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CHAPTER 4: IMPLEMENTATION AND EVALUATION IN FAMILY NURSING PRACTICE Araceli S. Maglaya Meeting the challenges of the implementation and evaluation phases is cn1ciol in family nursing practice. The nurse experiences with tl1efamily, a lived meaningful world of mutual. dy1mmic interchange of meanings, concerns, perceptions, biases, emotions and skills.,Just as the self nims to achieve body-mind integration to nchieve wholeness in the experience of "'being" and "becomtng", lhc mn·se must engage in foll awareness of being in this 1ived experience of caring with Lhe family", if she aspires to achieve "being'' and "becoming· in csperl cm·ing. The nurse can achieve cxperl caring within a dynamic and empowering family-nurse relationship directed at making choices in this meaningfu l world of coping, aspi1·ations, emotion;, nnd skills. EXPERT CARING: METHODS AND POSSIBILITIE ·s Expert caring during the implementa tion phase is demonstra ted when the nurse carries out intervention s bused on the family's understanding of the lived experience of coping and being in the world. Expert caring is developinl!, the capability of the family for "engaged care·. Through the m1rse·s skilled practice, the family learns to choose and carry out tl1e best possibilities of caring given the meanings, concerns, emotion~ and resources (skills and equipment) as experienced in the situation. W11ile the challenge for eirpert caring is a reality, the nurse _is enriched els a result of such an e:iq)erienc e (Benner and Wrubel 1989): .. ay belhg expen:s in ca. ring. nurses must take O-\i J::r and transform the notions of experttse. Exp~t c:,ring has nothlhg to do with possessing pri Vlleged Information that ihcrea'ses one's c-ont;t-QI a,cl donilnatfon of another. Rather, expert carlng unleasnes the possrbllities inherent in the self and ~ sltu:,tion, Expert caring liberates. :1nd facilitates in such a way that the one caring 1s enriched In the process (page 398). While expert caring does not happen overnight to the novice nurse, there are methods and possibilit ies that can enhance learning towards e>..-pert curing. Such methods and possibilities need to be carried out and experienced in real contexts a11d real relationship s to achieve skillful comportme nt nnd excellence in the current situation. 97	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
111 ree such major me L11ods and po;;sibilities are discussed in this chapter for ill ustrntiot1 purp OS<'. S: 11"41teatnfi ~ng ~~ :,P. ali!iift Telichl'h& I Oevelopment racttce COMPETENCY-BASED TEACHING A substantive part of the implementatio n phase is directed towards developing the famuy·s competencies to perform the health tasks. This is called co1npctency-based teaching. Competencies include lhecogn,itiv~ (knowledge), psychomo tor, (skills), and attitudinal or affective (emotions, feelings,,·alues). The following are farn. ily,11ealth competeucies deri,·e<l from their corresponding health tasks as exnmples : Health Task: The family recognizes the possibility of cross-infection of scabies to other family members. Comprer. c:lu: '!ltlaln$d'ltcaaseof-sca~ en~ avs I>), w~ ~ l)f-es tan occ. ur among :Ii 111'-"s. Health Task: The family provides a home environment conducive to health maintenance and personal development of its members. Health Task: The family decides to take appropriate health action. 111 nrd C'r le>,,,..stemnti=llv work tn,,. ·ards dcvclopm c11t of ti,e fomily"s c"mpl. !lcncics, such c-,omp<"tcnci~~ n<>Nl ln h~ explieith-defined. Cog nil ivc ~ind psyc-homo LOr eompc Lcncics n re n·Ocnecl e,Tllidily 1,s ohj,'<"1 h·,-; in th<. : n ur:,;i n~ L:. '1 rt· plan. The. ill ;1 w. li nal or affeclive <'Ompett!n<·ie~, na) ;; I!. <) be I ran>'l. 1tcd into ohj(·<"t i vcs of en n: :ii-fouli 11gs. emotions or philo,ophy i11 lif. ;-th. it enhanee the fomil~··s de,-ir'-' <Jr commitment t11 behavior change nnd sust;,in the ne.. Jed actions. The followin g,,ire examr,lcs of learning principles and teaching-leflrning methods nnd techniques that the nun;c c;ui use in competency-based 98	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
teachh1g (Abhr Ht 1980, pp. 35-73): (1. ) Learning is both nn intcllccr,wl and emotional proces!:i. Help Lhe family hancllc the affective componen ts of learning for sustained behavior ; (2) Leaming is facilitated when experience hns meaning. Focus learning on the family's meanings, concerns and situalecl p<Jssibilities; and (3) Leaming is :m individual matter. Ensure mastery by woddng 011 the family's current capabilities ~u1d potential s. Learning is an Intellectual and Emotional Process Bci. tig ;iware Lha L family member s as pc Tsons are integrated beings, a change io hm,,, they think about something or in their understanding of the situation will affect how they feel about that situation and the need to ch;in1,;e i L A change in beliefs or pe1·sonal meanings will affect emotions. Likewise, a shift in emotional oullook opens new ways of t J1i11king_ about siluali01 1s (Bmrncr ancl Wrubel, p. J83). To illustrate, the nurse C. 'ln motivate Lbe family to desire change by incrci:ising the salic11cc of thi;: problem through chi1J1J!,C in Lhe family's cognition (e. g. broadenin g ils knowledge base to m()dify pcrc:cplicm of the problem) and volition (e. g. developin g the necessary skills). 17. xperientiall y, s11ppc,r-t as an interven tion need to focus on fcc Ungs or emotions that i11tcrfcre with I lie fomily's feeling of"bcing in control" orl11esit ualion du1·i11g the change process (Mnglay:i 1988). The family needs to be aware of, acknowledge and analyze the source of i;ucb fee. lings of insecu1ity, anxiety, fe;ir. guilt, resentment or apathy in order to lrnnsform lh<iir energies into possibilities for clrnnge. Support makes Lht: family feel thnt the nurse is available and accessib le (_physically, psycholo~ica Uy or emotionall y) to provid P the necessary affirmation, reassurance, feedback and rc. ;source to regain s1rc J1g1h nnd refine newly developed skills to handle the barriers or blocks to sustained actiom;. Illness experie111:cs uf long duratiun (e. g., i:ar<liai: problem, mental illness all(] rel~trdation ) arc examples of such situations that c1tn deplete the family's emotional reserves if suppor1in! interventions are not carried out. Five general methods and techniques are discussed here as examples of bow to teach attih1des oi: help the f,u11ily handle the affective i;omponen ts of teadting-learning situations (Abbott, pp. 50-55; Benner and Wrul Jcl, pp. 165-168): 1. Provide luforn1ati. on to Shape Attitudes. Formal heliefs about health. choosinp,henlth and planning for health are shaped and changed by infom1ation wliich ure 11ot 11ecessarily restricted Loornltin,-ritlea langunge. Prom u phenomenologic. :a 1 pci:speclivc. ;, sensorimotor information through nctn,11 perc. :cplunl experience of Lhe sensation gives the b~sl information about thc situation. What a pernon/ family actually secs. h<'nrs,,c;me]ls, touches or feels influences his/her/its perc. :eplion and altitudes towar<ls a particul;rrobjccl, person orevenl. Experiendng health as hodilysens,1tions of"fccling good and strong" c. nn be a powerful first step in making healthy choicc5 of proper rest·. good nutrition, regulnr cxen:i:-;e and recreation. Rcframinl!, n :-. ituation by keeping the family members think about its understanding of the cu. n·cnl situation can open up new a11ernalives. rt require:; gelling in touch with the mcani. Jig :, an<l conc;crns thi H 11re st::ike in the situation. Foi· example. a fomily can be moliv::itccl to help the pregnant mother recoguize the need for re~ular prenalal c:heck-up by providin g t J1c nc<. :e. s:mry information l'egardfog the implication of the signs and sympl Dms as..:xpc:rienc. ;cd by the pregna11t men1bc1· and the consequence of failure lo lake the approprialc actions. Relaling :;rn::h c C)ns;cquences lo the prcgna 11t mother's meanings and concerns about being ;1 healthy, happy person, a produclive, caring mother ima n responsihle, lrwing wife. can lielp the family reframc the sihiation for her. 99	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
Through an,,thc. :r vnrinlion or the rolc-playin J!;. the client sils on lhc "hnt :,;c;it'' fr,c. :ing au empty chair onto which he pmjcct. <: hi,; mnny selves. 11Jis tcchniq111. : rrnvid<;~ ;1111,r,pnrt1111ity fnr Lheopposi ng fore~ within a person i-o rnlk ¼1th each t>thcr. have it out with each olher. forgive each other. comprom ise or gc:t to know each other. This can help the family member 1111clcrstand hirni;clr, his r. lrcams, fantasy and renlity (King and Gerwig 1981. p. 4S). Through role-pl;i};ng, f;,mil}" members c:an e..,-press. acknowledge and itlcntify lcdings and emotions generated by the day to day adjustments to cnch <Jlhcr':, n:ali Ly nnd c,,ping,,itl1 health am. I illness situations. TI1rough such flwm·,nr~s, c:11ch family mr·mbc. r c:an di~c. over additinnal r Jspcct,s of the self. This opens new experiences and altcm,Jtives to transfor m feelings anti emotions lo better opportuni ties for ach 1e,;ng a positive self-concept that cnahlcs one t<> learn to ca re for other members. (,. E:,plore the Benefits of Power of Silence. Encourage family mernlwrs It> use tl1f: p<Jwt:r <>f silence a~ a. 11 intervention to Lransfvnn the emotion. ~ or feelings th,H influence the attitude into less painful. less nhstinale and mnrc nbjcctivc e..,pcricnce of Ion king into the. ';elf for rrt'ative 11pp111·t1111ities tu lt1. :::1I. nurlurt: nr care. This is particularly useful during emntinn-lndcn f,1111ily encounter or recurrent psycho\ogi,;al irritations of daily ct,.. nppnintmcnts or cnntlicts. F,,mily rncmhcrs can lcnrn to use :. 1l,·n,·o. : (with «lnw d,ep brcalhrng) n. s an :-ic:tive Pxp Prif'nce r)f ht>ing aware or nm··-. sens..:,-. acccptini :-ind being tolerant of the self and others despite the fn11<trn1im1. ~. disappointme:msorstrcsses. Slow. deep breathing relaxes the body,md pro,ide. s for better o:..-ygcrn1tio n of brain cclb. Thii; allows a mm,· obj,·ctive and Jes$ emotiona l e.,,-icrience of being,,;th the self wbile anal~,inp, the problem or the issue for better problem-soh;ng. Learning is facilitated when experiences have meaning to the learner F11cu. ~ nnd rd Me lcarni11i:t e. 'ipcric. nccs to the clienfs/family's. meanings, a,;pirntion. s nnd lwst dn,in n111C1ng options ;n·ailable in the family situation_ To emphasize the imp<>rt:mt ·, "' ··11w:ininp... in learn in~. the follm,;ng exercise is used as an adaptation of a si 111 ilar 1;,,irris1· ill ust r. itcd by Ai>h;11t (p. 41) Look for nl>out two seconds nt the two di:igrarns below. I 101	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
-1, M:1k1 tltt! lr:nrnin;~ ;,clivc by pmviding opportunities for the (:1mily to do SJJ<!c-ifir· :ll'livili1:s, 11n1;v1Pr qw-:sli11ns nr apply learning in,,,lving prnf>l,:ms. l'r,ividc 1nn11gh orportunitics to pnic;ticc performing the skill,; such ;11, menu pbtnning, rrcp:irat i,,n of me. ii,; :ind feeding :i main nu rished memlwr. 2. Ernrnrt· r:larity in t1nd1ing. I isc wmds, r:x;impl Ps, vls11nl materials pnd ha11un111s I h:11 I hr: fr, m ily can 1md,m,t,,nd. J n t,iach ing skill,;, I he:: nurse mwa first desnilw 1111' Gkill: (11) 1:xplriining why ii is impnrt:rnr: (h) when j l,;l11,11lcl he 11<;1tl, :111d; ( t:) I he SI ;,~(,.,S Ill' <. lt!fl'i in performing the,;kj II. A ner describing 11,c skill. tile nurse must dernrmsln,lc it. correctly, explr1ining c:wh st111 as shl'. ! is dem<in'itrating ;rnd emphasizing important points (Alihall, pp. ~7-60). :i. Ensure adequate evaluation, feedback, rnr,nitoring and 1,upporl for sust:, i ncd action hy: (a) l:!XJllaining well how the family is doing; (h) giving lhe n('(·1·~s;11-y nflirrna1irins l)r r1::1<;sul'antr:<i; {c:) e. >:pl:Jining how the-:kill can be impmvcd ; ;ind, {d) exploring wilh lhc family how modifications ,·:in lw c:arricll CHII 111 maximil. r' si111;t1e<1 pos,;ihililic-,; or hc,;t option,; av:iil,1hlc 1,, the family. MAXIM IZING CARING POSSIBILITIES Effcctiv1 nursing of familie.-; can put n grc;il dcm:1nd nn th P. re. <;nurces of tlw nurse 10 11 point when c:hc rn,,y feel c:on1pl!. !t C rhysical, mental and e1110U<1nal depletion. This is :, r1ality i11 f:,mily nursing praclicc whi<. :h m:ikc\c: rrmtinc and pror·cdurturic,ntcd activ11i1s 1ik1· r1·1·nrdi11g, giving i11j<·ction;,, l:iking hlood pressures. and h1,11;,ekeer ing tusks nmn: ;ill ractiv,· nnd crmvc11ic;nl to make 111. :r:-cl( bu.-;y with. I lowever. lhe essence: ur n11rsi11g is (a ring. 111 tin, fat·1· of a fomily's co11flic. :1, cnnf11si0n 11r hl"iple~1-nes", the r111n<t' sh:n·es lwr,·. \Jll'rt is1 and cm01 icm:il/psyd1nlr,gical sl nmgth ns la mi ly rrwm bcrs learn w tl1\'cl11p i:11111pt,l£. !11cic. ~ l J manage hctillh L~>nditions or prtihlt"!ms. 11nlc·«s thr. : n11rsl' hus anp,ir,d ~u<'h 11 1,hilt,snphy n( caring, commitment lo cxccllem·e in nursing pr;1cl in will """"Y~ r(main an dui:ivc ic. lc,1I. Philosophy and commitment arc, therefore, i11gn·die111s of' effecth·c 1111r1,ing pr:11:tic£. !. ,\notltcr l'lialk-n~e i11 lamily 11111-sing practice is the difficulty in openitionali7. in g fnn1ily-1·,11i. red care'. Nursing c:ir·e or indi1. ;d11:1l family memhcrs in the home setting is, ufll011tinw~. lhl· nurse's idea aboul family 111m,inl! practit. :c. It is quilt' common 1ha1 nur/;CS offer rml~· lip service to the concept th;11 the whole familv is affectecl hy ;incl is nffec·1 i ni. : ib individ,,al memhcrs. It require~ a brnacl k11,,wh. :dgt:! ha!-'e on I he hch:1vinral ~a-i{:11ccs f'r11· the 1111 rse lo t11Hforsta11cl and concrc1i1. C" t lw concept of dynamic in l<'l'(:hangc lw1wrr11 family n,,. mhtr i; in 1hr ~,:hic\'erncnl nf hen Ith :rnd f:1111ily develripnwnt goals. Anolhcr sourr. :c 111 llw diffin1lty in op1. :r:1lio11. 1lizini: fnrnily-ccniercd cnrc is the nature :111d magni111dl' nf family t·orwc:-rn~ 1111d hl'nlih prc,blcm,-,. Ufh:11ti,nes health prnhl1,,ms c11,·111111ttrcd by fon,ilic,: an. ' l111gc, cnmpli1:;itud by a number of v;1riahles such :rn socin-c11h11rnl aud <1·0111 1111il' fnrtori;. 111 1hc fnct' of such complic:ations the nurse feds ht>lplcs1-lo tin: Jloi111 of withdrawing frnm tlw 11pportuni lics L,, work with familil!l> ns di1. :11ls. C11n,,id<'rini; s111:h a tllffirnlt:, of idcnlifyin11 the scope of help that lhc nurse c:in provide, )!,Ui<ldincs and lo<>b can develop her skill in breaking down hc:'lllh and 1111rsi11i. : prnbl1:1rn; into rnanag,eable uni ls of attack Problems in working with families. ire sometimes due Lo wrong definition of health nr nursin)!, problem. This mny be u conscqucm·c of improper collection or erroneou-. int. :rprclat ion of cul:!s, dat;J or fads. The nurse nmy lack the lrai ning or skill in (lb,er. ;ni. 103	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
3. Health-related motives may not always give rise to health-related hehavior and converse ly, hcalth-relatea behavior may not a Jways be determined by health-related motives. These principles on motivatic Jn have ddinile implications lo nursing interven tions. Utilizing Lhe lirst 11ri11ciple. tile nurse can help Lhe family n,eognizc Lhc existence of he,illh problems and motivate the family to tukc nc1inns on them by helping individual menibers see the problems ;is having serious consc. quences and high prohability of occurrence within the family's reality. The second priuciple,Hn guide the nuri-e to utilize social nnd cconomi<: moti\·cs in making rhe family renlize the 1:1J11scquenccs of health problems,rnd health ncti<ms. Cousiderini:; the Lhird principle. the n11rse can cncournge health bchaviu1· by ulilb. ing 1wo-hcal ll 1 11101 i ''CS wb ich have mol'e weight in influencing action. The need for,1ffirmalion. the need to belong, social pressures of relatives and signific,1111 others-rill these can generate enou1,;h motiv:ition for appropriate health behavior. Effoctb,e nursing of families mny not be too cn,;y n tnsk in i-hc face ofliruited resources. both material ancl m:111pm,· er. Considering the problem on limil C'd matcrinl resources, the nurse can explore I he pm<sibility of utilizing indigenous supr,Jies to substitute for e.,,,ensivc. commercial ones. In the face of mnnpowcr rnnstrainls. the nurse·s ability nt developin g th, cnpnbilitit:s of cli1:111,-; lo support the hc,llth cn1·c system can he put to use. Fc1r example, slw can leach incli,~duals or w-oups on the sii!,. m, :-mcl,;ymptoms or common health pn Jblems so lhal the_,, can serve as monilodnj:\ network in the comnmnity lo infvrrn Lite nurse of pn Jhlcms thal need her immi:Jiatc alien lion. The nurse clln also tr::iin a11xiliary :rnd village hci1hh w1wkcrs tn 1mm:ige simple health problems 1>r do roul in,iry work and pn:ieccl UJ·e()dentcd acth·itics. Hy doing U1is, sbe can utilize her time dt>i11g the fum:Lio11 lhal requires ltcr cxpertise-ht:lpinl!, f;1milic;; develop co1111wtc11de_:; for health dc,·clopmc11t. The nurse aims to at l. iin self-rcli:111cc among families hy ckvclnpi11i:; thcir skills to r<'cogniz~ and mnnage simple IIN1lth 11rohlems. Ni 1ltis is achieved. there i,; no need to hea Yily depend on the overburde ned limited health resources for problems I hat farnilie~ 1:an adequately manage by themi;elvcs. IL is, likewise. i. 111port:mt th:11 the nurse lie well-informed al Jout the available community resources so that !\he c::in utilize thcn1 apprr,priatcly. EXPERTISE THROUGH REFLECTIVE PRACTICE Th r<>11~h mfleet ivc prnclice. Lhc implc111cnlnl ion plrns(' 11ro,;c1e. ~ the best opportunities to wickn cxpl'rl i:;;I. ' in fom ily !wall h c·n rl'. S,!vcn, I authors de~cribe two sels of reflective l)rnctice: Relki:Lion-in-adinn and Rctlcclion-n n-:iction (Gl'l;'Cnw uod. 1998). Rclle<·tin11-i11-:1L·lio11 means to think whal one is clning whik nne is doing ii. lt allows 1 he nurse lo rc-dcsii. :. n wha1 she is doin~ whill' slw is doing il (S<. :hon. 198::i. L987). Reflection on.. actiou i1n"c,lvfs rcvic,,.. ln J!i 01· re-cvaluntin~ on C"·s :. H. :tiuns to: (L) relate what unc has lc. 1rned frnm this c:,,.-peri<incc lo her 1x. isti11g knowledge' ~tr11c111rns; (:!) mentally test her new 1111dcrstantlings in new contc:-:;ts; mid,(~~) 111nkc the knowledge gained J1er own tools for crilk,11 thinkin~ untl,·xpcrl c;irinp, Relh:t:tivc pn,clicc e111. :011ni;1es llw nurse lo immerse i1110 tin· cli<nt"s rc,ility :os hnlh lcarn tul-\cthc1· lo trnnsfonn lhc exp.,rionc:e intn new w:iy~ of heini. :. anct hccnmin)!.. Using l'ar:;o's Theory of Tlum1111 Flecnming as;, ~uide, the 1111rse learns to undcrntund full~-the clicnl·s responses. feelin:;s, nnd pt!rccplirnrn. This expcricnec 011 eli L11l-n11n,<' immersion in the dic111's reality guides both 1ow:1rtls trnn~i:cndin~ till!,·111-r1nt st~11us r·ueing. ") to the h<. !sl pus~ihh; hii. ;hcr level of stale or fum:t inn in~(.. Bc<:omini:(). Sample process quest ions for each type of reflective prnctice arc shown in Bo~ 4. L. 105	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
can ma:dniiw tcmchir1~-li. :. inling 11rpr Jrtunitics for the f:1mdy tnselec. :t :1nrl 11,. 'il 0111 inl1·rvc11ti1m r,µriw1-r t,1 d1t<·rminr thrir AJ')r,ropriarcnf"q S it1 hrlpi11g tl1t f. imily tow;1rd nt:1:c..l rc:mlutio11. THE EVALUAT ION PHASE Eval11;ilinn is lhc crrntirrnr,us r:ririq11ing of P:1d1 asper!,,r tl1c nursin14 pruccss (Clemen-Stone and others :. !l>IJ:l, p. 28:3). Althrm~h tv;d11;1tion is dis1·uss<?d as ;i scp,1ralc phase, il Ill usl t akc pl;u:e crn1nr rrint I~· with all r lw 11I lwr i,h:iscs,if the riursi ng process. ;i:, ill11stral1:d i11 f'i A, 1. 1 (in Ch:iprer 1). using an ad;1pt. ition of the diagram of /\lf:t1·n-l. t:Ftvn (:. !1111:. !, p. 191). Within 1his fnimework. two types ofevalw,tion include formative and !,,llll111lati\'C!. Formative cv;ilualinn oi:cun; during the course of the nurse-family relati<Jnship. Ongnin~ fccdh:1!'k is done and clicitccl Jnint Jy with Lhe family 1,, d Ptrrmine if ~oafs, pl::ms :md i11te.-·c1di1m str.,tt:gic.-s ;1n: apprl)J)riatcl~ f<Jcusecl. lbsed u1 the ev;ilu;ition plan which specifics th,· critcri:1/i11dicalo1-s, evaluatinn stand;ircl~. mf'lhods and tools. rt1m111tivc· 1v,1lua1inn is dcme ill pcrira1<. lk poin L, during the implcmenlation ph:,sc lo d<·lc-rmirw ch1111~Ps in tlw 1:li C'111·. s lw11lth conditirrn or hqmc :incl environment n:;ilities. Using t·val11atio11 <'i-iterl:, In help hoth nu1"s1: 1111d fomil~-tr, rlet,:rmine ;r the objectives ure :1ltai111,I. tlw nur.-e ncetl to r<\·iew ;ind determine hem· llw criteria rclale IQ each sta~C' nf thr nnr;;ini. prrwr-ss. \Vhc:n both the 1111rse and the fnrnily re. ilizt. : 1ha1 the objectives an· not 11r-l1 ievccl, the,· ca 11 a na h·zc pnssihle r~;<r-,ns. Some examples include: ( 1) inacl<'q1rn13 of ;i:-. sr,;smcnt d:1tn; (2) s. ;nals mid objective:-:1n· too hro:1cl nr unrealistic, or lhat 1hey,m· 1\<'Jt mutually estnhlisl H,d: (:-\} family resources or energiec: are not foi:11H·d 011 priori1y f. imily nccds or Jrc r. l C!plctcd ns n rc,;ult of crises-. itual inn:-: or (4) thr f:1111il. v lad;s lhf" inlrmnl or l'Xfernal '<t~rporl it needs to hnndk· the change process (Clcmtn-Ston L' :incl,,tfwr;: ::WO:!, p. 286). Form. iti,·e evalu;1t. ion µ;uid~ bolh lhc nun,e antl tlw family !Ill del"isinn:, nh0111 mnditic Mirms of gnals. ohjrcti,·es and inrenf'ntion st. rntc1;ics/meas11res, dq. 1c-11clinv. upon the current situation. emerging or addit1ona J hca IL h nc,·ds/ prnlil,n 1s nnd priorities of the family. Summativl cvnhmtio11 occurs at t. he encl of the fnmily-n11ri;,e relationship. It determine s if lhi: g,mls as sp L·t:itil-<l in the fam. ily nursing r~'lr<~ pl11n nre 11c-hir\'ed as n1e;is11red by the n11trn11w rrillrin and l. '\'lllual1on stnndards. Ba!;Cd on the famitv·s current situation an<l/,,r n·111:,i11i1 1!!, lwallf1 11cct. b or pr1>hlc111s. the n11r:;e cnn guide thr family on making c Jrnicc :-. ahi tlll ltnni11utio11 or referral. CHALLENGES AND DIRECTIONS Falllil_\ health n11rsi11~ prai:lkc is n pl1cnomenolop. ical l'S'[lf'rienr. e of r:iring and (·oping with c:11·,,gi\'il1);. F. xccllc·nrr in such nn cn)?H). \L-<l carin~ is reflected m skillful co111port111<11L, ~in. :11 Lhe 1111n;c's pcr:-onal antl pn1fessi11nul meanings. cunct1rns, e. xp1,·t:11i n11,-.. st~·lv. hahils ond rcsonrrcs. 11:Lrtinilarl y c:-.-perienced durin)!; the impl L·1111:11talio11 phas,:. Cn111111ilmcnt lo cxeellc::. ncc' or prai:tit:e i:,; :i li,·t-d 1;::xpt?rience of bei11" cffc1. :ti"<: in I 1arn. lli11~ th~: ch,\llen!;CS c f worki 11g wit Ii fa111 iii es. Th,· i rnplt' nwnt. it ion :1nrl 1·v:il uat i>n rhn"'<'S provide c,·e1;-· availnblc opp1,rtunity tor the nt1rsc and thi:: fa mtly tr,,·alidatc a:-!-. e,-. :,;mt·rtl d:11a and 111<1tlif) ah, 11ur"ing can plan h:ised on the family's pcn·,·pt i1111 of a111I n·~r1111"<'S 111 l'\'ery nur;,1:-family dfort,It explorini; the best choices in the family·:-:-ilu,tll·d pv:;.-;il,tlit1 e~. Throu~I, in1111ep,io11 inl<1 th,· client":-reality. the nurse gels a full tmc..lerstanding of thu dtp1h of tlw meaning of Lhe client"s experic11ce as both enhance cnc. h other's 11pport unities Ir> fod Jilatc thejoun1ey Crom apa Lbytocourage. vacillation lo decisiven ess, 107	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
9. Greenwood, J. (1998). The role of re!lcc-Lion in si. ngle and double loop learn1ng. Jo1wnal of Adua11ccd N11rsi11g. 27, 1048-105~. 10. Johns, C. and Freshwater, D. (Eds. ). (2005). Tram:;_fm·ming Nursing Thro11gh Reflective Practice. (2nd ed. ). Oxford: 131. ack,vcll Publishing Ltd. 11. l(jm, H. S. (2000). An Integ T:1th. :e Framework fvr Corn;cptuulizi11g Clients: A Proposal for a Nursing Perspective in the New Century. Nursing Scie11ce Quarterly. 1:; (1). ;37-44. 12. l(jng, V. G. and Gerwig. N. i\. (1981). H11111c111i ;,:i11g N11rsi11g l~cl11cotion: A Confluent Appruoc/1 1Jwougf1 Group P1·occ,s:;. \Vakdk ld. Mass. ich Ltsclls: Nursing Resources. 13. Kock. T. and Kraffk, D. (:wo6). Pnrl'icipolory Actiu11 Research 111 H,. wlth cm·e. Oxford: Bl. tckwcll l'ublishing Lld. 14. Mnglayn, l\.. S. (:wo8). Delivering Q11111i1y Service Serving Communit ies: Nurses leading Primary Health Cr,rn. Phi/i7Jpine. lounial of N11rsing. Vol. 78 (2), 10-13. 15. Maglaya, A. S. (2004). Nrll's;11g Practice i11 the Cn111111unity. (4th ed. ). Marildna City: Argonauta Corpoi:-:1Lion. 16. Maglaya,A. S. and others. (1999). Afc1milyhealthempo1uer·me11tinterl}(mfion model Inwards prevention mrcl co11trol of 111ctloric1 in tlw Philippines: The local gcwen1ment 1mit/1·w·ol hen/th 1111it pe,·speclivc. Marula: DOH -ENI-IR. 17. Maurer, F. A. and Smith, C. M. (2005). Conmwnit y/l'uhlic ffe C1lth 1Vu,-sing Practice. Health for Families ancl l'op11latio11. (3rd ed. ). SL Louis: Elsevier Saunders. 18. Parse, R. R. (1998). The Human Becoming School of Thought: A Perspective for Nurses and Other Health Professionals. Thousand Oaks, CA: Sage. 19. Parse, R. R. (1995). llluminadons: The Human Becoming Theory in Practice and Research. New York: National League of Nursing. 20. Rosenstock, M. (1960). What Research in 1Vlotivation Su~gests for Public :E-iea Jth. Amcrica11 Jountal of Public Heallfz, 50 (3), 295-302. 21. Schon, D. A. (1987). Educating the Ref/ectiue Practitio11er. San Francisco, CA: Jossey-Bass. . 22. Schon, D. A. (1983). The Reflective Practition er. New York: Basic Books 23. Vlilkinson, J. (2001). Nursing Process and Critical Thi11/. :ing. (3rd ed. ). Upper Saddle River, New Jersey : Prentice Hall, Inc. 109	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
100 2. Providing E. '-cperiential Learning Activities to Shape Attitudes. Specific simulation e.."Xercises can provide direct experience:'i to understand and handle iucli,;dual and fa. mily psychologi<:<11 /attituclinal issues. For e. "ample, "letting go·· and ··aggression-assertion·· exercises can pro,ide sensorimotor information~L1 e.,1>eriences for fa. mily member s to gain full awareness of and manage effectively issues like powei-play or family contlicts. Opportunities to see, observe. i. nteniew other patients or having a direct e. '-J)erienc e o( feeling the advantages of choosing n hea Jtl1y life style (such as engaging in regular exercise) can b1ing abo L1t attitude chaugc. To illustrate, a mother can be given lcnrning opportunity to obser..-c and intenie"· other families with malnoudsbed chj Jdren to help her realize the nature and magnitude _of malnutrition as a problem so that she can motivate her family to address the problem. 3. Providing E,xamples or Models to Shape Attitudes. This is done bv allowing the family to experience ideal situations or interview case_-=; or p~rsons demonstrating the attitude s or attributes to be developed. As an example, a family (specii. ically, the couple) cau inter-view other couples using differen t methods of family planning. If the couple has major -concerns aboul the side effects of family planning rnetbods, the couple can be exposed to scientifica1l y-basecl natural family planning n1ethods (NFP) such as t11e ovulation method, basal body tempe. rature 111ethod or syrnpto-thermal met11od. Couples who are successf ul autonon1ous users of ~FP can help explain U,eprocedu re and how intimac y issues are handled dur:ing the fertile phase. These autonomo us users can also act as models of how couple relationship and family life can be enhanced through better alternatives of relating. expressing affection, communicatin g and achievi. ug wholeness of self a11d of other family members. 4 Providing Opportunities f"or Small Group Discussion to Shape Attitudes. Discussion in small group (among family member s or among members of otl1er families shnring the same problem or situation) will belp make U1e previous three methods more effective. For example, when members de:;cribe a. ad discuss thefr e.,l)etieuces on specific health problems (e. g. addictions, coping with. chron ic illnesse s or disabilities) the sharing may influence the perceptions of other men1bers in t J1e group. Attitudes may change when g L-oup member s talk about their feelings, concerns and experiences on how hard they try to cope. The process of putting t J1eir ideas into words,rnd experiencing the caring, rnn·turing attitude of others in the gro LIP can be an effective way of b1inging about attitude change. For this techniqu e to be effective a group of 8 is ideal w:ith a maximum of 15. 5. Role-playing Exe1·cises. In thls techniqu e a family member either: (a) acts the part of auother to experience and understand the other person· s phenomeno logical reality; 01· (b) imagi11es and acts out all the parts in the sih1ation. The nurse concentrates on how the member is acting nov,, not on why he is actin A th. at way. This tec1rnique can he'lp clarify refotions b. ips behveen family member :; or help a family member become fully aware ofthc emotions being experienced and t J1eir effects on one's behavior or perception of a problem situation.	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
TI1rough another variation of the role-playing. the client sits on the ~hot senl~ facing an empty chair (>nto which he projects his many selves. This techt1iq11c provide.,; nn npporlun ity for the oppniaing forces within a person to talk with ench other. haw il out with end, other. forgive t:Hcl1 other. compromi. ~c or get to know each other. This cnn help the family member tu1dersland himself. his dreams. fantasy,md reality (King and Gerwig 1981, p. 45). Thrnugh rolc-pla~;ng, family 111c111bers c:111 express, :icknowlcdg c und identify feelings and emotions gencrat C'd by the clay to day :1djm:1 menu: to e:ich other's reality and copin~ 1,·ith hc,1lth ;111d illness situntions. Throuf!_h such a"·areness. each family m~ml>er can discover additiv11al aspects of the self. This opens newcxpcdc1n:c F and nlttnwtiv es lo tra11sform fcdings and emotions to better opportunities for achic\'ing a positive sctr-c;c Hwept thnt enables one to learn to ram for other 1111m1bcrs. 6. Explore the Benclits of Power of Silence. Encoura~c family members lo use the power uf silence us 1111 inlc1·vcntio11 to tr;msforrn the emotions or fcel. in)l. s that in:flue11C'e the nllillldc into less painful, less obstinate and more objective cxpcric1K e oflookini; into the self for crt!ali\'e opportunities to heal. nurture or care. This is particulal'ly useful during emotion-laden family encounter or recurrent ps~'chologicnl irritation s of daily disappointments or co11llkts. Family members can karn lo use silence (";111 slow deep breathing) a;; an acli\'c cxpcdcm :c ofbdng aware of one's senses. acc;epting and hl!ing tolerunl of till' self nncl others despite the frustrations, <lb:appoin tmcnts or stresses. Slow. deep bi-eathing relaxes the body nnd provides for belier oxygc1rntion of lll'ain cells. This allows n more objective ;ind less emotional expc,;cnc,~ of being with the self while analyzing the problem or the issue for better problem-solvi ng. Learning is facilitated when experiences have meaning to the learner Focus and relate leamin~ experiences to the clicnt's/fan1ily's, meanings, aspirations and bes1 choice among options avaj J. tble in t11e family situation. To emphasi ze the importance of"meaning" in learn Lng, the following exercise i1, usetl as an adaptation of a similar exercise i\lu1,trated by Abbatt (p-41) Look for about two i;econds nt the two diagrams below. A. B. 101	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
]02 Now 111r11 over lilt! hook anti tlraw dia~ran,s /\ and ll. /\l'lcr you lwvc «Jr. me. : I his rend nn. /\I 1110. sl l·crl a inly yo,1 c:t,11 lc J d rn w di. iv. ram 13. The pal 11,rn ofth rec. S~f11:t res pi r 1c<l 10141. :1 h,,,. mn kc. s st;ll Sf!. Dia gr;, 1 n /\ w;1s proln, bly Ju,nk:r lo rcmcmbcr hr:c;i mw Lh<:r·c is nn shnpc _ no 111c,11,ing 111 ii. Bui lhc 1tumbc1 of line.-. fo,· each diagram w;,s cxucl ly the. s111ne. J. ikc Dia14n1111 H which is c11. sy 10 remember hcc:,usc it is. similar lo a pallcn1 you h11vc scc11 hcfr,n·. tcachin14 111ust have mcanin14 so thnl fomilics lc:arn and rcmcrnbcr more easily. Sped lie,:x Hmplcs or lww to do this arc 1. uggcstcd: 1 Analyze and process with familymemher s all leacbin~-lcarning ln1sctl on LJ~cir grw;p of ·the lived experi ence of the situation in tcrn1s of i Lc; mean in,:; for· the. sc Jf. This hm; been previously c. liscui-st!d as the r>hcnomc11olo~ic. il n,:ilily I he fomily experiences. Such II reality is (l,c 1n1lltr11 lh,11 h;is mc:. 111i1114 IJccausc lhc mcrnbe1·s a,·e f:1mili;,1· with it.. Thuy Jive it. Within the fomily's 1·e:ility, the nurse can s1~1rl with the problem which h;). s lh,e, J11(). ';I,;aliencc to the f:1111ily. 'fhc c:nuple cnn be help1·cl t/J rct:r Jgni;r. c and an. ilyzc the situ,1tion in,·clat ion In f:orn Hy g,wls ;ind ;ispirminns. The critical issuc for the family is, not knowing what to <lo given 1he 1h1·c1. 1ts/fcun; rclatr~c J with :,rvai J:.,hl!! altcrn;it,ive.-.. Thc iss LJe c:..in be used by the nurse..,-.. in cnlry point in esi..iblishirt~ u working r<. :la Liun ship wilh the. : fumily lhat c:onlinucs on lo include the other hcrc-iinc. 1-now problems such a;:; high risk pregnancy and m. ilnut·rition. 2. Tnvolve the family activ-cly in determinjn. g areas for teaching learnin g hased on the health tasks that member s need to perform. The family must know in advance what competencies or objec:Livl!S arc to be learned_ These must Ix: related to the health t...-isks that thr· family pcn;civc.,, must be done and 1·he f:imily's situated possjbilitics or best options based on existing and potential resources, meanings and concerns. 3. Use examples or illustration s that the family is familiar with. Analogies that are similar or congrn enl w'ith the fomily's way of organi,:ing its experiences and perceiving the world (e. g., the family's world view) are effeclive examples. To i!lustr. :ite, in explaining to rural families the concept bthincl family plannjng methoclo;, 1bc nurse can use t J1c analogy of ~1n :. gri L"llltur&I pr:;<. :tice of farmers whe11 they prune or cut-off alternating lrnd. s r,r flr;"·er\ (that n. re tor) c:l()se to cnch other in a vine) lo e!lsu re heal thy fnii1.. s. /\n1lher example is LJ1c use <Jf lhe linear drawing of the fertility cycle (rather t/rnn the circular one) in explaining NFP concepts to most couples in th1, rurnl itn:;,s. The linear drawing is similar to the families' day to day or,;. ;i lendar way of experiencing the world. Learning is an Individual Matter: Ensure Mastery of Competencie5 for Sustained Actions J\llr,w for individual diffel'enccs by letting families learn at t J1eir own speed, providing en1>ug. h time 1,, pn,c:ticc the behavior and using a variety r,f teaching methods. These an, c:ril'ical in en~uring that the families arc confident and foci competent in performing the nec:. t __ :ssary cngni Uve and psyc:homotor ski JJ. s. Some tcclmiqucs to develop mastery are I he: following:	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
--1. Make the learning 11C:tivc by providing opportunitie s for 1he family I<> do sp1:cifi1: adivitics, ;111swe1· que.. :lions or 11pply leilrning in solving prohl1:m s. Provide cnnur;h nppnr LUnil 'ics to practice p,:rforming the skills such :-1s menu plnnning, prcpa rnlion of men ls and fecdi ng a malno11rished member. 2. Ensure c:larity in 11:aching. IJ!1C words.. cx;1mples, visual 111alerials and lrnnd()ul s Iha! the family c:111 u11derstand. In t,;;1ching skills, 1·lie nurse must first d1:sc:rihe lhc skill: (n) explainin g why it is impor1:111 t; (I>) whon it $hnuld h<> 11so,d, :ind; (c) the sl,1gcs orstqis in performing th1; Hkill. Aft(,lr dcs1:.-ihi11g the 1,kill, the 11ursc: must demonslnolc it cnn-ectly, explr1ining ench stcp ns,;he i~ demonstniting and cmphasbdng important points (Ahlwtt, pp. fi76o). 3. Ensure adequate evaluation, feedback, monitoring and suppurt for sustained action hy: (a) explaining well how the family is doing; (11) ~iving the n<:cr~. s,;;1ry nffir111:i\ir111 s or n,;,ssur:m,·e..~; (c:) explaining how the i;kill can l>c irnprnved; :,nrl. {d) exploring with the family how modificalions cnn he c:1rricd nut w maximize situnt. ed possibilities or best options avaik1blc lo the family. MAXIMIZING CARING POSSIBILITIES Effective nursing of fomilic. c; can put a great dem:md on the resources uf the nurse to a point when she may feel complete physic,d, mental and cm C>tiona l depletion. 111is is n reality in family nursing pruc:tice which makes routine and prncedure-o.-iented activities like recording, giving injections, taking blood pressures, and housekeeping tasks more attractive and convenic:nl lo make herself busy with. However, the essence of nursing is caring. In the foce of a family's t:annict, confusion or hclplc.,;. sness, the nurse shares hr,r cxpcrti. c;c and cmotinni,J/psychnl()gic:,I Sl Trmgth 11s family members learn to develop competencies t<> manage health conditions or problem s. Unless the nurse has acquired sucb a phil,Jsc,phy of caring, commitme nt to excellence in nursing practice will always remain an elusive ideal. Philosophy and commitmen t are, therefore, ingredients of effei:tive nursing practice. Another challenge in family nursing practice is the difficulty in operationa lizing family-centered care. Nursing care of individual family members in the home setti J1g is, oftentimes, the nurse's idea about family nursing practice. It is quite common that nurses offer only lip service to the concept that the whole family is affected by and is affecting its individu al memhers. Il requires a broad knowledge hase on the behavioral science-, forrhe nurse to understand and concrctizc 1·he c<>ncc_,pt of dynamic: interchange between family members in the achievement of health and family clevelupment goals. An<Jlher source of the diffie11lty in operationali :>:ing family-centered care is the narure ancl magnitude of family concerns and hea Ith problems. Often ti mes health problems encountered hy families art: huge:, complicated by a number of variables such as socio-cultur al nnd cc. onornic factors. In lhe fllce nf such complications the nurse feels helpless to the p(>int of withdrawing from the opportun ities to work,vith families as clients. Considering sueh a ui Jficulty of identifyi11g the scope ()f help that the 1. Lurse can provide, guidelines and tools can develop her skill in breaking down health and nursing problems into manageable units of attack. Problems in working with families are sometime. ~ due to wrong definition of health or nursing problem. This may be a consequence of improper collection or erroneous interpretation of cues, data c)r fact!;. The nurse may lack the training or skill in observing, 103	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
\ ]04 eliciting data or analyzing the informution gnthered. Working with Ute family C11n also be difficult if its coopcn1ti~n in carrying our he:ilth meas~re cannot be elicited. This m:iy he a consequence of the family"s faulty compre hensmn or non-ncccptnncc of the need to take m:tiom, on its heal U1 problems. The following factors or conditions (F1-ccman 19(,;{, pp. l34-135) may b1·ini; this about': (1) The family's information 111:iy be inadeq11:1lc or inaccurate; conscq11cntly it may not,,:ee the problem or :;ee only :1 part of the problem ; (2) The family has U1e necessary information but fails to relate them to the problem situation; (3) The family is not willing or ready to face lhe re:-ility of t J1e situ:ition or alter its behavior; (4) The members may not be willing lo oppose family, peer or soc. in I pressures; (5) There may be c1dhcrencc lo patterned hchnvior; (6) Thcrc is foih1re to relntc the needed nclion to family go;:ils; ;md, (7) There is lack of con lidence in the ;ic Liou pro1>osed. Problem s durin~ the implementation phase may be due to inappropriate choice of nursiug interventions. This may be brought about by the following causes: 1. 2. 3. The tendency of the nurse to usc pnttcrne d or "conned"' approaches in worki J1gwith fnmilieswithout recognition of the possibility or reality that she affects and is nffectc<l by cad, nurse-family illtcraclion, in the same manner th;tt the family is affected and reacts to ll1e nurse's behavior as she carries out nun,ing interventions. wadequate appreciation of social and cultural factors or realities which can be maximized or utilized e. g., mobilizing family support systems such as in-lnws, or use of bt:rbal medicine or other olternativc healing techniques based on culture/tradition. Inadequate or limited repertoire of intervention techniques and ski Jls in the foceofcomplic atcdbelrnvioral problems in family life like managemen t of marital disharmony. This can challenge the nurse to enhnnce her clinical competence and be updated wilh current literature on nursing practice, such as research findings for evidence-hosed p1·actice. There are several theories on motivation which the aurse can use as ~ases for interventions U1at she can implemept. Rosenstock's Uiree principles of motivation are used here as illustration (1960, p. 299): 1. Pr C\cntive or therapeutic behavior relative to a given health problem in the individunl is determined by lhe extent to which he sees the problem as having both serious consequences and a high probability of occurrence in his case, and the e11. 1:en t to which he believes that some course of action open to him will be effective jn reducing the threat. 2. Behavior emerges out of frequent conflict among motives and among course:; of action. \\there motives themselves conflict and compete for attention those which have Lhc highe~t value or salience for the individual will actually be aroused. Healll1 matters-at least in the individual who believes himself healthy-arc probably not as potent as are certain other motives, specially economic nn<l social ones. Where lhe con JJicl is based on lhe indhidual's bclieflhal no available course of action will be effective or where a prescribed course of action is believed to create equa Jly or more serious problems of other kinds, the conflict may be resolved in a variety uf malad11ptive ways.	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
3. Health-relat ed motives maynotalwaysg iverise to health-related behavior and conversely, health-related behavior may not always be determined by health-re lated motives. These principles on motivation have definite implications to nursing interventions. Utilizing the first principle, Lhe nurse can help the fomily recognize the existence of health problems and motivate the f,~mily t~ take actions on them by l~elping ind(v_idual members sec the problems as ha VJng senous consequ ences and high probability of occurrence within thefamily"s n!ality. The second principle c:in guide the nurse to utilize social and economi<. : motives in making the family realize the com;eq11cnccs of health problems and he. alth actions. Considering the Lhird principle, the nurse can encourage beallh behavior by utilizi 11g 11<Jn-hea 1th mo lives which have more weight in influencing tction. The need for affirmati on, the need to belong, socia! pressures of relatives and ~ignificant others-all these can generate enough motivati on for appropriate health behavior. Effective nursing offammes may not be too easy a task in the face oflimited resources, both material and manpower. Conside1;ng the problem on limited material resources, the nurse can e.,,. plon~ the possibility of utilizing indigenous supplies to substitute for e. xpensive, commercial ones. ln the face of manpow er constraints, the nurse's ability at developing the capabilities of clients to support the health care system can be put to use. For example, she can teach indiviouals or groups on the signs and symptoms of common health prnblerns so that they ca11 serve as monitoring network in the community to inform the nurse of problems that need be. r immediate attention. The nurse can also train auxiliary and village health workers to manage simple health problems or do rnutinazywork and procedure-oriented activities. By doing this, she can utilize her time doing the fonction that requires her expertise-helping families develop competencies for health development. The nurse aims to attain self-reliance among families by developing their skills to recognfae and manage simple health problems. As this is achieved, there is no need to heavily depend on the overburdened limited health resources for problems that families can adequately manage by themselves. It is, likewise, important tl1at the nurse be wel1-informed about the available community Tesouroes so that she can utili7,e them appropriately. EXPERTISE THROUGH REFLECTIVE PRACTICE Through reflective practice, the implementation phase provides the best opportunities to widen expertise in fainily health care. Several authors describe two sets of reflective practice: Reflection-in-action and Refle. ction-on-action (Greenwood, 1998). Reflection-in-action means to think what one is doing while one is doing it. It allows the nurse to re-design what she is doing while she is doing it (Schon, 1983, 1987). Re1lection on-action involves reviewir1g or re-evaluating one·s actions to: (1) relate what one has learned from this experience Lo her existing knowledge structures; {2) mentally test her new understm1dings in new contexts; and, (3) make the knowledge gained her own tools for critical thinking and expert caring. Ref Jective practice encourages the nurse lo immerse into the client's n:alit-y as both learn together to tr:)nsform the experience into new ways of being and becoming. Using Pai:se's Thco1y of Human 8ecoming as a guide, the nm·se learns to understand folly Lhe client's responses, feelings, and perception s. TJ1is experience on client-nurse immersion in the client's reality guides both towan:ls transcending the current status ("Being") to the best possible higher level of state or functioning (''Becom ing'"). Sample process questions for each type of reflective practice are shown in Box 4. 1. 105	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
1 106----~ lmlil,-.. t dllfeum W ,:aided aatco liii,i,. ~-~~-Acti"~" l fe~I abl'llll whilt hilppt?nt"di' lty uoders:tood th~ 1. ; 1,ent's or respbh-s~s to tht> h<-. ilth-lllooss ~ ac;lioni m Atch nw bellofs/ aee ot~rpo S$lble optlcu,s c;in J. 1$1 to Improve on how I can c Nr. stand the c Uent's conc. ?rns. ~lnp and potentials? How f~'these options to improve my ltyto ht-lp the cllent transcend a hlaher level of state or functioning? t would be the consequences hematiw actions for the family? f1 ha~~ Uf)!llrience changed mv &f kd OWt"'-a bout; (al this ~uent; ~f es a persbn ~nd as a nurse/ As sbown in Box 4. 1, reflective practice offers a guided expeiience on bow to make excel Jeuce in nursing practice a 1,ay of lifo. By focusjng 011 the family·s responses and umlerst~oding the depth of the family's reality in the "here-fu1d-now·, reflective practice can offer a systemati c appro. ach to: 1. Determine the accuracy and completeness of assessment data and analysis; 2. Validate responses to and perceptions of,. vhat is happening d UI·ing each interaction, or what the family and the nurse are expecting from each other to achieve Uie goals aod objectives of family health care; and, 3-Utilize the feedback mechm1ism to understand how each one is e>. l)eriencing the reality and challenges of behavior change. Through the ~Look-T h. ink-Act" cyclical process of the participa tory approach, the family and the nurse can analyze together the family"s issues and at:nbiva1ences regarding internal pressures for and against spontaneous or planned ch;mge or fear of getting out of t J1e comfort zone of status quo. Through the feedback mechanism of reflective practice, the nurse ..	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
t,rn maximize tcachinj. \-l<'m·11i11g oppcn-tunitics for the family to :,clccl llll Ll test l HII intervention option:; to tlctcn11ilu. their appm1>rintcncss in hclpi11g the fomily tow. ud need rcsol11tlon. THE EVALUATION PHASE E"nlual inn is tlw conli1111011:-criliq11ing of cnch asp Pl'l (Jr tile 1111rsi11g process {Cl,:nw11-S1011c and,>1hcrs :2002. p. :28;~). i\llhc111). th c\·al1111Lin1 1 is discnsscd ns u ,;cpant IL' phast. it must t ak, plu,·c <' llll'1tl TL·111 ly with nil t lw ot lwr ph. 1:-l'S of I he nursing 111·m·,:,;s. :ts illnstrnl,d i11 Fig. 1. 1 tin Chapter 1), 11s111i; :111 mlaptation of lhc. ' diagn11n of Alfnro-1.,F,vr, · (:. !t H 1:2. p. 1~1t). v Vi Lh in this frmm:wm·k. two Wpc:; of eval\1111 iun include fr,rmativc und s11111mali \'c. Ft)n11ali\'(~ C\':1'11:1tim1 occnrs d11ri11g the course of the 1111rsc-fn111il) 1·cl111ionship. Ongoing feedback is d Clnt,,md elidtud,ininl J~ with the family to clclcr111inc if gt1als, pl. ms and i111l'r\'c1ttit1 11 stral,:gics ;11·,· :1ppr<1prialcly foc:11sc1. l. llns,·d in lhl: eval11atic:m plan whil-h s1wcilics \he nitl·ria/i11dit-,11ors. cvalualitll l sland:mls, methods and tools, for111:1 I i\'c' ('\',1111 :11 ion L-: don,· n t p L1·ioclk points d11 ri 11A the i 111plt:111~·111111 ion phas~ lo dclcr111i1w c:h;m A<'S in llw eli(111·s h L·11Hh i. :011diliu11 or humc and e11virom11c11l H::1litics. L1::i11g ('\'al11atinn c-ril!ria tu hdp lmth nurs,· :111<1 family IP ddrr111i1H' ii' tlw 1,hj1ctivcs are nttnin,d, t·lt<:' nurse n..:cd lo n. :,·ic-w it11d t,lclt:nnine hnw th, criteria rclal. t lo each singe of till' 1rnrsi11µ. pn1niss. \Vhen b Nh. the 11111·s~ anti the family n:alizc thal the objccti\'CS an: nnt. icilicn:d. thl'Y can analy·,..... possiblt: r(·asnns. So inc 0x. 1111plcs include: (1) i11adcq11ac·y of assessn1c 111 d11t11: {2) ~oal:,; and ()bjcel i\'CS arc tnll J)l'oc Jd or 111Hcalistic, or that they are 11e11 mt1l\lallr established; (;3) familr rcso11rce-S or cntrgicn nre not focused on pric1rity familr needs or arc deplctccl as a result of nisei-si1. 11;1tio11s; or (,I) the family la C'ks the i11L,rnal or external support ii needs In hantllc the chan). tc process (Clemen-Stone and olhcn; :. !\ll):. !, p. :. !86). Fornwtivc cvaluatio 11 gui1. h:i; both Lhc nurse and the fa mil:, on <lccisiom; ah<l11I modilic. ations of goals, object i\le:S und interventio n strategies/measures, depending uplln the c11ne11l silualio11, emerging or. tll<lilional health needs/problems and priori tie:-of the family. Smumative evulua Lion occurs at the end of the family-nurse relationship. It determines iftbe goals as specified in the family m. u·sir. ig cnrc plan are il Chieved as measured by Ute outcome criteria a ncl evalualion standards. T3asell on the family's c11rrcnt sittrnrion and/Dr remaining health needs or pl'oblcms, the nurse can guide tho family on ma. king choices about tern1innl ion or 1·cfer1·al. CHALLENGES AND DIRECTIONS Family health nursing practice is a phenomenological e11.-perience of caring and coping,vi U1 cart:giving. Excelle L1ce in such nn engaged caring is reflected in skillful comport Jnent, given the nurse's personal and profession. il meanings, concerns, expectations, style, habits and resources, particulnrly experienced during the implementatio n phase. Commib11ent to excellence of practice is a lived experience of being effective in ltaudlingtbe challenges of working with families. The implementation and evaluation phases provide every avaifable opportunity for the nurse and the family to validate assessment data and modify Lbe nursing care plu. n based on the family's perception of ru1d responses to every nurse-famil y effort at e:-.."J)loring the best choices. in the family's sit1. 1ated possibilities. Through immersion into lhe client's 1·eality, the nurse gets a full understanding of the depth of the ·meaning of L11e client's experience ns both enhance each other's opportu nitiestofacil itate thejow·uey from apathy lo courage, vacillation to decisiveness, 107	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
hopelessness to cmpow1::rmc nt. The rhythmicity in the polnritles and parudoxes of the journey to human becoming (Parse, 1995) brini:;s clients to the threshold of their own learning in order lo maximize their empowering potential to make a choice about rcfcrr.,1 or termination of the nurse-family relationship and moving on. Nurses and fam_ilies e:q Jcricnce per:;oni'II feelings about separation or Mletting-go " during the termination ph:,se. Cllrt:ful planning (on when 1111d how to seek health care again), advance noticu (for l Tam:;fers) and nllowing opportunities to discuss issues ab01. 1t separation ~111ci e:1.-pressing reactions or emotions help families perceive themselves as being able to Jrnndle upcoming situations independent Jy. 'I11is e:1.-perience provides the necessary support for tlit J family lo make the trunsition to independence and termination. (Clemen-Stone and otliers 200. 2, pp. 312-313). Family health nursing practice challenges the ~o,~mun ity ~1ea J!h nu~se to syslema Lically establish and supervise a caseload of pnonty fam1J1es 1dcnt1ficd and classified geographically by health ~are need or h_calth progrn_m or service, using methods and tools like the eriidemiolog,cal map or client case registry by health problem or health program. l Js[ng the c~se munagc~1cn t ap'?roach, the nurse works with priority families guided by a frumly health n~rsmg practice mt:thodology such as what has been described in Chapters 2, 3 am! 4 (this chapter). Guided by nursing cru·c standards/protoco) s, recording and reporti ng systems and referral procedur es, u_ll c~icnr re Alities, responses, progt·~s and outcomes arc documented. Rcrords. u·e ma, ntamed to en bance tcamw0t·k, coordina tion, and healtli program and pe1fonnancc evaluation to support quality assurance and enhance excellence in community health nursing practice. REFERENCES 1. Abbatt, F. R. (1980). Teaching for /Jetter Learning: A Guidefor Teachers of Primary Health Care Sta. ff Gc. ncva: World Health Organization. 2. Alforo-Le Fevre, R. (2002). Applying Nursing P1·ocess: PT"omoting Collaboratiuc Care (5th ed. ). Philadelphia: Lippincott, Williams & Yl'ilkens. 3. Andrews, M. (1996). Using reflection to gain clinical e"-pertise. British Journnl of Nursing, !i (8),508-513. 4. Balfour, M. and Clarke, C. (2001). Searching for sustainable change.,lou1nal of Clinical Nursing, IO (1), 44-50. 5. Benner, P. and Wrnbel,,J. (1989). The Primary of Caring: Stress and Coping in Health and IUness. Menlo Park, Ca: Addison-Wesley. 6. Baud, D., Keogh, R. und Walker, D. (1985). Promoting reflection in learning: a model. Ia D Daud and others (Eds. ), Reflection: Turning Experience into Le. anting (pp. 38-40). London: Kogan Page. 7. Clemen-Stone, S., Mc Guire, S. L. and Eigsti, D. G. (2002). Comprehensive Community Health Nursing: Family,. 4-ggregale and Community Practice. St. Louis: Mosby. 8. Freeman, R. B. (1963). Public Health Nursing Practice. Philadelphia: w. B. 108 Saunders. ....	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
9. Greenwood, J. (1998). The role of reflection ia single and double loop learning. Journal of Advanced Nursing, 27; L048-1053. 10. Johns, C. and Freshwater, D. (Eds. ). (2005). Transforming Nursing Through Reflective P,·actice. (211d ed. ). Oxford: Blackwell Publishing Ltd. 11. Kim, H. S. (2000). An Integrative Framework for Com:eptualizing Clients: A Propo~al for a Ntu-sing Perspect ive in tl1e New Century. N11,-si11g Science Quarterly, 13 (1), 37-44. 12. King, V. G. and Gcnvig, N. A. (1981). Humanizing Nursing Education: A Corifluent · Approach 111r-ouglt Gmiip Process. Wakefield, Massachusetts: Nursing Resources. 13. Kock, T. and Kralik, D. (2006). Participatory Action Research in Healt!, ca,·e. Oxford: Blackwell Publishing Ltd. 14. Maglaya, A. S. (2008). De Uvedng Quality Service Serving Communities: Nurses leading Primary Health Care. Philippine,Journal of Nursing, Vol. 78 (2), 10-13. 15. Maglaya, A. S. (2004). Nur·sing Practice in the Commun ity. (4th ed. ). Marikina City: Argonauta Corporation. 16. Maglaya, A. S. and others. (1999). Afamily /wall!, empowerment intervention model towards prevention and control of m,,lal"ia in the Philippines: The local government unit/rural health u. nil per-spectiue. Manila: DOH -ENHR. 17. Maurer, F. A. and Smith, C. M. (2005). Comnnmitr J/Puhlic Health Nursing P,-actice. flealthfor Families and Population. (3rd eci). St. Louis: Elsevier Saunders. 18. Parse, R. R. (1998). The Human Becoming School of Thought: A Perspective for Nw·ses and Other Health Professionals. Thousand Oaks, CA: S:ige. 19. Parse, R. R. (1995). Illuminations: The Human Becoming Theon J in Practice and Research. New York: National League of Nursing. 20. Rosenstock, M. (1960). What Researcl1 i. n Motivation Suggests for Public Health. American Journal of Public Health, 50 (3), 295-302. 21. Schon, ti. A. (1987). Educating the Reflective Practitioner. San Francisco, CA: Jossey-Bass. 22. Schon, D. A. (1983). The R~flective Practitioner. New York: Basic Books 23. Wilkinson, J. (2001). Nu,-sing P,-ocess and Critical Thinking. (3rd ed. ). Upper Saddle River, New Jersey : Prentice Hall, Inc. 109	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
Chapters THE PARTNERSHIP APPROACH and the PARTICIPATORY ACTION METHODOLOGY: THE NURSING PERSPECTIVE A1·aceli S. Jvlaglaya HUMAN CARE AND NURSING PRACTICE Globally, tbc crilical role of the nurse has been enlrnnced by knnwledge development in nursing science nncl utilized by nurse practitioners in various health cnre settings. Humna response :md human-universe health process as pivota J concepts in n:ursing practice promote and sust:1i11 better options for health care or human en1·e, defined as recognizable and structured i11teraetion in human sodeties tlnongh which persons give and receive assistance with basic human needs, in. wellness and illness, across the life ::. l)nn before birth, throughout life and beyond death (Cody, 2006). With human response ns the focus of nursing practice, the nurse's main concern is the person's perspective of health. with e;;1ch human reality as the meaning of the situation. To elucidate. Parse (199;;) explai Jl S tbat qua[ity of life cannot be detennined by those not living the life: t Jrns t J1e person is the only Oile who can describe his or her quality of lifo. Tile person's perspective becomes the critical working arena for motivation to pro111ote, sustain or cbiinge any hnman reality, will J the 11w·se acting as transition pm:tner-cal alyst to provide technical, affective or instrumenta l support to facilitate creation of the human reality desired by t]1e person as client-partner (Maglaya, 1988). The n un;i ng perspective emphasizes partnership and the participatory approach in its practice methodology. The participatory pe,-spective is not a new concept especially in community healtll. In 19781 it was specified by v Vorld Health Organization as the critical element in primary health care (PHC) as n global call to achieve l1ea Jth for all by the year 2ooo_Primacy health care is defined as essential benlth c. irebased on practica l, scientifically sound and socia11y acceptable methods and technology made universally accessible lo individuals and families in the communjt y through their full participation and at a cost t J,at the conunuuity and countrv can afford to maintain al every stage of their development in the spirit self r:eliance ~d self-determination (WHO 1978). Three decades later, mnny developing countries are still ex--periencing a limited capacity of Lhc health care system to deliver outcomes with inadequate resources for the health sector nnrl geographical and !i Ocio-economic inequities. Social, cultural and political differences are sources of inequalities nmong groups, ci-eating biases and mies in institutions that favor more powerful and privileged groups. 111e striking 110	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
differences in health status among socio-economic groups reflect inequalities in access to informati on, facilities that provide decent standards of living and means to pay for ~ood c11re. Specific harriers lo quality care include: ( t} lack of voice or sense of empowerment which delay decision-making 10 address health needs/ problems; (2) unresponsive set"\;ce pro,;ders who nealc a social tl. islance which discriminate ag:iinst the p0<)1·,md the mal'ginali,. ed: (3) inaccessible or poor quality service!; and prohibitive cost of health care especial ly for treatment or major illnesses and injuries (Ashford, 2006; 'Norld Bank Report, 2006). OPTIONS FOR CHANGE Wlrnt are possible areas for analyses Lt) understand the current scenario? Based on outcomes and barriers explicated in the Ashfon. l and \Nodd 13ank reports, it seems that the fnll participa tion or Lhe key players of primary hcaltl1 care, Lhc imlividuals and families in the community. nrc not quite in t J1c working. irc11a 10 achieve the go. ii of health for all. \-Vhy have we missed the full parlicipntion of the key players'? On review, of document:,; and c.,perknccs or t~u·ct dcc. idt'S, there are nt least three areas lo analyze. First, the report of a \>Vl-l O Expert Committee 011 education and tr. iining of nurse teachers and mauagcrl. ' \,;t J1 special rcgnrcl to PHC (1984), emphasized managerial and supcrviso1-y roles with competencies of 11un<ill'1, personnel ;11 the periphcrnl level geared towards direct care to the community. training of community health workers and improving 01· cxtcnding the knowledge and sldlls t1flraditiurml hcnlth prm:titioners. The rule uf nursing personn el on cnmmuni ty parlicipat ion inclndcs :u·ousiug the interest of the cc;mmrnn:ity in the benefits of a posith·e health approach and collaboraling in identifying health nncl related prnhlc!1ls and priorities for action. In nursing practice, nurses often realize that ccillahnrati()n wilh lhc comnnmit)' in identjfying problems and priorltie:; for action is not quite a reality in many villages hl!cm1sc identified locnl leaders and volunteers Lack prnblem solving l'lnd leadership skills and competencies for collective action. Local and internationa l evaluative studies ( Constantino-David, 199s; Laverack, 2001) provide evidence that this compcte11ey limitation among leaders and volunteers is a barrier to i11ili,1l attempts at involving the community in developme nt effo1·ts. Within this contexi:, unresponsiveness of ser,..icc providers can be analyzed as a consequen ce of inadequacy in educational preparation to address the challenges of installing the participatory framework as rcqt1isite of communi ty self-rcliunce andself determination. Second, autborit:V-dr ive1i practice as a consequence of socialization into 011. e·s profession, c,111. control and predict client-pai·tners· perspective of health and human reality. Combined with inadequate I mining on tl1e particip::ilory approach, the arrogancl. ! of "knowing it all'" sustains an autocratic behavio r which can create social distance between service providers and clients. This nurtures lack of voice ilmong clients causing frustration, pessimis m, a. pathy or their derivatives. ln any case, tl1e cycle causes delay in decision-making to address health needs and problems and the economicnlly disadvantaged groups struggle \,ith dysfunctional health services. A third area for analysis is the possibility that nurses do not quite understand how to address human response lo inequities in resource allocation and barriers to "health for all", such as poverty and related bu. man responses Uke hopelessness, hardiness and apathy. The current scenario will be perpeh1ated by both nurses and client partners if they do not realize that there is a 11eed to c:t·eate a i:e;ility where both perform the best orchestra tion, rhythm and pattern wl1ich p1·oducethe harmony required for unleashin g the empowering potentia l for health and healing. The participatory approach creates the working arena for client-partne rs and nurses to change the current reality as a new one is envisioned and unfolds. It gnide·s the partners to move in the same rhythm, creatin. g a pattern together and being invisibly nou1ished by it. Both _partner-cli ents 111	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
and nu J·se-ca talyst go through the prot:ess of looking al the cu1..-ent situation, analyze wby il is happen. in~ anti acl to co-create a renlity which provides aa expciience of being strengthened thrnug!J relief and e:ise; enhances quality of life; ensures healthy life:;tyle or encourages p Os!-libilitics and options to address h11mnn ancl environm ental challenge:.. Pnrlicipating with people (clients a. nd ct,mmunity) is the way tn move forward towards sustain;iblc buurnn c;u-c. and se1·viccs LJ1al evoke human flourishing (Koch,md Kralik, 2tm6, p1). The cydic,Ll., iterative pruce~s of look, think and act is facilit. 1ted by t. he nur. ;e through molivnlion-support intervent ions lo create Lhe desire to go through eat:h phase nf look-think-a ct and provide the necessary technica l help to access speedy flow of infonnation or service anti true presence as source of courage, offirmalion, hope 01· comfort (Maglaya,-1988). This chapter focuses on partne,·ship concepts and the pr,1ctice methodology of participatory action with emphasi:; on reqi1isite cognitive, psychomotor and :1ffcclive compelenci cs to enhance the nursc·s options to address issues on unresponsiveness. social clistar\ce, apathy or hopele~sncss. Nurturing the cnpabilityofinclividua ls. families, population groups and the commun it~,r to utilize participatory action to enhance their empowering pu Lenlial is the key to co-cre,1ting order through ehaos, affirmntion through st Tuggle and contentment through discontentme nl, ;ill inevitable realities of learning ;ibout collective action for social change and transformation. Partne1·sh:ip aud the participntory approach enhance competencies for interdisciplina ry an. d ioteragency collabor ation. 112 PAR:f. JCI 'TOGE Partid unde ners 11n emotfonal man car~ -partners roblems, th these s an~ In of the raphs orn a OM tune ,;s has Is. true ent, as ..	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
Thinking refers to exploring, analy Zlng inte. and lnterpretations. It Involves info'. rpreting and explaining events, story llnes s Jtuation. Partners Interpret, explar::~8~ ~econ5ttuctins ~nd or confrontfng the success (nwhatmade ltwork")ord fi 1 " lyze the situation In terms of areas of here?· Why are thihgs·as the' 8., e Whc encles, lssu~and optfons: What Is happening re, at Is missing? 1-iow dad Do we need to challenge certal t ke f, we come to be llke this? evident In our"thfnklng/ practic. e~,:., 7;.,~r-gt ranted assumptions/ realilies that are ? Th e. a can we do to address the sltuatton and move on. e nurse as facllltator encourag~s ell n / ~ e,-partners Rarticlpantstoengage In discussion and dialogue to de,velop mutu--11y a~ pt bl d...,.. ce a e accounts escrtbtng their experlence J,. Participants learn from each othe t th h..,, a e same nme, e. ac person has an opportu_nrty to t>e heard. Facilitators and parttclpants share perspectives ' to create meanings through convers.,,-r th ....... ons.,Qge er they compare and contrast their various l,~terp1"£ltati01:"1s. Stories and analysis occur conturreritly ; wh1ch help id_entl~~ ~merg1. ng ·under. standing from early data to gulde "the ~bsequent group , d1seuss1_'. 'ns. Ongoing feedback support validation ofth8'data. generatfon process. The, rnam:them. es or construetfons fr-0mthe prevrous group session. or meeting are rtesented and,co"fll'me~ at each gathering or conver-sation. ' Acti Rg atte_n,pts, to ·addres,s the Issue ·or elrmlnate ttie problem. The participants questi0n wnat is importan t in their lfves, consider the options that ar~·availabla to , · th1rm, 1sarcry:thern o. ~_tan_djotn!lydet-erm;{ne the-worth, eff~ctlvent:. ss, appr Qpnaten~s , ard outc0me softne-;ict1~1'\S1a~en... l:\cfing rnv. olves reconstructing (e. g., "How might ,;, Wf# do things differently?':), and evaluating (e. g,, "Hpw wlll we know ~if thlngs have cn~ng~d7".,). ·wheh workil)g. Wlth multiple,groups of people focused on the same , top re, it: is imp0rtant tq',retain. both Ifie dlst1nct111e,f~<lt Ures orthetnes of each group while detei:mining recurring constructs or themes across,groµps, " ( Throughaut the took-think-act. cy-cle anq wlthi A the context of sharing multj"~le. , p. erspettives, tti. e 11urse0fitcillta\or can help :1:. Jient Yesommunity-partners address qu'est!cios oriss,ues rel/ited with posslbl~sourees,ohhepfoblern ·or gaps rn solutions ') where,. f:t>'r. example,epidemiolo-gicaf, medfca J and othel' ac:ad~J111c-pased models are need,~d to·answe:r-guestions like "Why dkl 1t happen?'' or "Why did it-net work?". 'i. '. Koch an"d. Kralik (2006; p. 30).. explain that in practice, the conceptual differences be~ween · the 'look, think anq act' elern~rits begin to dissolve and merge. The ' particfpants engage in-many, cycles of reflection on action, leam1ng about actl. on conslderlhg p 1os~Jbilltli!s i!l'ld'. the A dmlo P,ing new Informed action which in t~rn becomes· ther-toplc ·or theme of further r~ection (Wadsworth, 1998). During ,dlal. ogues; p~pie l(l~rn1new ways o. fs. e'elng,or th1nklng In the ltghtof. tt;ei~ experience, feading,to hew abtio Qsi'With p Mctlc. e, these beoam. e,the focus~f dlscus;;lon, further rerecti6n,and gt,<>UR se,lf underst. ndlng, €henge as a,re. sult·Of the 'action' ~art · ofn!the_e'xpe~leric~ does not·1:15ually happen at ~tt:ie end ofa partfdpatory action, 'lnq ulrry. ' lt,h"a·~_pe(ls,througho"1t (W~dswotth 1 1998). Duol'lg the l)B~cipatory ac:tipn p'roc~ss, lt,oft;~n 1,app\an"S'that the focus of what 11eeds to change will shfft over time as partners a!ter,thefr;i,mcferc Star:fdlrig of What·ts rea Uy lmpc0rtent to them. ,. ,..,,I ',.,,:.,... .. 113	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
, 114 PARTICIPATORY ACTION AND EMPOW ERING EXPERIENCES OF FAMILIES IN DANGLAS: ABRA In 11 1111111hlt,1·ipli11u1: l"\'"·. 1rd1 pn1J,""1. 'l nf r1 (,1n1hy h·nm from tlu ll11iqr1-itv of the Phih Pl''""" 'l 11111 l,1 (;\I 11-:ln,,1 n ntl Pl h·r-.. 1,,,11)) and f11 nd,d h,· t lw n,pa rl llll'n l 111 I h:n Ith 1:,,n1t1i'll,.,1i,11,II I k,1llh 1',·,,·,111'11. f;11nih 1111pc1w,n1w111 ·r,,r 111:alnri11 p1·,·,·1·111ion nnd ,--.,11lt"I u11lt1t<i '··~ . i n,·1,·, "' !Pol-. thin\..,u-1· p11w,,-,,·, ~L·11·r111i111;,·111piri1· al tlatn ,;;uppurt"l 11f """°"111,·,,,t p. 1rt1np. 11111-..·. 1,·111111 to,·11h. 1111·1· tlw 1·1>11111111 11it~ ·, uplions Ct. r l>,·11,r.,r,-. ·,, 111 l1t·. 1lth,.,r,·. ind,,r-.. 11..,_ thn>u):h,df-d1·t,111 1i11ation an. J l:'clf-1'. "1i:11w,: Th,· n·"·. 11d1,it,· 1-.. 1 nir,1111)!ra. ·11h11r. 1l, 111,1)!1' n1 tlw f,1n1hilb anti 1111·nins of tb, '-l1111kip. d11, 111 P,1111:l.,, 111 \hr,1 1'1cl\1m·,,;it11. 11,d 011 tlw 1ast11·11 :-id, of the Ct>l'llill,r,1 \1111>1111 11,.,,,, K,1-:11>11 (l'\Rl. Hn,. 111)!11 ~ n.,111~l. 1s i,: hi~111rit·:dly II cu11111111nity <>f i11tlii:,·1hn",,.,..,,,1, .,11,-. 1 I 111. :. 1:u1, 111, or 1111..:~. But. 1, n,·011s,q11c111·c c,f 111igr:1tion. ,t i--, 11rn·u1h :1,, 1111 lll·t,·r,, :·11... 11" rt1m1u1 111i1y ";th.,fliliation h~· hund,: of n,arringc with 11,.,. in,". llu,il.,·11,..:. 11ul \ "·"·""· \\"hik tlw nrigi11al di:ilt Tl i!o l';tllcd l11':111d. nil U,,, 1-.,1111111m11,· r,,i,k11t,,. 111 un J,·r-o 1. 111d anti :-:pcnk l'ilipino. th1: 11111 innal l:111g1111gc. At th, um,,. ( 1lw n,,::ird1,tll,i,,y-111111' houi:..-h,1ld:-: wl. 'rc· n·pns111t(d in H,·crnl c:ip1lo, 11-,,-h11dd11i... com nm III t,. t,.,,,·d 1,p,·ril' t1 t i. 1 I It-a rn ini: :-cs,i<111s I h ro11J,!ho11 t Lhc fir-. 1, 1 tr,,/ ·h· pnf, I ll1t n·.... ·. 1n·h 11;1m 11tih1t·tl lht partic-ip:. itoi:· nc-tinn prcc<'S. '-n: t,,a,u 1111, r, .,,,.,11 111, th,,. J.. J~~, tn d,·,·, lt>p 11pt 1011!-,111d,chcmt:-tu 11111kr-. 1:111d field re:\. IJIH'' "' "'" m. d 1rt 1 ;... 111.,111,t. 1,· m m. 111y rur. il,;lta,. :es nnd lwlp thl c-Pmlllttnity ns clil'rll. 1,.,rt 11 r 1,i,,Id r,,:-I h, · 1 "If<"' ;ind f:1cto,-.. rc I a I,·d "i th I h,· prt,h h n L Th1' n:<cn rch prnj,'\'! u,,.. J ",, ral pr,,,:\. '1. lun·-t,"<"l1111qu,:--.. and i11t,1-..·l"nlion to m11'i111i1,1 fnmily l)_-,'-('<l,,r1..,.., n11,,, 1n<l t:1>mpr tt>111·1-., l11r,:. trl~ ca..., tim. linj!. apprnpri :'11e and prompt m. or1·c, 1·11 nt. prr, n11oa 1hn11ch ~If prut("t. ·ti>n mc.,,,ure " :tnd mo'<rp,ito v1:ctor contn>I rh1 11ur. _.-1,·J J, Al ~o,.. mmrnt htr. dtli 11ni1 111 J)Jrtm. :,-... hip with th<' mnyrn. th(' muninral I m1111 ii. m J th,·-ill. t;. ?' (c.,lltd har. in~fl~ ) l·c,11111;il "lll k L..J dn,,1~ "ith the re:~~n·h 1rani,ind th, (. 1mil1,,.._ :p.,.,..-,r;,I p:1nk1pnt111:-,· at·t111n :-l'J-.,io11:-. on 1wr,011. il :ind aix. '--' r,I. H,·tf,...... u,-.. nd pr,. l,I, m'-cen,·r:11,·,J in,i~Ju., on factor,; aff L-clin,; outcomes of a C"ll'< ·.. ~,I, t-. inn I 1h->rat1ri di:i;:nri,i,. cf,,,.,. _,. manai;:t·m L· nt. l:1r-.. :11 m<mi1ori ng anu :-1r,. m1 d,n11~. _knnin J,:. The n:,~·.,n h,r-< tng,lhi-r,,,1h tht· n1ml he. dth team leamt'<l. _,.._,r. tl J,.......,,n, no "h:, :wt h c ~-.,...,i detect ion,111 n 11~ t lw fi r-1 I w, 1 qua rt1r, of l he pro J"'<I,.,111J n,,, ""''r,~,.,nil....... ""~ 1wrc(11111f th,· P"JJ11la111m.. :ven 1( 111:1-,, blood <un 1-. ,,, n Jr,n, 1n I h,,;JJai:,· \,·1w-< ;J nd da UJ?h t]r' ~, ht> w c. r1 pn nu ul. irl v mot Iv., tcd at l'r. 11na,: h,ihh pr 1>01< n '>' 1h,·1r hrii1,.. hnld:-:-harc,J fomil: ri:,ht H·.,. ;,'1,r-goini; thn,111!. h ti.. c. /11.... lion. "\\na1,, IL,pfl<nin;: h,·n·r:-K:tp:i1,t,d:im na darntin~ k;,~o p:ira k"l. lmuh;, 11i:. dt1J. !"·.,ng 111~! ;i,,H,':t nam111 at mi:a an:i~: nn l:il:i~·, :t~ :1. 11y11111~,,a h1111dok P3ra m;1~ 1. 1111~111 d.,... ~;i 101,)(1 l:tng,. n111:11. 1k Jt m;,gp;1k11h:i ng, tl11~" k;"l 111111,akit da~ Ltr>~ ·11111111. 1,i f\\'h·n u11r h11h:in,h :ind.,,,n-. nali1r-th;,1 \<>11 an nit11i11~ to ,:;et hlr><>d-..unpl, tlwy wnnld "'" 11p thr-nir111111;i1r1 11, d,, "k. nng,111" la l:,nd d,arin~ prc,~... 11ir, t· pn JHr· 1h1,p,l· (r. r upl,,11d f.,nmn~J Th<· tn,th i~ 1h1·~· ar· afraid I> );Cl 1Jw-1r fllll(t r,. pn ~·d t..-c.,u,, :ir, t1rrf111~ 111 tlwm. it,.. p:,inful. J Aft,r u11tl1r... 1:111di11g fu U~ '"·II th, Jl(t-... 1l11li1,. 111,J u,11-.,<Jllf' n,,,,.,,,{ dru ~ n-.,... l111w1· from vr rnl, i,· Ch I,,n,q11i nc intal.. n hmi: n,amh "",.,...,rand c l1111, 11r 11<,rll n,,,mpl1trns, r,( 111al:iria withrnll lhc b<-11,-f11.. 1 l,borat, I"\ J,.. :,n,1,.., \,1\1·,.,n<I \t111th pn,p<t...,d npti1111<,, lo 1·,p:11111 family ba.-...,1 <»mp,:, nu,-~ ""'uni? tulun1.,11 l..am1 J>,,ra l..11m11l,a n~ du~o. l..,1111i '"' ans. : g,:ihaw. i. At J~. 1111,,,,l. i na l..,t~ nlto. m. 1):,1,1. !,n,,1 p,1 r111 11,1mm. p:iro1 m:111111111~:111 di11 nng h11on~ bar.. n1,..n fl(~,,u c;111 ll,Hh '" hi,\, 1,, Rl'I hlr1od....,,r11pl1<., ht· \,"JI,1,, tht· 1,1(,.,d,;111c:ir mll1-<t1nn. \n,t,,,·n 1(~011 ;u, ~"111 "' <,Jll<">llttnu d1,111_c 11. v1 w, 1·:111 h,lp lhl· re..'-1 o: ti,,,,11.,i.., t TI,, 1,,..~ tlur. ~,1t1 ph.,.,..,,,f th, p,1r11np,,t,,r)·.,ppn,:wh ·11hnnct'd funl,, r i!u,, 11wt1\,,,,. n 111 h-1111 hl,,.,d,m,. tr 1111!,·t ''""·.,... tlw, r1·,di1td 111. 11,nmc mm11Hsn11, r,-,1d, Ill'-h. 1. i rn . tnn., p. 1r. 1,11f·, 1n 1hr ir hlrw,d ~mr;ir,. \'t t tht\' did not suff. _.., rrum th.-d.. i.,1,· ma Jann tl. "'\tr,m,J d11JJ., du..-tu the di11ic-:i l plit:1wmcnc111 cnlkd p.,rtfal 1rnmurur,.. Aftrr thr 'ne11t111 pan of tr:iinini i111<noc;1ed fornily mcmhern on	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
prep a rnt ion of blood <illll"II rs. I he cwcrt1:i;c cif :1cl ivc case detl'cl inn incrc;1sc:<. 1 lo nlrr HJSl 11incty-11ini: 1wrel' 11t, with nllll'r 1·om111111ii1 y 111c:mbcrs twin~ nut of the vilfagc al the t jnw of hlor id s1111:<1 r nilll'r·Li1,n. I >11 ri 11,i. p<-ritld <t when fnm i lif"S s11. s1wt·I members tr J have malaria. blood snwnr:; w,·n· lnkc11, witlr lab,,r;iliry clin~nw{is d0111: inili:illy l>y vill;i~t· ht·:dl h 1vn1k.. rs :111d midwivt'1 wl1< 1 were tr. rine<l while tire rt<,,:;ir ch wa-: <Jfl-W)ing. Con fir111at inn of l:1h11rn I, HY r J i;1h11w,11-was dnne :11 1 he prnvinda I hospital l:1h1Jratory in the capilal 1n1111i1·ip:rli1v,,f Bani. :11t·d, :-:ituatcd scvtral kilorn<:lc·rs c1way throug,h the Abrn River t h:11 sw1:lls 11p d11rln;. ; 1l1c rni11v srasr)n. /\ccess problem w;,1.-;,idurcssc<. I bv the cmpr,wcred families 111ilb:ini. ; lht· 'look-1hirrk-11d pr.,,·,ss 1hr1,11le(h the 1vork grnup npproach. ~lid,. <; wrr, lak1·n t J tlit· pn1vi11ci;tl lahor. ·11,,ry hy v1tl11nlc·cr <''>rnmunity n,cmhcrs who \Vo. :nl r,.,g111i,rl~ lc1 Ban)!,IIP< I 1t1 huy )!,Oods anti f11r,d-;upµly for tl1eir village sari-sari stem.. :~. Part of tlw 'al'I i1111 · phase nnalyzc·d hr tlw w,,rk,i. roup::, wa:, the scheme where l;,lmratory rcs11hs were brcrni. ;h1 hack Jr, the rurrtl hc;1l1lt unil or w lhe village health worker (HIIW) hy the s:rmc enrnmunity members after lhey were done with morkcting in Bn11g11cd. 1,..·H"v,il 111011itori ng 11ntl slrc;1m clearin)!;/clean ingactivitiesgener. ited additiona I insight<;, H;wing 1111d,·n,1r11,d Lhc cpitlcmiology nf malari;1 m, p,1rl of Ll1c: 1:apnhility-builcling cxpc.-i<'ncc. s<1111c male members of I he \·ill:1gc. who opted l CJ be in-,;harge of larva J 111onit rffi 111!, in lhc t ril,11 I ar-ics of the vi 11:ige strc;1m, 11skc<l fa rnily work g. ruups why there wen· ~ti II 111:ila rir1 <:a. 'ws <lrspi Ir i nrr,;i,;ccl c,, <;c det<'rl inn,,·it h treatment a n<l regular llfl C:('-:1-1\'t'"k 'ilrt·11111 cl1;1ring/ c:le;,ning. Tht· 1111rse-r£'-t:'/lr('hcr g11i<lc<l them through 1111: 'lnr,k-lhink-;u-t· eye-le-111ilizin;. \ 1hc wr Jrk 11,ro11ps' trnining :md,·omp<t1~r H'il'J; l)n the bitmomics/ Ir fc cyclt r1f the,\11upl,des niosqui Lu vector of malar-fa: "Ano !"a pa la gay nyo ;111g d:il1il. r11 k1111~ !,;,kit sa paglili11ii-rryo ng il,1g rnim,ar1 isa1111. lingo 11y meron pa ring nagkakc1s;ckil n~ nwl,11 ia s,, h;1ra11):\ay'!'' (Wh. rl tlo yuu tlri11k is the n·ason "'lry clespile thc onc~·-n-w~r·k stn:;,rn dc;1ring/clcnnirig. there nre s Lill mala·rin cases in the village?) :\n:-ilysis nf thc reply gener:11cd the "·ork j;rnups' dc{'i:,inn lo increase the frequency of s1 rrnm c-lc-:i ring/cl,an in~ to al Ira oat two Limes ii week ;r nd shiirc their compctcnc:ics with fomili L'S in r,lllt'r,·illug,·1-, nfter lhc_\ reviewed what they lc. nrn~d uhout tlw hionomics/ lifc eyclr:-of Jill' mn-<1p1iln v~·c-tni-of maluria.-111c consensus r,f the work XTOup:-o;ipat pa~ka111ptt-: 11;i1 in~ maglini,; ng ilog/wai//,. l111)?,nan kung k.,ihrn ulil mcrong kili-kiti/ lxtlhallik. ll;1k;1 knl:tn~ <Hl~ niinsan isanp; linxgon)a\ pfl,l,\lilinii; kun)I. mav mga lamok ria 111a11gigi1lo p. 1tlit, pi1~k,1l:ip11" m1li11)1. maglinis, Ka~i m~,1 1all(m!{ arnw pa Jang ang kiti-ki1i,I\ 11rn. t. :i~i111; l,1111111-. na. Pu:-il1le rin na ang mga lamok sa ihang banlngay ay 111:ik:ika lipnd. Jitt, dahil i:-all H kilonwtro nil). : k;iyn nilnn J?. liparin. ·· {Soon after we have <lune st r,·a 111 1·k;1 ri 11g/cha11inle(. we need to check when there would he larvae in the stn·am agnin. The 011c;c-a-\,1c. k c·lc:aring/clcaning might nol hf' arlrquntc if mosquitoes l:1y C). :). :S :<111111 after Wt' i:han 1111',,1r,·a111. \Vithin l11rt'f' clr1y-<, I h P larvae bet:qme adult 111osq11itul·s. II ii; alsn possible lhal rnosquiloes cnme from other 1r1llagt,:; bt::cause they ha\'l' a llighl rail)?,<' Ill° one kilometer. ) A~:, con,cquence of the cy..:lical. iterative 'look-th ink-act' <::-qwricncc, 1 he work ~rnups dedd,·d lo ~xpa 11tl their activities in other villugcs. Thrn11J. !. h the,,ffuns of the prnvinl'ial hcalt. h ofiic..:. th<;> <:ommunity members log,tlwr wilh till' niral h,:tlth unit :111d th,· lt. ':1dcr!' ni the,illagc were trained by the radio rnana,:cr lit prcparc :iudin laµcs usin)!. family empowerment experiences ;ind com1w1,nl·i~.._-: ;1.-; ::~·ri111,;. which w,rc ni~d regularly lhroug,h tbc province-supported radio prn)!. rnm, DZPJ\. ENHANCING INTERDISCIPLINARY AND INTERAGENCV COLLABORATION For many ye;Jrs, nurses. other members of the heallh learn and organizatio ns hnd been re. I uctanl in establishing rclalionships wi U1in lhe perspective of"world ng together' liccnusc of t J1c complc.-city of address ing personal and professional differences and l. 15	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
-prcparal ion nf hloml smears, the covcrngc of octh·c case dclcction increased Lo almost ninety-nine pcn;cm L \~;th olhcr co11111111nity mcrnhers being oul of the village al the time of blnoc J smear c:ollccl inn. During periods when fam. ilics suspect members to have malarin, blmid smears were taken, with Jahoralory rlia~osis done initially by village heal I h w<'>rkc,rs :ind rnidwivcs wht J were I rained whilt: the rcsenrch was on--gojng. Confirmutio n r,r 1. ibnratory diagnosis was dr,nc at the pro~;ncial hospilal labornlory in the capit,1'1 municip,ilily of lhln). \ucd. situated scn:rnl kil"'nctcrs away through the 1\bra River that swells up during rhe rainy season. Access problem was addressed by the ernpowerc<l farnilic:s utilizing the 'lor Jk-think-nct' process through tht! work group approud1. Slides were tnken 10 the provinci11I lahnra11>ry by volunteer community members who went regularly ro Flanguetll to buy good,; and food sup_ply for their village sari-sari slnn:s. Par·1 or the ·aclirm' ph. ise,inalyzed by the wr)rk gmups wa5; the scheme where lahor:ilnry results wc,·e brought back to the rural health unit or to the village he::ilth worker (fll-l W) by the same community members after they were done with marketing in Jfang11ed. Larval mnni I oring:1nd stream clearing/cleaning nctivitiesj!,enert1ted additional insights. Having 11nderstnod the epidemiology of malaria as part of the capability-building experience. so111e male members of the village. \,·ho opted tr) be in-charge of laival monilnrin g in 1 he trib111arics of the village stream, asked family work grnups why there were still malarit1 cases dcr-;pite incrcar-<ed c,1sc detection ~,;th treatment and regular oncc-a-\,·cck stream dc:iring/ c:leaning. The nurse-researcher guicled them through the 'look-think-net' cyt'lc utili1. ing the work groups· training :ind competencies on the bionomics/ Ii fe r·yc·k of lhe-\11opheles mosquito vertnr of mr1h1ria: J,\no /'. rt palagay nyo ani; aahilan k1111~ h:ikit sa paglilinis nyo ng ilog minsan isang lingo ay meron pa ring nagkaknsakil ng m:dari-a sa barangay?-(\Nl1at do yoll think is the re!l,.,<;On why despite the once-a-week sl Tcam clearing/cleaning, there are still malaria cases in the \illage?) Annlysis of the rq,ly p,enl. 'rated the work grours' deci~ion tu increase U,e frequency of stream dcnring /dcnning tn. it leasnwo times,1 week and shart: their competencies \v;th fomilic:-in other villa11,es,. :ifter they re,·iewed what they lc. imed about the bionom ics/ life cydc of the mosquito vector of malaria. The consensus of the work group: "Dapat pagkntapws 11:iting rnaglinis ng il<Jg/waig. Lingnan kung kailan ulit merong kiti-kiti/ balbaltik. Bak;i kulang ang minsan isani linggong paglilinis kung may mga lar:nok na manµi1;ill1ig ulit. pai,;katuptis 11ati11g maglinis. Kc1si mgn tatlong arnw pa lang ang kiti-kili a~ 111a~i4in~ lt1mok na. Posible: rin na ang mga lnmok sa ibang h Rrangay ay mnk:ikalipad t. litn dnhil isang kilometro ang kaya nilang lipnrin. ~ (Soon nftcr we have <lone slrcum clo. ::1ri11g/clcaning. we need to check when there would he larvae in the slrcam again. The once-a-week clcnrin)!;/clcnning might not be adequate if mosquitoes lay Cf,)-\S ~oon after we dean the stream. V11ilhin three <lays, the hn·vae become adult rnm;q11i1n..:.,;, lt is also possible 1lrnt mosqtntoes come from other villages because they haven ni1-1,ht r·;rnge of one kilometer. ) As n conse<. juencc or the cyclical, iterative 'look-thin k-net' experience, the work groups decided Lo expand their activities in other villages. Thro'l1gh the efforts or the provincial health office. the community members together wi Lh the n. iral bl'alth unit ;im. l the lcadt::n; of the village were tr Jined bv the radio m:. rnager lo prepare audio tapes usin~ ramily empowennent experiences' and co111pclencics as scripts, which were aired reiularly through tbe province-supported rndio progrnm. DZPA. ENHANCING INTERDISCIPLINARY AND INTERAGENCY COLLABORATION For many years, nurses, other members of the bealth team an. d organiza tions had been reluctnnt in establishing relationships within the perspective of'working together' because of the complexity of addressing personal and professional differences and 115	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
potent i:,I loss of conlrol. With lhc increasing complcxi Ly of hen Ith problems, increasing cos ls f11r ins I it,,tion-Lrnscd health cnrc/ hculthscrvicesnncl incre:1singexpertjse lo audre:;s spcdlic lwallh needs. prohlems 1111d issues. there is enhanced mo1iv. 11ion for initiatir1g or gl'llini; involved with inltrdisciplinary nnd inle. ragcncy coordination that fndlitate inlegration ofsh:n-c<l ). \oals and n'sourccs lo incrcaseeffc,·tivcncss and tifficiency. where rnsonrcc:-:1l'l' limited or inacccssiblc. (Pl>livka, 1995). Utilizing part ncrship concepts nnd till' partidpalory upprom. :h, cconllict rc:,;vlulion mechanisms. optimum infornrntinn excl1an~c uppurtunilic,:, e11hanced decisio 11-111nkiog proces~es ancl quality intcrngcncy comnrnnication can be achieved Lhrnugh mutunl tn Lst and respect and shared vision. THE ESSENTIAL INGREDIENTS OF PARTNERSHIP P,u-Lnership is n type of rdntionshi p churnctedzed by a close cooperation belween p:1rtieia having svecitied and joint rights and responsibilities as t J1ey try to work on a common venlun:. lt is nn egalitarian rclntmonship where pm1. 11c L-s consider each other as co-equals in so far a:s the intrinsic \,·ort h and access to rights :111d 1)rivileges of the group arc concern(. "<. l. They pni-ticip,1te eq1Lally in assuming 1·esponsibi1iti. es to achieve the ob_iectivcs und goalsjointl_v ide11titicd. Such a genuine p M"licipntion is not common. Health workers ore often faced with the reality thilt pilrticipants in commn. nily health developmenl work (i. e. members of the commm l. ity, represent atives of i1ge11. cy resources, and the health wodwrs themselves) need lo learn l1ow to wod~ together as real partners. Jnordertoengage in a partnership thnti!, characterized as a mutually growth-promoting relationship, the parlnets nee<! to internalize tl1e following essential ingredient s: 1. belief in egalitadan relationship;· 2. open-mindedness; 3. respect and tn1st; and, 4. commitmen t to enhance each others capabilities for partner ship. Belief in Ega J;tarian Relationship Partnership can not be a reality unless an egalitarian relationship is considered vital by the identified part11ers in health development. The health worker must firmly believe that in order to achieve personal, professional or organiz-ationa l goals and objectives, she/he must engage in an ega Jitarian relationship with membe1·s of the community and others involved with development work. Commu nity members n1ust also 1·e-alize that for health services and programs to become more effective and accessible to their families, they must be co-equals of health professionals in community health development work. Open-mindedne ss Individu als who are gathered together to do partnership on a common venture carry with them their past experiences which affect the way they see, analyze, and understand things, evenls, nnd people. As practical beings with limited functions and duties to perform, they are inclined to feel intensely the importanc e of these duties and the significance of the situations that call these forth. '111 us, some actions of others 1nay be judged as stupid, useless or bad by those who have become so used to doing or se,eing things in an entirely different way. People moy become so absorbed in their particu1ar 116	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
c;,,-pcric nces and 111oclcs of actions to be open to 01'11er ways of doin~ or looki:ng al things and events. Hence, Lbc danger of presuming to decide in nn nbsolule \Wl)' on the worth of other people's conditions or ideals. Pc11·tncrship requires that participants lenrn to be open-mi nded in order lo sec rind undcrs111ntl thini:;s. events, and people,-. ithout limitntions imposed by prejudices ond itliosync. rnsics. Partners arc expected to po:=:scss the skill lo view things a ncl experiences from each ol'ht:r's perst)Cctivcs to arrive at a more relevant and npprnf)rintc! snlution Ill any problem that concerns them both. Respect and Trust Fo1· persons to he able lo engage in ;111 egalitarian rel;itionship they need lo hnvc respect for each other's worth and trust on the potentialities ;md c,1pabililie s of c:1ch one despite difforl!nc es in beliefs. vnl11cs. and experiences. P:irtnurs may come from 1111 sectors representi ng a cross-section of socio-economic. cultur:il. ed11calional or political backgrounds. These backgrounds may nffcct rho partners' expect:1tions and perception s of each other. A concrete cxnmplc is what can be obsuned duting community assemblies. The poor and the le. ss ed11c1. 1ted go to the mectin~ with the e~pertnrion that the professionals ancl other beller-ed11catcd mcmh<-'rs will nnnirally display their verbal prowess ;md dominate the disew,sion. Likewise, the prnfrssionals v. rill expect the pnor and the less educated to be passive, submissive, anrl subsc'r Yicnt members. These expectatio ns become such a self-fulfilling pr()pbecythatthcdesignatcd partners could not learn to have respect for the capabilities and potentia Uties of each other. Respect and t,,. 1st also form the basic ingredients of a relationship where each partner does not use the other to gel the honor or rewai·d only for himself. Many health p1·ofessiona ls and the organizations Lhey represent are not too encouraged Lo engage in a partnership because past experiences proved that others get the recognition for t J1e success of an endeavor, the efforts and investments of which had been a shared activity in the first place. Failure to earn respect and trust is one major cause why i J1jtial experiences 011 establishing partnership can not be sustained through the working phase of the relationship. A sustained commitment to the partnership is a result ofrespcct and trust that partners earn by-~uch actions as do E. ng one·s share of the work to the best of one's ability, keeping promises and appointments, maintaining a hvo-way commun ication and being sincere and honest with one's relationships. Commitment to enhance each other's capabilities for partnership As mentioned earlier, not everyone designated to engage in a p,irtuership has the necessary skills to do so. Beliefs, values. feelings, idiosyncrasies and prejudices affect the partne1·'s capabilities to initiate and sustain an eg Hlitarian relationship. Partnersh. ip l'equires a co-responsib ility. Participants must constr\l Ct together the foundation of a mutuall y growth~promoting relationshi1) using themseh·es as "bricks". Each partner must be ready to help build up another and he, in turn. should be wi Jli. ng to be helped build up himself. If a member does not havetheeapability necessary for him to perform his share of the work, the partner must be able to develop such capability. Each one must be able to pull up the other to u level of functioning where both of them c. 111 work as co-equals. Each parlner mu. <;t have tl,e commitment tn bring n11t the best in the other as much as he brings out the best in himself. Such a commitment is 111:!cessory to support each other through the grm,ving puins of establishin g a viable p,1rtncrship. 117	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
CAPABILITIES NECESSARY FOR PARTNERSHIP In order to develop a complex skill, the person must understand conceptually and beha,;orallywlrn t the skill is. By havingclea rand concrete ideas about the skills necessary for partnership, the p1·ofessional health worker or the change agent can identify and utilize the best opportunities or methods to develop these ski11s. A discussion on the capabilitie s necessary fur partm:n,hip shall he la ken up in this section. These are of two major ~i,cs: (a) skills necessary to work with others in order 10 function effectively as an integrated unit; (b) skills that the professional health worker and the other partners need to perform together to attain community health developme nt. Skills Necessary to Function as an Integrated Unit These skills include the capabilities necessary to be able to work together as a coordinated unit. The fo Uowing arc major e:-:amples of these skills: 1. The Skill Necessary to he Broadm inded ol· Opcn-J:\fiod ed. This involves beh1g able to see and understand th_ings. evenls, and experiences from all perspectives. It therefore, entails being genui. nely willing to enler another's private world and see how things appear from l1is poi11l of view-without adding any persona l evaluation. 2. The Skill to Develop and l\'[aintain Trust. Al~cording to. Johnson and Johnson, the crucilll clements of trust are openness, sharing, acceptance, support, and cooperative intentions. a. Openness is the sharing ofinfom1ation, thoughts and feelings on the issue the partners are pursuing. b. Sharing is the offering of resources in order to help :move the group toward goal accompli shments. 118 c.. Acceptance ismaking the other person feel that he and his contributions are highly regarded. d. Support is making tbe other person feel. that he bas the strength and the capabiliti es needed to manage productive ly the situation he is in. e. Cooperative intentions are expressions of expectations that tl1e partners are going to behave cooperatively to achieve the group's goals. 3. Group Skills. The partnership approach is effectively sustained through work groups which nre utilized as the basic compone nts of the organiz ~tional structure in community health development. Group slalls are, therefore, important components of pa1·tnership, These iaclutle the capabilities necessary to help t1Je group achieve its tasks (task functions) and build relationships and cohesiveness among members termed group building and maintenance function s. (. Johnson and Johnson 1975, pp. 26-27). a. Ti Jpes of behavior under task. fu11ctio11. s include the following: 1. Starter: Proposes goals and tasks to tnitiate action within the group.	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
2. information and Opinion Secker: Asks for focl S, informati on, opinions, ideas, and feelings from other members to help group discussion. 3. Coordinator: Shows refationships among various ideas by pul Ung them together and harmonizes activilies of various subgroups and members. 4.. Information and Opinion Giver: Offers focls, opinions, ideas, suggestions, and relevant information to help group discussion. 5. Direction Give1·: Develops plans on how lo proceed and focuses attention on the task lo be done. 6. Summarizer: Pulls together related ideas or suggcstio Ds and restates and summarizes majo1· points discussed. 7. Realit1· Tester: Examines the pr,\cticality and workability of ideas, evaluate alternative solutions, and applies them to real situations to see how they will work. 8. Diagnoser: Figures out sow·ces of difficulties the group has in working effectively and the blocks to progress in accomplishing the group's goals. 9. Evaluator: Compares group deci!s. ions and accomplishm ents with group stand11 rds and goals. 10. EJaborator : Building on previous comment, giving examples, enlarging on it. 11. Energizer: Stimulates a higher quality of work from the group. 12. Consensus Taker: Checks the group to see if the members are re. ady to make a decision or to take some action. b. Types of behavior under group building and maintenance functions include the following: 1. Communicat ion Helper: Shows good communicat ion skills and makes sure that each group member understands what other members are saying. 2. Encourager of Participation: Warmly encourages everyone to participate,givingrecognitionforcontributionsdemonstrating acceptance and openness lo i. deas of others, is fdendly and responsive to group members. 3. Active Listener: Listens and serves as· an intereb1:ed audienc e for other members, is receptive to other's ideas, goes along with the group when not in disagreem ent. 119	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
I. 4. 120 Jntcrpersonal Problem Solver: Promote s open discussio n of conflicts between group members in order to resolve con Oict:s antl increase group togetherness. Stondartl Sellei·: Expresl'. csgroupstandards and goa Js to make members nware of the direction of the work and the progress being made toward the goal and to get open acceptance of group norms and procedures. Trust Builder: Accepts and supports openness of other 6· group members, reinforcing risk taking and encourag ing individuality. 7. Harmonizer and Compro miser: Persuades members to analyze constructive ly their differences in opinions, searches for common clements in conflicts, and tries to reconcile disagreements. B. Tension Reliever: Eases tensions and increases the enjoyme nt. of group members ·by joking, suggesting breaks, and proposing fun approaches to group work. Process Observer: Watches the process by which the g.-oup is working and uses the observations to help examine effectiveness. 9-0 Evaluator of Emotional Climate: Asks members how they feel l. about the way i. n which the group is working and about each other. eommurucation Slci Jls. All cooperative, integrated action is conting ent upon rhe use of communkation skills. Through these skills, partners reach some understanding of one another, build trust, coordinate their actions, plan strategies goal accomplishment, agree upon a division of labor, implement and evaluate actjvities. There are two major types of communication skills. The following ~ubscction discusses important examples of communication skills under each type. a. Sending messages effectively. This involves being able to make others understand clearly what one wants to commuojca te, whether in verbal or written form. Some examples of this type of commuojcation slo11s include the follmving (,Johnson and Johnson 1975, pp. 114-115). 1. Making messages complete and specific_ The sender should include clear statements of all necessary information the receiver needs in order to understand the message. This means the sender needs to communic ate the frame of reference he is taking, the as~umptions be is making, the intentions he has in communicating, and tl1e leaps in thinking be is making. 2· Making the messag,e appropriat e to the receiver's frame of reference. v Vhen explaining concepts and ideas, the sender sho~l_d use words, ana Jogies, and examples that the receiver is fam1J1ar ~,ith.	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
3. Making verbal and nonverbal messages congruent with each other. Cornmunic:;_ilion prublerm; arise when Lhc S(!n<. ler·s verbal and nonverbal messages arc contrmlic:lory. If an individu al says "Herc is some data lhat mny he of help to you" ,vith a scornful look oa his face anti:, mrn:king tone of voice, the receiver is confused by Lhc meaning of the statement because of the twu different m1;;5sagc s being simultaneously sent. 4. Expressing ownership for messages sent hy w;ing personal pro. nouns such as YI ",md my". Terms imc:h ns "some people," "most indivi<luals," "our group members" make it difficult lo determine whether tlic !>emler really thlnks and feels what he is saying or whether he is just rep~aling the thuughts and feelings of olhers. Personal ownership includes clcarly taking respons·ibility for tbe ideas and feelings that are expressed. 5. Getting feedback,concerning the way messages are being received. The sender must determine what meanings U1e receiver is attaching tu her messages by seeking feedback on how the message is being i. nterpreted aad processed. 6. Payiagcloserattention to oneself, to others and to the situation in which one finds oneself relating to others. This kind of awareness of perception enables the sender to understand clearly the "what" and U1e '"why" of the message before he communicates this to the receivcr. By bein/!, clear about the content of tl1e message and the feelings it generates, the sender can choose the best way to make the receiver understand concretely the message the sender wants to communicate. 7. Using varied methods and opportunities to communicate the same message. The sender can help the receiver understand the messages better by repe;iling them more than once and using more than one channel of communication. Examples include use of diagram, piclu~·es, written reports, announcements, verbal cues, and gestures. 8. Responding with immedia cy. This involves discussing with another person directly and mutually where the sender stands at the present i. n his relationship with another and where he sees this other person standing in his relationship to the sender (Egan 1977, pp. 235-246). b. Receiving messages effectively. According to Johnson and J0 oho. soo (1-975, pp. 115-116), this includes two basic parts: (a) communkating the intention of wanting to understand the ideas and feelings of the sender; and (b) understanding and interpreting the sende I"'s ideas and feelings. Examples of receiving skills are given below: 1. Attending skills. These include being actively present to another person. By using observation and listening skills, the receiver can learn to be attenlive to the person....,;th whom she is having a discussion (King and Gen... ;g 1981, p. 70).	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
5. 122 2. Parnphrasin g accurate ly nnd noncvnluativcly the content of the mcssnge ~ind the feeling..<: of the sender. Th_is involves restating the sender's expressed ideas and feeli ogs in one's own words. 1n doing Lhis, the receiver must avoid any indication of approval or disapprova l. He must also refrain from adding to or subtracting from the sender's message (Johnson and . Johnson 1975, p. 116). 3. Describi J1g what is perceived as the sender's fee Hngs. Another receiving skill is describing what is perceived as the sender's feelings. The description tontativc Jy identifies those fce)ings without attcmpr ing to inteq)ret them or explain their causes. It communicates this message to the sender... Here is what I understand your feelings to be. Tell me if I am correct. " 4. Stating one's interpretation of the sender's message and negotiating with him until there is agreement as to the meaning of the message. When paraphrasing the content of a mes/:age does little to communicate one's understanding of Lhe message, the receiver needs to negotiate '"'ith t J1e sender the actual meaning of the message. The receiver may wish to preface his negotiation for meaning response with, "\'\That 1 think you mean is... " If the receiver's interpretation is correct, he makes n corresponding reply. If his interpretation is wrong, ll1en the sender is. given an opportunity to restate the message until the receiver can state what the essential meaning of the message is. Skills on the Management of Conunittee or Task Groups. Committees or task gronps are organized in order to carry out the goals, objectives, and functions of groups or organizations. A productive committee or task group is a result of adequate ba J1dling of committee dynamics and mechanics. The following arc examples of the skills on the manageme nt of committees or task groups (Cox and others 1977, pp. 255-265) : a. Selecting appropriately lhe chairman and member·s using as a guideline the purpose for which the committee or· task group was formed. A group of mon~ than 15 members can liardly encourage adequate participa tion of all members. b. Ensuring adequate Pre-meeting Preparations: 1. Preparing the agenda well. (a) Selecting the topics properly such that the issues can be discussed ndeqm1tely· '1--vithin two hours. Beyond this lime, members may feel exhausted to carry on effectively with decision making and problem solving processes. (b) Defining each item in ~he agenda as explicitly as possible. This sh. all guide members on what exact Jy will be taken up in tbe meeting. This can he]p them	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
identify concrete aspects to prepa1·e for, sucl1 as looki11g U(J facls or figures in advance. Useful device for heading each item (e. g., "For information. ~ ''For discussion," or "For decision.. ) can guide members as to where thex are trying to get to. (c) Sequencing the items properly. The following are some guidelines that can be followed. Items that need urgent decision have to come before those that can wait till next time. Since it takes awhile for the group to get its mind in gear. the first item shou Jd be that which is most accessible to the mind (e,g., items tlrnt are. interesting or cnsy to handle). An item that needs mental energy, bright ideas, and clear heads should be placed high up oo the list to coincide with the lively, creative atmosphere of the meeting. It is a good idea to find a unifying item witl, wh. ich to end the meeting-one which will unite the meeti. ng in a common front rnther than divide the group members one from anothel'. 2. Circulating in adv:mce, background or p1:oposal p A. pers together. vith the minutes of the previous meeting. These papers prepare members for a productive discussion when they attend Lbe meeting. 3. Ensw·ingattendan ceofth. osewhos hall make vital contributions for effective decision-mt1lcing during tl1e meeting. This is accomplished through adequate communication with and follow-up of these people. 4. Enstuing adequate preparations for tl1e physical facilities such that they are conducive to ancl supportive of a productive discussion. c. EJJectiue handling of committee meeting pr·ocess. ln order to make sure that the meeting nchieves valuable objectives, the chairman's role as facilitator itwolves assisting the group toward the best conclusion or decision in the most efficient manner possible: to interpret and clarify; to move the discussion forward; and Lo bring it to cl resolutfoo that everyone underslamls and accepts as bei 11g the will of the meeting. Tl1ere are two tasks necessary for the facilitator to handle effectively the committee meeting pr Qcess. These are: (1) dealing with the topic or agenda; and (2) dealing with members (Cox and others 1977, pp. 266-269 ?. 1. Dealing with the topic. The following skills are necessary in order to keep the meetii1g pointed towards its objective/s: (a) Utilizing an "Order of Busines s" so that members are clear about the sequence of topics or items to be discussc cl during the meeting. The following guide maybe used: 123	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
\ 124 The meeting is ''called to order" by the chairman or the. pr_esiding officer; The minutes of the previous meeting ru·e read by the secretary (if a copy of tl1e minutes has not been given out to each member prior to the meeth1g). The minutes may he approved. as read or written or may be approved with additions or corrections; Business arising from the minutes are discussed ne;,,. 1:. These include prog1:ess reports ou the items discussed in the previous meeting ; Agenda items are ne;,,.-t in line. These may either be reports of standing and/or special committees or other to_pics either for information, for discussion or for decision; Financial statement report is read by the treasurer; The last item in the "Order of Business" before "Adjournment" is "Other Matters. " These include announcements or other items,vhich members feel should be shared ¼'itl1 the rest of the group but have ool been pa1·L of the agenda items; "Adjo UTnment" is made after the group has decided on tl1e date, place, and possibly, the agenda of the next meeting, if these bave not been previously made or agreed upon. (b) Making it clearw here the meeting should try to get to by the end. The members should know if they are hoping to make a clear decision or firm recommendation or if they are only making a preliminary deliberati on in order to l1ave something to go away witll and think about. The chairman can give the members a choice: "If the group can come u. p with a cour;:;e of action now, that's fine. However, if it shall be difficult to do so, then we can set up a working group to study tl1e problem and recom. mend possible solutions before our next meeting. " (c) Making sure that all members understand the issue and why they are discussing it. Sometimes the issue is obvious <:ir that the group may have been through it before. If not, then the chairperi;oo or someone who knows the issue or has been previously briefed on it can ex. plain the fo)]o V'. ing: (1) some indicatio n of the reason why the topic is on the agenda; (2) the history of tl1e items and its present status; (3) what needs to be establish ed, resolved, or proposed; and (4) some	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
indication of Jines of inquiry or courses of action that have been suggested or explored, as well as arguments on both si,des of the jgsuc. Once all of these arc clear, the member s can utilize a structnrc for the discussion of the item or problem, specially if it is goi. ng to be long or complex. (d) Using a logical order for the discussion of a problem or an issue. This includes: (1) identifying what seems to be the trouble; (2) gathering..incl anal. y. dng lbe pertinent or relevant background/facts in order to determine how things stand al lhe monumt; (3) diagnosing the problem based on estnblished facts; and, (4) choosing a course of action derived from a number or well thought-out, col1ere11t, and sensible options. In following th. is s. tructure, the cl1<1irma11 should listen carefully in case members jump too far ahead (e. g., start suggesti ng a course of action before the grottp has ag1·eed on the cause/s or the p,·oblem), or start re11eating points that have been made t!arlier. The chairman bas to end discussion of irrelevan t topics or sterile areas (e. g., the rights and wrongs of past decisions or actions that 11re too late to change, or distant possibilities that are too remote to affect present aclions). (a) Preventing misunderstanding and confusion. The chairman's responsibilicy on this aspect can be done through: (1) seeking clarification from the speaker if she does not follow an argument or understand a reference; (2) asking people for facts or e. "q)erience that perhaps influence their view but are not know11 to others in the meeting ; and (3) making an interin1 summary to help some members who are getting out of their depth_ (b) Discussing a draft document. The group should never redraft the document during the meeting. If there are faults in it. the members sbo\lld agree on what the faults are and the c11airman should delegate someone or a small group to produce a new draft later. (c) Terminating the discussion ea. rly enough. Once the group has effectively reached an agreement, the chairman should terminate the discussion on the item before it goes nowhere at all. The chairman should also tenninate the discussion if: (1) the members need more time to think about the topic and possibly discuss it with colleagues; (2) the discussion has revealed that views of people not present during the meeting 125	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
126 are vit:cil: (3) more information are needed before fui-the1· progress can be made; (4) the meeting, does not allow enou~h time to go over the Lopic proper!> ' or a<lequa Lel)'; (5) the events ;1re l'haugin g ::md likely to modify or clarify tl1e ba~is of the decision quite ·soon; or (6) it is hecoming cle. :11· that two or three or the members can settle the matter or ll1e a. J!'gument outside lhe meeting without taking up the time of the others. (d) M11king a brief and clear su1nman 1 of what has been ag,-ecd upon. This ht:lp:-p~l the item on 1·e,. ::twd and makes people reali-:e what was achieved as a result of the discussion. lf the summary involves :ciction by a mem Ler, he shm1ld he asked to confirm his acceptance of the task. 2) Dealing ·with people. Th<. 1 task of the chairman. as fadlitator is to help Lbe group proceed to attain the objectives of tbe meetfog in the most effident manner possible. The following are examples of skills necessary to achieve this objective. (a) Managing oneself for effective conunittee meeting process. In 01·der to be effective,vi U1 ber lask, the first person the chairman has to deal with is herself. She must lean1 to manage herself such tbat maximum mcmher-inleraction is encouraged. She must be able to handle her needs and feelings in order lo be sensitive to Lhe needs, feelings, and thoughts of members whit:11 affect U1e committee meeting proces:-,. He1· clearest danger signal of yielding to the temptation or indulging in a pleasurable inflation of the ~go is he;_1ri1. 1g he Tself talk too much during a meeting. Engaging members in a heated aq~un1ent is tmother example of a behavior that reflects her inability to overcotne the need to impose her: will on the group. The chairm. an acts as the model of the group on such aspects as punctualit y and respect for members. For examp'le, when the chainnan starts and ends the meeting on time, she emphas izes punctuality as a virtue; sbe also shows the group the impo1·tance of respecting prompt rnember 's allocation of time for specific activities. l'vlembers who are punctual in attending meetings expect that their :rnhsequen t activities du. a·ing the day are not affected by a p1·evious meeting which has to end late because it started late. (b) Focusing the energy of the group on the group's goal/objectives. When members are well-oriented to the fact that the objectives of	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
the meeling arc effectively 11chicvcd only through group decision-making. the clrnirman can elicit the help of members in <lcaling with certain types of prohl<'m participants. JJ~· rocusing the group's attention on its goals/object ives and nn how the members are 11:;ng to achieve them, the chairman c.,11 encourage pnrticip,rnts lo ucal,vith specific problen, members. Thcs,:, indmlc pcr>f>k, who talk loo much and dumin;. ilc th. : 111ccli11~. members who kl. 'CP b·ringin)?. up th.-!:Came JNint un!r,rnd over ag. iin, thusc who cnnsmanlly whisper to neighbors and those who start la I king be. fore others arc finished. The dwirman can bring gro111> members to look nl the cxpcrit:ncc they arc going thrnugh 11si11i; s11ch II tc C'hniquc m: saying. ··1f our ~0,1I is gm11p dl·<'ision on,_whnt can you say nbout how we are r,,)ing through thc process of nchieving this g~)a)T '"'ith this inlt!rvcntion, the ch. iirmnn can e1u:ou1·age members lo,111aly'l. e their mv,1 parlit'ipation during the meeting. J\,Jcmbcn; increasingl y bccoml! obscrv,111t ;m<l sensiti,·c lo particular bcli. wio rs Lltal d1. :lay or imped!! progre:;s of a meeting. Thl!) e,·cnl11ally lcarn spccifil' skills un how to be "partners" in order to achieve the grot. q>'s goal. without having to spend so much time and energy putting up,,"ith problem members. (c) Helping the group find "in/win solutions. Quite often, meetings are used by group members as hattlegrounds to fight for their ideas in order lo meet their socio-psyt·hologicnl needs for status, prestige, power, and the like. Tl1cy ucspcratcly feel the need to,,rin, no m. iller· how much Lime 11r t:ncrgy the group spends lo put up with unnccessnry debate or argumen L. To handle such ~1 situation. the clrnirman must help the group attain a win/"in solution. This strategy makes everyone feel that he has won. The grnup comes up with a solution that every member con accept,,itbout feeling that he is losi11g,rnythins importan t, or compromi sing any strung convictio n. The chairperson can help group members listen earefu Uy and analyze varying viewpoi nts in order to understnnd their underlying assumptions. Then, she can guide them to look for ways t. o combine or modify these viewpoints in order to arrive ;it acceptable alternntives wi U1 objective and logically sound foundations. She, therefore, encour~1ges the group to always work toward turning objections into positive alternatives. By using the \\;n/win strategy, the chairperson uses the meeting as a venue for helping members learn the ''how~ of parb1ership. Group members ;1 re encouraged to be open-minded enough and unclerstnnd an opposing viewpoint first before evaluating it. They 127	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
128 (d) SUMMARY fr. from squashing ideas and suggestion lel,rn to r; 1!~~ns to provide a supportive atmospher : T 1e grou b, ·s protect others from attack. where mem er · . g pnrticipation. By establishing a positive Encourogm. portive atmosphere durin ' non-threaterung, sup g a ..,. the chnirperson helps members express mect111~. tl l tt 11 thcmsclv<'-" ei:;pcciolly,c s_ lf, :1a irba y quiet ones SJie can promote parttc1pation y making · emhcrs re. ilize that everyone has an equal group 111 d. t d" opporttmity to be 1_,ear~ an 1s pro tee e,rom l)Crso,,al attnck. p,11tidpat10o 1s also encouraged when the ,·~ 11113de ro feel that each member has a vital group-~. 1. 1 contribution to make which he P~ all~n1 t le group's go·rl ¼'hen each one feels 1hat he 1s an important part of Ll~e h'Toup, th1: number of uninvolved m_emhers are minintized. Examples of these member:-include the curly leaver who Ienves before the 1neeting ends; tbe dropout \\'ho sits at the back ?f thl: room, does7:1~ say :rmtlring. and gets preoccup1ed with other a Ctivities lik~ rcadi11g a book; and the busybody who always gets in and out of the meeting, constantly receiving messages, 1usbing out to take a phone call or deal with a crisis. The chapter explicated partnership concepts and the participatory action met11odology that enhance the nurse practitioner's competence and confidence to J1urture, support ;,nd sustnin the community's desire and effort to assume o:wnership of the challenges that create llcalth and human care possibilities through cycles of capability-builuing towards community competence as the nurse engages in collaborative interdisciplinary or interagency efforts, where needed. REFERENCES 1. Ashford LS and others. (2006). Designing the Programs to Reach the Poor. N,v: Population Reference Bureau. 2· Cody VVK. (::?006). Values-basecf Practice and Evidence-based Car·e: Pursuing Fu'. 1dame1!tal Qucst1:011s in 7!ur-sing Philosophy and Theory, in J/11'. K" Cody, (Ed) Plulosopl ucal and 1'heorehcal Perspectiuesfor Advanced Nursing Practice, s-12. M:. issaclmselts: Jones and Bartlett Publishers. 3-Constantino-D avid K. c199 ) c... · 5 · ommumty organizing in the Philippines· The expenence of development NGOs · G Cr. ·. Participation and Deuelon. t ' m aig and M Mayo, (Eds) A Reader m ;-men, 154-167. London: Zed Books. 4. Cox FM and others (1977) Ti. Itasca: F. E. Peaco~k p b'1. ·h acnes and Techniques of Community Practice. u 1s ers, Inc. 5. Egan G. (1977). You and li1e: The Sk' Others. Monterey C:tliii · 8 rl/s of Communicating and Relating to orma: rooks/Cole.	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
6. Johnson OW and Johnson FP. (i997). Joining togcthel': G1·ot1p ·Theo,·y and Group Skills (6th ed. ). Boston: Allyn and Bacon. 7. Johnson OV\7 and Johnson FP. (1975). Joi11ing Together: Group Theoi;y and Group Skills. New Jersey: Prentice-Ha JI, Inc. 8. King VG and Gerwig NA. (1981). 1-lwnanizi11g Nursing Education:A Co,iflurmt App1·oach Through G,-oup Process. Wakefield: Nursing Resources. 9. 10. Kock T & Kralik D. (2006). Pa,·ricipntory Action Research in Health Care. Q,-_-ford: Blackwell Publishing ' Laverack G. (2001). An identfficatio n and intcrpre t-ario11 of the 0t·ga11izatio11a l aspects of community empowerment. Community Development. Jounw/. 36 (2), 134-145. u. Maglaya AS. (Ed). (2004). Nrwsing Practice in tire Comm1mit. y. Fourth Edition. · Matikina City: Argonauta Corporation. 12. Maglaya AS, de las Llagas LA, Ancheta CA & 13elizario VY. (1. 999). A family fiealt/z empowerment intervention model towards J)re1Jen/-im, anrf con. h·ol of malaria in the Philippines: the local gover11nre11t 1111it/ rttl"a/ health unit perspective. l'vlanilu: Deparlmcnt of Hca JLh-Essential National Health Research. 13. Maglaya AS. (1988). Behauinral Catalysis: A Theory of Nursing lnte,·vention ih Family Health Care. The ANPHI Pape1·s, 23 (2), 14-20. 14. Parse RR. (Ed). (1995). Illuminations: The Human Becoming Theory in Practice and Research. New York: Nationa l League for Nursing Press. 15. Polivka BJ. (1995). A Concepll. Lal Model for Community I11teragency Collaboration. Image: Jou,-nal of Nursing Scholarship, 27(2), u. o-u5. 16. Ross M. (1967). Community Organizatio n: Theor·y, Principles and Pr·actice. (2nd Edition). New York: Harper and Row Publishers. 17. World Bank. (2005). World Development Report 2006: Equity and Development. Washington, DC: Wodd Bank, 5,142-143. 18. WHO E. xpert Committee. (1984). Technical Report Series No. 708. Education and training of nurse teadiers and managers wit·h spe. cial regard to primary health cai·e. Geneva: World Health Organization. 19. World Health Organization. (1978). Alma Ata 1978. Primary health care. u Healthfor All" Sel'ie:s No. 1. Geneva: World Health Organization. 129	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
130 Chapter 6 DEVELOPING COMMUNITY COMPETENCE THROUGH THE WORK GROUP APPROACH Araceli S. Maglaya INTRODUCTION The concept of community as client can be difficult for the commun ity health nurse, especially when the emphasis of a community is a location in space and time of aggregate s or groups of people. Precision in explicating community as client-par tner is attained when nursing practice is focused on comn1u11ity compete nce, as both process and outcome of integrating individual selves into functioning collectives. It is rooted in social interaction, where each participant in the interaction becomes part of lhe other, learning not only his or her own part but the part o. fthe other as it is experienced or understood. Sustained social interaction results in increasin gly congruent mutual perception among members as they develop a generalized concept of t J1e group or community which shapes U1eir expectations and actions (Cottrell & Mead, 1980). Within this social interaction framework, the community as client-partner can deve. lop or enhance its ability as constin. 1ent pnrn to create,md 1,1i;;e :1tnicturl;!s ~nd l?Chemes t. hat allow it to address problems, issues and challenges related with its col Jective life such that its members can e Kperience improved psychosocial adaptation, socioeconom ic productivity or better quality of life. Working with the community or i L'> aggregate parts is facilitated when the nurse-partn er understands the psychosocia l processes in the life of community aggregates or groups as members go through a 'lived' experience of interacting with each other in addressing problems, issues and challenges as a functioning unit. This chapter discusses U1e concept and dimensions of community competence and how the nurse catalyst-partner can work with the community as client-partner to develop, enhance or sustain its ability to address issues or manage problems related to its collective life, using the work group model as strategic approach to an empowerment tract. Stages of group develo J)ment will he described in order to understand the behavior of the group as a funct. ioning unit. Specific interventions to facilitate group growth towards the work group stage are included. The work group model can facilitate the community's confidence and com. mitment to pursue empowerment challenges.	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
COMMUNITY COMPETENCE In the last three decades, the concept of community competence has been utilized as bases for developing, impleme nting or evaluating programs, projccls or strategies within the global initiative of 'health for all' through primary heal U1 care. Cottrell (1976, p. 197) refined Lhe concept and described a competent commun ity as one in which its interdependent parts can: (1) collabora te effectively in identifying the needs and problems of the commun ity; (2) achieve a working consensus on goals and prioritie s; (3) agree on ways and means to implement the agreed-upon goals; and (4) collaborate effectively in carrying out the actions. Cottrell describes eight essential conditio ns that must exist to some degree in a community for it lo function effectively. Stolte (1996, pp. 271-272) used Coltrell's concept as guide in explicating wellness nursing diagnoses for communities. She describes Cottrcll's eight dimensions as: (1) C0MM1TMENT-lndividua 1s can see that the community has,tn impact on their lives and that whatever affects it will affect them; they believe thul they have a significant role in the community; and they see positive results from their community efforts; (2) SELF-OTHER AWARENESS-Each communitycomp!m ent knows its identity and how it relates to the other compone nts of the community ; (3) ARTICULATENESS-Each component of the community can slate/ fonnulatc Lts views, atlitudes :rnd intentions in relation to other compon ents of the community; (4) COMMUNICAT ION-Components of the community can send messages/ transmit information as well as see how their message or information will be received or understood; (s) C0NFLICTC0NTAJNMENT AND ACCOMMODATION-\~hen conflict exists, it is "kept in bounds.. and efforts at resolution continue such tbat interact;on among communi ty groups are sustained despite differences in opinions or perceptions; (6) PARTICIP ATT0N-As components of the community interact, they become c. ommittecl, define goals, and find ways to reach those goals; (7) MANAGEMENT OF RELATI0NSWl TH THE I. ARGERS0C IETY-Any community is a part of a larger social system and must determine how it fits within that system. A competent community utilizes the input/resources/sup port from the larger system while ;icting to reduce threats from Lhat system. When necessary, it stimulates the creation and use of a ltemative or supplementary resources; (8) MACH !NERY FOR FACILITATING PARTICJPANTINTERACTI0N AND DECISION MAKING-Constant monitoring through flexible and responsive formal/i nformal procedures that facilitate interaction/communica tion for decision making. THE WORK GROUP MODEL AS STRATEGIC APPROACH TO COMMUNITY COMPETENCE Community competence as a process is rooted in social interaction to enhance better options for a collective life. Community members relate with each other as aggregates or groups to address ·issues or problems, whicl1 can not be effective ly done or sustained otherwise. Within t Ms operational framework, community health nursing practice is facilitated when the work group model is utilized as a strategic approach to develop or enhance the cornpetence of the commun ity as client-partner. · Realities of practice challenge many community projects or activities when members realize that the group undergoes dissolution before they can learn the uniqueness of group life as a natural phenomenon occurring in smnll group processes. Tbe nurse catalyst-partner can facilitate developm ent of the competencies of the group to work together as a productive functioning unit, The empowering potential of the community can be emerged to transform isolated individua ls into interaclional groups. Specific interventions enhance the group's experiences through the stages of group growth till the wo1·k group stage, the arena for optimum group productivity as a consequence of enhanced relatedness among group members while they experience affirmation of 131	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
132 each other·s contribution to group output/goal and respect for each other's differences, idiosyncrasies or uniqueness. THE STAGES OF GROUP DEVELOPMENT The Stage of Orientation The two tasks confronting group members during the initial stage are: first, they must determine a way of achie,;ng their primary tasks-lhe purpose for which they joined the group: second, they ruust find a place for themselves in Lhc group, one that wi. U not only pro,;de the comfort necessary to attain their primary task. but,vi. l J also result in additional gratitication from the pleasure of group membership. In achieving these t"·o tasks. the group member's behavioral patterns are basically attempts at warding of T anxiety. The main concern of the membei-s is whether they are ujn" or "out-of the group. They search for a role for themseh·es in the group, wondering if they will be tiked and respected or ignored and rejt-x. :led. Tu ham. lie an~iety, they invest most of their energy in a se. trcb for approval. acceptnnce, respect or dontlnation. Consequently, the content and the style of commun ication during the initial stage are relatively limited, repetitious and reslr. lined. Lt is not surprising to observe that during this stage members are c. :ireful with their choice of words because they are not sure how they \,;11 be taken by others in tbe,zroup. Members may endlessly discuss topics of apparent I~-little substantive in le rest to any of the participants; however, these topics serve :is vd1. icles to explore how thc. y are perceived by co-members. With these exploratory atte111pts, a member eventually discovers w J10 responds favorably to him, who sees things the way he does. whom to fear, and to respect. Gradually be begins to formulate a picture of the role he will play fo the group. Another common experience in the group is the search for similarities. Members try l1ard to let others know that they are similar-with everyone in the group. Trus experience offers great support to members and prnvides part of the foundation on which group cohesiveness will eventually develop. Givingandsceldngadvicei sa. nothcrcharactcr isticoftheear]ygroup. Members atte. mpt to share some type of practical solution; however, this is rarely of any functional value except as a,,ehicle through ~vhich n1embe:rs can engage in social relationships in the group. Thus, the early group can he described as a groping, testing, reluctant group. It is also a dependent one. The members e..,:pectthe leader to pi-ovide the group v. ith structure and answers. They "look to the leader for appr C>val and acceptance. Members demonstrate beha,ior which in the past has gained approval from authority. The leader's early remarks are carefu Jly anal)r. 1ecl for guide) ines about desirable and undesirable behavio r. Many of the comments in the group are directed nt or through the leader. The lines of inter;iction w:ithin the group are leader-cen tered as illustrated in Figure 6. 1. The arrows indicate that tbe lines of interaction are from the leader to the members. The responses of the members are in turn directed back to the leader. Interactions among members are rai-ely observed. Oftentimes the leader needs to. initiate the opportunities so that members are encouraged to respond to others in the group.	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
1,e~er or Facilitator Figure 6. 1 Lines of Interaction wlthln group when leader-centered The Stage of Conflict This stage is characterized by the group·s concern over dominance. cont Tol and power, Toe e. xperience on connict is behveen members or between members and the leader. Each member tries to establish for himself his prcft::rrcd amount of initiative and power, and graduall y a control hierarch y within the ~roup is established. Members become judgemental of others. Negative comments and inter-member criticism become more frequent. Members make su"estions or gh·e t1dvice, not as a manifestation of acceptance and understandin g but as part of their attempts to establish their places in the control hierarchy within the group. The struggle for control is part of the dynamics of every group; it is always present. sometimes too tranquil to be recognized, at other times suppressed, and al some other time may become a full blown eiq>ression akin to a blazing fire. The emergence of hostility toward the leader is an ine Yitable occurrence in the life sequence of the group. Wbile hostility toward the leader may be present even as early as stage one, hostility toward the leader becomes more ob,-ious in sta~c two. Tho. : sources of hostility toward the leader become clear when we recall Lhe members· perceptions of the leader in stage one. TI1e members' expectations of him a.-; a powerful being are so limitless that regardless of11is competence, he will disappoint them. Gradually. as the recognition of his limitation s becomes obvious, members st. art tn fctl di,rnppointed about his behavior. By no means is this a clearly couscious process. The members may intellectually advocate demo<.-ratic group which draws on its own resources. However, they may on a deeper level wjsh for dependency and attempt first to create and then to destroy an authority figure. The leader refuses to fill the traditional authority role: he does not lead in the ordinary manner; he does not pro,idc answers and solutions; he urges the group to explore and to mobilize its own resources. The members' wish lingers howeve l" and it is usu~y only after se,·eral sessions·tbat the group comes to 133	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
134 realize they nre wishing for nn ·'old lime'' leader. Anol11er source of resenbnent toward the leader stems from the gradual recognition by eacb memher that he will not be the leader's favorite "group member". He begins to reali1. e thal l Jte leader i. s no more interested in him thon in the olhers. This leads to the emergence of rivalrous. hostile feelings toward the other members. To overcome tbe anxiety that l11c members experience at this stage, counter-dependent expressions (fight) begin to replace the over-dependency stage. The group may be clivide J into competing groups-ench subgroup is unnble to give up power. Vvitbout proper inlen·ention. this may lead to a group that moves rapidly toward e J1.-tinction, where there is splintering. i11lo lwu ur three subgroups. :Moreovt?r_. drop out rate is high at this point as group mc. mbe. i:s Lhnt are not committed to either subgroup attempt to handle and ce Sl)lve their contlicl by leaving the group. With the necess. ti:· interventions employed. lhe group can be helped to resolve the issues on dcpendc. nce (stage one) and authority (stage two). New values and behavioral patterns emerge out of the emotional experiences of stages one and two. The group membe_rs begin to.. 1ccepl Uleir full share of the responsibility for whal happens in the group. The group begins to experience independence as it goes through the last two stages of intimacy and i11terdependeoce.. The Stage of Cohesivene ss Following the previous period of conflict, the group gradually develops into a cohesive unit. During this stage, lhere is an increase of morale and mutual tn. Jst as members feel group belongingness. Consequently. members are \,,1ling lo share more about themselves lo others in Lhe group. There is intensification of personal involvement, a growing awareness and mutual recognition of tbe significance of the group experience in terms of personality growth and change. The chief concern of the group is with intimacy and closenes s.,\n. xieties have to do with not being liked or close enough to people, or with being too inti. male. Although members experience a greater freedom to talk about themselve..5, there may be communication restrictions of some lcind: often lhe group suppresses a Jl expression of negative feelings in order to maintain a harmonious atmo~phcrc. The members, in a sense unite ::tgainst the world. wilh much inter-member support, much pride in the group. and much condemnation of the member's ~enemies" <Jutsidc the ~roup. Eventually. howen!r, the ~rour·s cohesiveness or feelings of unity,.,rill seem ritualistic unless tl1e hostility in the group is permitted to develop. On Jy when all feelings can be expressed and constn1cti-vely worked through in a cohesive group does the group become a mature work group. The Work Group Stage During this !ttage, the uniqueness of the members and the leaders are seen and expected. Members can accept one another"s differences \...-ithout associating ·'goodn and Jbad \\-ith Lhe differences. They become aware of their own involvement, and of the other aspects of group pmccss, without being ovcrv,il1elmcd or Alarmed_ Conflict exists but these are on s11bstantive issues rather than emotional ones. Consensus is reached from a rational di:-<·11s.,ion rather than Crom a compulsi\'C attempt nr 11mrnimity. The group become..'-a feedback \'Chicle where members can clarify and evaluate each other's perceptions ~ind the group process. There emerges a group sy~-cem for mutual support for indh;duality; and, where needed, the. re develops in the group, consistent	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
control when individual. behavior becomes group-destructive. From a sense of group identity comes a sense of individual identity. TI1e state of the mature work group may l'ast for the remainder of the group's life, with periodic short-lived repetitions of earlier stages. During the stage of advanced work group o·r true teamwork, the tension is between "workr or progress, and regression to an earlier stage. The nursing interventions, tasks, and techniques can help minimize the group's tendencies for regression at an earlier stage, or these can help minimize the eff~ts of regression on group members or on the group process. The Termination Stage After being together and working on specified "tasks·~, members of groups experience a sense o[ ending. Sometimes this can be temporary as when a particular session or meeting ends. At other times this can be a permanent one, when the group's reason for being ends, as when a project or program has been accomplished. According to Dunphy (1965, pp. 384-399), tl,e tasks of the group at this stage may include: finishing the agenda, estnblishing key decisions and completing the group product, tying up loose ends and writing oft unfinished business. The key emotions are joy and sadness. The group celebrates for the work and achlevements done. However, there is emotion al coping \. vitb the loss of valued personal relationships. There is a joking, laughing, ritual (parties, graduation, etc. ) and expression of sorrow or withdrawal_ The Various Stages at Work Although the stages can be described as such, the developmental sequence should not he taken literally. The stages are rarely demarcated. There is consider able overlapping of the boundaries bcnveen them. The group may go through the various stages in one session. 1 t may. however, CJrperienc e the manifestations of one stage quite dominant in one session and those of lhe next stage in a subsequent session. It is to be made clear also that rnrely does the group pemrnnently graduate from one stage. In describin g group formatio n or group growth, Wilfo1m Schutz (1965, pp. 123-135), uses the analogy of tighlenlng the behs of the wheel one after another just enough so that the wheel is in place; then the process is repeated, each bolt tightened in turn until the wheel is ent-irely secure. In a similar fashion., the stages of a group emerge, become dominant, and then recede, only to have the group return again later to deal,vith the same issues, concerns and problems with greater t J1oroughness. The group returns to the same issues but each time from a different perspective and each time in greater depth. The nature an<l extent of the group's expression of interpersonal issues, conflicts, needs, and problems depend upon the degree of cohesiven ess existing in the group during the initial stage of its formation. A group whose members had worked effective ly together on some activity sometime in the past, may ex-perien ce more depth in dealing with interpersonal concerns and problems tlian a group whose members are meeting only for the first time to do teamwork on a tas·k or project. INTERVENTIONS TO FACILITATE GROUP GROWTH The discussion on the stages of group formation provides a means for understanding the dynamic processes that go on in groups. It can help the nurse identify where the group is, to predict in what direction it might move, and to identify the assets within the group that might be utilized or max:imi. zed. The interventions, tasks, and techniques that shall be discussed in the following subsections are all directed towards 135	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
developing and maintainu,g work groups. These interventions, tasks and techniques can help group members to handle the psychological processes-the interplay of valied personali ties, feelings, needs and concerns-that bring about anxiety or discomfort. To facilitate cbanp. e nnd growth in the group, Lhe amdety lhat everyone ex-perieaces in various degrees shou Id be kept tu a level that enhances rational nnd effective decisions and actions. The individual s must feel the rewards for working Logether rather than having to resort to a,·oidance of the discomfort (that the anxiety brings) by leaving the group, being passive members of the group or being overwhelmingly aggress ive to other members. Tbe nursing inlerventions, tasks and techniques emphasize U-1e importance of working on feelingi;, needs and communication. Since most acts of problem-solving in social spheres arc acts of communication, helpillg community members handle the psyd1ulog ical processes as e:... 1>erienced in the g Toup can enhance or strengthen their capabilitie s for l!ffecli\'e prub Jem-solv ing. As group gro"vth reaches tl1e stage of independenc e, thccnpabilityofthegroup for problem-solving increa:;t!s. As the personal relations among group members change from depe11dency to conflict, to cohesion, and eventua JJy to interdependence, the resources of the group improve such that more data are available to help the group go througll effective problem-solving. The group has easy access to t J1e necessary ideas, tools and materials needed for rationa J decision making, effective implementation and eva1 uation of activities, pi-ejects and programs. fnlaf:ventio As, ta5ks, and techniques lr. i. ctude the folk>w Tngi ' ·. '. ma ne'8SSary orientatio n, str,ucture and directions. eet'i'nembe r S' Interpersonal needs. '. tfa~ and re,olve conflicts to evervonits s~tfsf~cti,on., i:He effects 9f own behavk>r,on the group:. use the se-:ff for' group to apply learning on another situation Provide the Necessary Orientation, Structure and Direction During the stage of orientation and dependen ce, the level of anxiety can be decreased by helping provide the necessary orientation, structure and direction to the group. Jn instances wl1en the g.-oup members do not know each other, tl,e prelimina i-ies of introductions should be made. There is a great positive impact on group members if they got intrnduced by the leader or facilitator. They can also be encourage~ to get to know one nnother by making them introduce a co-member. The time to interview co members should be provided in this instance. Opportunities to clarify or elucidate on the goals and purposes of U1e·gro11 p, the expectation s and perceptions of eve1y members as regards role$ a. nd responsihililics should be maximized. Certain structured learning exercises oo group decision-making and consensus may be utilized to help group member s experience perforn1ing the various t:. tslc and group-bui Jding or maintenance functions necessary for effective gr·oup work. These exercises also provide opportunities to rele. ase, t J1rough a game, the energy generated by anxiety. Moreover, tbe dependence that is aggraw1ted by certain socio-cultural tendencies to be submissive a. ad authority oriented can be minimized early in the group's experience. Tbe lines of interaction can be changed markedly from the leader-centered to group-ce ntered (see Figure 6. 2), as members learn how to corumunic ate effectively and participate actively in discussions and group work. 136	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
-teader or Facilitator / 0, CT ~~~D ' /. 'O,.,,.. Figure 6. 2 lines of Interaction within a group when group centered The facilitator or leader creates an,1tmosphe Ni for productive group work when members' interpersonal needs are met to a satisfactory degree for each one. Meeting these interper sonal needs may be initiated by the leader. ln time, members learn to initiate his modeling beha\>ior and they, eventuall y help meet the interpersonal needs of co-members. Helping group members meet their interpersonal needs to belong and to be a part of the group can be em:ouragetl by acknowledging the importance of their prnsence in the g Toup and contributions they make. The leader should communicate the message tl1at each one is important in the achievement of group goals. During ex-periences of heightened level of anxiety, the mentbers concerned. should. be provided ·with the necessa111 emotional support by acknowledging the discomfort being experienced, and by eliminating or minimizing the sources of anx1ety or its effects. The leader may avoid making demands 1mtil group an1dety has ab:ited. Members "open up" when Chey feel secure in expressing ilieir attitudes and ideas; when they know they won·t be ignored, ridiculed, criticized or otherwise embarrassed by the other group members. The Jeader·s tasks and techniques (,Johnson and Johnson 1975, p. 283) may include: 1) listening allenlively lo whal each is saying; 2) not judging the contributions of members or commenting on every cnntrihution made; 3) doing away with preaching, teaching, or moralizing; and 4) avoiding forcing members into participation befo1·e they a1·e ready. The leader can encourage productiv e participation (Johnson and Johnson 1975, p. 283) by: 1) observing for signs of a member's efforts lo be hearcl anti giving her an opportunity to contribute ; 2) being sensitive in identifying Lhose too eager to talk as they can take up all the group's time; 3) encouraging and supporting all members who participate; 4) summarizing and clarifying the contributions; and 5) not monopolizing the discussio n or commenting too frequently. He should show enthusiasm for U1e discussion aod a sincei'e interest in the group members. In a discussion group, there are eiiperi. ences when a member obstructs the functioni ng 137	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
l)f Lhe group. And quite frequently, the 0U1er group members are not able to solve the problem constructively; they either support the obst. n1clur or reject him-botb of which arc unde:-irnblc. The leader may have to intervene if Lhe conflict siluution is to be himdled productively. Process, Negotiate and Resolve Conflicts to Member's Satisfaction 111c d)11amism characteristic of the work group is maintained if the hostility and connicl in U1e gruup ore pt:nniltcd lo de\'C:?lop. However, stability, in Lhe face of turbulence. cannot be sustained 11nlcss gro11p rn. cmben; have the necessary attitude towards conflicts and the compett-ncies necessary to handle or manage Lhem. Specific inte. rvt>ntions focus on developing the member·s competencies to handle conflict cvnslrut:tively: Help members underst. Jnd the nature of conflicts Help members so through the coping process of conflict resolution using the problem-solving approach. Help members pnerate new ways of looking at the situation or problem. Help members analyze the here-and-now experience. 1. Understandin g tl1e Nature of Conflicts. Group mem. bers Jear11 to develop a positive at Utude towaid conflict when they realize that it has the follovvi. np; characteristics: a. It is a natural part of any relationship and of any group. It is inevitable in a problem-solving group primarily because persons differ from each other in many ways-needs, motives, interests, ideas, and , perspectives. 138 b. Conflict is desi. rable and e,,. _trernely valuable for several 1·easo11s, according to Johnson and Johnson (1975, pp. 148-153): It encourages inquiry, promotes objectivity and sharpens analysis since it provides for a greater diversity of opiniu11s, inle1·esls, v;ilues, and ideas among group members. Thus when conflict is handled constructively, Lhe group is able to come up with creative and high-quality decisions aod solutfons. Conflict stimulates interest and curiosity, and increases t J1e motivation and energy of group members. These, in turn, enco11ra~e active iuvolvemen1 and commitment of members to group functioning. It can greatly reduce the natural tension and frustration of working together. Contlict allov,rs for the expression of emotions such a. c; indignation and anger that would interfere wilh group work if suppressed. Feelings t Jiat an: unn:solved nfld. ;ire not dealt with make for biased, non-ohjcctivc judgements and act ions. They affecl the members' pe,rceptiu11 of cvc11ts a11d i11for111ation. They lead to distortion of other·s ideas or mi. sintcrprct. nion of their actions. Thus. if members withdraw from conrlicts. reln1ionships within the group become so fragile 1hat mcmhcrs cr1 nnot stond the strain of prolonged differences.	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
Members derive r>ersonal benefil. s from lhe experience of conflict. An individual in the group is provided an opportunity lo nchicvc gre<1tcr sclf-11nderst:1nding :is a result of working thrnugh a conflict with co-mcmhcrs. Havin J?, to talk about his position anrl think more c:irefillly about how smmd itis often generates greater awareness of values and identity. Conflict ;:illows the individual to test ud assess himself an<l experience the pleasure of using fully and actively his capabilities. Conflicts br-ing inforrna tinn to member s about where they 11re, what is important to each of them, how the group work can be ma<le effective, and how their rehllionships can be imprvve<l. When the conflict is handled as it is being experienced by members in the here-and-now, arguments nre kept up-le>-dat e. This helps group members avoid being bothered by the past, which they cannot ch,mge. J\1erubers who ;;irguc regularly and constructive ly need not carry a load full of grievances. All past differences or disagreements lwve be:en dealt witb so tllat members do nol constrain working together and appreciating one another in the present. c. Any conl"lict can be bandied constructively by the group when the following aspects are considered: Members should develop specific group nonm; or rules to create an atmosphere conducive to healthy rnana S?;ement of conflicts. E,xamples of such grou J) norms or rules are: l11e cou. J1icl should be over issues and not hctwecn persons; members who disagree with others ruust understand both the positions ancl the frame of 1·eference of their opponents; the situational power (e. g., being more verbal, having a louder voice are having more power) should be balanced :;uch that negotiations are condltcled between "equals". Conflicts are managed effectively byencouragin g group cooperation and by using the problem-solving approach. The hasic steps of this approach a. re discussed in the nex1: sub-section. 2. Conflict Resolution Th. rough the Problem-Solving Approach. A conflict can be analyzed, negotiated, and resolved utilizing the problem solving approach. Tl. le bnsic steps (Johnson nnd,Johnson 1. 975, pp. 182-269) of this approach ru·e: a) clarify the b;,isic rules; b) diagnose the causes of the confl. icts: c) explo1·e ways to settle the con0icls; d) decide upun mid implement an agreemeu l that is satisfactory to all members; c) evaluate the success of tl1e ;iction/s taken. a. Clarify the hasic is..c;ues. The opposing viewpoints must be dear to every member of the group. I Ll order to do this, each member wishing to express an opposing viewpoin t must first have an accnrarc person::il understanding of bis own needs, goals. positions an<l proposals. Once this is done, the member can be helped to communicate accurately the underlying assumptio ns and frame of reference of his viewpoint. This promotes 139	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
140 C'larity. predicwhili ty. and mutual understandin g of posi Uoos, feelings, and frame of references. Consc4111mtly. the group is able to identify the opposing viewpoints of coulcoversies. b. Diagnose the tlimension ~md Ctlllses of conflict. The objective here is to define the nat·ure and m. ignitm. lc of lhe forces that bring about the conflict and forces thut mi11imize the c011flicl. These forces may be cognitive or intellectual in nature as when fl1e cunflicl is u,·er substantive issues. These include r. Jifferent"es in infornrnt. ion. heliefs, opinions, assuniplions, and ideas. Forces mny also be p~·yclmlogieal c,i· emotional in 11atu1·e such as interpersona J lllc!Cds. motives or feelings. Once these forces are listed, the group is ready to take the ne'-"t step i11 the problem-soh;ng approach. c. Explore wnys to :-et tic the cortflict. There ai-e four sleps to settle the conflict. First. is eliminate or reduce the furces thnt bring nhout the conflict and/ or strengthcn/inrrease the forces that minimize the conflict. Second, is to integrate positions or ideas \hat are si111ih11· such as the dimension or magnitude of the conflict is red11ce J. The third step is to help the members anal~?. e if the opposing views can bi:! taken by the group as its decision. If the group is constrained lo take only one viewpoint, the members can be helped to go th Tough the next c. omponent of the problem-solving approach. d. Decide upon and implement an agreemenl sat. isf»clory of the group. 111e oppnsi. ng viewpoints can be listed. together with the posi1 ive and negative aspects of eoch. in :1s fo. r as Lhegroup·s goals and tasks are concerned. Then, identify the resoun. :c:, needed Lo Utr Ty out and implement the alternatives to operationalize ench vi C'wpoint. Evaluate how realistic the alternatives are and the probabilities of success a_gainst the cost ofimplementation. Try to anti<. :ipate all the blocks to i mplemcntation and how the group members w;IJ handle them. Once tl1cse. an:: all identified, the group can now decide which ~;ewpoin t Lo Lake based on mini. mum resources that shall give the maximum benefits to the. group. \-vhen n decisif Jn is made, t J1e group can put the ideas and activities into a time sequence with lbe specific dates for uctiviliei, \o Qr,;r,;w·, Iviembers c;an be given specific assignments in order to implement the agreement. e. Evaluate the success of the net ions ta ken. J n order that the group learns to be dynamic in pursuinv. its goals, it has to learn to evaluate t J,e success of its aclions such thal J)wvisions for. replanning are ade(luately considered. Jf the rl1·cision to t1-1ke A particular viewpoint as its course of action does not prov P. successfu J, the J1 the group Cfln be nrnde to realize tl1e benefits of going through the problem-solvfog approach on another viewpuin l. Tb. is cyclic process is done until the group is able to find the best solution to its conflicts. Although connicts resolution is outlined as such, tbe group does not necessarily have to go through all the steps before it can come up ·with a consensus. The steps nre <m Llincc. 1 in this man. nc1· so Lhat group members are guided u D how lo arrive at· a consem,us. The group may be able to come up with n consensus without ncr. cssnrily going Lhrough all tl1e steps. In many instances grnup members learn to give up their i<leas in favor of a brighter) more crealive and workable proposal by anolher member once tl1crc is muh1al understanding 11nc. l rrcdictahility of assumptions, frames	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
3. L of references, positions, and feelings. In utilizing the problem-solving stratet,,y for conflict resolution, other intervention s, tasks, ond tech11Jiques cnn be employed to maximize the group's capabili Lies to define,tnd anal:n,e the ea uses of the conflict and develop ;:iltenn1tiv1c:s Lo solve Lhe problem. These interventions, tasks, and techniques are presented in the following suhseclions. Generating New \Nays of Looking at the Situation or Problem. During experiences of connict amrn1g group members, a feeling of frustration, tension, and discomfort can result from the gronp':-; failure to produce an adequat e alternative to re.-;olve the conrlid. Qui le often, memhers feel the need to withdraw from the issue. As part of the group's defense mechanism to attain cql Lilibrium during such a st1Jrmy stage, members may d. rop off the issue, consciously or unconsciously hoping Lhat some form of quiescenc: e can be a good resolution of the conflict. In lite absence of the better alternative, such a coping mechanism may be often resorted tr., hy Lbe group. This c. _rn eventually lead to a permanent incapability of the group lo handle. ind resolve conflicts to everyone's sa Lisfoction. The relationshir, among group 1111;:mbers remain superficial as expenses revolve only around routine or procedural concerns/ prnblem s. Group member's enthusia sm and commitment may eventually become affected because the };roup bas lost the very reason for its vitality-its capability for dynamism. During such expe1-iences on fmstrations and de<1d ends brought about by the group's incapability to handle conflicts, the nurse as a facilitator of group growth, can help the members look at the situation/s or data from various perspectives such tha L new orientations and insights can be derived from them. The facilitator can c. nco11rage group members to have available diverse ideas tl1at can be flexibly put together into new and varied patterns. This may require changing perceptions. finding new ways of looking at things and changing ideas and conrepts that membcrs have t·cligiou5ly adhered Lo in the pa$1:. Threat a. nd excessive temsion i. :an result from uccepting the challenge of questioning the ideas and beliefs firmly based upon how we linvc nicognized. clarified, defined, la be. led and analyzed e:q)criences in the past. Threatsbrin?,about defensiveness and redui. ;e both tolerance toward tllnl1iguity and receptivene ss lo tbe new and unfomiliar. Too much tension 1ea<ls stereotyp ing of t·hought processes. In order lo help group members break away from thinking tradition and accept 1. he challc. 11ge of changing perceptions and providing new ways of looking at experiences on conflict, the facilitator need to develop conditions that a Jlow concerns, issues, and problems to be reformulated. During group discussion, the atmosphere must be such thnt mem be. rs are given tll°e freedom and support to have the self-confidenc e needed to enle1tain ant. l express novel ideas (that may initially seem wild,me] implausible) without being afrait. l of censure. They should be given the freedom to question initial assumptions or the framewo rk within which the problem occurs-Each group member also needs to become sufficient ly detached from her original viewpoint to be able to sec the problem from new perspective s. To help group members gel detached from ideas and viev,i,oints and analyze/re solve conilkls lhal act as psyd1olog ical barriers to productive group discussion, the fo,llowing are some practical teclmiques that can be ut-ilized: a. More often members react to and e:q)erience conflict with persons (co membcrs), not necessaril y because of their ideas, beliefs, or concepts. Con. flicl s can be minimized by helping members isolate/separa te the 141	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
1,r rd1·rr·rlt'I",,,,,,,,j I i,111,. :111d f1:rli IIK,I;, I 11 11! 11 i,. I 11g t fir pr olllt111<:<Jl\'i11r.,;t r:111;,r for cnn rli"I r P">11l11li<>n. other i11l1·rvr111iu11'i. la,. b. a11rl l1· lrni'(IW~ 1·;111 hf' rmpl,,v,,d lo maximize lhr~ 1,rr,11p',; 1·11p:il11lilw· 111 tlf'f1111· and ;111:liy11 1111' rnn~,.., of the rrmflict an<l 11<-v,lop 11lt1ni;1I 1..-1·,,,, '>olv,· 1111' pmbl1111 'I la<, 1ntcn;cnt inns. tasks. and 1,c·l111iq111:.. irr 111'"··1111'<1 in 1h1° t,,IJn1°,irn:,11li,te<"liirns. Gc1wrn1i11J: Nc. :w \o\l;ry~ of J,1111ldng :ii tlw Situation "r Problem. 1)11ri11J~ c:p<'ri,0111·,<; r,f 1'011l lirt. 1111011;~,~m11p nll'rnh·r,. :, fc·clinr, nf fnr,lrntion, 1c11,i1111. :111d <lh1·11111f 1J1i can 11",1111 frr11n rlw ~r1,,1p\ f. 11iun l" rr<1duce an :ulvq11:it1· 11l1,r11:rl1'1° '" ll",,Iv, llr,..,11rl H'l. l,)111:i: 1;ftf'n 111r·rnb1·r s foci 1hr. need to \d I hdr:11\ t n,111 t 111 11,~111·. 1\!i p;1 rl,,r I Iii· ;;11,up·:, di·f·w,c tn N:ha ni. ~m t<, :itt:iin eq11dihri11111 d11ri111'.-;111·h :r ~11,rm,· ·<tai;,-rn1mlwr, m. i} drnp off th E: issue. ,....,mwi1111°,ly 111 1111c:t J11~1·i1111sly liopi11,: t li;il "Jm1· form 1J( qui1-<. rcncc ran be a w;11d n. :.-. ol11li11n nfllw c1,nll1l'l. In th· r,b,,·nr·r· nfthc lwtt1r;1ltcma1iv1. ~uch a copin~ 1111·t·ha11i.,111 111ay Ill' 11fl,,11 n·sorlr·d l111, th· f. r'"Uf' Thi-. ran r·. c,nu1ally lend 111 a p Tlll,1111·111 rnc·:,pahilit), "' the· ~r()ll Jl tr, ha11Jlr· iinrl rr,-;olve <'nnflicts w 1·vcry1t11·<; ~.,11,;l:,i·tirn1. The r('la1i,,n,l11r amon~ group mcmbf. lr~ remain s11rwrtir-i,d a:i c,1w11,,-, n",'lh:1 ()11ly :,round rr,utim·,ir prr.,1. cdur al <:f Jncems/ prohl1·111,.. C:rnup 1m·111lil,r \ crllhusi,1. sm anti cnmmitm cnt may eventuolly bc-crirnt nffcttl'd h1'l'fl\l~C the l!,rr,up IHI'-' l,.,.,t tlw Vf'r) n,a.,;rm for its,;w Jity il S capal,ilr1, · frir ch namr,-111. Durin}I "11d1 1~r·ri,-ncc<; on fni"trntior H, nnd dend ends brought about by the grw11p·, 1111. :q1,1biht, 111 handle· lt,nllic1, th(' nur<;<: ll" a iacilirnw r ll( group i:rnwth. r:111 l11lp tlu· nll'nihr< lrlllk <11 llw,.,;,u,,tirm/, or data fmm,-a. rious pcr-,p,·t·l",.,,u, It tli,,t '"'" 1,rin1a I j,,n,; nnd in~il!,h l" can b,, clf'riw·d from 1hcm. ·1 he frir11itatnr c,rn e11r11uni~L' ~rroup 1nr:111l>cr lr, ba\e ;1,·;11l. 1bl!> di,erse ideas 11i:1t,·an 111· 11,-"1,1, p11111,g.-tlwr i11l<11w,, ;wd,·nr i Ni rattrrn~ Thi~ rnny rl.-quire d1,111g111g 1,..rnpt,, 11,. Irr I lmi: 11cw w;I\,. nl Ir 11,ki 11~ nt tlii n~ 1 nd ch,1 n,i;iniz ideas ,111rl 1·1111,,p1,. 1h,11 111,011 h, r~ ha,,. r1ligir111;;I\',1dh1·r Pcl 1r, tn th1 pn:11 Threat and ,·,rr·,,I\·,· t.-1i-11,r1,;,n f'l,ult fr11rn ;w,·.-ptin)( th<' ch~lle111cw uf que.,tirming the i,1,a,. rnd h,11..t:1 hr1111' ha;;1d upon huw,..-,. ha\'e rero~ni,cd. d,1rifil'd, defined, hil 1,·l,·tl 1111 I,1 n. t h t1·d,., 1wri1·t1t, .., i 11 th,· l'""l lh n·,ll, hrmr.,1h11u I defcnsi vcne.,;s 111d nd11,·, l111tl1 t,IPr,u11·L· t,J1:nrd :1111lii>!lltly nml nct:p1h'c11css to the new ,ind 11111. 1111111. 11 1'111111n11·h t1·11,i1111 h·,,d,,1,-rl·11t11>in!! 1ii lho11ght pmccs. ~es. ln 1111!,,1 J., 1..-11',:r111p m,·111h L"1" h1,·uk aw;1~ from 1l1111kin~ tradition and accept th,· d1111l,11g1 111,·h,tn)!IIIJ. ! p,r, r·ption, :ind 1,111,idin~ 11"'-' wa:: nf IMking :tt ,·x1w1·i,·11, 1:-,111 n,111111 I, th,· l,H"iltt.,tor n,,·d 111 d,·Hluµ n111dit10 11s that allow 1·u11,·,0rn,.,,,. u,·~-and pr,1hl1111s tu lw r\'111mrnl,1i,d P11nn}c ~1111p clic;cu. si. ion. I h,' n I 11111..,pl 1r ·re 11111,1 Ii,·,11d1 I h. 11 111<'111 hc·r-,. 1rc-:h rn t hi: t'n:cdom and :;11 pport ln h. 1\ · 1111 s,ll<'J11ilcl,·nn' m·,d,1d to 1'ntcrt,1in nm! l'\IH<'~" 1H1\ l!l idens (that 1111,y ini I ially ~,·,·111 \, iltl :111d implausihl, J 1\11 hout I win~.,frair. l <,I c. :cn<mre. They ,-hnuld b,· )(l\1'11 tht lr,·,d11m t11 q1JC.,11011 i11111. 1l. 1~-. :11rnp1i1111~ or 1he framewo rk 1,i1hi11 wlti1·lt 1h,· pr11hlt·111 111-r11r, F,1,·h gm11p mc·rnl-i,·r. 1!,11 ne Pru; to hec-ome s11l'lki,·11tl, rl..t.,dll'd frn111 hr1-t>n1:rn,il,·i"" point tn h,· :ihl, to s;:, the pmblem rro111 111'\' p,r-:p,,·li,,., To lttlp ~roup 1111111h,r,; ):\t'I d... r11rlwd from i Jeas :i_nd \'il'wpoi111, ·111d. wah/,·/1,·-.,1he c'tmlli, l~ th. it,rd ;is P'-''Cholo~1nil barriers to p111d11rtiw group 1li.. t·11:-:-,i1111. tlll' folio\, ing art? ~On H, pr.. aclit:al tedmiqucs tb Rt l':111 l,l. 11tili,,·d· a. 1'l JJ<' 1111111 11w111ht·1..., n;icl tn. 1111! expcrn:11re 1:011llict "ith per. suns (co m.-111\wr,). n HI n<c·,--s:irily IM'<'alt. ~e of tll Pir ideas, belief.,, or concepts. Cuullicts <'. lll be 1111111mi1,d by helping members isolate/separate the 1111	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
142 iuuas. beliefs, and concepts from tl1e pen;ons advocating them. One best way lo do lhis is lo put ;ill ideas, beliefs, and concepts on the hlackboard or other,risual materials. This shall free the group ruembers from always associaling these ideas \\rilh the persons, everytime they have to look at those concerned when they discuss the issues/conflicts. b. Role reversal is another way to help group members understand each other's position and frame of' references. '11irough role reve1·sal, membe~-s cnn be encouraged to rc-crea tc exactly how it is for the other person. This 111cans actuall~ trying to see the idea from his point of view, to sense how one feel~ about it, to put onc:s:clf in nnother person ·s frame of reference. c. Certain structure d exercises c. in help group member s understand and appreciate the nature of co 11flicts and some ways to resolve tbem by generating new ways of looking H. 1 sit11,1li()n/ s and c. iq:>erienccs. One such e.--. ercise is called "Breaking Balloons Exercise" (Johnson and. Johnson 1975, p. 187). This exercise seeks to demonstrate a non-ve1·bal conflict. The focilitntor's procec Jure is as follows: have each participant blow up a bnlloon a11d tie it lo ltis ankle with a string; then, when a signal is given, the participants are to try lo bllrst one another's balloons by stepping on them. The person whose balloon is bw·st is "out" and must sit aod watch from thesicleline s; the last person to have an nnburst balloon is the winner. The pnrticipnnls can then discuss their feelings of aggression, uefcnse, defeat. and victory. Strategies for prolectiug thei1· balloons while attacku1g others shoulu L,e noleu. During the group discussion of the exercise, let the member s an0Jy7-e the nature of con JHcts. by relating their ex-periences on the exercise wilh "personal" conflicts they have wi U, neighbo rs significant others, co-wol'kers or co-mem bers. Relate the strategies used in the exercise with tl1eir behavior dur:iag experience s of connicls. A variation on the exercise. is to have tea,ms with different colored balloons compete ag Dinsl each olher. Another exercise is called ''Coanect the Dots" (Johnson and Johnson 1975, p. 163 and p. 330). 111is struchu-ed exercise can help 1nemhers experience the need to detach themselves from usua J ways of solving pl'oblems. The exercise requires the group to be creative in attempting to solve it. The facilitator shall ask the group to be divided into triads (group of three). E:1cl1 triad's 11ssignment is to connect all nine dots (Figure 6. 3) v. ritb only four straight and connected lines. The correct answer is illustrated in Figure 6-4. FIG 6. 3 Connect the Dots L	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
-FIG 6. 4 Solution to Creativity Problem The ability to solve the problem is based upon the ability to go ()utside t J1e obvious boundaries in reaching the solution. During the group discussion, let Lhe members describe and analyze how they tried to connect the dots. De,·ive insights from their experiences on this exen:ise, hy helping them sec how rigid adherence to original viewpoints, beliefs, fr,une of reference, assumptions, and p. ist experiences can retard the group. members capability lo reach ag Teed-upon gm1l und objectives. Going outside the obvious boundarie s is nnnlogou s tr, going beyond the boundari es of rigidity and explore new ways of looking at situation/s or data to resolve conflicts, which on close examination can be considered as by products of thinking traditions. 4. Helping Members Analyze the Here-and-Now EA-pcricnce. The third intervention to keep the group analy7. e, negotiate, and resolve conflicts is to focus on tbe feelings and experience s of the members in the present moment, in the here-and-now. During experiences of conflicts, tension and anxiety c,in affect group process to a degree that indiddual members feel the need to do something about the situation they are in. Members can learn to assume the responsihility for sustaining the vitality of the g"oup and to gain control over tension-laden experiences by helping them reflect back on the reasons why tl1ese experiences or events happened. Essentia. Lly, this intervention helps members recog1ilie, examine, and underst and the "bow" and "why" of interactions or behavior soon after they are ex-perienced by tl1e group members. Through a focus on the here-and-now, the blocks or barriers to group progress are pinned down an<l analyzed for possible alternatives, re-direction or behavior change. Sample communication techniques that shall help the facilitator initiate/utilize the here-and-now -process illumina tion include: a. "Is there an_ything you can feel/say about how we are going through this group e J\.-periencc? b. "Can we describe what's happening to our group for the last few minutes"? c. "What do you thin J< are the reasons why we feel we are on a dead-end since a few minutes ago"? d. "How have we been discussing theissue/s? What are the feelings generated in us by this gl'oup experience? Why do we feel this way"? 143	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
144 c. "v Vhat im;ights cau we derive from this experience? What arc lhe imrilic. 1tions of our insights tu help us identify alternatives'? Before such ;111 intervention can be utilized, the "facilitator must learn tn be aclept al identifying hcrc-an<l-nuw cxpcric11ccs that need lo be analyzed/proccsst:d. Some pr::iclical lessons Lhat can help her to be sensiti\'e t·o these events include the following: a. Keep on eye or conccn\Tntc not only on the content of the group discussion but on how the messages,ire sent and received. The facilil,1lor should not only he concerned with connol. 1lions and lalenl clements of messages. . Metnco111municatio 11 isanotbcrai;pectc >fo message tbat ncetlto be analyzed. Metacomm11nication refers to n comn H111icalio11 aboul n communication. Yalo1u(1975,p. 122-12:_$)explai11s1ha t it is:, 111csf;;1gc:1ho11l lilcnaturl!ofthe relationship bt!twccn inleracting mcmbcr·s. Fro111 the relationship aspect, for example, Lhe foi;ilitalor can analy%c, wliy is the member making this statement at this time, to this person, in this 111a11ner? The process behi J1cl a scqm:ncc of slalc111cn t rnudc by ;1 member or hy seve,·:il members can help the facilitator determine the relation,;hip between one member and the at. her meml Jers, or behvcc. m clusters or cliques of members or between the members nnd the leader, 01· finally. between the group as whole and its primary Lask. b. Be an active participant of the here-and-now e;,,. 'Perience. Focus on how the interaction is affecting you as a group member rather than on what you fear or hope will bappe11. or what you shoulc. l say next afler a membe r or two have talked. By concentrating on the here-m1d-now, the facilitator strenbrthern; her gut-feeling. This helps her achieve an awarenes s, an objective assessme nt of everything in the situation being faced. The choice of an appropriate intec. ·ention is guided by the g:roup process as experienced in the here-and-now by the facilitator. To help members expeiiem:c conflict a. nd analy-'e the here-aud-uow event it brings, U1e facilitator can utilize u structured exercise which is n modification of the one described in Appendi,-; I). Instead of just task and-maintenance l"Oles lo be played by the group members, some self-serving roles can be incorporated in Envelope 1 of the ex1:1rcise, J\. ny number of the follo·wing self-serving roles can be ndde<l to ·the structured exercise (Wilson and Kneisl 1979, p. 444): a. Aggressor: Deflates status of others by expressing disapproval of their values, acts, or feelings by attacking the group or :the problem it is working on. or by joking aggressively. b. Blocker: Tends to be oegati\le and stubbornly resistant. Atte1npts to maintain or bring back issu. es after the group bas rejected or by passed iliem. · c. Recognitio n s·eeker: Calls attention to self through boasting, reporting on personal uchic\'cments, acting in unnsual ways, or strugglin g to prevent being placed in an "inferior" position. d. Self-confessor: Uses group as audience fo T expression of personal, non g Toup-or iented feelings, insights, or ideology.	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
e. f. g. h. Playboy: Displays look of involvement. in group's horseplay, and other more-or-lc. ss st1Jdied forms of inelevant behavior. Nominator: Tries to assert authority or superiority by engaging in flattery, claiming superiority status or right to attention, giving directim1s authorit,itively, and interrupting contributions of others. Help seeker: Attempts to evoke sympa U1y response from other group members or from the whole group, through expressions of insecurity, pe:·sonal confusion, or self-depreciation beyond "reason". Special interest plo1dcr: Speaks for some underdog-the "smull business person", tbe "grass roots community ", U1e "housewife~, "labor" 1::lc. -usually cloaking own prejudices or biases in stereotype that best fits own individual need. ouiing the group dfacussion of this modified structured exercise described in Append L,. _ D, the following questions can be added to the list: a. What are the effects of the self-serving roles on the group and its capability to attain its goal? b. What are the feelings generated by these self-serving roles? c. What arc the insights that can be derived by the group members having others assume self-se. rving roles? The Conflict Resolution Model (see Figure6. 5) illustrates specific intervention s to help handle the intra personal and interpersonal aspects of the "conflict experience" while supporting the group towards productive outcomes. Be Aware of the Effects of Own Behavior on the Group: Use the Self for Group Growth 'n1e nurse as the facilitato r or coordinator of group discussion exerts an influence on the behavior and experience of group members. As described earlier, members look up to the facilitator or leader for approva l of certain behavior, responses or actions. 'n1e fncililal'or becomes the model of the group as regards behavior that is expected or acceptabl e. This is exemplified by such experiences as being on time for meetings, keeping appointments and promise s. Another instance is wl1en tl1e facilitator lbandles conflicts, especially when the group associates tbe conflict and its sources 1Nith her. The facilitator must utilize every available opportunil y to maximize group growth ·by making sure that she does not ran road the group's decision. This requires a,n openness on her part as she tries to be free from the tendencies to be proud and authoritative; she must allow the group's decision to dominate gr5mp life. · It is, therefore, vital that the facilitator becomes aware of her own behavior aad its effects on the group. Otherwise, her behavior may potentiate or mitigate such e..'C])eriences and expressions of aggression, passivity, aad rebellion. When these are allowed to happen and are not hand. led effectively, the group may not be allowed to grow from the earlier stages, or it may eventually undergo dissolution. 145	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
146..-------.-------------NURSE'S INTERVENTIONS To handle emotions (own & participants') I I t r1 ddeenntltiityvtithhleeiip;j'. :roobtilie !'rmnl~--. s oeti ne the is SU e Identify own feelings before th~y are e>cpre. sse d: listen carefully Dlscern wisely Focus conscious ly Encourage: Sharing or validation of perceptions Re. statemen ts Reframlng of issues t------~ Develop e. xpectancies for win-win outcomes 1 Be aware of own interests, issues, motives/ intentions, feelings Analyze reasons for disagreement Understand participants' motives, interests, feelings Generate creative options Combine options to win-win solutions Redefine remaining areas--I ' I of disagreem ent Yes Jointly acknowledge agreement Create a safe and caring environment Encourage shared responsibility & ownership of problem and outcomes Separate: > people from problem > facts from opinion Encourage: "Big picture" per. spectlve Multiple options/ solutions Points of converge nce ~-------------------------------~ fie 6. 5 COnflict resoludon model. (Adapt9d fl'Dffl Uttletleld, L, Lave, A., Peck, c., & Wertheln, E. {1993]. A ffl Odl!I forr M01v1111 confllct: same theareti cal, empirical, and pracdc:al appficiltlons. Australian Psycholosfst, 2813), 80-85).	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
Act as the Group's Completer/Resource Person In order 10 max:irniw thcgroup'scap:1bility fordecisio n-rm1ldngnnd problem-solving, the neccssnry data, experi1,ncc, and resources mui;t be made,wailuhlc to the grouµ. Jf not one among the Al"Oup members con provide what th... group rteccls al anyone time, the f.-1dlitator is expected 1. n acl ns Lhe group'::, completer ::incl cnsmc thal the missing aspeels are made av:1ilable lo the )?;roup. One exmnplc of 1. hc fodlilalor acting as the group's completer is when she perfun11s the necessary task functions or group building fu11cliot1s uol being performed by the memhe. rs. Another instance is when the necessa1y expertise or information is not available and the facilitator acts as a resource person to have this accessible to the g1·oup for good decision-making. There, may bl:! situations when the facilitator does not have the expertise needed by the group to do effective problem-so lving on a particular situation or area of concern. During these instances she may help group members identify and mobilize resources of the oute1· reality, the world outside o[ the group. She. tcts as the group's completer by making sure that the missing ua La, expertise or resources are made available or accessible to the group. Derive Opportun;ties to Apply Learning on Another Situation Gronp experiences provide vnrh:d learn:ing opportunities for members. 11-lore often, the basic concepts and principles for effective group life are re-lived in various group experiences. Members gain more depth in understandin g group process as they realize that the co11cepts and principles previously learned in hand Ung a particular issue can be applied in another situation dealing wit11 a different issue. A sample communication techniques is: «111 analyzing whal we are !;oiug through cight now, is there anything we learned from the group's eiq:>erience io our previous sessions that can help us better understand this present experience. '' · This µarticu Jur i nten>ention is also helpful when the facilitator helps the group undergo successful ly the stage of termination. More often, the e:'1.-perience on separation brings about overwhelming feelings of sadness. hurt, and other unpleasant emotions that affect people's capability to establish relationships again at some future time. By deriving the lea Tni1,g opportunities that 1rroup life offereu lhe members, the facilitator can hel I) them reali:tc that the advantages of investing resources, efforts and feelings for a successfu l group,,vork far ou L1. veigb the unpleasant emotions o[ separntion, though how real they may he. WORK G. ROUP: HUB OF COMMUNITY ORGANIZATION, COMPETENCE AND EMPOWERMENT Vvork groups representing various geogrnph ical segm. ents and socio-cultu,ral political units can be the hub of community organization process for competence and empowerment. Operationally done in CI-IN practice,,vork groups can take any or both types: ( 1) Structural or organizational sub-model such as fom11:1lly cre11ted committees, task/core/sti. 1dy groups, dubs or other community organizations; (2) Functional sub-model where community residents demonstrate commitment to participat e in communit y projects/progr ams to create and sustain their own health initiatives, but they do so out of a sense of connectedness and <·ommitment to improve collective life, not necessarily because of a responsibility as committee or club officers or members. Strategically designed to represent the voice of several sodo-economic-political units in the community, the workgroup's political wi U and connectedness can be orchestrated by 147	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
148 lhe nurse c. tl Alyst-parl ner and the community as client-partn er to en ha nee a collectiv life of competence and empowerment. The i Uustration below show~ a scheinatie diagram of how U1e community, represented by Lhe b~~ cii·clc, _<. :an be organi?,ed int~ w?rk j?,rnups. _ represented by tbe _sn!~I _cii:-dcs, to mob1hzc the mflu~ncc and political \-,JI of the neighborhood to sustam m1liut1vcs and support efforts al 1mpruv 111g health care and scn;ccs in a co Declive life. The boundary of the big circle is represented by hroken lines to emphasize serni permeability. allowing for cxchangt-of resources or linkages with other socio-econom ic po Htical units or outside i;1ge. 11ts and institutions to en J1ance growth or make available robust options lo address problems or handle change. As work groups e:,.-perience the dimensions of community competence, they feel motivated and confident in pursuing empowermen t domains as areas of inilnenc e that a 1Jow commun ity residents to,11ork together and mobilize tbcmsclves toward increased critical consciousness. level of control and choice over health, health c. :. are/se rvicc/ program decisions and nptions. I~-iverack (2ou5) describes these empowe rment domains as: (1) improved participati CJn; (2) developed local leadership; (3) increased problem assessment c;:ipaci ties; (4) enhanced ability to 'ask why'; (5) im provec. l resource ruobilizalion: (6) strong organizational structa. u·es/s upport groups; (7) strong links with other org,rnizalion s and peuple; (8) egalitaria D/equitable relationship between the community and out. side agent; and, (9) i11crc:ascd control over prngram 1nnnagement. REFERENCES 1. Boyd MA. (2002). Psychiatric Nursing : Contemporary Practice. Philadelphia: Lippincott.. 2. Cottrell LS. ( 1976). The competent community. In Knphln BH & Others (Eds), Further Explora tions in Social Psychiauy. New York: Basic Books, pp 195-209.	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
--3. Dunphy D. (1985). P,-occsses of Group Po111(dot io11. Adapted from Tuckman, EW. Developmental Scqt1e11ce in Small Group. l'sycholo~h:al llullctin, 6~. 4-5-6. 7-Eng E& Pa. rker J. ::. (1994). Measuri. ng Comrnunity Cornpete ncein the M ississippi Delta: The Interfuce between Program Ev;iluation and Empowerment. Henlt. b Education Quarterly, Vol. 21 (2), pp 199-220. Goeppinger J, Lassiter PG&Wilcox 13. (J982). Communit y I £cnlth is Community Competence. Nursing Outlook. Scptembcr-Octubc:r, pµ 464-467. Helvie CO. (1998). Advanced Practice Nursing in the Community. Thousand Oaks: s.,ge Publication. Hendricks VV. (1991). How to i\1'annge Coriflicc. Kansas. National Press Publications, Rockhurst College Continui llg Education Center, Jnc. 8. Jedlicka AP. (1977). Orga11i:mtio1tfor Rw·al Development: Risk Taking and Appropria. te Technology. New York: Praeger Publishers. 9.,Jolmsnn OW and Johnson PP. (1997). Joining Together: Group Theory and G1·011p Skills (6th ed. ). Boston: Allyn and Bacon. 10.,Johnson OW and,Johnson FP. (1975).,Joining Togethe,-: Group 1'/1eory and Group Skills. New,Jersey: Prentice-Hall, Inc. 11. Laverack G. (2005). Using a 'domains' approach lo build community empowerment. Commw1hy Developm ent Journal, pp 1-9. 12. Lltllefield L and Others. (1993). A Model for Resului11g Co,1/licl: Some Theoretical, Empirical, and Practical Applicatio ns. Anstralian Psychologist, 28 (3), 80-85. 13. Lundy S. and James S. (Eds. ) (2001). Community Health Nursing: caring for the Public's Health. Massach. usetts: Jones and Bartlett Publications. 14. Maglnya, AS. (Ed. ) (2004). Nw·sing Pl·actic~ in the Communih J, Marikina City: Argonauta Corporation. 15. Payne Rand Cooper CL (Eds. ). (1981) Groups at Work. New York: John Wiley and Sons. 16. Stolte KM. (1996). \<'Jellness Nursing Diagnosis for He;ilth Promotion. Philadelphia: Lippincolt-Raven Publishers, pp 271-272. 17. Schutz WC. (1965) Interpersonal Underworld. Havard Business Review, 36. 18. Thelen WR. (1954) Dynamics of Groups al Work. Chicago; University of Chicago Press. 19. Watt S, Higgins C & Kendrick A. (2000). Community pnrnc1pation in the development of sen,;ces: a move towards community empowenne nt. Community Development Journal, Vol. 35 (2), pp 120-132. 149	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
150 Chapter 7 ASSESSING COMMUNITY HEALTH NEEDS Luz Barbara P. Dones INTRODUCTION In community health nursing, the community is not simply a context of the existence of the nurse's clients nor is it just a setting for 01Lr nursing interventio ns. Spradley (1990) emphasizes that the community is the primary client for nvo main 1·easons. First, the communi ty has a direct influence o·u the health of the individual, families and sub-populations. Second, it is at this level th. at most health service provision occurs. 111e hallmark of community health nursing :is the fact that it is population-focu sed (Clark, 2003) and thal the pr:imary client and recipient of care of the nurse fo a group of people in the community. The community heal U1 nurse gets to work w:ith differenttypes of client in her practice. She may be involved with families, populutio ns or sub-grou ps, each has distinguish ing characteristics that the nurse must recognize in order to direct her nursing involvement. Clark (2003) makes the following distinction: Population refers to the general public or society or a collection of communities and generally do not display social action among its members (Kuss et al, 1997). Within the population are smaller subgroups oftea referred to as aggregate, neighborhood, and community. Aggregates are defined by their common characteristics and concerns but similar 10 populations, I hey may not interacl: or work together to address these concerns. Aggregates are often seen as populatio n having high risk for certain health conditions. (Helvie, 1998) Some examples of aggregat es include the children under five years old, the school-aged children, the adolescents and the eldel"ly. Matteso n (2000) describes a neighborhood as more homogeneous as a consequence of having common langua!!,e or cultural traclil:ion but may not have specific physical or geogn1ph ic bounduries. This is especially true in the Philippines when people from the rural arc. as migrate into the metropolis but are drawn together \Vitl, other people whom they sl1are dialect or traditions with to form a neighbor hood. As different neighborhoods converge and expand, the need to institute a system of governance becomes crucial. This give rise to communities that Sanders (1958) and Cassells {1993) define as a collection of people, a place and social system. Community health nurses need to know the defining characteristics of a community (see Chapter 1) because these "set" the stage in understanding the different aspeds that directly or indirecl'ly influence the health status of the community. The community health nurse,viii also deal with these community characteristics in planning and developi ng specific programs and in ensuring the delivery of effective healtl1 services. THE COMMUNITY DIAGNOSIS Caring for the community as client starts with detem,ining its health status.	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
commun ity health diagnosis in nursing consists of two important parts (Muecke 1989). The nurse collects data about the community in order to identify the different factors tbat may directly or indircdly influence lhe health of the population. Then, she proceeds to analyze and seek explanations for the occurrence of hcaltl1 needs and problems of the community. This is the first part of the community diagnostic process culled the comn1unit y assessment and is considered to be the "keystone-of community heallh nursing process. (Freeman and Heinrich 1981; Muecke J989) TI1e nurse utilizes these c1ssessmcnt data to derive the community health nursing diagnoses and become the bases for developing and implementing community health nursing intervent ions and strategies. TI1is process completes the community diagnosis. Ecologic Approach to Community Diagnosis The ecologic approach to community health diagnosis (Payne, 1965) recognizes the fact that the healtl1 status of the community is a product of the various interacting elements such as population, the physical and topographical characteristics, socio economic and cultu_ral factors, health and basic social services and the power stn1cture within the community. The interrelationship of these elements will e. xplain the health and illness patterns in lbe community. Fayne (1965) attributes much of the failure lo address the health problems of the community to this lack of ecologic approach. Communityhealtl, problems are often viewed as technical problems that need technical solutions without regard to the interrelatedness of all factors and forces that are bearing down oa comrnw:ti tyheallh. According to Freeman and Heinrich (1981), commun ity health diagnosis is based on three interdependent, interacting and constantly changing conditions: 1. The health status of the community, includin g the population 's level of vulnerability An estimate of the health status relates the characteristics of two factors, namely: the people and. the environment. This is consistent with the epidemiologic approach that Finnegan and Ervin (1989) described as a model for community assessment in which measurable variables to describe the person, place and time support the presence of an actual or potential cmnmunil y health probh::m. Person variables include demogra phic characteristics as age, sex, ethnic group, occupation, income or educational attainment may explain population grov..1:h trends, death and illness experiences as well as identificat ion of vulnerab le or special risk groups in the population. Environmental factors include not only the physical environment (e. g. air, water, housing, and climate) but those of biologic environment (j. e. plant and animal life) and social environm. ent (e. g. presence of war or armed conflict, poverty) associated with disease development. · · 2. Community health capability or the ability of the community to deal with its health problems The commun. i"ty's capacity to pt·omote or sustain health depends on ilie extent of its economic, institutional and human resources. The mere presence or availability of sucl1 resources does not necessarily guarantee people's health. People need to make out bow the_se resources can be optimally used to ilieir advantage. 151	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
152 3. Community action potential, or the patterns In which the community is likely to work on its health pr,oblems Communities take different courses of action to address their health needs and problems. Each develops its own approach to mobilize communi ty participation for health. The nurse assesses the comn1unity for its attributes that determine the pattern of health action. Freeman and Heinrich (1981) describe the following importan t aspects of community hea1th action: a. Value people give to health over their other needs in life that provide the forward motion for health action-Is the health problem perceived to be important to the people? Is it perceived to need immediate attention? Are there otber concerns in the community that take priority? b. Community's relationship with the politicalsy sten1 a ndgovernn1 ent institutions that support health actions-How responsive is the government to the health needs and problems of the community? To what extent does the political system or government institutions allow for people's organizations' participation in decision-making about planning and implementation of health actions? c. Habits that the community has d. eveloped for dealing with common problems-Is there genuine partnership among all stakeholders to push the agenda of promoting and sustaining health in the community? What are the different approaches or strategies that they have developed and implemented ? Types of Community Diagnosis In the assessment of the commun ity's health status, the nurse considers the degree of detail or depth of inquiry. Comprehensive assessment is normally done when the nurse bas not had opportun ity of working with tbe community and its people. The nurse needs informati on to help hel' understan d the community and facilitate its enabling process. Oftentimes, the nurse is c9nfronted with a specific problem area llke a disaster situation or an outbreak of disease. In these instances, a problem-orien ted assessment will have to be conducted. A nurse may decide to assess a specific population group in the community, in which case, she may opt to conduct a comprehensive assessmen t of that group and at the same time, focus on the specific problems of that same group. It is important, therefore, to decide on the objectives of the comm. unity diagnosis, the resources and time available to implement it. Comprehensive Community Diagnosis A comprehensive community diagnosis aims to obtain general information about the community "with the intent of determining not only prevalent health conditions and risk factors (epidemiologic approach) but also the socio-economic conditions (socio economic approach) and lifestyle behaviors and attitudes that have effect· on health (behavioral approach). TI1e following are elements of a comprehensive commun ity diagnosis and the basic data that are needed to characterize each variable:	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
Jt,,.. Demographic Variables The analysis of the community's demographlc characteristi cs should show the size, composition and geograph ical distribution of the population as indicated by the following ; 1. Total population and geographical distributi on including urban-rura l index and population density 2. Age and sex composition 3. Household size 4. Selected,. ;tal indicators such as growth rate, crude birtl1 rate, cn1de death rate and life expectancy at birth 5. Patterns of migration 6. Popu Jation projections Jt is also important to know whether there are population groups tl1at need special attention such as indigenous people, internal refugees and oilier socinlly dislocated groups as a consequence of disasters, calamities and development programs. B. Socio-Economic and Cultural Variables There are no limits as to the list of socio-economic and cultural factors that may directly or indirectly affect the health status of the community. However, the nurse should consider the following as essential information: 1. Social indicators a. Educational level whichmaybe indicative ofpovertyandmayreflect on health perception and utilization pattern of the community b. Housing conditions which may suggest health hazards ( congestion, fire, exposure to elements) c. Social classes or groupings 2. Economic indicato rs a. Poverty level income b. Unemployment and underemployment rates c. Proportion of salaried and wage earners to total economica lly active population d. Types of industry present in the community e. Occupation common in the commun ity f. Communica tion network (whether formal or infotmal channels) necessary for disseminating health information or facilitating referral of clients to the health care system g. Transportation system including road networks necessary for accessibility of the people to health care delivery system 3. Environmental indicators a. Physical/geographlcal/topographlcal characteristics of the community land areas that contribute to vector problems terrain characteristics that contribute to accidents or pose as geohazard zones · land usage in industry climate/season b. Water supply % population with access to safe, adequate water supply source of water supply c. Waste disposal % population served by daily garbage collection system % population v. ~th safe excreta disposal system 153	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
154 types of,.,.-aste disp-0sal and garbage disposal system d. Air, water and land pollution industries within the community having health hazards associated,vith it air and water po Uution inde.-c 4. Cultural factors a. Variables that may break up the people into groups within the community such as: ethnicity social class language religion race political orientation b. Cultural beliefs and practices that affect health c. Concepts about health and illness c. Health and Dlness Patterns In analyzing the health and illness patterns, the nurse may collect primary data about the leading causes of illness and deaths and their respective rates of occurrence. If she has access to recent and reliable secondary data, then she can also make use of these. · 1. Leading causes of mortality 2. Leading causes of morbidity 3. Leading causes of infant and child mortality 4. Leading causes of maternal mortality 5. Leadio. g causes of hospital admission 6. Leading causes of clinic consultation 7. Nutritional status D. Health Resources The health resources that are available in the community are an important element of the community magnosis mainly because they are the essential ingredients in the delivery of basic health services. The nurse needs to dctemline manpow er, institutional and material resources provided not only by the state but those which are contributed by the private sector and other non-government organizations. 1. Manpower resources categories ofbealth manpower available geograph ical distribution of health manpower manpower-population ratio distribution of health manpower according to health facilities (hospitals, rural health units, etc) distribution ofhealth manpower according to type of organization (government, non-government, health units, private) quality of health manpower existing manpower development/po licies 2. Material resources health budget and expenditures sources of health funding categories of health institutions available in the commun ity	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
hospital bed-popu lation ratio categories of health services available E, Po Utical/Leadership Patterns The political and leadership pattern is a vital element in achfoving the goal of high level wellness among the people. It reflects the action potential of the state and its people to address the health needs and problems of the community. It also mirrors the sensitivity of the government to the people's struggle for better lives. In assessing the commun ity, the nurse describes the following: 1. Power structures in the community (formal or informal) 2. Attitudes of the people toward authority 3. Conditions/events/is sues that cause social conflict/ upheavals or that lead to soci. al bonding or unification. 4. Practices/ap proaches effective in settling issues and concerns within the community. Problem-Oriented Community Diagnosis The problem-oriented community diagnosis is the type of assessment that responds to a particula r need of a target group. (Spradley, 1990; Clark, 2003) For example, a nurse is confronted with health and medical problem s resulting from mine tailings being disposed into the river systems by a mining company. Since a community diagnosis investigates the community-mean ing, the people and its environment the nurse proceeds with the identification of the population who were affected by the hazards. posed by mine tai. lings. Then she goes on to characterize the biophysical, psychological, physical environmental, socio-cultural and behavioral as well as health system factors relevant to the specmc problem being investigated. COMMUNITY DIAGNOSIS : THE PROCESS Community diagnosis consists of collecting, organizing, synthesizing, analyzing and interpreting health data. Before data are collected, the community diagnosis objectives must be determi ned as these will direct the depth or the scope of the community assessment. It is fundamental to resolve whether a comprehensiv e or a problem oriented community diagnosis will accomplish the objectives. The community health nursing process emphasizes the active involvement of the clients in its care. The community is an active partner not a passive recipient of care. The nurse works with and not for the communi ty. People tend to believe that their participa tion is only required when it is time to implement program activities. In working with a community in a diagnostic exercise, the nurse needs to be conscious about the appropriate participatorym. ethods for mobilizing community participation. The nurse does not operate like an e. xternal assessor of community needs, but as the faci Utator working in a team composed of community members and leaders. Figure 7. 1 sumrnacizes a model of community diagnosis process adapted from F. J. Bennett (1979). The community's involvement starts early during the assessment phase to create awareness of their health needs and problems. Their participation in the community diagnosis develops their commitment and enthusiasm to carry on with the planning and implementation of health programs that address their needs and problems. The nurse must ensure the community's input in the communjty diagnosis considering th. eir capacities and limitations but with enough room to develop their potential s. 155	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
Prior to actual conduct of community diagnosis, a rapid appraisal can be carried out by the nurse to gain a general impression of the community. It is exploratory in nature but can provide direction and focus for the actual community diagnosis. It is also an opportunity for the nurse to immerse in the commun ity and get to know its problems, issues and concen1sthat will contribute in shaping the plan for subsequent community organizing process. It is participatory (WHSMP-PC, 2003) because the data are drawn from the people through focus groups and corroborat ed by the com. muruty through interviews of key informants and community leaders. P ann Tng ac. ti. on & health program ant groups an hem on lmplicatlons/ o~tionli' · Rapid Apprai Commun! Immersion Esta Is war Ing re altonshlp with community leaders and representatives. peclyng w tcan e lnvestjp ted and whel'e (objectives) Plannlns the ata colle~on methods and toels (e,g,,-survev & questionnaire) ewers Rewot 1n1 ata collection fnst FUITferit;s FIi, 7,1 Thepnac ess D'JCD1111nunltyd facnosfs. Adapted from F. ~. Bennett (1979} STEPS IN CONDUCTING COMMUNITY DIAGNOSI S '!. In order to generate a broad range of useful data, the community diagnosis must be carried out in an organized and systematic manner keeping in mind that the community should take an active part in identifying community needs and problems. The nurse plans with the community members to create a team that will be responsible in overseeing the planning, implementation of the community diagnosis. The nurse emphasizes the importance and value of people's participation in the activity because their detailed knowledge about the community will fundame. ntally shape health actions 156	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
that are responsive and relevant to their needs. The plan fo C' carrying out the community diagnosis is based on the results of the rapid appraisal. The breadth and depth (comprehensh·e,ersus problem-focused). the target population (entire community or a specific aggregate) and the problem focus are cla. rified and make it easier for the nurse and the people involved to develop :in arrange ment that will facilitate the conduct of tl,c community diagnosis. 1. Determining the objecnves Whether a comprehensive or a problem-oriented communit y diagnosis will be undertak en by the nurse ;md the community, ii is c,;tic. '. ll to determine the occurrence and distribulio111 of selected environment. ii, socio-econo mk and behavioral conditions. (DC\'cr, 1980) These are importanl in defining the hea Jth problems of Lhc communit-y. Later on during the planning phase. these will serve as guide in directing disease control :rnd wellness promotio n in. the community. In stating the objectives, lhc following questions should be answered : a. What is the pre. c;ent heal t11 condition of the people in the community? (This will describe the pn:vailing disease conditions and healt J1 needs of the targel population) b. Why are the people in the c ommunity ia such condition? 'Nhat specific problems are et1using these conditfons? (This will explain the health behavior s or risk factors tl1at give rise to the health problem) c.. W11at arc the roots of lhese problems? (This will provide the nnalyses related to the socio-economic, cultural and environmental factors that sustain or allow for the perpetuation of the health problems of the largetpopulation) d. What solutions will address the problems? (This will reflect the possible solutions of the. health problems based on the community's capabilities a. nd resources) 2. Defining the study population Based on the objectives of the community diagnosis, the nurse and the community diagnosi s team identify the population group to be included in the study. It may include the entire population in the community or focused on a specific population group such as women in the rcprndu ctive age-group or the infants and young children. If a complete enumeration of the desired population is not possible, the data may be collected data from a sample or a subset of the target population. The example that follow shows the objectives of a community diagnosis after rapid appraisal results led the nurse and the team to focus on the 0-12 population group. 157	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
Thefol.._ 1. t1ad tt M 2. To 3. s. 6. 1. 3. Determining the data to be collected After the objectives and the study population have been defined the nurse together,..,,;u1 the colil J11unity members need to figure out a scheme to rationalize the relevant data to be obtained. This is achieved hy developing a data collection plan. The data collection plan uses the objectives to guide the data collectors to decide on specific infom1ation or data to be collected, tbe methods of data collection, the instrun1cnts or tools for data collection and the possible sources of these data. Data can be categorized as primary or secondary based on the source. Data that are directly obta. ined by the nurse specilica lly to answer the community diagnosis objectives are ca Jled primary data. Secondary data are existing data that were obtained by other people whicb the nurse can use to answer the community diagnosis objectives. There are advantages and disadvantages of using primary or !;econda. ry data. In the end, the nurse decides based on the desired qmilities of data such as timelines~ of data, completeness, accuracy, precision, relevance and adequacy. (Mendoza el al, 2000) 4· Collecting the Data Different methods maybe utili2. ed togeneratehea J th data. The nurse decides on the specific methods depending on the type of data to be generated. For example, through an ocular survey the nurse is able to detem1ine the physical and topograph ical characteristics <>f the community. She may interview people about Uleir health be Jie Js or she can review existing health records in the Rural Hea JU, Unit. [n general, we use the follo\. ving methods to collect data: a. Observation Observation is extracting information from subjects by observing their behavior and their environme nt. Observa tion methods provide 15. a an opportunity to check the validity or truth of many verbal statements	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
which people make. (Feuerstein, 1986) Observation techniques maybe supplemented or documented by the use of bard equipme nt such as videotapes or cameras to ta. ke photographs, sphygmomanometer to measure blood pressure or weighing scale to determine weights of children. Observation is an important and useful method of collecting data when informant s are unable to directly supply informati on o. r may likely give inaccurate information. Some respondents may resist questions or are unwilling lo am;wer questions or may have problems on recall. On the other hand, there are limitations to the use of observation in data collection especially when observation periods are limited to a specific period of time. Some events may not be accessible to direct observation at the time one schedules the data gathering. Sometimes, it is impossib le to predict occurrenc e of events or events occurred in the past. In these cases, the historical or "limelinc" approach-a participatory technique utilizing the collective memory of community members, particularly, its older members have proved helpful. Prior to actual conduct of community diagnosis, the ·nurse must have a bird's eye view or a "feel'" of what the commun ity looks like. This helps the nurse plans and directs the focus and tne depth of the communi ty diagnosis. A comri1on approach is to perform a rapid appraisal through an ocu1ar survey or what others call as windshield survey. (Hunt, 2005) It consii:;ts of walking around tbe commun ity or in the case of windshie ld survey, dtiving through the community appreciatin g wbat can be seen and perceived as the people go along with their daily lives. Admittedly, the oculru· or windshield survey,vil!l yield cursory or even trivial data but that can be brought to light in the actual community diagnosis. A nurse investigating lifestyle patterns is likely to affect the people they are observing and can cause "artificia!M behavior among them. Observers, therefore, need to live and be fully integrated with the commun ity they are studying and be part of what is happenin. g in the community; This is called participant observation (Feuerstein, 1986). b. Recor. ds l'Cvi. ew Records are written information that are kept in folders, files or books which we often refer to as hard copies but they may also be kept on tape or electronic form as database to be retrieved or access. eel for specific purposes. Records or documented sources offer the data collector savings in time, money. energy and effort since data are pre-collected. However, like any data source, one must recognize the I. imitations of records or written documents. Aside from completeness, accuracy, usefulness or appi:opriateness of data, the nurse needs to evaluate the data's worth if they are up-to-date. Data may be obtained by reviewing those that have been compiled by health or non-health agencies from the governmen t or other sources. The nearer one is to the source of data, the better. For example, if the nurse is looking for data about a sitio or-barangay, data sear-ch will be more productive in the ba. rangay or in the municipal records than when search is done at the provincial or regional records. 159	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
I 160 c. Interviews Interviews are the most common and v. ridely used method of data collection. It involves asl-.-ing and answering questions follo-..ving a systematic procedure aimed at yielding first band information from the subject of inquiry. Interviews are categorized based on presence of face-to-face interaction number of interview participants at a given time and interview structure' (Tan and Dalisay, 1999) · Based on the presence of face-to-face interaction, interviews may be conducte d in person or via telephone inte1. views. Face-to-face interview allows the person being in. terviewed to seek clarifications about the questions. At the same time, the interviewer can pick up non-verbal cues from the respondent to indicate congruence with his/her verbal response. Telephone interview has more limitations than face-to-face interview to be considered of use in gathering voluminous data. For one, telephone calls are rather expensive when one calls from a mobile phone. Definitely te. xt:messages can only provide limited data. Finally, people respond bettc; when they keep an eye contact with the person they talk to making the interview more fruitful and constructive. ' Interviews can be individual or group interviews. Individual interview takes place between a respondent and an interviewer and is most useful when sensitive issues are being discussed. When a pei-son known to be an expert or an authority on a. specific subject is interviewed, this is known as the Key Informant lntervic'W (Kil). For in~tance, if we want lo know the program for integrated development of a municipality, the best person to interview would be the local chief executive or the tuunicipal development officer. But if one wants to find out the efforts to address . health issues at tbe barangaiy level, the barangay captain or the kagawad (councilor) for health,-vill be the appropriate persons to shed light on the matter. Group interview consists of one interviewer and several participants, usually around 10 to is which a Uow the interviewer to gather data from a good number of people at the same time. It takes a very experienced interviewer to be able to facilitate a good group interview and turn up with a high quality data. A skilled interviewer must eosuc-e equal par6cipation from the respondents and to be able to prevent antagonism when tl1ere are conflicts of ideas. Interviews may be structured 01-unstruc tured. S-tructu~·ed interview -follm,vs a list of questions ca Ued an interview schedule which becomes the "script" in the conduct of the interview. A set of possible responses are indicated in the interview schedule from which the participant s will choose from. The interviewe, is expected to adhere to the interview schedule, and is not allowed to alter tl1e sequence of the questions, reword or rephrase the questions. The set of responses should consider all possible answers that the participants may articulate. Unstructured interview is useful in collecting qualitative data that seek to desctibe opinions or perceptions of people focusing on a particular issue, problem or phenomenon. lt makes use of open-ended questions and more often, takes off from the responses elicited from the person being interviewe d. In order for the interview to be	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
productive, the interviewer must he skillful not only in evoking responses from participants but also in leading them to crysta. Llize their ideas. d. Focus Group Discussion The Focus Group Discussion (FGO) is a qualitative research technique utilized for its value in understanding and documenti ng human behavior. (Tan and Dalisay, 1999) It is a very popular mctl,od appropriate in the community to elicit :ind e:-.-plore opinions of people, determine their attitudes and practices regarding a limited set of concepts. Data collection time with FGD is signilicanlly reduced because a cc>nsidcrab le number of participants can become i Jivolved ut a given time. The participants are selected based onthevari. ablcs that are being studied. Fm· instnnce, we wish to determine what factors in the child feeding practices in the community will likely contribu te to tl,e incidence and prevalence of malnutrition, TI1e mothers and other child care providers ;:ire I. he probable participants for the FGD as they are the ones involve in the day-lo-day pursuit in caring for the children. In the conduct of focus g1·oup discussions, make sure to set the characteristics of the participants in terms of a. those characteristics that will be common to them; and b. those characteristics tbat will differentiate them from each other. Such characteristics may include socio-eco11omic status, demographic variables as age, sex, civil status, educatio nal attainment, n:!1igious affiliation, ethnicity and occupation. Th. esc arc importnnt factors that,,;11 dictate variability in people·s perceptions and opinions about certain issues. As in group interview, a focus group discui:;sio n will need a highly skilled fadlitator with deep understanding of the issues being discussed; making sure that everyone contnlmtes into the discussion, and with all angles of the issue well-covered. It is also crucial that the facilitator can engage the participants back into impartiality when the debate becomes heated. Finally, the facilitator has to summarize and synthesize the discussio n to make certain that the issues have clarified rather than confused the participants. 5. Developing the instrument Instruments or tools facilitate the nurse's data-gathering activities. The tools or instruments to be used depend on the method of data gathering needed to supply the information for the community diagnosis. The following are the 1nost common instnnnen ts that the nurse uses in her data co11ecticm: a. Survey questionnair e The survey questionnaire, also called the survey instrument is tlie form one uses to document the data being collected. The survey questionna ire may be in the form of an interviev, schedule or a self administered questionnai re. (Hawe, Degeling and Hall, 1990) W11en the nurse uses the interview schedule, she reads out the question and records the respondent's reply to th~ questions. If the respondents read the questions and,,Tite down their responses, they are filling out a self completed or self-ad. ministered questionnaire. Vvhetherthe tool is an interview schedule or a self-competed questionnaire, 161	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
162 it is importantthat the instrun1ents are designed. ill a way that they generate data thnt are honest, complete and accurate. Elt AMPLE Of A S£LF-AD MINISTEQED QUESTIONNAIRE SEGI\/IENT: A, PANG-EKONOMIYANG KALAGAYAN 1. Pangkaranlwang bu~11ang l<ita: Lagyan ngtsek (") ang angkop na kahon na nagsasaad ng kab1. 1uang regular na kit. a ng lahat ng miyembro ng pamllya na may ha nap-bu hay 0 < 1000 0 1000 to 3000 D 3000 to sooo 0 5000 to 10. 000 D >10,ooo 2. Pagsunud-sun Urin ang mga sumusunod ayon sa lnyong prlyorlclad na plnaglalaanan ng buwanang bad~t. Ang bilang 1 ang itinuturlng na pinakamaha Jaga o nilalaanan ng may pinakalamalaklng baclyet _Pagkain _ Tu big at kuryente Edukasyon = Komunlkasyon (bayad sa telepeno, cell pho. ne load) _ Kalusugan · _ Pagpapanatfli ng kaayusan at kalinisan RB kabahayan __ Pagpapanati li ng kalinisan ng katawan (sabon, shampoo, toothpas te, sabon na panglaba) __ Libangan o bisyo (banggltin) _ Transportasyon (pamasahe, gasolina ng sasakyan) _Pananamlt 3". May Iba pa bang p Tnagkakakltaan llban sa regular na plnagkakakitaan 7 (Sideline) D Wala D Mayroon Uri ng pn,3gkakakltaan : __ _ Tantifang lcaranlwang h-. tlaga ng klta sa isang buwan: ___ _ 4. Mayroon bang nagblblgay ng suportang pamplhansyal sa pamllya? ' ,..... s. May m1yernbro bang pamll Vil na kasapl sa n,ga surnusunod? Lagy. in ng tsek ang l■hat na naaangkop na sagot. Banggltfn kung aneng benepisyo ang Jnaasahang matansgap ng mlyembro. 0 GSJS D sss 0 Pag-lblg 0 Phil Health 0 lbapa I	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
EXAMPLE OF AN INTERVIEW SCHEDULE SEGMENT KALIGTASAN NG INUMING TUBIG 1. Pinagmumulan ng lnumlng tubig 0 Bumibili mula sa water refilling station (proceed to #6) 0 Mula sa tubig na slnusuplay ng MWSS 0 Mula sa tubig na galling sa dleep-well D lniigib mula sa balon/artesian well 2. Nagsasagawa ba ng karagdagang proteksyon sa lnuming tu big? D Oo (If yes, proceed to #3) D Hindi (If no, proceed to 114) 3. Paraan ng pagpapanatiling ligtas ang inuming tublg. (Check as appropriate) D Pagpapakulo ng 15-30 minuto D Paggamlt ng w,ater filters D Paglagay ng kemikal (chlorination, iodination) D Iba pa, banggitin: __ _ 4. Dafl Han bakit hindi nagsasagawa ng msa nabangglt sa #3: (Check as appropriate) D Magastos D Matrabaho D Hindi na kallangan pa dahll malinls naman ang tubig D Hind, na kailangan pa dahil wala ng mga batang maselan ang kalusugan D Hindi alam kung ano ang mga paraan upang mapanatiling malinis ang inuming'tubig D Iba pa, banggitin:,~-------b. Focus group discussion guide The focus group discussion guide serves to facj)jtate the direction and flow of exchange of ideas on specific topics or concepts among the participants. It should specify the objectives of the discussion and the general characteristics of the participants. The facilitator does not need to strictly adhere to the sequence of the questions but makes certain that all concepts are exhaustively discussed. 163	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
164 EXAMPLE OF A FOCUS GROUP DISCUSSION GUIDE Focus Group Discussion Topic: Malnutrition F<Kus Group: 10-12 mothers or care providers of children 0·12 years old seated · in a semi-circular ari:angement; facilitators and persons in charge of documenting the discussion will be seated among the participants Objectives of the FGO: a. To determine the knowledge, attitudes and practices on nutrition of mothers and care providers in Barangay Sto. Rosario b. To describe the perceptions or mothers and care providers regarding factors that affect children's nutritional status in Barangay Sto. Rosario c. To determine available alternatives for mothers and care providers to address problems on nutrition in Barangay Sto. Rosario lntroductton: Before the actual discussion, make sure that all participants including facilitators have name tags. This is to ensure that participants are properly acknowledged when they want to talk and for the nole takers to properly documen t their contribution to the discussion. Allow participants to be comfortably seated. Greet the participants and make proper introductions. State the objectives of the FGD and the general rules of the discussion. Gulde Questions : /1,. Perception of a healthy and well-nourished child 1. S. a lnyong palagav, ano po ang katangian ng isang malusog na bata? Respond ents may characterize a healthy child based on physical (mataba, maliksi), mental (matalino), social (bibo) and emotional (masaya) paramete rs. 2. Ang lahat ng inyong nabangglt ay pamantayan ng malusog na bata. Ito ay kar. inlwana resulta ng pagkakaroon ng wastons nutrisyon. Ang wastons nutrisyon ay nasusul<at ng pag kakaroon ng was tong timbang ayon sa edad. llan sa inyo ang nakakaa lam kung ang kanilang mga anak ay may wastong timbang ayon sa kanilang edad? Responses of participants reflect their recognition of the importance or maintaining ideal body weight as a nutrition parameter. Follow-up questions may Include: a. Maituturlng bang malusog ang lsang batang sobra sa timbangi' b. Okay lang ba ang batang payat nga pero madalang naming magkasak i(? 3. Sa inyong pananaw, ano ang maaaring mangyarl sa lsang bata na ang timbang ay nananatiling mababa kung ihahamblng sa kanyang ideal body weight? · Summarize and synthesize responses on consequences of below normal body weight. L	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
L 8. Knowledge, Skills and Attitudes on Nutrition 1. Ano po ba ang inyong pananaw kapag slnasabi na ang isang bata ay may ma In utrisyon? Responses will tend to draw attention only to undernutrition. Try to bring them back to earlier discussio n about overnutrition and emphasize that these are two forms of malnutrition. 2. Maaari ba ninyong ibahagi ang lnyong nalalaman tungkol sa kadahilanan ng malnutrisyon? Responses will usually focus on lntal<e of lnadequate amount of food based on required allowance. Make sure that the quality of required daily intake of nutrients based on the food pyramid will also be pointed at. Keep in mind that there are other reasons like presence of infectious diseases, parasitism or diarrhea. 3. Maaari ba ninyong ibahagi kung anu-ano ang inyong ginagawa up-ang mapanatili sa wastong timbang a:ng inyong mga anak? Saan po ninyo natutunan ang mga paraang ito? 4. Sa inyong palagay epektibo ba ang mga paraang isinasagawa ninyo upang mapanatill sa maayos na timbang at kalusugan ang mga bata? Kung oo, sa paanong paraan nakatulong ang mga ito? Kung hindi, ano ang inyong nakitang mga dahilan kung bakit hindi nakatulong ang mga paraang ito? C. Socio-economic, Cultural and Environmental Dimensions of Malnutrition 1. Marami sa atin ang naghahangad na mapanatill natin ang maayos na kalusugan at wastong pangangat'awan ng ating mga anak. Hindi lingid sa Inyo na maraming bagay o sitwasyon sa ating buhay ang nakakaapekto sa ating pagsusumikap na brgyan sila ng pagkain naaayon sa wastong dami at uri na angkop sa kanilang edad. Try to evoke responses that relate to social, economic, cultural and environmental factors that prevent them from giving proper nutrition, Examples of these include poverty, popularity of fast food chains that in Auence food choices, religion, lack of knowledge about required energy and nutrient intake according to age, etc. D. Available Alternatives to Address the Problem 1. Mayroon ba kayong nakikitang solusyon o alternatibo sa mga nabanggit nating dahilan ng malnutrisyon sa ating komunidad? Maaari ba nlnyong ilahad ang mga paraang pwedeng Isagawa sa ating mga kabahayan? 2. Sa bahagi ng health center at ng barangay, ano ang inyong nakikitang maaari nilang maiambag upang maiwasan ang paglaganap ng suliranin ito sa. komunidad? Closing the FGD: Summarize and synthesize main polnts·of discussion. Acknowledge. and thank the p.-rtlcipants ' active Involvement in the FGD. 165	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
166 c. Key jnformanl interview. guide Simjlar to t Jte FGD guide, the key informant interview or Kl I guide helps give direction to the pe I"Soo doing the interview using a set of pre1n1recl questions on a very i-pccific $11bjccl. The person being inter-viewed is selected for his or her h_,iown expertise or concern on the subject matter. For Lhc interview to be effectively i;teercd. the inten;ewer must be conversant or al least, have a working knowledge about the issue being discussed. Care must be taken that the interviewer·s own beliefs are not imposed to the person being interviewed. Presenting a perspective different from the person being interviewed shou. ld on Jy sen·t> to highlight hi~,:ie"l)Oint or standpoint. EXAMPLE OF A KEY INFORMANT INTERVIEW GUIDE Key Informan t: Barangay Captain; Kagawad (Councilor) for Health Objectiv es: 1. To determine the local leadership's perceptions of health and health related problems in the community. 2. To determine the magnitude and extent of these problems to the overall community's health conditions_ 3. To describe the local leadership 's perceptions of the social, economic, cultural, political and environmenta l roots of these health problems 4. To describe efforts of the local leadershrp to address the health problems rn the community. Introduction : &efore the actual interview, greet the key informant and introduc e oneself State the objectives of the Interview. Gulde Question s: 1. Among the concerns in your barangay, how do you rank health of the people In terms of importance or priority? Why? 2. As the barangaycaptaln/kagawad for health of this community, what do you perceive to be the most important health problem/s of your com mu nil y? Do you think the people recognize or acknowledge the existence of this/these problems in the community? To what e,ctent this/these problems affect/s the community? Can you cite possible consequence/s If the problem/s Is/ are not addressed? 3. In your opinion, what are the possible factors/causes that have contributed to this/these problems? Are the people aware of this/these factors? If yes, wtiat have the people done to mitigate the effects of this/these problems? Wf!I'e they effective In addressing the problem? If not, were there any Interventi ons from the locial leaders to address the problem/s? 4. As the barangay captaln/kagawad for health, how do you envision the people and the local leader. s to work as partners to address the issues and -c. oncem of the people related to solving the health problem/s? Can you cite efforts In terms of programs or projects that your office or committee has undertaken?	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
s. How would you rate people's Involveme nt in commun ity de1telopmen"t7 Why? 6. What do you think. should your administration lay emphasis on to Improve people's participation on community health a11d development? d. Observation checklist The observation checklist is a list of data that are manifestations or indicators of a health need or problem. The list could i. nclude the physical or environmental hazards where the community is situated; it could also be indicators of health resources such as health facilities and presence of health personnel and services. EXAMPLE OF AN OBSERVATl t:>N CHECKLIST SEGMENT: Barangay Water Source A. Type of water source: D Deep well/artesian well D Dugwell D Piped water from MWSS ' B. Location of water source. Estimate distance from: D Communa l toilets. D Garbage dump site D Polluted bodies of~;;-0 Other facilities that can b_e_s_o_u_r_c_e_s of water contamination, specify _____ _ C. Protection of water source 1. Deep well/artesian well Depth, __ _ Human activities ;;:;,un'd the water source 0 laundry 0 bathing 0 defecating or urinating D others, specify __ ~ Presence of protection from con~ation with waste water 0 drainage for excess water D cemented al the base of the pump or concrete slab to prevent waste water to seep unto the ground/soil that may contaminate watertable), D others, specify ____________ _ _ 167	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
1. 68 6. Actual Data Gathering Before the actual data gathering, it is suggested that the nurse meets the team of people ·wbo "ill be involved in the datn collection. TI1e instruments are discussed and analyzed. If necessary. tl1e instruments mny be moclified or simplified in order not lo overburden the people who may ha'"e Limitations in terms of educational preparation or available time to finish data oollection. Pre-testing of the instn1ments is highly recommended. Th. e data collectors must be gh-en an orientation and training on how they are going to u..o:~ the i~'-trtlrnents in data gathering. The nurse can_ ask the dat~ colle~tors_lo role-play an 1ntel"'-iew scene so that they can place them. selves 1n an actual interview situation. As al1eni. ativl'-"' to th<' c,J. !-,nrnriry hou SE'hold. su l"'\'ty which can t. tke long to finish, the nurse can teach the data collectors to use participatory tools and ti:chniques to facilitate and si. mplrfy data ~auwring. Cn?al:ivc> ;incl in11a\·;1ti'\·e methods,~ill likely increase people's panjciparion in data cr,llect inn b... >cau. sc n( their non-I h n·:-i ltmi ng (ea h. lres. Among other participator) tvul!" or tc. chnique. s fur data gathering are the following: Scm1-s1ructured inter. iews-infonnal, guided interview sessions where only ~ome of the questions are predetermined and new questions or lines or quc~tfrming arise during the int. erview. in response to an S\-~e. rs from those intervic\"t. '<i. A. nalytfral games-a quick me. ans of finding out a. a incli,ridua. l' s or a group's list of priori1ic. <: or preferences. Storie,,md ponrai1s. are c:hnr1. colorful descriptio ns of situations encountered b, the nuro:..: in the field ur !'. 1ories rec:ounted by people. The:, de5-Lnl><· ·111formati,m 10 "-ays rural people themselves perceive local condilfon«. notahl} problems and uppurtunities. Diagrams !. 'implt:. :-chem;itic: de,icc..., "·hich present information in a readily unde P--tand,1\ile,i~unl forms. Thc... e arc analytical prf Jccdurcs; n means of communicntion t>et-,<:cn and :imoog different people. \\'orkshop-nw11n~ of hnn~in~ people together and ou Lr;idcrs int Toduccd for their skills and e!\-pericnce, t() participate actively in reviev,ing, analyzing aod evaluating the information g,ithered. During the a<'tual data gathering. the nurse supervises the data collectors by chcckjng the filled-up inst. rumenbi in tem,~ of completeness, 11ccuracy and rcliobility of the iofonnation co)k,<"te-d. If there are gaps or problems in acc.-uracy or reliability of dutu, the nurse emphasiz~ the nel!d to go back to the. source ond secure t J1e appropriate in..fonnation. Tb. is b lhe only way to maintain the integrity and good quality of datu for the community diagn<Jsi ~.	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
7. Data Collation After data collection, the nurse and the team are now ready to put together all facts and figures to generate Lnfonna tion about the health status of the community. Two types of <lut., arc gcncru1cd. They are either nu111eric. 1I or descriptive data. Nu~erical data arc those which can be counted like age or how nwny children are there in a family or how many communal toilet;; arc there in the community. Descriptive data are those that can be descdbed or that can reveal characteristics of an observable fact. The nurse cxpl;:1i11s the importance of data types and characteris Lics to facilitate data col. lation. Even before the actual data gathering. the nurse and team should have already developed a plan for data collation. This is done by creating or constructing categories fur classifit:alion of responses. In creating the categnries, r Jne must make sure that these are mutually exclusive and exhaustive. Mutually exclusive choices do not overlap. This means that a re.,;ponse can only fall in one category from a set of choices. This is tnie for both numerical and descriptive data. Taken look at the examples: To classify gender or seic: 0 Male D Female To classify monthly income: 0 Below Php 10,000 0 Php 10,001-15,000 0 Php 15,001-10,000 0 Php 20,001-25,000 D Php 25,001 and above Exhaustive categories anticipate all possible answers that a respondent may give. For example: Question: What famfly planning method/s are YQU using? C..l Lactational Amenorrhe a Method I. J Natural o Basal body temperature o Cervical Mucus Method o s. ymptotherm al Method 0 Standard Days Method o Others (specify); ll Artificial o IUD O Pills O Injectable (DMPA) 0 Condom o Others (spe. cify): Permanent o Tubal ligation o Vasectomy 169	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
How <lo you summnrize data from fixed response and open-ended questions? Fixed response questions provide choices the respondent will select from. These choices will serve as categories for colluling the responses. In some community diagnosis designs, dutn collcclors use flashcards to help the respondenl choose his answer. Tilis is espcciully useful if one is dealing '"''ith very young respondents or respondents whose levels of education arc limited. '111c flashcards arc assigned uumbers or letters corresponding to a specific category of choice. The respondent will just call out or point to the letter or number that match or is consistent with his or her 1·esponse. 170 Open-ended questions do not provide choices or categories. Unlike fixed-response questions, categories are only constructed after data collectio n is over. Categor ies ai:e constructed from responses in randomly selected questionnaires. For example, a nurse wishes lo know Ute J'Cftsons why molhers do not breast feed their infants. Respondents are expected to brive out a wide selection of responses. The responses from randomly selected questionnaires will be the b~1ses for constructing the categories. QI__..Dfl ft.-1t hll'ldl ka n.. papasuso n1 lyon1 sannol~ Reiponse 10: Gumara~ alto ogoral contracepttve pllls. Response 27: Pumapaolc 'na ~ sa trabllho: Response BO: Ayaw nl mister, makalcasira daw n~ aklng,ftgur;e. Rupanse 45: SUmasakft ans aldns uton1 pag nagpapadede. Response 59: Bottle feedlnt Is more corwenlent. Response &Ot Glna1amot ako npypn sa saklt ns bap. Response 62: Naic. kahlya maa Pasuso p.,a1~nasa l;abas ng bahay. Response 67: Nakalalabala lalo na kung maramlng 1awalng bahay. Response 77: Nalcakllwala rig ~· · For these ~nses ;pos,ible c:ate110rles Include: Persorral convenience: Rwotues2'7, 45, ss, 67, Mildlcal reasons: Responses 10, 60 ~ pers U8$10n/. l>elll!ft "~nses 30, 62, 77 The next step after categorizing the responses will be to summarize the data. There arc two ways to summarize data. One can do it manually by tallying the data or by using the computer. Tallying involves entering the responses into prepared tally sheets showing all possible responses. For example (Table 7. 1): st JPPLY, When computers are going to be used in summanzmg results, a coding manual is needed where the responses are given numbers or codes. Using software such as EPITNFO, the responses are inputted into the computer for tallying.	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
for example: Variable-w Code. Sex Male 1 Female z Roman Catholic 1 I· Religion Protestant 2 h11lesla nl Kristo 3 Jehovah's Witness 4 s. Data Presentation Data present. I lion will depend largely on the type of data obtained. Descriptive data arc presented in narrative reports. Examples of data appropria te for descriptive presentation are geographic d:1ta, histo1y of a place or beliefs regarding illness and de. 1th. Numerical data may be presented into table or graphs. Tables or graphs are useful in showin J?; key informatio n making it easier to show comparisons including patterns and trends. The choice of graphs will depend on the type of data being presented, some of w1,ich are shown as examples. Type of Graph ' Line graph Hlstosrani or frequency polygon Proportional or component bar hor lechar;t Scattered diagram s ows. ata tren or c anges n time or age with respect to some other variab For comparisons of absolute or r tive counts and rates between cat. o,14?$ Graphic presentation of frequency , distribution or measurement Shows breakdown of a group or total where the number of cate orles Is not too ma Correlation data for tw O variables ~rn t!<l wilh Cam Soa 11q~1 171	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
Pie Chart 172 Pie Chart 83% Below Poverty Threshold Above Poverty Threshold Proportion of Famllfes Below and Above 2007 NSCB Poverty Threshold in Zone 3, lf'IY. Sto. RDAr O-Kanluran : UPCN, Septemb er 2008 Bar Graph 40. 00 35. 00 0 30. 00 go 25. 00 c,:, 20. 00 I:? ~ 15. 00 10. 00 5. 07 5. 00 0. 00 D,. :::,c:,t,u Souru: F1orendo et al, 2008 Bar Graph 33. 45 19. 26 19. 59 5. 07 H:;gl::~1 Colk-µ ~, a-a:. :! ;. i. :. e ·eot ~..d,c:oi:;;,k-'~ Educationa J Attainment 15. 54 2. 03 l C. 01"-~ '\·ou-tio ul uu!e:. ce eocne ~ Ed Cl!IIOl M 7 ! fl af. &4l4jljl,. G1 I-1t"8 %ane 3,, SID. llasario-Kanluran : UPCN, la Ill a 2IINNI ~-" il:I-IWllldi,h-et c,t 2IJOII	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
Alcohol fn Lnkc Tnadcquntc Fruh t ntn. k. o High Snit l);c1 Bar Graph Obesity-Furn Uy Mbtory of C,rdlo\:u,cut:sr Ol,u!n~~ r-: Fam Jly Hi. !ltory o(Hypenen!'ll On L ____________ _j 0 20 40 60 80 F'orccntago of Hyperton slvo Risk Factors for Hypertension, Zone 3, Brey. Sto. Rosarlo-Kanluran, UPCN: September 2008 Source: Florendo et al. 2008 Line Graph ------Line Graph 25. 00 :;;-= 20. 00-~ !!! "' a: 15. 00 ¢> u. i 10. 00 ;: e 5. 00 CL 0. 00 2005 2000 2007 2008 Year Preval~nce of Acutl! Diarrhea In Chllclr'en of Masaprua. Pateros:; 2005-2008 ~. Jii&,i«al ;20011. ~,,,,_osls -·=--a~~ &v,t:-Sm. Ana. Pat&Ol.... 173	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
174 9. Doto Analysis Data nnalysis is the most crucial stage in community diagnos is. Tt in,. ·olves quant:ificntion. description and dassification of data. Since there are multiple sou. rces of data which were collected using different methods, consistency and v;:ilidity of data can be checked. This is =lied triangi1lation. Data are sorted. classified in terms of relatainess. and interpreted for any significance or implication. TI1is process aims to establish I rends and patterns in tcrrns of health needs and problems of the community. Patterns in terms of human relations. time. and space help the nurse view and ana J:y7,e which are indicators of health problems and which factors give rise to health problems. The magnitude and e.,-tcnt of tl1e problems and their implication can be derived by comparing them wilh standard values or norms. Data analysis sbou. ld be done not only by the nurse or tl1e team conducting the communit y diagnosis. It seems unthinkable that the entire community should be "present during the data analysis. but it can be done. 1t may not be t}1e entire p Dpu lation but representatives oft. l1esectors that comprise the community. The nurse can facilitate a simplified 1malysis using the l'roblern Tree Analysis approach. (WHSMP-PC. 2003) The Problem Tree Amilysis approach looks at health problems in tern1s of their causes and effects.. Just like a tree. \\hat one sees in Lhe condition of lbe leaves and branches (whether they arc healthy or infested '";fh pests) are mnnifestations of the overall state of the plant and caused by what it gets from the soil in terms of nourishment through tb. e roots" Problems indicate that there are factors that cause them. The nurse ond the team can facilitate the participatory process in data analysis by ,mting the data in colored cartolina or constn1ction paper cut into 3 x 12 inches size. Using adhesive tape, post all the cards in one area. In a manila paper or in a board, draw a very big tree that details the leaves, branches, trunk and the roots. The people are the asked to look at the data/informati on ·written in the cards. Have them think which of these can be considered as the main or central problem, the causes and the effects of the problem. l\1ain or central problems should be posted in the trunk; the causes are posted in the roots :md the effects are posted in the branches or leaves. The nurse and the team should encourage the people to give opinions, comments and reactions or seek clarification on what and how the others viewed the data. Facilitate the discussion in order to deepen the analysis by posing question s such as: How are the main or central issues or problems related to one another? Which oftbe problems seem to be the most serious or needing urgent attention? Among tl1e roots of the problem, which are the easiest to address? Which are the most difficult? Which of the effects should not be allowed to continue? What could possibly happen if the nothing is done? What should be done? 10. Identifying the Community Health Nursing Problems Data analysis should lead the nurse and the team to have a better grasp of the community's health situation. Defining the community health nursing problems will help the nurse and the team to decide with the people what actions will effectiv ely address and improve community 's health. Community healt. 11 nursing problems are categorized as:	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
0 Hcalt J, status probkm. s-di. :scribcu in tenns of incre. 1S<?d or decrca S(.,'O morbidity, mortnlity, fertility or reduced c. ipability for "·elln css: t,. Health resources Jlroblems-dc..'leribt'CI in tcm1s of lock of or nbse. nce of manp11wer. money. materials or institutions necessary to sol.-c health problems: c. Hcal!Jl-relnled pr Jblcms-dcscrih~-d in temls o( exi J;tcnce of i:. ocinl. economic. em;ranmcnt:il ;incl political fnctor!l thnt nr. grnvate t·he Ulness-inducing !lit1rntions in Lhc com11u111ity. a\)0,-e procel>S is much like the a.-. scss111cn L phnsc of the PRECEDE-PROCEED ~:iel of Green and Kr_eutcr ( 1999~ involving sndnl. cpi<le1111olo~ic~I. ~nvior?-1/ r, wironmcntal. cduc;:1t10nal/ecoloy. 1r:1l as:<es..<:mcnl ~mu nd1111111strnt1vc/pohcy ei ~cssmcnt s. Using rhis 1m1dcl c1mhll's not rml\ the nur. :c but nlso t J11 lornl y. ovcmmcn t. ass-J I · I d '. '<l l t· ' ' I the people nm ol 1cr sectors mw J v<: 111 co11111111n1ty ns..-;,:. s.,smcnt to I cnt y cr1hcn as where each contrihut~l to lltt· prnhlcm and poi111s when· they,·an net to rc.,;olvc :: problem. This will be d_isc,~sscd wit? more depth i11 the nc. ~ chapter on plnnning for communi ty health 1mrsmg tnlt!rvent mas. 11. Priority-setting After Lhe problems have been identified, the next task for Lite nurse nnd lhe commun ity is to prioritize which llca. llh r,rohlcms 1. 'llll he (lltcndtd lo <. 'Onsidcrin. g available resources, limitations and c.-onslr. :rints. In priority-setting. the nurse makes use of the following criteria: a. Nature of the condition/proble m presented-problems ~ire classified as health status. hcalt J1 resources or heullb-related problems: b.. Magnitude of the problem-rl;!fers to the severity o( the problem which cn n he measured in lerms oflhe proportion of the population affected by the problem; c. Modifiab ility of the problem-refers 10 the probability of reducing, controllin g or eradicating th c problem: d. Preventive potential-refers to t11e probability of conlr OUing or reducing the effects posed by the problem ; e. Social concern-refers to ilic perception of the population or the community as they are affected by the problem and tl1eir readiness lo act on the problem. Table 7. 2 shows the scoring system which the nurse can use lo prioritize health conditions/p roblems. Each problem will be: scored according to each criterion and divided by the highest possible score multiplied by the weight. Then the final score for each criterion will be added to give the total score for the problem. The problem with ilie highest total score is given high priority by the mtrsc. 175	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
r. """' TABLE 7. Z PRIORm ZING HEALTH CONDITIONS/PROBLEMS: SCORING SYSl'EM ' Criteria Scor-e Weight· ;; Nature of the Problem 3 O liealth status 0 t-1ealt'1 resource ' 2 l ',. 0 Health-related 1 ' '.. Magnitud e of the Problem. J.-, Affect ts 7S-100% of the population 4 I. ' C Affects 50-74'6 of the population 3 3 Affects 25-49'K, of the population 2 D Affects less than 25% of the population 1 ' '' Modfffablllty of the Problem ·.,, i J High 3-Moderate. 2 u 4 0 Low 1 ',. u Not modiffabfe 0 Preve11tive Potentfal ··..: I 0 Hfgh 3,, Moderate 2 1 ' low l 11 Social Concern ,. Q Urgent community concern ; el(pressed readiness for action 2 1 !J Recognized as a problem but not needing Immediate action 1 ','., D Nol a co,r1munit V concern 0 ..-~~ source: UP Cnllege of Nur5lng, Communit y Health Specfo~ y Group., 1989. ~-. 176	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
r !. : ~ i fl t E ~ r .......,..., EXAMPLE OF A DATA COLLECTION PLAN SEGMENT: -; To describe the demograph ic characteristics of the 0-12 years old population lo diidlbe ~ulth status of children (0-12 years old) in terms of: common causes of Illnesses common causes of health center consultal!on common causes of hospltalllilti On common causes of death -nutritional status Proportion of target population vis-a-vis total community populati(111 Characteristics of the target population in terms of age and sex distribution Trends,n the health and illness pattern of the target group over 2-3 year period Reported causes of Illness among 0-12 years old Nutritional status of the 0-12 years old DATANHDED Tota. I population s11e of the communfty Total population of the target population, 0-12 years old Disaggregated population size according to: a. age b. sex 0-11 months l ·S years old 6-12 years old male female leading causes of deilths and illness of the 0·12 age group over the past 2-3 years number of recorded deaths number of recorded health centei-consultations -number ofrecorded referrals to hospitals and other health facilities Incidence and prevalence· rates of diseases among the 0-12 year. ; aid Number of children with normal weight for age weight below normal weight above normal Magnitude of the problem :no!{ Review of municipal or barangay records Household survey Household survey Records review of the barangay health center Key informant Interview of earangay Health Worker Councilor for Health Health Center Physician/ Nurse or Midwife Records review of health center; household survey Review of health center records on nutritional status of children; weight-taking KIi of Nutritionist Records review checkllsl Survey questionnaire Survey questionnai re Records review checklist KIi guide Records review checklist; survey questionnaire Records review checklist; weight-for age table KIi guide 7	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
i t g_ S°· &> ij, ~ " ~........, 00 OIJECTMS To aetetm1ne tilt socio-economic, cultural and envlronff\tntal factors which contribute to high pre Yalence of ARI and malnutrition of chlldren (0·12 years old) ' -~ INFORMA TION NEt OID Risk factors/bena V IOl'S that contribute to malnutrition and ARI Socio-economic and cu\tural factors that contribute to malnutrition and ARI Environmenta l factors that may account for the problem of malnutrition and ARI Per(eptions of the people regarding the problem of maloutritfon and ARI In the community Perteptlons of the health workers/community leaders regarding the problem of malnutrition and ARI in the community ---~ DATANEIDID DATA COl LECT10N METHOD TOOLS Lil1!St'(le, n. ealln nan1ts and Screening; risk ractor Screening, risk assessment and practices that contribute assessment; KAP Survey; visual KAP survey forms; observation to malnutrition and ARI observation checklist Social, economic and Household survey; KAP survey; Survey questionnaire ; KAP survey cultural profile of vlsual observation form; observatfon checklist fafl'lllles that lnftuence children's susceptibility to malnutrition and ARI Observation checklist Environmental Environmental scannlnl!. charaeteri$tlts that acco11nt for increased cases of malnutrition and ARI Knowledge, attitudes and Focus group discussion of FGOguide practices of the people on selected mothers or caregivers malnutrition and ARI of children Extent of problem, Kev informant lnter\/iew of cause/s1 perceived local community leaders and KIi guide solutions and current health workers actions to address the problems .. ".	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
APPLICATION OF PUBLIC HEALTH TOOLS IN COMMUNITY HEALTH NURSING Aside from the biophysical and social sciences, community health nursing also synthesizes in its practice the concepts, knowledge and skill. s der-ived from public health. The population and wellness emphases of public heallh are the same essential features of community health nursing. Tools in measuring and analyhing community health problems such as epidemiology and biostatistics were :. ipplied to form part of our assessment tools in the diagnosis of communily health nursing problems. TI1e health disciplines of demography, vital statistics and epidemiology a-re three important tools that help the nurse in identifying the commun ity's health needs. DEMOGRAPHY More than just being aware of how large a population is in a community, the nurse also needs to comprehend the characteristics of the population that makes t J1e people vulnerable to certain health condition s. She can determine the nature and magnitude of existing and potential communily health nursing problems if she possesses knowledge about the population's size, composition and distribution in space. Demog. rapby, the science of population helps the nurse find reasons or rationale why or how a particular population or group is influenced by a variety of factors resulting in vulnerability to diseases. Demography is the science which deals with the study of the human population's size, composition and distribution in space. Population size simply refers to the number of people in a given place or area at a given time. \'\/'hen the population is characterized in relation to certain variables such as age, sex, occupation or educational level, then the population compos ition is being dcsc:ribed. The nurse also describes the spatial distribution or how people are distributed in a specific geographic location. The three events descn'bed above are affeqted depending on bow fast or bow slow people are added to the population as a result of births, deaths and migration occurring in the community. Sources of Demographic Data Demographic information can be obtained from a variety of sources but the most common come from censuses, sample surveys and registration systems. Census is defined as an official and periodic enumeration of population. During the census, demograp hic, economic and social data are collected from a specified population group. These data are later collated, synthesized and made known to the public for the purpose of determin ing and explaining trends iu terms of population changes and planning programs and services. There are two ways of assigning people when the census is being taken. The de ju. re method is done when people are assigned to the place where they usually live regardless of where they are at the time of the census. On the other hand, when the de facto method is used, the people are assigned to the place where they are physically present at the time of the census regardless of their usual place of residence. Since the census asks for a complete enumeration of the population, it is usually a very expensive undertaking. It will requi:re money to pool together people and other 179	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
2. Relative increase is the actual diffecence between the two census counts expressed in percent relative to the population size made during ao earlier census. Relative Increase = where: Pt = population size at a later tlrne Po = population size at an earlier time population Composition Pt Po Po The composition of the population is commonly described in terms of its age and sex. The nurse utilizes data on age and sex composition to decide who among the population groups merits attention in terms of health services,md programs. 1. Sex compositio n To describe the sex composition of the population, the nurse computes for (he sex ratio. The sex ratio compares the number of males to the number of females in the population using the formula below. number of males Sex Ratio =---------X 100 number of femafes The sex rntio represents the number of males for every 100 females in the population. 2. Age composition There are two ways to describe tbe age composition of the population. a. Median age divides the populatio n into two equal par~. So, if the median age is said to be 19 years old, it means half of the population belongs to 19 years and above, while the other half belongs to ages below 19 years old. b. Dependen cy Ratio compares the number of economically dependent with the economically productive group in the population. The economically dependent are those who belong to the o-14 and 65 and,1lxwe age groups. Considered to be econornicnlly productive are those "ithin the 15 to 64 age group. The dependency ratio represents the number of economically dependent for every 100 economically productive. Dependency Ratio = total populat!Ofl of the o-14 and 65 and above a_ge group--·-----------x100 total po PUlation of 15-64 age sroup 181	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
65+ 60-64 55-59 l l 50-54 45-49 I 'F 40-44 2 35-39 ~ 30-34 a, 25-29 < 20-24 15-19 10-14 05-09 00-04 6 4 2 0 2 4 6 Percentage (¾) of Population Figura 7. 2 Popufatfon Pyramid for Zone 3, Sto. ltosarlo-«anluran (UPCN, September 2008) Sourre: Florendo et al, 2008 Population Distribution The distribution of the population in space can be described in terms of urban-rurn J distribution, population density and crowding index. The measures help the nurse decide how meager resources can be justinably allocated based on concentration of population io a certain place. t. Urban-rural distributio n s. imply illustrates the proportion of the people living in urban compared to the rural areas. Rlon r an ura nao Popu at1on Dens y fpersq Ian) 27. Sc~mr~c. J wili1 Cam Scanr11:;1 183	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
Fertility Rates General Fertility Rate = __ number of live births __ )( 1oo O--·-----------------midyear population of women, 15-44 yea~s of age Morbidity Rates· --__.,, f number of new cases of disease Incidence Rate = _ _c:eveloplng from a period of time population at risk of developing the disease Prevalence Rate= number of old and new cases of a disease _-,. f ----.-------------------------populanon examined Mortality R. tes Crude Death Rate = number of deaths ----······ x 1o OO midyear population number of deaths in a Specific Mortality Rate _ specified group----·--------,c 1000 midyear population of the same specified group cause-of-Death Rate= Infant Mortality Rate= number of deaths rrorn a specified cause ________________.. midyear population deaths under one year of a Ge-----··----------------number of live births number of deaths due-to pregoan GY delivery and puerperlum " 1oo O Maternal Mortality Rate =---·-·-------------number of live births	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
-the t)l"'(':u:-n,·,· or nh:-. cncc of whkh mny,;crvl' ns llli111ulu11 tn lnilhll<' or purp ·tuttlc 11 disc:1sc pro,(-..... 111is lrnppc11,; onlywl Hn tht. ' 11grn11 cornc11 in contn<:t with n r;u,iccplil. ile host :111d unolt>r prtlp<. 'r environm ental r1111rlitio11. s. Acnt E11arnpte e1olog1cal vlnn, bactl!f'fa, fungu,. para~ile Chrrn1cal !@ad, mt'rcurv. ln~«ttclde Physical hurnldtty, atfl\osph11rlc pr OY11re. rlldlatton MC!Chanical stab, trauma Nutritive lr Ofl or Iodine deficiency, cholesterol A host is any organism that harbors uml provides 11ourishrn cnt for onothcr ori. ani:m1. TI1e characteristics of I he host will affect l,is or it. s risk of cxp Mnrc 10 sources of infection and his or its s11sccptihility or resistnncc. The rcsistt111l·c 11f lhc host may be specific or non-specific. Specific rc!'<istancc re. ~111ts fr111n 1111 i111mu11o ln1,:ic experience such as undergoing immuni1. a tion or vacdnnticm. Nun~p1. :dlic r(·~istanc:c re.. sults from an intact skin, muco,1s membrane, reflexes ns lacrimalion. coughing, diarrhea. or vomiting. They can be maintain ed U1rough 1:,ersonal hygienic prnctices, environmental sanitalioi;t, proper nutrition and n healthy lifestyle. Since the nurse considers the community as /\ host she protects tbe h Mhh of the oommu. nity by increasing its herd immunit} '· Herd imrnunil y is the probability of a group or community developi ng an epidemic upon introduc tion of an infectious agent. It is the proportio n of the immunes and the susceptible in Lhc group. The environme nt is the sum total of all e:..1:ernal conditions and innuences that affect the life and developme nt of an organism. The environm ent both affects the agent and the host. There are three components of the environm ent: 1. Physical environment is composed of the inanimate surroundings such as the geophysical conditions or tbe climate; 2. Biological environment makes up the lhing things around us such as plant and animal life; 3. Socio-economic environment which maybe in the form oflevel of economic developmen t of the community, presence of social disruptions and the like. The three elements of the ecologic triad interact with one another in an attempt to maintain equilibrium. Any major change in any one of the factors may bring about a disturbanc e in the equilibrium provoking the appearance of a health problem. Natural H;story of Disease Describing the natural history of disease seeks to identify factors related lo the course of a disease once established in order to determine its duration and the probability 187	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
i t g_ S°· &> ij, ~ " ~ Tertiary Prevention Tertiary prevention limits disability progression. The nurse attempts to reduce the magnitude or severity of the res\dua\ effects of both infectious diseases (e. g. hearing impairment from frequent ear infections or impaired vision from severe conjunctivitis and shingles) and non-tommunicab\e ones (e. g. mental illness, cardiovascular-diseases, COPD). Day care centers and sheltered workshops are examples of opportunities to achieve the objective of tertiary prevention in mental illness and drug abuse. . TABLE 714 NATURAL HISTORY OF DISEASE ~ND ~PLIC!ATION p F DIFFERENT LEVELS OF DISEASE PREVENTION (LEAVALL & CLARK, 1968) Stage Events Level of Application of Preventive Specific Interventions...-. Health promotion - Health education.. I Nutrition counseling . Adequate housfng Interrelations ofvario'us host, Personal hygiene agent and environmental factors Environmental sanitation I Prepathogenesis bring host and agent together Primary prevention: alms to prevent Family planning or susceptlblnty Disease-provok io¢stlrnulu~ I~ development of disease E>entai hygiene prod·uced in the known host Specific protection - lmmuni2ation-Chemoprophyla Kis . Protec. lion ag. ilnst ln Juries and occupationalhai. irds ,, Interaction of host and sumulus Secor:1darv prevention : alms to: Stimulus or agent b-ecomes Promptly diagoose and treat disease Early dfagnosls and prompt II Pathogenesis established (lfirifectious agent Prevent spread of disease to healthy treatment Screening · Early pathogenesis Increases by m!,lltip!ication) population Case-finding Beglnhlng tissue and physiological Prevent complications aod sequefae Selective examinatioo changes Shorten period of disability..i'. ·: '. ? ... ~	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
Concept of Causality and Association The concept of causality lay on two premises. First, it states that disease does not occur at random; and second, disease has identifiable cnusal and preventive faclors. The Henle-Koch Postulate asserts tbat a cause of a disca5C is any event, condition. characteristic or a combination of these factot·s thut play an important role in produci,ng the disease. further, a c:mse must precede a disease irnd lhe cm1se of a disease must be necessary :md sufficient for the occurrence of disease. Necessary cnusc refers Lo the fact thnt the factor ffillfil be present for the disensc to occur. Su fficicnt cause indicates that if a factor is present, the discn. sc c..m occur, hut the foclor's presence ru:,es not ah D1YS result in the disea8e's occurrence. Thus, when Lhc spntum from a person suspe<:ted of tuberculosis demonstratc. s the bacilli in the smear examination, it confirms lhe presence of tuberculosis. The tubercle bncillus is a 11cccss,1ry cause for TB to occur. The presence of diabetes mellitus in n person dues nut. ii ways lcm. 1 to occurrence of tuberculosis; but studies have shown that il is a sufiicient cause for Til to occur. The condition of reduced blood glucose seems to lower the person's immunity and make him susceptible to communicable diseases like tuberculosis. Thenurse is not only responsible for making sure U1atthcsick in thecommnnityrecover from their illness and injury. In caringforthepopulnlic111, themoreimpo1·tantdimcnsion is for the healthy to remain in Uieir optimum level of wellness whilst preventing them from developing disec1se conditions. There arc segments of the p OJ')1Jl. 1Lion who have certain risks of acqufring certain diseases. Risk is the probability of an w1fnvurablc event-disease, disability, defect or even death. It is imporwnt for the nurse,rnd the people to have knowledge about these risk factors associated with disen.-,c conditions. Disease can only be prevented if tbe risk factors are iclen1ified and dealt with. The concept of association does not necessarily imply a c. iusal relationship. It only states that if there is concurrence of two variables more often lhan would be ex-peeled by chance, then the two variables under investigation are said lo be associated. The following are the different factors associated with increased rii:;k of disease: P. redisposing factor-any characteristi c ofan Individual, a community or an environment that predispo ses behavior or other conditions related to health; Includes knowledge, belief arid attitude but may include other factors such as soeio-economk: stat1JS Enabllng factor-any characteristic of an lndlvldual, aroup or the environment that facilitates or make po»ible a certain health behavtor or other conditions affectina health; inc:ludes any skill or resource required to attain that condition Relnforcfr,g factor-any reward or punishment or any feedback followlns or anticipat~ as a consequen ce of health behavior The relationship between a risk factor and a certain disease can be described in terms of the following types of association: L Spurious or artifactual association-association when none actually exists 2. Indirect-presence of a known or unknown factor common to both a characteristic a11d a disease may wholly or partly e.,1>lain a statistical association 3. Direct or causal-presence of a factor which wholly and directly explain the cause of disease; no intervening variables One to one causal-suggests that when one factor is present, disease results; conversely, when the disease is present, the factor must also be present 191	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
test. It measures the probability of the test correctly identifying a positive case of a disease (tnie-positive). Specificity is the proportion of person:; wilhoul a disease who have negative results on a screening lcsl. II n1cns11res the prr>hability of correctly identifying non-cases (true-negative) (Ander. son an<l Mcfo',irlane, :wn7). ·111e nurse must be aware of the sensitivity,incl spccificity rntes of screening measures that are used to detect a disease. In community situ:itions when there is ;m imm!!diat e need to as<.-crtain disease status, the nurse sel!!cts scrr:ening measures thal will yield I he highest probability of true-positive for the purpose of providing appropriate treatment and consequently prevent the transmission of cfo;. casc tot he rest of the healthy ropulation. On the othe. r lwncl, if resources are limitcd to the extent th:il scrcc!ning can not he done to all people suspected of the disem,c, the nursc will have to c Qrnpromi sc with screening tests with high specificity, identi(ying only those who "do not have the disease". TI1e choice of having a specific or a sensitive scrc.-enini. : test is not an easy one fnr the nuri,e. If she chooses one thal hns high sensitivity, there is Lhut probabil ity of some people having the disci1sc that will not be detected hy the screening test. This is referred to as false negative. 'J11is implics thrit these? reople may not be given ;ippropriate treatment having tested neg;itive rn the test. If the nurse decides on tests lhal have high specificity, there is probability that some people who do not actually have tl1e disease will be diagnosed !L'l "diseased"'. This is rcforrccl to as false positive. Peorle who arc false positives may be referred lo hospitals for trc,1Lmcnt when in fact, they are not ill. Table 7. 5 shows the rclnlion~hip of sensitivity a11d specificity of a screening test: TABLE 7. 5 SENSITIVITY AND SPECIFICITY OF A SCREENING TEST Screening Test Disease Status Results-Wlttiout Total With Disease . True Positive Positive True Positive False Posftfve +False Positive ' ' ' False Negative, Negative False Negative True Negative +True Negative ' Total Total Wlth Disease Total Without \ ' Disease. ' '. '.. True poslt1Ve5 Se'nsltll,:lty, or True-Positive Rate=------------Kl OO Total with disease ' ' True negatives Speclficit-y: or True,Ne~tive Rate. =---·-xl OO I; I ' ' Total without. clsease ' False negatives False-N'egatlve Rate =-------·---IC 100. ;. ' Total with disease I ' ' ' '.. False positives ' ' False-Positive Rare =-·--------------xl OO ' ' Total without disease ' ' '. ' Ma0c Mahon & Pugh, (1'9"70). Epidemldlogy: Pr/help/es and Methods. Boston, MA: Little, ', ' · Brown and Co. 193	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
1. 94 After the nurse ascertains the diagnosis of disease, she n1akes observations of the disease frequency and recorded as disease rates. The attack rate (Valanis, 1992) is used to calculate an identifiable populatio n exposed to an infectious agent. It represents the incidence of the illness among the exposed population. They are frequently used in surveillance and control of communicable diseases. 2. Describing disease as to person, place and time characteristics After the disease or condition has been identified with reasonable certainty, the number of persons who possess the disease are recorded noting down the characteristics of the afflicted persons, the time the disease was initially recognized and the characteristics of the place where the cases came from. To a certain extent, the nurse can derive associations between the risk of acquiring a disease and characteristics of persons. Some variables provide clues as to the probable cause of the disease. These variables include age, sex, marital conditions, occupation or socio-economic status. In viewing the susceptibility of the community as host, the nurse determ ines the characteristics of the community and its population in terms of the following: 1. Herd immunity is tbe basis for determining the community's reaction against disease invasion since it represents the immunity and susceptib ility levels of individuals comprising the populatio n. Tbe immunity level is inversely proportional to the soscepbbility level. When the proportion ofthesusceptib le are high compared to the proportion of tbe immunes, then the community is experie ncing an epidemic. An epidemic is a situation when there is a marked upward fluctuation in disease incidence. An cnd. emic occurrence of disease implies the habitual presence of diseas,,> in a given geographic location accounting for the low number of both immunes and susceptib le. Wb. en disease occurs every now and then affecting only a small number of people relative to the total population, then we have a sporadic type of disease oceurrence. 2. Exposure or Contact Rate represents opportunities for progressive opportunities for progressive transfer or transmission of an infectious agent to a susceptib le host and depends on the frequency of contact. and facility of transmission. 3. Chance is the probability of contact between the source of infection and the susceptib le host and depends upon the number of sources of infection, the number of immunes and location of the source of infection.	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
The nm·se characterizes the pattern of disease occurrence in terms of date or time onset. This is indicated by the epidemic or attaek curve. Disease occurrence can be described by the following: 1. Short time fluctuations common in epidemics: a. Common source epidemic is cliaracterized by simultaneous exposure of a large number of susceptible to a common infectious agent; b. Propagated epidemic is caused by a person-to-person transn1ission of disease agent; 2. Cyclic variation refers to recurrent fluchlations of disease that may ex. hibit cycles la,;ting for certai o 1>eriods; 3. Secular variation refers to changes in disease freque11cy over a perio. d of many years. The demonstration of association of a disease with place implies either t J1at t J1e people living in a certain geographical location have certain traits or are uni([nely different from those residing in other places. The differences in terms of traits may have been influenced by certain environ. menta l factors present in tlle biologic, chemica J, physical or social environments of the people inhabiting that place. 3. Analysis of the general pattern of occurrence of the disease or condition After establishing the disease frequency and distribution in a population and defining the characteristics of the d. isease or condition in relation to time, place and person, the nurse proceeds to correlate the data and attempts to formulate. a causal association between the disease under shldy an·d the probable factors surrounding it. It focuses on clinical observations using case reports or case series. This stage is called hypothesis testing. The exposure factors and the disease wi. U be tested or proven in the next phase of the epidemiological process. Analytical Epidemiology More than just describing the disease in terms of person, place and time, Analytical Epidemiology attempts to identify the possible factors as&oc;iated with disease oc. currence. Using the concepts of causality and association, it seeks to establish the risk of developing specific disease or condition among people exposed to known factors or situal'ions. It consists of hypothesis-testing of causal association using different epidemiological study designs. Case-contro l and cohort studies are employed in investigating patterns of disease and cause in individuals. Correlational or ecologic studies are utilized in analyzing patterns of dis-ease and cat1se in populations. Analytic studies employ measures that show strength of association between a purported health condition or factor to increase risk of disease. These measures, a. lso called risk estimates a. re relative risk ratio (RRR), odds ratio (OR) and attributable risk (AR). Risk Estimates The relative risk to an individual developing a disease due to a particular exposure is derived by comparing the occurrence of a disease in a population exposed to the suspected factor to u,e occurrence of disease in a population not exposed to the suspected factor. It is a direct measure of the strength of associatio n between a suspected cause and effect (Lilienfeld et al, 1994) The relative risk ratio only implies an increased probitbility of developing a disease as a result of exposure to a risk factor. A relative risk ratio of 1. 0 means that the ris. k is the same for botl1 exposed and non exposed populations. A risk greater than 1. 0 indicates excess risk in the exposed group. (Valaois, 1992) 195	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf
l 196 lnddenat Rate amcng those exposed Relaaw Risk Ratio = Incidence Rate among those not exposed An e.-. :ample cited in Mac Mahon and Pugh (1970) describes the relationship of heavy smoking (defined as smoking of 25 or more cigarettes per day) and incidence of lung cancer among British m:1le physicians from 1951 to 1961. The incidence rate of lung =~among heavy smokers was 2. 27/1000 population.. Among the non-smokers, the incidence rate was only 0. 07/ 1. 000 population. Using the above formu Ja, the RRR is 32. 4. It means that 1he risk of lung cancer among heavy smokers is 32 t. imes greater compared to non-smokers. The odds ratio is similar to relati Ye risk in a way that it establishes tl1e probability of disease development as a result ofbeinge..,q :,osed to a suspected factor. In epidemiologic studies where incidence rate. s or prevalence rates are not available, the oddi:; ratio is used to estimate tlw risk or probability of disease de,·elopmeut. ff the odds ratio is equal to 1. 0. it suggests that the factor is not a risk factor to the dise~'lse or condit:-ion being inv·estigatt>d. (. :-\. nderson and l\1c Farlane, ::1007) To compute for the odds ratio, a cross tabulati on showing the proportion of persons exposed to a suspected factor with or without cilseca. se a. ad proportiou of persons ·who were not exposed to a suspected factor that de Ye]opt'd or did not develop disease. Exposure to a Rlsk Health Status Total Factor With Disease Without Disease Ep1 dtoafactor A 8 a+b Not e,:po,ed to a factor C D c+d Taal a+c b+d a+b+c+d The odds of having the disease when exposed to a suspected factor is represented by a(b in table 7. 6 wb. ile the odds of having the disease when the factor is absent is represen ted by c/d. The odds ratio is computed: TA8LE 7. 6 ODDS RATIO FORMULA 8/b ad Oclds..a. tro---w.-c/d be The use of odds ratio is demonstrated in a case-control study on the associati on of meat consumption ·with enteritis necrotic. ans in Papua New Guinea (Millar et a J, 1985 cited by Beaglehole, et al, 1993) Enteritis necrotica ns is inflammation of the small bowel, usually the jejunum and ileum leading to ulceration and perforation of the small intestine. rt is a fatal type of food poisoning caused by 13-toxin of Clostridium perfri ngens.	Nursing Practice in the Community 5th Edition Aracelis. Maglaya Rosalinda G. Cruz-Earnshaw etc. Z-Library.pdf