implementing the community health nursing services

Implementing the Community Health Nursing ServicesIntroduction

The World Health Organization’s (1978) definition of health emphasizes not only the prevailing physical and mental conditions of the people and the community. It also considers the political, economic, social and cultural dimensions that affect their living conditions and quality of life. In this context, the interventions of the nurse cannot be limited to actions geared towards the reduction of mortality and morbidity. Community health interventions necessarily call for improvements in the standards of living and quality life of the people and the community. The WHO definition of health, therefore, clearly makes a stand on the link between health and development. It implies that a healthy population is a moving force for economic growth of the community. Consequently, marked improvement in the economic conditions of the people will enable them to enjoy a sustained level of health and wellness.

In the health development process, the Alma Ata Declaration (1978) stress two important concerns in addressing health issues in the community. The first concern is the need for an integrated approach in solving health problems. Community health needs and problems are not solved by simply inducing changes in personal and group attitudes and behavior. If one expects a lasting and sustainable solution, reforms have to be carried out within the health care delivery system and the larger socio-economic and political system. The second important concern is the need for enhanced capability for greater participation and involvement of the people in health efforts including policy making and influencing decisions. Often, the people most affected by the problem feel helpless simply because they do not believe they have the power to change their situation. In other words, community health nursing interventions focus on providing health-related interventions to improve the health status of the population and enhancing the capability of the community to manage its own health.

Community Organizing

Community organizing work is carried out by the nurse with the goal of motivating, enhancing and seeking wider community participation of decision-making in activities that have the potential to impact positively on community health. Unlike in health education activities where the nurse aims to influence, change and modify attitudes and behavior of people as individuals, the nurse’s efforts are directed towards organizing and mobilizing the people to initiate and sustain changes as a group or as an organization. The people act not as individuals but as members of these groups or organizations. In community organizing, the emphasis is more on strengthening the members’ capability in problem-solving and decision-making skills necessary for self-reliant development initiatives.

Community organizing is a process whereby the community members develop the capability to assess their health needs and problems, plan and implement actions to solve these problems, put up and sustain organizational structures which will support and monitor implementation of health initiatives by the people.

In organizing the community, the nurse goes through the following phases (Andamo, 1968; Manalili, 1985):

A. Preparatory Phase

The activities in the preparatory phase include area selection, community profiling, entry in the community and integration with the people.

1. Area selection

To guide the nurse in choosing and prioritizing areas for community health development, the following questions must be answered:

Is the community in need of assistance?

Do the community members feel the need to work together to overcome a specific health problem?

Are there concerned groups and organizations that the nurse can possibly work with?

What will be the counterpart of the community in terms of community support, commitment and human resources?

2. Community profiling

Once the area has been selected, a community member who is known and accepted by the people will be chosen to act as the contact person. The contact person can identify other persons who can be depended upon to initiate activities in the community. These people will compose the core group who will assist the nurse in doing a community profile. A community profile provides an overview of demographic characteristics, community and health-related services and facilities. It will serve as an initial database of the community and provide the basis for planning and programming of organizing activities. It can also help determine the appropriate approach and method of organizing specific to the population or group sectors that will be organized.

3. Entry in the community and integration with the people

Before actual entry into the community, basic information about the area in relation to th cultural practices and lifestyle of the people must be know. Establishing rapport and integration with them will be much easier if one is able to understand, accept or imbibe their community life. Living with the people, undergoing their hardships and problems and sharing their hopes and aspirations help build mutual trust and cooperation.

Here are some guidelines in conducting integration work:

Recognize the role and position of local authorities.

Adapt a lifestyle in keeping with that of the community.

Choose a modest dwelling which the people, especially the economically disadvantaged will not hesitate to enter.

Avoid raising expectations of the peoples. Be clear with your objectives and limitations.

Make house calls and seek out people where they usually gather.

Participate in some social activities.

B. Organizational Phase

The organizational phase consists of activities leading to the formation of a people’s organization.

1. Social preparation

The integration work paves the way for the nurse to be introduced into the community and signals the beginning of the social preparation phase. While continuously learning more about the conditions of the community, the nurse deepens and strengthens her ties with the people.

2. Spotting and developing potential leaders

As a result of living and being with people, the nurse comes to know who among them have a deep concern and understanding of the conditions of the community. However, it is necessary that they should also be able to gain the trust and respect of the community members. Providing opportunities that will demonstrate their potential as leaders can test their commitment to the community’s well-being. The nurse must consciously provide learning experiences that will prepare them as future leaders of the community.

It is not necessary that the potential leader is highly educated or one belonging to affluent family in the community. What is more important is for that person to be able to identify with, understand and articulate effectively the problems that beset the community. It is to his advantage if he has a relatively wide influence not only among the poor but also among the elite. Perhaps, one important consideration in selecting potential leaders will be their willingness to work for the desire change.

3. Core formation group

The core group consists of the identified potential leaders who will be tasked with laying down the foundation of a strong people’s organization. Ideally, the core group represent different sectors of the community—women, youth, farmers or workers—depending on the type of community. The nurse assists the sectoral representatives in forming core groups in their respective sectors. She also facilitates in skills development of core group members related to the tasks they will assume in the organization. See Chapters 14 and 15 for specific interventions to develop partnership competencies and workgroups task and maintenance functions. The core group serves as training ground for developing the potential leaders in:

Democratic and collective leadership

Planning and assuming tasks for the formation of a community-wide organization.

Handling and resolving group conflicts

Critical thining and decision-making process

4. Setting up the community organization

When all sectoral organizations have been put up, the people are ready to form a community-wide organization. This organization will facilitate wider participation and collective action on community problems. When the organization is formed, the nurse makes sure that there is maximum participation of and control by the members in all its activities. The organizational structure must be simple to facilitate consultation and decision-making among its members. Part

of the organizational structure will be working committees specifically created to look into the different concerns of the organization and community. One such committee is the health committee. The nurse assists in laying out plans of the health committee that initially includes identification of prospective community health workers (CHW’s). The committee may decide to involve them in the next phase.

C. Education and Training Phase

The purpose of the education and training phase is to strengthen the organization and develop its capability to attend to the community’s basic health-care needs. This can be achieved by conducting the community diagnosis, training of community health workers, undertaking health services and mobilization and leadership skills training.

1. Conducting community diagnosis

The community diagnosis is done to come up with a profile of local health situation that will serve as basis of health programs and services to be delivered to the community. The nurse assists the people in developing a plan and in the actual conduct of community diagnosis. She also helps the community to identify, analyze and understand the implications of the data that they have collected.

2. Training of community health workers

After the results of the community diagnosis has been presented, the community decides on the roles the community health workers are expected to perform and the competencies and personal qualities they should possess. Based on an agreed upon criteria, the people will decide who will be trained as community health workers based on the expected roles of the CHW’s.

After the community health workers have been names, the nurse facilitates the conduct of a training needs assessment (TNA) to determine the level of health skills and knowledge will serve as the basis for the health skills training curriculum which will focus on the required competencies.

3. Health services and mobilization

The organization takes the lead in undertaking activities that will solve the problems the community is confronted with. Engaging them in collective work gives the people opportunities to test and strengthen collective spirit and at the same time, build and enhance their confidence. Oftentimes, people are very eager to act without consideration to resources needed to carry out the action. It will do well for the nurse to teach the people how to prioritize the problems that need to be addressed at a given time. This will prevent frustration on the part of the people when they do not seem to achieve their goals right away.

4. Leadership-formation activities

The process of developing community leaders is a continuous and sustained process. Leaders learn a lot by engaging in actual organizational activities such as conduct of meetings, assessment, implementation, monitoring and evaluation of activities. They can utilize these opportunities in mastering organizing skills, human relations development or supervisory skills. However, they are not enough. Their experiences can very well serve as

bases for theory learning when they undergo formal leadership skills training which can include skills in financial and project/program management. As the nurse works with the organization and the community, she will be able to assess the specific training and other practical needs of the leaders and plan for a continuing education program for them.

A. Intersectoral Collaboration Phase

As the organization grows, it will also grow. Thee need for resources-material, human, financial will have to be source externally. Assistance and support in any form can be funneled into the organization through collaboration with other organizations and communities. The nurse is in the best position to facilitate and coordinate with institutions, agencies and other key people to articulate the community’s need for support and assistance.

B. Phase-Out

As the organization and the community assume greater responsibility in managing their health-care needs, the nurse gradually prepares for turn-over of work and develops a plan for monitoring and subsequent follow-up of the organization’s activities until the community is ready for full disengagement and phase-out.

Partnership and Collaboration

Health and health-related problems in the community are varied. Most often, the problems are complicated and too many for the nurse and the people or their organization to handle. They cannot solve the problems alone. They must work with other people or groups to increase the probability of accomplishing the goals that they have set. As the saying goes, there is strength in numbers. The nurse must plan to establish and maintain valuable working relationships with people such as peoples’ organizations, health organizations, educational institutions, the local government units, financial institutions, religious groups, socio-civic organizations, sectoral groups and the like.

The aim of partnership and collaboration is to get people o work together in order to address problems or concerns that affect them. It gives people the opportunity to learn skills in group relationship, intermaking process in the context of democratic leadership.

Working together enables organizations to accomplish their goals much quicker because resources, skills and views are pooled together. Organizations can commit and work together in different ways (ICHSP, 2000).

A. Networking is a relationship among organizations that consists of exchanging information about each other’s goals and objectives, services or facilities. This results in the organizations’ becoming aware of each other’s worth and capabilities and how each can contribute to the accomplishments of the network’s goals and objectives. Networking requires a small amount of time, yet it has great potential in terms of joint actions.

B. Coordination is a relationship where organizations modify their activities in order to provide better service to the target beneficiary. To a certain extent, this level of organizational relationship becomes time-consuming as it requires more involvement and trust on the part of the committed organization. Modification of activities that are more responsive to community’s needs may significantly improve people’s lives.

C. Cooperation is a relationship where organizations share information and resources and make adjustments in one’s own agenda to accommodate the other organization’s agenda. In this type of relationship, rewards as well as problems and hassles that go with working together.

D. Collaboration is the level of organizational relationship where organizations help each other enhance their capabilities in performing their tasks as well as in the provision of services. At this point, people become partners rather than competitors. Collaboration entails a lot of work but the potential for change can be great.

E. Coalition or Multi-sector Collaboration is the level of relationship where organizations and citizens form a partnership. All parties give priority to the good of the community. It requires great investment in terms of effort, time, trust and the will to make a change.

The following are general ideas for the nurse on how to get started in partnership and collaboration work:

1. It is imperative for the nurse to involve all the stakeholders in the process of forging partnership and collaboration with the community.

2. In working together, the nurse and the community face risks together. It is important therefore, that they need to know and trust each other.

3. Determine how each organization views the problem, how it proposes to solve the problem and how it perceives an organizational relationship can help solve the problem.

4. Organizations should agree on the kind or level of relationship that will help best accomplish the group goals considering needs and available resources.

5. When organizations have agreed on the type of organizational relationship, formulate ground rules that will become the bases for decision-making. The following are the most important points:

Listen to what each has to say. Points of agreement can only be reached if there is an exchange of information.

Take time to listen to people who voice different opinions or concerns. Keep an open mind. Try to identify points of unity from diverse opinions.

Don’t force organizations to give up their identities. Remember, organizations work together for a common good. They do not work together just so they can outdo each other.

Advocacy

Advocacy work is one way the nurse can promote active community participation. The nurse helps the people attain optimal degree of interdependence in decision-making in asserting their rights to a safe and better community. Advocacy work in nursing has gone a long way from one who just acts on behalf or intercede for the client to one who assists parties to understand each other so that agreement is reached (Stanhoppe and Lancaster, 1992). Today, the nurse as an advocate places the client’s rights as priority. She is responsible for providing mechanisms for people to participate in activities that aim to improve the conditions of the community. The nurse as an advocate helps empower the people to make decisions and carry out actions that have the potential to better their lives. Advocacy work involves (Kohnke, 1982):

A. Informing the people about the rightness of the cause .

The nurse conveys the problem to the people, shows how it affects them and describes what possible actions they can take.

B. Thoroughly discussing with the people the nature of the alternatives, their content and possible consequences.

While discussing alternatives, the community’s needs and problems are amplified and eventually become the basis for decision-making. It is through this process that the nurse and the people come to agree on the relevance and appropriateness of the actions to be taken to solve the problem.

C. Supporting people’s right to make a choice and to act on their choice.

The nurse puts emphasis on the people’s right to decide on actions that they think should benefit the community. It is also the nurse’s responsibility to facilitate the precess of weighing the benefits and losses of the alternatives. Whatever the outcome of the decision-making process, the nurse assures the people that they do not have to change their decisions because of others’ objections or pressure.

D. Influencing public opinion.

The nurse affirms the decision made by the people by getting powerful individuals and groups to listen, support and make substantial changes to solve the problem.

Supervision

Supervision is a developmental and enabling process whereby the nurse supervisor ensues that work is done effectively and efficiently by the person (Morrissey, 1970) being supervised and at the same time keeps the person satisfied and motivated with his work. Supervision is also seen as a facilitating process that consists of inspecting and evaluating the work of another in order to remedy rather than punish poor performances (Gillies, 1989).

If the goal of community health nursing is community health and community development, it is necessary for the nurse to invest in training members of the community organization not only in the provision of actual health services but also in management functions. In community managed health programs, it is the intention that the nurse will eventually hand over the management of the health program to the people and the organization.

What are the objectives of supervision? Supervision is done in order to:

Identify the supervisory needs of the worker

Determine ways of meeting the needs of the worker

Develop the capability of the worker to solve own problems and meet own needs by providing continuing personal guidance and professional development.

Evaluate the performance of the worker as it becomes the basis for providing help or guidance

In community health nursing, supervision is seen more as a coaching (Gillies, 1989) function rather than a function of control. This is so because the intensity of supervision can not be likened to institutions where the environment can be readily controlled and where the supervisor can expect a certain level of competence from the workers having more or less passed certain qualifying criteria for the positions. This is quite different in the community where the workers have varying levels of cognitive and psychomotor capabilities not to mention their attitudes towards health work. In the community, most of the supervisory functions of the nurse are directed towards lower level health workers, thus, they will require closer supervision than do professional health workers. In addition, supervision is not based on set rules or formula but on each supervisory situation.

The nurse as a coach to health workers uses persuasion, exhortation and judicious mixture of reward and punishment to motivate the players toward higher levels of performance. She emphasizes group Goals rather than fulfilling the needs and desire of individual group members.

A nursing supervisory plan is a written document on how to organize and systemize supervisory activities. It includes objectives, strategies, resources and timetable of activities to meet the identified needs of the person being supervised. Generally, supervisory needs arise from:

Inadequate skills, knowledge and attitude

Conflict between organizational and individual goals

Work and personal situation

Lack of motivation

Making a Supervisory Plan

The following are the steps in making a supervisory plan (Public Nurse Manual on Supervision, DOH):

1. The nurse conducts a situational analysis focusing on supervisory needs assessment. Information regarding supervisory needs of the workers can be taken from the following:

Review of records and reports

Observation of the person at work

Interview of the worker

Interview of co-workers and clients of the worker in the community

2. Supervisory needs and problems may be prioritized based on the following criteria:

Degree of importance or urgency of the problem/need

Activities/strategies needed to meet identified needs

Magnitude and extent of the problem/need

Time frame to carry out actions

3. Set objectives.

4. Select activities, strategies and resources needed to meet identified objectives.

5. Identify indicators of evaluation.

Met the needs

Performance increased

Improved quality of service

Methods and Tools for Supervision

Methods Tools

Analysis of records and reports Record forms

o Personal data sheet of the worker

o Client records

o Performance evaluation

o Daily time record

o Reports submitted

o Accomplishment reports

o Target client list

Actual observation of worker’s performance in various situations:

o Clinic home visit

o Conduct of individual or group classes

o Nursing conference

o Organization/implementation of community projects and activities

Observation guide in the form of:

o Questionnaire

o Checklist

Individual/group conferences and meetings Anecdotal report

Critical incident report

Performance evaluation form

Minutes of meetings

Manuals/handbooks

Modules/case studies

Nursing audit

Supervisory logbook

Conducting a Supervisory Visit

1. All supervisory visits must be planned. The nurse reviews the outcomes and recommendations of the previous visit and based on these, formulate a work plan for the visit. If necessary, discuss the work plan with other team members for collaboration. Determine what materials are needed for the conduct of the supervisory visit.

2. The actual conduct of the visit is divided into three parts:

a. Opening – the nurse creates a warm, open and friendly atmosphere. Discuss the objectives of the visit, expected outcomes, the process and the time frame.

b. Body – the nurse discusses the following points with the worker:

o Results and recommendation of the last visit.

o Actions taken by the worker and the outcome of these actions.

o New areas of concern of the health worker.

o Review objectives and extent to which they were attained.

c. Closure – the nurse expresses the appreciation and support extended during the visit. Together with the worker, she plans for the subsequent visit.

Case Study Illustrating the Application of the Steps in Supervisory Planning

Linda, a Public Health Nurse of Municipality of San Juan, has five midwives under her supervision. They are Nona, Mildred, Letty, Celia and Jane.

While Linda was doing her annual evaluation of midwives, she found out that their targets were not being met. She conducted supervisory visits to all midwives and found out the following:

Sometimes, logistics and supplies come late and inadequate; requisition not submitted on time.

Target client lists, tally sheets/reporting forma and treatment records were not properly filled up and updated. Reasons given by the five midwives are the following:

Wrong computation of targets; don’t know updated guidelines

In target-setting

Inadequate reporting and recording forms

Confusion in the use of FHIS form

Difficult terrain affect the performance of Celia and Nona

Inadequate KAS of Jane who is new in the service

Based on the above situation, Linda makes a plan. Following this steps in planning, she identified the priority problem that is poor recording and reporting which is common to the five midwives under her supervision. Poor recording and reporting are due to:

Wrong computation of targets; they do not have the updated guidelines in target-setting

Confusion in the new FHIS form

Inadequate recording and reporting forms

A sample supervisory plan is shown on Table 6. The supervisory strategies/activities are directed at achieving the identified learning objectives and the evaluation indicators as learning outcomes in supervision.

TABLE 6. SAMPLE SUPERVISORY PLAN

PROBLEM IDENTIFIED OBJECTIVES STRATEGIES/ACTIVITIES TARGET TIME FRAME INDICATORS

Poor reporting/recording due to:

a. Wrong computation of targets, don’t have an updated guideline for target-setting

b. Confusion in the use of new FHIS form

c. Inadequate logistics/supplies

The midwives will be able to:

a. Compute targets correctly based on updated guidelines

b. Use and fill-up the FHIS form properly

c. Request logistics/supplies on time

d. Keep inventory of stocks up to date

Exercise on computation of targets based on updated guidelines.

Follow-up during supervisory visit.

Discussion on the

purpose/objectives of the new FHIS form.

Exercises on the procedures on the procedure for filling up FHIS form.


Discussion on the importance of submitting requisition of logistics/supplies on time.

Exercises on how to fill-up requisition forms.


Demonstration and exercises on how to set up an updated monitoring system to set up an updated monitoring system for inventory of stocks.


5 Rural Health Midwives




3 hours during Saturday meeting




Midwives compute targets correctly for different programs based on updated guidelines.

Midwives accomplish FHIS forms accurately

Midwives demonstrate proper filling-up of requisition forms

Midwives submit requisition of logistics and supplies on time.

Midwives show updated inventory of stocks

implementing the community health nursing services

Documents