Scanned with Camse anne NURSING PRACTICE IN THE COMMUNITY Fifth Edition O & Cc ee »Scanned with CamSeerner Philippine Copyright © 2009, 2004, 2003, 2002, 2000, 1997 by ARGONAUTA CORPORATION Marikina City and ARACELI S. MAGLAYA ROSALINDA G. CRUZ-EARNSHAW MA. BRIDGETTE T. LAO-NARIO MA. CORAZON S. MAGLAYA LUZ BARBARA L. PAMBID-DONES LUCILA B. RABUCO WINIFREDA O. UBAS-DE LEON ALL RIGHTS RESERVED A written permission of the editor and publisher must be secured if any part of this book is reproduced by any means and in any from whatsoever. Every authentic copy of this book bears a serial number and the signature of the editor or Published and exclusively distributed by: Corporation iling Street Marikina Village, Nangka Marikina City Tel. No. 941-61-60Scanned with CamSeerner CONTRIBUTORS Araceli S. Maglaya, RN, PhD Professor Centennial Professorial Chair College of Nursing University of the Philippines Manila Rosalinda G. Cruz-Earnshaw, RN, MIN, MPA Nurse Educator ‘Feumenical Christian College Former Faculty College of Nursing University of the Philippines Manila Former Consultant Philippine Department of Health-Local Government Assistance and Monitoring Service and Essential National Health Research Luz Barbara L. Pambid-Dones, RN, MPH Associate Professor College of Nursing University of the Philippines Manila Ma. Corazon S. Maglaya, MD Medical Consultant Smith Bell Group of Companies Resource Person “Doctors-On-Line” Program, DZAS Ma. Bridgette T. Lao-Nario, RN, MA Faculty Azusa Pacifie School of Nursing Second Careers in Nursing Program Auusa, California, USA Telemetry Nurse Definitive Observation Unit Whittier Hospital Medical Center Azusa, California, USA Winifreda O. Ubas-de Leon, BSMT, MPH Professor (Retired) Department of Parasitology College of Public Health University of the Philippines, Manila Lucila B. Rabuco, MSc Public Health (Nutrition), PHD Professor Centennial Professorial Chair Department of Nutrition College of Public Health University of the Philippines ManilaSeannes with CamSeerner PREFACE ‘The fifth edition of the book Nursing Practice in the Community focuses on theory-based practice methodologies using the competency-based framework. ‘Theories which describe, explain and predict behavior of clients (particularly families, groups and the community) provide background frameworks to guide readers on the bases for the selection of content and critical thinking directions by phase of the nursing process. Within these purposes and background of the book, the editor and contributing authors hope to enhance the teaching-learning empowering competencies of practitioners, teachers and students based on the uniqueness of every client and the health-healing situation in every nurse-client relationship. Precision and coherence in concept elaboration and illustration hopefully achieve clarity in breaking down complex processes to describe the application of the nursing process by type of client. Particularly for clinical instructors and students challenged enough to pursue the breadth and depth of community health nurse practice, the theory-based methodologies presented in this book provide teaching-learning alternatives to prevent the likelihood of using “ready-made” nursing care plans and client records to comply with course requirements. ‘The book begins with a presentation of community health nursing (CHIN) as context and practice using a four-client perspective: the individual, family, population group and community. Within the backdrop of social, political, cultural and evonomie determinants of health and illness, the chapter discusses the health care delivery system, the national health situation and the components, processes and ethicolegal aspects of community health nursing practice. As a CHIN practice option in many countries, community-based case management is discussed towards the end of the chapter. Chapter 2 presents theory-based methods and tools on assessment in family health nursing practice. The Assessment Data Base and The Typology of Nursing Problems in Family Nursing Practice are updated using precise concepts related with major family theories: The Systems Model, Interactional and Development Models and The Structural Functional Framework. Genograms, ecomap and family-life chronology are discussed as additional assessment tools with specific guides on construction and {erpretation contained in Appendices B1 to B3. Chapter 3 focuses on concepts, steps and intervention options in developing the family nursing care plan. A sample evaluation plan illustrates how to specify evaluation criteria/indicators, standards and types of methods and tools. Chapter 4 covers concepts, methods and tools related with the implementation and evaluation phases in family nursing practice. Two types of evaluation are discussed: formative and summative evaluation. Each type is presented to address specific components of family health nursing care based on evaluation criteria/indicators and standards. Challenges and directions include supervision of a case load of priority families by geographical assignment or catchment area and the case management approach in working with priority families. Chapter 5 focuses on the nursing perspective of the partnership approach and the Participatory action methodology explicitly illustrating the “Look-Think-Act” cyclical process using empirical data on the empowering experiences of families in a village in Abra Province. Interdisciplinary teamwork and interagency collaboration are enhanced through competencies on partnership with diverse groups forming cross functional teams.Scanned with CamSeerner Chapter 6 presents the concepts and methods of the work group approach in developing community competence. Chapter 7 describes the processes, methods and tools for assessing community health needs by type of community diagnosis. Application of demography, vital statisties and epidemiology as public health tools are illustrated by major concept oF tool. Chapter 8 discusses the approaches and steps involved in planning community health nursing programs and services. Community competence and community strength or empowerment as change outcomes are illustrated as examples of evaluation measures to pursue using the participatory approach. Chapter 9 presents the nursing interventions for community health and development Within the perspectives of primary health care, health promotion and community competence, community health development strategies include community organizing towards community participation in health, capacity-building through competency- based training, partnership and collaboration, advocacy and supervision. Caseload management is described as a process and an approach to systematically address the health needs and problems of a number of clients under specific health programs or services. Chapter 10 presents assessment and management protocols for safe motherhood and well-baby care. Chapter 11 deseribes nurse-managed maternal care in the community. Based on standards of prenatal care, home delivery and postpartum care, application of the nursing process in a nurse-managed care is presented. Chapter 12 describes independent nursing practice using specific strategies, examples and experiences such as conducting developmental screening for preschoolers and maintaining a health promotion clinic to address client concerns like nutrition, comfort, mobility and sleep pattern. The components of nursing consultation together with other topics such as charging nursing professional fee, marketing services of the nursing clinic and establishing linkages and a ceferral system are discussed. Chapter 13 focuses on enhancing competencies on nutrition for wellness, presenting the functions and food sources of macronutrients (carbohydrates, proteins and fats) and micronutrients (vitamins and minerals). Methods and tools to assess nutritional status (eg, dietary and anthropometric methods, biophysical tests and clinical examination) are also described in the chapter. Competencies on nutrition and wellness enhance the nurse's confidence to assume an independent role or work in collaboration with the health team in addressing malnutrition as a health problem and risk factor of lifestyle diseases in many communities in the Philippines and in many parts of the world. Chapter 14 focuses on concepts, strategies and interventions to addres: early childhood based on common causes of undernutrition among Fi jalnutrition in ino children. Chapter 1g describes the life cycle and measures for prevention and control of parasites as causative agents of selected communicable diseases such as malaria, filariasis, schistosomiasis and intestinal parasitism. Chapter 16 describes assessment and management protocols to address selected common lifestyle-related health concerns and problems of adult clients.Scanned with CamSeerner per 17 presents the concepts and principles of nursing management i Chapter 27 iepal considerations are discussed. wement in the local public health system™ Ethie Finally, Chapter 18 discusses community-based participatory research t Fingpanity health nursing Praches. The nature, process and guicames Gee empowerment are Hiwstrated using empiries! data based in a thi of family multidisciplinary Fe: arch on_ malaria prevention and control involvin; ‘irty-month families as community resident ‘ifa village of Danglas Municipality, Abra Provan” ° winee, ‘trent edition sa product of five years of exploring options based on f practitioners, clink 4] instructors, senior faculty and students nse on feedsae: from Pract tate entice! thinking and analysis in comm unity health nursing peace and faciste Crpectives provide the bases for the application of the oes by type of client using practice-based methodologies. Each chapter ng process, by at aity for practitioners, clinical instructors End istudanta.ie eae Be eee oppe tunity apecive from the vantage point of partielpatory gore the sutsing ach towards ee hancing client's empowcring potential. tice, sthe book is dedicated to all families and nurses who are sources of! strength to enhance healing and attain wellness. hope, wisdom and Araceli S. Maglaya ‘Tagaytay City July 16, 2009Seannes with CamSeerner TABLE OF CONTENTS CHAPTER 1 Community Health Nursing: Context and Practice Rosalinda G. Cruz-Earnshaw Community Health Nursing 16 Framework for Community Health Nursing 7 Clients of Community Health Nurses 17 = Individual a7 * Family 1s Population group 18 = Community 18 Health 19 © Factors affecting health 19 Health Care Delivery System 22 © Publicheslth 22 The Philippines health care delivery system 23 Department of Health 23 Millennium Development Goals (MDGs) _ 74 Mediur-Term Philippine evelopment Plan (MTPOP) Health Sector Reform Agenda (HSRA) 24 FOURmula ONE for Health (F1) 24 National Objectives for Health (NOH) 25 Devolution of health services 25 The National Health Situation 26 + Demographic profile 26 * Health profile 27 Primary Health Cere and Health Promotion 30 ‘* Primary health care 30 * Health promotion 32 Nursing Practice in the Community 23 * Critical thinking in community health nursing 34 Nursing process 24 Program planning, implementation and evaluation Health education 38 Management and supervision 38 Research and evidence-based nursing practice 38 Community Health Nursing in the Philippines 39 * Public health nursing a0 Occupational health nursing 42 * School nursing 42 Community-Based Case Management 43 Ethicolegal Aspects of Community Health Nursing 4 19 2Scanned with CamSeerner CHAPTER 2 50 Assessment in Family Health Nursing Practice Araceli S. Maglaya Family Perspective in Community Health Nursing Practice 50 Family Nursing Practice: Theoretical Perspectives 1 Nursing Assessment: Operational Framework $4 Steps in Family Nursing Assessment ss + Data-gatheri Data Analysis 62 Nursing Diagnoses: Family Nursing Problems 63 The Typology of Nursing Problems in Family Health Care 64 Conclusion 72 in Family Nursing Assessment 57 @ Methods and Tools 57 CHAPTER 3 Developing the Family Nursing Care Plan Araceli S. Maglaya 76 ‘The Fomily Nursing Care Plan 76 Steps in Developing a Family Nursing Care Plan 76 ‘© Prioritizing Health Conditions and Problems 77 © Factors Affecting Priority-Setting 79 * Scoring 81 + Formulation of Goals and Objectives of Care #1 Developing the Intervention Plan 83 © analyze Realities and Possibilities based on Family’s Lived Experience of Meaning and Concerns 3a © Focus on Interventions to Help the Family Perform the Health Tasks 85 * catalyze Behavior Change Through Motivation and Support 90 * Criteria for Selecting the Type of Nurse-Family Contact 91 Developing the Evaluation Plan 92 Documentation 92 CHAPTER 4 Implementation and Evaluation in Family Nursing Practice 7 Araceli S. Maglaya Expert Caring: Methods and Possibilities 97 Competency-Based Teaching 98 = Learning isan Intellectual and Emotional Process 99 + Learning is facilitated when experiences have meaning to the learner 101 Learning is an Individual Matter: Ensure Mastery of Competencies for Sustained Actions 107 Maximizing Caring Possibilities 103 Expertise through Reflective Practice 105 The Evaluation Phase 107 Challenges and Directions 107Scanned with CamSeorner CHAPTER 5 The Partnership Approach and the Participatory Action Methodology: The Nursing Perspective 110 Araceli S. Maglaya Human Care and Nursing Practice 110 Options for Change 111 Participatory Action and Empowering Experiences of Families in Danglas, Abra 114 Enhancing Interdisciplinary and Interagency Collaboration 115 The Essential Ingredients of Partnership 116 © Belief in Egalitarian Relationship 116. * Open-mindedness 116 © Respect and Trust 117 © Commitment to Enhance each other's Capabilities for Partnership 117 Capabilities Necessary for Partnership 118 * Skills Necessary to Function asan Integrated Unit 2318 Summary 128 CHAPTER 6 Developing Community Competence through the Work Group Approach 130 Araceli S. Maglaya Introduction 130 Community Competence 131 ‘The Work Group Model as Strategic Approa ‘The Stages of Group Development 122 * The Stage of Orientation 132 The Stage of Conflict 133 The Stage of Cohesiveness 134 The Work Group Stage 134 The Termination Stage 135 * The Various Stages at Work 135 Interventions to Facilitate Group Growth 135 = Provide the Necessary Orientation, Structure and Direction 136 © Process, Negotiate and Resolve Canflicts to Member's Satisfaction 128 + Be Aware of the Effects of Own Behavior on the Group: Use the Self for Group Growth 145 ‘+ Actas the Group's Completer/Resource Person 147 * Derive Opportunities to Apply Learning on Another Situation 147 Work Group: Hub of Community Organization, Competence and Empowerment 147 h to Community Competence 131 CHAPTER7 Assessing Community Health Needs 150 Luz Barbara P. Dones Introduction 150 ‘The Community Diagnosis 150 + Ecologic Approach to Community Diagnosis 151 © Types of Community Diagnosis 152 * Comprehensive Community Diagnosis 152 © Problem-Oriented Community Diagnosis 155, Community Diagnosis: The Process 155Scanned with CamSeorner fe Community Diagnosis 156 ing the Objectives 157 Population 157 steps in Conductin + Determining the + Defining the Stucy J Determining the Data tobe Collected 158 Collecting the Dato 158 Developing the Instrument 261 ‘Actual Data Gathering 168 Data Collation 169 + Data Presentation © Data Analysis 374 «Identifying the Communi 175 Jools in Community Health Nursing 179 aa ty Health Nursing Problems 174 © Priority-setting ‘Application of Public Health Demography 175 ; 2 sources of Demographic Data 379 = Population Size 280 = Population Composition * Population Distribution Vital Statistics 184 Epidemiology 186 «The Multiple Causation Theory 186 Natural History of Disease 188 Levels of Prevention of Health Problems 188 Concept of Causality and Association 182 + The Epidemiological Approach 192 = Descriptive Epidemiology 192 * Analytical Epidemiology 197 * Interventional or Experimental Epidemiology 158 © Evaluation Epidemiology 198 Conclusion 199 181 183 CHAPTER 8 Planning for Community Health Nursing Programs and Luz Barbara P, Dones a a a a Introduction 202 What is Planning? 202 Approaches to Planning Health Programs 203 * Participatory Planning for Community Health 203 Planning for Health Promotion 206 The Planning Cycle 206 Situational Analysis 206 * Goal and Objective Setting 212 + Strategy and Activity-Setting 213 * Developing an Evaluation Plan 234 Conclusion 220 202Scanned with CamSeerner CHAPTER9 Nursing Interventions for Community Health and Development 223 Luz Barbara P. Dones Introduction 223 Community Competence as Outcome of Community Health Nursing Interventions 723 Community Health Development Strategies 225 Health Promotion 226 Community Organizing towards Community Participation in Health 229 Capacity-Building through Competency-based Training 233 Partnership and Collaboration 236 Advocacy 237 Supervision 238 + Making a Supervisory Plan 239 * Methods and Tools for Supervision 220) * Conducting a Supervisory Visit 240 * Case Study Illustrating the Application of the Step: Caseload Management 241 Conclusion 243 Supervisory Planning 241 CHAPTER 10 Logic Trees for Safe Motherhood and Well-Baby Care 247 ‘Ma. Corazon S, Maglaya and Araceli Maglaya Introduction 247 The Use of Logic Trees 247 Assessment Protocol for Initial Pre-natal Checkup 248 Logic Tree Flowchart No. 28 250 Management Protocol for Initial Pre-natal Check-up 251 Assessment Protocol for Follow-up Pre-natal Check-up 255 Logic Tree Flowchart No. 29 257 Management Protocol for Follow-up Pre-natal Check-up 258, Assessment Protocol for Home Delivery 260 Logic Tree Flowchart No. 30 261 Management Protocol for Home Delivery 262 Assessment Protocol for Care of the Newborn Immediately after Birth 267 Logic Tree Flowchart No. 31 269 Management Protocol for Care of the Newborn Immediately after Birth 270 Assessment Protocol for Postpartum Check-up 273 Logic Tree Flowchart No. 32. 274 Management Protacol for Postpartum Check-up 275 Assessment Protocol for Well Baby Check-up 280 Logic Tree Flowchart No. 33-A 281 Management Protacol for Well Baby Check-up 282 Assessment Protocol for Well Baby Check-up, Patient is more than one month old 264 Logic Tree Flowchart No. 33-B 225 Management Protocol for Well Baby Check-up, Patient is more than one month old 286Scanned with CamSeerner CHAPTER 11 Nurse-Managed Maternal Care in the Community Maria Brigette T. Lao-Nario Introduction 288 Role of Maternal Care 289 Standards of Prenatal Care 290 Components of Pregnancy Care 291 + Antenatal Registration 292 * Tetanus Toxoid Immunization 293 Macronutrient and Micronutrient Supplementation 294 Micronutrient Supplementation: Iron Supplementation 294 + Vitamin A Supplementation 295 * Treatment of Diseases and Other Conditions 296 Early Detection and Management of Complications of Pregnancy + Family Planning Counseling 237 + STO/HIV/AIDS Prevention and Management 297 Standards in Home Delivery 237 Standards in Postpartum Visit 300 The Nursing Process in a Nurse-Managed Care 302 Nursing Assessment and Diagnoses 302 Determining Outcomes of Care 303 Choosing Nursing Interventions 304 Home Visit as an Intervention 304 CHAPTER 12 Demonstrating Independent Nursing Practice Ma. Brigette T. Lao-Nario Experiences in Setting up Independent Nursing Practice 317 Metro Manila Developmental Screening for Preschoolers 313 Providing Consulting Services 313 The Health Promotion Nursing Clinic 216 Commonly Used Nursing Diagnoses 318 Establishing the Outcomes of Care 320 ‘The Nursing Consultation and its Components 320 Charging Clients a Nursing Professional Fee 322 Marketing the Services of the Nursing Clinic 323, Establishing Linkages and a Referral System 323 CHAPTER 13 Enhancing Competencies on Nutrition for Wellness Lucila B. Rabueo Introduction 326 Nutrition 326 Food 327 Nutrients 327 © Macronutrients 327 © Micronutrients 329 ‘Assessment of Nutritional Status 233 * Indirect methods 334 296 288 310Scanned with CamSeerner * Direct methods 337 Common Nutritional Problems of Public Health Importance 340 Protein-Energy Malnutrition (.E.M.) 340 Iron Deticieney Anemia» Vitamin A Deficiency Disorders 342 lodine Deficiency Disorders 343 + Overweight and obesity 343 Summary 348 CHAPTER 14 Appropriate Technology for the Prevention and Control of Malnutrition in Early Childhood 346 Araceli S. Maglaya Nutritional Status of Filipino Children: Consequences and Implications 346 Causes of Malnutrition Related to Feeding Practices 347 + Non-breast-feeding or Early Weaning 347 + Absence of or Inadequate Complementary Feeding during Extended Periods of Breastfeeding or Dependence on Artificial Feeding 248 + Lack of or Inadequate Skill in Managing Diarrhea at Home aaa Interventions Using Appropriate Technology 348 + Family Competency-Building on Nutritional Status of Children and Options to Enhance Proper Nutrition 343 + Regular Complementary Feeding Using Protein Powders 349 + Increase Knowledge on the Daily Recommended Energy and Nutrient Intakes (RENI) for Infants and Toddlers 351 + Appropriate Home Management of Diarrhea 352 Summary 354 CHAPTER 15 Parasitology in Nursing Practice 356 Winifreda O. Ubas-de Leon Introduction 356 The Parasites 356 Directly-Transmitted Parasite 357 © Enterobius (Oxyuris) vermicularis 357 SoilTransmitted Parasites 388 © Ascaris lumbricoides 388 © Trichuris trichiura 362 = Hookwarms 362 Food Transmitted Parasites 369 Tacnia solium and Taenia saginata 369 © Paragonimus westermani 370 © Capillaria philippinensis 371 + Heterophyid Fiukes 371 Water-borne Protozoa 372 = Entamoeba histolytica 372 © Giardia lamblia 273 © Cryptosporigium hominis 374 * Cyclospora cayatensis 377Scanned with CamSeerner + Blastocysts hominis 377 vector-Borne Parasites 378 + Plasmodia 378 + Babesia spp 379 ‘+ Wuchereria bancrofti and Brugia malayi 280 + Schistosoma japonicum ana Conclusion 385 CHAPTER 16 Logic Tree for Common Adult Health Problems ag2. Ma. Corazon S. Maglaya and Araceli Maglaya Introduction 388 The Logic Trees 368 Assessment Protocol for Problem on Cough, Colds or Difficulty of Breathing not Associated with Fever 389 Logic Tree Flowchart No.7 391 Management Protocol for Problem on Cough, Colds or Difficulty of Breathing not Associated with Fever 392 Assessment Protocol for Problem on Skin Lesions 394 Logic Tree Flowchart No.9 395, Management Protocol for Problem on Skin Lesions 396 Assessment Protocol for Problem on Body Weakness 399 Logic Tree Flowchart No. 10 400 Management Protocol for for Problem on Body Weakness 401 Assessment Protacol for Problem on Abdominal Pain, Epigastric 403 Lopic Tree Flowchart No. 11 404 Management Pratecol for for Problem on Abdominal Pain, Epigastric 405 Assessment Protocol for Problem on Insomnia 407 Logic Tree Flowchart No. 16 408 Management Protocol for Problem Insomnia 409 Assessment Protocol for Problem on Dizziness 412 Logic Tree Flowchart No. 24 413 Management Protocol for Problem Dizziness 414 CHAPTER 17 ‘“rsing Management in the Local Public Health System 419 osalinda G, Cruz-Earnshaw Introduction as Management Functions as '@R@gement in Public Health 422 J The Local Public Health Organization 421 The pup oMtext Of the Local Public Health Organization +421 5a Manager and Supervisor 421, Planning 421 Organizing 423 Stafting 425 leading (directing) 425 Controlling 426 . Phi “olegel Considerations 429Scanned with CamSeerner CHAPTER 18 Enhancing Practice through Community-Based Participatory Research 432 Araceli S. Maglaya Introduction 432 Community-8ased Participatory Research 432, Enhancing Empowering Potential: The Human Response Perspective 433, Facilitating Behavior Change thru Motivation-Support Interventions 35 Empowerment: Nature, Process and Outcomes 436 Health in the Hands of the People «38 Behavior Change Over Time 438 Community Leaders Update the Researcher at the University 439 Community-Based Research: Insights for Enhancing Nursing Practice 439 APPENDICES Al Community Health Nursing Practice Model 445, A2_ Laws that Impact on People’s Health and CHN 446 A3 Health Programs ofthe DOH 248 B Family Assessment Tools 249 B1 Constructing and Interpreting aGenogram a9 82 Constructing the Family Ecomap 455 83 Constructing the Family-Life Chronology 436 C1 Charting Nursing Care, Progress Notes and Client Responses/Outcomes 457 C2 Family Service Progress Record 458 3__ Instructions on the Use of the Family Service and Progress Record 461 D Selecting a Fruit Exercise 467 E Empowerment for Health Promotion Lifestyle Change «72 F Recommended Energy and Nutrient Intakes Per Day For Selected Population Groups 473 G Trends in Community Health and Community Health Nursing Practice 474Seannes with CamSeerner Chapter 1 COMMUNITY HEALTH NURSING: CONTEXT AND PRACTICE Rosalinda G. Cruz-Earnshaw Community health nursing (CHN) is one of the two major fields of nursing in the Philippines: the other is hospital nursing. Some people use the terms community health nursing and public health nursing interchangeably. However, the former is broader than the latter; it ineludes public health nursing, occupational health nursing and school nursing, COMMUNITY HEALTH NURSING Clark defines community health nursing as a “synthesis of nursing knowledge and practice and the science and practice of public health, implemented via a systematic use of the nursing process aind other process population groups” (2008:5). The other processes include management, supervision, research, advocacy and political action. Annex Ai presents a model of community health nursing practice which illustrates the relationship between nursing practice as science and art, core community health functions and essential community health services. to promote health and prevent illness The following statements characterize CHN: (3) Promotion of health and prevention of disea: the goals of professional practiee; (2) Community health nursing practice s comprehensive, gencral, continual and not episodic; (3) There are different levels of chentele-- individuals, families and population groups and the practitioner recognizes the primacy of the population as a whole; (4) The nurse and the client have greater control in making decisions related to health care and they collaborate as equals; (5) The nurse recognizes the impact of different factors on health and has a greater awareness of his/her clients’ lives and situations (Cle 10-13) CHN is the totality of its philosophy and beliefs, principles, processes and standards. As one of the subsystems, it influences and is influenced by the health care delivery system. CHN is practiced within a specific economic, political, socio-cultural and environmental context. The roles and functions of CHNs directly contribute to the health of their clients: The essence of nursing is the same even if practiced in different settings. Nur defined as the science and art of caring. Nursing as an art is reflected in the nurses’ interactions and communication with clients that are geared towards the improvement not just of their health but also their ability to deal with the determinants and consequences of their health problems. ig is According to Parse, the responsibility of nursing to society is to guide individuals and 16 CnScanned with CamSeerner famili n changing the health process which is accomplished by intersubjective participation with people” (George, 2002:439). The art of nursing is demonstrated by nurses who can maintain the delicate balance between doing things for their clients and doing things with them, thus co-ereating a better or more meaningful reality. The practice of community health nursing, therefore, cntails active interaction and partnership between the nurse and the client. Such partnership recognizes the autonomy of both parties and the potential of each one in enriching their relationship. Nursing is also a science, which means that community health nurses should use practice-based and evidence-based methods and tools. They also need to engage in generating evidence to support their praetice through research. Quantitative research is needed to describe or quantify variables of interest to community health nurses or to evaluate the effectiveness of existing practices, procedures or interventions. Qualitative research can be done to understand specific human response phenomena such as client-partners’ lived experiences on poverty and adaptation. ‘The roles of CHNs are grouped by Clark (2008: 14-22) into client-oriented roles (caregiver, educator, counselor, referral resource, role model and case manager); delivery-oriented roles (coordinator, collaborator and liaison); and, population- oriented roles (case finder, leader, change agent, community mobilizer, coalition builder, policy advocate, social marketer and researcher).In recent years, the ease manager role in the community setting is gaining importance as an innovative strategy to provide high quality care in a financially restricted cnvironment. As the case management concepts of client independence, control, advocacy and coordination are already reflected in current nursing models and philosophies, nurses are considered the most appropriate professionals to fill the role of case managers(Knollmueller, 1989; Bergen, 1992). As a CHN practice option in many countries, community-based case management is discussed at length towards the end of this chapter. FRAMEWORK FOR COMMUNITY HEALTH NURSING ‘The practice of nursing, particularly in CHN differs from one geographic area (country or region) to another. Ttis influenced by a number of factors primarily the scope of practice as defined by the nursing law, policies and standards of the Department of Health and organizations where CHNs work and the health needs and problems of the people. ‘The macro framework for CHN practice has four components: (1) the health care delivery system, with its CHN subsystem; (2) the clients (individual, family, population group and community); (3) health which is the goal of the health care delivery tem (HCDS); and, (4) the economic, sociocultural, political and environmental factors that affect the HCDS, the practice of community health nursing and the people's health. ‘These constitute the context of community health nursing practice in the Philippines ‘This chapter elaborates on the different components of the framework. CLIENTS OF COMMUNITY HEALTH NURSES There are different levels of clientele in community health nursing—the individual, family, population group and community, with the latter as the primary client. Individual | 7 | SSESeannes with CamSeerner ‘The CHN deals with individuals—sick or well-- on a daily basis. Since the health problems of individuals are intertwined with those of the other members of the family and community, they are also considered as an “entry point” in working with these clients. Family From a systems perspective, a family is defined as a collection of people who are integrated, interacting and interdependent (Hunt, 1997:126). Just like other systems, the parts (amily members) interact with each other and the action of one affects the other members. The family hass boundary which means that other people can recognize its members and those who are not. In fact a person may be identified primarily as a member of a particular family. ‘There have heen many changes in the social context of the Filipino family and these may have modified how it performs its health tasks and its capacity to remain as the primary source of support to its members. Population group A population group is a group of people who share common characteristics, developmental stage or common exposure to particular environmental factors, and consequently common health problems, issues and concerns. Allender and Spradley (2001) identified population “aggregates” with develop mentai needs (suchas: maternal, prenatal and newborn populations; infant, toddler and preschool! populations; school- aged and adolescents; adults and working populations; and, older adult populations) and those that are vulnerable (rural clients, the poor, migrant workers, minority populations experiencing health disparities, those with mental health issues, those living with addiction, those in correctional facilities and those in long-term care settings). Population groups are the usual targets or beneficiaries of social services and health programs. Community is a group of people sharing common geographic boundaries and/or and interests within a specific social system. This social system includes health system, family system, economic system, educational system, religious system, welfare system, political system, recreational system, legal system and communication system (Allender and Spradley, p. 360). Behringer and Richards describe a community as “webs of people shaped by relationships, interdependence, mutual interests and patterns of interaction (Leonard, 2000:93). Acommunity common values Although all communities are the same (according to the general systems theory), each one is unique because it functions within a specific sociocultural, political, economic and environmental context. They also vary in terms of community dynamics~-citizen pation, power and decision making structures and community collaboration lender and Spradley, 362-364). A community is regarded as an organism with its own stages of development and it matures through time. Development is facilitated by some catalysts from within and outside the community. Anderson and McFarlane (Anderson, 2000:157) developed the community-as- client aeScanned with CamSeorner model which later on was renamed to community-as-partner model. The two elements of the model are: focus on the community as partner and the use of the nursing At the core of the assessment wheel are the people of the community—their ics, values, belie people are affected by, and also influence eight subsystems of the community—physieal environment, education, safety and ‘ion, polities and government, health and social services, communication, economies and recreation, HEALTH Health ii right. On the 6" Global Conference on Health Promotion in 2005 the United Nations affirmed. its recognition that the enjoyment of the highest standard of health is one of the fundamental rights of every human being (The Bangkok arter for Health Promotion, 2005). Health whieh is viewed as a continuum, is considered as the goal of public health in general, and community health nursing, in particular, It is an important prerequisite (and consequence) of development. By promoting health and preventing disease, CIINs, therefore, contribute to the country’s economic and social development. ‘There are a number of definitions highlighting the different dimensions of health and basically focusing on the individual. These should guide nurses lentifying areas for assessment and interventions. The most frequently cited is that of the WHO : “Health sa state of eomplete physics], mental and social well-being and not merely the absence of disease or irmity” (WHO, 1995). Dunn (1959, in Pender, 1987:21), on the other hand, emphasized high-level wellness which he defined as: “an integrated method of functioning which is oriented toward maximizing the potential which the individual is capable. It requires that the individual maintain a continuum of balance and purposeful direction within the environment where he is functioning”. Rene Dubos in his book Man Adapting (1965) defined health as “a quality of life, involving social, emotional, mental, spiritual and biological fitness on the part of the individual, which results from adaptations to the environment (Butler, 2001:2). Florence Nightingale Jooked into health and illness in relation to the environment— ventilation, noise, light, cleanliness, diet and restful bed. She prescribed ways toimprove health by manipulating the environment. Dorothea Orem, on the other hand, defined health as a “state characterized by soundness and wholeness of human structures and bodily and mental functions"(1985 in Pender, 23). Factors affecting health ‘There isa strong link between a society's health and its economic development, whieh in turn is determined by its social and political structures and processes. The link between inequalities in income and wealth and inequalities in health is well-established (Wilkinson, 1996 in Naidoo and Wills, 2000:12). Culture and environment which impact on people’s health are also affected by the country’s polities and economy. ‘The different international conferenceson health promotion identified the determinants of, or prerequisites for health such as peace, food and shelter, clean water, education, adequate economic resources, a stable ecosystem, sustainable resources, social justice and equity and access to basic human rights. In her keynote address during the 5 19Seannes with CamSeorner International Conference on Health Promotion in 2000, the UN Secretary Gencral pointed out that “many of the major determinants of better health lie outside the health system. Knowledge made available-to people. Clean environments, Access to basic services. Fair societies, Fulfilled human rights. Good government. Enabling people to make decisions relevant to their lives, and to act on them” (Proceedings of the 5" International Conference on Health Promotion, 2000). In 2005, the Bangkok Charter for Health Promotion identified ical factors” that now influence health and these are: inereasing inequalities within and between amption and communication, commercialization, i factors that influence health , economic and demographic ng environments, family patterns countries, new patterns of cons global environmental change and urbani identified by the Charter arc rapid and often adver changes that affect the working conditions, le: and the culture and social fabric of communities Poverty and health . a ; Poverty is an indication of the continuing social injustice and failur development efforts. It is a multidimensional construct that goes beyond income measurements. The United Nations(UN) Human Development Index(HD1) summarizes a composite index of life expectancy, adult literacy rate, combined primary, secondary and tertiary gross enrollment ratio and gross domestic product (GDP), among others (MTPDP 2004-2010). The Philippines is the 90" among the 177 countries ranked by the United Nations Development Program in terms of human development (Philippine Star, 2/28/08). ‘The poverty incidence in the country was estimated at 34% in 2000, up from 33% in 1997 (MTPDP 2004-2010). More than half of the total income flows to the richest 20% of the population (MTPDP 1993-1998). According to the Social Weather Station (SWS), almost 16 of every 100 survey respondents claimed to have experienced involuntary had nothing to eat in early 2008 (Mangahas, 2008). se the} hunger bee: The poor have poor health because they do not have the resources to afford the ba requisites of health; they are not covered by health insurance; and they do not have the capacity to effectively transact or negotiate with the health care system which seems to be more responsive to the needs of those with the necessary financial resources. Poverty, however, is a not a complete explanation for poor health. The poor are not a homogencous group. Martin and Henry point out that poverty is the only characteristic that the poor share for their cultural orientations, values, beliefs, practices and needs vary greatly (1991: 523). Culture and health Culture is, broadly speaking, a way of life; it is the totality of who we are as a people. It is stable, which means that it endures over time and is passed on from one generation to the next. As such, it is obviously an important influence on people's health. Culture cludes many things such as beliefs, values and customs or practices how we socialize or interact with others, how we relax and spend our free time, the food that we cat or do not eat, how we prepare our food, how we treat and care for pregnant women, how we deliver babies and take care of newborns, how we cope with our problems, how and when we seek help, among many others. Culture has positive effets on health. An example is the value that we Filipinos place on close family ties and social relationships. Families, relatives and friends are a major source of financial, emotional, instrumental and social support, especially during crisis 20 eeScanned with CamSeorner situations. These relationships contribute to our sense of emotional well-being and mental health, Some people ave belie! os that adversely affeet hi and pt th. It is, however, difficult to isolate the effects of eulture because of the concurrent influences of poverty and ignorance, and the inadequacies of the health care delivery system, Environment and health ‘The environment plays a direct influence on the health of people. For example, it provides breeding sites for insect vectors of di malaria, dengne and filaria which are still major health problems in some parts of the country, An unsanitary environment is alsoa major factor in the causation of diarrheal diseases such as cholera and typhoid fever. It is the breeding ground of animals and inseets that harbor and transmit microorganisms. Malaria, dengue and filariasis are still major problems in many parts of the country. In the environment could be found toxic substances such as Tead, mercury, ashes! pesticides, tobacco, salventsand PCBs. These could adversely affect human. the brain and immune system and could cause eaneer (Needleman and Landri 1994). Tobacco particularly is a major threat to health because it contains over 4000 chemicals (ineluding hydrogen cyanide, sulfur dioxide, carbon monoxide, ammonia, formaldehyde, arsenic, benzene, chromium, lead, nitrosamines, benzopyrene, nicotine, admium and carbon monoxides) many of whieh are irritants, carcinogens and mutagens, toxins and substances that increase blood pressure, promote tumors, affect the heart and brain, damage the lungs and cause kidney and reproduetive malfunctions (Framework Convention on Tobaeeo Control Alliance, Philippines) ‘The inerease of carbon dioxide, methane and nitrous oxide (among other gases) in the earth’s atmosphere hes depleted the ozone layer. The deterioration of the ecosystem has been implicated in the rapid inerease of cancer cases and other health problems throughout the world. Specifically, there is a rise in caneer-causing ultraviolet radiation, surface air temperature and earbon dioxide. The denudation of our forests has directly and indirectly resulted in many health problems. Rivers have dried up or are extremely polluted, thus depriving many people of their major source of dietary protein. The International Physicians for the Prevention of Nuclear War estimates that millions of cancer cases will result from the nuclear testing conducted in the past. The WHO also estimates about 20,000 deaths a year in the world due to pesticide poisoning alone (Philippine Breast Cancer Network, 1997). ‘The so-called El Niio and La Nifia phenomena which have been caused by insults to the environment have caused thousands of deaths due to disasters (Nash, 1998). ‘The state of the world’s environment is the direct result of the interaction of a number of factors such as industrialization, government policies, poverty and an uncaring attitude towards the environment. Politics and health Policies reflect the priorities of government and the value system of policy makers. The health budget is the most concrete expression of the government's political will. Many Filipinos do not have full access to basic health goods and services because of the severely limited health care finaneing. In 1999, the amount spent for health was only 3.4% of the gross national product, lower than WHO-recommended 5%. This aScanned with CamSesrner translates to the fact that almost half of health expenditures is out-of-pocket; in other words, the “financial burden on individual families is heavy, leaving access to care highly inequitable” (NSCB, 2002). The severely limited health budget is also the bigge: nce to the full implementation of well-meaning policies such as national ith insurance. ea number of laws that impact on people’s health direetly (such as the salt aw and food fortification law) and indirectly such as those that affect their purchasing power (minimum wage, expanded value-added tax, energy law, etc.), family and social relationships (e.g., laws protecting women and children), environment, and access to education and employment opportunities. the Local Government ‘There are also laws that affect the delivery of health services Code, National Health Insurance Act and the professional practice acts of the different professions (nursing, midwifery and medicine). HEALTH CARE DELIVERY SYSTEM Ahealth care delivery system is the totality of “societal services and activities designed 10 protect or restore the health of individuals, families, groups and communities (Banta, 1986 in Cookfair, 1996:66). It includes both government and non-government health facilities (hospitals, clinics, diagnostic centers, health centers), programs, services and activities (preventive, promotive, curative and rehabilitative). Preventive health care is a major concern of the government-owned health centers while curative care is, provided by hospitals, both government and private. ‘The health care delivery system is affected by policies such as RA 9439 and RA 9502 (refer to Annex Az for a listing of laws that impact on people’ health and the health care delivery system) Public health Public health is generally regarded as a responsibility of government. One of the most quoted definitions of public health is that of Winslow (1920): “Public health is the science and art of preventing disease, prolonging life, and promoting health and efficiency through organized community effort; for the sanitation of the environment; the control of communicable infections; the education of the individual in personal hygiene; the organization of medical and nursing services for the early diagnosis and preventive treatment of disease; and, the development of the social machinery toensure everyone a standard of living adequate for the maintenance of health, so organizi these benefits as to enable every citizen to realize his birthright of health and longevi (Hanlon and Pickett, 1979:4). Today public health could be defined in terms of its three core functions: assessment, policy development and assurance. Assessment is the regular collection and analysis of health data, These data are used for program planning and poliey development. Policy development involves advoeacy and political action to develop policies in various levels of decision making. Assuranceis making sure that health services are effective, available and accessible to the people (Institute of Medicine, 1988 in Clark, 2008:87-88). Related to the core functions of public health there are ten essential health services (ASTDN in Lundy and Janes: 2001: 875) which are: (1) monitoring health status to identify community health problems; (2) diagnosing and investigating health problems and hazards in the community; (3) informing, cducating and empowering people 22Scanned with CamSeorner about health issues; (4) mobilizing community partnerships to identify and solve health problems; (5) developing policies and plans that support individual, family and community efforts; (6) enforcing laws and regulations that protect health and ensure safety; (7) linking, people to needed personal health services and ensuring the provision of health care that is otherwise unavailable: (8) cnsuring competent public health and personal health care workforce; (9) evaluating effectiveness, accessibility and quality of personal and population-based health services; and, (10) researching for new insights and innovative solutions to health problems. Public health nurses should participate in these essential health services. The Philippine health care delivery system ‘This section presents some of the major components of the Philippine health eare delivery system that constitute the context of community health nursing—the Department of Health, Millennium Development Goals, Medium- Term Philippine Development Plan, Health Sector Reform Agenda, FOURmuta One for Health, National Objectives for Health and local health care system (devolution of health services), Department of Health ‘The DOH leads in efforts to improve the health of Filipinos, in partnership with other government agencies, the private sector, NGOs and communities. With the exception of a few government agencies (such as the University of the Philippines and Armed Forces of the Philippines) and affluent cities (such as Manila, Makati and Quezon City) operating their own health facilities, the DOH remains to be the national government’s biggest health (particularly curative) care provider. ‘The DOH used to have control and supervision over all barangay health stations, rural health units and hundreds of hospitals throughout the country (special and specialty hospitals, medical centers, and regional, provincial, district and municipal hospitals). ‘Today, only the regional hospitals, medical center specialty hospitals and a few re-nationalized provincial hospitals are directly under it ‘The DOH exercises regulatory powers aver health facilities and products lead in the formulation of policies and standards related to health facilities, health products and health human resources. It provides LGUs the necessary support in managing their local health system. It also implements a number of health programs (Refer to Annex A3 for a listing of DOH health programs). t takes the ‘The DOH has undergone transformation to be more responsive to its post-devolution functions. One of the major changes at the Central Office is the ereation of the Bureau of Local Health Development, which is concerned with local health systems development, health care financing programs, quality improvement programs, inter-sectoral (public- private) coordination and local projects. 2324 Scanned with CamSeerner Millennium Development Goals (MDGs) The concern to improve people's health is universal because there is a strong correlation between health and development. Poor health is a consequence and cause of poverty and underdevelopment. Poverty also breeds despair and turmoil, ‘To address these problems, the United Nations spearheaded the formulation of the MDGs with the corresponding targets. These goals are: (1) eradicate extreme poverty and hunger; (2) achieve universal primary education; (3) promote gender equality and empower women; (4) reduce child mortality; (5) improve maternal health; (6) combat HIV/AIDS, malaria and other diseases; (7) ensure environmental sustainability; and, (8) develop a global partnership for development. Medium-Term Philippine Development Plan (MTPDP) Chapter 12 of the Medium-Term Philippine Development Plan 2004-2010 spells out the priority strategies to meet the basic necds of the poor. The following health priorities were identified: (1) reduction of the cost of medieines; (2) expansion of health Tusurance particularly for indigents through premium subsidy; (3) strengthening qational and local health systems through the implementation of the Health Sector Raform agenda: (4) improvement of health care management system; (5) improvement of health and productivity through R and D; and, (6) establishment of drug treatment and rehabilitation centers and the expansion of existing ones. Specifically for public health, the plan provides for the strengthening of health promotion and disease prevention end control programs: (2) achieve and maintain immunized children coverage to 95%: (2) achieve and maintain sputum positive TB cace detection rate of 70% and cure rate of 85%; (3) widen the choice and reach of family planning services and increase the prevalence rate of men and women/couples practicing responsible parenthood using either modern, natural or artificial methods (4) contain HIV/AIDS prevalence to 1% or less for groups at high infection: (5) reduce malaria morbidity rate by 50% from 48 cases per joo.ov0 population in 2002 to 24 cases per 100,000 population by the year 20103 (6) implement micronutnent fortification of foods; and, (7) heighten advocacy for the provision of adolescent health services including sexuality education and counseling. Health Sector Reform Agenda (HSRA) Towards the end of the twentieth century, the DOK has come up with the HSRA 1999-2004 that included the follawing reforms: (1) provide fiscal autonomy to government hospitals; (2) secure funding for priority public health programs; (3) promote the development of local health systems and ensure its effective performance; (4) strengthen the capacities of health regulatory agencies; and (5) expand the coverage of the National Health Insurance Program. FOURmula ONE for Health (F1) The FOURmula ONE which is the implementation framework of the HSRA, has three goals: better health outcomes, more responsive health systems and equitable health care financing. The elements of the strategy are: health finaneing, health regulation, health service delivery and good governance. According to the Secretary of Health, F1is the guiding philosophy and strategic approach of the DOH (Foreword, NOH 2005:8).Scanned with CamSesrner National Objectives for Health (NOH) ‘The NOH 2005-2m10 is an important document that refleets the MDGs. MTPDP, HSRAand Fi. includes a statement of vision, mission, prineiples, goalsand objectives, key ideas. targets. indicators and strategies to bring the health sector to its desired outcomes (http:/ /www.doh.gov.ph/noh). ‘The vision ofthe NOH is"health forall Filipinos” and the mission isto ensureaccessibility and quality of health care to improve the quality of life of all Filipinos, especially the poor. The basic principles are: (1) fostering a strong and healthy nation; the performance of the health sector; (3) ensuring universal access to qui health care: and. (4) improving macro-economic and social conditions for better health gains, The goals are: (1) better health outcomes; (2) more responsive health system: and. (3) more equitable health care financing. The medium-term objectives are to: (1) secure inereased, better and sustained investments in health; (2) assure the quality ordability of health goods and services; (3) improve the accessibility and avai of basic and essential health care for all; (3) Improve health systems performance at the national and local level Devolution of health services One of the most significant laws that radically changed the landscape of health care delivery in the country is RA 7160 or more commonly known as the Local Government Code, The Code aims to: transform local government units into sel reliant communities and active partners in the attainment of national goals through a more responsive and accountable local government structure instituted through a system of decentralization. Throughout the country, there are about 79 provinees,133 cities, 1,496 municipalities, and 41, 943 barangays. (http://uww.doh,gov.ph/kp/ statistics /no_cities_prov). Tn 1993. health services were devolved or transferred from the Department of Health to the local government units -- all provincial, district and municipal hospitals to the provincial governments and the rural health units (RHUs) and barangay health stations (BHSs) to the municipal governments. In 1999 there were 2,381 RHUs and 11,393 BHSs (Bautista et al., 2002719). Each provinee, city and municipality has a Local Health Board (LHB). This body is a good venue for making the local health system more responsive to the needs of the people. It is mandated to propose annual budgetary allocations for the operation and maintenance of health facilities and services within the municipality, city or province. At the provincial level, it is composed of the: governor (chair), provincial health officer (vice chair), chairman of the Committee on Health of the Sangguniang Panlalawigan, DOH representative and NGO representative. At the city and municipal level, the LHB is composed of the following: mavor (chair), municipal health officer (vice chair), chair of the Committee on Health of the Sangguniang Bayan, DOH representative and NGO representative. At the municipal level, many publie health nurses have been appointed as DOH representatives. This means that they have been retained by the DOH. Many of them, however, perform dual functions~those of « public health nurse and those of a DOH representative. Many of the local government units “cannot afford” to hire a