Unit 5: Nursing care process in the care of population groups and community

Topic Outline
1. Principles of Community Health Care
2. Conditions in the Community Affecting Health
3. Characteristics of a Healthy Community
4. Nursing Process in Community Health Care
4.1 Community Assessment
4.1.1 Community Health Assessment Tools
4.1.2 Types of Data
4.1.3 Source of Data
4.2 Community Diagnosis
4.2.1 Types:
4.2.2 Traditional
4.2.3 Participatory Action Research
4.2.4 Schemes Staffing

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4.2.5 Community diagnosis
4.2.6 NANDA
4.2.7 Shuster and Goeppinger
4.2.8 Omaha System
4.3 Community Health Planning and Implementation
4.4 Evaluation of Community Health Interventions
4.5 Planning Community Health Interventions
4.5.1 Priority Setting: WHO Special Considerations
4.5.2 Formulating Goals and Objectives
4.5.3 Deciding Community Interventions/Action Plan
4.6 Implementing Community Health Interventions
4.7 Evaluation of Community Health Interventions

Learning Objectives
After studying this unit, you will be able to:
1. Illustrate the principles of community health nursing.
2. Describe conditions affecting the health of a given community.
3. Recognize characteristics of a healthy community.
4. Utilize the nursing process in managing community health concerns.

Introduction
The community health nurse’s aim is to improve the health status of the community in general. Just in other
fields of nursing practice, care of the community is undertaken utilizing the nursing process in a cyclical process of
assessment, diagnosis, planning, intervention, and evaluation.
To the nurse the community is not just the setting or the context for providing community health nursing.
It is the focus of nursing care. To the community health nurse, using the nursing process in dealing with the
community health needs requires the nurse to work with the community as an equal partner. Since the nurse’s
responsibility is to the community, nursing action is usually focus on primary prevention and promotion of a healthful
physical and psychosocial environment. The community health nursing process which is cyclical systematic begins
with assessment leading to community diagnosis which is used as the basic for planning community health
interventions for implementation and finally evaluation follow. And these are the steps undertaken by the nurse
and other members of the health team and community representatives. All of these are discussed below.

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 Activating Prior Knowledge
Please refer to ikonek. Answer the following questions in the discussion forum.

Overview: Community Health Nursing

Principles of Community of Health Nursing (Adapted from the 8 Principles of Public Health by
the American Nurses Association (2007)
1. Focus on the community as the unit of care.
2. Give priority to community needs.
3. Work with the community as an equal partner of the health team.
4. In selecting appropriate activities, focus on primary prevention.
5. Promote a healthful physical and psychosocial environment.
6. Reach out to all who may benefit from a specific service.
7. Promote optimum use of resources.
8. Collaborate with others working in the community.
Conditions in the Community Affecting Health
1. People - include size, density, composition, rate of growth or decline, cultural characteristics, mobility, social
class, and educational level
2. Location - Including natural (i.e., geographic features, flora & fauna) and man-made variables

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3. Social System - include the family, economic, educational, communication, political, legal, religious,
recreational, and the health systems (Allender, et al., 2009)
Characteristics of a Healthy Community (Adapted from Hunt, 1997 and Duhl, 2002)
1. A shared sense of being a community based on history and values
2. A general feeling of empowerment and control over matters that affect the community as a whole
3. Existing structures that allow subgroups to participate in decision-making in community matters
4. The ability to cope with change, solve problems, and manage conflicts within acceptable means
5. Open channels of communication and cooperation among the members of the community
6. Equitable and efficient use of community resources, with the view towards sustaining natural resources.
• A healthy community is in fact, “The process of enabling people to increase control over, and to improve,
their health”.- Ottawa Charter (WHO, 1986)
Community Health Nursing Process in the Care of Community
COMMUNITY ASSESSMENT
• The data need to be collected depend on the objectives of community assessment. In general, the nurse
needs to collect data on the three categories of community health determinants:
• 1) People – population variables that affect the health of the community include size, density, composition,
rate of growth rate or decline, cultural characteristics, mobility, social class, and educational level.
o Population size and density influence the number and size of health care institutions in urban areas.
o Health needs of communities vary because of differences in population composition by age, sex,
occupation, level of education and other variables.
o Rapid growth or decline of a population affects health of the community. Rapid population growth
usually results from migration of many people in the community from rural areas to the city. A rapid
decline in population may result from disturbances brought about by circumstances like disasters,
political instability, or economic changes such closure of an industrial area.
• 2) Place or location – affected by both natural and man-made variables
• 3) Social system – is the patterned series of interrelationships existing between individuals, groups, and
institutions and forming a coherent whole which include the family, economic, educational, communication,
political, legal, religious, recreational and health systems.
• Planned Approach to Community Health (PATCH) is a community health planning model that builds on
a set of quantitative and qualitative data for profiling.
Data Collected for the PATCH process for health planning
1. Community profile: demographic, educational, and economic data
2. Morbidity and mortality data, including unique health events (e.g., completion of a BHS, a typhoon that
caused flooding of residential area)

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 3. Behavioral data focusing on behavioral risk factors, such as smoking, drinking, and leading a sedentary
lifestyle, and prevailing good health practices in the community, such as BF and getting regular exercise.
4. Opinion data from community leaders, such as what they think about the main health problems of the
community, their causes, and measures that may alleviate or correct them.
There are several approaches in conducting community assessment.
1. Comprehensive Needs Assessment – the nurse gathers information about the entire community using a
systematic process where data is collected regarding all aspects of the community to be able to identify
actual and potential health problems.
o It requires much time and effort particularly the health assessment of the community is being done
for the first time.
o A periodic evaluation of health programs is required.
2. Problem-Oriented Assessment – focused on a particular aspect of health. The nurse collects information
with a certain community problem in mind, and then proceeds to gather information from the aggregate
vulnerable to the problem.
o This is workable when the nurse is familiar with the community such as comprehensive assessment
has been previously done.
o For example, in the comprehensive assessment you learn that the catchment population has a large
proportion of 0–5-year-old which are susceptible to malnutrition, so in problem-oriented assessment
the nurse will conduct a nutritional assessment focusing on feeding and dietary pattern of the
parents of infants and young children.

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Community Health Assessment Tools
Community health needs may be assessed using a variety of methods.
Data sources:
1. Primary Data- data that have not been gathered before and are collected by the nurse through observation
(Ocular/windshield survey and participant observation), survey, informant interview, community forum, and
focus group discussion.
Collecting Primary Data
• Rapid observation of a community may be done through an ocular or windshield survey, either by
driving or riding a vehicle or walking through it. This gives the nurse the chance to observe people as well as take
note of environmental conditions and existing community facilities. Participant observation is a technique that
suits community organizing and participatory action research.
• Survey is necessary when there is no available information about the community or specific population
group to be studied. It is made up of a series of questions for systematic collection of information from a sample
of individuals or families in a community and maybe written or oral.
• Informant interview are purposeful talks with either key informants or ordinary members of the
community. Key informants consist of formal or informal community leaders or persons of position and influence,
such as leaders in local government, schools, or business.
• Community forum is an open meeting of the members of the community.
• Focus group differs from community forum in the sense that the focus group is made up of a much smaller
group, usually 6-12 members only.
2. Secondary Data- what is already known; are taken from existing data sources.
Sources consist of vital registries, health records and reports, disease registries and publications.
Secondary data sources
• Registry of vital events Act 3753 established the civil registry system in the Philippines and requires the
registration of civil events, such as births, marriages, and deaths. RA 7160 (Local Government Code) assigned the
function of civil registration to local governments and mandated the appointment of Local Civil Registrars.
The National Statistics Office (NSO) serves as the central repository of civil registries and the NSO
Administrators and the Civil Registrar General of the Philippines before 2014. All these functions are now
under the Philippines Statistics Authority (PSA) by virtue of RA 10625 otherwise known as the “Philippine Statistical
Act of 2013”.
• Health Records and Reports
As specified by EO No. 352, the FHSIS is the official recording and reporting system of the Department of
Health and is used by the Philippine Statistics Authority to generate health statistics. The FHSIS is an essential
tool in monitoring the health status of the population at different levels.

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Recording Tools in FHSIS
a. Individual treatment record (ITR) – building block of the FHSIS. Contains the date, name, address of patient,
presenting symptoms or complaints of the patient on consultation, and the diagnosis (if available), treatment and
date of treatment. Maintained at the facility on all patients seen.
b. Target client list (TCL) – second building block of the FHSIS. The following are maintained in RHU’s and health
centers: prenatal care, postpartum care, under-1-year-old children, family planning, sick children, national
tuberculosis program TB register and national leprosy control program central registration form.
c. Summary table (ST) – accomplished by midwife. This record is kept at the BHS and has two components: Health
program accomplishment and Morbidity/Diseases.
d. Monthly Consolidation table (MCT) – accomplished by the nurse based on ST. Serves as the source of document
for the quarterly forms and the output table of the RHU or health center.
Reporting Forms in FHSIS
a. The monthly form (Program Report, Morbidity Report) – prepared by midwife and submitted to the nurse
for preparing the quarterly forms.
a. Program report (M1) – contains indicators such as maternal and childcare, family planning and
disease control.
b. Morbidity report (M2) – contains a list of all cases of disease by age and sex.
b. The quarterly form – prepared by the nurse
a. Program Report (Q1) - contains the 3-month total of indicators such as maternal and childcare,
family planning and disease control.

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b. Morbidity Report (Q2) – is a 3-month consolidation of morbidity report (M2)
c. The annual forms
a. A-BHS – report of midwife that contains demographic, environmental and natality data
b. Annual Form (A-1) – prepared by nurse and is the report of RHU or health center. It contains
demographic and environmental data and data on natality and mortality for the entire year.
c. Annual Form 2 (A-2) – prepared by the nurse. Is the yearly morbidity report by age and sex.
d. Annual Form 3 (A-3) – prepared by the nurse. Is the yearly report of all deaths (mortality) by age
and sex.
• Disease registries
A disease registry is a listing of persons diagnosed with a specific type of disease in a defined population.
Data collected through disease registries serve as basis for monitoring, decision making and program management
(DOH, 2011).
• Census data
A census is a periodic governmental enumeration of the population. During census people may be assigned
to a locality by de jure or de facto.
• De jure assignment is based on the legally established place of residence of people, a method used by PSA
during national census; whereas
• De facto is according to the actual physical location of people.
Methods to present community data:
Community data are presented to the health team and the members of the community for the following purposes:
• To inform the health team and members of the of existing health and health-related conditions in the
community in an easily understandable manner.
• To make members of the community appreciate the significance and relevance of health information to their
lives.
• To solicit broader support and participation in the community health process.
• To validate findings.
• To allow for a wider perspective in the analysis of data.
• To provide a basis for better decision making.
Depending on the context and the purpose of the presentation community data may be presented as text, in tables
or in pictorial form such as maps and graphs.
Maps can be used to show difference or similarities across geographic areas.
In contrast numeric data are usually more clearly presented through tables and graphs.
1. bar graph – to compare values across different categories of data for example population pyramid
2. line graph – to have a visual image of trends in data over time or age for example trend of the TFR
3. pie chart – to show percentage distribution or composition of a variable such as population or households

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 4. scatter plot or diagram – to show correlation between two variables. For example, correlation between BMI
and waist circumference among men aged 18 years of age.
COMMUNITY DIAGNOSIS
• As process: Is the process of determining the health status, resources and health action potential or the
likelihood that the community will act to meet health needs or resolve health problems.
• As a finding: A quantitative and qualitative description of the health of citizens and the factors which
influence their health
• Community diagnosis allows identification of problems and areas of improvement, thereby stimulating
action.
Schemes use in stating community diagnoses.
• NANDA nursing diagnostic labels focused more on individual rather than the community responses to
health conditions, have included diagnosis at the community level.
Shuster and Goppingen proposed a practical adaptation of a format of nursing diagnosis for population groups
previously presented by Green and Slade (2001).
The three parts consists of:
1. The health risk or specific problem to which the community is exposed.
2. The specific aggregate or community with whom the nurse will be working to deal with the risk or problem.
3. Related factors that influence how the community will respond to the health risk or problem.
The OMAHA System

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Initially designed for clients in a community setting and has been used as a framework for the care of individuals,
families and communities by nurses, nursing educators, physicians and other health care provider. (Please
refer to the Omaha System website)
• Domains and Problems of the Problem Classification Scheme
a. environmental domain – materials resources and physical surroundings both inside and outside the living
area, neighborhood, and broader community.
b. psychosocial domain – patterns of behavior, emotion, communication, relationships, and development.
c. physiological domain - functions and processes that maintain life.
d. health-related behavior domain – patterns of activity that maintain and promote wellness, promote
recovery, and decrease the risk of disease.
PLANNING COMMUNITY HEALTH INTERVENTIONS
• As in other fields of nursing practice, planning for community health interventions is based on findings during
assessment and formulated nursing diagnosis.
• Planning is a logical process of decision making to determine which of the identified health concerns requires
more immediate consideration and what actions may be undertaken to achieve goals and objectives
involving: Priority-setting, formulating goals and objectives and deciding on community interventions
1. Priority Setting
WHO Special Considerations (Criterion)
• Significance of the problem – is based on the number of people in the community affected by the problem of
condition.
• Community awareness – level of community awareness and the priority its member gives to the health concern
• Ability to reduce risk – is related to the availability of expertise among the health team and the community itself
• Cost of reducing risk – consider economic, social, and ethical requisites and consequences of planned actions.
• Ability to identify the target population – for the intervention is a matter of availability of data sources, such as
FHSIS, census, survey reports, and/or case-finding or screening tools.
• Availability of resources – accessibility of outside resources and the link to these resources are considered.
• Requires the joint effort of the community, the nurse, and other stakeholders, such as other members of
the health team.
Shuster and Goeppinger (2004) suggested a flexible process using the nominal group technique where in each
group member has an equal voice in decision-making, thereby avoiding control of the process by the more dominant
members of the group or based on the opinion of the majority.
Steps in Priority Setting
1. From a scale of 1 to 10, 1 being the lowest, the members give each criterion a weight based on their perception
of its degree of importance in solving the problem. For example, each member assigns a weight to the significance
of the problem in response to the question, “How important is significance of the problem to its solution?”

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2. From a scale of 1 to 10, 1 being the lowest, each member rates the criteria in terms of the likelihood of the
group being able to influence or change the situation. For example, each member rates significance of the problem
in response to the question, “Can the group influence the significance of this problem?”
3. Collate the weighs (from step 1) and ratings (from step 2) made by the members of the group.
4. Compute the total priority score of the problem by multiplying collated weight and rating of each criterion.
For example:
Assigning criterion Weigh through the Nominal Group technique
Problem: Risk for maternal complications leading to maternal mortality in Barangay Bagong Bayan
Question: How important is the criterion in solving the problem?
Criterion Nurse Yna Midwife Yano BHW Yeye Mrs. Santos Mr. Reyes Average Weight
Significance of the problem 8 10 7 6 8 8
Community Awareness 8 8 5 5 5 6
Ability to reduce risk 10 10 10 10 10 10
Cost of reducing risk 8 8 8 8 8 8
Ability to identify target population 4 5 6 5 6 5
Availability of resources 8 8 6 5 8 7
Assigning Rating through Nominal Group Technique
Problem: Risk for maternal complications leading to maternal mortality in Barangay Bagong Bayan
Question: Can the group influence the situation in relation to the criteria?
Criterion Nurse Yna Midwife Yano BHW Yeye Mrs. Santos Mr. Reyes Average Weight
Significance of the problem 6 8 4 6 6 6

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Community Awareness 10 10 10 5 5 8
Ability to reduce risk 6 6 6 6 8 6
Cost of reducing risk 6 6 6 4 4 5
Ability to identify target population 10 10 10 8 6 9
Availability of resources 4 4 3 2 2 3
Computation of Problem Priority Score
Problem: Risk for maternal complications leading to maternal mortality in Barangay Bagong Bayan
Criterion Criterion Weight (1-10) Criterion Rating (1-10) Problem Score
(Weight X Rating)
Significance of the problem 8 6 48
Community Awareness 6 8 48
Ability to reduce risk 10 6 60
Cost of reducing risk 8 5 40
Ability to identify target population 5 9 45
Availability of resources 7 3 21
Total priority score of problem 262
2. Formulating Goals and Objectives
As in family health nursing, goals are the desired outcomes at the end of interventions, whereas objectives
are the short-term changes in the community that are observed as the health team and the community work
towards the attainment of goals. Objectives serve as instructions, defining what should be detected in the
community as interventions are being implemented. It should be specific, measurable, attainable and time bound.
3. Deciding on Community Interventions/ Action Plan
Because of their inherent differences, what may work for one community may not be effective in another. The group
analyzes the reasons for people’s health behavior and directs strategies to respond to the underlying causes.
For example, reasons for preference of home delivery over facility-based delivery should be identified. If most of
the women would choose to have a home delivery because of cost or lack of access of birthing facilities, strategies
should then be focused on improving facility-based services.
IMPLEMENTING THE COMMUNITY HEALTH INTERVENTIONS
• Often referred to as the action phase, implementation is the most exciting phase for most health workers,
aside from being able to deal with recognize priority health concern, the entire process is intended to
enhance the community’s capability in dealing with common health problems/conditions.
• The nurse’s role therefore may be to facilitate the process rather than directly implement the planned
interventions. Implementation also entails coordination of the plan with the community and other members
of the health team. This requires a common understanding of the goals, objectives, and planned
interventions among the members of the implementing group. Collaboration with other sectors such as the
local government and other agencies may also be necessary.
EVALUATION OF COMMUNITY HEALTH INTERVENTIONS
• Evaluation approaches may be directed towards structure, process, and/or outcome.

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Structure evaluation involves looking into the manpower and physical resources of the agency responsible for
community health interventions.
Process evaluation is examining how assessment, diagnosis, planning, implementation, and evaluation were
undertaken.
Outcome evaluation is determining the degree of attainment of goals and objectives.
Ongoing evaluation or monitoring is done during implementation to provide feedback on compliance to the plan
as well as on need for changes in the plan to improve the process and outcomes of interventions.
Standards of Evaluation
1. Utility – is the value of the evaluation in terms of usefulness of results. This will provide a basis for utilizing
the community health process in dealing with other community concerns in the future. Disseminating the
results of the evaluation will allow the community to identify barriers, and in the future, think of strategies
to overcome or minimize these barriers.
2. Feasibility – answers the question of whether the plan for evaluation is doable or not considering available
resources which includes facilities, time, and expertise for conducting the evaluation. Feasibility entails
anticipation of how the results of the evaluation will be received by different groups and how to avoid
possible misuse of data derived from the process.
3. Propriety – involve ethical and legal matters. Respect for the worth and dignity of the participants should
be given due consideration. The results of evaluation should be truthfully reported to give credit where it
is due and to show the strengths and weaknesses of the community.
4. Accuracy – refers to the validity and reliability of the results of evaluation. A high degree of validity and

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reliability can be achieved by choosing and properly utilizing the right evaluation tools.

Read
Chapter 7 The Nursing Process in The Care of The Community on pages 134-150 of the book authored
by Zenaida U. Famorca et.al.

Activity 1
Please refer to ikonek. Answer the following activity.

Interactive Link

Summary
• Community health work requires a systematic process of ADPIE
• The goal of this process is a healthy and empowered community.
• A nurse must work with the community as an equal partner
• The nurse oversees the efficient use of resources through the entire community health process

Readings and References

• Nursing Care of the Community: A comprehensive text on community and public health nursing
in the Philippines by Zenaida U. Famorca, Mary Niew and Melanie McEwen
• Community Health Nursing and Community Health Development: Text-Workbook 1st ed. 2021
by Cecilia Estrada-Castro, RN,MAN, MSPsychology
• Community and Public Health Nursing 2nd ed by Mary A. Nies, PhD, RN, FAAN, FAAHB, Melanie
MCEwen, PhD, RN, CNE, ANEF and Philippine Ed Adapting editor Earl Francis Rualo Sumile, PhD.
RN
• Community/Public Health Nursing 7 th edition by Mary A. Nies and Melanie McEwen
• Community Health Nursing Services in the Department of Health Philippines (2000). Community
Health Nursing. 9th Edition. National League of Government Nurses, Inc.

All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
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All information contained in this module are property of UCU and provided solely for educational purposes. Reproduction, storing in a retrieval system, distributing, uploading or posting online, or transmitting
in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise of any part of this document, without the prior written permission of UCU, is strictly prohibited.
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