Community Nurses’ Perceptions of Their Role as Health Promoters in Collective Prevention: A Qualitative Study in Dutch Community Nursing Care

Prevention

CNs gave a wide range of answers and definitions to the research team when they were asked to describe the term “prevention.” What we observed was that in the first round of focus groups, the term “avert” was used by most participants to describe prevention. With aversion, they meant that they would prevent any potential negative health outcomes. In their descriptions, they mentioned separate phases to prevent adverse health outcomes, to avoid becoming more ill, and to avoid side effects of disease. For instance, pressure ulcers or the risk of getting a disease, such as diabetes. One CN said that prevention is a way of averting and explained the following: “Yes, physical activity, smoking, alcohol, nutrition, and relaxation. For me, those are the traditional prevention topics.” (Participant 46, DN, phase 1 – exploring).

Individual and Collective Prevention

In our analysis, we noticed that CNs initially used common descriptions for prevention that aligned with individual prevention interventions. However, over the course of the research, we observed a shift towards a more group-based approach, looking at common problems or shared risks on a group level and using collective-based interventions. In the first round of focus groups, most CNs explained the term “prevention” in terms of individual prevention, referring to the prevention they do in their daily work when they visit clients at home. They describe prevention as making sure that someone is not becoming more ill or deteriorating due to the consequences of the disease.

It is not always easy. But I do try to bring up prevention early in conversations. For instance, if someone is very short of breath, you might adjust their medication, but at the same time, I explain why it is important to stay active, to keep the circulation going. I always try to weave that into the discussion. (Participant 67, NP, phase 2 – deepening).

What we found is that CNs describe prevention as something they just do. It is a routine intervention applied with clients, carried out automatically, without much conscious reflection. For instance, they may place an anti-decubitus cushion for someone developing early pressure ulcers.

And I find it truly important (and genuinely fulfilling) to feel that I’m not just dealing with symptoms, so to speak, but that I’m also working on the other side, actively preventing things from happening. That gives me a very rewarding feeling. (Participant 44, DN, phase 1 – exploring).

In the second round of focus groups, the participants described prevention more in terms of focussing on group risks in the community, in line with common conceptualisations of collective prevention. Especially the CNs who participated in the research project developed a different understanding of the term “prevention” over time. They explain that prevention can be something carried out collectively within a neighbourhood. “Doing it together” is frequently mentioned in these second focus groups, in contrast to the first round when it was rarely mentioned. CNs describe how joint activities such as walking groups or lifestyle groups bring people together to engage in health-promoting practices instead of them personally visiting and advising individuals. The participating CNs describe that these activities are ideally continued by community members themselves, sometimes with the support of local volunteers. Many such activities have a dual purpose that CNs consider strengthens their effectiveness: for instance, combining physical activity with a social element, such as sharing coffee afterwards, thus addressing both physical and social well-being.

Collective prevention is about connection, about social encounter. (Participant 39, DN, phase 2 – deepening).

Health Protection, Health Promotion, and Disease Prevention

CNs started to make a difference in the description of prevention and redefine it over the course of the project. Their understanding came to align more closely with the 3 forms of prevention as described in the literature, namely health protection, health promotion, and disease prevention. CNs describe health protection from a more strategic, population-level perspective to address recurring health issues within a neighbourhood. By identifying patterns among clients living in the same area; such as frequent addiction problems or social vulnerability, CNs working in collective prevention develop interventions that reach the wider community.

If you have many clients in the same neighbourhood, you can identify patterns and move from an individual to a group-level approach. But you need the right conditions: a strong community focus, good local network knowledge, and a clear map of the area and its people. (Participant 66, NP, Phase 2—deepening, April 2024).

Health promotion is seen as preventing disease, decreasing negative health outcomes when being ill, and providing lifestyle advice too. CNs also provide health promotion to caregivers, family members, and/or the client’s wider network. They also gave different examples of whom they give health promotion to. For example, for people with diabetes, they encourage community members to join walking groups to promote physical activity: “It is also a bit about how you think of yourself or how you approach life. For me, lifestyle is important. But you also want to convey that. In some way, when you are with clients and something comes up, you feel you can share [. . .] maybe eat a bit more of this or less of that or be more physically active (things like that) it makes a difference.” (Participant 42, intern/RN, phase 2 – deepening).

As CNs reflected on their evolving role as health promoters during the World Café workshop in phase 3, they expressed a growing awareness of prevention as a broader concept. It has become a new, collective vision. Many mentioned that through participating in collective prevention initiatives, they had begun to see their work in a new way.

As illustrated in Figure 1, they described this as “looking through different glasses.” This new perspective focuses on connection, empowerment, and a shared responsibility for health at a group-based level.

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Figure 1.

Phase 3 – validation, “Looking through other glasses.”

The Importance of Prevention

When reflecting on the importance of prevention, CNs emphasised that prevention is much more than just preventing illness. It contributes to the quality and meaning of life.

And of course, we applied for the duo bike subsidy together with a community member whose wife was disabled [. . .]. We made a health-promoting intervention, and one colleague went cycling with the community member. The person was absolutely delighted and feeling included. (Participant 58, DN, phase 1 – exploring).

CNs often emphasise prevention’s necessity for the future. They explain that the rising number of people living with chronic conditions who remain at home makes prevention essential. With this increase, CNs highlight prevention not only as necessary but also reiterate policy discourses in seeing prevention also to ease the growing pressure on healthcare professionals and resources:

Prevention is also about stopping people from getting sick in the first place. So many illnesses in the neighbourhood are lifestyle-related; they can be prevented, which means less care is needed. Right now, so many people already work in healthcare, and by 2040 it will have to be even more. That is simply not sustainable. So, prevention is also about making sure we do not collapse under the weight of it all; we need people to stay healthier and to live together differently. (Participant 44, DN, phase 1 – exploring).

In the end, you would have lower healthcare costs. If people stay healthy for longer, they visit the GP less and need fewer medicines, that is the idea behind it. (Participant 61, DN, phase 2 – deepening).

Detector

The prevention projects were initiated by CNs following a Buurtzorg-provided training session, which included both online and face-to-face workshops, 6 in the first 2 years, then 2 per year. CNs start prevention projects in the neighbourhood with identifying community issues. They begin by mapping out the health landscape of a neighbourhood. This involves both desk research using epidemiological data and direct interaction with community members. Essential parts of this approach are interviewing people at random in the neighbourhood and simply walking around to observe everyday life. The emphasis lies on listening, watching, and identifying what might otherwise remain unnoticed and may not be identified through structured questionnaires. The detector role in collective prevention has a group-based approach. A CN scouts for underlying social, health, and other common problems or shared risks that affect community members who are not yet receiving community care.

Indeed, we conducted research in the community to understand the wishes and needs of local residents. Students helped to complete a large number of questionnaires. (Participant 58, DN, phase 1 – exploring).

Participants identified observational skills as indispensable competencies for their proactive role as scout. One CN metaphorically described this as “peeking” into the lives of residents; not intrusively, but with a sense of social awareness and concern to understand the lives of their community members:

For instance, a house that appears somewhat neglected. Who lives there now? And can we make a difference if you step inside? Literally peeking. Not peeking into their care but peeking into the overview [of their life]. Are there children? How large is the network? (Participant 47, RN, phase 1 – exploring).

Most CNs described the need to be proactive in individual and collective prevention. CNs stress the value of early identification of risk, underlining the benefits of a proactive rather than reactive approach.

After 1.5 years, we indeed have fewer crises to manage, because we have mapped out all older adults. We can identify risks earlier. (Participant 64, NP, phase 2 – deepening).

And identifying needs for prevention is not only for a client; it can also be given to a caregiver. One CN explained what she did as prevention for a caregiver: “I have been working on this for years now, and as a CN, I see severely overburdened informal caregivers. I make them aware and try to protect them from the big pitfalls ahead [. . .]. So, I involve the carer in our collective project early on.” (Participant 58, DN, phase 1 – exploring).

Finally, CNs emphasised that working with a holistic approach is important in collective prevention. Recognising the uniqueness of each context, they stressed the need to respond to people’s actual needs rather than rely on standardised solutions.

Motivator

CNs noted their responsibilities in individual prevention by stimulating individual behaviour change through home visits and lifestyle advice and in collective prevention by promoting participation in activities. In this context, the role of motivator goes beyond traditional motivational interviewing with a client. It involves a group-based approach by inspiring community members to participate in collective prevention initiatives and programmes. More specifically, NPs described that they transform initiatives to programmes. One NP shared an example.

You might say, ‘In this neighbourhood, we have noticed that alcohol problems play a significant role, along with loneliness. Shall we set something up to address that?’ We also organise a community lunch, where a large table is set up, and everyone is welcome to join. (Participant 67, NP, phase 2 – deepening).

CNs described their role as motivators, not only in relation to community members but also in reaching out to other key stakeholders in the neighbourhood. They often acted as professional coaches or, as one metaphor suggested, as a “spider in the web.” In this role, they link individuals to other professionals and community services.

As shown in Figure 2, they also integrate all types of tasks in their daily work. They give advice, provide wound care and personal care, use clinical nursing skills, and engage socially. They have personal conversations, manage administration, and give attention to others, all of which are captured in this “spider in the web” visualisation.

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Figure 2.

Phase 3 – deepening, “Spider in the web.”

Facilitator

CNs often see themselves as connectors and bridge-builders, working across the boundaries of the medical, public health, and social care domains. As a facilitator, the CN’s expertise in both medical and social domains allows them to bridge the gap between medical nursing care and community development, translating complex health data into health and social interventions.

And at a certain point, we started making a lot of connections and thinking about how it could work. But you also notice that, through the contacts you build and by getting to know your neighbourhood well, you can sometimes also provide better care. This is because you have a clearer understanding of where someone can go with specific questions if you are aware of the available services. (Participant 44, DN, phase 1 – exploring).

CNs highlighted that they have dual expertise as nurses in a community, encompassing nursing, medical, and community care. This enables them to interpret public health data in ways that can be meaningful at the neighbourhood level, making practical interventions but also fostering collaboration between the various organisations active within the same community.

We also have knowledge of illness and health, which is more than what they [i.e., professionals from the social domain] have. We can, for example, see through research whether activities like exercise or sports can help prevent falls. They might know this as well, but we can complement that by sharing knowledge from the community with the social domain. So, I think you can complement each other, but I believe you do need each other. (Participant 68, NP, phase 2 – deepening).

Particularly NPs, among the CNs, emphasised their role as bridge-builders between the nursing and medical domains. In collective prevention they utilised this role in early detection but also in interprofessional collaboration with GPs and elderly care specialists.

Organiser

CNs described the need for collective prevention in the community and demonstrated many different competencies, such as taking initiative, creativity, and a keen eye for new opportunities. Through our observations, it became evident that many were well known locally, both by community members and by other (healthcare) professionals. They act autonomously and have an entrepreneurial spirit. The organiser role is shifting from organising nursing care to organising community initiatives.

Because that is sometimes the challenge in our conversations; getting people on our radar. So sometimes we simply take the initiative and walk in somewhere ourselves. [. . .] And that’s how it goes. (Participant 30, DN, phase 2 – deepening).

They also emphasised the importance of perseverance. Working in prevention takes commitment; setbacks are common, progress may be slow, and sustaining enthusiasm over time is essential.

We went to the municipality, and we are working on community living, but of course, that takes a long time. [. . .] And that, in turn, affects your own enthusiasm. And it is also about yourself. Of course, you know it’s a long-term effort. (Participant 51, DN, phase 2 – deepening).

CNs also reported that they often initiate and organise projects. This involves translating ideas into actionable steps, arranging funding, and bringing people together.

In the early stages of our project, people in a group said, ‘We’d like more connection in our communities. . . like creating a hangout spot for older people.’ [. . .] So, behind the scenes, we took it on ourselves. (Participant 6, DN, phase 2 – deepening).

NPs described a leadership role in initiating and sustaining preventive programmes. One NP shared an example of joining a fall-prevention initiative and transforming it from a general screening to a more comprehensive programme involving medical assessment, advice, and community care:

There was a fitness test day where seniors could assess their vitality, but no healthcare professionals were involved, so no one mentioned fall risk or high blood pressure. Last year, we added a preventive screening, and it reached a wide audience. It was really successful. That’s what we can do; bring in that broader picture and build that bridge between prevention and medical care. (Participant 66, NP, phase 2 – deepening).

Furthermore, they acted as coaches within community projects, encouraging local ownership and gradually stepping back when appropriate. The aim is not to control but to enable and facilitate.

Our senior fitness group is actually running really well. They are now doing everything themselves, and we do not really get involved anymore. . . (Participant 24, RN, phase 1 – exploration).

At the same time, the CNs underscored their responsibility to initiate meaningful conversations about prevention and explain the vision, even when met with hesitation or resistance from colleagues.

A summary of the different roles and competencies is shown in Figure 3.

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Figure 3.

Summary of the roles and competencies of CNs in collective prevention.

Facilitators

Barriers

Time and Workload

The urgent and complex needs of clients often take precedence, leaving little room for preventive initiatives. This challenge was even more present when team members were absent, forcing fewer CNs to manage the same workload. Under such types of conditions, the capacity to invest in collective prevention is, in fact, minimised: time. “That plays a very big role. We even reached the point where we thought, can we even continue like this?” (Participant 24, RN, phase 1 – exploring). Figure 4 illustrates how important CNs find time and the lack of time to work in collective prevention initiatives.

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Figure 4.

Phase 3 – validation, “time pressure.”