CHAPTER 1

I. Community Health Nursing Concepts

A. Definition
 “The utilization of the nursing process in the different levels of clientele-
individuals, families, population groups and communities, concerned with
the promotion of health, prevention of disease and disability and
rehabilitation.” ( Maglaya, et al)

 Special field of nursing that combines the skills of nursing, public health
and some phases of social assistance and functions as part of the total
public health program for the promotion of health, the improvement of the
conditions in the social and physical environment, rehabilitation of illness
and disability ( WHO Expert Committee of Nursing)

 A learned practice discipline with the ultimate goal of contributing as

individuals and in collaboration with others to the promotion of the client’s
optimum level of functioning thru’ teaching and delivery of care (Jacobson)
 A service rendered by a professional nurse to IFCs, population groups in
Health centers, clinics, schools, workplace for the promotion of health,
prevention of illness, care of the sick at home and rehabilitation (DR. Ruth
B. Freeman

B. Philosophy and Principles

“The philosophy of CHN is based on the worth and dignity of man.”(Dr. M.
Shetland)

Principles of CHN:
 The community is the patient in CHN, the family is the unit of care and
there are four levels of clientele: individual, family, population group (those
who share common characteristics, developmental stages and common
exposure to health problems – e.g. children, elderly), and the community.
 In CHN, the client is considered as an ACTIVE partner NOT
PASSIVE recipient of care
 CHN practice is affected by developments in health technology, in
particular, changes in society, in general
 The goal of CHN is achieved through multi-sectoral efforts
 CHN is a part of health care system and the larger human services system

C. Features of CHN
Characteristics of Community Health Nursing:
There are six important characteristics of community nursing; those are
mentioned in the following:
  It is a specialty field of nursing.
 Its practice combines public health with nursing.
 It is population based.
 It emphasizes on wellness and other than disease or Illness.
 It includes inter-disciplinary collaboration.
 It amplifies client’s responsibility and self-care.

D. Theoretical models/ approaches

1. Health belief model (HBM)
 This model is based on the premise that for a behavioral change to
succeed, individuals must have the incentive to change, feel threatened by
their current behavior, and feel that a change will be beneficial and be at
acceptable cost.
 They must also feel competent to implement that change.
 The purpose of the model is to explain and predict preventive health
behavior.
 The Health Belief Model
o Initially proposed in 1958, the model provides the basis for much of
the practice of health education and promotion today.
o This model found that information alone is rarely enough to
motivate people to act for their health. Individuals must know what
to do and how to do it before they can take action.

Concept Definition
Perceived susceptibility One’s belief regarding the
chance of getting a
given condition
Perceived severity One’s belief in the seriousness
of a given condition
Perceived benefits One’s belief in the ability of an
advised action to
reduce the health risk
or seriousness of a
given condition
Perceived barriers One’s belief regarding the
tangible and
psychological costs
of an advised action
Cues to an action Strategies or conditions in one’s
 environment that
activate readiness to
take action
Self-efficacy One’s confidence in one’s
ability to take action to
reduce health risks

 The model’s concepts all relate to the client’s perceptions

 For example: the cue to action in the prevention of dengue fever may be
provided through an information campaign. This makes the people in a
barangay aware of the disease and that everyone is susceptible to the
possibly fatal disease. The HBM would be used by the nurse to help clients
in making behavior modifications to avoid dengue.

2. Milio’s Framework for Prevention

Milio’s Framework for Prevention
 Nancy Milio developed a framework for prevention that includes concepts
of community – oriented, population- focused care.
 Milio stated that behavioral patterns of the populations-and individuals
who make up populations – are a result of habitual selection from limited
choices.
 She challenged the common notion that a main determinant for
unhealthful behavioral choice is lack of knowledge.
 Milio’s framework described a sometimes neglected role of community
health nursing to examine the determinants of a community’s health and
attempt to influence those determinants through public policy.
Levels of Prevention Model
 This model, advocated by Leavell and Clark in 1975, has influenced both
public health practice and ambulatory care delivery worldwide.
 This model suggests that the natural history of any disease exists on a
continuum, with health at one end and advanced disease at the other.
 The model delineates three levels of the application of preventive
measures that can be used to promote health and arrest the disease
process at different points along the continuum.
 The goal is to maintain a healthy state and to prevent disease or injury.
It has been defined in terms of four levels:
 Primordial prevention
 Primary prevention
  Secondary prevention
 Tertiary prevention

Primordial prevention
 Prevention of the emergence or development of risk factors in population
or countries in which they have not yet appeared.
 Efforts are directed towards discouraging children from adopting harmful
lifestyles.
Primary prevention
 An action taken prior to the onset of disease, which removes the
possibility that the disease will ever occur.
 It includes the concept of positive health that encourages the achievement
and maintenance of an “acceptable level of health that will enable every
individual to lead a socially and economically productive life.
Secondary prevention
 Action which halts the progress of a disease at its incipient stage and
prevents complications.
 The domain of clinical medicine.
 An imperfect tool in the transmission of disease.
 More expensive and less effective than primary prevention.
Tertiary prevention
 All measures available to reduce or limit impairment and disabilities,
minimize suffering caused by existing departures from good health and to
promote the patient's adjustment to irremediable conditions.

3. Nola Pender’s Health Promotion

Nola Pender’s Health Promotion Model theory was originally published in

1982 and later improved in 1996 and 2002. It has been used for nursing
research, education, and practice. Applying this nursing theory and the
body of knowledge that has been collected through observation and
research, nurses are in the top profession to enable people to improve
their well-being with self-care and positive health behaviors.

The Health Promotion Model

 Designed to be a “complementary counterpart to models of health

protection.”
 It develops to incorporate behaviors for improving health and
applies across the life span. Its purpose is to assist nurses in
 knowing and understanding the major determinants of health
behaviors as a foundation for behavioral counseling to promote
well-being and healthy lifestyles.
 Defines health as “a positive dynamic state not merely the absence
of disease.” Health promotion is directed at increasing a client’s
level of well-being. It describes the multi-dimensional nature of
persons as they interact within the environment to pursue health.
 The model focuses on the following three areas:
o individual characteristics and experiences,
o behavior-specific cognitions and affect,
o Behavioral outcomes.

Major Concepts of the Health Promotion Model

Individual characteristics and experiences (prior related behavior and

personal factors).

Behavior-specific cognitions and affect (perceived benefits of action,

perceived barriers to action, perceived self-efficacy, activity-related affect,
interpersonal influences, and situational influences)

Behavioral outcomes (commitment to a plan of action, immediate

competing demands and preferences, and health-promoting behavior).

Sub concepts of the Health Promotion Model

A. Personal Factors

Personal factors categorized as biological, psychological and socio-

cultural. These factors are predictive of a given behavior and shaped by
the nature of the target behavior being considered.

 Personal biological factors. Include variables such as age gender

body mass index pubertal status, aerobic capacity, strength, agility, or
balance.
 Personal psychological factors. Include variables such as self-
esteem, self-motivation, personal competence, perceived health status,
and definition of health.
  Personal socio-cultural factors. Include variables such as race,
ethnicity, acculturation, education, and socioeconomic status.
B. Perceived Benefits of Action
Anticipated positive outcomes that will occur from health behavior.

C. Perceived Barriers to Action

Anticipated, imagined or real blocks and personal costs of understanding

a given behavior.

D. Perceived Self-Efficacy

Judgment of personal capability to organize and execute a health-

promoting behavior. Perceived self-efficacy influences perceived barriers
to action so higher efficacy results in lowered perceptions of barriers to the
performance of the behavior.

E. Activity-Related Affect

Subjective positive or negative feeling that occurs before, during and

following behavior based on the stimulus properties of the behavior itself.

Activity-related affect influences perceived self-efficacy, which means the

more positive the subjective feeling, the greater the feeling of efficacy. In
turn, increased feelings of efficacy can generate a further positive affect.

F. Interpersonal Influences

Cognition concerning behaviors, beliefs, or attitudes of the others.

Interpersonal influences include norms (expectations of significant others),
social support (instrumental and emotional encouragement) and modeling
(vicarious learning through observing others engaged in a particular
behavior). Primary sources of interpersonal influences are families, peers,
and healthcare providers.

G. Situational Influences

Personal perceptions and cognitions of any given situation or context that

can facilitate or impede behavior. Include perceptions of options available,
demand characteristics and aesthetic features of the environment in which
given health promoting is proposed to take place. Situational influences
may have direct or indirect influences on health behavior.
 H. Commitment to Plan of Action

The concept of intention and identification of a planned strategy leads to

the implementation of health behavior

I. Immediate Competing Demands and Preferences

Competing demands are those alternative behaviors over which

individuals have low control because there are environmental
contingencies such as work or family care responsibilities. Competing
preferences are alternative behaviors over which individuals exert
relatively high control, such as choice of ice cream or apple for a snack

J. Health-Promoting Behavior

A health-promoting behavior is an endpoint or action outcome that is

directed toward attaining positive health outcomes such as optimal
wellbeing, personal fulfillment, and productive living

Major Assumptions in Health Promotion Model

 Individuals seek to actively regulate their own behavior.

 Individuals in all their biopsychosocial complexity interact with the
environment, progressively transforming the environment and being
transformed over time.
 Health professionals constitute a part of the interpersonal environment,
which exerts influence on persons throughout their life span.
 Self-initiated reconfiguration of person-environment interactive patterns
is essential to behavior change.
Propositions
 Prior behavior and inherited and acquired characteristics influence
beliefs, affect, and enactment of health-promoting behavior.
 Persons commit to engaging in behaviors from which they anticipate
deriving personally valued benefits.
 Perceived barriers can constrain commitment to action, a mediator of
behavior as well as actual behavior.
 Perceived competence or self-efficacy to execute a given behavior
increases the likelihood of commitment to action and actual
performance of the behavior.
  Greater perceived self-efficacy results in fewer perceived barriers to a
specific health behavior.
 Positive affect toward a behavior results in greater perceived self-
efficacy, which can, in turn, result in increased positive affect.
 When positive emotions or affect are associated with a behavior, the
probability of commitment and action is increased.
 Persons are more likely to commit to and engage in health-promoting
behaviors when significant others model the behavior, expect the
behavior to occur, and provide assistance and support to enable the
behavior.
 Families, peers, and health care providers are important sources of
interpersonal influence that can increase or decrease commitment to
and engagement in health-promoting behavior.
 Situational influences in the external environment can increase or
decrease commitment to or participation in health-promoting behavior.
 The greater the commitments to a specific plan of action, the more likely
health-promoting behaviors are to be maintained over time.
 Commitment to a plan of action is less likely to result in the desired
behavior when competing demands over which persons have little
control require immediate attention.
 Commitment to a plan of action is less likely to result in the desired
behavior when other actions are more attractive and thus preferred over
the target behavior.
 Persons can modify cognitions, affect, and the interpersonal and
physical environment to create incentives for health actions
Strengths and Weaknesses
Strengths
 The Health Promotion Model is simple to understand yet it is complex in
structure.
 Nola Pender’s nursing theory gave much focus on health promotion and
disease prevention making it stand out from other nursing theories.
 It is highly applicable in the community health setting.
 It promotes the independent practice of the nursing profession being the
primary source of health promoting interventions and education.

Weaknesses
  The Health Promotion Model of Pender was not able to define the nursing
metaparadigm or the concepts that a nursing theory should have, man,
nursing, environment, and health.
 The conceptual framework contains multiple concepts which may
invite confusion to the reader.
 Its applicability to an individual currently experiencing a disease state was
not given emphasis.

4. Lawrence Green’s PRECEDE-PROCEED – MODEL

PRECEDE/PROCEED model
 PRECEDE/PROCEED model is a widely used model in public health for bringing
change in behavior.
PRECEDE stands for: PROCEED Stands for:
P – Predisposing, P – Policy,
R- Reinforcing, R – Regulatory,
E – Enabling, O – Organizational,
C – Construct in, C – Construct in,
E- Educational, E – Educational and
D – Diagnosis and E – Environmental,
E – Evaluation. D – Development.

 PRECEDE model was put forward by Lawrence W. Green and colleagues in year
1970s. Further in year 1991, PROCEED was added to the model encompassing
policy, regulatory and recognizing environmental factor as an important
determinant of health and behavior of individuals.
 It emphasized on improving health of people by bringing change in health related
behavior.
 This model is used for implementing programs and for carrying out behavior
change interventions.
 PRECEDE/PROCEED model is used in planning, implementing and evaluating
behavior change program in order to promote and protect health.

Purpose of PRECEDE/PROCEED model:

 It provides structural framework for developing behavior change intervention.
 This model is also used for monitoring and evaluating the intervention program.
  It is participatory model and involves community participation.
 Content, methods/media for a particular program is selected according to need.

Phases of PRECEDE/PROCEED Framework

PHASE 1: Social diagnosis
 In this phase, social problem that can affect the quality of life of target population
are identified and evaluated.
 During this phase, programmer try to figure out the connection between social
problem and quality of life affected resources availability, needs of given
population, readiness of community people towards the change and determine
desired outcome.
 Information regarding social problem is gained by using various methods such as
interview, focus group discussion, surveys, community forums etc.
PHASE 2: EPIDEMIOLOGICAL DIAGNOSIS
 Health problems associated with quality of life is determined in epidemiological
diagnosis.
 Primary or secondary source data are used for acquiring required information.
 It seeks to identify the specific health problems and non-health factors associated
with poor quality of life.
 Health problems are described on the basis of time, place and person.
 Priorities are set within health problem and with target population.
 Epidemiological data includes vital statistics, disability, incidence, prevalence etc.
PHASE 3: Behavioral and environmental assessment
 Behaviors, practices, lifestyle, environmental factors are determined affecting
health problem identified in phase 2.
 This assessment facilitate planner to prioritize behavior which will be targeted in
intervention program.
 Behavioral diagnosis analyzes behaviors that influence the problem identified in
phase 1 and 2.
 Environmental diagnosis analyzes physical and social environment that would
affect the behavior of the individual.
 Non behavioral factors include factors such as climate, workplace, availability and
adequacy of health institutions.
PHASE 4: Educational diagnosis
 In this phase, predisposing, reinforcing and enabling factor that may support or
form barrier to changing environment.
Predisposing factor
It includes any characteristics of individual or population that affects personal motivation
to bring change in their behavior. It includes:
 Knowledge
  Beliefs
 Values
 Attitudes
 Norms etc.
E.g. believe that smoking harmful for health.
Reinforcing factors
Reinforcing factors are feedbacks from others which may be positive or negative;
continued reward, incentive can motivate repetition of certain behavior. It includes:
 Reward/Punishment
 Peer influence
 Teacher
 Family etc.
E.g. peer pressure for smoking.
Enabling factors
They are social and environmental factors that enable motivation attain specific
behavior.
 Availability
 Access
 Health related laws
 Resources
 Skills
E.g. cigarette is readily available in market.
PHASE 5: Administrative and policy diagnosis
 It identifies administrative and policy factors which should be focused before
program implementation.
 Policy diagnosis: it analyzes if goals/ objective of program is compatible with that
of organization.
 Administrative diagnosis: it analyses policies, resources in organizational situation
that facilitate or hinder development of program.
PHASE 6: Implementation of program
 In this phase, planned program is put into action in targeted population.
PHASE 7: Process evaluation
 In process evaluation, implementation process is evaluated; it helps to determine
if the program is being conducted as planned and helps to bring modification if
necessary to improve the program.
PHASE 8: Impact evaluation
 This evaluation is carried out immediately after implementation of program.
  It helps to determine effectiveness and efficiency of the program as well as
change in predisposing, reinforcing and enabling factors.
PHASE 9: Outcome evaluation
 It evaluates if the program implemented produce effect favorable to outcomes
identified in phase 1.
 It measures achievement of overall objective of program and change in quality of
life.
 It determines effect of program in health and quality of life of the community.

E. Different Fields of Community Health Nursing

1. School Health Nursing
 School Nursing is a type of public health nursing that focuses on the
promotion of health and wellness of pupils/students, teaching and non-
teaching personnel of the school.
 Assist young people in making choices for a healthy lifestyle, reduce risk
taking behavior and focus on issues such as prevention of drugs and
substance abuse, teenage pregnancy, sexually transmitted infection,
malnutrition, communicable and non-communicable disease.
Objectives:

General: To promote and maintain the health of the school and

populace by providing comprehensive quality nursing care.

Specific:
1. Provide quality nursing service to the school population
2. Create awareness among school children, personnel and
administration on the importance of the promotive and preventive
aspects of health through health education.
3. Encourage the provision of standard functional facilities.
4. Provide nursing personnel with opportunities for continuing
education and training
5. Conduct and participate in researches related to nursing, and
6. Establish/ strengthen linkages with government and non-
government organization/agencies for school community health
work.

Duties and Responsibilities:

1. Health Advocacy
 2. Health and nutrition assessment including other screening procedures
such as vision and hearing
3. Supervision of the health and safety of the school plant.
4. Treatment of common ailments and attending to emergency cases.
5. Referrals and follow-up of pupils and personnel
6. Home visits
7. Community outreach like attending community assemblies and
organizing school community health councils.
8. Recording and reporting accomplishments.
9. Monitoring and evaluation of programs and projects.

Functions:
A. School Health and Nutrition Survey
 This shall done initially to provide data for evaluation and for
planning purposes.
 Survey shall include among others the current health and nutritional
status of school children, situation on health facilities as well as
actual status of health education activities undertaken by the
teachers and health personnel

B. Putting up a Functional School Clinic

 R.A 124 mandates that all the schools are to provide school clinics
for the treatment of minor ailments and attendance of emergency
cases.
C. Health Assessment
 Aims to discover the signs of illness and physical defects in order to
correct them, check on the health habits of pupils and prevent the
progress of those which cannot be corrected.

D. Standard Vision Testing for School children


E. Ear examination
F. Height and Weight Measurement and Nutritional Status Determination
G. Medical Referrals
H. Attendance to Emergency cases
I. Student Health Counselling
J. Health and Nutrition Education Activities
K. Organization of School Community Health and Nutrition Councils.
L. Communicable Disease Control
M. Establishment of Data Bank on school health and Nutrition Activities.
N. School Plant Inspection for Healthy Environment
O. Rapid classroom inspection.
P. Home Visitation
 The school nurse visits four to six schools per month, with each visit lasting
for 3 days or more, depending on the type of school and school location and
population.
 Revisits may be done within the month in a particular school.
 Teachers who also serve as school guardians, provide primary care as
necessary. Such as detection of obvious health problems and administration
of first aid.
 The school nurse is responsible for planning and conducting training
programs for teachers on health and nutrition.
 Poverty is associated with decreased or inferior health care and has been
linked to serious health problems that result in absenteeism and failure in
school.
 The school nurse and in the absence of the school nurse, the well-prepared
school teacher, serving as school health guardian, can effectively manage
minor complaints of illnesses, helping these children to return to or remain in
class.
 There is a need for mental and physical health services for student of all ages
in an effort to improve both academic performance and the sense of well-
being.

 School health program were defined as :

1. School health services
2. School health education
3. A healthy school environment to include both physical and
psychosocial aspects of environment( WHO, 1997)

 RA 124 in 1947- an act to provide for Medical Inspection of Children

Enrolled in Private Schools, Colleges and Universities in the Philippines.
This law stated that it was the duty of the school heads of private
schools with a total enrolment of 300 or more to provide for a part-or full
time physician for the annual medical examination of pupils and
students.
 The physicians were to render of their school health activities at the end
of every quarter of each school year to the Director of Health.

 SCHOOL HEALTH SERVICES:

 Health Education- these are culture sensitive and based on the
identified educational needs of the target population.
Areas of concern for health education:
 1. Oral Hygiene- the oral health care program involves the 7 o‘clock tooth
brushing habit activity.
2. Injury prevention and developing safety conscious behavior in the use of
the school playground, while engaging in sports, and the like. MAPEH
period is a good time for the school nurse or teacher to talk with and
counsel students about risk of developing health problems related too
physical activity.
3. Tobacco Use- Smoking is a major problem in this country.
- Prevention should be emphasized in young people.
4. Substance Abuse- The use of alcohol and other drugs is associated with
problems in schools, injuries and violence, and motor vehicle deaths.
- National Drug Education Program- designed to promote collaboration of
other sectors with the school system by establishing linkages among
government, private and socio-civic organizations.
- Random drug testing is also carried as part of this program.
5. HIV, AIDS- School-base HIV and AIDS Education and prevention program
is an information dissemination campaign to educate the general
Population on the risks of HIV and AIDS.

EIGHT COMPONENTS OF SCHOOL HEALTH RPOGRAMS

Health Physical Health Nutrition

education Education Services Services
Family and
Counseling, Healthy Health community
psychological school promotion for involvement
and social environment staff
services

 Physical Education - Sedentary lifestyle is associated with obesity,

hypertension, heart disease and diabetes
- Regular Physical activity helps build and maintain healthy bones and
muscles.
  Health services
1. Health Screening- one of the objective of the school health nursing
program in the Philippines is to detect early signs and symptoms of illness,
disabilities and deviations from normal.
a. Annual Individual health assessment- examination of the eyes, ears, nose,
throat, neck, mouth, skin, extremities, posture, nutritional status, heart and
lungs.
b. Visual acuity test is done with the use of Snellen’s chart, E-chart or symbol
chart.
c. Ball pen click test (auditory screening) - test for hearing acuity.

d. Height and weight measurement- done at the beginning and at the end of
the school year.
e. Rapid Classroom Inspection- inspection of the pupils in the classroom or
while they are in line formation outside the classroom.
b) Done to detect illness, particularly when there is outbreak in the community.
 Emergency Care- emergencies can include natural events such as
typhoons, floods, and earthquake and man-made disasters, such as
hazardous material spills, fires and civil disobedience.
- Basic first aid equipment should be available in all schools.
- The school nurse and school health guardians must be knowledgeable
about standard first aid.
- EMS activation and Referral system should be in place.
 Nutrition- a variety of foods must be ingested to meet their daily
requirement.
- Diets should include a proper balance of carbohydrates, proteins, and
fats with sufficient intake of vitamins and minerals. S
- Skipping meals, especially breakfast and eating unhealthy snacks
contribute to poor childhood nutrition.
- Food preparation is expected to be undertaken by the home economics,
feeding teachers, homeroom Parent-Teachers Association on a rotation
basis or both.
 Obesity – not considered as an eating disorder
- must be of concern to the school nurse
- 3 most common eating disorder:
1. Anorexia- severely restricted intake of food
based on an extreme fear of weight gain.
2. Bulimia- chaotic eating pattern with recurrent
episodes of binge eating.
 3. Binge eating-out of control eating of large
amounts of food whether hungry or not.

 Counseling, Psychological and social services- children and teens

struggle with depression, substance abuse, conduct disorders, self-
esteem, suicide ideation, eating disorders and under or
overachievement.
- One of the most important roles of the nurse with various vague
complaints, such as recurrent stomachaches, headaches, or
sexually promiscuous behavior.
- Early detection and treatment may prevent untoward
consequences.
- It is important for the nurse to be cognizant of the warning signs
associated with suicide and to recognize and refer at-risk
adolescents to appropriate mental health professionals.
-
 Healthy School Environment- the healthy school environment should consist of
(WHO, 1997)
1. A Physical, psychological and social environment
2. A healthy organizational culture within the school
3. Productive interaction between the school and community.
 Health Promotion for school staff- staff that participate in health promotion
increase their health knowledge and positively change their attitudes and
behaviors relative to smoking practices, nutrition, physical activity, stress and
emotional health.

Truths about adolescent suicide

1. Most adolescent who attempt suicide are torn between wanting to die and
wanting to live
2. Any threat of suicide should be taken seriously
3. There are usually warning signs preceding an attempt(depression, isolation,
sleep changes)
4. Suicide is more common in adolescents than Homicide
5. Education concerning suicide
6. Does not lead to an increased number of attempts.
7. Females are more likely to attempt suicide. Males are more likely to suicide
8. One attempt can result in a subsequent attempt
9. Firearms and strangulation are predominant modalities of completed suicides
in children and adolescents.
10. Most adolescents who attempted suicide have not been diagnoses as having
mental disorder.
11. All socioeconomic groups are affected by suicide.
Warning Signs Of Stress

 Difficulty eating or sleeping

 Use of alcohol or other substances(sedatives, sleep enhancer)
 Difficulty in making decisions
 Persistent angry or hostile feelings
 Inability to concentrate
 Increased boredom
 Frequent headaches and ailments
 Inconsistent school attendance

 Healthy School Environment- the healthy school environment should consist of

(WHO, 1997)
4. A Physical, psychological and social environment
5. A healthy organizational culture within the school
6. Productive interaction between the school and community.
 Health Promotion for school staff- staff that participate in health promotion
increase their health knowledge and positively change their attitudes and
behaviors relative to smoking practices, nutrition, physical activity, stress and
emotional health.

Standards of school nursing practice

Standards Of Practice

Standard 1. Assessment Nurse collects comprehensive data

pertinent to the clients health or the
situation

Standard 2. Diagnosis Nurse analyzes the assessment data to

determine the diagnoses or issues

Standard 3. Outcomes identification Nurse identifies expected outcome for a

plan individualized to the client or the
situation

Standard 4. Planning School nurse develops a plan that

prescribes strategies and alternatives to
attain expected outcome.

Standard 5 A. Coordination of care Nurse provides health education and

employs strategies to promote health and
 a safe environment.

Standard 5 B. health teaching and Nurse provides health education and

health promotion employs strategies to promote health and
a safe environment.

Standard 6. Evaluation School nurse evaluates the client’s

progress towards attainment of
outcomes.

Standards of professional performance

Standard 7. Quality of practice School nurse systematically enhances

the quality and effectiveness of nursing
practice

Standard 8. Education School nurse attains knowledge and

competency that reflects current school
nursing practice.

Standard 9. Profession practice Nurse evaluates ones own nursing

evaluation practice

Standard 10. Collegiality Nurse interacts with to the professional

development of peers and school
personnel as colleagues.

Standard 11. Collaboration School collaborates with the client, family,

school, staff

Standard 12. Ethics School nurse integrates ethical provision

in all areas of practice.

Standard 13. Research School nurse integrates research findings

into practice.

Standard 14. Resource utilization School nurse considers factors related to

safety, effectiveness, cost and impact.

Standard 15. Leadership School nurse provides leadership in the

professional practice setting and the
profession

Standard 16. Program Management Manages school health services.

 School Nursing Practice- is a specialty unto itself. School nurses need education
in specific areas, such as growth and development, public health, mental health
nursing, case management, family theory, leadership and cultural sensitivity to
effectively perform their roles.

2. Occupational Health Nursing

OCCUPATIONAL HEALTH

 Occupational Health Nursing is defined as a specialty practice that focuses on

the promotion, prevention, and restoration of health within the context of a safe
and healthy environment. It includes the prevention of adverse health effects
from occupational and environmental hazards.

 Department of Labor and Employment – the lead agency on Occupational

Safety and Health

 They are given RULE MAKING and RULE ENFORCEMENT powers to

implement stipulations of the Philippine Constitution and the Philippine Labor
Code.

 The National Profile on Occupational Safety and Health (of the Department of
Labor and Employment – Occupational Safety and Health Center (OSHC) –
defined OSH as a discipline involved in “the promotion and maintenance of the
highest degree of physical, mental and social well-being of workers in all
occupations.”

EVOLUTION OF OCCUPATIONAL HEALTH NURSING IN THE PHILIPPINES

 MS. MAGDALENA VALENZUELA – she instituted the INDUSTRIAL NURSING

UNIT of the Philippine Nurses Association on November 11, 1950.

 MS. PERLA GORRES – from the Philippine Manufacturing Company (PMC)

served as the first chairperson of the said unit.
  MS. ANITA SANTOS – was elected as first president on August 19, 1964. She
paved way to the modification in the name of the organization to Occupational
Health Nurses Association of the Philippines, Inc. on November 12, 1966.

 June 5 – 6, 1970 – first annual convention was held.

 September 25, 1979 – the organization was registered with the Securities and
Exchange Commission.

ASSESSMENT AND CONTROL OF HAZARDS IN THE WORKPLACE

 HEALTH HAZARDS – are the elements in the work environment that can cause
work-related disease.
 SAFETY HAZARDS – are the unsafe conditions or unsafe acts that significantly
increase the risk of a worker to be injured.

TYPES OF HAZARDS:
1. Biological-infectious hazards – infectious agents such as bacteria, viruses, fungi.
2. Chemical hazards – various forms of chemical agents.
3. Enviromechanical hazards – factors that cause accident, injuries, strains or
discomfort (eg. Poor equipments)
4. Physical hazards – radiation, electricity, temperature, and noise
5. Psychosocial hazards – anything that causes emotional stress and strain or
interpersonal problem.

CONTROL MEASURES FOR OCCUPATIONAL HAZARDS:

1. Administrative Control – refers to the development and implementation of
policies, standards, trainings, job design and the like.
2. Engineering – refers to the adoption of physical, chemical or technological
improvements to limit exposure to hazards.
3. Materials Provision – refers to providing the workers with supplies or
supplements that can decrease their exposure to hazards.

DUTIES OF OCCUPATIONAL HEALTH NURSE as stated in Rule 1965.04 of the

amended OSHS by DOLE:

“The duties and functions of the Occupational Health Nurse are:

(1) In the absence of a physician, to organize and administer a health service program
integrating occupational safety, otherwise, these activities of the nurse shall be in
accordance with the physician;

(2) Provide nursing care to injured or ill workers;

(3) Participate in health maintenance examination. If a physician is not available, to
perform work activities which are within the scope allowed by the nursing profession,
and if more extensive examinations are needed, to refer the same to a physician;

(4) Participate in the maintenance of occupational health and safety by giving

suggestions in the improvement of working environment affecting the health and well-
being of the workers; and

(5) Maintain a reporting and records system, and, if a physician is not available, prepare
and submit an annual medical report, using form DOLE/BWC/HSD/OH-47, to the
employer, as required by this Standards.

CODE OF ETHICS OF THE AMERICAN ASSOCIATION OF OCCUPATIONAL

HEALTH NURSES:

1. The American Association of Occupational Health Nurses (AAOHN) articulates

occupational and environmental health nursing values, maintains the integrity of our
specialty practice area and the nursing profession, and integrates principles of social
justice into nursing and health policy

2. The occupational and environmental health nurse (OHN) practices with compassion
and respect for the inherent dignity, worth, and unique attributes of every person.

3. The occupational and environmental health nurse's (OHN) primary commitment is to

the client, whether an individual, group, community, or population.

4. The occupational and environmental health nurse (OHN) promotes, advocates for,
and protects the rights, health, and safety of the client.

5. The occupational and environmental health nurse (OHN) has authority,

accountability, and responsibility for nursing practice; makes decisions; and takes action
consistent with the obligation to prevent illness and injury, promote health, and provide
optimal health care.

6. The occupational and environmental health nurse (OHN) owes the same duties to
self as to others, including the responsibility to promote health and safety, preserve
wholeness of character and integrity, maintain competence, and continue personal and
professional growth.

7. The occupational and environmental health nurse (OHN), through individual and
collective effort, establishes, maintains, and improves the ethical environment of the
work setting and conditions of employment that are conducive to safe, quality health
care.

8. Occupational and environmental health nurses (OHN) help advance the nursing
profession and our specialty practice through research and scholarly inquiry,
professional standards development, and the generation of nursing and health policy.

9. The occupational and environmental health nurse (OHN) collaborates with other
health professionals and the public to protect human rights, promote health, and reduce
health disparities.

COMPETENCY CATEGORY IN OCCUPATIONAL AND ENVIRONMENTAL HEALTH

NURSING by AAOHN

1. Clinical and primary care

2. Case management
3. Workforce, workplace and environmental issues
4. Regulatory and legislative
5. Management
6. Health promotion and disease prevention
7. Occupational and environmental health and safety education and training
8. Research
9. Professionalism

IMPACT OF LEGISLATION ON OCCUPATIONAL HEALTH:

The DOLE possesses legislative and rule-making powers with regards to the following
laws and standards:
1. Presidential Decree 442 Philippine Labor Code on prevention and compensation
2. The Administrative Code on Enforcement of Safety and Health Standards
3. The Occupational Safety and Health Standards
4. Executive Order 307
5. Presidential Decree 626
6. RA 9165 or the Comprehensive Drug Act
7. RA 8504 of the National HIV/AIDS Law
8. DOH: Sanitation Code
9. DA: Fertilizer and Pesticide Act
10. DENR: RA 6969
11. RA 9185 or the Comprehensive Dangerous Drug Act
12. RA 6541 of the National Building Code of the Philippines
13. RA 9231 or the Special Protection of Children against Child Abuse, Exploitation
and Discrimination

THE PHILIPPINE LABOR CODE (PD 442)

- Aims to protect every citizen desiring to work locally or overseas by securing the
best possible terms and conditions of employment.
 - Under Article 6, all rights and benefits granted to workers under this Code shall,
except as may otherwise be provided herein, apply alike to all workers, whether
agricultural or non-agricultural.

WORKING CONDITIONS AND REST PERIODS:

Article 83. Normal hours of work. The normal hours of work of any employee shall not
exceed eight (8) hours a day.

Health personnel in cities and municipalities with a population of at least one million
(1,000,000) or in hospitals and clinics with a bed capacity of at least one hundred (100)
shall hold regular office hours for eight (8) hours a day, for five (5) days a week,
exclusive of time for meals, except where the exigencies of the service require that such
personnel work for six (6) days or forty-eight (48) hours, in which case, they shall be
entitled to an additional compensation of at least thirty percent (30%) of their regular
wage for work on the sixth day. For purposes of this Article, "health personnel" shall
include resident physicians, nurses, nutritionists, dietitians, pharmacists, social workers,
laboratory technicians, paramedical technicians, psychologists, midwives, attendants
and all other hospital or clinic personnel.

Article 84. Hours worked. Hours worked shall include (a) all time during which an
employee is required to be on duty or to be at a prescribed workplace; and (b) all time
during which an employee is suffered or permitted to work.

Rest periods of short duration during working hours shall be counted as hours worked.

Article 85. Meal periods. Subject to such regulations as the Secretary of Labor may
prescribe, it shall be the duty of every employer to give his employees not less than
sixty (60) minutes time-off for their regular meals.

MEDICAL, DENTAL AND OCCUPATIONAL SAFETY

Article 156. First-aid treatment. Every employer shall keep in his establishment such
first-aid medicines and equipment as the nature and conditions of work may require, in
accordance with such regulations as the Department of Labor and Employment shall
prescribe.

The employer shall take steps for the training of a sufficient number of employees in
first-aid treatment.

Article 157. Emergency medical and dental services. It shall be the duty of every
employer to furnish his employees in any locality with free medical and dental
attendance and facilities consisting of:
The services of a full-time registered nurse when the number of employees exceeds fifty
(50) but not more than two hundred (200) except when the employer does not maintain
hazardous workplaces, in which case, the services of a graduate first-aider shall be
provided for the protection of workers, where no registered nurse is available. The
Secretary of Labor and Employment shall provide by appropriate regulations, the
services that shall be required where the number of employees does not exceed fifty
(50) and shall determine by appropriate order, hazardous workplaces for purposes of
this Article;

The services of a full-time registered nurse, a part-time physician and dentist, and an
emergency clinic, when the number of employees exceeds two hundred (200) but not
more than three hundred (300); and

The services of a full-time physician, dentist and a full-time registered nurse as well as a
dental clinic and an infirmary or emergency hospital with one bed capacity for every one
hundred (100) employees when the number of employees exceeds three hundred
(300).

In cases of hazardous workplaces, no employer shall engage the services of a

physician or a dentist who cannot stay in the premises of the establishment for at least
two (2) hours, in the case of those engaged on part-time basis, and not less than eight
(8) hours, in the case of those employed on full-time basis. Where the undertaking is
non-hazardous in nature, the physician and dentist may be engaged on retainer basis,
subject to such regulations as the Secretary of Labor and Employment may prescribe to
insure immediate availability of medical and dental treatment and attendance in case of
emergency. (As amended by Presidential Decree NO. 570-A, Section 26).

Article 159. Health program. The physician engaged by an employer shall, in addition
to his duties under this Chapter, develop and implement a comprehensive occupational
health program for the benefit of the employees of his employer.

COMPENSATION

Article 86. Night shift differential. Every employee shall be paid a night shift differential
of not less than ten percent (10%) of his regular wage for each hour of work performed
between ten o’clock in the evening and six o’clock in the morning.

Article 89. Emergency overtime work. Any employee may be required by the employer
to perform overtime work in any of the following cases:

When the country is at war or when any other national or local emergency has been
declared by the National Assembly or the Chief Executive;

When it is necessary to prevent loss of life or property or in case of imminent danger to

public safety due to an actual or impending emergency in the locality caused by serious
accidents, fire, flood, typhoon, earthquake, epidemic, or other disaster or calamity;
When there is urgent work to be performed on machines, installations, or equipment, in
order to avoid serious loss or damage to the employer or some other cause of similar
nature;

When the work is necessary to prevent loss or damage to perishable goods; and

Where the completion or continuation of the work started before the eighth hour is
necessary to prevent serious obstruction or prejudice to the business or operations of
the employer.

Article 91. Right to weekly rest day.

It shall be the duty of every employer, whether operating for profit or not, to provide
each of his employees a rest period of not less than twenty-four (24) consecutive hours
after every six (6) consecutive normal work days.

The employer shall determine and schedule the weekly rest day of his employees
subject to collective bargaining agreement and to such rules and regulations as the
Secretary of Labor and Employment may provide. However, the employer shall respect
the preference of employees as to their weekly rest day when such preference is based
on religious grounds.

Article 92. When employer may require work on a rest day. The employer may require
his employees to work on any day:

In case of actual or impending emergencies caused by serious accident, fire, flood,

typhoon, earthquake, epidemic or other disaster or calamity to prevent loss of life and
property, or imminent danger to public safety;

In cases of urgent work to be performed on the machinery, equipment, or installation, to

avoid serious loss which the employer would otherwise suffer;

In the event of abnormal pressure of work due to special circumstances, where the
employer cannot ordinarily be expected to resort to other measures;

To prevent loss or damage to perishable goods;

Where the nature of the work requires continuous operations and the stoppage of work
may result in irreparable injury or loss to the employer; and

Under other circumstances analogous or similar to the foregoing as determined by the

Secretary of Labor and Employment.

Article 93. Compensation for rest day, Sunday or holiday work.

Where an employee is made or permitted to work on his scheduled rest day, he shall be
paid an additional compensation of at least thirty percent (30%) of his regular wage. An
employee shall be entitled to such additional compensation for work performed on
Sunday only when it is his established rest day.

When the nature of the work of the employee is such that he has no regular workdays
and no regular rest days can be scheduled, he shall be paid an additional compensation
of at least thirty percent (30%) of his regular wage for work performed on Sundays and
holidays.

Work performed on any special holiday shall be paid an additional compensation of at

least thirty percent (30%) of the regular wage of the employee. Where such holiday
work falls on the employee’s scheduled rest day, he shall be entitled to an additional
compensation of at least fifty per cent (50%) of his regular wage.

Where the collective bargaining agreement or other applicable employment contract

stipulates the payment of a higher premium pay than that prescribed under this Article,
the employer shall pay such higher rate.

ETHICAL INSIGHT: CONFIDENTIALITY OF EMPLOYEE HEALTH INFORMATION

In dealing with health information, the employee has a right to privacy and should “be
protected from unauthorized and inappropriate disclosure of personal information”
(AAOHN, 2004). However, exemptions must be made. These include:
(1) life-threatening emergencies
(2) authorization by the employee to release information to others
(3) worker’s compensation information
(4) compliance with government laws and regulations

LEVELS OF CONFIDENTIALITY
 LEVEL 1: relates to the information required by law (eg. Data on occupational
illness and injuries)
 LEVEL 2: covers information that will assist in management of human resources
(eg. Info from job placement and workability status of employee)
 LEVEL 3: focuses on personal health information
- Disclosure of levels 1 and 2 information to management should be
allowed only on a need-to-know basis.
 - Disclosure of level 3 information to management and regulatory agencies
should only be allowed as required by law.

- Disclosure of level 3 information to health insurance providers should

only be made with the written authorization of the employee.

Community Mental Health Nursing

DEFINITION

 Is the application of specialized knowledge to populations and communities to

promote and maintain mental health, and to rehabilitate populations at risk that
continue to have residual effects of mental illness

Why develop Nursing Resources for Mental Health?

 Mental health is crucial to the well-being of individuals, societies and
countries:

 Mental health is more than the absence of mental disorders. It

involves a state of well-being whereby the individual recognizes their
abilities, is able to cope with the normal stresses of life, works productively
and contributes to the community.
 Mental health problems are common: 450 million people suffer from a
mental or behavioral problem and nearly one million people commit
suicide every year. Depression, alcohol use disorders, schizophrenia and
bipolar disorder are among the ten leading causes of disability worldwide.

 Treatment is not available to most people: Despite the existence of

effective treatments, these are not available to the overwhelming majority
of people with a mental disorder. Many of the resources that are available
are wasted on ineffective interventions.

 Nurses are important providers of treatment and care: In most

countries, nurses are the largest group of professionals providing mental
health care in both primary and specialist health services. However, in
many countries the education of nurses is inadequate and their role is
under developed. With education and support, nurses can contribute to
the promotion of mental health and the prevention and treatment of mental
disorders

What are the priorities?

1. Primary Health Care
 WHO recommends that mental health treatment should be part of or
integrated into primary health care. However, many nurses lack the
knowledge and skills to identify and treat mental disorders. Education is
effective in improving the recognition of mental disorders in primary health
 care, increasing the referral to more specialized health providers and
enhancing the initiation of supportive therapies. In addition ongoing
supervision and support from specialist mental health services are needed
to assist nurses to care for people with more complex mental health needs
and facilitate referral to specialist services when required.

2. Nurse Education
 Mental health should be incorporated into basic nursing and midwifery
education with mental health concepts introduced early, reinforced and
expanded throughout the curricula and developed through experiential
learning opportunities. Ongoing education is also needed to assist nurses
to further develop their knowledge and skills, foster changes in attitudes
and beliefs and reorient them from custodial models of mental health care
to community based treatment. Specialist or post basic education
programs for nurses should be established to ensure that nurses are able
to provide services for people with severe mental disorders and provide
support to primary care providers.
 The areas to include in the education of nurses will depend on the needs
of the country, the role of the nurse, current competencies and the
resources that are available. The following is not intended as a
comprehensive list of areas for education, but as general guidance when
developing education programs:
o Advocacy
o Assessment of mental disorders
o Communication skills
o Community mental health nursing
o Emotional self-care (i.e. Nurses caring for their own mental health)
o Evaluation and research
o Legal and ethical issues, including understanding the rights of
people with mental disorders
o Management of emergencies (e.g. suicidal behavior, violence)
o Management of psychotropic medication
o Mental health care in humanitarian emergencies
o Promotion of mental health
o Public health models of mental health
o Stigma and discrimination
o Substance abuse
o Treatment of mental disorders
o Working in teams
o Working with service users and their families
o Working with specific groups (e.g. children and adolescents,
elderly)
 It is important to ensure that educational programs include practical
opportunities to develop skills.
 3. Involve nurses in the development of mental health policies
 Mental health policies define a vision for improving mental health
and reducing the burden of mental disorders in a population, and
establish a model for action based on agreed values, principles and
objectives. Nurses are important stakeholders who should be
consulted and actively involved in the development policies and
plans.
 The development of nursing resources for mental health should be
coordinated through a mental health policy. The WHO Fact Sheet
'Mental health policies and service development' provides more
information on developing and implementing policies and plans.

4. Information for decision-making

 While there is a growing body of research documenting good practice,
many countries have little or no information on the size, composition,
or quality of their nursing workforce for mental health, and no
knowledge of their impact on health outcomes. It is important that
countries gather this information in order to better inform mental health
policy development and the role of nursing within this context.

II. Concept of the Community

The nursing process in the care of the community

A community is a group of people who:

 Have a common interest or characteristics
 Interact with one another
 Have sense of unity or belonging
 Function collectively within a defined social structure to address
common concerns
A community may be phenomenological (functional) or geopolitical
(territorial)

Principals of community health nursing

1. Community is the focus of care, nurse responsibility is to the
community as a whole
2. Give priority to community needs
3. Work with the community as an equal partner of the health team
4. Focus on primary prevention for appropriate activities
5. Promote a healthful physical and psychosocial environment
6. Reach out to all who may benefit from a specific service
7. Promote optimum use of resources
8. Collaborate with others working in the community health

A. Types of Communities
 1. Formal communities
2. Informal communities
3. Urban communities
4. Rural communities
5. Global communities
6. Sectoral communities
7. Social Space communities

1. FORMAL COMMUNITIES Engage in joint activities and discussion, help

each other, and share information with each other; they care about their
standing with each other.
Examples of formal communities
▪ Ecovillages
▪ Co-housing communities
▪ Co-ops communities
▪ Religious communities
2. INFORMAL COMMUNITIES consists of a set of personal relations, social
networks, common interest and emotional sources of motivation.

Examples of informal communities

▪ Academic communities
▪ Recreation communities
▪ Retirement communities

3. URBAN COMMUNITIES Large in terms of land area & population,

advanced in science & technology, with favorable physical environment
and & diverse cultures, and the people are engaged in various
occupations.

Characteristics of urban communities

▪ Advancement in science and technology
▪ Many business establishments, recreational centers, educational
and religious institutions
▪ People are crowded
▪ Social heterogeneity
▪ Class extremes
▪ Greater pollution 21
▪ Many crimes are committed
▪ Family ties tend to be weak
▪ Limited space
▪ Greater impersonality among neighbors
▪ Higher standard of living
▪ Shortage of employment
▪ Informal settlers are rampant
▪ A lot of hazards and dangers
 ▪ Greater number of separation of spouses and live- in
arrangements
▪ Major occupations are industrial, administrative and professional
▪ Divisions of labor and occupational specialization are very much
common

4. RURAL COMMUNITIES Usually produce their own food for subsistence

Characteristics of rural communities

▪ Greater personal interaction
▪ Deep, long-term relationships
▪ generally, peace and order exists
▪ Mutual give and take affairs
▪ Emphasis of shared values
▪ Vernacular is usually spoken
▪ Wider area
▪ Influence of blood relationships in decision making
▪ Homogenous type of culture
▪ Belief in supernatural and superstitious beliefs
▪ Relationship is more personal and informal
▪ Less pollution
▪ Few establishments and institutions
▪ Few goods and services

5. GLOBAL COMMUNITIES It is the international aggregate of nation-

states.
Global communities
▪ “World Community”
▪ Common point of view towards issues of human rights, global
warming and climate change, peace and order, socio-economic
conditions as well as disputed issues such as territorial conflict.

6. SECTORAL COMMUNITIES Include the voluntary sector or non-profit

sector
▪ Voluntary, non-profit and non-governmental
▪ also called third sector (in contrast to public and private sector)
▪ NGOs: Non-governmental organizations

7. SOCIAL SPACE COMMUNITIES Based on social spaces

▪ a social space is a physical or virtual space
▪ Physical: social center, gathering place, town squares, parks,
pubs, shopping malls
▪ Virtual: online social media, websites
Characteristics of social spaces
 People gather at information grounds for a primary purpose
other than information sharing
  Attended by different social types
 Social interaction is a primary activity
 Information occurs in many directions
 Information is used in alternative ways
 Many sub-contexts exist; together they form grand context

B. Characteristics of a Healthy Community

 a shared sense of being a community based on history and
values
 general feeling of empowerment
 existing structures that allow subgroups within the community to
participate in decision making
 the ability to cope with change, solve problems, and manage
conflicts within the community through acceptable means
 open channels of communication
 equitable and efficient use of community resources

Aims
1. achieve a good quality life
2. create a health supportive environment
3. provide basic sanitation
4. supply access to health care

C. Components of a Community
 The concepts of community and health together provide the
foundation for understanding community health. Broadly defined, a
community is a collection of people who share some important
feature of their lives. In this text, the term community refers to a
collection of people who interact with one another and whose
common interests or characteristics form the basis for a sense of
unity or belonging

D. Factors Affecting Health of the Community

1. Characteristics of the Population
 Population variable that affect the health of the community include
size, density, composition, rate of growth or decline, cultural
characteristics, mobility, social class, and educational level
(Allender et al., 2009).
 Population size and density influence the number and size of health
care institutions (Allender et al., 2009).
 Negative effects of overcrowding include:
o Easy spread of communicable diseases
o Increased stress among members of the community
o Rapid degradation of housing facilities
o Water, air and soil pollution.
  Sparsely populated areas like rural areas, have limited resources,
resulting in difficulty in providing health services.
 Health needs of community varies because of differences in
population composition by age, sex, occupation, level of education
and other variables. (Allender et al., 2009).

2. Location of the Community

 Health of the community is affected by natural and man-made
variables related to location.
 Natural factors consist of
o Geographic features
o Climate
o Flora
o Fauna
 Community boundaries, whether the community is urban or
rural, the presence of open spaces, the quality of the soil, air
and water.
 Location of health facilities are influenced by human decisions
and behavior (Allender et al., 2009).

3. Social Systems within the Community

 Is a patterned series of relationships existing between
individuals, groups and institutions and forming a coherent
whole (Merriam Webster Online Dictionary, 2012b)
 Social system components that affect health include:
o Family
o Economic,
o Educational
o Communication
o Political
o Legal
o Religious
o Recreational
o Health systems
E. Roles and Activities of Community Health Nurse
Functions of Community Health Nurse:
There are seven major functions of community health nurse, those are
mentioned in the following:

1. Clinician,
2. Educator,
3. Advocate,
4. Managerial,
5. Collaborator,
 6. Leader,
7. Researcher.

Clinician Role or Direct care provider:

The clinician role in the community health nurse means, the nurse ensures
health care services, not just to individuals and families but also to groups
and population of the community. For community health nurses the clinician
role involves certain emphasis different from basic nursing, i.e. – Holism,
health promotion, and skill expansion

Educator Role:

It is widely recognized that health teaching is a part of good nursing practice

and one of the major functions of a community health nurse (Brown, 1988).
Assesses the knowledge, attitudes, values, beliefs, behaviours, practices,
stage of change, and skills of the community people and provide health
education according to knowledge level.

Advocate Role:

The issue of clients’ rights is important in health care today. Every patient or
client has the right to receive just equal and human treatment. Community
health nurse is an advocate of patient’s rights in relation to their care. They
encourage the individuals to take right food for maintaining health, right drugs
for the treatment and right services at right place where ever needed. They
provide sufficient information to make necessary health care decision,
promote community awareness of significant health problems.

Managerial Role:

As a manager the nurse exercises administrative direction towards the

accomplishment of specified goals by assessing clients’ needs, planning and
organizing to meet those needs, directing and controlling and evaluating the
progress to assure that goals are met.

Collaborator Role:

Community health nurses seldom practice in isolation. They must work with
many people including clients, other nurses, physicians, social workers and
community leaders, therapists, nutritionists, occupational therapists,
psychologists, epidemiologists, biostaticians, legislators, etc. as a member of
the health team (Fairly 1993, Williams, 1986).
Leader Role:

Community health nurses are becoming increasingly active in the leader role.
As a leader, the nurse instructs, influences, or persuades others to effect
change that will positively affect people’s health. The leadership role’s primary
function is to useful change of health policy based on community people
health; thus, the community health nurse becomes an agent of change.

Research Role:

In the researcher role community health nurses engage in systematic

investigation, collection and analysis of data for the purpose of solving
problems and enhancing community health nursing practice. Based on the
research result community nurse improve their service quality and improve
community people health.

A. The client or “unit of care” is the population.

Population-focused
 The central mission of public health practice is to improve the
health of population groups. Community health nursing shares
this essential feature: it is population-focused, meaning that it
is concerned for the health status of population groups and their
environment.
B. The primary obligation is to achieve the greatest Good for the greatest
number of people or the Population as a whole.
The Greatest Good for the Greatest Number of People
 A population-oriented focus involves a new outlook and set of
attitudes. Individualized care is important, but prevention of
aggregate problems in community health nursing practice
reflects more accurately its philosophy and benefits more
people.
C. The processes used by public health nurses include working with the
client(s) as an equal partner.
Clients as Equal Partners
 The goal of public health, “to increase quality and years of
healthy life and eliminate health disparities” (USDHHS, 2000),
requires a partnership effort. Just as learning cannot take place
in schools without student participation, the goals of public
health cannot be realized without consumer participation.

 Community health nursing’s efforts toward health improvement

go only so far. Clients’ health status and health behavior will not
change unless people accept and apply the proposals
 (developed in collaboration with clients) presented by the
community health nurse.
D. Primary prevention is the priority in selecting appropriate activities.
Prioritizing Primary Prevention
 In community health nursing, the promotion of health and
prevention of illness are a first-order priority. Less emphasis is
placed on curative care.
 Some corrective actions always are needed, such as cleanup of
a toxic waste dump site, stricter enforcement of day care
standards, or home care of the disabled; however, community
health best serves its constituents through preventive and
health-promoting actions (USDHHS, 2000).

E. Selecting strategies that create healthy environmental, social, and

economic conditions in which populations may thrive is the focus.
Selecting Strategies That Create Healthy
Conditions in Which Populations May Thrive
 With our population focus, it is prudent for community health
nurses to design interventions for “education, community
development, social engineering, policy development, and
enforcement” that “result in laws and rules, policies and budget
priorities” (ANA, 2005, p. 13). Advocacy for our clients, whether
they be individuals, families, aggregates, communities, or
populations, is an essential function of public health nursing. We
want to create healthy environments for our clients, so that they
can thrive and not simply survive.

F. There is an obligation to actively reach out to all who might benefit

from a specific activity or service.
Actively Reaching Out
 We know that some clients are more prone to develop disability
or disease because of their vulnerable status (e.g., poverty, no
access to health care, homeless). Outreach efforts are needed
to promote the health of these clients and to prevent disease. In
acute care and primary health care settings, like emergency
rooms or physician offices, clients come to you for service.

G. Optimal use of available resources to assure the best overall

improvement in the health of the population is a key element of the
practice
Optimal Use of Available Resources
 It is our duty to wisely use the resources we are given. For
many public health agencies, budgets have been stretched to
the limits. Tertiary health care uses up the greatest percentage
of our health care dollar, leaving decreased funds for primary
and secondary services. Decisions for programs or services are
 often made on the basis of the “cost-benefit or cost-
effectiveness of potential strategies” (ANA, 2005, p. 13).

 It is vital that community health nurses ground their practice in

research, and use that information to educate policy makers
about best practices. Utilizing personnel and resources
effectively and prudently will pay off in the long run.

H. Collaboration with a variety of other professions, organizations, and

entities is the most effective way to promote and protect the health of
people. (ANA, 2005, pp. 12–14)
Interprofessional Collaboration
 Community health nurses must work in cooperation with other
team members, coordinating services and addressing the needs
of population groups. This interprofessional collaboration
among health care workers, other professionals and
organizations, and clients is essential for establishing effective
services and programs. Individualized efforts and specialized
programs, when planned in isolation, can lead to fragmentation
and gaps in health services.

III. Health Statistics and Epidemiology

A. Tools
1. Demography
 Sources of data
o Census
o Vital Registration system
o Disease notification
o Disease registries
o Surveillance system
o Hospital data
o Health insurance
o School health program
o Downloadable data sets
o Surveys ( morbidity, demographic, and health)
2. Health Indicators
TYPES OF HEALTH INDICATORS AND THEIR EXAMPLES

TYPE OF HEALTH INDICATOR EXAMPLES

Health status indicators (morbidity) Prevalence, incidence
Health status indicators (mortality) Crude and specific death rates, maternal
mortality, infant mortality, neonatal mortality,
postnatal mortality, child mortality, etc.
Population indicators Age-sex structure of the population,
population density, migration, population
 growth (crude birth rate, fertility rate)
Indicators for the provision of health care Access to health programs and facilities,
availability of health resources (facilities,
health manpower, finances)
Risk reduction indicators Causes consulting health provider., infants
exclusively breast-fed for the first 6 months
Social and economic indicators Quantity of suspended particulate matter,
hydrocarbons, oxidants. Portability of
drinking water
Disability indicators DALYs, indicators of restricted activity,
indicators of long-term disability
Health policy indicators Allocation of manpower and financial
resources, mechanisms for community
participation, collaboration between
government and non-government
organizations
Health indicators- these are quantitative measures usually expressed as rates, ratio,
or proportions that describe and summarize various aspects of the health status of the
population. These are also used to determine factors that may contribute to a causation
and control of diseases, indicates priorities for resource allocation, monitors
implementation off health programs, and evaluates outcomes oh health programs.

 MORBIDITY INDICATORS – are generally based on the disease specific

incidence or prevalence for the common and severe diseases such as malaria,
diarrhea, and leprosy.

(P) Prevalence proportion measures the total number of existing cases of disease at
a particular point in time divided by the number of people at the point in time. Thus, if
the point in time is the time of examination, then the denominator is the number of
people examined.

Prevalence can be calculated by:

P= number of existing cases of a disease at a particular point in time XF

Number of people examined at that point in time

 Where F is any number of the base 10 that is used as a multiplier to avoid having
decimals as the final value of the indicator.
 Incidence – measures the number of new cases, episodes, or events occurring
over a specified period of time, commonly a year within a specified population at
risk.

FACTORS AFFECTING PREVALENCE

Increased by Decreased by
Longer duration of the disease Shorter duration of the disease

Prolongation of life of patients without care High case-fatality rate from disease

Increase in new cases Decrease in new cases

In-migration of cases In-migration of healthy people

Out-migration of healthy people Out-migration of cases

In-migration of susceptible people Improved cure rate of cases

Improved diagnostic facilities

 Cohort- is a group of people who share a common defining characteristics.

INCIDENT DENSITY RATE- is computed using the total person-time at risk for the
entire cohort as the denominator

- This indicators measures the average instantaneous rate of

disease occurrence.

ID= number of new cases that develop during the period XF

Sum of person-time at risk
MORTALITY INDICATORS

Crude death rate (CDR) – the rate with which mortality occurs in a given population. It is
computed as

CDR= Number of deaths in a calendar year

Midyear population X 1,000

 Factors affecting CDR includes age, sex composition of the population, the
adverse environmental and occupational conditions.
 Specific mortality rate – shows rate of dying in a specific population groups.

SMR= number of deaths in a specified group in a calendar year

Midyear population of the same specified group XF

 Cause-of-death rate – identifies the greatest threat to the survival of the people,
thereby pointing to the need for preventing such deaths.

CODR= number of deaths from a certain cause in a calendar year XF

Midyear population

 Infant mortality rate – is a good index of health in a community because infants

are very sensitive to adverse environmental conditions. Thus, a high IMR means
 low levels of health standards that may be secondary to poor maternal health
and child health care, malnutrition.

IMR= deaths under 1 year of age in a calendar year

Number of live births in the same year X 1,000

 Neonatal mortality rate and postnatal mortality rate add up to the IMR. The
reason for such division is that the causes of neonatal deaths, that is, deaths
among infants less than 28 days old are due mainly to prenatal or genetic
factors.

NMR= number of deaths among those under 28 days of age in a calendar year X 1,000
Number of live births in the same year

PNMR= number of deaths among those under 28 days of age

To less than 1 year of age in a calendar year X 1,000
Number of live births in the same year

 Maternal death - death of a female from any cause related to or aggravated by

pregnancy or its management during pregnancy and childbirth or within 42 days
of termination of pregnancy, irrespective of the duration and the site of the
pregnancy.

MMR= number of deaths due to pregnancy, delivery, puerperium in a calendar year

X 100
Number of live births in the same year

 Case fatality rate – is the proportion of cases that end up fatally. It gives the risk
of dying among persons afflicted within particular disease.
- It is similar to an incidence proportion because it also a measure
of average risk.
CFR= number of deaths from a specified cause
Number of cases of the same disease X 100

POPULATION INDICATORS

Include not only the population growth indicators but also other population dynamics
that can affect the age-sex structure of the population and vice versa.

 Crude birth rate- measures how fast people are added to the population through
births.
- Measure of population growth.
CBR= number of registered live births in a year X 1,000
Midyear population

 A CBR greater than or equal to 45/1,000 live births implies high fertility while a
level less than or equal to 20/1,000 live births implies low fertility.

B. Philippine Health Situation

1. Demographic profile
 Population Density
The 2019 population density in the Philippines is 363 people per
Km2 (939 people per mi2), calculated on a total land area of
298,170 Km2 (115,124 sq. miles).

2. Health profile

 The Philippines has made significant investments and advances in

health in recent years. Rapid economic growth and strong country
capacity have contributed to Filipinos living longer and healthier.
However, not all the benefits of this growth have reached the most
vulnerable groups, and the health system remains fragmented.
Health insurance now covers 92% of the population.

 Maternal and child health services have improved, with more

children living beyond infancy, a higher number of women
delivering at health facilities and more births being attended by
professional service providers than ever before. Access to and
provision of preventive, diagnostic and treatment services for
communicable diseases have improved, while there are several
initiatives to reduce illness and death due to non-communicable
diseases (NCDs).

 Despite substantial progress in improving the lives and health of

people in the Philippines, achievements have not been uniform and
challenges remain. Deep inequities persist between regions, rich
 and the poor, and different population groups. Many Filipinos
continue to die or suffer from illnesses that have well-proven, cost-
effective interventions, such tuberculosis, HIV and dengue, or
diseases affecting mothers and children.

 Many people lack sufficient knowledge to make informed decisions

about their own health. Rapid economic development, urbanization,
escalating climate change, and widening exposure to diseases and
pathogens in an increasingly global world increase the risks
associated with disasters, environmental threats, and emerging and
re-emerging infections.

C. Epidemiology and the Nurse

1. Definitions and related terms
EPIDEMIOLOGY- is the study of the DISTRIBUTION and
DETERMINANTS of health-related states or events in specified
populations, and the application of this study to the prevention and
control of health problems

DISTRIBUTION- refers to the analysis by time, places and classes of

people affected.

DETERMINANTS- include all the biological, chemical, physical, social,

cultural, economic, genetic, and behavioral factors that influence
health.

PRACTICAL APPLICATIONS OF EPIDEMIOLOGY

1. Assessment of the health status of the community or community
diagnosis
2. Elucidation of the natural history of disease
3. Determination of disease causation
4. Prevention and control of disease
5. Monitoring and evaluation of health interventions
6. Provision of evidence for policy formulation

2. Natural life history of Disease

 Natural history of disease refers to the progression of a disease
process in an individual over time, in the absence of treatment.
For example, untreated infection with HIV causes a spectrum of
clinical problems beginning at the time of seroconversion
(primary HIV) and terminating with AIDS and usually death. It is
now recognized that it may take 10 years or more for AIDS to
develop after seroconversion.
 Many, if not most, diseases have a characteristic natural
history, although the time frame and specific manifestations of
 disease may vary from individual to individual and are
influenced by preventive and therapeutic measures.
 The process begins with the appropriate exposure to or
accumulation of factors sufficient for the disease process to
begin in a susceptible host. For an infectious disease, the
exposure is a microorganism. For cancer, the exposure may be
a factor that initiates the process, such as asbestos fibers or
components in tobacco smoke (for lung cancer), or one that
promotes the process, such as estrogen (for endometrial
cancer).
 After the disease process has been triggered, pathological
changes then occur without the individual being aware of them.
This stage of subclinical disease, extending from the time of
exposure to onset of disease symptoms, is usually called
the incubation period for infectious diseases, and the latency
period for chronic diseases. During this stage, disease is said
to be asymptomatic (no symptoms) or in apparent. This period
may be as brief as seconds for hypersensitivity and toxic
reactions to as long as decades for certain chronic diseases.
Even for a single disease, the characteristic incubation period
has a range. For example, the typical incubation period for
hepatitis A is as long as 7 weeks. The latency period for
leukemia to become evident among survivors of the atomic
bomb blast in Hiroshima ranged from 2 to 12 years, peaking at
6–7 years.

3. Epidemiological process and investigations

Once the decision to conduct a field investigation of an acute outbreak has been made,
working quickly is essential — as is getting the right answer. In other words,
epidemiologists cannot afford to conduct an investigation that is “quick and dirty.” They
must conduct investigations that are “quick and clean.” Under such circumstances,
epidemiologists find it useful to have a systematic approach to follow. This approach
ensures that the investigation proceeds without missing important steps along the way.

Epidemiologic Steps of an Outbreak Investigation

1. Prepare for field work
 The numbering scheme for this step is problematic, because preparing for
field work often is not the first step. Only occasionally do public health
officials decide to conduct a field investigation before confirming an
increase in cases and verifying the diagnosis. More commonly, officials
discover an increase in the number of cases of a particular disease and
then decide that a field investigation is warranted.
  Sometimes investigators collect enough information to perform descriptive
epidemiology without leaving their desks, and decide that a field
investigation is necessary only if they cannot reach a convincing
conclusion without one.
 Regardless of when the decision to conduct a field investigation is made,
you should be well prepared before leaving for the field. The preparations
can be grouped into two broad categories: (a) scientific and
investigative issues, and (b) management and operational issues.
Good preparation in both categories is needed to facilitate a smooth field
experience.

A. Scientific and investigative issues

o As a field investigator, you must have the appropriate scientific

knowledge, supplies, and equipment to carry out the investigation
before departing for the field.
o Discuss the situation with someone knowledgeable about the disease
and about field investigations, and review the applicable literature.
o Before leaving for a field investigation, consult laboratory staff to
ensure that you take the proper laboratory material and know the
proper collection, storage, and transportation techniques.
o You also need to know what supplies or equipment to bring to protect
yourself. Some outbreak investigations require no special equipment
while an investigation of SARS or Ebola hemorrhagic fever may
require personal protective equipment such as masks, gowns, and
gloves.
o Finally, before departing, you should have a plan of action. What are
the objectives of this investigation, i.e., what are you trying to
accomplish? What will you do first, second, and third? Having a plan
of action upon which everyone agrees will allow you to “hit the ground
running” and avoid delays resulting from misunderstandings.

2. Management and operational issues

o A good field investigator must be a good manager and collaborator

as well as a good epidemiologist, because most investigations are
conducted by a team rather than just one individual.
o The team members must be selected before departure and know
their expected roles and responsibilities in the field.
o Depending on the type of outbreak, the number of involved
agencies may be quite large.
o A communications plan must be established. The need for
communicating with the public health and clinical community has
long been acknowledged, but the need for communicating quickly
and effectively
2. Establish the existence of an outbreak
 An outbreak or an epidemic is the occurrence of more cases of
disease than expected in a given area or among a specific group
of people over a particular period of time.
 In contrast to outbreak and epidemic, a cluster is an aggregation
of cases in a given area over a particular period without regard to
whether the number of cases is more than expected.
 One of the first tasks of the field investigator is to verify that a
cluster of cases is indeed an outbreak. Some clusters turn out to
be true outbreaks with a common cause, some are sporadic and
unrelated cases of the same disease, and others are unrelated
cases of similar but unrelated diseases.

3. Verify the diagnosis

 The next step, verifying the diagnosis, is closely linked to verifying
the existence of an outbreak. In fact, often these two steps are
addressed at the same time.
 Verifying the diagnosis is important:
(a) To ensure that the disease has been properly identified,
since control measures are often disease-specific; and
(b) To rule out laboratory error as the basis for the increase in
reported cases.

4. Construct a working case definition

 A case definition is a standard set of criteria for deciding whether an
individual should be classified as having the health condition of
interest. A case definition includes clinical criteria and — particularly
in the setting of an outbreak investigation — restrictions by time,
place, and person.
5. Find cases systematically and record information
 As noted earlier, many outbreaks are brought to the attention of
health authorities by concerned healthcare providers or citizens.
However, the cases that prompt the concern are often only a small
and unrepresentative fraction of the total number of cases. Public
health workers must therefore look for additional cases to determine
the true geographic extent of the problem and the populations
affected by it.
 In some investigations, investigators develop a data collection form
tailored to the specific details of that outbreak. In others,
investigators use a generic case report form. Regardless of which
form is used, the data collection form should include the following
types of information about each case.
  Identifying information. A name, address, and telephone
number is essential if investigators need to contact patients
for additional questions and to notify them of laboratory
results and the outcome of the investigation. Names also
help in checking for duplicate records, while the addresses
allow for mapping the geographic extent of the problem.
 Demographic information. Age, sex, race, occupation, etc.
provide the person characteristics of descriptive
epidemiology needed to characterize the populations at risk.
 Clinical information. Signs and symptoms allow
investigators to verify that the case definition has been met.
Date of onset is needed to chart the time course of the
outbreak. Supplementary clinical information, such as
duration of illness and whether hospitalization or death
occurred, helps characterize the spectrum of illness.
 Risk factor information. This information must be tailored
to the specific disease in question. For example, since food
and water are common vehicles for hepatitis A but not
hepatitis B, exposure to food and water sources must be
ascertained in an outbreak of the former but not the latter.
 Reporter information. The case report must include the
reporter or source of the report, usually a physician, clinic,
hospital, or laboratory. Investigators will sometimes need to
contact the reporter, either to seek additional clinical
information or report back the results of the investigation.

6. Perform descriptive epidemiology

 Conceptually, the next step after identifying and gathering basic
information on the persons with the disease is to systematically describe
some of the key characteristics of those persons. This process, in which
the outbreak is characterized by time, place, and person, is
called descriptive epidemiology. It may be repeated several times
during the course of an investigation as additional cases are identified or
as new information becomes available.
This step is critical for several reasons.
 Summarizing data by key demographic variables provides a
comprehensive characterization of the outbreak — trends over time,
geographic distribution (place), and the populations (persons) affected by
the disease.
 From this characterization you can identify or infer the population at risk
for the disease.
 The characterization often provides clues about etiology, source, and
modes of transmission that can be turned into testable hypotheses (see
Step 7).
  Descriptive epidemiology describes the where and whom of the disease,
allowing you to begin intervention and prevention measures.
 Early (and continuing) analysis of descriptive data helps you to become
familiar with those data, enabling you to identify and correct errors and
missing values.

7. Develop hypotheses
 Although the next conceptual step in an investigation is formulating
hypotheses, in reality, investigators usually begin to generate
hypotheses at the time of the initial telephone call. Depending on the
outbreak, the hypotheses may address the source of the agent, the
mode (and vehicle or vector) of transmission, and the exposures that
caused the disease. The hypotheses should be testable, since
evaluating hypotheses is the next step in the investigation.
8. Evaluate hypotheses epidemiologically
 After a hypothesis that might explain an outbreak has been
developed, the next step is to evaluate the plausibility of that
hypothesis. Typically, hypotheses in a field investigation are
evaluated using a combination of environmental evidence, laboratory
science, and epidemiology. From an epidemiologic point of view,
hypotheses are evaluated in one of two ways:
o By comparing the hypotheses with the established facts
o By using analytic epidemiology to quantify relationships and
assess the role of chance.
9. As necessary, reconsider, refine, and re-evaluate hypotheses
 Unfortunately, analytic studies sometimes are unrevealing. This is
particularly true if the hypotheses were not well founded at the outset. It is
an axiom of field epidemiology that if you cannot generate good
hypotheses (for example, by talking to some case-patients or local staff
and examining the descriptive epidemiology and outliers), then proceeding
to analytic epidemiology, such as a case-control study, is likely to be a
waste of time.
 When analytic epidemiology is unrevealing, rethink your hypotheses.
Consider convening a meeting of the case-patients to look for common
links or visiting their homes to look at the products on their shelves.
Consider new vehicles or modes of transmission.

10. Compare and reconcile with laboratory and/or environmental studies

 While epidemiology can implicate vehicles and guide appropriate
public health action, laboratory evidence can confirm the findings.
 Environmental studies are equally important in some settings. They
are often helpful in explaining why an outbreak occurred.
11. Implement control and prevention measures
  The primary goal is control of the outbreak and prevention of
additional cases.
 The health department’s first responsibility is to protect the public’s
health, so if appropriate control measures are known and available,
they should be initiated even before an epidemiologic investigation is
launched.
 Confidentiality is an important issue in implementing control
measures. Healthcare workers need to be aware of the
confidentiality issues relevant to collection, management and sharing
of data.
12. Initiate or maintain surveillance
 Once control and prevention measures have been implemented,
they must continue to be monitored. If surveillance has not been
ongoing, now is the time to initiate active surveillance.
 The reasons for conducting active surveillance at this time are
twofold.
o First, you must continue to monitor the situation and
determine whether the prevention and control measures are
working.
o Second, you need to know whether the outbreak has spread
outside its original area or the area where the interventions
were targeted.
13. Communicate findings
 Development of a communications plan and communicating with
those who need to know during the investigation is critical. The final
task is to summarize the investigation, its findings, and its outcome
in a report, and to communicate this report in an effective manner.
 This communication usually takes two forms:
o An oral briefing for local authorities. If the field investigator
is responsible for the epidemiology but not disease control,
then the oral briefing should be attended by the local health
authorities and persons responsible for implementing control
and prevention measures.
o A written report. Investigators should also prepare a written
report that follows the usual scientific format of introduction,
background, methods, results, discussion, and
recommendations. By formally presenting recommendations,
the report provides a blueprint for action.
 It also serves as a record of performance and a
document for potential legal issues.
 It serves as a reference if the health department
encounters a similar situation in the future.
 CHAPTER 2

Nursing Process in the Care of Population Groups and Community

A. Community Health Assessment Tools

1. Collecting Primary Date
 Observation
 Done through an ocular or windshield survey, either by driving
or riding a vehicle or working through it.
 Gives the nurse the chance to observe people as well as take
note of environmental conditions and existing community facility.
 Survey
o A survey maybe necessary when there is no available
information about the community or specific population
group.
o Made of series of question for systematic collection of
information from a sample of individuals or families.
 Informant Interviews
o Purposeful talks with either key informants or ordinary
members of the community leaders or persons of positions
and influence, such as leaders in local government, schools
and business (Hunt, 2009; Lundy and Janes, 2009)
 Community Forum
o An open meeting of the members of the community (Lundy
and Janes, 2009) Pulong-Pulong sa Baranggay is an
example
 Focus Group
 o Differs from community forum in the sense that focus group
is made up of much smaller group, usually 6-12 members
only.

2. Secondary Data Sources

 Registry of Vital Events
o Act 3753 (Civil Registration Law, Philippine Legislature)
enacted in 1930, established the civil registry system in the
Philippines and requires registration of vital events such as,
births, marriages and deaths.
o R.A. 7160 (Local Government Code) assigned the
function of civil registration to local governments and
mandated the appointment of Local (city/municipal) Civil
Registrars.
o The NSO/PSA serves as the central repository of civil
registries and the NSO/PSA Administrator and the civil
Registrar General of the Philippines.

 Health Records and Reports

o Field health service information (FHSIS) recording and
reporting tools

FHSIS is as basis for:

1. Priority setting by local governments
2. Planning and decision making at different levels
(barangay, municipality, district, provincial, and national)
3. Monitoring and evaluating health program implementation

The FHSIS manual of operations

2. Individual treatment record (ITR)
 building block of FHSIS)
 Health workers are advised not to rely on client-
maintained records, like the home-based mother’s
record.
2. Target client list (TCLs)
A. TCL for prenatal care
B. TCL for postpartum care
C. TCL of under 1-year-old children
D. TCL for family planning
E. TCL for sick children
F. National tuberculosis program register.
G. National leprosy control program central
Registration form
3. Summary table (accomplished by midwife)
4. Monthly consolidation table (MTC)
  The reporting forms, as enumerated in the FHSIS
manual of operations
1. Monthly forms (regularly prepared by the midwife and
summited to the nurse)
A. Program report (M1)
o Contains indicators categorized as
maternal care, child care, family
planning
B. morbidity report (M2)
o Contains list of all cases of disease by
age and sex.
2. Quarterly forms (prepared by the nurse)
A. Program report (Q1)
o 3-month total indicators categorized as
maternal care, family planning, Child care,
dental health and disease control
B. Morbidity Report (Q2)
o 3 month consolidation of morbidity report
(M2)
3. Annual forms
A. A-BHS
o report by the midwife contains
demographic, environmental, and
natality data
B. Annual form 1 (A-1)
o Prepared by the nurse and is the report of
the RHU or health center. It contains
demographic and environmental data and
data on natality and mortality for the entire
year.
C. Annual form 2 (A-2)
o Prepared by the nurse, is the yearly morbidity
report by age and sex
D. Annual for 3 (A-3)
o Prepared by the nurse, yearly report of all
mortality by age and sex.
 Disease Registries
o Is a listing of persons diagnosed with specific type of a
disease in a defined population
o Data collected through Disease Registries serve as basis
for monitoring, decision making and program management
(DOH,2011a)
 Census Data
o Periodic governmental enumeration of the population
(Merriam Webster Online Dictionary, 2012a).
 o Batas Pambansa Blg. 72 provides for national census of
population and other related data in the Philippines every 10
years ( Batasang Pambansa, 1980)
3. Methods to Present Community Data
 Community data are presented to the health team and the
members of the community for the following purposes:
o To inform the health team and members of the
community of existing health and health-related
conditions in the community in an easily
understandable manner.
o To make members of the community appreciate the
significance relevance of health information to their
lives.
o To solicit broader support and participation in the
community health process.
o To validate findings
o To allow for a wider perspective in the analysis of
data.
o To provide a basis for better decision making
B. Community Diagnosis
1. Types
 Traditional
 Participatory Action Research (PAR)
2. Schemes in Stating Community Diagnosis
 NANDA
o Nursing diagnostic labels, although focused more on
individual rather than the community.
 Shuster and Goppingen
o Proposed a practical adaptation of a format of nursing
diagnoses for population group previously presented by
Green and Slade (2001)
 Omaha System
o Designed for clients in a community setting.
o Been used as a framework for the care of individuals, families
and communities by nurses, nursing educators, physician and
other health care providers.
C. Planning Community Health Interventions
1. Priority Setting
 WHO Special
o Suggested the following criteria to decide on community
health concern for intervention
 Significance of the Problem
 Based on the number of people in the
community affected by the problem or
condition.
  Level of Community Awareness and the priority
 Its members give to the health concern is a
major consideration.
 Ability to reduce risk
 Is related to the ability of expertise (Shuster
and Goeppinger, 2004) among the health
team and the community itself.
 Involves health team’s level of influence in
decision making related to actions in resolving
the community health concern
 Ability to identify the target population
 Is a matter of availability of data source, such
as FHSIS, census, survey reports and/or case
finding or screening tools.
 Availability of resources in the reduction
 To intervene in the reduction of risk entails
technological, financial, and other material
resources of the community, the nurse and the
health agency.

 Considerations
2. Formulating Goals and Objectives
3. Deciding on Community Interventions/Action Plan
D. Implementing Community Health Interventions
1. Importance of Partnership and Collaboration
2. Activities involved in collaboration and advocacy
3. Community Organizing and Social Mobilization
4. Core principles in Community Organizing
5. Goals of Community Organizing
6. Community Organizing Participatory Research
 Proper excreta
 Disposal
 Food safety
 Sanitation
 Vermin and vector control
 Built environment
E. Monitoring and Evaluating Community Health Programs Implemented
1. Designing and Implementing Evaluation Plan
 Monitoring
 Evaluation
2. Types of Evaluation
 Planning
 Formative
 Summative
3. Steps of Program Evaluation
 F. Documentation and Reporting
1. Family Health Records
2. Community Profile

CHAPTER 3

I. Working with Groups towards Community Development

A. Stages of Group Development

 Group must move through developmental stages before it
becomes a productive, functional unit.
 Group members must deal with issues, problems and tasks that
occur in each stage before progressing to the next. These
stages are characterized by specific behavioral patterns and
areas of concern.
Five Major Stages:
1. Stage of Orientation
 The two task confronting group members during the initial stage
are:

B. Intervention to Facilitate Group Growth

1. Orientation, structure, direction
2. Process, negotiate and resolve conflicts
3. Awareness of the effects of behavior
4. Application of new learning
C. Collaboration and Partnership

II. Information Technology and Community Health

A. Definition of e-health
 eHealth is the use of ICT for Health (WHO,2012) Information and communication
technologies (ICTs) – diverse set of technological tools and resources used to
communicate and to create, disseminate, store, and manage information.
 May 25, 2005 the fifty – eight World Health Assembly, was adopted by the WHO
recognizing eHealth as the cost -effective way using ICT in the health care service, health
surveillance, health literature, health education and research.
 Extensive capabilities of eHealth
Communicating with a patient through a teleconference, electronic mail (email),
short message service.
Providing patient teaching with aid of electronic tools such as radio, television,
computers, smartphones, and tablets
Recording, retrieving, and mining data in an electronic medical record.

According to the WHO, ehealth encompasses three main areas.

- The delivery of the health information, for health professionals and health
consumers, through the internet and communications.
- Using the power of information technology and e-commerce to improve public
health services.
Ex. Through education and training of health workers.
- The use of e-commerce and e-business practice in health systems
management.

Health care system builds heavily on accurate recording of obtained data.

Paper based methods may bring inconvenience when it comes on interoperability of health
services, information backup and instant data access. Problems may also emerge.
1. Continuity and interoperability of care stops in the unlikely event that a record gets
misplaced.
2. Illegible handwriting poses misinterpretation of data.
3. Patient privacy is compromised.
4. Data are difficult to aggregate.
5. Actual time for patient care gets limited.

Internal and external changes affecting health care informatics

1. The ability to manipulate large amounts of data.
2. The ability to relate data to cohorts of people who shares similar health problems
3. The ability to link to genomic data.

Information system benefits

1. Data are readily mapped, enabling more targeted interventions and feedback.
2. Data can be easily retrieved and recovered.
3. Redundancy of data is minimized
4. Data for clinical research becomes more available.
5. Resources are used efficiently

 Storage
 Retrieval
 Transmittal
B. Power of Data in Information
 C. E-health situation in the Philippines
Factor affecting eHealth in the country
1. Limited health budget
2. The emergence of free and open source software
3. Decentralized government
4. Target users are unfamiliar with the technology
5. Surplus of “digital native” registered nurses. Digital native describes a
person who grew up and is familiar with digital technologies and who
uses them in daily living.

D. Using e-health in the community.

 Major goal of community health nursing is to preserve the health of the
community.
 It is best achieved by focusing on health promotion and maintenance of
individuals, families and groups within the community.
A. Universal Health Care (UHC) and ICT
DOH Administrative Order No. 2010-0036, outlined the policy directions of
Universal health care (UHC). Known as Kalusugan Pangkalahatan this
reform agenda has three priority health directions:
1. Financial risk protection through program enrolment and benefit
delivery.
2. Improved access to quality hospitals and health care facilities.
3. Attainment of the health- related Millennium Development Goals

B. Electronic medical records - is basically comprehensive patient records that are

stored and accessed from a computer or server.

C. Telemedicine – WHO define telemedicine as, “the delivery of health care

services, where distance is a critical factor, by all health care professionals using
information and communications technologies for the exchange of valid
information for diagnosis, treatment and prevention of disease and injuries,
research and evaluation and for the continuing education of the health care
providers, all in the interests of advancing the health of individuals and their
communities”

Four elements for telemedicine

1. Its purpose is to provide clinical support.
2. It is intended to overcome geographical barriers, connecting users who are not
in the same physical location.
3. It involves the use of various types of ICT.
4. Its goal is to improve health outcomes.
 eLearning is basically the use of electronic tools to aid in teaching. Can also be used to
educate fellow health professionals.

E. Roles of the community health nurse in e-health

1. Data and records manager. Maintain the quality of data inputs in
the EMRS, making sure that information is accurate, complete,
consistent, correct and current.
2. Change agent. Working closely with community and implementing
eHealth with them and not for them.
3. Educator. Nurses provide health education to individual and
families through ICT tools.
4. Telepresenter. Needs may need to present the patient’s case to a
remote medical specialist.
5. Client Advocate. Nurse must safeguard patient records, ensuring
that security, confidentiality, and privacy of all patient information
are being upheld.
6. Researcher. Responsible for identifying possible points for research
and developing a framework, based on data aggregated by the
system.

CHAPTER 4

I. Current Trends in Public Health: Global and National

A. Role of a Community Health nurse in the National and Global Health Care
Delivery System

II. Delivery the Health Care to the Filipino Family and Community

A. Filipino Culture
B. Filipino Customs and Tradition
C. Filipino values, traits and beliefs

III. Positive qualities and Values of a Community Health Nurse

A. Personal Attributes
B. Professional Competencies

IV. Health Related Entrepreneurial Activities

A. Community-based Projects
 B. Wellness Clinics

REFERENCES:
Ariola, M. (2017). Community Engagement, Solidarity and Citizenship. Manila:
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