody weed, thriving in areas of disturbance. Ngahere is an indigenous forest. For many years the management of gorse was biochemical suppressant, but little was done to change the fundamental environment. More recently ecologists promote considering the gorse as a nursery plant for forest species. This means we work with what we have and grow something new from it. Came et al. go on to say that ‘one response to decolonisation is to focus on strengths and return to one’s ancestors’ teachings, values, ethics and knowledge’ (p. 103). When we consider the practice of a Tohunga who looked at the person in front of them, they treated the whole person and all

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aspects of their lives from the physical ailment, to their mental health and feelings of well-being, their spiritual belief and their cultural practice. As Came et al. puts it ‘Māori observed the ngahere and other features of the environment for survival and applied the knowledge gained from the ngahere into all facets of life … The ngahere was a source of spiritual enrichment, cognitive development, reflection and physical health and aesthetic experiences’ (p. 104). Then, when we consider the perspective of the nurse researchers, applying the CHASE model, there is synergy. The way primary healthcare is practised in relation to Te Tiriti can be considered as a continuum (Kidd et al., 2022) with a variety of practices and a system that is slow to change. Within this system, we believe that the nursing community should take a significant lead role in establishing a power-sharing relationship at all levels – with individuals, hapū and wider communities. Kidd quotes a service provider: ‘by understanding what the inequity is and where, by prioritising high needs Māori population in what we do and how we do it, working with other providers who contribute to social determinants of health and our Māori health strategy’ (p. e109). Came et al. conclude with a description of imbalance: The presence of gorse and the compromised state of the ngahere is a symptom of a profound imbalance in the landscape. This ecological imbalance, like the imbalance of ethnic inequities and racism, needs to be corrected to benefit all those that live in this whenua. Gorse eradication like the eradication of institutional racism is a wicked problem that needs to be addressed from multiple fronts, using the collective and individual spheres of influence of many within the health system (para. 26).

So how does CHASE contribute to this? First, CHASE has placed the nurse learners in a space where they understand their own positioning. As Freire (1985) described ‘washing one’s hands of the conflict between the powerful and the powerless means to side with the powerful, not to be neutral’ (p.122). Freire’s point highlights the importance of nurse learners being cognisant of their own positioning. Second, CHASE needs to put nurse learners in a position where they understand the health and well-being requirements of the community. As Freire so described: ‘One cannot expect positive results from an educational or political action program which fails to respect the particular view of the world held by the people. Such a programme constitutes cultural invasion, good intentions notwithstanding. (Freire, 1972, p.68) In keeping with Freire, nurses who are learners should construct their practices in ways that align with the culture of the communities where they work. We can take a leaf from Warbrick et  al.’s (2023) work on Maramataka (the lunar calendar)  – health is in the environment. CHASE does this by taking a holistic approach to the community assessment (as discussed in Chaps. 2 and 3)  – it starts with genuine curiosity and desire to help. It then tailors solutions for that community rather than imposing blanket solutions. It returns power to communities. Tuck and Yang (2012) warn us to avoid the mistake of using decolonisation as a metaphor for human rights and social justice but demands an indigenous framework, land sovereignty and indigenous ways of thinking. Māori expected, in signing Te Tiriti, that European colonisation would allow the sharing of benefits, including the health and well-being, of those peoples. This sharing must be a real sharing, in

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which Māori participate in making decisions for our own well-being, in consultation with healthcare professionals, and not merely as a problem to solve. Learners using CHASE need to be careful not to take a deficit approach. Sherwood and Anthony (2020) describe a strength-based approach to Indigenous ethics, arguing that ‘Indigenous people should not be classified as a disempowered vulnerable people but as an empowered yet oppressed peoples through Western constructs situated within colonial structures’ (p.  20). Using this strength-based approach, which respects and accepts that Indigenous people are experts in their lives and knowledges, learners need to look to Māori’s successes in developing their action plans. In this framing, we need to focus beyond the negative critique of constructions of cultural difference, but on the productive possibilities of the seams amongst differences (Philip et al., 2012, p. 8). These seams – between conventional nursing and a decolonised approach – are where we need to be looking to develop the CHASE process. As Akama et al. (2019) argue, we need to ‘critically interrogate techno-­ deterministic objects and systems through a sensitivity to difference in culture, power, history, politics, knowledge, and practices in all their complexity and diversity’ (p. 5). In short, we can summarise too many Māori experiences of health as ‘if the health system doesn’t make things better for you, then there is something wrong with you, your education and your cultural understandings, not the system’. In acting as a decolonising force for nursing learners, CHASE provides an opportunity to remedy this. This is showcased in the Whakatāne case study.

 ASE STUDY 2022 – Rural Community, Whakatāne, Bay C of Plenty, New Zealand Compiled by Jean Ross

Community Planning Community planning commences with the academic lecturer initially engaging with potential community stakeholders to gauge their interest in participating with a community development project. A local community stakeholder from the rural community of Whakatāne situated in the Bay of Plenty of the North Island in Aotearoa New Zealand (Fig. 5.1) extended an invitation to one of the nurse facilitators inviting nurse learners to collaborate on a community development project in 2021. And in 2022 the invitation was accepted and a group of nine nurse learners embraced this opportunity. The academic facilitator together with the community stakeholder planned the project and answered any questions.

5  CHASE as a Vehicle for Decolonised Rural Health Fig. 5.1  Map of New Zealand highlighting Whakatāne

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Whakatāne

CHASE Model in Action 2022 Nurse learners drew on the CHASE 2022 model to guide their community development practice (Fig. 5.1) which comprises a pre-engagement, pre-orientation, orientation and nine phases showcased in this case study. CHASE pre-engagement commenced with the collaborative relationship between the community stakeholder and nurse academic to work on a community development project together. The pre-orientation stage requires the academic facilitator to gain ethical approval for learners to proceed with the project. At the orientation stage nurse learners are introduced to the rural community of Whakatāne situated in the Bay of Plenty of the North Island in Aotearoa New Zealand (Fig. 5.1). Nurse learners build on the history, demography and topography of Whakatāne; they were guided by the CHASE model’s phases one and two to conduct a community profile and assessment and gather and analyse primary and secondary data associated with this rural community. Nurse learners share this information with local community stakeholders as they work collaboratively to identify the potential of a vulnerable population and their health needs which focusses on the community development (Fig. 5.2).

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CHASE Model 2022

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Students received Microcredential endorsed in Sustainable Development Goals from the educational institution referred to as Community Development Practitioner.

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Report and health promotion resources distributed to community and stakeholders

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Evidence-based literature review and consultation aligned with population health needs

Community assessment primary and secondary data collections. Consultations with stakeholders and Kaitohutohu (Mā ori ethical approval)

United Nations 17 Sustainable Goals considered relevant to the community project. One or more are identified that could be improved with the successful implementation of the developed health promotion message and resources.

Final presentation to stakeholders and Kaitohutohu (M ā ori ethical approval)

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Student orientation Team dynamics, team roles identified and planning community projects included in ELM weeks

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Ethical approval and consultation with stakeholders

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Initial presentation with stakeholders, Kaitohutohu (M ā ori ethical approval) and identify health needs Summary included prior to presentation

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3-6 months following Phase Five an impact assessment completed by research assistant

Facilitator Responsibility Teams’ Responsibility Research

Community Health Assessment Sustainable Education Model adapted by Ross & Mann (2022) published with permission from Ross, Crawley & Mahoney (2017).

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License

Fig. 5.2  CHASE Model 2022. (Produced by Ross and Mann with permission from the Authors)

Community Engagement Community engagement connects the learners with community stakeholders from Whakatāne in phases one and two of the CHASE model. Learners define the cultural topography of this rural community by gathering information on the physical environment, history and demography which forms the basis for the community assessment. Learners describe the community’s land, people, their culture and demography which offers the opportunity to explore the relationship and connections between the people/s’ past and present and the environmental and cultural influences of residing in Whakatāne, and its peoples’ associations with this place.

Cultural Topography Land Whakatāne District is in the Bay of Plenty region on the east coast of the North Island, New Zealand. It is located 90 km east of Tauranga and 89 km northeast of Rotorua. Auckland is 298 km away and within a four-hour drive. Whakatāne District combines both rural and urban areas and has been described as one of the most diversely beautiful areas in Aotearoa New Zealand with long sandy beaches and warm tropical climate with many choosing to relocate or holiday in the areas

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(Whakatāne Information, 2016). Whakatāne township is the principal centre in the eastern part of the Bay of Plenty. The other main towns in the district are Kawerau and Ōpōtiki. Aspects of physical environment in the Whakatāne District include two forest areas  – Te Urewera and Whirinaki Te-Pua-a-Tāne and the Whakatāne river, or Ōhinemataroa. Whirinaki Te-Pua-a-Tāne is a Department of Conservation Park and is co-governed with Ngāti Whare, the Iwi which lives with a close relationship to the forest and the rich natural resources (Department of Conservation, 2022). Te Urewera is the largest rainforest in the North Island, and as of 2014 was disestablished as a national park to become the first natural structure recognised by law as a legal person, meaning it owns itself and has its own rights to exist for its own sake (Tūhoe, 2022). Te Urewera expands across Bay of Plenty, Hawkes Bay, and Gisborne areas and is 2127 km2. The Whakatāne River rises from within Te Urewera and runs 112 km north to meet the ocean in Whakatāne town. The river presents flood hazards, especially to the surrounding dairy farms, as there are many farms found on the eastern floodplains of the river (Paulik et  al., 2021). The area was drained in the twentieth century to accommodate the expanding dairy industry but is now at risk due to the changing climate (Fig. 5.3). Over the last 20  years, Whakatāne District communities have been severely impacted by several natural disasters, including the Edgecumbe earthquake in 1987, floods in 1998 and 2004 and the Matata debris flow in 2005 (Bay of Plenty Regional Council, 2007). Whakaari/White Island is a volcanic island located 49 km offshore from Whakatāne and is estimated to be between 150,000 and 200,000 years old. In December 2019, it erupted killing 22 people and injuring many more. It occurred while a tour of the island was conducted impacting people from New Zealand and international visitors (Whakatāne District Council, 2020).

Fig. 5.3  Waimana River. (Produced by Dennis Turner with permission from Authors)

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People and Their Culture One of the first parts of the Bay of Plenty to be settled by Māori is the eastern aspect. According to the Māori legend, Toi-kai-rakau was one of the first people to be born in New Zealand and he settled in the Whakatāne area in 1150, where he built a pa (Maori village) on the highest point of the land. The site named Kaputerangi sits high above Whakatāne which was the territory held by Toi where Toi’s sons founded several tribes or Iwi of their own (Whakatāne Information, 2016). These include Ngāti Awa, Ngāti Mākino, Ngāti Manawa, Ngāti Tūwharetoa (Bay of Plenty), Ngāti Whare and Ngāi Tūhoe. Settlements with the Crown have been achieved on four occasions in the last 5 years with Ngāti Rangitihi currently in negotiations with the Office of Treaty Settlements. Iwis are actively involved in many activities within the Whakatāne district such as the development of Murapara, Kani Rangi Park and Ruatāhuna Community hub (Whakatāne District Council, 2018) (Fig. 5.4). Settlement by Europeans occurred around the 1830s. As the settlement of Whakatāne grew, stores, hotels, a flax mill and a schoolhouse were founded in 1875. The surrounding farmland was brought into use after the adjoining Rangitiki swamp was drained in the early twentieth century. In the 1921 census, the borough had a European population of 1707. By 1956, the total population of Māori and Pakeha Fig. 5.4  Rata Te Urewera. (Produced by Dennis Turner with permission from Authors)

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had risen to 5445 residents. In 1939, a paper mill was established which was the largest employer until the 1980s (Te Ara, 2015) and is still in operation today. Demographics The 2018 Census of the Whakatāne District had a total population of 35,700 with 63.2% of them identifying as European and 46.8% as Māori. About 18,258 were identified as female and 17,442 males, with the median age being 39.8 years for non-Māori and 27.3 years for Māori residents (Statistics New Zealand, 2018). Whakatāne town itself is a predominantly Māori community; they respect and recognise the history and the culture embedded within the district and this is of significant value. The Māori culture is a large part of the community’s identity. This is evident through the number of churches and cultural gathering facilities such as maraes. In the central town of Whakatāne there are four maraes and a further five in the wider district (Te Ara, 2015). Nurse learners connect community members and stakeholders in partnership and take collective action on issues identified through community profiling and assessment (Francis et al., 2013). A component of community engagement and assessment requires the learners to complete a SWOT (strengths, weaknesses, opportunities and threats) and needs analyses of Whakatāne, and in partnership with community stakeholders and the Kaitohutohu Panel (cultural guidance) they identified two vulnerable population groups and their health needs as issues of concern.

Identified Populations and Health Needs The learners identified two vulnerable population groups in Whakatāne: 1. Youth (13–18-year-olds) identifying as LGBTQ+. The poor mental health outcomes throughout the LGBTQ+ communities in Whakatāne and their families/ whānau struggling to accept this population group were recognised by the learners as having a lack of resources to help them transition and accept their identity. 2. People with chronic illnesses, specifically Type 2 Diabetes within the adult Māori population in Whakatāne.

Identified Evidence-Based Review Nurse learners are further guided in phase three of the CHASE model to conduct a review of regional, national and international evidence-based literature related to the identified populations and health needs and consider whether these findings could potentially improve the mental health of youth recognised as LGBTQ+ and

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people with diabetes in Whakatāne. The suitability of these findings and the need to adapt them are considered in response to the identified population and local rural community context. How nurse learners respond to this critical analysis is determined in phase four of CHASE when they develop an appropriate health promotion message and resource with the aim to improve healthcare of these vulnerable groups. Mental Health for LGBTQ+ Community Fish (2020) discusses the dynamic social changes occurring in the modern-day world and how these impact the younger generations, and their vulnerability to compromised mental health. Young people aged 15–24 years are particularly vulnerable to influence and attitudes of their peers around them. It is also a crucial phase for the health and well-being of these individuals. Poor mental health is a major concern for those within the LGBTQ+ community. These issues include a higher chance of poor well-being, psychological distress (including anxiety and depression) and suicide (Tan et  al., 2021). Anti-LGBT stigma or discrimination causes increased distress among young adults and interferes with positive mindsets (Fish, 2020). The Youth Under 19 survey (Greaves et al., 2021) indicated that 53% of Māori and 49% of the non-Māori population LGBTQ+ people reported serious episodes of depression, in comparison to Māori and Pakeha who do not identify as LGBTQ+, where the percentages sit at 27% and 18% respectively. In this same report, 46% of queer Māori respondents disclosed they had serious thoughts of suicide and for queer non-Māori respondents that statistic was 45%. For Māori and non-Māori population who do not identify as a part of the LGBTQ+ community, it was reported only 23% and 15% had suicidal thoughts, respectively (Greaves et al., 2021). Adults with Type 2 Diabetics The second health need identified by the learners was Type 2 Diabetes in the adult population of Whakatāne. Diabetes affects over 250,000 people in New Zealand with the rate of Type 2 Diabetes increasing and is more common in Māori, Pacific and Asian communities than in European communities (Ministry of Health, 2022). A retrospective, population-based, longitudinal cohort study (Yu et  al., 2022) focused on ethnic differences in mortality and hospital admission rates between Māori, Pacifika and European New Zealanders with Type 2 Diabetes. The pattern of poorer outcomes amongst Māori and Pacifika patients with Type 2 Diabetes over such a long period of time highlights the importance of the development of new, more intensive approaches to Type 2 Diabetes prevention, early detection and management and to incorporate broader strategies to address socio-economic inequalities contributing to the disparities in diabetes rates within these communities (Yu et al., 2022).

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Kāinga Ora provides homes to the vulnerable population with their priorities, which include addressing homelessness and making homes more affordable for New Zealanders (Kāinga Ora, 2022). No data is available to indicate how many people with Type 2 Diabetes live in Kāinga Ora houses; however, the vulnerability of the Māori population has been identified (Whakatāne District Council, 2018).

Health Promotion Messages and Resources The key consideration in developing health promotion resources by the learners was to create visual resources to reduce health inequalities for the identified population groups. The nurse learners were guided by the Ottawa Charter for Health Promotion as a framework and supported by the literature to design and develop resources for this project. As nurse learners progressed with the community development project, in phase four of the CHASE model they engaged with the Ottawa Charter for health promotion (World Health Organisation, 1986) which provides five action strategies that, when employed together, are most likely to envisage a health promotion change in a community and a framework for potential strategies to alter health status. CHASE phase four provides nurse learners an opportunity for imagining and shaping the improvements to the health of this identified population and together develop an appropriate health promotion message while co-designing a suitable (for the identified population and rural contextual encounters) resource showcasing the message. The first was mental health needs of the LGBTQ+ and the learners made four recommendations for this population aggregate. These four recommendations are: • • • •

Health promotion in schools Educating older people Support groups in the community Promoting LGBTQ+ inclusivity into rural General Practice clinics

Mental Health Needs of the LGBTQ+ Community A banner pen (Fig. 5.5) was designed with pull-out information for all ages about the use of pronouns. The pens would be provided to places such as youth leaders, school nurses, rural General Practice clinicians and nurses within rest homes to include populations of all age ranges. Two small cards were designed to be accompanied with the pen. The first, (Fig. 5.6) has pictures showing the pronoun use for different genders or those who are non-binary and the second (Fig. 5.7)

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Fig. 5.5  Health promotion resource – Banner Pen. (Reproduced from Sustainable community development through evidence-­based health promotion focusing on the Whakatāne community by Sullivan et al. (2022) with permission from the Authors)

Fig. 5.6  Health promotion resource – Information Card. (Reproduced from Sustainable community development through evidence-based health promotion focusing on the Whakatāne community by Sullivan et al. (2022) with permission from the Authors)

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Fig. 5.7  Health promotion resource – Information Card. (Reproduced from Sustainable community development through evidence-based health promotion focusing on the Whakatāne community by Sullivan et al. (2022) with permission from the Authors)

Type 2 Diabetes Amongst Māori Population For the Type 2 Diabetic population group in Whakatāne, the learners identified that there were already widespread public health initiatives happening throughout New Zealand and globally including strong policies within the New Zealand Ministry of Health and primary healthcare organisations, including implementing the DESMOND education approach. However, the learners considered that there must be a gap or some form of miscommunication between these initiatives and the public particularly for Māori as the rate of diabetes continues to rise in New Zealand, especially for Māori living in Whakatāne. Two health promotion initiatives were developed to address this issue and intend to work in partnership with the stakeholders to develop trust and a relationship with the Whakatāne community. For the health promotion resources to be well received within the community, the resources included: • A written submission was sent to Kāinga Ora (Housing New Zealand) about rules on the prohibition of the development of vegetable gardens within their properties. • A fridge magnet that contained information on seasonal planting of fruit and vegetables relevant to the Whakatāne climate was developed to encourage this population to grow their own vegetables (Fig. 5.8).

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Fig. 5.8  Health promotion resource – Fridge Magnet. (Reproduced from Sustainable community development through evidence-based health promotion focusing on the Whakatāne community by Sullivan et al. (2022) with permission from the Authors)

Learners’ Rationale and Consideration of Resources The banner pen (Fig. 5.6) was designed to address people using the pronouns in a respectful and understanding manner. The two small cards were designed to be accompanied by the pen and aim to reach out to those who are LGBTQ+ and feeling lost within themselves with some help resources on this. The goal to improve the population with Type 2 Diabetes was to implement a change in the Kāinga Ora establishment by resolving the ongoing problem regarding the restriction of growing vegetable gardens within these properties. Stakeholders confirmed that most Kāinga Ora houses within the Whakatāne district have large enough properties to plant fruit trees or have vegetable gardens; however, Kāinga Ora do not allow residents to do this because of the cost of removing such gardens lies with Kāinga Ora. The written submission aimed to improve the inequalities, reduce poverty and improve the health of the Māori population. The submission proposed comprehensive guidelines clarifying that Kāinga Ora house rentals are allowed to develop a garden. To assist in growing vegetables the learners produced a poster and fridge magnet with information as to when and what to plant and when to harvest produce in the Whakatāne region.

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Community Development Identified Impact Analysis Impact analysis related to the Whakatāne community development project is now presented in this section of the case study. The impact aligns with the community stakeholders’ feedback; ethical cultural considerations nurse learners addressed related to disparities for Māori presented to the Kaitohutohu Panel; teaching and learning pedagogy associated with the CHASE model; United Nations’ 17 Sustainable Development Goals (United Nations, n.d.) and graduate nurse professional practice reflections concludes this case study as reported below. Phase three of CHASE is aimed at learners to address the disparities for Māori and present their findings from the community research and needs analysis to the Kaitohutohu Panel. The Kaitohutohu are advisors within the educational institute who give support and advice on matters pertaining to Māori. This ensured that the learners approached constructing primary and secondary data with an emphasis on being culturally sensitive and maintaining a focus on the Māori population of Whakatāne were to highlight, address and alleviate any inequities, demonstrating cultural sensitivity and understanding of Māori cultural protocol, values and beliefs. The cultural respect is represented in the Code of Conduct regarding a person’s cultural, values and beliefs (NCNZ, 2012). In phase six of the 2022 CHASE model the nurse learners are encouraged to evaluate with the local stakeholders the potential impact the health promotion message and resources developed in phase four of CHASE whether these improved the health of the identified population and their health need. All feedback from the Whakatāne community stakeholders including their impression of engaging with the community project is noted and welcomed. Ethical Considerations: all resources were discussed with local stakeholders prior to researching and developing for approval. To ensure cultural safety was carried out through the course of the Whakatāne project, the learners gained consent from the Kaitohutohu office. In doing this they answered the following four questions regarding the Indigenous population of Māori within New Zealand. These are listed below with our answers: • Will the research involve Māori? Yes. The research will involve Māori as the population of Māori in the Whakatāne district is 16,722 (Statistics New Zealand, 2018). Due to the large Māori population within this region, it is important to focus on an issue that affects this ethnicity, and therefore, the community. • Is the research being conducted by Māori? No, the research is not being conducted by Māori, as no one in the group is identified as Māori. But they worked closely with stakeholders who identified as Māori and is a strong advocate for the Māori community in Whakatāne. • Could the research potentially benefit Māori? Yes, the results are likely to be of relevance because of the high Māori population in Whakatāne. The results will enhance awareness and improve the health outcomes of Māori who have Type 2 Diabetes and identify as LGBTQ+.

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• Are the results likely to be of relevance or are of specific interest to Māori? Yes, this research could potentially benefit Māori as there are Māori who identify as part of the LGBTQ+ population and Māori who have been diagnosed with Type 2 Diabetes. This research will potentially provide Māori with ways in which they can access help lines and or resources made if they require additional support or need further education to improve overall health outcomes. Impact Analysis – CHASE Model in Action 2023 CHASE 2022 was engaged with for this case study to guide learners’ community development practice (Fig. 5.2). This model was evaluated by the facilitators who acknowledged its contribution but agreed the model needed to be updated to maintain effectiveness as a teaching and learning model and CHASE 2023 was created (Fig. 5.9) for nurse learners to engage with and direct their community development projects in 2023 (refer to Chap. 2 for further information). The impact assessment in phase six of the CHASE model engages back with academic nurse facilitators instead of the research assistant (related to inadequate research funds); a new phase, phase ten, focusses on the academic facilitator to take responsibility and conclude each of the community development projects with a written case study. A new phase, phase eleven, aligns with a post-planning discussion between all academic facilitators evaluating community development outcomes, identifying and theming the population health issues and disparities associated with the various community development projects. The aim is to identify what has been learnt and how can the academic facilitators progress this valuable work as they engage with forward-looking reflections.

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Fig. 5.9  CHASE Model 2023. (Produced by Ross with permission from the Authors)

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Impact Analysis – United Nations’ 17 Sustainable Development Goals At the completion of the Whakatāne community development project, nurse learners reflected on whether their health promotion message and resources could make a difference to one or more of the United Nations’ 17 Sustainable Development Goals (United Nations, n.d.) as considered below. Goal 1 – No poverty – The learners’ aim was to find ways to reduce the rates of Type 2 Diabetes within the Whakatāne community. The goal of ‘no poverty’ applies to this project through providing education on how to create a sustainable vegetable garden, and providing a cheap way of obtaining fresh produce, therefore reducing poverty within the community by freeing up money to be spent on other essential resources. Goal 2 – Zero hunger – To reduce Type 2 Diabetes learners wrote a submission to the Kāinga Ora office. Kāinga Ora houses are rental houses allocated to families who are often low socio-economic families. With the ever-increasing prices of buying food, especially fresh produce, the ability to grow fruit trees and develop a vegetable garden will be a huge asset to not only these houses but also the people who live in them, by providing a constant food source that is cheap to produce. The learners integrated this goal by ensuring that whānau and tamariki of all ages can participate in gardening which promotes the well-being of the cornerstones of health and positive mental health well-being. Goal 3 – Good health and well-being – For the LGBTQ+ group, promoting inclusivity of all individuals will benefit the mental health of the LGBTQ+ community. Good mental health means a healthy mindset and better well-being, which is something that will be carried throughout their lifetime. Goal 4  – Quality education – This Goal aims to ensure inclusive and equitable quality education and promote lifelong learning opportunities for all through educating older people about the appropriate terminology for the LGBTQ+ community. This helps bridge the gap of understanding. Goal 5 – Gender equality – The objective of this Goal is to achieve gender equality and empower all women and girls by working to raise awareness of the mental health stigma surrounding the LGBTQ+ community. The health promotion messages and resources aim to spread awareness and provide a positive resource for gender equality amongst other aspects. Goal 10 – Reducing inequalities – The health promotion message aimed at supporting the LGBTQ+ community promotes the reduction of inequalities and assumptions found within and about the LGBTQ+ community and young adults. For Type 2 Diabetes in Whakatāne, the submission to Kāinga Ora wanted to ensure that low socio-economic families living in Kāinga Ora houses can all grow fruit and vegetable gardens on these properties. Fresh produce is unaffordable for many households impacting the health of diabetics within the Māori population. Access to fresh home-grown produce that is at low cost could help reduce the gap in the inequalities that exist within this population.

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Goal 12 – Responsible consumption and production – The ideal of this Goal is reached by providing strategies to help decrease the rates of Type 2 Diabetes within the Whakatāne community, by offering education on how to create a garden at home and how to sustainably grow and produce vegetables and fruit in the garden. Graduate Nurse – Professional Practice Reflections Graduate nurses reflected (discussed in Chap. 6) on whether engaging with this Whakatāne community development project has had an impact on their future practice. This case study is an edited version of the community development project completed by nurse learners and facilitated by nurse academics, titled Sustainable Community Development through Evidence–Based Health Promotion Focusing on the Whakatāne Community. To review the full report, refer to Sullivan et al. (2022).

Concluding Reflection Ultimately, in reflection, I am very thankful that I had the opportunity to work with the team. My hope that I cling to is that those nurse learners were able to take something from the time we shared and use that something to enable or inspire them to be the change. I hope that they are aware of the disparities that prevail in so many of our communities, the intergenerational nature of the social problems we are working with, and that they have given some thought to how we might address those wicked problems. The report generated by the nurse learners was comprehensive and enabled a holistic view of the strengths and challenges the Whakatāne community faces in improving health outcomes across the community. The resources the nurse learners produced were intelligent, sensitive and useful. The report and the resources made a difference. They provided a unique opportunity to view the community through the lens of people who do not live in the community – sometimes distance provides a different perspective. That was certainly achieved in this instance. I am proud to have been part of this project and proud that others in my community were able to engage with this work. Nāu te rourou, nāku te rourou, ka ora ai te iwi With your food basket and my food basket the people will thrive Nga mihi Mawera Acknowledgements  We wish to acknowledge the mahi and insights of Jean Ross and her colleagues who developed the CHASE model and the nurse learners who cared for the communities of Whakatāne. We are also indebted to Scott Klenner, Ron Bull and Adrian Woodhouse for the encouragement and insightful comments. Ka pai.

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Whakatane.info. (2016). Living history. www.whakatane.info/business/living-­history Whitinui, P., Glover, M., & Hikuroa, D. (2013). Ara Mai He Tētēkura: Visioning our futures: New & emerging pathways of Māori academic leadership. Otago University Press. Winner, L. (1980). Do artifacts have politics? Daedalus, 121–136. World Health Organisation, (1986). Ottawa Charter for health promotion. http://www.who.int/ healthpromotion/conferences/previous/ottawa/e Yu Zhao, Z., Osuagwu, U., Pickering, K., Baker, J., Cutfield, R., Orr-Walker, B., Cai, & Simmons, Y. (2022). Ethnic differences in mortality and hospital admission rates between Māori, Pacific, and European New Zealanders with Type 2 Diabetes between 1994 and 2018: A retrospective, population-based, longitudinal cohort study. The Lancet Global Health, 9, 209–217.

Chapter 6

Impact Evaluation on Rural Community Health Samuel Mann and Jean Ross

Abstract  Research is not an end in itself; it is desirable that it contributes to social good and has an impact on social justice. Impact evaluation is a way of assessing whether and what beneficial impact research has had on community project work. In this chapter, we refer to the case studies showcased throughout this book, including Heratini/Geraldine, Moeraki and Whakatāne in Aotearoa New Zealand, rural Wales and cross borders with England and Vanuatu in the Pacific, as to how the creative resources developed by the nurse learners have had an impact on reducing health disparities and improve community/population health. The chapter therefore focusses on the overall theme of impact and shares the data generated to evaluate any outcomes. The evaluation and the impact that the resources have made on the identified community population is assessed in Phase 6 of the Community Health Assessment Sustainable Education model, initially 6 to 12  months following the completion of Phase 5. Further, the local community rural nurses’ practice attributes and community resilience including the national and international ongoing concerns of the COVID-19 pandemic on population health, lock down, health concerns and rural nursing practice are evaluated. Keywords  Evaluation · Impact · CHASE model · Health · Education · Inequities

S. Mann (*) College of Work Based Learning, Otago Polytechnic | Te Pūkenga, Dunedin, New Zealand e-mail: [email protected] J. Ross Te Kura Tapuhi | School of Nursing, Otago Polytechnic | Te Pūkenga, Dunedin, New Zealand e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. Ross et al. (eds.), Rural Landscapes of Community Health, Global Perspectives on Health Geography, https://doi.org/10.1007/978-3-031-43201-9_6

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Introduction Community development projects are completed by all Bachelor of Nursing (BN) Year 3 learners in their primary healthcare (PHC) clinical placements, supervised by a registered nurse (RN) academic. In teams of 9–12, learners undertake a community profile, health needs assessment, literature review and develop health promotion messages and resources. The Community Health Assessment Sustainable Education (CHASE) model (Ross et al., 2017) is underpinned by the principles of PHC and in Aotearoa New Zealand, by the principles of the Primary Health Care Strategy (Ministry of Health, 2001) and the 2016 New Zealand Health Strategy (Ministry of Health, 2016). This transcends the ‘norm’ of the content taught nationally to nursing learners in the PHC context which is in general practice or other nursing contexts where the nurse works with individual clients and or families/ whānau. We offer an alternative approach to education which embraces a community assessment problem-solving, systems-thinking partnership approach to solve local solutions in a systematic way. This process transcends the paradigm of student nurse education promoting a dynamic educational/community development/partnership paradigm with emphasis on rurality and with a focus on making a positive difference including an impact on social justice: The learner will develop clinical inquiry, practice, and critical thinking by reflecting on socio-political influences in a range of community health contexts. (BN701002 Course Descriptor: Aim)

So how do we know this alternative approach is working? How do we know that it is making a difference? How do we know that it is working for the student learners? In this chapter, we explore the impact of the CHASE model. We examine the impact of the use of the CHASE model, and in doing so, highlight the importance of evaluation in the CHASE process. We use Patton’s Developmental Evaluation Mindset (2010) as a framework to highlight key insights. Following Patton (2015), it is not the intention here to examine the fidelity of either the CHASE model itself or the CHASE development process as a Developmental Evaluation or even a Developmental Evaluation Mindset. Rather, we use the principles of Developmental Evaluation as a sensemaking device to help illuminate features of this rural community-­based educational innovation. While Patton (2015) are careful to preface these principles as being a mindset rather than a formula, Patton (2015) describes eight essential principles. Using each of these in turn as a lens, we consider the development of the CHASE model. 1. 2. 3. 4. 5. 6. 7. 8.

Developmental purpose Evaluation rigour Utilisation focus Innovation niche Complexity perspective Systems-thinking Co-creation Timely feedback

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In 2022, we surveyed graduates (with OPREC ethical approval) of the BN, School of Nursing, Otago Polytechnic, Dunedin, Aotearoa New Zealand (NZ) from 2017 to 2021. We aimed to explore the reflections of learners who had undertaken the CHASE model community projects and who are now practising in their careers. Those responses are threaded through the sections below. We were interested in exploring the following: to what extent are the learners taking ownership of CHASE? How is it preparing them for work? How is it contributing to their professional identities? While we did record the graduate’s current field of practice, location and which project they completed, it did not add to the narrative except to note that responses of all types came from wide ranges in all these regards. In the few cases where this information does add value to the narrative, it is noted along with the quote. Other material and quotes in this chapter are derived from notes and reflections of the RN team supervising and facilitating the CHASE projects.

Developmental Purpose CHASE is considered a development on several fronts. It is an innovative educational practice that continues to evolve. Its purpose is the development of nurse learners  – both those intending rural practice and all other professional nursing outcomes. The CHASE model also seeks to provide developmental benefits to rural communities. Each of these aspects is integrated with evaluation processes. It is worth noting that the development of the CHASE model did not set out to be a Developmental Evaluation nor did it have a single explicit role as ‘evaluator’. Rather, the ‘innovation and evaluation develop together – interwoven, interdependent, iterative, and co-created – so that the developmental evaluation becomes part of the change process’ (Patton, 2015, p. viii). In this way, evaluation is tied to development not in terms of accountability but intrinsic to the developmental goal – innovation is to make something better, and the evaluation makes that something better. Patton also describes types of innovation, in our case, a hybrid of a new, original approach to a problem and an adaptive innovation. The original CHASE model was created in 2017 initially for the rural Otago, Aotearoa New Zealand context to solve an ongoing lack of community (PHC) clinical placements for BN Year 3 nurse learners. The School of Nursing at Otago Polytechnic ensures nurse learners experience community learning and clinical practice at BN levels 5, 6 and 7. The stated aim of this experience is to acknowledge that people live and work in communities rather than hospitals. The institution is therefore committed to establishing a deep commitment to understanding that the provision of healthcare is responsive to people and their contexts. This includes nurses’ responsibilities to the promotion of health while minimising potential health issues and health disparities. The original CHASE model (Fig. 2.1 in Chap. 2) was created to guide learners through their clinical placement. The model itself offers a visual representation of the sequence of phases and stages necessary for the community development project to be completed by the learners. We listened to the learners both throughout the process of the

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project and their course evaluations and learnt they were first apprehensive of commencing the community project as there were several unknowns as they progressed with ethical, cultural, professional and critical thinking, engaging with verbal and written communication and visual presentations. This original CHASE model 2017 has been adapted to accommodate learners’ evaluations and changes in community and disruptive contexts. The model has also expanded in response to application beyond Aotearoa New Zealand, in wider national and global landscapes including the rural geographical regions of the UK, USA, Australia and the Pacific (Ross et al., 2020). More recent adaptions of the model have recognised developments in nursing education, rural communities and the changing healthcare landscape that includes the COVID-19 pandemic. What makes the CHASE model innovative is the degree of change compared to the existing situation and the recognition that understanding the problem is both the first task and never-ending: ‘the effort to tackle a complex problem may generate new/deeper insights about the nature of the challenge being addressed and/or the context’ (Patton, 2015, p. 294). This applies to all three aspects of our innovation – the new approach, the learning and the community impact. Key to innovation is that while there is a commitment to major change – in our case the dual motivations that initiated this development, the challenges of education for rural nursing practice and those of community development – the nature of that change was yet to be determined and indeed the approach to innovation is also emergent. So, while the course that holds the CHASE project (BN701002) has learning outcomes that describe the change that is intended in nurse learners and the learners follow the CHASE framework, the nature of the project itself is not predetermined. Rather than specific modalities (a 2000-word essay, say), the emphasis in guidance to learners is on having an impact: Your research project will have outputs, for example your report/recommendations, a journal, a presentation, and a design or prototype (resource). This will result in outcomes, for example your learning, and the external organisation implementing your work (this is your Intellectual Property). We also want your work to have an impact, for you to make a difference. (Project summary template)

Evaluation Rigour It might be stating the obvious, but for Patton (2015) if there is no data there is no evaluation. The developmentally inquiring mind must have some rigorous basis. For Patton, evaluation rigour comes from rigorous evaluative thinking. ‘Ask probing questions, think and engage evaluatively, question assumptions, apply evaluation logic, use appropriate methods and stay empirically grounded’ (Patton, 2015, p. 299). In the CHASE model this questioning is fundamental. Patton (2015) cautions ‘the problem … is in the focus on methods and procedures as the primary, or even only basis for determining quality and rigour’ (p. 296).

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Fig. 6.1  Mapped to phases of CHASE. (Produced by Suzanne Thornton with permission from the Authors) KEY: Claim (star) and Evaluative Questions (magnifying glass). Lower Section, Overall Claims

The rigour lies in ‘diligent, systemic situation analysis‘ and ‘principles-based evaluative thinking’. This rigour comes from clarity about the purpose of the innovation and inquiry  – what will inspire confidence in findings amongst those who will use them? In all cases the purpose of these evaluations is improvement. We were asking questions we did not know the answers to and so these questions continually evolved as our own understanding deepened. Accordingly, evaluation takes many forms in CHASE and has evolved over time. Figure  6.1 represents in summarised form the claims made within phases of CHASE – that is the underlying premise of that phase – and the respective evaluative question(s). As with all educational structures, the BN701002 course is required to meet institutionally mandated evaluation processes. These include those in development and approval of the course, and ongoing compliance processes. Every year, monitors are externally appointed to report to the qualification authority and the Nursing Council of New Zealand (NCNZ). Their brief is to review the entire nursing degree to ensure that it is meeting its accreditation. This includes the CHASE model:

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BN701002 meets the course objectives and NCNZ competencies equally. It incorporates evidence-based practice and primary health care principles while engaging with theories to assist in data collection and community resilience. (External Monitor, via RN CHASE Supervisor)

Similarly, according to the NCNZ auditor: The external audit of the BN programme 2012 and 2019 recognised the course outline as meeting Primary Health Care clinical practice and NCNZ competencies and allowed it to continue and include the 120 clinical hours could be credited as a component of the 1100 allocated minimum as registered nurse. (Auditor via RN CHASE Facilitator)

While these areas of compliance-based evaluation do not provide much benefit for learning (other than the obvious benefit of continuing accreditation), another area of compliance evaluation – ethics – is fully integrated into the model and the learning experience. Ethics is explicit as the first of the NCNZ competencies lists, ‘Accepts responsibility for ensuring that his/her nursing practice and conduct meet the standards of the professional, ethical and relevant legislated requirements’ (Nursing Council of New Zealand, 2016, p.  3). It is also a requirement in the BN701002 descriptor: ‘Community project ethical summary and impact analysis including evidence of Kaitohutohu consultation which clearly demonstrates student’s commitment to Te Tiriti ō Waitangi.’ This ‘ethics’ requirement encompasses procedural research ethics and ethics of nursing practice. In the time available for learners engaging with the CHASE model, it is not possible for each student group to obtain research ethics approval. Ethical application is initiated by the RN facilitators prior to the commencement of the community projects. Successful approval is granted Category B Ethical approval from the educational organisation. This process requires the student groups to present to the Office of Kaitohutohu (discussed in Chap. 2) in week two of the four-week placement on their research to date, with consideration of what potential impact the project could have on Māori, which is guided by the Māori ethics framework (Hudson et al., 2010). Learners are also required to identify any issues that have arisen that may involve or affect Māori. At the end of the project, the teams of learners reflect on the impact that the resources will have on Māori identify what ethical issues arose and how to mitigate these. At the commencement of the BN programme in Year 1 learners are introduced to the principles of Te Tiriti ō Waitangi (Orange, 1989) which offers the Indigenous people  – the Tangata Whenua of Aotearoa New Zealand certain rights. Tangata Whenua have suffered under the hands of colonisation and in the process have not received equal access, for example, to healthcare, education and opportunities resulting in socially and economically disadvantage. Disadvantage for some has led to health disparities associated with chronic health issues, mental illness, high addiction rates and obesity (Hogarth & Rapata-Hanning, 2023). Learners are encouraged to reflect on their own values, belief systems and views of the world as they enter the BN Year 1 programme. This provides learners with the opportunity to consider ‘other world views’ and ‘cultural and belief differences’ to their own, the

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aim being to raise awareness of cultural diversity. A degree programme which is fundamentally underpinned by this philosophy positions these learners to practice cultural safety (Papps, 2002) in Aotearoa New Zealand and equally globally. Despite Māori identifying as indigenous to New Zealand and the following questions relating to Māori, there was an expectation that learners would still consider these questions in relation to the Bishop’s Castle community development project – the belief being that consideration of indigeneity and (de)colonisation is of global concern. This ensured that the learners approached analysing primary and secondary data with an emphasis on being culturally sensitive and maintaining a focus on being in an informed position to alleviate any inequities, demonstrating understanding of cultural protocol, values and beliefs. Cultural respect is represented in the Code of Conduct regarding a person’s cultural, values and beliefs (NCNZ, 2016). The questions posed by the Office of Kaitohutohu (KTO) are: 1. Will the research involve Māori? 2. Is the research being conducted by Māori? 3. Are the results likely to be of specific interest or relevance to Māori? 4. Could the research potentially benefit Māori? While these questions could be answered at a surface level (‘no, no, no, maybe’), learners are instead encouraged to think deeper and to use these questions as a prompt for research and reflection. For example, why might there not be any Māori in the student group? What does it tell us about the nature of the nursing profession? Maybe Māori are over-represented in the vulnerable population  – why might that be? The same questions are asked again on the completion of the projects and are included in the Clinical Project Ethical Summary. In summary, all teams except for those researching international communities identified the Māori population living in the areas being researched, recognised the research may be relevant to Māori and would therefore potentially benefit Māori. An example of a typical response to the question ‘Are the results likely to be of specific interest or relevance to Māori?’ might be: Yes, considering that Hokitika situated on the Westcoast of the South Island, New Zealand has a relatively higher population of Māori compared to the whole of New Zealand (16.5%), the research and health resources we produce will be relevant to both Māori and non-Māori. Additionally, one of the population groups of focus is Māori mothers. (Illustrative example recalled by RN CHASE Facilitator, pers comm, October 2022)

Acknowledging these KTO questions instils social justice in the learners wherever they practice while acknowledging other cultures’ histories and health disparities that have eventuated acknowledgements and positions world views as the project progresses. Equally reflecting on whether project results could be of interest, relevance or benefit to Māori, assist the learners a vehicle for considering wider ethical implications. At the end of the year the BN701002 course supervisors/facilitators write a summary of ethical issues. For example:

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2020 was an extraordinary year with COVID-19 impacting on how 3rd year learners were able to complete their Community Development projects. Due to the COVID-19 pandemic, half of the year-three nursing cohort completed the requirements of the coursework from home or off-campus during the national lock-down period in April-May (Level 4, the most restrictive lock down). Following the lock down, a further quarter completed their community projects under COVID Level 3 (restricted movement, learners primarily in their home ‘bubbles’). The other quarter cohort of learners completed their projects when the country was verging between Levels 2-3 (Level 2 allowed mingling of small groups but with physical distancing, tertiary education remained primarily online). For all students, this meant that most of the data collected to support their research was retrieved from secondary data sources, and the primary data collected was from meetings with community leaders via phone, email or video-conference platforms rather than face-to-face. No ethical issues were identified by half of the teams. Some teams identified the management of information being gained virtually, as an ethical issue – due to their research being undertaken virtually (due to COVID-19), that they needed to maintain professionalism about the information gained and how this would be documented. One team focusing on children as the population aggregate, pointed out that they were aware children are a vulnerable group particularly children under the age of 16 years who cannot consent to participate in research. Under Category B Ethics approval, the learners knew they were unable to meet with children to gain their perspective of living with autism spectrum disorder (ASD) and they thought that this would have provided a deeper insight into the needs of this population group. The learners did however meet with external agencies about children with ASD, for instance Autism NZ and health professionals, and this uncovered a common theme of discrimination and exclusion occurring for children with ASD in school settings. A further ethical issue identified by this team of learners was the presence of bullying and exclusion in schools from other students and teachers towards children with ASD. The use of appropriate language/terminology was raised by one team of learners who were studying people with the chronic condition of stroke. Understanding what terms people preferred, for example, ‘stroke survivor’ was an issue they found with different people preferring different titles, and the learners struggled to know what the most appropriate term was to use. One team of learners said that they were aware of the degree of stress related to the COVID-19 pandemic for nurses and healthcare workers and community members and that having students contacting them could exacerbate the stress. The time the learners spent in Moeraki, North Otago, New Zealand could have been longer, to develop stronger relationships with the stakeholders within the community. During the community assessment they were unable to get in contact with some community members which was a limitation to gathering data on the community. Funding was a further potential limitation but within the community, solutions were found. Being rural, limitations to phone and internet access were an issue, therefore a hardcopy of the resource was also designed for the local newsletter. The team working with Bishop’s Castle, a UK community, reported that the key ethical issue that arose for them, was in the cultural differences between New Zealand and the Bishop’s Castle community. This occurred when interpreting how the UK statistics defined groups of people and themes, for example cultural safety. Their comments were as follows; ‘It was a hard situation because it challenged not only cultural safety topics, but it also pushed the bioethics of the research. By including bioethics in research, we would be ensuring the rights of patients, research subjects and public policy guidelines are upheld. Morally, it felt hard to approach the research without conducting it in the culturally safe way we have been taught to practice in New Zealand.’ (RN CHASE Facilitator, pers comm, October 2022)

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Managing and mitigating these ethical issues is an important part of learning. It also can be seen to improve the outcomes of the project. For an ASD project (described in the Supervisor’s end of course reflection above), the learners found a way of engaging the children within the bounds of ethical approval  – the children were engaged via their parents to create artwork for a health resource on bullying and exclusion, raising awareness on the condition and hopefully destigmatise the condition. The added complexity of an international project was not lost on learners. From the annual ethics report describing the team working with the Bishop’s Castle community: With the team researching UK the learners understood the importance of recognising the differences between the UK and NZ cultures, for instance the NHS/Health systems. They maintained the same professionalism, level of respect, cultural safety, and beliefs in how they conducted themselves and our research. They felt that they were respectful to the way things work in the UK, but also stayed true to themselves. (RN CHASE Supervisor, pers comm)

The evaluation rigour of CHASE can be seen in way that underlying assumptions and premises are stated and tested on an ongoing basis. In this section we have explored evidence of this approach, further evidence is woven into following sections.

Utilisation Focus Patton (2015) describe focusing on the intended use by intended users from beginning to end, facilitating the evaluation process to ensure utility and actual use. Again, we can see this applies to both the evaluation at the core of the CHASE process – leading to a positive impact for the community – and the role of evaluation and reflection for the learners. We can also see the role of the end-of-year reporting and reflection in the continual improvement of the CHASE process itself (refer to Chap. 2). In this section, we focus on utility in the sense that the evaluative processes themselves facilitate development of nursing competencies. Other aspects of utilisation focus such as processes leading to community development are discussed in sections on innovation and systems thinking below. Reflective practice is a key skill taught to all student nurses early in their degree using either Gibbs’ (1988) or Holm and Stephenson’s (1994) Reflection Frameworks. It forms the basis of much of their learning throughout their clinical placement experience. We focus here on the reflection of learners during the CHASE process. Throughout the community development project, learners individually reflect in writing on their progress and upload this to the student portal as part of their coursework. Their RN supervisors review these reflections as formative assessment which acts as an evaluation tool positioning the learners’ developing understanding. This provides the academics with direct feedback and allows timely interventions where required. The reflections are also aggregated at the end of the year and inform the

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academics end-of-year report. Note: Because these reflections were collected for assessment, they are outside the scope of approved ethics and cannot be reported in detail here, but Mullens (n.d.) summarises the themes from learners’ reflections as: • Emotions involved with the experience – challenging but rewarding, appreciation for the resilience of the community and deep respect. • Reflection on learning – change in perspective, the experience of health is not the same for everyone. • Connection – with community and team through the work. • Culturally Safe Practice  – inspired to consider pre-conceived ideas and assumptions. Reflections upon beginning with the CHASE model demonstrate a nervousness about a process that is outside their prior experience within the BN degree. They do not like group work and foresee conflict amongst the group and unequal workloads. A common challenge is students at that stage do not see the value of the community project and would rather work in general practice. Last, students’ (learners’) fear of the unknown is raised – this is the first time in the degree that they have been challenged with a task for which there is no known correct answer. These reflections are not consistent and vary from year to year and group to group. It is vital, therefore, that the supervising RN academics pay close attention to the feedback, and work with their groups accordingly. The aggregated feedback also informs the end-of-year reflections by the teaching team. In response to learners reporting the challenge of unfamiliar ground, the teaching team developed a series of resources with animations and voice-overs to introduce concepts. The teaching staff have increased their references back to the CHASE model to provide a familiar anchoring framework. Also, to head off a feeling of CHASE not fitting with the rest of the more obviously clinically focused placements, a detailed orientation is given to the community projects in the first week of the year (CHASE is staggered for different groups throughout the teaching year). Later student feedback showed the success of this approach ‘Excellent resources, we can refer back to these throughout the project to remind ourselves on what is required.’ In response to student reflections on the despised ‘group work’, the teaching team changed the language to ‘teamwork’: ‘Evidence indicates students don’t like group work, but learners can’t complain about teamwork as it is Nursing Council of New Zealand competency which each learner needs to identify’. No mere linguistic trickery, the term ‘team’ is fundamental to the NCNZ competencies, and learners are explicitly engaged in the roles and functioning of effective teams. A leader is identified from the team/and expected to lead the team. From the teaching team end-­ of-­year report: Teamwork exercises are introduced at the commencement of Year 3 rather than in the middle of the year; this makes a big difference to the learners’ understanding of teamwork and leadership. And it’s fun for the learners to get to know each other. (Graduate nurse)

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While there are still some negative comments about teamwork in the graduate responses from recent graduates, reflection on the value of teamwork is more common: I believe using a strength-based approach to delegate tasks most appropriate to the attributes and skills of each team member contributed to the outstanding results achieved in our submission to WellSouth (a local Primary Health Network) regarding the development of a web-based portal to facilitate General Practice (GP) enrollment, access basic health information and locations of services that could be translated to several languages. (Graduate nurse)

By midway through the community project, the tenor of the learner reflections changes. While they are still daunted by looming deadlines, they are generally enjoying the project, teamwork is working well and can see the prospect of making a difference. They tend to reflect on their own contribution and reflect on their own style and how that can be improved in the future. The reflections tend to change from a feeling of missing out on a proper placement to one where they see working with the community as a bonus and feel like they are making a contribution of which the community is appreciative of their efforts. In addition to reflective processes (Kolb, 2015), they are well practised with the use of the NCNZ competency template (NCNZ, 2016) as a framework for their self-­ evaluation and reflection. The competency template comprises four domains including corresponding indicators (nine templates in total). The domains include: • Professional practice responsibilities including cultural diversity and how the students demonstrate working within the Treaty of Waitangi (see Chaps. 2 and 5). • Management of nursing care – here adapted to relate to management of a community project, from assessment, planning, action and evaluation of the CHASE model. • Interpersonal relationships. • Interprofessional healthcare and quality improvement of which indicator 4.1 relates to teamwork (NCNZ, 2016). For example, the NCNZ Competency 2.6 says: ‘Evaluates client’s progress toward expected outcomes in partnership with clients.’ Together as a group we were able to evaluate a client’s progress towards expected outcomes, this competency was achieved by working in partnership with stakeholders whose input assisted with the development of relevant resources. For example, upon speaking with a stakeholder we were able to identify that Tamariki (children) emotional wellness was an area that was lacking in resources in this school. We undertook a literature review focusing on Tamariki wellbeing and came up with a health resource concept which we then took to our stakeholder for further discussion showing the research to support our idea. A health resource was agreed on and throughout the four weeks of this placement we regularly liaised with our stakeholder to keep them updated on our health resources progression. (Anonymised student group competency assessment in final report)

NCNZ Competency 3.1 lists: ‘Establishes, maintains, and concludes therapeutic interpersonal relationships with client.’

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As a team we completed this competency through our interactions with our stakeholders. We would start with an email or text to briefly introduce who we were, what we were doing, and the questions we had for each stakeholder. This helped establish a relationship before we interviewed them. After the interview, we maintained contact to ask follow-up questions and seek guidance around the usefulness of the health promotion resource. All communication was conducted with respect, empathy, and professionalism. At the end of the project, we thanked the stakeholders and offered them a copy of our written project as well as gave them the resources. (Anonymised student group competency assessment in final report)

It could be argued, of course, that in this self-assessment the students are merely writing what they know their lecturers want to hear about meeting competencies (though one could also argue that knowing what to write is in itself not a bad thing). So, to triangulate, it is useful to look for evidence of contributions to capabilities in the graduate survey: It actually helped my nursing practice but helped me understand the bigger picture and think outside the box. (Graduate nurse) It made me think outside of the box in ways to reach and make a difference to a population specifically whether that be stigma or accessing resources. (Graduate nurse)

A range of these graduate reflections illustrate the breadth and depth of the impact of the CHASE community project on graduates’ nursing practice. These include: • Social determinants: • Being careful to consider invisible factors that could impact health of people. (Graduate nurse) • Made me more aware of inequality and decreased health literacy of people in the community … Long term health disabilities need better management especially in rural communities. (Graduate nurse) • Increased awareness of additional populations in the need to provide holistic care to the person rather than meeting the needs that I would want to be met. (Graduate nurse) • Added insight on the environmental and social aspects of holistic care. Also gave me the knowledge and confidence to undertake a community health project and ways to increase awareness with the community. (Graduate nurse) • Open-mindedness: • More open minded and aware of my surroundings. (Graduate nurse) • Thinking outside one bubble. (Graduate nurse) • Empathy: • Allowed me to really truly consider barriers for people and have a deep understanding of empathising with people. (Graduate nurse) • It has changed the way I look at and value each patient, and that each person deserves care specific to their needs. (Graduate nurse) • Problem-solving: • It has strengthened my capacity to narrow down tangible solutions to broader healthcare issues. (Graduate nurse)

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• Holistic: • When working with COVID-19 positive patients and trying to identify their needs I have a bigger toolkit to pull from when trying to ensure they are well looked after in the way that they require in terms of their culture, family, beliefs etc. (Graduate nurse) • Being more vigilant about the holistic care. (Graduate nurse) • This taught me how to think of the bigger picture for a patient, especially on discharge. For example: what supports do they have in place, how do they engage with their community, and what is available for them to receive the care they need. (Graduate nurse) • It has made me think more broadly, to look at all aspects of patient health. (Graduate nurse) • It has influenced my nursing practice, by making me think more critically and broadly about all the different elements which play into the lives of those clients who live in the community. (Graduate nurse) • Passion: • Parts of this promoted my passion into nursing research which is the field I currently work in. (Graduate nurse) • We can see a close link between utility (in terms of learning) and authenticity. Herrington et  al. (2006) laid out a set of situated learning principles for authentic learning. The key elements include: • A real-world problem that is ill-defined at the beginning. • The learners need to incorporate multiple perspectives to first understand the problem and then propose and select from a diversity of solutions that are seamlessly integrated into the real world; the development requires complex activities over time to deliver polished products that are whole and valued. • All take the learners outside their comfort zones, with work across subject boundaries and into diverse roles; and much of the learning is through reflection. The application of the CHASE model as a framework for rural nurse learning meets all of these objectives. The learners engaged with a community without preconceived or predetermined ideas of what the problem is. They used the tools of CHASE to engage with the community to understand the health of the community as a system and identify a pressing health need that could be addressed in the relatively short time available. The learners engaged with each other through virtual platforms and pitched their potential solutions to the community. In terms of Herrington et al.’s (2006) description of authentic learning, the CHASE model can be seen to be operating in a sweet spot. CHASE enables learners to navigate the complexity of learning rural practice. The project mirrors rural nursing practice in that it is unavoidably purposeful, collaborative and relationship based.

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Innovative Niche Patton (2015, p. v) describe how the developmental evaluation niche: …focuses on evaluating innovations in complex dynamic environments because these are the types of environments in which social innovators are working. Innovation as used here is a broad framing that includes creating new approaches to intractable problems, adapting programs to changing conditions, applying effective principles to new contexts (scaling innovation), catalyzing systems change, and improvising rapid responses in crisis conditions. Because social innovation unfolds in social systems that are inherently dynamic and complex, and often turbulent, social innovators typically find themselves having to adapt their interventions in the face of these system characteristics.

Rural health settings meet the descriptions of complex dynamic environments. So how do we know we are setting the learners up to make a change that makes a positive difference in such inherently dynamic and complex systems? The portfolio instructions tread a careful line between precision and ambiguity: • • • •

Comprehensive and succinct analysis of the community’s health need. Health need is identified and relevant literature reviewed. Thorough analysis of the health promotion message. Develop a health promotion message consistent with the community’s need and response (CHASE instructions to learners 2020).

There are a lot of choices here. Learners must find the population group at risk, identify the need, the nature scope and scale of the intervention (mediated by being something this group can do in the next couple of weeks). And it is not deterministic. Different groups working with the same communities at the same time will, and do, produce different answers to all of these. So, for evaluation, the question becomes: how do we/they know what they chose is the best thing to do? Some of the answers to this are easy – we are not giving the students a community for which we already know the problem and the solution, nor even ‘here is the predetermined answer, go and find a problem that fits’. It is open-ended – we do not know the best answer because we do not know the answer. So, the evaluation must be of process – have they gone through robust process? But how are we equipping them for wickedness etc.? How do we expect them to follow a process when the problem is wicked? (Rittel & Webber, 1973). The clue is in wickedness – such situations are complex, unpredictable, open-­ ended and intractable. An issue with the wicked problem framing is the nomenclature – the people of Bishop’s Castle are neither wicked nor a problem (ironically perhaps this is one of the very lessons of wicked problem framing). Patton (2015, p.  302) stresses the difference between innovation and improvement and argues ‘social innovation approaches wicked problems through engagement, learning and adaptation (of process) rather than an imposition of project-like solutions or models’. What we should be looking for in our process, therefore, is engagement, learning and adaption.

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This engagement is one of the strongest themes in the graduate survey: We were able to connect with different community groups, hear what the community wanted done to help support the growth and how to present the information in a good-­looking way. (Graduate nurse) As Nightcaps, Southland New Zealand is a very small community we needed to come up with ideas that would be feasible without costing too much. Things that the community could do with what they already had in place. The community was very remote and had very little resources. Limited access to health services with GP only available a couple days per week. Limited ambulance services. What to do for people that have very little to work with made it harder. (Graduate nurse) Yes, I didn’t realise the community of physically disabled youth in Dunedin would be so vulnerable in different aspects. (Graduate nurse) The response from the community, people being open to talking about their health issues and different health groups/organisations sharing their resources with us. (Graduate nurse) The ability to interact with Pamaa, Vanuatu was very rewarding as we could tell the community really needed/wanted our support and loved interacting with us as much as we did. (Graduate nurse)

We can explore these issues with the example of Bishops’ Castle 2021.The Impact Report from the 2020 CHASE community project contained the observation that: The 2020 report was a great insight for the community, like holding up a mirror for the community to see ourselves. (Keith Whiddon, personal communication, 2021)

The 2020 community report for Bishop’s Castle identified a need for mental health services within the community as the closest mental health facility is approximately 40 miles away from the community. The 2021 group of New Zealand nursing students worked with community representatives of Bishop’s Castle and undertook a Community Partnership process and subsequent SWOT analysis. Three key health needs were established – transport, physical health and mental health. For all these needs, the Ottawa Charter was implemented to identify health promotion opportunities (McMurray & Clendon, 2015). Transport was identified as there is a lack of public transport to travel outside of Bishop’s Castle which has a significant impact on work, social and education mobility and access to healthcare and other services. Using the Ottawa Charter, the group decided to make a formal submission to the Shropshire Council with recommendations such as repainting disabled parking lines and the addition of adequate signage to ensure disabled parks are available for those who require them. An educational flyer was also created to be placed on cars that are parked in disabled parks without permits. This was produced with the hope of increasing awareness in the public and allowing them to be kept free for those who need them. It is worth noting that this working with the community is not always a simple matter. Communication and change require learners to understand and navigate established community relationships and nuanced understandings: I knew that any new ideas we had would have to be approached delicately and in a non-­ confronting way. I was surprised by some of the subtle push back we received from the community contacts where it was apparent anything that suggested moving away from the

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status quo was not readily welcomed…and while they maintained enthusiasm about ­participating with the project I at times felt they were almost offended at any suggestion to divert from status quo. (Graduate nurse) Challenge of community: I worked with an international community which made things a bit harder. It’s hard to get a feel for a community without being immersed in it. And when speaking to only a few select representatives it’s hard to know whether they were giving an accurate representation of the community as a whole as they are limited by their own personal experience. The representatives we spoke to were diverse and did a lot of work with the community, so we likely did get a good picture of life in Bishop’s Castle but it’s impossible to know for sure. (Graduate nurse)

Mental health is an issue as community members shared concern aboutf increasing suicide rates and mental health decline of the younger people. This has a strong impact on a community like Bishop’s Castle due to its small size and closeness. The students made a submission to the Shropshire Council regarding lack of mental health support and suggested that healthcare workers, such as general practitioners, receive education on mental health so they are equipped to assist those who seek support locally. They also adapted a slogan from the World Health Organisation (WHO) to produce, ‘There is no health, without mental health’, which was intended to highlight the importance of mental health in the public eye and reduce stigma. The slogan was displayed on posters and stress balls, for distribution throughout the community. The poster also included mental health resources that were available to the Bishop’s Castle community, for example, Samaritans, Shout, KOOTH, which provide support and information for mental health either online or by telephone. Physical health is a concern as obesity is highly prevalent in Bishop’s Castle in conjunction with poor diet, lack of exercise, smoking and drug/alcohol misuse, which negatively impacts all aspects of health. The students developed a recommendation for a post COVID-19 community event and proposal for a community kitchen and cafe in a community hub. It is difficult for the learners themselves to evaluate the impact of their project. The CHASE model though has a built-in evaluation process. A few months after the project, the community organisations are contacted for a follow-up evaluation (Fig. 6.2). In the case of Bishop’s Castle 2021 the evaluation report states: We believe that these resources and recommendations will support the community post COVID-19 regarding mental wellbeing, but for effective support and intervention, the provision of a mental health nurse is crucial in Bishop’s Castle. The creation of a digital platform that will be depository of mental health resources, designed specifically for the youth aggregate. The community has been active in securing funding for the creation of this platform, with the nursing students supplying recommendations for content and layout. Submission to Shrewsbury National Health Service for a mental health nurse, dementia friendly shop stickers and criteria, content for youth mental health Moodle shell, youth mental health promotion stickers to advertise Moodle shell. The community has secured a facility with a proposal to form a community hub. The group made recommendations to incorporate a community kitchen and café, that is accessible to the community. The idea of the kitchen is to build on the interest in community health through food that is an indirect outcome of the project. (Student final report).

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Research Impact Evaluation – Students DO NOT COMPLETE Organisation 1 – Information of the organisation/s can be found on page 3 of the Template Research Assistant will undertake the impact evaluation (3-6 months at completion of the project) Describe the impact. What difference has the project/resources made? Is this impact Economic, Social (including health), Cultural, Sustainability or Environmental? Is it a positive or negative impact, overall? Explain. Gauge the impact, it would be good to include a question about the community process and if that had any legacy. Common pathways include direct engagement with beneficiaries, indirect engagement through an intermediary knowledge broker, influencing policy change, or engaging generally with the public. How did the research cause the impact? How long after completion of the work did you notice that the impact was achieved? What factors contributed to the impact occurring? Any outstanding comments?

Fig. 6.2  Impact evaluation. (Produced by the Authors)

The resources themselves are discussed in the following chapter. What concerns us here is how we know this was an appropriate set of outcomes. The answer is that they are right for the community because the community decided: The ideas that have been put forward are realistic and focused on the community. (Valerie Woodmansey. Personal communication, 2021)

Keith Whiddon is chair of Bishop’s Castle Community Partnership. He was able to identify the stimulus for the mental health of youth. In addition to what the students produced last year, this influenced the community to feel confident enough to apply for a grant to encourage innovative ways to support individuals suffering from poor mental health, with a particular focus on young people, and this funding will go towards an online Moodle platform for youth mental health resources. As a graduate mentions: Regardless of the amount of time we had we were able to come up with ideas and initiatives alongside community members that stayed with those communities. Therefore, even though we weren’t able to follow up, develop plans or continue with implementation, communities had new ideas that they could continue on with. (Graduate nurse)

A dose of realism is needed, in terms of what the students can realistically achieve. For example, while the Submission to Shrewsbury National Health Service (NHS)

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for a mental health nurse described above did result in contact and ongoing engagement from the NHS, a dedicated mental nurse has not yet eventuated. This is a national issue of investment and highlights the need for learners to be aware of systems and processes of change (see section Systems-Thinking below). Similarly, community development processes would normally take longer than time allowed in the project. The CHASE model needs to include consideration of the scale of intervention in relation to making impact across community with drivers and mechanisms on different temporal and spatial scales.

Complexity Perspective Patton’s (2015) fifth principle calls for the application of complexity concepts. Here he defines complexity as referring to emergence, non-linearity, uncertainty, dynamics and co-evolution (distinguishing these from systems thinking focusing on relationships). Recognising this complexity means that at the outset, ‘developing from rudimentary ideas … you cannot predict what will be the results, or even what you will be doing’ (Patton, 2015, p. 305). We have already seen how the directives to student teams are open-ended. Within the overall framework of the CHASE model, the teams are provided with several frameworks to help navigate the complexity: • The teams used the Community as Partner Assessment Wheel (Anderson & McFarlane, 2011, and extended by Ross et al., n.d.) which has the community at the core of the model surrounded by a description of 11 sub-systems: health and social services, economics, transport and safety, communication, education, physical environment, politics, recreation, housing, climate change and COVID-19. The Māori model of health that underpins the whole nursing degree Te Whare Tapa Whā is complemented by Te Ara Tika – the Māori ethical framework (Hudson et  al., 2010) tikanga Māori and its philosophical base of mātauranga Māori (traditional knowledge) and integrates understandings from the Treaty of Waitangi, indigenous values and Western ethical principles. (Refer to Whakatane case study in Chap. 5.) • In addition, the students consider the United Nations 17 Sustainable Development goals (SDGs) (Nilsson, et al., 2017; Allen et al., 2019; United Nations Sustainable Goals, n.d.) to show how their research might contribute to achieving these. • Strengths, Weakness, Opportunity, Threats (SWOT) analysis  – the learners undertake a SWOT analysis to produce a MIND MAP to identify health needs of the identified populations. The health needs within the community/population or aggregate with whom they are working are discussed. • PICOT Model – From this community assessment, SWOT analysis and community stakeholder engagement, a health focus is identified to direct the learner’s literature review and areas of focus within the community. The broad question is finalised by engaging with the PICOT (Population, Intervention, Comparison, Outcome, Time) (Riva et  al., 2012) model in order to formulate a workable revised question and undertake a review of the literature.

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• Ottawa Charter – Engaging with the Ottawa Charter learners will further identify needs or gaps in services that will help guide the development of health promotion messages and resources which are protected by Otago Polytechnic Intellectual Property Policy. A good example of how frameworks are used in an integrated fashion is a CHASE project to create a pilot programme for Type 2 Diabetes Mellitus (T2DM) education and health promotion for Māori, Pasifika and lower socioeconomic communities in the Dunedin region. Prompted by the Ottawa Charter for Health promotion (World Health Organization, 1986) and Te Whare Tapa Whā (Durie, 1998), the team identified the following areas needing attention: whānau involvement, education about the disease, education about healthy kai, physical activity involvement and clinical monitoring of patients with diabetes. The SDGs (particularly Goal 10, reduced inequality) also came into play as the learners considered the inequities of health outcome disparities and the lack of affordable and accessible health services provided for Māori. There is no singular resource or service provided for people with diabetes in Dunedin. The learners realised that there was a need for practical strategies and resources to be combined and utilised for Māori with diabetes and their whānau/family. Diabetes Education Self-Management Newly Diagnosed and Ongoing Diabetes (DESMOND, Department of Health, 2002) is a self-management health promotion model. DESMOND provides group education to clients with Type 2 Diabetes and encourages them to establish behaviour change through active involvement. But the DESMOND model has not been widely used with Māori communities. The team worked with Māori communities to develop resources incorporating te reo in health promotion material and made a submission to the regional health authority. Complexity not only describes the problem but also the solution – not that the solution is complex, but also that it imposes a narrow solution to tame the complexity – rather we need to seek elegant community health and educational responses that allow for uncertainty, non-linearity and emergence. The CHASE community projects have a balance of framework and flexibility to navigate this complexity.

Systems-Thinking Systems-thinking underpins the CHASE model, and using the model develops systems-­thinking in nurses. In writing of systems-thinking as a principle of a Developmental Evaluation Mindset, Patton (2015, p.  306) describes a means for ‘conceptualising multi-dimensional influences, interrelationships and interactions as innovative processes and interventions unfold’. Systems-thinking is apparent in the responses of the graduate nurses: Made me think about different ways of spreading awareness and knowledge and allowed me to see that there are always different ways of communicating and reaching out to people. (Graduate nurse)

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It showed us a community that is very much underrepresented and under-resourced. It meant we had to educate ourselves and think outside the box for a community that couldn’t be put in a one size fits all basket. (Graduate nurse) It was creative as we had to think outside what had already been used in the community, while also having to be realistic. (Graduate nurse) It was an eye-opening experience, good to be able to go out into communities and look at the health inequalities that the community faces and trying to find solutions to help was great, get you to really think and be creative and feel a sense of accomplishment when you create something the community can use. (Graduate nurse) Our project developed in-hospital education/resources to ensure a more patient informed discharge process to aid with better chances of staying well in the community. It highlighted to us the importance of providing education at every moment and ensuring patients are fully informed of their situation to aim for a higher chance of staying well in the community. Our project was used as an example for nurses on the ward to develop a patient board that is now utilised on the hospital wards. (Graduate nurse)

Learners are doing systems thinking in how they identify resources. They might not describe it in these terms, but they are looking for leverage points in the systems (Meadows, 1999; Abson, et al., 2017). An example of this can be seen in the following excerpts from the CHASE community project in Heratini/Geraldine (in the case study presented in Chap. 2). The team identified migrants as a vulnerable population. Geraldine has many permanent migrants, mostly from the Philippines, working on dairy farms. There appears to be a disconnect between migrants and the agencies who are capable of delivering assistance, which arises from factors including… (challenges of identifying migrants, isolation, difficulty of finding points of contact for vulnerable populations). (Student final report)

So, the critical question here is how did they get from this need to the following health resource development? …the researchers created a poster for distribution within Geraldine. The poster identifies service providers, lists contact numbers and outlines what documentation one needs to access such services. (Student final report)

This is not in any way suggesting the resource was wrong, but observing that there are many other places to intervene in the system – why this one? Student learners and facilitators are aware that the projects must be completed within a four-week period, and when looking at the CHASE model, the interventions (health promotion messages) are usually completed in the third or fourth week; therefore, any interventions must be realistic and generally tackle the local level. However, several teams of learners write submissions or lobby relevant government Ministers including those responsible for health and education portfolios, thereby tackling the health concern at a national level. Other teams attempt to tackle the health issue at a local level by writing articles for newspapers, lobbying local governments, producing pamphlets and posters and targeting e-platforms, for instance social media platforms or the Internet webpages for agencies and other imaginative mediums for sharing the health message, for instance, on keyrings, beer coolers and others (refer to Chap. 3).

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In Phase 4 of the CHASE model, nurse learners engage with the Ottawa Charter for Health Promotion (World Health Organization, 1986). The Charter has five key action areas and three health promotion strategies, and when employed together, may envisage an improvement of the identified health need (discussed in Chap. 3). For example, in the CHASE community project in Heratini/Geraldine, learners focused on health issues around migrant labour. New Zealand has recognised migrant labour vulnerability and has online resources including a guide for farmers’ legal and pastoral responsibilities (Ministry of Business, Innovation and Employment, n.d.). Information in this brochure includes immigration protocols, points of contact, health and safety information and instructions and photographs to identify how to use machinery. However, in 2017, this booklet was only published in English. Therefore, the learners created a poster (refer to case study in Chap. 2) with information on how to contact emergency and other services to assist them and was translated into Tagalog (Filipino). The key considerations in developing health promotion resources by the learners were to create visual resources to reduce health inequalities for migrants. The posters were designed as a guide to understand the complex nature of the New Zealand’s primary health system. Methods on how to communicate with healthcare professionals were added including useful applications. Phone numbers of relevant services for migrant workers locally were included in the pamphlet. Tagalog is the most spoken language in the Philippines and translating into Tagalog aimed to address the language barrier. But are all the interventions the same, relatively short-term fixes to information flows? No, there are more systems that change things: submission to council, establishing community hub, council action plan and the education ones (that go beyond lists of services) are at the more effect end of Meadows’ (1999) lever. If we expand the scope to the CHASE process itself, we can use Meadows’ leverage points (in order of increasing effectiveness) to explore where in the system the community projects are acting: 12. Constants, parameters, numbers (such as subsidies, taxes, standards). N/A for CHASE nurse learners. 11. The sizes of buffers and other stabilising stocks, relative to their flows. N/A for CHASE nurse learners. 10. The structure of material stocks and flows (such as transport networks, population age structures). 9. The lengths of delays, relative to the rate of system change. The teams have very little time to effect change, so they have to look for timely opportunities. 8. The strength of negative feedback loops, relative to the impacts they are trying to correct against. Bishop’s Castle 2020 is an example where the nurse learners did not pick up on dementia of older people (pre-COVID-19) as a significant issue. Feedback from the core stakeholders noted this as an issue that was not attended to and in 2021 (post COVID-19) we attended to this health need. 7. The gain around driving positive feedback loops. An example of this is continuing working with the same community Bishop’s Castle 2020/2021/2023, in 2023

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being in a position to develop a community strategic plan and identify the assets of the community. 6. The structure of information flows (who does and does not have access to information). Many community projects are about making information more widely available. While learners offer this information (either finding it or creating it), the stakeholders have control over how they use the resources. 5. The rules of the system (such as incentives, punishments, constraints). The incentive is to improve healthcare and reduce health disparities, 1000 hours of project time at no cost/punishments. Constraints relate to buy-in from stakeholders, their interest (they can see the value) and stakeholders leaving the community. 4. The power to add, change, evolve or self-organise system structure. Often the CHASE community project is a prompt for further community action. This might be extending the resources – for example, the drink holder with mental health messaging provided to 200 farmers was picked up by the national organisation (refer to case study Gore in Chap. 3) – or the energising of the system, such as Bishop’s Castle community (in the following chapter). 3. The goals of the system. At one level CHASE includes phases which act as goals which are evaluated impact 3-6 months following the completion of Phase 5. At a broader level, the system is the rural health system, which was seen, for example in the influence of the Whakatāne case study driving goals of new Māori health system (in Chap. 5). 2. The mindset or paradigm out of which the system – its goals, structure, rules, delays, parameters  – arises. CHASE is rooted in systems-based public health theories – the Ottawa Charter, for example – which are themselves about changing the mindset and approaches to health. 1. The power to transcend paradigms. This holistic and transdisciplinarity is a feature of the CHASE model. This can be seen in Chap. 4 related to teaching and learning pedagogy, Chap. 2 related to the CHASE model adaptation, in Chap. 3 the nurse as designer and Chap. 5 associated with decolonisation. The CHASE community project is about helping the nurse learners to see and think of systems. For many this is the first realisation that their practice is more than a sum of the set of technical skills. This is discussed further below.

Co-creation We have already seen strong aspects of co-creation in the relationship with the community. CHASE teams maintain the community ownership of opportunity identification (vulnerable populations and health needs), prioritising and of the developed resources. Here, we focus on graduate reflections on process and ask to what extent is their learning co-created? It is worth asking if this is really co-creation? Patton (2015, p. 307) describes:

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The developmental evaluator works collaboratively with social innovators to conceptualize, design, and test new approaches in an ongoing process of adaptation, intentional change, and development. Developmental evaluation is interactive  – engaging social innovators, funders, supporters, and other core stakeholders to tailor and align the dynamics of innovation, development, adaptation, and evaluation. This dynamic amounts to the co-creation of both the unfolding innovation and the developmental evaluation design.

In order to explore co-creation, we really need to be guided by the student voice. Most graduates report being excited about the CHASE project at the start: I thought the project might lead to something really worthwhile, a change for the target group. (Graduate nurse) I was excited to see what change we could make. (Graduate nurse) I thought it was going to be fun and the chance to make a difference was exciting. (Graduate nurse)

Some of the nurses reported not liking the CHASE project. In the first iterations, the restructuring of the degree resulted in students feeling they had missed out on a placement (in fact they had one more, but their perception is their reality). Note that for this 2018 learner ‘practice skills’ were entirely clinical: I feel like the lack of a primary health care placement in the final year of an undergraduate nursing degree really was detrimental to our skills – some of my colleagues had still not given an IM injection, or removed sutures, or even set foot in a general practice, and this really had a big impact on confidence and experience when we were applying for jobs. (Graduate nurse)

Yet others in 2018 were able to see past this ‘lacking’ placement: At the start, I was interested but felt an extra placement would have been more useful…but looking back now, opportunities like this always just reinforce to me that people from all lives can be struggling, to be mindful of this and understand that the one brief interaction you have with someone could be very important in connecting them with services that may help (or even just being a person to listen to them!). (Graduate nurse)

Many others, while hesitant at the start, came to appreciate the project, and it is worth noting that these nurses are now practising in intensive care, rural practice, addiction and education: I didn’t think it would be as important as it was to me. (Graduate nurse) Wondering whether it would be relevant to my nursing practice… It is a very valuable and worthwhile experience which I hope continues as it develops an understanding of primary health and public health. (Graduate nurse) During the beginning I thought it was a waste of time. I entered nursing school wanting to be a Primary Practice Nurse and I hadn’t had the opportunity to have a primary practice placement…I genuinely forgot about the content of the project however completing this survey has helped draw back those memories and has helped my reflection on what has shaped the type of nurse I am today. It’s ironic that I was initially annoyed about the project because I felt like it took away my chance to have a primary care placement however now I am Clinical Lead for a primary care initiative that will benefit rural communities. And that the Access and Choice Programme we started has been developed by a larger project to address community needs. (Primary and Addiction nurse leader in a small city whose area of practice includes the rural area where they did the CHASE project). (Graduate nurse)

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I was wanting a more traditional hospital or GP based placement. So was hesitant to participate…. It really changed my perspective on work as a nurse in the community…You will always get student resistance to this placement but it really is valuable even if you don’t realise it straight away. (Graduate nurse) Much more learning than I anticipated, and learning what I could and continue to apply to my everyday practice. Not a waste of time because the experience and knowledge has influenced my practice greatly. (Graduate nurse) At the start, I thought ‘yawn, more research’ – no practical learning to enhance my future practice. … But now I think it is a great way to think of nursing strategies and then tools to implement your research. (Graduate nurse)

The graduates reported a wide range of insights from the CHASE community projects. For some this was about realising complexity: Was very interesting, a great idea to get your head around all the primary health issues and try to find ways to help reduce them in a way the community can do together. (Graduate nurse) My biggest insight was that there can be so many different ways in which the health and wellbeing can be influenced. It spans from each individual up to public policy. This was all great learning and an eye-opening experience to see how so many factors influence the health of a community. In regards to family violence it was a surprise to me to learn about just how prevalent it is in New Zealand. (Graduate nurse)

For many, the insights were about rurality – distance, resources and social isolation – and they often described this in terms of equality: I was surprised how separated and isolated the Westcoast seemed to be. (Graduate nurse) Yes, I was surprised at the little services they elderly had access to including transportation. (Graduate nurse) Recognising the inequality. But hard being able to try and make those inequalities fairer. (Graduate nurse) I didn’t know a lot about the [place name removed] so it was surprising to learn about what resources they DID and DIDN’T have available and the amount of immigrants the region is serviced by. I had an idea about the rural suicide statistics as one of my colleagues came from a rural background and I had learned about the impacts of droughts on the farming industry. (Graduate nurse) It gave me an insight into the health inequities some communities have. (Graduate nurse)

Again, the learners were aware of the added complexity of international projects: A different approach than what we would normally take in New Zealand, so we had to make sure that we were adhering to appropriate cultural safety measures and not imposing a westernised view of health care. (Graduate nurse) Understanding needs and available resources for this community. Having to conduct thorough research to figure out this was going to be a sustainable and culturally appropriate resource to implement. The needs of this community were very different from our own in NZ so made us look at health from a very different perspective. (Graduate nurse)

It is clear from these graduate voices; they co-created and took ownership of their learning. It was a great opportunity to be creative. We first had to learn about what might actually be effective and functional for people to use and we came up with the idea of the key ring resource. Looking back, I think there could be so much more important things that could have been done above something as simple as a key ring. (Graduate nurse)

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It showed how broad nursing can be and how no two jobs are the same. A key learning I have taken from it for sure. That growth can be very much self-led and how well working as a team can contribute to the outcome. (Graduate nurse)

They also reported co-creation of solutions: It gave me a good insight into another side of nursing, planning and working with communities to try and achieve primary health goals. (Graduate nurse) I think it made me think about nursing in a different way. Reaching out to vulnerable people and giving them an easy and accessible way to ask for help. (Graduate nurse) I liked that the brief could be altered to suit our ‘agenda’ (e.g. the community needs). Half of us wanted to focus on one need and the other half wanted to focus on another need so we split up so we could cover both topics and this was able to be achieved under the brief. (Graduate nurse) It showed me that there are no limitations to working creatively within the community to meet the needs identified by the community. (Graduate nurse)

Timely Feedback Patton’s principle of Timely Feedback concerns evaluative results on an ongoing basis rather than at predetermined times. This suggests a shift to an evaluative mindset where every interaction is an opportunity for feedback and every premise needs investigating. The CHASE community projects have in-built evaluation. This can be seen in the critical awareness and reflection throughout the process, and the ability to adapt projects on the fly according to outcomes and decisions of community stakeholders. CHASE itself is also subject to ongoing evaluation and timely adaption (refer back to Fig. 6.1 and Chap. 2). While students are surveyed on completion of their qualification, a gap in the evaluative mindset was feedback from graduate nurses who undertook a CHASE community project reflecting on the impact of this on their professional practice. So, for this chapter, we took the opportunity to survey these graduate nurses. Their insights on their experience of CHASE have informed much of this chapter including the following section which takes a longer-term perspective.

Nursing Practice Evaluation and Conclusion By way of summary and conclusion, we explore the longer-term impacts of CHASE through the graduate nurses’ reflections on the nature of the nursing profession, the influence of CHASE on their own practice and any impact on their career progression. The most common reflection on the nature of nursing practice is the realisation that it is more than a narrowly defined clinical care. (Note the CHASE community

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development project is explicitly recognised by NCNZ as contributing to required clinical hours, refer to Chap. 2.) In the words of graduate nurses: Nursing in a community sense requires a different approach to care than solely providing clinical care. Thanks for your efforts in providing a placement that shows another side of nursing. (Graduate nurse) This project highlighted the scope of nursing practice and the role of nursing outside the clinical setting. It encompassed Public Health response at the community level and in partnership with community members. (Graduate nurse)

The other nature of nursing practice is the role of community as partner: It has made me more aware of the bigger picture of community and its impact on my clients’ health and wellbeing. (Graduate nurse)

For some, the project helped them find the edges of nursing practice – and perhaps widened their ideas of the multidisciplinary teams: Some of the research we conducted was out of the way for the nursing profession e.g. Road safety and contacting the transport agency to propose our ideas. (Graduate nurse) I think that there were certain areas, for example, parking that really needed to be analysed by someone specialising in urban development or related area. (Graduate nurse)

CHASE is helping the learners to position nurses as change agents: I have a better awareness of the processes regarding change, the resistance regarding progress and the effort required to promote real change. (Graduate nurse) It has influenced my perception of how much power a nurse has to make positive change within a community. Nurses aren’t just working on hospital wards. They are also out in the community engaging in higher level change processes and development. (Graduate nurse) Overall, I thought it was a really exciting project. I do know that quite a few of my peers didn’t appreciate it as much as I may have. I think this may have been because their passion was found within hospital nursing whereas I always knew I had more interest in this side of nursing. Either way, I think it’s valuable for student nurses to recognise the influence nurses can have on making change. (Graduate nurse) I hadn’t considered this, but now that I work in the community, I realise how we are all working together to improve the health of clients as a whole and how important it is to be open to new ideas and work as a team. (Graduate nurse) I am always on the lookout for community-based resources I can link people into as well as how can I work with those resources to improve their outcomes. My mindset is less siloed and more Inclusive. (Graduate nurse)

Despite the structure of the CHASE community project meaning learners do not come in direct contact with patients (except as representative stakeholders), a theme in graduates’ reflection on practice is the impact of CHASE on their relationship with patients: Learning personal stories and how people live at home after the acute event. (Graduate nurse) Recognising the difficulties of rural life and access to health care and health literacy. I see a lot of ambulances at the bottom of the cliff kind of patients in my workplace. And remembering that it is not all their fault that they are left their condition to that point. (Graduate nurse)

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This patient focus can be the mindset, or realising that a patient is a person at the centre of their system: I work as a practice nurse, so a big focus of our work is addressing health needs in a way that works for our patient population. Being able to identify different needs amongst our community and consider aspects and challenges of individuals transfers directly to my work, particularly managing covid in the community as I’m one of the team members who make contact and manage needs amongst our covid positive patients. (Graduate nurse) It enabled myself to think widely on what sort of diet, health services and community activities a person would have been exposed to whilst living at home. Screenings they may or may not have had. Awareness and health education. (Graduate nurse) It has influenced my nursing practice greatly, as I see so many patients come in with health inequality, it helps me to understand them more and their situation, so then I can in turn help them to achieve their health goals. (Graduate nurse)

The community project course must work for learners no matter what area of practice they intend on entering. While it would not be a good thing if it only worked for those planning a career in rural nursing, it would not be a positive outcome if all learners decided to become rural nurses (because who would then work in city hospitals?). Most of the reflections on the impact on practice presented above are indeed not from rural nurses – yet the experience and the contributions to their practice are positive. There are some graduate nurses, however, who report a lasting impact of CHASE on their career direction: I began my nursing career in a clinical setting (Operating Theatres). I am currently working as a Registered Nurse in a children’s surgical ward. I have recently begun studying part-­ time, working towards a postgraduate certificate in Public Health. The community project has influenced my decision to work towards gaining this qualification and moving into a health promotion/community development space. (Graduate nurse) I have developed a passion in community health and would like to pursue it in the future after the experience I am gaining on a paediatric surgical ward currently. (Graduate nurse)

Last, from a graduate who thought the CHASE project was a ‘waste of time’ at the start: Once I graduated from the degree I moved to the city and pursued forensic inpatient nursing. At some point in my career, I noticed recurring themes with the clients coming through the forensic service and thought ‘if only there had been early intervention to prevent this’. I have since relocated back to [place name removed] to take up my role as Clinical Lead of Integrated Primary Mental Health and Addictions. This is a programme funded by the MOH through the access and choice programme to offer free appointments in Primary Care with a mental health specialist clinician, to help with problems with thoughts, feelings and behaviours. The programme makes appropriate care accessible and without stigma of accessing secondary services. Helping change behaviours may prevent serious mental illness and reduce the impact on secondary services. As a part of my role I will set up services in the rural regions including [place name removed]. This project gave me an understanding of the community profile and needs, and I feel well prepared for my role. In terms of my own nursing practice, I have written my own unpublished research articles as I understand the importance of evidence-based information when advocating for change. I didn’t realise it until now but this project helped me develop these skills. I never felt suited being a ward

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nurse (ambulance at the bottom of the cliff) and I could probably attribute this project for my desire to be a nurse who leads and drives change in the New Zealand health care system both nationally and locally. (Graduate nurse)

Any innovation can be seen as a set of interrelated premises. These claims are directly stated or more often inferred. CHASE is an innovative approach to nursing education based on the overarching premise that these teams of learners’ interactions with the rural communities is beneficial for the learners and the community. We can drill down on each of these claims – that it is beneficial for learners regardless of their intended area of practice – and so on. So how do we know this alternative approach is working? How do we know that it is making a difference? How do we know that it is working for the student learners? In this chapter, we have explored the impact of the CHASE model. We have examined the impact of the use of CHASE through the lens of Patton’s Developmental Evaluation Mindset (2010) as a framework to highlight key insights.

References Abson, D. J., Fischer, J., Leventon, J., Newig, J., Schomerus, T., Vilsmaier, U., Von Wehrden, H., Abernethy, P., Ives, C. D., & Jager, N. W. (2017). Leverage points for sustainability transformation. Ambio, 46, 30–39. Allen, C., Metternicht, G., & Wiedmann, T. (2019). Prioritising SDG targets: Assessing baselines, gaps and interlinkages. Sustainability Science, 14(2), 421–438. Anderson, E., & McFarlane, J. (2011). Community as partner: Theory and practice in nursing (6th ed.). Wolters Kluwer Health | Lippincott Williams & Wilkins. Department of Health. (2002). National service framework for diabetes: Delivery strategy. United Kingdom Government. Durie, M. (1998). Whaiora: Māori health development. Oxford University Press. Gibbs, G. (1988). Learning by doing: A guide to teaching and learning methods. Further Education Unit. https://www.ed.ac.uk/reflection/reflectors-­toolkit/reflecting-­on-­experience/ gibbs-­reflective-­cycle Herrington, J., Reeves, T. C., & Oliver, R. (2006). Authentic tasks online: A synergy among learner, task, and technology. Journal of Distance Education, 27(2), 233–247. Hogarth, K., & Rapata-Hanning, M. (2023). Māori health in Aotearoa New Zealand. In J. Croft & C. J. Gordon (Eds.), Understanding pathophysiology (pp. 1179–1197). Mosby Elsevier. Holm, D., & Stephenson, S. (1994). Reflection – A student’s perspective. In A. Palmer, S. Burns, & C. Bulman (Eds.), Reflective practice in nursing: The growth of the professional practitioner (pp. 53–62). Blackwell Scientific Publications. Hudson, M., Milne, M., Reynolds, P., Russell, K., & Smith, B. (2010). Te ara tika. Guidelines for Māori research ethics: A framework for researchers and ethics committee members (Vol. 29). Health Research Council. Kolb, D. (2015). Experiential learning: Experience as the source of learning and development (2nd ed.). Pearson Education. McMurray, A., & Clendon, J. (2015). Community health & wellness: Primary health care in practice (5th ed.) Churchill Livingstone/Elsevier. Meadows, D. H. (1999). Leverage points: Places to intervene in a system. Solutions, 1, 41–49. Ministry of Business, Innovation and Employment. (n.d). New Zealand immigration: Are you recruiting migrant workers? What do you need to know? https://www.immigration.govt.nz/ employ-migrants

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Ministry of Health. (2001). Primary health care strategy. Ministry of Health. Ministry of Health. (2016). New Zealand health strategy 2016. https://www.health.govt.nz/ publication/new-­zealand-­health-­strategy-­2016 Mullens, C. (n.d.). Compassionate pedagogies: Nursing learners collaborating for global health and social justice in New Zealand. Otago Polytechnic, Te Pūkenga. Nilsson, M., Griggs, D., McCollum, D., & Stevance, A. (2017). A guide to SDG interactions: From science to implementation. https://council.science/wp-­content/uploads/2017/05/SDGs-­Guide-­ to-­Interactions.pdf Nursing Council of New Zealand. (2016). Competencies for registered nurses. Wellington https:// www.nursingcouncil.org.nz/Public/Nursing/Standards_and_guidelines/NCNZ/nursing-­ section/Standards_and_guidelines_for_nurses.aspx Orange, C. (1989). The story of a treaty. Bridget Williams. Patton, M. Q. (2015). The developmental evaluation mindset: 8 guiding principles. In M. Q. Patton, K. McKegg, & N. Wehipeihana (Eds.) (pp. 289–324). Developmental evaluation exemplars: Principles in practice. Guilford Publications. Papps, E. (2002). Nursing education in New Zealand-past, present and future. In E. Papps (Ed.), Nursing in New Zealand: Critical issues different perspectives (pp. 95–107). Pearson Education. Patton, M. Q. (2015). The developmental evaluation mindset: 8 guiding principles. In M. Q. Patton, K.  McKegg, & N.  Wehipeihana (Eds.), Developmental evaluation exemplars: Principles in practice (pp. 289–324). Guilford Publications. Rittel, H. W. J., & Webber, M. M. (1973). Dilemmas in a general theory of planning. Policy Sciences, 4(2), 155–169. Riva, J. J., Malik, K. M. P., Burnie, S. J., Endicott, A., & Busse, J. W. (2012). What is your research question? An introduction to PICOT format for clinicians. Journal of Canadian Chiropractic Association, 56(3), 167–171. Ross, J., Mann, S., & Whiddon, K. (2020). Collaboration enhances community wellbeing: A community development research framework. Contemporary Research Topics Scope, Health & Wellbeing, 5, 60–64. https://doi.org/10.34074/scop.300509 Ross, J., Mahoney, L., Mullens, C., & Askerud, A. (n.d.). Adaptation of Anderson, E. & McFarlene, J. (2011). Community as partner: Theory and practice in nursing (6th ed.). Wolters Kluwer Health | Lippincott Williams & Wilkins Unpublished. Otago Polytechnic, Te Pūkenga. Ross, J., Crawley, J., & Mahoney, L. (2017). Sustainable community development: Student nurses making a difference. Scope Contemporary Research Topics: Learning and Teaching, 4, 8–17. www.thescopes.org United Nations Sustainable Goals. (n.d.). http://www.un.org/sustainabledevelopment/news/ communications-­material/ World Health Organization. (1986). The Ottawa Charter for health promotion. https://www.who. int/healthpromotion/conferences/previous/ottawa/en/

Chapter 7

Future Landscapes of Collaborative Rural Community Development Samuel Mann, Keith Whiddon, and Jean Ross

Abstract The application of the Community Health Assessment Sustainable Education model has showcased direct community development in the former chapters as well as its adaptation. So, it is fit for purpose as it acknowledges changing rural and contextual circumstances. It can ensure the vision of its goal to maintain and improve rural community health. Improving community health related to population groups or aggregates has been motivated within these chapters with case study examples engaged with Indigenous populations’ health, sustainable community health, minority health, young people’s mental health, seniors’ health, maternity and child health. The motivation to improve health of these populations has remained in the foreground of all the community projects as the nurse learners have engaged with evidence-based knowledge to inform the application of the creative resources developed by non-designers and instil health promotion messages as a component of these resources and evaluate the impact of those messages on these identified populations. We offer our impact evaluation of the Community Health Assessment Sustainable Education model and its adaption; so, it is fit for purpose for rural contexts as health disparities and (in)equity related to rural health have been uncovered. This chapter concludes by examining the pedagogy underpinning both the Community Health Assessment Sustainable Education model and the communities of practice which are forming through its use. It also considers how learning and teaching theories apply in rural community development, research, and S. Mann (*) Te Kura Tapuhi | School of Nursing, Otago Polytechnic | Te Pūkenga, Dunedin, New Zealand College of Work Based Learning, Otago Polytechnic | Te Pūkenga, Dunedin, New Zealand e-mail: [email protected] K. Whiddon Bishop’s Castle, Community Partnership, Shropshire, UK e-mail: [email protected] J. Ross Te Kura Tapuhi | School of Nursing, Otago Polytechnic | Te Pūkenga, Dunedin, New Zealand e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. Ross et al. (eds.), Rural Landscapes of Community Health, Global Perspectives on Health Geography, https://doi.org/10.1007/978-3-031-43201-9_7

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education and ways forward. To achieve this, we take an education design fiction approach, positioning the discussion as a narrative of a hypothetical Bishop’s Castle Community Health Assessment Sustainable Education model 2033. Keywords  Rural · Health · CHASE model · Narrative · Reflection · Future

Introduction In this final chapter we reflect on the contribution the previous six chapters have played in the promotion of rural community development while engaging with the Community Health Assessment Sustainable Education (CHASE) model in action (Ross et al., 2017). We take an education design fiction approach, positioning the discussion as a narrative of a hypothetical Bishop’s Castle CHASE 2033 (Mann et al., 2022). These stories are based on a set of five and ten-year trends identified through a Delphi-sort approach to identifying and prioritising. All contributors to the book were invited to participate (ethical approval was granted from OPREC 2022) in an iterative process of identifying future themes from the chapters. People from various fields connected to CHASE, including nursing, education, community development and design who were also invited to contribute. In a series of three interactions (via a survey tool), the panel of authors and other experts identified and ranked trends likely to affect the CHASE model and finally suggested story nuggets or scenarios that formed the basis of the narratives that followed. The events of the stories are not intended as predictions, nor as utopian or dystopian visions. Rather, they are intended to highlight potential future directions, challenges and opportunities for the future of the CHASE model – both rural community development and education of nurses (and beyond). After resetting the context of Bishop’s Castle in 2033, the stories are presented around the experiences of five townsfolk who have engaged in the CHASE model, and then a sixth story is that of a nurse learner. Lastly, the experience of the CHASE model nurse academic/lecturer in 2033 doubles as a summary, pulling together the themes. While the story focusses on a hypothetical CHASE 2033, we start the story much, much earlier, in 1533 (Fig. 7.1).

Bishop’s Castle: Past, Present, Future Smoke clings to the sides of the wooded valley. The morning air resounds to the steady beat of broad-axes squaring-off newly felled oak timbers. Sawyers are see-­ sawing beams lying across trestles in readiness to be incorporated into the new building. It is the spring of 1533. In the days of King Offa, back in the eighth century, a Saxon noble called Edwin Shakehead had granted 18,000 acres of land here to the Bishop of Hereford as

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Fig. 7.1  Map of United Kingdom highlighting Bishop’s Castle. (Produced by Suzanne Thornton with permission from Authors)

thanks for a miraculous cure for his palsy at St Ethelbert’s tomb in Hereford Cathedral. Between 1088 and 1127, the Bishop, as one of the Marcher Lords charged with securing the frontier with Wales, had built a castle on this rocky outcrop overlooking the valley. The castle attracted settlers spreading southwards down the hillside towards a church. By 1167 the original castle had been replaced by a stronger fortification of stone and in 1203 King John granted the settlement its first charter to hold markets (Fig. 7.2). However, under the rule of the Bishops, the little place failed to grow significantly. Not only was it a remote location, but it was also under constant threat of attack from the nearby Welsh hordes, being situated right on the ever-changing Welsh border near Offa’s Dyke. Furthermore, the Bishop demanded a lot from the townsfolk – those who brewed commercially, for example, were obligated to give the Bishop 24 gallons annually. But back to our scene in 1533. By now the rule of the Bishops is in decline. Masons have started robbing the northern castle tower for its quality building stone, which is in short supply hereabouts. Some of this stone has already been used to build a sturdy ground floor for our new building on which the timber frame is being erected. It is a tall ‘open hall’ – open to the rafters and with a hole in its thatched roof to allow smoke from the firepit to escape. Our newly built ‘Bull Inn’ will become a much-needed watering hole for the growing town. It is beside the marketplace for the town, built in a prominent location next to the old castle at the top of the hill. Bishop’s Castle, as it is now known, has become an important drover’s town, with livestock brought in from Wales along drover ways.

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Fig. 7.2  Artist’s impression of the Bishop’s Castle circa 15 Century. (Illustrated by Drusilla Cole with permission)

Indeed, the ‘Bull’ would remain the marketplace Inn for the next 400 years. In 1933, a rise in beer duty coupled with an economic depression put it finally out of business and it became a private residence (Fig. 7.3). We now jump forward to 2033. The Old Bull Inn is celebrating its quincentennial – 500 years since it was built. Its original smoke-blackened timbers have witnessed centuries of change. Also, being celebrated in this year, the Town is looking back to the first of its annual ‘Community Celebration’ events, initially founded after the COVID-19 pandemic in 2023 to help to re-establish community organisations, clubs and societies and provide an opportunity for them to showcase their work and attract new participants. The year 2033 is a time for reflection, a time to take stock and consider the future. And it is 10 years since nurse learners from School of Nursing, Otago Polytechnic, Dunedin, Aotearoa New Zealand undertook a community development research project with the folk of Bishop’s Castle. Meet the learners in Fig. 7.4 as they were introduced to the Bishop’s Castle community public meeting. Using the CHASE model, they identified a number of issues affecting the health and well-being of this community (Fig. 7.4). Back in 2023, the CHASE Model held a mirror up to our community. It reflected to us things we were blind to, being too close to the issues. In particular, the two key issues relating to community health and well-being were:

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Fig. 7.3  The Old Bull Inn dating from 1533. (Produced by Whiddon with permission from Authors)

1. Mental Health: • Bishop’s Castle has had 11 suicides in 11 years which is significant for the population size. • Issues relating to mental health and support are a significant challenge here, with barriers such as inaccessibility to services and limited mental health resources due to a lack of funding. 2. Physical Health: • Food poverty is an issue in Bishop’s Castle. • A high number of those within Bishop’s Castle community are considered overweight/obese. The Bishop’s Castle Community Partnership took responsibility for responding to the CHASE model findings on behalf of the wider town community. The Partnership was set up to advance citizenship and community development by: • Providing a strategy for the development of the Town and its key economic, social and environmental priorities • Regularly consulting the community on its needs and prioritising the actions required • Supporting the community of Bishop’s Castle and its environs to achieve a better quality of life for residents

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Fig. 7.4  Bishop’s Castle’s Response to the CHASE Model Study – Setting the Strategic Direction. (Produced by Whiddon with permission from the Authors)

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The Partnership had engaged with the community to write a community-led plan for the Town. This laid out the strategy for community development going forward. Projects to address the identified CHASE model issues were incorporated into the Plan, along with strategies to tackle the key issues of concern to the community as a whole, especially the: • Lack of affordable housing • Lack of local employment • Declining local services, including public transport, local shops, local healthcare and education

Bishop’s Castle: 10 Years After CHASE It is 2033. The Community Partnership’s strategy to help address the issues raised by the CHASE Model combined with those of the wider community has been running for 10 years. The aim has been to keep Bishop’s Castle a sustainable community by: • • • • •

Creating a sense of place Community capacity-building and empowerment Widening the horizons of the local community and challenging low aspirations Promoting digital transformation Finding local solutions to public funding cuts and the centralisation of public services

Here are some stories from townsfolk about the positive changes that have played a significant part in improving the health and well-being of the Town over the last 10 years:

Creating a Sense of Place Mark is 40. He moved to Bishop’s Castle in the last six months to take up the role of Head Chef in the busy Castle Hotel. Mark is single and did not know anybody here when he arrived. He had read about the Town being voted one of the top places to live in the UK by the Sunday Times yet again and the description of it being ‘arty, fun and quirky’ appealed to him. Mark has worked in the hospitality industry for several years and understands how important tourism is to the economy of a small and remote rural town like Bishop’s Castle. Indeed, Mark knows that without its tourism industry there would not be work for him here. However, since Mark has gotten to know Bishop’s Castle and its community, he also understands that while it is vital to encourage tourism to boost the wider

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Fig. 7.5  The ‘March of the Elephants Artworks Trail’ Bishop’s Castle. (Produced by Whiddon with permission from Authors)

economy; at the same time, he is keen to make sure that it does not change the unique nature of the Town. He likens this to ‘ecotourism’ as discussed by the Global Ecotourism Network (2016). What makes Bishop’s Castle such a popular destination for visitors is its honesty as a town. It is not like nearby ‘chocolate-box’ Ludlow. This is not a museum but instead a thriving bohemian place where its residents share a very strong sense of community and pride. Bishop’s Castle is unique because of its artistic and musical reputation. Mark knew of this when he saw the job at the Hotel advertised – it is one of the key reasons he applied. He has become a regular at the long-established ‘Open Mic’ evenings at the Three Tuns Inn, singing and playing guitar (Fig. 7.5). Mark loves the ‘March of the Elephants Artworks Trail’ – a celebration of the history of the Town and its links with the elephant, from Clive of India’s crest to the elephant kept at the Castle Hotel during World War II. He also enjoys a coffee at the quirky ‘Poetry Pharmacy’ which prescribes ‘Poemcetamol’  – little bottles with poems hidden in each capsule to cure ‘all manner of emotional and spiritual ailments!’ The annual Arts Festival has nearly 40 open-studio artists across Town each February and the Town is buzzing. Mark has signed up for Bishop’s Castle’s online ‘Moodle’ learning platform – ‘Bishop’s Castle Interactive Rural Community Learning Resource’ (BCIRCLR). He has his own login, and this provides him with his own website where he is starting to write a blog. The site is free to residents and has enabled Mark to join various community projects and keep in touch through chatrooms and forum. Mark has learned that the platform came about as a direct result of the CHASE model project

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Fig. 7.6  Bishop’s Castle Michaelmas fair. (Produced by Whiddon with permission from Authors)

where New Zealand nursing learners identified the high number of young male suicides there had been in the Town. The Community Partnership were able to use the research work undertaken by the New Zealand students to apply for and win a grant to build the platform to promote mental health and community well-being. Mark believes that communities that are said to have a ‘sense of place’ are those with strong identity and civic pride that is deeply felt by inhabitants and visitors alike. One of the aims of the Bishop’s Castle Community Partnership over the last 10 years has been to support and encourage activities that bring the community together. Events such as the annual ‘Michaelmas Fair’ are critical in symbolising the community’s cultural identity and manifesting what the community is about. The Fair is about showcasing who and what the community is and fosters a huge sense of pride. It promotes a sense of belonging, or ‘being part of the tribe’. It creates a shared understanding that ‘this is a community that stands together’, strong and against the world if necessary (Fig. 7.6). It is this sense of place that makes Bishop’s Castle so special and plays an important part in its community health and well-being.

Community Capacity-Building and Empowerment Joanne is 30. She is a single-parent mum with two young children who attend Bishop’s Castle primary school. Joanne works part-time in a local care home supporting older residents suffering from dementia. Bishop’s Castle has a high

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proportion of older people as it has long been a popular retirement location, so the percentage of those with dementia is higher than average. Joanne is an active member of the ‘Bishop’s Castle Befriending Circle’ – a group set up by the Community Partnership some 12 years ago to help tackle social isolation and loneliness. She enjoys meeting such people for a coffee and a chat at a local café when she is not working. She also uses the BCIRCLR online learning platform to communicate with people isolated on surrounding farms for whom travelling into Town is an obstacle. Social isolation in rural communities is often hidden, but the Befriending Project has done much to reach out and help as many people as possible over the years. It is fair to say that Joanne struggles to make ends meet. Her part-time job is low-­ waged. She cannot afford a car, so she has no option but to work in Town as there is no public transport whatsoever. She also needs to be on-hand to pick up the kids from school at 3 pm as child-care facilities are very limited. Her other big concern was finding an affordable place to rent in Town, but luckily thanks to the Bishop’s Castle Land Trust, she was able to take a low-rent flat above a former newsagent that had been redeveloped by the Trust 10 years ago to help support people like her. Lack of employment opportunity and affordable housing are still the two main issues facing small rural towns like Bishop’s Castle. What employment there is tends to be low-waged. Rural poverty is a serious issue here and results in food poverty and poor health, as the CHASE model project identified 10 years ago. Joanne relies on the Bishop’s Castle Food Bank which was established during the COVID-19 pandemic. It is now housed in a converted barn in the centre of Town and serves approximately 200 people weekly. It is a vital lifeline for the community. The focus is not simply to provide basic foodstuffs, but to aim to improve health by offering fresh vegetables organically grown at a local community market garden. Joanne volunteers to work picking vegetables at the market garden after school. She takes her kids with her as the farm provides a free afterschool creche and children’s activities for volunteers, who also earn a free ‘veggie box’ (Fig. 7.7). When the Food Bank noticed that its clients were not keen to take fresh vegetables it realised that people did not know how to prepare and cook these. They used some of the grant funding that converted the barn to create a kitchen area and now run free courses and demonstrations for their clients on how to eat more healthily using fresh, locally produced food and thereby improve community health and well-being. Joanne depends on support and advice she receives from ‘The Thrive Lounge’ – Bishop’s Castle’s Community Hub. The aim of ‘Thrive’ is to be ‘a place connecting people – an informal drop-in venue for anyone wanting advice, support, friendship and an important base for a wide variety of local groups and services’. Its message is ‘walk in – talk to us – connect to your community’. Thrive is a place to help build an optimistic, vibrant community, full of opportunity and prosperity. Building the capacity of the community and investing in social capital has resulted in a united and proactive response and has promoted the mental health and well-being of the community.

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Fig. 7.7  Vegetable Box. (Produced by Daphne Page with permission from Authors)

Joanne values the services Thrive provides for her, including youth provision, budget advice, benefits advice and energy advice. It is also the base for Social Prescribing – an approach that connects people to activities, groups and services in their community to meet the practical, social and emotional needs that affect their health and well-being. It is estimated that as many as 25% of patients visiting a doctor do not need medical intervention but have social needs that may be addressed from within their communities. Joanne’s Social Prescribing Link Worker has helped her to develop a personalised care and support plan to combat her lack of self-esteem and self-confidence. She was supported to join a local drama group and she is very proud to have taken a leading role in the group’s recent production in the local theatre. Thrive measures the impact it has on the community by creating a value and a ratio that states how much social value (in £ sterling) is created for every £ sterling of investment. It is a way of quantifying the more intangible things it provides. The Community Partnership believes that the best way to achieve a sustainable community is to enable local people to develop, implement and sustain their own solutions to problems in a way that helps them shape and exercise control over their physical, social, economic and cultural environments. Investing in social capital and harnessing the talents and resources of our local community promotes health, well-­ being, skills and knowledge.

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 idening the Horizons of the Local Community W and Challenging Low Aspirations Adam is 12. He is a pupil at the Bishop’s Castle Community College. He is not academic and finds some subjects a challenge. This used to cause him to be frustrated and disruptive in lessons, resulting in a suspension from school on one occasion last year. However, the school’s Social Prescribing Link Worker intervened to help address why Adam was unhappy. She discovered that while Adam saw little value in academic subjects, he was in fact passionate about dance and music. As Link Worker she was able to arrange for Adam to join the ‘Youth Music Project’ which was funded through the Children and Young People’s Social Prescribing Service. The project hosts a Youth Open Mic twice a month in ‘The Underground’, part of the Thrive Lounge Community Hub. The Project also has its own section on the BCIRCLR platform where Adam uploads his recorded music and networks with other musicians online. Adam has become a keen member of the project, which is helping him to learn to play electric guitar and how to use a DJ mixing desk. Last month, the project arranged a visit to a professional recording studio in Birmingham where some of Adam’s favourite dance tracks were recorded. Joining the project has given Adam new purpose and enthusiasm. He now understands that it is possible for him to aim for a career in the music industry. But to do so he needs to do well at school and gain the appropriate qualifications so that he can gain a place on a Music Production course at a college. The Youth Music Project owes much to a similar project started 20 years ago to develop and support youth music groups here. It has engaged many young people, providing them with a reason to stay in the Town or to return there to live, following university studies. It is one of the reasons why Bishop’s Castle has such a rich reputation for music. A sustainable community is one that is outward-looking, with a willingness to learn from other communities. Fostering links and networking spreads existing good practices and challenges esoteric and narrow ideologies by raising expectations.

Promoting Digital Transformation John is 22. He is a young farmer having been brought up on his parent’s farm just outside Bishop’s Castle. He attended the Community College and has never been far from the local area. In recent years John has had mental health issues. Living and working full-time on a remote farm has meant that his social life has been limited. He finds it hard to make friends and is quite isolated. Last year John had a mental health crisis. He had nobody to talk to. Luckily, he had picked up a beermat in the Kings Arms pub which advertised the BCIRCLR

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Fig. 7.8  The BCIRCLR Platform – In Crisis Urgent Help. (After BCIRCLR with permission from Authors)

crisis support website. When he accessed this, he was able to click the ‘I’m in Crisis’ button which signposted him to a number of support options for urgent help. He was able to contact ‘Shropshire Rural Support’ – a service designed to help local rural farmers with issues such as his. He also made use of ‘Togetherall’ – a service free to Shropshire residents where members can support one another online (Fig. 7.8). The BCIRCLR Crisis Support website is promoted by the local Medical Practice, Community College, local mental health counsellors and the Samaritans charity. It came about as a result of the CHASE model project 10 years ago, which identified the serious problem of young male suicides in Bishop’s Castle  – 11 young male suicides in 11 years. One of the health promotion messages and resources created by the nurse learners to improve the health outcomes for young males is shown in Fig. 7.9 and this was further built (note image of the brain) with the creation of the Community Moodle platform in Fig. 7.10. As a direct outcome of the CHASE model, the Community Partnership bid for and won a grant from the ‘Cameron Grant Memorial Trust’ to ‘encourage innovative ways to support individuals suffering from poor mental health’. The Trust’s objectives are ‘to raise awareness of suicide, to urge all who are suffering in silence to speak up and ask for help, and to support people, especially young people, who are fighting to overcome poor mental health’.

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Fig. 7.9  Health promotion resource – poster mental health support. (Produced by Restieaux et al. (2020) with permission from the Authors)

Fig. 7.10  Health promotion resource – community moodle platform. (Produced by Krueger et al. [2021] with permission from the Authors)

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BCIRCLR is a Moodle platform freely accessible to our whole community, to promote awareness of mental health and be a bridging tool to combat loneliness, social isolation and suicide. It has two key functions: • To provide information, support and resources to support mental health in the community • To promote positive mental health and well-being by support people to participate in a wide range of community projects and activities (a social prescribing model) Through the online BCIRCLR platform John found out about the ‘Invisible Illnesses’ self-help support group hosted by the Thrive Lounge and finds the group very valuable. He is free to speak his mind knowing that whatever he says will be treated in confidence. The Invisible Illnesses group has a secure online forum too, which is vital to John as it is difficult for him to attend face-to-face sessions due to commitments on the farm. BCIRCLR aims to: • • • • • • • •

Promote awareness of and destigmatise Mental Health Promote self-esteem and empowerment Combat loneliness and social isolation in the community Promote team building and networking Engage people pro-actively to help with community development Enhance individual learning development Showcase community knowledge and share ideas Become a positive influence on our community culture

Back in 2025, the UK replaced its copper telephony system with fibre as part of the ‘Digital Voice’ initiative. The Bishop’s Castle Community Partnership supported the roll-out of a Gigabit fibre network facilitating the use of government vouchers to pay for installation costs. This investment in digital technology has resulted in significant benefits for both the economy and the community health and well-being of the Town. It has enabled many townsfolk to work from home and has done much to make Bishop’s Castle less remote by being more connected. Bishop’s Castle is now classified as a ‘Smart Village’ (European Commission, 2018) – a rural area where traditional and new networks and services are enhanced by means of digital telecommunication technologies, innovation and the better use of knowledge. Here digital technologies improve economic activity and the quality of life, accessing knowledge and markets previously only available to urban areas.

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 inding Local Solutions to Public Funding Cuts F and the Centralisation of Public Services Anne is 62. She regards herself as a community activist. Bishop’s Castle has a reputation of being pro-active, creative and taking control of its own services and Anne has been at the vanguard of many such initiatives. As a remote, rural settlement, local and national government economic cuts have been a fact of life here for decades. Too often, service provision designed for urban areas is not appropriate or affordable for rural communities. Anne and her fellow community activists believe that a ‘place-based’ approach to rural policies and services is essential here. An empowered rural community has the best understanding of what services it needs and is best suited to deliver this through community-led actions and projects. Anne calls this process ‘de-colonisation’. The Bishop’s Castle Town Council took control of local housing development when it wrote its ‘Neighbourhood Plan’. Beforehand, the choice of site and mix of housing tenure were the decision of the County Council. Now the community has the responsibility of determining where new housing should be sited and how much of it should be for rent and affordable. This is a big responsibility for the community but has resulted in development that better meets local needs and is more democratic as the community now owns the decisions made. Anne remembers the time when Bishop’s Castle’s Public Library was threatened with closure. Then, the Town’s own Enterprise Company took control of it from Shropshire Council through a Community Asset Transfer. It now runs the library, directly employing its own staff. The same is true for both the theatre and leisure centre which are both thriving through local control. As a member of the Bishop’s Castle Community Partnership, Anne has helped to instigate a number of projects where local people take responsibility for their own community – for example: • ‘Fight the Plastics’ – a campaign to tackle the problem of wasteful and unsustainable single-use plastics • ‘Food Waste’  – where surplus local supermarket food is redistributed to the ‘Meals on Wheels’ service and the local college canteen • ‘Bishop’s Castle Climate and Ecological Plan’– adopted by the Town Council • ‘Bishop’s Castle Food Resilience Strategy’ – adopted by the Town Council • ‘Bishop’s Castle Community Wind Turbine and Heat-Network’  – a project to provide energy to heat homes sustainably and affordably Anne has been an active member of Bishop’s Castle environmental projects, in particular, the establishment of the Bishop’s Castle Seedbank and the ‘Go Wild in BC’ project  – which has successfully helped to ‘green’ the Town and encourage biodiversity by encouraging planting trees, hedgerows, herbs, shrubs, ponds, and nest boxes. However, she remembers the time when the Partnership was low on members. The responsibility for establishing all these new projects fell heavily on her and a few others. Anne and her fellow activists took the initiative to publicise the

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Fig. 7.11  Bishop’s Castle Town. (Produced by Whiddon with permission from Authors)

work of the Partnership in the community and campaigned for new recruits as part of a succession plan. As a result, the work has been shared by many more people and the pressures and potential burn-out of individuals has been reduced. As a project leader she has made full use of the town-wide online events calendar on BCIRCLR to help organise teams of volunteers to take part in environment activities. One of the aims of BCIRCLR is to encourage community members to join such activities as a way of boosting their mental well-being. The Bishop’s Castle Community Partnership’s aim has been to empower the community to come together to recognise potential threats in the belief that community action is the best way to lead to change and improve outcomes for individuals (Fig. 7.11).

Learning from and Contributing to Thriving Communities Kiri, a final-year nursing student, has just completed a rural community healthcare project for the Bishop’s Castle community in rural Shropshire. The nurse learners’ team is distributed internationally and so worked remotely. The team includes Indigenous learners who were particularly keen to explore the ‘darker side’ of Bishop Castle’s celebrated elephant history involving colonisation in India. While some of the learners were final-year nursing students, the cross-disciplinary group

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included social services learners, planners and business students. One of the nursing learners was already in practice, completing their degree through an apprentice pathway. In addition to the supervising registered nurse (RN), the team also benefited from the advice of a nursing graduate as a professional mentor. Their advice was really useful in framing the project in terms of the implications of their learning for their professional framework of practice. The team also considered the AI to be a team member rather than just a tool. The AI was able to produce a draft report within hours of the start of the project giving an early insight for the team and the community of the likely direction of the project. Another innovation of recent years is the rolling cohort approach; some of the teams were in their first and second years and would revisit this project in subsequent years, meaning a longer-term relationship could be established. These things combined to mean the community and learners could work together on initiatives that would have a greater impact, using Donella Meadows’ leverage approach (Meadows, 1999). The project linked in with the 500-year celebration of several of the buildings in Bishop’s Castle and took the opportunity for a retrospective look at the progress of the past decade of the CHASE model projects. They observed how the projects were taking place in an increasingly volatile, uncertain, complex and ambiguous environments (VUCA) (Bennis & Nanus, 1986; Stein, 2021), and by taking the CHASE model 2033s wicked problem framing (Rittel & Webber, 1973), the team was not expected to ‘solve a problem’ but to nurture positive things that were happening in the community using a strengths-based approach (Bryant et al., 2021). So, the team worked with the community to organise a celebration of Bishops’ Castle in which activities were developed to engage the community in designing the future of rural health care. The goals of ‘thriving people, healthy communities’ were explored by the community, not just in public meetings, but in plays, music, public artworks (based on a reinterpretation of the elephant history) and even a family sports event. These activities confirmed the long-term community goals of: • Community capacity-building and empowerment • Promoting digital transformation • Finding local solutions to ongoing public funding cuts and the centralisation of public services From these activities the community and student partnership identified the objectives for the community  – and CHASE 2033  – to explore demand-driven ‘High Street Healthcare’, finding ways of enhancing virtual care platforms (while recognising that a techno-utopia is unrealistic so needs graceful failure), and hyper-local care  – community-controlled healthcare  – based on the social-determinants of health. Kiri is part of the changes in education which has embraced technology. Education is community-led with community stakeholders being active contributors to all community development projects. Learners continue to work collaboratively and embrace a multidisciplinary approach as they proceed with the community development projects. Teachers continue in their facilitative capacity. Knowledge

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and resources are shared amongst learners and community stakeholders applying information ‘in place’, referred to as applied knowledge.

CHASE Lecturer End of Course Reflection 2033 Wow, what a year that was! We have facilitated numerous community development projects in 10 different countries. However, I am going to focus on the Bishop’s Castle project because it exemplifies the changes, we are currently seeing across rural community health. It was great to have the community and learners use the celebrations of some of Bishop’s Castle’s buildings to look back on the last 10 or so years of the CHASE model in the community, but also to use this as a springboard for the next phases of CHASE. What has happened in these past years since CHASE first visited Bishop’s Castle is likened to a mirror that has been turned on itself where the community has become the hub of all healthcare. Bishop’s Castle community in 2022 engaged with the CHASE model to complete a community development project in which nurse learners were encouraged to reflect on the previous work undertaken by nurse learners during 2020 and 2021. Having worked continuously with this community between 2020 and 2022, nurse learners focused on the principles of the Ottawa Charter for Health Promotion (World Health Organisation [WHO], 1986) can enhance, empower, strengthen and re-orientate a community, based on the information gathered. Nurse learners in 2022 found the Bishop’s Castle community had numerous positive assets including community strengths which could be further enhanced. This led to the learners and community developing a strategic direction for the community for 2023-2027 (Fig. 7.12) that could improve the health of the individuals while embedding the principles of the Ottawa Charter (WHO, 1986). The goal then was to enable, advocate and mediate community development to improve healthcare, including strengthening the community, re-orientating health services, building healthy public policy, creating supportive environments, strengthening community action and developing personal skills. The learners in 2033 are able to use the Ottawa Charter to reassess this progress but also to reset with a broader holistic approach. This community is central to its future health. Proud to be a part of the community development project, Kiri and her teammates feel that, given the longstanding issues, they now realise the importance of the development of a Community Hub as an asset for this community and how it has been such an important struggle and returning theme for the CHASE projects. Perhaps for next year we need to develop two versions of CHASE, one for long-­ term recurring projects such as Bishop’s Castle, and another for new geographical locations for CHASE. While these new areas are fresh for CHASE and thus require a focus on relationship building and orientation, we must not lose sight of factors that these communities have long-established histories – they are not ‘greenfields’. Geographic Classification for Health (GCH) (Whitehead et al., 2022) has brought together a multidisciplinary approach to rural understanding while breaking barriers

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Fig. 7.12  Health promotion resource – community-led plan. (Produced by Miller, et al. [2022] with permission from the Authors)

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between the urban and rural. The GCH provided a reset on rurality. The articulated differences between rural and urban communities, geographical boundaries, rural definitions, funding structures and access to healthcare are now embedded in CHASE. Even the multidisciplinary approach of GCH is now reflected in community development and the CHASE teams. Through a retrospective and visioning project, this year's learners have gained insight into the evolution of community healthcare. They have observed a shift from a reductionist paradigm to a more holistic approach, which incorporates a sustainability focus on planet health, community health and individual health. This natural progression aligns with climate action, community development and the United Nations' 17 Sustainable Goals, and is consistent with the social model of health. Adopting a holistic, sustainable approach to community development and well-­ being is critical to advancing society in the 2030s, encompassing sustainable, educational, socio-ecological, political, economic and cultural aspects of healthcare. A restructuring of the CHASE process now spans across the three-year undergraduate curriculum, with an introduction to the model in first year of the Bachelor of Nursing (BN) programme while joining with an identified rural community, Pacific Nation or Island community. Community connection in this way assists learners to build a relationship together with the community, establishing a therapeutic working relationship with this identified community. Ethical considerations are considered in this initial engagement including the development of a Memorandum of Understanding between Aotearoa New Zealand educational organisation and the community stakeholders in Bishop’s Castle. The aim being to specifically outline expectations from the community with the capacity of the learners to engage in meeting mutually agreed specific indicators for community health in alignment with community needs. There is time allocated for relationship building and connection between the team of learners to form a community of practice together. In the second year, continued engagement between the same group of learners and the same community is maintained to establish identifying health disparities amongst population and Indigenous groups. This leads learners onto considering the community as a system. This relational approach engages learners from numerous disciplines to work collegially together and alongside the community stakeholders. Facilitators of education are now embedded within the rural community, and this is the model which has developed specifically in Bishop’s Castle. Such ‘educational facilitators’ are aware of the diversity of learners and the diversity of learning styles. This has been taken into consideration as facilitators have transformed learning opportunities and included holistic models that are applied in practice, alongside and with communities who welcome educational institutions into their community. In the third year of the BN programme, the educators/facilitators are no longer expected to be bound to the classroom, the community is the ‘living lab’ (Circ4life, n.d.) emphasising the way forward and working collaboratively with communities. Education is community-driven and can be led by the identified communities’ requirements. Learning continues to be aligned with virtual technology to assist in

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Fig. 7.13  CHASE 2033. (Produced by Ross, Mann and Whiddon with permission from the Authors)

learning as learners work together in teams. Learners are mentored by experienced graduates from traditional educational programmes in community development related to health. Learners are further engaging with multidisciplinary teams for the improvement of community action, climate action, sustainable education and sustainable healthcare. Learners are part of a model of community health which improving health disparities, health inequities and the social determinants of health. Equality has improved which meets the UN 17 Sustainable Goals, for example the improvement of gender conflicts, peace, children and poverty, food security, improved water and sanitation, education and violence has decreased, improved health and well-being, availability of work and industry and infrastructure. A significant focus on the health of the planet has improved life on the land and below the water, climate action and responsible consumption. These goals are encouraging community development practitioners from all facets of traditional disciplines to work together and improve the health of the community, the health of the residents, the tourists, the visitors and the health of the planet. As 2033 ends Sam, Keith and Jean invite you to collaborate on your experience of engaging with CHASE and your work related to community development. They invite you to the hybrid symposium where you will be welcomed as CHASE Fellows. At this symposium they will present the poster, exhibited in Fig. 7.13. Acknowledgements Keith Whiddon would like to thank the members of the Bishop’s Castle Community Partnership, as well as the core team involved in the CHASE study (2020-2022) with Aotearoa New Zealand learners; Valerie Woodmansey; Bishop’s Castle Community Partnership; Dr Tom Davies; Daphne Page; Bernard Edwards; Dr Adrian Penney; Kyla Richards and Hope Robson.

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References Bennis, W. G., & Nanus, B. (1986). Leaders: The strategies for taking charge. Harper & Row. Bishop’s Castle Climate & Ecological Plan. https://lightfootenterprises.org/bishops-­castle-­cap/ Bishop’s Castle Community Wind Turbine and Heat-Network. https://lightfootenterprises.org/ climate-­action/ Bishop’s Castle Food Resilience Strategy. https://bishopscastletowncouncil.gov.uk/wp-­content/ uploads/2023/01/BC-­FOOD-­POLICY-­22-­Edit-­DDC.pdf Bishop’s Castle Michaelmas Fair. http://www.michaelmasfair.org.uk/ Bryant, J., Bolt, R., Botfield, J. R., Martin, K., Doyle, M., Murphy, D., Graham, S., Newman, C. E., Bell, S., & Treloar, C. (2021). Beyond deficit: ‘strengths-based approaches’ in Indigenous health research. Sociology of Health & Illness, 43(6), 1405–1421. Circ4life. (n.d.). A circular economy approach for lifecycles of products and services. https://www. circ4life.eu/what-­are-­living-­labs European Commission. (2018). Smart villages: Revitalising rural services through social and digital innovation. https://enrd.ec.europa.eu/sites/enrd/files/tg_smart-­villages_leaflet.pdf Krueger, T., Caderas, K., Chote, L., Dobbs, G., Dunford, N., Fairbairn, S., Gallacher, J., Woodward, I., & Ross, J. (2021). Sustainable rural futures: A perspective on the mental well-being of residents from Bishop’s Castle post COVID-19. Report available from the community and School of Nursing, Otago Polytechnic, Dunedin. Mann, S., Mitchell, R., Eden-Mann, P., Hursthouse, D., Karetai, M., O’Brien, R., & Osborne, P. (2022). Educational design fictions: Imagining learning futures. In K.  MacCallum & D.  Parsons (Eds.), Industry practices, processes and techniques adopted in education: Supporting innovative teaching and learning practice (pp. 303–326). Springer Nature. https:// doi.org/10.1007/978-­981-­19-­3517-­6_15 Meadows, D. H. (1999). Leverage points: Places to intervene in a system. Solutions, 1, 41–49. Miller, A., Kain, B., MacDonald, H., Koch, H., Tiu, J., O’Brien, L., Lawson, O., King, S., Matthews, T., & Ross, J. (2022). Sustainable rural futures: A health perspective on Bishop’s Castle community and youth. Report available from the community and School of Nursing, Otago Polytechnic, Dunedin. Restieaux, P., Norgate, A., Lyttle, C., Anderson, C., Monaghan, J., Baxter, J., Gonsalves, L., Gray, N., Thompson, S., Hooker, S., Stanton, T., Gartner, T., & Ross, J. (2020). Sustainable rural futures – A health perspective on Bishop’s Castle. Report available from the community and School of Nursing, Otago Polytechnic, Dunedin. Rittel, H. W., & Webber, M. M. (1973). Dilemmas in a general theory of planning. Policy Sciences, 4(2), 155–169. Ross, J., Crawley, J., & Mahoney, L. (2017). Sustainable community development: Student nurses making a difference. Scope Contemporary Research Topics: Learning and Teaching, 4, 8–17. www.thescopes.org Shropshire Rural Support. https://shropshireruralsupport.org.uk/ Social Prescribing, NHS England. https://www.england.nhs.uk/personalisedcare/social-­prescribing/ Stein, S. (2021). Reimagining global citizenship education for a volatile, uncertain, complex, and ambiguous (VUCA) world. Globalisation, Societies and Education, 19(4), 482–495. The Bishop’s Castle Community Partnership. https://bishopscastletowncouncil.gov.uk/ about-­the-­community-­partnership/ The Bishop’s Castle Interactive Rural Community Learning Resource (BCIRCLR). www.bishopscastlecommunity.org.uk The Cameron Grant Memorial Trust. https://www.camgrant.org.uk/ The Global Ecotourism Network. (2016). What is ecotourism? https://www.globalecotourismnetwork.org/what-­it-­is-­not-­ecotourism/ The Poetry Pharmacy. https://www.poetrypharmacy.co.uk/ Togetherall. https://account.v2.togetherall.com/

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What is Social Prescribing? The King’s Fund. https://www.kingsfund.org.uk/publications/ social-­prescribing Whitehead, J., Davie, G., de Graaf, B., Crengle, S., Fearnley, D., Smith, M., Lawrenson, R., & Nixon, G. (2022). Defining rural in Aotearoa New Zealand: A novel geographic classification for health purposes. The New Zealand Medical Journal, 135(1559), 22–38. World Health Organization. (1986). The Ottawa Charter for health promotion https://www.who. int/healthpromotion/conferences/previous/ottawa/en/

Index

A Assessment, 22, 23, 26–28, 30, 32–36, 39–41, 44, 46, 52, 54, 57, 59, 62, 73, 74, 95–97, 99, 105, 107, 114, 120, 121, 123, 142, 161, 163, 164, 167, 174, 182, 188–192, 198 C CHASE model, 11, 13, 15, 22–62, 68, 70, 72–76, 93–96, 101, 104–109, 114–116, 118–121, 125, 127, 128, 132–134, 139, 140, 143, 144, 161, 163–164, 167, 169, 173, 174, 176, 182–186, 190, 191, 193, 196, 198–202, 208, 212, 214–218, 220, 223, 228, 229 Classifications, 7–11 Community, 2, 22, 68, 114, 150, 182, 212 D Decolonisation, 15, 159–161, 202, 226 Design, 2, 13, 26, 50, 59, 62, 68–109, 115, 118, 128, 132, 139, 153, 154, 159, 169, 184, 203, 212 Disparities, 6, 11–13, 15, 22, 24, 26, 28, 39–41, 50, 60, 62, 69, 70, 72, 73, 93, 104, 105, 107, 108, 123, 125, 132, 133, 135, 144, 168, 173, 174, 176, 183, 186, 187, 199, 202, 231, 232

E Education, 11, 13, 22–24, 27–30, 32, 45, 47, 50, 69, 70, 104, 105, 114–118, 135, 137, 139, 140, 142–144, 154, 156, 158–160, 162, 171, 174–176, 182, 184, 186, 188, 195, 196, 198–201, 203, 207, 208, 212, 217, 228, 231, 232 Evaluation, 15, 27, 28, 33, 34, 38, 50, 60, 62, 94, 95, 120, 134, 140, 182–208 F Future, 13, 15, 99, 139, 142, 156, 160, 191, 204, 207, 212–232 G Global, 2, 11–13, 22–24, 28, 32, 34, 62, 70, 75, 126, 134–137, 139, 140, 143, 154, 184, 187, 218 H Health, 2, 22, 68, 114, 151, 182, 214 I Impact, 9, 11, 13, 15, 28, 29, 33, 35, 36, 38–41, 50–52, 59–62, 69, 73, 94, 95, 104, 105, 120–122, 126–127, 132–139, 142, 143, 154, 155, 158, 159, 168, 173–176, 182–208, 221, 228

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. Ross et al. (eds.), Rural Landscapes of Community Health, Global Perspectives on Health Geography, https://doi.org/10.1007/978-3-031-43201-9

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236 Indigenous, 2, 11, 15, 23–25, 29, 30, 32, 33, 74, 105, 144, 150, 155, 157, 159–162, 173, 186, 187, 198, 227, 231 Inequities, 23–25, 34, 51, 60, 69, 76, 106, 133, 153, 154, 156, 158, 161, 173, 187, 199, 204, 232 L Learner, 26, 28, 33, 35, 39, 132, 140, 141, 143, 144, 182, 190, 191, 203, 212

Index Populations, 2, 5–13, 15, 22, 24–27, 30–33, 36, 40, 41, 46–48, 50, 51, 56–60, 62, 68–70, 72–76, 78, 93, 98, 99, 101, 105–108, 114, 121–128, 132, 133, 135, 137, 140, 143, 144, 159, 161, 163, 166–169, 171–175, 187, 188, 192, 194, 198, 200–202, 207, 215, 231

N Narrative, 7, 150, 183, 212 Nurses, 12, 13, 22–27, 33, 34, 41, 52, 62, 68–70, 73, 76, 95, 105–108, 116, 139, 143, 150, 157, 158, 160, 161, 169, 174, 176, 183, 189, 199, 200, 203, 205–207 Nursing, 7, 12, 13, 22–24, 26, 27, 29, 33, 34, 50, 51, 69, 70, 73, 76, 94, 104, 106–108, 114–116, 133, 139, 140, 142–144, 159–162, 182–193, 195, 196, 198, 203–208, 212, 214, 219, 227, 228, 231

R Reflections, 40, 50, 52, 62, 104–108, 114, 115, 132, 139, 144, 150, 157–162, 173, 174, 176, 183, 187, 189–193, 202, 203, 205–207, 214, 229–232 Resources, 2, 6, 9, 12, 13, 15, 23, 26, 27, 30, 32–34, 36, 38, 39, 41, 47–50, 58–60, 62, 68–109, 114, 117, 121, 123–132, 134, 135, 137, 138, 142–144, 154, 155, 165, 167–176, 182, 184, 186–192, 195–197, 199–202, 204, 206, 215, 218, 221, 223–225, 229, 230 Rural, 2, 22, 73, 114, 158, 182, 212

P Pedagogies, 13, 15, 50, 60, 94, 104, 108, 109, 114, 115, 121, 132, 139–144, 173, 202

S System thinking, 68, 69, 72, 73, 107, 108, 182, 189, 198–202