COMMUNITY HEALTH NURSING PROCESS

I. LEARNING OBJECTIVITIES

After completion of this report, the reader will be able to:

 Discuss the basic concepts in community health nursing process.

 Discuss the basic principles in community health nursing and to relate
them on present community health setting.
 Discuss the context of primary health care and its importance to
clientele.
 Identify and differentiate community clients to be provided with nursing
care.
 Classify the types of communities and to identify and enumerate the
factors affecting community health.
 Recognize the vital role of the application of the process of community
assessment or community diagnosing.

II. INTRODUCTION

Changing demographics, changing disease patterns, an increase in

chronic illnesses resulting in underestimated health-care expenditure, a reform in
the health financing system, and a renewed focus on health promotion open up
new opportunities for providing community-based care in community settings.
Health care in the context of the community represents an alternative mode of
health-care delivery. Emphasis is placed on promoting health and access to care
by addressing the health-care needs of people where they live and work.

Moreover, local community needs, resources and preferences of the

people drive community health services. In any country, the health
services/family health/disease prevention and health promotion provided to the
community are delivered through the available community health service system.

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 Principles, theories, and concepts of community health nursing are utilized
to generate an understanding of the roles and functions of community health
nurses. Therapeutic communication, group process theory and its application to
practice are included. Special focus is given to the nursing process and nursing
roles needed to promote system stability and maximum functional status of
individuals across the lifespan, families, groups, aggregates, and community.

III. DISCUSSION

Community health nursing is a unique division of health care in that its

focus is on populations rather than individuals. In this way, a nurse develops an
awareness of health risks in her clients by assessing those of the community as
a whole. Beddome, Clarke, and Whyte (1993) state that "health cannot be viewed
in isolation from the social, political, and physical environments that people live.
Rather, a health care provider must consider many factors that influence the
health of a client "such as housing, literacy, nutrition, child care and employment”.

Community Health Nursing (CHN) is a vital part of Public Health and there are 12
PRINCIPLES the govern CHN.

1. The recognized need of individuals, families and communities provides the

basis for CHN practice. Its primary purpose is to further apply public health
measures within the framework of the total CHN effort.

2. Knowledge and understanding of the objectives and policies of the agency

facilities goal achievement. The mission statement commits Community
Health Nurses to positively actualize their service to this end.

3. CHN considers the family as the unit of service. Its level of functioning is

influenced by the degree to which it can deal with its own problems. Therefore
the family is an effective and available channel for the most of the CHN
efforts.
4. Respect for the values, customs and beliefs of the clients contribute to the
effectiveness of care to the client. CHN services must be available

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 sustainable and affordable to all regardless of race, creed, and color or socio-
economic status.

5. CHN integrated health education and counseling as vital parts of

functions. These encourage and support community efforts in the discussion
of issues to improve the people’s health.

6. Collaborative work relationships with the co-workers and members of the

health team facilities accomplishments of goals. Each member is helped to
see how his/her work benefits the whole enterprise.

7. Periodic and continuing evaluation provides the means for assessing the
degree to which CHN goals and objectives are being attained. Clients are
involved in the appraisal of their health program through consultations,
observations and accurate recording.

8. Continuing staff education program quality services to client and are essential
to upgrade and maintain sound nursing practices in their setting. Professional
interest and needs of Community Health Nurses are considered in planning
staff development programs of the agency.

9. Utilization of indigenous and existing community resources maximizing the

success of the efforts of the Community Health Nurses. The use of local
available ailments. Linkages with existing community resources, both public
and private, increase the awareness of what care they need what are entitled.

10. Active participation of the individual, family and community in planning and
making decisions for their health care needs, determine, to a large extent, the
success of the CHN programs. Organized community groups are encouraged
to participate in the activities that will meet community needs and interests.

11. Supervision of nursing services by qualified by CHN personnel provides

guidance and direction to the work to be done. Potentials of employees for
effective and efficient work are developed.

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12. Accurate recording and reporting serve as the basis for evaluation of the
progress of planned programs and activities and as a guide for the future
actions. Maintenance of accurate records is a vital responsibility of community
as these are utilized in studies and researches and as legal documents.

PRIMARY HEALTH CARE

Primary Health Care is essential health care based on practical,

scientifically sound and socially acceptable methods and technology made
universally, accessible to individuals and families in the community by means of
acceptable to them, through their full participation and at a cost that community
and country can afford to maintain at every stage of their development in the
spirit of self-reliance and self-determination. It forms an integral part of both the
country’s health system, of which it is the central function and the main focus and
of the overall social and economic development of the community.

PRINCIPLES AND STRATEGIES OF PHC:

1. Accessibility, Availability, Affordability and Acceptability of Health

Services
Strategies:
a. Health services delivered where the people are
b. Use of indigenous/resident volunteer health worker as a health care
provider with a ratio of one community health worker per 10-20
households
c. Use of traditional (herbal medicine) with essential drugs.

1. Provision of quality, basic and essential health services

Strategies:
a. Training design and curriculum based on community needs and priorities.
b. Attitudes, knowledge and skills developed are on promotive, preventive,
curative and rehabilitative health care.

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 c. Regular monitoring and periodic evaluation of community health workers
performance by the community and health staff.

2. Community Participation
Strategies:
a. Awareness, building and consciousness raising on health and health-
related issues.
b. Planning, implementation, monitoring and evaluation done through small
group meetings (10-20 households cluster)
c. Selection of community health workers by the community.
d. Formation of health committees.
e. Establishment of a community health organization at the parish or
municipal level.
f. Mass health campaigns and mobilization to combat health problems.

3. Self-reliance
Strategies:
a. Community generates support (cash, labor) for health programs.
b. Use of local resources (human, financial, material)
c. Training of community in leadership and management skills.
d. Incorporation of income generating projects, cooperatives and small scale
industries.

4. Recognition of interrelationship of health and development

Strategies:
a. Convergence of health, food, nutrition, water, sanitation and population
services.
b. Integration of PHC into national, regional, provincial, municipal and
barangay development plans.
c. Coordination of activities with economic planning, education, agriculture,
industry, housing, public works, communication and social services.
d. Establishment of an effective health referral system.

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5. Social Mobilization
Strategies
a. Establishment of an effective health referral system.
b. Multi-sectoral and interdisciplinary linkage.
c. Information, education, communication support using multi-media.
d. Collaboration between government and non-governmental organizations.

6. Decentralization
Strategies
a. Reallocation of budgetary resources.
b. Reorientation of health professional and PHC.
c. Advocacy for political and support from the national leadership down to the
barangay level.

8. Essential Health Services in Primary Health Care (ELEMENTS)

E – Education for Health
L – Locally endemic disease control
E – Expanded program for immunization
M – Maternal and Child Health including responsible parenthood
E – Essential drugs
N – Nutrition
T – Treatment of communicable and non-communicable diseases
S – Safe water and sanitation

CLIENTS OF CARE

a. Family

Family is defined nucleus of civilization and the basic social unit of society.
A family is a group of people affiliated by consanguinity (by recognized
birth), affinity (by marriage), or co-residence and or shared consumption.
According to Aristotle, it is believed that for the civilization to succeed, the family
must succeed. The types of family includes: nuclear, extended, single-parent,
matrifocal, blended etc.

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b. Community

Broadly defined, a community is a collection of people who interact with

one another and whose common interest or characteristics gives them a sense of
unity and belonging.

A community is a group of people in defined geographical area with

common goal and objective and the potential for interacting with one another
(Dryer’s den). The function of any community includes its members’ sense of
belonging and shared identity, values, norms, communication, and supporting
behaviors.

Some communities who may share almost everything, while other communities
(large, scattered and composed of individuals) who may share only there
common interests and involvement in certain goals.

TYPES OF COMMUNITIES

A. Urban Community

- An Urban Community is a big city or town. It is considered an Urban

Community if there are more than 2,500 people living in the
community. Urban communities are often busy and crowded. Normally, the
city is the most central location in a region.

B. Rural Community

-  Rural community is set outside of the city and towns. Rural communities
are often farm lands. However, a rural community can also be woodland
forests, plains, deserts, and prairies.  There are few buildings, businesses,
and people in rural communities. In these communities people live far
apart from one another. Rural communities are the farthest from urban
communities or the city.

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C. Sub-urban Community

- A suburb is a residential area or a mixed use area, either existing as part

of a city or urban area or as a separate residential community within commuting
distance of a city.

FACTORS AFFECTING COMMUNITY HEALTH

According to the World Health Organization (WHO), many factors combine

together to affect the health of individuals and communities. Whether people are
healthy or not, is determined by their circumstances and environment. To a large
extent, factors such as place to live, the state of the environment, genetics,
income and education level, and relationships with friends and family all have
considerable impacts on health, whereas the more commonly considered factors
such as access and use of health care services often have less of an impact. It is
now well recognized that the health of individuals and populations is shaped by
broad societal factors that lie outside the influence of the health sector.
The determinants of health and wellbeing include the social, economic and
physical environment, as well as individual behaviors and characteristics.

A. Economic/Social Environment

One example of how the economic environment impacts community health

is income and social status. Higher income and social statuses are linked to
better health, according to WHO. Furthermore, the greater the difference
between the richest and poorest peoples in a community, the greater the
differences in their health.

Social support networks also impact the health of a community in that

greater support from family and friends contributes to better health. Culture -
customs and traditions, and the beliefs of the family and community all affect
health. Likewise, educational levels are linked with poor health, more stress
and lower self-confidence.

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B. Physical Environment

Factors in the physical environment that affect community health include

safe drinking water, clean air, safe workplaces and adequate housing. The
WHO Health Impact Assessment presents evidence for determinants of
community health. For example, evidence for physical environment impacts
includes the number of motor vehicle accidents, pollution caused by fossil
fuels, homelessness and urbanization of communities, according to the WHO.
Moreover, access and use of health care services by the community
influences health by preventing and treating disease.

C. Individual Behaviors

Genetic makeup plays a role in determining a person's lifespan and

likelihood for developing certain diseases. Another factor would be gender,
men and women suffer from different types of diseases at different ages.
These individual behaviors, such as maintaining a healthy diet and exercise
routine, contribute to the health of a community.

COMMUNITY NEEDS ASSESSMENT/ COMMUNITY DIAGNOSIS

Community health purposes and goals are realized through the application

of a series of steps that lead to described results. As a profile, it is a description
of the community’s state of health as determined by physical, economic, political,
and social factors. It defines the community and states community problems.

Community diagnosis enables the nurse/program coordinator to set

priorities for planning and developing programs of health care for the community.
The data gathered through the process serves as the material for analysis.

The community health nursing process, like the nursing process in

general, composed of Assessment, Diagnosis, Planning, Implementation, and
Evaluation. However, for purposes of tradition, community assessment is already
integrated into the process of community diagnosis.

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Purpose: To be able to obtain a quick picture of a community as accurate as
possible and to identify the resources available to the community people.

Types of Community Diagnosis:

A. Comprehensive Community Diagnosis

- Aims to obtain general information about the community or a certain
population group.

B. Problem-Oriented Community Diagnosis

- Type of assessment that responds to a particular need.

Elements of a Comprehensive Community Diagnosis

A. Demographic variables
- show the size, composition, and geographical distribution of the
population.

B. Socio-economic and Cultural Variables

- Social indicators, Economic Indicators, Environmental Indicators and
Cultural Indicators.

C. Health and Illness Patterns

- Gather the leading causes of morbidity, mortality, infant and maternal
mortality and causes of hospital admission

D. Health Resources
-refers to manpower, institutional and material resources provided not only
by the state, but also those that are contributed by the private sector and
non-government organizations.

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E. Political/Leadership Patterns
- reflect the action potential the state and its people to address the health
needs and problems of the community. It mirrors the sensitivity of the
government to the people’s struggle for a better life.

STEPS IN CONDUCTING COMMUNITY DIAGNOSIS

1. PLANNING
Planning is based on the actual and potential problems that were identified
and prioritized. Strategic and Operational plans are the two types of plan.

Why is there a need for planning?

a. Provides more rationale decision-making instead of gut-free, vested
interests, or political considerations.
b. Given the multiple needs of the people and the scarce community
resources, planning utilizes available resources properly.
c. With the conflicting values and views within the community, planning
assists in the determination of common goals, objectives and strategies.
d. Positive change and growth is feasible with planning.

Characteristics of Planning:
a. Futuristic
b. Flexible
c. Change-oriented
d. Continuous and dynamic process
e. Systematic process

1. Determine the objectives

- Decides on the depth and scope of the data to be gathered, regardless of

the type of community diagnosis to be conducted

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 - Determine the occurrence and distribution of selected environmental,
socio-economic, and behavioral conditions important to disease prevention
and wellness promotion.

Note: Statement of objectives should be SMART (Specific, Measurable,

Attainable, Realistic and Time-bound).

2. Define the study population

- Identifies the population group, based on the objectives of the study, the
study population may be the entire community population or be focused on
a population group.

3. Prepare the community

- Courtesy calls for meetings are a must to enable to formulate the

community diagnosis objective with the key leaders of the community

4. Choose the Methodology and Instrument of Community Diagnosis

- Primary data may be gathered through surveys, interviews, community

meetings, observations, while secondary data may be gathered through
the review of program and public records
- Pretesting of the instrument is highly recommended.

5. Setting the Targets

- Involves constructing a timetable of activities, taking into consideration the

sample size and the number of personnel that will work.

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Collection of data/Data Gathering

- includes demographic data, vital health statistics, utilization of health

services, health status, family dynamics, environment, patterns of coping,
community dynamics, education, socio-cultural, religious, occupational
background

Methods of Collecting Data/Instrument

a. Community surveys
b. Interview of individuals, families and groups
c. Observation of health related behaviors and environment
d. Review of statistics: epidemiological and relevant studies
e. Individual and family health records
f. Screening tests and P.E. of individuals

Categories of health problems

a. Health deficit – occurs when there is a gap between actual and achievable
health status.
b. Health threats – are conditions that promote disease or injury and prevent
people from realizing their health potential.
c. Foreseeable crises – anticipated periods of unusual demand on the individual
or family in terms of adjustment/ family resources.

Note:
a. Health need – exists when there is a health problem that can be
alleviated with medical or social technology.
b. Health problem – is a situation in which there is a demonstrated health
need combined with actual or potential resources to apply remedial
measures and a commitment to act on the part of the provider or the
client.

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2. IMPLEMENTATION

1. Actual data gathering

- During the actual data gathering, the nurse supervises the actual data
gathering; the nurse supervises the data collectors by checking the filled-
out instruments for completeness, accuracy and reliability of the
information collected.

2. Collation/Organization of data
- There are two types of data that may be generated: Numerical data and
descriptive data

3. Presentation
- Data collected may be presented as: Statistical tables, graphs, descriptive
data.

4. Analysis of Data
- Aims to establish trends and patterns in terms of health needs and
problems of the community. It allows comparison of obtained data with
standard values.

5. Identification of community health nursing problems

- Make a list of health problems and categorize them as:
 Health - status problems- may be described in terms of increased
or decreased morbidity, mortality, or fertility.
 Health - resources problems- they may be described in terms of
lack of or absence of manpower, money, materials, or institutions
necessary to solve health problems.
 Health - related problems-they may be described in terms of
existence of social, economic, environmental, and political factors
that aggravate the illness-inducing situations in the community.

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 6. Priority setting of Community Health Nursing Problems
- Make use of the following criteria:
 Nature of the problem presented- problems are classified by the
nurse as health status, health resources, or health-related
problems.
 Magnitude of the problem- refers to the severity of the problem,
which can be measured in terms of the proportion of the population
affected by the problem.
 Modifiability of the problem- refers to the probability of reducing,
controlling, or eradicating the problem.
 Preventive Potential- refers to the probability of controlling or
reducing the effects posed by the problem.
 Social concern- refers to the perception of the population or the
community as they are affected by the problem.

7. Feedback to the Community

- Community meetings are held to inform the community people of the
results of the community diagnosis. This is done to:
 Increase their awareness on their health status as an entire
community and
 Enhance community participation in action planning.

8. Action Planning
- Action programs are the activities necessitated by the results of the
community diagnosis. Feasibility, impact on the community, scope or
coverage, and community acceptance are the factors to consider in
formulating an action program.

III. EVALUATION
- Specify criteria and evaluation on tool for each objective. In this phase,
evaluation/determination of accomplishment outcomes is made.
- Done to:

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  Measure the achievements of the program
 Serve as basis for introducing corrections or revisions to the action
program
 Provide concrete basis for the validity and appropriateness of the
action plan. Since impact evaluation of the community, a follow-up
to the community diagnosis is necessary.

IV. REFERENCES:

Book-Based References:
Cuevas, Frances Precilla L., et.al. (2007). Public Health Nursing in the
Philippines (10thEd). Philippines: Publications Committee, National League of
Philippine Government Nurses.

Hunt, Roberta (2009). Introduction to Community –Based Nursing (4 th Edition).

Wolters Kluwer Health | Lippincott Williams & Wilkins.

Reyala, Jean P. (2000). Community health nursing services in the Philippines.

Community Health Nursing Section (9th Edition), National League of Philippine
Government Nurses, Inc.

Web-based Reference:
World Health Organization (WHO) Determinants of Health accessed at
http://www.who.int/hia/evidence/doh/en/ at March 17, 2016 at 10:40 a.m.

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