CHN Lect - Module 4  the keystone of community health nursing

NURSING PROCESS IN THE CARE OF process

POPULATION GROUPS AND COMMUNITY  the data collected depends on the goals and
objectives of the assessment

COMMUNITY HEALTH ASSESSMENT GOALS OF COMMUNITY HEALTH

ASSESSMENT
COMMUNITY – “Primary client” of the Community  deals with community characteristics in planning
Health Nurse and developing specific programs
 ensures the delivery of effective health services
SIGNIFICANCE OF THE COMMUNITY IN THE
HEALTH CARE SYSTEM SIGNIFICANCE OF COMMUNITY HEALTH
1. It has a direct influence on the health of the 1. Community Health Nurses
individual, families and the sub-populations.  as part of public health function
2. It is at this level that most health service 2. Nursing students
provision occurs.  as a compulsory requirement of the Nursing
curriculum
COMMUNITY HEALTH NURSES 3. Community Health Nurses and Nursing
 deal with community characteristics in planning students
and developing specific programs  Assess the data, analyze and interpret the
 ensuring the delivery of effective health services data and diagnose the health status of the
community
COMMUNITY HEALTH NURSING PROCESS
 A systematic, scientific, dynamic, ongoing Best persons to assess the community’s health
interpersonal process in which the nurses and the condition and status are the community health nurses
clients are viewed as a system with each and Nursing students who interact with them and
affecting one and another and both being observe their social environment.
affected by the factors within the behavior.
 It refers to systematic series of steps which are
followed by public health nurse in community
health and nursing problems using community
approaches and resources.
 Community health nursing uses the nursing
process to prevent disease, prolong life and
promote health and efficiency through holistic,
systematic and organized community activities.
 The use of the nursing process requires the nurse
to apply their knowledge of the science that
describe the natural history of disease, their
causes and treatment and concepts of public
health.

ASSESSMENT
 Process of collecting, organizing, processing,
and analyzing data or information obtained TOOLS FOR COMMUNITY ASSESSMENT
from the client and other sources. 1. Collecting primary data
 data which have not been collected before
COMMUNITY HEALTH ASSESSMENT  data is collected through: observation,
 A process by which community members gain survey, informant interview, focus group
an understanding of the health, concerns, and discussion and community forum.
health care systems of the community by
identifying, collecting, analyzing and
disseminating information on community assets,
strength, resources and needs. (de Belen, 2008)

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OBSERVATION
 done through ocular or windshield observation
 Allows the nurse to take note of the
environmental conditions and existing
community facilities
 Identification of vulnerable groups
 Utilize participant observation (PO) – a
technique or purposeful observation of formal
and informal community activities
 PO helps the nurse determine the community
values, beliefs, norms, priorities, concerns and
power or influence structures
SURVEY
 is made up of a series of questions for systematic
collection of information from a sample of
individuals or families in a community.
 Necessary when there is no available
information about the community or specific
population group
 Appropriate for determining community
attitudes, knowledge, health behaviors and
perceptions of health and health services
 An opportunity for making the members of the
community more aware of community problems
and their effects.
INFORMANT INTERVIEW
 purposeful talks with either key informants or
ordinary members of the community
 Key informants – consist of formal and informal
community leaders or persons of position and
influence
 Can provide the nurse valuable information on
community perceptions about health and health
care.
COMMUNITY FORUM
 an open meeting of the members of the
community
 “Pulong-pulong sa barangay”
COMPONENTS OF COMMUNITY HEALTH
 An effective tool in providing the people with a
NEEDS ASSESSMENT
medium for expressing their views and
1. Health status – health condition, health illness
developing their capacity to influence decision
makers.
 May be a venue for informing the people about
secondary data, for data validation and for
2. Health resources – RHU, BHS, hospitals &
getting feedback from the people.
FOCUS GROUP
3. Health action potential – health implementation
 made up of a much smaller group (6-12
members only)
 This method effective in the assessment of
health needs of specific groups in the
community
2. Secondary data source
 taken from existing sources such as
registries, health records, reports, disease
registries and publications
1. Registry of vital events
 Act 3753 – Civil Registration Law
 RA 7160 – Local Government Code
 PD 856 – Sanitation Code –
requiring a death certificate before
a burial (death should be reported
with 48 hours)
2. Health records and reports
 FHSIS – Field Health Service
Information System
 (ITR, TCL, Summary Table,
Monthly Consolidation Table)
3. Census data
 a periodic governmental
enumeration of the population
 (10 years – Batas Pambansa Blg.
72)
3. Methods to present Community Data
 data may be presented through text, in tables
or in picture form
 Purposes:
 To inform the health team and members
of the community of existing health and
related conditions in the community
 To make members of the community
appreciate the significance and
relevance of health information to their
lives
 To solicit broader support and
participation in the community health
process
 To validate findings
 To provide a basis for better decision
making
pattern and trend (causes of morbidity/
mortality); health knowledge, attitudes,
practice
specialty clinics, equipment & facilities;
manpower resources, financial resources)
and services
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COMMUNITY DIAGNOSIS
DIAGNOSIS
 process of identification of the client’s needs
and problems based on the analysis of data and
or information gathered
COMMUNITY DIAGNOSIS
 the process of determining the health status of
the community and the factors responsible for it.
 a quantitative and qualitative description of the
health of the citizens and factors affecting their
health
 allows the identification of problems and areas
of improvement, thereby stimulating action
SCHEMES IN STATING THE DIAGNOSIS
1. NANDA (North American Nursing Diagnosis
Association)
 nursing diagnostic labels
 more focused on the individual
2. Shuster and Goeppinger
 a format of nursing diagnosis for population
groups
 utilizes a 3-part statement:
a. The health risk or specific problem to
which the community is exposed (Risk)
b. The specific aggregate or community
with whom the nurse will be working to
deal with the risk or problem (Among)
c. Related factors (strength and
weaknesses) that influence how the
community will respond to the health
risk or problem (Related)
3. Omaha System
 a framework for care of individuals, families
and communities by nurses, nursing
educators and physicians and other health
care providers
 a comprehensive and research based
classification system for client problems
that exists in the public domain.
3 COMPONENTS:
1. A problem classification scheme
 serves as a guide in collecting, classifying,
analyzing, documenting and
communicating health and health related
needs and strengths
 Areas of Concern:
 First Level – general level : 4
Domains
 Second level – problems or areas of
concern under the 4 domains
 Third level – the problems or areas of
concern is categorized
o Qualifier 1: Health promotion,
potential problem or actual problem
o Qualifier 2: Levels of clientele
 Fourth level – specific level where
signs and symptoms of actual problems
are clustered
2. An intervention scheme
3. A problem rating scale for outcomes
3 CONDITIONS IN FORMULATING A NURSING
DIAGNOSIS
1. The health status of the community including the
population’s level of vulnerability
2. Community health capability or the ability of the
community to deal with its health problems.
3. Community action potential or the patterns in
which the community is likely to work on its
health problems.
TYPES OF COMMUNITY DIAGNOSIS
1. Comprehensive Community Diagnosis
 aims to obtain a general information about
the community.
 Elements:
A. Demographic Variables
 should show the size, composition
& geographical distribution of the
population.
 Total population
 Age & sex distribution
 Vital indicators e.g. growth rate,
CBR, CDR, life expectancy
 Patterns of migration
 Population projection
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 B. Socio-economic & Cultural Variables
1. Social indicators
 communication
 transportation
 educational level
 housing conditions
2. Economic indicators
 poverty level
 unemployment &
underemployment rates
 types of industry present
 common occupation
3. Environmental indicators
 land areas that contribute to
vector problems
 terrain characteristics, land
usage
 climate/season
 water supply, waste disposal
 air, water land pollution
4. Cultural factors
 Ethnicity, religion
 social class, race
 political orientation
 language
C. Health & Illness Patterns
 leading causes
D. Health Resources
 manpower resources
 material resources
E. Political/ Leadership Patterns
 vital element in achieving the goal
of high level of wellness among the
people. It mirrors the sensitivity of
the government to the people’s
struggle for better lives.
2. Problem- Oriented Community Diagnosis
 type of assessment that responds to a
particular need of a target group
 EX:
 Air pollution
 Improper Disposal of Garbage
 Flooding
 Unsafe water supply
STEPS IN CONDUCTING COMMUNITY
DIAGNOSIS
1. Determining the objectives
2. Defining the Study Population
3. Determining the Data to be collected
4. Collecting the data
5. Developing the instrument
6. Actual data gathering
7. Data Collection
8. Data Presentation - will depend largely on the
type of data obtained.
 Descriptive data – narrative report.
 Numerical data - may be presented into
tables or graphs. Making it easier to show
comparisons including patterns & trends.
9. Data Analysis
10. Identifying the community health nursing
problems
11. Priority Setting.
 Criteria:
a. Nature of condition/problem presented
 Categories of CH Nursing
Problems
1. Health status problems
 increased or decreased
morbidity, mortality,
fertility
 reduced capability for
wellness
2. Health resource problems
 Lack of or absence of
manpower, money,
materials or institutions
necessary to solve health
problems
3. Health-related problems
 social, economic,
environmental and political
factors that aggravate the
illness producing situations
in the community
b. Magnitude of the problem
 severity of the problem that can be
measured in terms of the proportion
of the population affected by the
problem
c. Modifiability of the Problem
 refers to the probability of reducing,
controlling or eradicating the
problem
d. Preventive Potential
 probability of controlling, reducing
the effects posed by the problem
e. Social Concern
 perception of the
population/community as they are
affected by the problem and their
readiness to act on the problem
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 PLANNING COMMUNITY HEALTH
INTERVENTIONS
PLANNING OUTCOMES AND INTERVENTIONS
PLANNING
 A logical step-by-step process in designing a
plan of action to accomplish specific goals and
objectives (desired outcomes)
 It refers to the process of constructing a
program, formula or alternative model that will
be used as a basis for a course of action or
decision.
 "Forecasting" is the essence of planning to
determine whether the plan is short-term or long
term.
 A logical process of decision making to
determine which of the identified health
concerns requires more immediate consideration
(Priority Setting) and what actions maybe
undertaken to achieve goals and objectives
A. PRIORITY SETTING
 provide the nurse and the health team a
logical means of prioritizing
concerns/problems among the health
concerns/problems identified.
Criteria (WHO)
1. Significance of the problem
 should be base on the
number of people in the
community affected
 consider the prevalence rate
for disease conditions
 If a potential problem,
estimate people at risk for
developing the condition
2. Level of community awareness
 degree of concern given by
the community and its
members
 motivation of the
community to deal with the
condition/concerns
3. Ability to reduce risk
 availability of an expert
(from the health team or
community)
 may require the health team'
influence in decision
making related to the
actions to be taken
4. Cost of reducing risk
 the nurse has to consider the
economic, social and ethical
requisites and consequences
of the planned action
5. Ability to identify the target
population
 information coming from the
FHSIS, census, surveys or
case finding can determine
the intended population
6. Availability of resources
 Requires technological,
financial and other resources
of the nurse, health agency
and the community
 may require the accessibility
to external resources
B. FORMULATING GOALS AND OBJECTIVES
 Goal - the desired outcomes at the end of
interventions; long term
 Objectives - the short term changes in the
community as the health team and the
community work towards the attainment of
goals; serve as instructions; more specific
 Specific - manifest a particular behavior
 Measurable - quantifiable indications of
the achievement
 Attainable - in conformity with the
community's resources
 Relevant - realistic, appropriate to the
need or problem of the community
 Time-bounded - has specified target time
or date
Attainment of goals and objectives is more likely
to occur when the community has participated in
the process of identifying and formulating and
has mutual (the nurse and the community)
agreement.
C. DECIDING ON COMMUNITY
INTERVENTIONS
 Each community has it own unique
characteristics, appropriate interventions
should match the particular need of the
community.
 Consider the demographic, psychological,
social, cultural and economic characteristics
of the community and also the available
resources.
 Identify reasons for the people's behavior in
the community to identify strategies to
address these behaviors
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REASONS FOR PLANNING
1. Planning provides more rational decision
making instead of gut-feel decisions or vested
interest considerations.
2. Planning utilizes available resources properly.
3. Planning facilitates the determination of
common goals, objectives and strategies.
4. Planning brings about positive change and
growth in the community.
COMMUNITY ORGANIZING AND SOCIAL
MOBILIZATION
COMMUNITY ORGANIZING (CO)
 A process consists of steps and activities that instill
and reinforce the people's self-confidence on their
own collective strengths and capabilities.
 A process of educating and mobilizing members of
the community to enable them to resolve
community problems.
 A process that promotes the development of
people's autonomy and self-reliance leading to
people empowerment.
3 VALUES WHERE CO IS BASED
1. Human rights
2. Social justice
3. Social responsibility
CORE PRINCIPLES OF COMMUNITY
ORGANIZING
1. Community organizing is people-centered.
 any community organizing endeavor views
the people as the means and end of
development
 the people serve as the instruments in their
own development
2. Community organizing is participative.
 the participation of the community is
ensured in the entire process.
 decision-making and responsibility is in the
hands of the people
 community participation is a critical
condition for success
3. Community organizing is democratic.
 the decision should reflect the will of the
whole especially the common people and the
leaders and the "elite"
4. Community organizing is developmental.
 should be directed towards changing current
undesirable conditions.
 CO promotes empowerment of the
community by gaining insights, honing their
capabilities and development of confidence.
5. Community organizing is process-oriented.
 CO allows organizers to follow a process of
change.
 Monitoring and periodic review of plans is
important.
GOALS OF COMMUNITY ORGANIZING
1. People's empowerment
 CO is aimed at achieving effective power
for the people
 CO allows the people to overcome their
powerlessness
 CO develops the community's capacity to
maximize their control over the situation
2. Building relatively permanent structures and
people's organizations.
 CO aims to establish and sustain permanent
organizational structures that best serve the
needs and aspirations of the people.
 Structures ensure people's maximum
participation and provide a venue which
allows linkages to other groups and sectors.
3. Improved quality of life
 CO seeks to secure short-term and long term
improvements in the quality of life of the
people
 CO facilitates the fulfillment of basic needs
for food, clothing, shelter, education and
HEALTH.
PARTICIPATORY ACTION RESEARCH (PAR)
 An approach to research that aims at promoting
change among the participants.
 Members of the group being studied participate
as partners in all phases of the research
 Introduced around mid-90s as useful tool in
community organizing
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COMMUNITY ORGANIZING PARTICIPATORY
ACTION RESEARCH (COPAR)
 A social development approach that aims to
transform the apathetic, individualistic and
voiceless poor into dynamic, participatory and
politically responsive community.
 A process by which a community identifies its
needs and objectives, develops confidence to
take action in respect to them and in doing so,
extends and develops cooperative and
collaborative attitudes and practices in the
community (Ross, 1967).
 A community development approach that allows
the community (participatory) to systematically
analyze the situation (research), plan a solution
and implement projects/programs (action)
utilizing the process of community organizing.
THE COPAR PROCESS
I. Pre-entry Phase
 Community consultations, meetings,
dialogues
 Setting of issue/considerations related to site
selection
 Development of criteria for site selection
 Conduct of Preliminary Social
Investigation (PSI)
 Networking with LGUs, NGOs & other
departments
II. Entry Phase
 Formalizes the start of the organizing
process
 Courtesy calls to local leaders, elders in
the community, and selection of
contact persons (BHW)
 Gaining entry to the community
 "Padrino" Entry - organizer
gains entry through a "padrino"
or patron
 "Bongga" Entry - organizer
gains entry through "approval"
of the community by exploiting
the weaknesses of the people
(eg. free medicine, donations) -
reinforces "dole-out" mentality
 Integration with the community
 requires immersion in the
community life
 "Pakikipamuhay" - organizer
lives in the community to
understand the community
better and build rapport with the
people
 "Pagbabahay-bahay" or
occasional home visits - observe
daily activities
 "Huntahan" - informal
conversations
 Respect for the community's culture
and tradition
 Manner of dressing in accordance with
the norms of the community
 Sensitization of the community;
information campaigns
 Core Group (CG) formation
 development of criteria for the
selection of CG members
 defining the roles/
functions/tasks of the CG
 Coordination/dialogue/consultation
with other community organizations
 SALT - Self Awareness and Leadership
Training
III. Community Study/Community Diagnosis
Phase (Research Phase)
 Selection of the research team
 Training on data collection methods &
techniques
 Social Analysis - the process of
gathering, collating and analyzing data
to gain extensive understanding of
community conditions, assist in
identification of problems of the
community and determine the root
cause of these problems.
 Presentation of community
study/diagnosis and recommendations
 Community validation
 Prioritization of community
needs/problems
IV. Community Organization and Capacity
Building Phase
 Education & Training
 Community meetings
 Election of officers
 Development of management systems &
procedures
 Team building/trainings of the CHO
officers/community leaders
 Working out legal requirements for the
establishment of CHO.
 Organization of working committees
and tasks groups
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V. Community Action Phase
 Intersectoral Coordination
 Mobilization Phase
 Organization & training of CHWs
(Community Health Workers)
1. development of criteria for the
selection of CHWs
2. selection of CHWs
3. training of CHWs
 Setting up linkages/network referral
systems
 Initial identification & implementation
of resource mobilization schemes.
VI. Sustenance and Strengthening Phase
 Formulation & ratification of
constitution and by laws
 Identification and development of
secondary leaders
 Setting up & institutionalization of a
financing scheme for the community
health program/activities
 Formalizing and institutionalization of
linkages, networks & referral systems
 Development & implementation of
viable committees, management
systems & procedures
 Continuing education & training of
community leaders. CHWs, CHO
members, residents
 Development of medium and long term
community health & development plans.
VII. Termination Phase (Phase Out)
 Organizer should have a clear vision of
end of the process
 "The best entry plan is an exit
plan"(Manalili, 1990)
 Organizer turns over the work and
develops a plan for monitoring
 People’s organization takes over
 Transfer of community organizing roles
and responsibilities and documents
 Indications of Readiness for Exit:
 Attainment of set goals of the
community organizing efforts
 Demonstration of the capacity
of the people's organization to
lead the community
 People empowerment as
manifested by collective
involvement in decision-making
and community action
EVALUATING COMMUNITY HEALTH
PROGRAMS IMPLEMENTED
EVALUATION
 A process that systematically and objectively
assesses compliance to the design of the program,
the performance, relevance and success of a
project or program, the extent to which a project
accomplishes its intended results (outcomes) and
achieves measurable impacts.
 Evaluation of interventions determines the
effectiveness of actions implemented.
 Evaluation also helps in finding out the reasons for
not achieving the desired goal.
APPROACHES TO EVALUATION
1. Structure Evaluation
 involves looking into the manpower and
physical resources of the agency responsible
for community health interventions
2. Process Evaluation
 examines the manner by which assessment,
diagnosis, planning, implementation and
evaluation were undertaken
3. Outcome Evaluation
 determines the degree of attainment of goals
and objectives
STANDARDS OF EVALUATION
1. Utility
 the value of evaluation in terms of usefulness
of results
 results will be of great use to the community
health group
 provide a basis for utilizing the community
health process in dealing with other
community concerns in the future
 prompt dissemination of results is essential
since it promotes:
 identification of barriers; develop
strategies to overcome or minimize these
barriers
 policy changes (eg. budgetary allocation)
 build up of community experience ang
develop confidence or capability to deal
with community concerns
2. Feasibility
 refers to whether the plan for evaluation is
doable or not utilizing the available
resources such as facilities, time and
expertise for conducting the evaluation
 entails anticipation of how the results will be
received by different groups
 should be able to produce results (data)
worthy of the resources needed to collect
and process them
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 3. Propriety
 Ensures that the evaluation is an ethical one,
conducted with regard for the rights and
interests of those involved.
 results should be provided to everyone
involved, especially the community
4. Accuracy
 refers to the validity and reliability of the
results of evaluation
 accurate evaluation requires accurate
documentation
 a high degree of validity and reliability can
be achieved by choosing the right evaluation
tools
PROGRAM EVALUATION
 the systematic collection of information about
the activities, characteristics and outcome of
programs to make judgements about the
program, improve program effectiveness, and/or
inform decisions about future program
development.
 Evaluation findings should be used both to make
decisions about program implementation and to
improve program effectiveness.
STEPS OF PROGRAM EVALUATION
1. Engage stakeholders
2. Describe the program
3. Focus the evaluation design
4. Gather credible evidence
5. Justify conclusion
6. Ensure use of evaluation findings and share
lessons learned
1. ENGAGE STAKEHOLDERS
 Stakeholders people who care about what will be
learned from the evaluation and about
 what will be done with the knowledge gained.
 2 types of stakeholders :
 those involved in the program
 those affected by the program
 Including stakeholders in evaluation planning
and implementation is one way to ensure a
quality evaluation to meet evaluation standards.
 Standards:
 Utility
 Propriety
2. DESCRIBE THE PROGRAM
 explains what the program is trying to
accomplish and how it tries to bring about those
changes
 outlines the foundation to ensure a well thought
out program evaluation
 Standards:
 Accuracy
 Propriety
3. FOCUS THE EVALUATION DESIGN
 developing a well-focused plan or strategy to
improve the usefulness of the evaluation to
intended audiences
 It ensures that the evaluation design meets the
needs of all users, that the process answers the
questions that have been raised
 Standards:
 Utility
 Feasibility
 Accuracy
 Propriety
4. GATHER CREDIBLE EVIDENCE
 presenting meaningful results
 It ensures that the benefits of evaluation (the
uses of this information) are clear to all
stakeholders and that the processes followed
meet everyone’s agreement.
 Standard:
 Accuracy
5. JUSTIFY CONCLUSION
 involves interpreting evaluation results so that
they make sense to all stakeholders and reflect
stakeholders’ values about what is important.
 Standards:
 Utility
 Accuracy
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6. ENSURE USE OF EVALUATION FINDINGS
AND SHARE LESSONS LEARNED
 ensures that the lessons learned from an
evaluation are shared in such a way as to
influence program decisions, policy makers, and
community-based initiatives.
 Standards:
 Utility
 Propriety
 Accuracy

GOAL OF THE COMMUNITY HEALTH

NURSING PROCESS

HEALTHY AND EMPOWERED COMMUNITY

(GOAL)

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