Table of

Contents
Editorial 1
SPECIAL FEATURE ARTICLE
• The Changing Health Care Context: Impact and Implications to Nursing 3
Amelia Mangay-Maglacas, BSN, RN, Dr.Ph, Sc.D(hon)
• Mga Nars: Putting Care in Healthcare 7
Atty. Jansen Taruc Nacar

RESEARCH ARTICLES
• Capacity Needs Assessment of Primary Health Care Providers 11
in Selected Municipalities in Cavite
Irma I. Almoneda, MAN, RN1, Sheila R. Bonito, DrPH, RN,
Luz Barbara P. Dones, MPH, RN, Josefina A. Tuazon, DrPH, RN
• From Testing to Coping: The Voices of People Living with HIV/AIDS 21
Mark Gilbert S. Milallos, RN, LPT, MSN1 and Jezyl C. Cutamora, RN, MN, PhD
• Assessment of Knowledge and Skills of Barangay Health Workers: 28
Basis for Diabetes Education Program for Lay Persons
Joylyn L. Mejilla, MAN, RN1, Anjanette S. De Leon, MAEd, MAN, RN,
Ana Leah D. Esguerra, MAN, RN, Josefina E. Florendo, EdD, RN,
Leyden V. Florido, MAN, RN, Mercerose P.J. Puno, MAN, RN,
Ray Justin M. Reyes, RN and Eleonor C. Tangkeko, PhD, RN
• Normalizing Advanced Practice in Public Health Nursing in The Philippines: 35
A Foucauldian Analysis
John Joseph Posadas, RN, MSAHP1, Luz Barbara P. Dones, MPH, RN
and Peter James B. Abad, MSc, RN
• Promotion of Safe Motherhood in the Nursing Competency-Based Curriculum 41
Arnold B. Peralta, RN, MAN, MHPEd1, and Erlyn A. Sana, PhD
• A Five-Year Trend Analysis of the Philippine Nurse Licensure 47
Examination (2014-2018)
James Montegrico, MSN, RN

FEATURE ARTICLE
• Compassionate Nurse: A Concept Analysis 52
Geraldine Y. Ferreras, MSN, Rna

NURSES’ VOICE FROM THE FIELD

• The Importance of Encouraging Child Development 56
Pimkanabhon Trakooltorwong, RN, MSN
• Motivators and Demotivators: Navigating Self-Care and Silencing Self-Doubt 58
Gia Laarni Indonto–Simbulan, RN
Guideline for Authors 60

PJN VOL. 88 | NO. 2 Abstracts and articles may may accessed at the following links: http://www.pna-pjn.com
This pubication is not for sale http://www.pna-ph.org/archives/philippine-journal-nursing and http://www.wprim.org

SPECIAL FEATURE ARTICLE
THE CHANGING
HEALTH CARE CONTEXT:
IMPACT AND IMPLICATIONS
TO NURSING
Amelia Mangay-Maglacas, BSN, RN, Dr.Ph, Sc.D(hon)
Former Chief Scientist for Nursing, World Health Organization, Geneva Switzerland
Once upon a time, nursing was straightforward and clearly understood.
The task composed of carrying out procedures that met actual needs for care and cure.
t he nursing task have changed, however, under a wide range
of influences, including: (a) changing trends in demographic
distribution and epidemiological patterns of morbidity and
mortality; (b) the amount of money available for health care; (c)
the structure of the health care system and its rewards; (d) the
expectations of patients, families and the community, including
the politicians: (e) the number and distribution of the health
workforce and the policies that affect the allocation of health
services: (f) progressive growth in specialization and adaptation
of new technological opportunities; and (g) demands of
professional groups in protecting their areas of expertise and
securing their uniqueness and values in the health care
spectrum.
The latter influence has been a major force in the nursing
profession`s effective role in health development or could be a
disaster nursing grapple for the health of the profession rather
than the health of people.
Across the world, critical issues concerning health have moved to
the top of the social and political agenda of countries. The 'health
of all goal' that the World Health Assembly set out in 1977 for the
world to pursue has accelerated the movement towards the
increasing awareness of health needs and the enhanced
demand for health security. Several reports have documented
that in the last decade there have been overwhelming world
trends towards bringing about healthier people and communities,
1 This paper was delivered at the UP Manila-College of Nursing Symposium held on January 23, 1996. It is being reprinted for its valuable insights then and now. A paper worthy for critical
reflection and united action.
3
1
and longer life expectation but at the same time the startling
realization that the quality of life is worsening.
In these final years of the 20th century, the overriding
characteristics of our times is rapid change: political change,
economic change, environment change, and technological
change. This pervasive and rapid change has led to widespread
improvements in material standards of living for many people.
Nevertheless, the gap between the rich and the poor has
increased. Poverty continues to be a major obstacle to health
development. The number of poor people has increased
substantially especially in the slums of the great cities. Poverty,
however, needs to be understood not only in the economic sense,
but in the multi-causal dimension that results from inequalities,
lack of education and information and inaccessibility of essential
services, technology and resources.
The structure of the family continues to change, generally
becoming more nuclear (for the Philippines, separation of parents
and children for economic pursuits) and thereby weakening
traditional relationships based on caring and support and eroding
value systems, culture and beliefs which gave primacy to family
solidarity.
In the Philippines, for example, the mass exodus of the more than
four million workers is rupturing the country`s social fabric by
breaking down traditions of kinship and community. One out of
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every three Filipino homes has a family member working abroad.
Also, officials estimate that there are 1.79 million undocumented
workers overseas. These changes in family structure and family
breakdowns have had repercussions on the health of individual
family members and of the family as a whole. It also has an
impact on behavior, especially that of the young people and
particularly in the areas of tobacco, alcohol, drugs, teenage
pregnancy and prostitution, with important short-and-long-term
consequences for health. We have entered into a new age of
violence and these include rising street crimes, weakening
social fabric, moral decay and the threat of social disintegration.
Human health is being and will continue to be profoundly
affected by these changes.
Changes in the physical environment and the application of
technology have produced some new health risks and
conditions of ill-health, ranging from occupational diseases to
the effects of toxicity and pollution of differing types. Accidents
and man-made disasters (e.g, violence, child abuse) have
grown in scale and intensity and have become one of the leading
causes of death and industry, nuclear power and a host of other
activities, with automobile accidents taking the lead in accidents
in general.
The growth of ill-health linked to new and changing lifestyles and
patterns of consumption have become an important part of the
disease burden. Living longer but not better will have an
important bearing on the choice and implementation of health
development strategies including the services to be provided by
nurses. The health hazards of changing lifestyles, value systems
and rapid technological changes are greatest for the young.
These can manifest themselves in insecurity, alienation, drug
abuse, promiscuity, violence and suicide. Health care systems,
including nursing services, normally enters after the event, when
they have to provide care for the victims.
With the establishment of the goal “healthy for all”, followed by
defining primary health care as the strategy to achieve the goal,
most health systems worldwide underwent and are undergoing
far-reaching changes. The central focus is to replace the health
systems of curative medical care systems with a new and
different model consistently based on the principles of the
Primary Health Care Declaration at Alma Ata in 1978. I need not
repeat or elaborate what these principles are for you all have
been imbued about these in your nursing education program and
in the many continuing education programs on primary health
care. To date these fundamental principles have not been
completely understood or else the will to understand them
correctly has been lacking.
With the establishment of the goal “health for all”, followed by
defining primary health care as the strategy to achieve the goal,
PJN VOL. 89 | NO. 2
most health systems worldwide underwent and are undergoing
far-reaching changes. The central focus is to replace the health
systems of curative medical care systems with a new and
different model consistently based on the principles of the
Primary Health Care Declaration at Alma Ata in 1978. I need not
repeat or elaborate what these principles are for you all have
been imbued about these in your nursing education program and
in the many continuing education programs on primary health
care. To date these fundamental principles have not been
completely understood or else the will to understand them
correctly has been lacking.
The “health for all goal” offers us a new professionalism that puts
health first before illness and primary health care as the mode for
practice.
Some of the major challenges the nursing profession is facing
today and well into the end of this century are: Unprecedented
growth of the population with concomitant problems of
widespread poverty, social, economic and gender inequalities,
wasteful consumption patterns increasing humans suffering
depleting the earth`s resources and intensifying environmental
degradation.
To most of us today, this reflects that recognition of these
problems are inseparable and that the quality of life of current
and future generations hinges on how well the development
process, including health development responds to all of them.
How many nurses feel any kind of responsibility as they read the
latest statistic on drug, alcohol and nicotine addiction rates? Or
on child prostitution and on street children? On the increase of
violence and crime? On the number of tobacco caused deaths?
Do these facts not concern nurses and nursing? Can nurses just
stand around and see these happen?
(2) According to the WHO, “AIDS is an ever-expanding plague
and there has been scans progress in the search for ways to
tame the disease and that Asia, a relatively new comer to the
epidemic could soon become its epicenter”. The Philippines is
one of the countries where estimates are on the increase. Do
these facts not concern nurses? What adequate preparation and
nursing care practices are nurses making with today's victims for
their lives before death? And for allaying the victim's fears and
those of their families and partners?
(3) What needed nursing intervention can be given to the millions
of people coping with one or more of life's critical events, such as
bereavement, homelessness, unemployment, old age and
loneliness. Are nurses aware? And if they are, do they as nurses,
care that there are inequalities in health care, education and
employment? What about people without access to safe water
supply and basic sanitation? Can and will nurses accept that they
have a responsibility to enable people to achieve a full life?

Accepting the notion of a responsibility towards developing the
health potential, means moving the focus to health. In order to do
this, nursing actions health care providers. Involvement of
people themselves and other sectors, i.e., education, labor,
agricultures and environment, are equally important to bring
about healthy people. Too many nurses still think in terms of
medical care systems rather than thinking and understanding
the determinants of the “new health problems” and to grasp
opportunities that reach far beyond the health care system and
the roles of just the health care providers in the system.
My challenge and vision for nursing is that nurses should be
running health services, not illness services. I first publicly
espoused this vision in 1987 at Washington, D.C. in my keynote
address to the 15th Scientific Session of the American Academy
of Nursing and then in 1988 at the J.V. Sotejo Lecture series at
the University of the Philippines and again in 1994 at a
symposium organized by the International Nursing Foundation
of Japan held in Tokyo. I will draw and repeat several aspects I
felt and still do, that nurses need to be concerned with as they
practice nursing for health.
Nursing has no future if it has only room for sickness care.
Nursing must imbibe a new human-centered culture of health
development in which the environment, the economics, the
politics, social justice, health policy designs are all considered to
be distinct aspects of the drive towards a healthier society. Many
nursing education programs, research designs and services
tend to be based more or developed following professional
ideals which are rather removed from the real needs of people,
the context of health care systems and the presenting socio-
economic, political and environmental factors.
Much has changed. Nurses and nursing associations have
grown astute in implementing better recognition and conditions
of work, but not enough to assume as increasingly important role
in health care reforms due to the changing development and
health scenario. Nurses need an education and practice that
places emphasis on examining and reviewing critical conditions
and vulnerability that are closely associated with the changes
caused by the ongoing processes of social economic
developments and not just on disease-specific approaches and
interventions.
It should not be forgotten that there are two sides to Florence
Nightingale. There was the image that so many of us have in our
minds of the caring “Lady with the Lamp” who tended the
wounded throughout the night, yet still had time to write to her
former soldier patients. But the other side was a nurse with the
courage to expose the scandal of appallingly unsanitary
conditions in the field hospitals during the Crimean War in 1854.
She refused to be quieted and her determination was rewarded
by a public outcry in Britain, which led to a major reorganization
5
JULY - DECEMBER 2019
of conditions and supplies for her patients. She went on to find
the Red Cross and initiated many other major changes in health
care. It was the social concern of this nurses that gave her
healing skills so much power.
Perhaps we should make an effort to construct and breathe life
into new nursing theory to health without its needing to be
separated from ill-health care. Can we attempt to re-order and
refine nursing knowledge with open and dynamic
conceptualization of the suffering of individuals according to the
sociological niches within which they must live? Can we organize
our efforts to prepare nurses to lead them to achieve an
integration of the physiological process with the sociological
context in which it occurs? We need to move from the exclusive
concern with illness, in our education, practices, research and
leadership, towards a broader visualization of health as it relates
to policy or politics in the broadest sense. I believe that it is
through taking up that political challenge raised at the Alma Ata
Declaration that we can begin strengthening nursing's viability
and visibility for the future.
The future starts now. The areas for action in nursing are clear.
Most important to bear in mind is that not only is it important to
have good technology and sound knowledge with which to attack
priority health problems but also to be able to generate the right
kind of attitudes.
We need nursing education programs that are based on and feed
into the framework of the country`s health development plan.
Such programs must be learner-oriented and based on meeting
the needs of populations and solutions of actual or typical health
needs. Such programs use the problem-based approach that
encourages and stimulates independent study and continuing
learning and the acquisition of knowledge and skills in
community/patients involvement, social organization,
economics of health, health policy and politics. Such programs
will also emphasize wellness besides pathology and link health
with the development process as well as o health care system
design and healthy public policies. In all these we need to think
about the broader issues of health development and look at the
bigger picture of positive health. Such nursing education
programs will help create the critical reflective practitioner.
New directions for nursing research must place priority on health
and nursing services research. Some example are, research on
promotion of community/patients participation; those concerned
with the socio-cultural and economics components of health
problems and nursing care; as well as those measures that will
help people to change their lifestyle in ways that are conducive to
improved health and a better quality of life, and those geared to
developing nursing technologies that are of direct relevance to
real needs of people.
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For those actions to be developed and implemented, responsible
nursing leadership is necessary. A leadership that moves
molding the future rather than just managing the present. A
leadership that forges vision, imagination, innovation, and
realism. A leadership that grasps the issues of health and nursing
development rather than becoming a prisoner of events, reacting
than leading, and aiming to retain stereotype complexes.
Let me now capitulate some succinct points that could make the
differences in nursing for health.
On sensitivity: In the past, nurses have been known for their
sensitivity to needs of the hospital patients. Now, they need to
acquire sensitivity to the broad issues of health in communities
that militate against individuals achieving a high quality of life.
On additional skills: In the past, nurses have been skillful in
carrying out tasks and procedures for people, and to people.
Now, they need to enhance other skills so that they can work with
people and from people; skills such as those of strategic
planning, economics of health care, networking and coalition
processes, epidemiological analysis and computers, policy
formulation and political processes.
On reorganized structure: In the past, nurses have always felt
secure within the walls of an institution and hierarchical structure
of nursing services. Now, they need to develop the individual
confidence to represent nursing within a multi-disciplinary team
and to speak within a multisectoral setting.
On re-formation of statutes: In the past, nurses knew that their
practice was legally covered as they were “carrying out
physician's directives”. Now, they need to be prepared to be self-
directive, interdependent, and accountable as individual
practitioners.
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On having a courageous and animated spirit: In the past, nurses
have been socialized to simply do and not to question. Now, they
need to explore research, change, innovate, imagine and create.
On professional solidarity: In the past, nursing has been
characterized by a serious lack of unity among its members.
Now, if nurses' collective energies are to be mobilized to serve as
a powerhouse for social change, it must work in concord, toward
common objectives, and with mutually agreed and supported
leaders.
On effective strategies: Strategies are needed to be spelled out
to effect changes. Leadership that is visionary, vital and vigorous
is required.
The future of nursing needs to be charted now. We need to
quicken our pace now. The health needs of people cannot wait.
Time for the 21st century is fast running out, running out more
quickly than we are moving forward.
_______________
ABOUT THE AUTHOR
Amelia Mangay-Maglacas, BSN, RN, Dr.Ph,
Sc.D(hon) is a former Chief Scientist for
Nursing, Division of Health Manpower, World
Health Organization, Geneva, Switzerland.

KEYNOTE
MGA NARS:
PUTTING CARE IN HEALTHCARE
Atty. Jansen Taruc Nacar1
What if we lived in a world without nurses? Can you imagine that? No? Great! Because I cannot
either. Who will be with my wife if I get confined in the hospital if there were no nurses?
Introduction
G ood morning and welcome, everyone.
Before you endure my forty-minute keynote speech, allow me to
give my thanks to the organizers of this event for making it
possible for me to be part of this, PNA National President, Erlinda
C. Palaganas, the Chapter Presidents, Ms. Carmen C. Bolinto,
Mr. Vicente Panagan, Mr. Mark Robin Daguio, Mr. Darren Carino,
Mr. Lilian Tumapang, Mr. Jandel Taguiam, and Mr. Val Marcelo.
and thank you to all of you who are here. Without you, there is no
Regional Conference to speak of today.
I am not a nurse, as you already know. I am a lawyer by profession
and an advocate for nurses, among others, by passion. However,
I can say that I know a bit about your struggle.
You might be wondering, what is this lawyer going to talk about?
Is he going to blabber about laws? “But we don't speak Legalese,”
you might say. No, let us do away with that.
I am here to talk about how nurses touch lives, how and why you
should be valued more, some legal matters which I promise to
explain in English and not Legalese, and why you are the prime
movers in the realization of universal health care for every
Filipino.
Let us first talk about how nurses touch lives. Your clout is far-
reaching. You are partners of doctors, other healthcare workers,
patients, and families of patients.
I married into a family of healthcare professionals, and my
youngest sister is a nurse in Australia, too. She worked at a
private hospital here for about nine (9) years and eventually went
overseas. I am sure you know this story well. Hers is one of the
many pages of the familiar narrative surrounding the nursing
profession these days.
1 Abridged version of the Keynote Address delivered on the PNA-CAR's Regional Convention, September 14, 2019 held in La Trinidad, Benguet.
1 Legal Counsel, PNA, 2019
7
Anyway, back to my anecdote. My wife's grandmother had a brain
surgery last year after having a fall. She survived it, though it
rendered her unable to speak, walk, and comprehend. She stayed
in the hospital for almost a month, until we took her home after
having a PEG. In the hospital, our Lola Sabel was patiently cared
for by the nurses. I saw how religious they were on checking up on
her Glasgow Coma Scale and her other stats. I also saw how they
managed to communicate with our family and with the doctors. My
wife would always tell me, “They [the nurses] were happy when
Lola progressed. They were sad when she regressed. When her
GCS was a single digit, what I appreciated was the empathy.”
At home, her children made sure she was given the best medical
care. We set up her own hospital bed, her own suction machine,
oxygen tank and regulator, feeding tube and other medical
equipment and supplies. She had her own health care team on
rotation: four (4) private nurses and three (3) caregivers who
became instant family. Our family loved them for loving our
grandmother. My wife, who was then the family's point person
said, "Grabeng dedikasyon ang dinedemand ng trabaho nila."
Lola's nurses educated us about the care she needed and about
her physical expressions. They bravely faced and entertained the
visitors who asked about her condition. Explaining to them and
accompanying the visitors was beyond their job description, but
they still did it. Nights, they would be tired holding 12-hour shifts,
yet come day, they had the energy to converse with those who
came to see Lola before their turnover. They took charge of listing
down what Lola needed, how much supply she still had, what
medicines needed to be bought. They also did her morning and
afternoon exercises in coordination with her therapists.
Lola never had any bedsores, not a single one; our aunts who are
nurses attribute this to the good care plan Lola's team executed.
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Most important of all, Lola's nurses talked to her even when she
could not reply, and encouraged her even when she could not
thank them. In that way, they empowered her. We would like to
think that this is one of the reasons why Lola's will to go on was
nurtured longer than predicted.
Of course, these came with a pretty price. The truth is, it was
expensive to maintain home care. But her children made sure she
got the best so that we could have her longer, even if it was on
borrowed time. Lola held on for almost 14 months. Aside from the
outpouring love from family and friends, I am certain we had her
for 14 borrowed months because of the dedicated nurses and
caregivers who looked after her.
But here's the thing: Lola Sabel's case is not the same case for the
average Filipino.
Three of her five children are nurses abroad. One is a doctor
overseas, and one is an engineer here in the Philippines. You see,
this is the glaring irony of my anecdote. My wife's aunts and uncle
are like many of our healthcare workers who go overseas for
better opportunities and leave their families behind. In fairness to
them and with my respect, they all went home when Lola had her
brain surgery. When she was already cleared for transfer to the
private room from the ICU, one by one, they bid farewell – a
choice dictated by economic reasons. As one of our aunts said,
the irony is that they had to leave their mother in the care of others
so that they may afford to give her a comfortable recovery and the
medical care she deserved.
As I said, Lola's case is not the same for the average Filipino.
Lola's case is one of those where the patient is blessed to have a
family that can afford access to quality health care. But what about
the others who cannot afford to buy the prescribed antibiotics for
say, the minimum five (5) days? What about the mother whose
son has pneumonia but cannot afford to go to the hospital, not just
because of the expected medical expenses, but also because of
the cost of transportation? Or the student afraid of taking lab tests
because his/her pocket cannot pay for it?
Ideally, universal health care targets this. Universal health care or
Kalusugang Pangkalahatan, means accessible, comprehensive
health care for all Filipinos. Alagang pangkalusugan ay abot-
kamay at abot-kaya para sa bawat Pilipino.
Keynote Proper
We are living in an era where the international community has set
goals that each nation must incorporate in their development.
Simply put, the global goal is sustainable development. We want
a world where no one is left behind. In essence, that is what
universal healthcare is: healthcare where no one is left behind.
How near are the facts to the ideal?
The sad reality is, Filipinos have only three options when they get
sick: first, go to scarcely-resourced and understaffed public
PJN VOL. 89 | NO. 2
hospitals; second, go to an expensive private hospital; or third,
disregard health problems for lack of financial capacity.
Sometimes, there is a fourth option: go to faith healers or quack
doctors and hope for a miracle.
With well-planned universal health care, the Filipino need not go
through the labors of the second, third, or fourth options to access
quality health care. We must always remember that health care is
a right. It is not a mere privilege. It is something that cannot and
should not be alienated from anyone. But for us to enjoy this right,
we must have the appropriate human, financial, and structural
resources.
Recently, the President signed the Universal Health Care Act. The
law entitles every citizen to health coverage that makes quality
care accessible. It is not 100% percent free, but it includes the
provision of basic services, accommodations, primary care,
medicines, and lab tests, among others.
We are all for universal health care because it is humanitarian,
humane, and for the common good. Nonetheless, we know that
what the law guarantees in principle is not always what is done in
practice, although it should be.
The UHC law is not the panacea to the problems of our health care
sector. The problems are so deeply entrenched that they are
related to other integrated sectors of society: policy, economy,
culture, education, and others.
Before we can have health care that is universal, we must first be
capable of providing quality health care. Are our nurses, who are
the front liners, guaranteed pay that is commensurate to their
work? Though Section 23 of the law says that “All health
professionals and health care workers shall be guaranteed
permanent employment and competitive salaries,” the
government must be prepared, lest it fall short of its pledges
embodied in law.
The intent of the law is noble, sure. But at what price? Our nurses
are already overworked, underpaid, undervalued, unappreciated.
Much as you would all want to cater to all patients, must it be at the
expense of your own mental, emotional, and physical health? No.
Nurses are the backbone of our health care system. A weak
backbone may result in a fall. We must therefore bolster the
backbone first.
One of my most respected advocates, who President Caster
personally knows as well, said that you nurses must be at the front
of the struggle for UHC because of your number and your
Florence Nightingale heart for health and the poor. I agree.
Before we go into the primary role of nurses in achieving UHC,
allow me to first walk you through some legal matters. I will do my
best to be as simple as possible. This is the legal part of my
keynote. What are the tools that our nurses can now use in
realizing the ultimate goal of universal access to healthcare?

1. Universal Health Care Law. On Feb. 20, 2019, the Universal
health care law was passed. It guarantees equitable access
to quality and affordable healthcare services for all Filipinos. It
will also automatically enroll Filipino citizens into the National
Health Insurance Program and expand PhilHealth coverage
to include free medical consultations and laboratory tests.
Among others, it also aims for the improvement of health
facilities especially in underserved areas; responding to the
gap in health workers throughout the country; strategic
engagement of the private sector; and creating and
expanding new functions in the Department of Health (DOH)
to improve the delivery of health services, according to an
official statement by the DOH.
We also have other nursing concerns that need to be addressed
by our laws –
2. Increase in compensation -
a. Originally, RA 6578, under the salary standardization law,
nurses have a salary grade 10 entry level.
b. Under RA 9173, or the Philippine Nursing Act of 2002, the
entry level is salary grade 15. One of the salient features of
the law is that it increases the salary grade of government
nurses. In 2008, Congress enacted Joint Resolution No. 4,
which “authorized the President of the Philippines to modify
the existing Compensation and Position, Classification
System of civilian personnel and Base Pay Schedule of
military and uniformed personnel…” Thus, in 2009, then
President Gloria Macapagal Arroyo issued Executive Order
(E.O.) No. 811, which classified a Nurse I, among others, as a
Salary Grade 11 employee. E.O. 811 contradicts R.A. No.
9173, which provides that a Nurse I is classified as a Salary
Grade 15 employee.
c. This is now the petition before the Supreme Court in Ang Nars
vs. Executive Secretary. PNA intervened in that case
because it was the earliest opportunity afforded to the new
set of PNA officers to participate in the legal battle that seeks
to advance the welfare of our nurses.
d. There are new bills have introduced now in Congress, such
as –
i. HB 3477 - Comprehensive Nursing Bill; an act to provide
towards safe and quality health care system, repealing RA
9173; appropriating funds thereof
ii. HB 3478 - An act upgrading the minimum salary of nurses
to PHP30,000.00
iii. Senate Bill 562 - It recognizes that “[n]urses provide safe,
humane, quality and holistic care to individuals of varying
age, gender and health status, population groups and
communities,” and that '[t]hey render professional
services in various health facilities and institutions,
including hospitals, in shifts and irregular hours for so
long as their services are needed.” No other proposal,
h o w e v e r, t o u c h e s a g a i n t h e a b o l i t i o n o f
contractualization of nurses.
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JULY - DECEMBER 2019
e. Existing labor law legislations are also in place. They are the
following –
i. Labor Code, as amended on condition of working.
ii. DOLE Department Order No. 182, series of 2017 -
guidelines governing the employment and working
conditions of health personnel in the private healthcare
industry. Under section 17, the practice of profit-oriented
hospitals in accepting trainees is prohibited.
3. Nurses likewise face issues on regularization, job orders,
and contractualization.
a. EO 51 was issued as a promise to end ENDO.
b. Consolidated Senate Bill No. 1826/House Bill No. 6908 were
likewise proposed to address contractualization. Sadly, the
proposed Security of Tenure Bill was vetoed. It reiterated the
Labor Code's prohibition on labor-only contracting. It
likewise reiterated legitimate job-contracting (independent
contractor) or outsourcing, especially when job-contracting
will result in economy and efficiency in their operations, with
no detriment to the workers, regardless of whether this is
directly related to their business
4. There is also the issue on the slowdown of deployment of
nurses. No one should be prevented, by the government or
by the PNA, from looking for jobs abroad. It is a moral choice
that everyone should respect. It is also everyone's
constitutional right to do so. The reality, however, is that the
diaspora of nurses hurts the demand of the local workforce.
On this point, Secretary Bello III clarified: there should be a
slowdown in the deployment of nurses so that the Filipinos in
need of healthcare assistance will be serviced.
Surely, Secretary Bello's remark calls for the possible
exercise of the State's police power in order to regulate the
number of nurses leaving the country. Even without the call
for a slowdown, he has alternative solutions to the problem
of undersupply of nurses. For one, he strongly urged the
PNA to report all hospitals that do not meet labor standards
beginning with those who fail to give their nurses the proper
compensation and those who charge fees for nurses'
trainings, an act which violated DO 182, series of 2017.
5. RA 10351 or the Sin Tax Law of 2012 earmarked 85% of
revenues to health and 15% to tobacco producing regions.
Hopefully, this objective should be met and sustained for the
years to come.
Let me show you some headlines regarding Filipino nurses.
***
The headlines paint a picture of who nurses are.
Ÿ Nurses are overworked, underpaid, undervalued, and
underappreciated.
Ÿ Nurses are in the frontline of healthcare. You absorb
shock and all sorts of emotion from all angles: from
colleague nurses, doctors, from patients, from families.
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Yet, you do your work. You do patient education
regardless of the circumstance.
Ÿ Nurses are hand holders. Your care does not end with
paperwork.
Ÿ Nurses are advocates. By demanding for the passage of
equitable access to health care, whose rights are nurses
fighting for? It is the right of every single Filipino to health
care. Nurses are the best advocates for the
development of the health care system.
Ÿ Nurses are heroes. You save lives every day, yet the
media tends to magnify more the efforts of the bystander
who called for help for a hit-and-run victim, than the
struggles you face in your workplace.
Ÿ Nurses are very versatile people. Imagine caring for
people you met for the first time? People who are
strangers, yes; these people are treated with care, even
when you've had a long, toxic day. How many shifts in a
row can you pull off anyway? I cannot even function well
with less than 6 hours of sleep.
As I have told you earlier, I am a lawyer by profession, and an
advocate by passion. I believe nursing is both. It is your passion
and your profession.
What, then, is your role in achieving universal health care? You
are agents of empowerment.
Take it from what the PNA does now:
1. It challenges the status quo. It petitions and lobbies for
increase of compensation for all nurses, those in the
government or not.
2. It files cases against hospitals that do not pay nurses
properly, fails give them proper salary, overtime pay, and
other benefits.
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3. It talks and coordinates with DOLE regarding visitorial
powers and inspections on erring hospitals.
These are just some of what the PNA does with regards to your
struggle.
Succinctly, the healthcare needs of this country can be
addressed only when the plight of nurses is addressed.
Nurses make up a large part of the health care force. You work in
proximity with patients on a daily basis. You know what
management system works and what doesn't. You can evaluate
which policies are effective and efficient and which are not. You
have a say. You must have a say.
A staunch advocate, my mother-in-law, Cheryl Daytec-Yangot,
said –
“The nursing profession is a potent force in the
promotion and fulfilment of universal health care.
Nurses must educate, organize, and mobilize our poor
health service consumers for them to be active
participants in the realization of universal health care.
But […] it is only when the nursing profession is
empowered that it can empower others because it
cannot give the poor and marginalized that strength it
does not possess.”
I add to that – it is indubitable that nurses put the care in health
care! Be empowered nurses to achieve UHC. Be empowered so
you can empower others.
Pagpupugay sa inyong mga magigiting na nars!
Iyaman! Thank you.
 11

RESEARCH ARTICLE

CAPACITY NEEDS ASSESSMENT

OF PRIMARY HEALTH CARE PROVIDERS
IN SELECTED MUNICIPALITIES
IN CAVITE
Irma I. Almoneda, MAN, RN1, Sheila R. Bonito, DrPH, RN,
Luz Barbara P. Dones, MPH, RN, Josefina A. Tuazon, DrPH, RN

Abstract
Purpose. Primary Health Care (PHC) refers to essential health care that is made accessible, acceptable and affordable to individuals
and families in the community. As such, it is imperative for PHC providers to possess the necessary competencies responsive to the
current health care demands. This study aims to determine the current capacity of PHC providers and their need for capability building.
Methods. The study employed a quantitative descriptive design with 87 purposively-selected PHC providers and five administrators
from selected rural municipalities in Cavite. It is adapted from the study, “Capacity-building of primary healthcare providers in 10+3
Southeast and East Asian Nursing Education and Research Network (SEANERN) countries”.
Results and Discussions. The perceived level of knowledge of the PHC providers on the elements of PHC were all rated to be
proficient. Maternal and child care received the highest score, while health education received the lowest score. The perceived level of
skills of the PHC providers was also rated to be proficient. Sanitation and water received the highest score, while treatment of common
diseases and injuries received the lowest score. Similar to the perceived levels of knowledge and skills, the perceived level of attitudes
of the PHC providers were also proficient, with environmental sanitation having the highest score but treatment of common diseases
and injuries having the lowest score. However, from the perspective of health administrators, they rated the PHC providers one level
lower or needs minimal support. Training and capacity building in all elements of PHC was identified as the most needed by the PHC
providers. Their most preferred method of training is workshop.
Conclusions. There are high perceived levels of knowledge, skills, and attitudes of the PHC providers in the elements of PHC. Despite
the high scores, objective outcomes such as the MMR and immunization coverage do not reflect the proficient scores of the PHC
providers. There are also other health conditions and issues such as noncommunicable diseases and injuries that need to be
addressed using PHC approach. Given this, it is vital that appropriate training and adequate hiring of PHC providers be reinforced
nationwide in order to meet the health goals and needs of the country.

Introduction

P rimary Health Care (PHC) is defined by the World Health

Organization as “an essential health care made universally
acceptable to individuals and families in the community by means
1979. Since then, PHC has been an approach to the delivery of
health care services (Cuevas et al., 2007).

acceptable to them through their full participation and at a cost
that the community and country can afford at every stage of
development.” With the Declaration of AlmaAta adopted at the
International Conference on Primary Health Care in September
1978, the Philippines also ratified PHC through the Letter of
Instruction 949 signed by then President Marcos on October 19,
The Alma Ata declaration put forward eight essential components
of PHC, which include: (1) health education, (2) food supply and
proper nutrition, (3) safe water and basic sanitation, (4) maternal
and child health and family planning, (5) immunization against
infectious diseases, (6) prevention and control of endemic
diseases, (7) treatment of common infections, and (8) essential

1 Corresponding Author: University of the Philippines-Manila, College of Nursing; iialmoneda@up.edu.ph

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drugs. All eight elements of PHC are provided for in the rural
health units in the Philippines as it is the first point of contact for
government- provided healthcare (Dayrit et al., 2018).
The rural health unit is mostly composed of doctors, nurses,
midwives, and medical technologists despite the need for also
other professionals such as physical therapists, pharmacists and
many others. This is a reflection of the human resources for health
situation wherein the top four categories of health professionals
working in health institutions in the Philippines are nurses,
doctors, midwives and medical technologists (World Health
Organization, 2018). But aside from these professionals, the
communities are served by the by nurse auxiliaries, locally trained
community health workers, traditional birth attendants, and
healers (Cuevas, et al., 2007).
To boost PHC, the Department of Health Fourmula 1 Plus was
launched, a program that envisions Filipinos to be among the
healthiest people in South East Asia by 2022 and Asia by 2040, by
leading the country in the development of a people-centered,
resilient, and equitable health system. The program's strategic
focus is on institutionalizing a people-centered Service Delivery
Network and leading a whole-of-society collaboration at all levels
to help people live healthy. The program's strategic pillars include:
1) financing, 2) service delivery, 3) delivery, 4) governance, and 5)
performance and accountability (DOH, 2018).
On 8 April 2019 during the event that corresponds with this year's
global celebration for World Health Day that centers on the theme
of universal health coverage with a focus on primary health care,
the Department of Health (DOH), World Health Organization
(WHO), and key stakeholders come together to highlight the need
to strengthen primary health care as the foundation for the
Universal Health Care (UHC) Act. According to Dr. Gundo Weiler,
WHO representative in the Philippines, “Primary health care
means multiple sectors working together to bring care closer to
home, with the involvement of the community. The UHC Act is just
the beginning of our journey to health for all Filipinos.” (Joint DOH
and WHO News Release). The UHC Act was signed into law by
President Rodrigo Duterte on 20 February 2019 with the
effectivity of the Implementing Rules and Regulations on 10
October 2019.
PHC, together with the implementation of the Universal Health
Care Act, provide the means of improving the health and well-
being of Filipinos. It is imperative that health care workers in the
community who are the PHC providers possess the necessary
competencies responsive to the current health care demands.
This study aims to determine the current capacity of primary
health care providers and the need for capability building in order
to ensure that health care workers are ready to deliver PHC.
Methodology
Descriptive research design was used in this study. A structured
questionnaire was administered to assess the knowledge, skill,
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and abilities of PHC providers by the PHC administrators and
PHC providers themselves.
The study setting was situated at Region IV-A (Cavite, Laguna,
Batangas, Quezon) region of Luzon Island. Situated 21
kilometers southwest of Metro Manila, it is one of the most
industrialized and fastest growing provinces in the Philippines. In
this study, the University of the Philippines Manila College of
Nursing (UPCN) is in collaboration with the UP Manila
Community Health and Development Program (UP-CHDP) in
assisting communities in attaining enhanced capacities in their
own health care and development through the PHC approach.
The current community partner of UP-CHDP is the Province of
Cavite through the A.M.I.G.A. Inter-LGU Health Collaboration
Council, consisting the municipalities of Alfonso, Mendez,
Indang, General Emilio Aguinaldo, and Amadeo (UP Manila,
2017).
According to the recent Philippine Health Statistics (2015),
among the top five (5) leading causes of morbidity in the region
are acute respiratory infection, pneumonia and acute lower
respiratory tract infection, hypertension, urinary tract infection,
and influenza. These are treatable conditions that can be
addressed through primary health care in the region. In terms of
mortality, Region 4A-CALABARZON, holds the third highest
mortality rate of 5.6 deaths per 1000 population across all regions
and highest percent share of total deaths amounting to 14.4%
(Philippine Health Statistics, 2015).
The main point of collection in the study is the rural health unit of
each municipalities. A rural health unit is at the primary level of the
national health system. Each rural health unit is led by a municipal
health officer. The municipal health officer, a medical doctor,
together with the team composed of nurses, midwives, medical
technologists and sanitary inspectors, bring primary health care
to its constituents. Each rural health unit offers outpatient
consultation on medical and pediatric cases, maternal care,
family planning, dental services, laboratory examinations, minor
surgical operations such as excision and suturing, and
counseling. At the barangay level, a satellite of the rural health
unit is present, which is called the Barangay Health Station
(BHS). This BHS is supervised by a midwife or a nurse with
auxiliary personnel such as barangay health workers who
delivers certain primary health care program at the grassroots
level.
The study used a purposive sampling design to recruit
participants in different health facilities/institutions. To recruit the
participants – the PHC administrator and PHC provider the
following inclusion criteria was met. For the PHC provider: 1)
currently working on a PHC position in his/her respective health
institution; and 2) have worked in the two weeks prior to the
questionnaire administration. For the PHC administrator:
currently working as administrator, trainer, or other related
position of the PHC institution; and 2) have worked in the two

weeks prior to the questionnaire administration. The exclusion
criterion for the respondents is that they should not have any
condition that causes physical or mental disabilities that would
prevent the participant from participating and completing the
procedure of the study. The target sample size was 80 PHC
providers and 5 PHC administrators.
The research survey tool was adopted from the collaborative
study on capacity of providing primary healthcare service and
training needs in countries in Southeast and East Asian Nursing
Education and Research Network (SEANERN). This mainly
consisted of versions for the two groups of respondents: PHC
administrators,' and providers' version. Each of them included a
demographic part (e.g., items regarding respondent's age,
gender, working years, etc.) and capacity part (i.e., items
assessing the capacity of PHC providers and strategies
suggested to strengthen it). The PHC administrators were given
an extra form to gather information about the PHC services of the
institution. The item pool was derived from relevant literatures and
existing similar scales. Items will use questions and a variety of
response options, such as multiple choice, single choice, Likert-
scale and open-ended and follow the structure of the conceptual
framework that includes three dimensions (knowledge, skill &
ability) and eight aspects (health education, nutritional promotion,
sanitation, maternal & child health care, immunization, disease
prevention and essential drugs).
The researchers sought referrals from the PHC institutions/
facilities in recruiting participants for the research. Upon retrieval of
consent, the researchers administered the questionnaire to
participants during the provided time for the PHC providers and
administrators.
Table 1. Characteristics of the rural health units
Table 2. Distribution of respondents according to age, sex, and work experience
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JULY - DECEMBER 2019
This study was given ethical clearance by the UP Manila
Research Ethics Board upon compliance of the ethics
requirements ensuring protection of privacy and confidentiality
of research information, minimal risk in the participation,
benefits of the study, proper recruitment and informed consent.
Quantitative data collected from the questionnaire survey were
imported into SPSS version 22 after coding for analysis.
Descriptive statistics, such as frequency, percentage, mean,
standard deviation, etc. were used.
Results and Discussion
The results of this study were divided into two parts:
administrator level and PHC provider level.
Part 1. Administrator Level
There were five administrators who participated. The five
administrators came from the following municipalities with its
accompanying number of populations: Alfonso with around
59,016 population; Mendez with around 39, 891; Bailen with
around 24, 475; Indang with around 72, 248; and Amadeo with
around 40,000 population.
Table 1 shows that the number of personnel per rural health unit
varies from a minimum of eight to a maximum of 41 personnel.
The personnel is composed of at least one medical doctor, who
is usually the municipal health officer, registered nurses (2-4
per RHU), midwives (4-5 per RHU), and a sanitary inspector.
None of the rural health units have a registered pharmacist.
On Table 2, most of the municipal health officers were female
and their ages fell within the range of 50-65 years old. In terms of
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clinical experience, most of the municipal health officers have at
least 15 years of relevant clinical experience. Among the
municipal health officers, the MHO at Alfonso Rural Health Unit
has the highest number of years spent in the primary level while
the MHO at Mendez Rural Health Unit has the lowest number of
years.
In terms of current work and frequency, all of the municipal health
officers deliver primary health care services as part of the basic
services of the rural health unit. As municipal health officers, they
primary focus on health education, maternal and child care,
prevention and health care, and medication. However, elements
such as nutrition, immunization, family planning, and
environmental sanitation are co-delivered with nurses, midwives,
barangay nutrition scholars, and sanitary inspectors, respectively.
Table 3 shows that the educational background of personnel for
each rural health unit is mostly composed of bachelor's degree
holder or high school graduates.
In terms of training (Table 4), some rural health units like Bailen
receive trainings for its personnel as frequent as at least once a
month and in Alfonso, quarterly, and no response from the others.
The most commonly used method is through a workshop or
through visual aids.
Table 5 shows the knowledge scores of the personnel in terms of
the elements of primary health care as perceived by the
administrators. In terms of health education and maternal and child
care, four out of five (4/5) municipalities rated the knowledge of their
personnel as needing minimal support.
On nutritional promotion and essential drugs, most of the
municipalities rated their knowledge on it as needing minimal support
to proficient. However, one (1) municipality rated the knowledge of its
personnel as needing whole process guidance. In addition to this, the
same municipality rated itself to be needing assistance in
immunization and prevention and control of locally endemic diseases;
components which were rated to be highest in other rural health units.

Table 3. Educational background of personnel to include training and learning activities

Table 4. Training and learning activities of administrators

Table 5. Knowledge on primary health care of personnel according to administrators

PJN VOL. 89 | NO. 2


In terms of the most required knowledge in their current setting, two
out of five (2/5) administrators identified maternal and child care. In
terms of the least required knowledge, most of the administrators
identified environmental sanitation. This function could have been
rated as the least required as the local government unit is mostly
responsible for the clean-ups and ordinances for sanitation.
In the perspective of administrators, their personnel need the most
training in maternal and child care, health education, and nutritional
promotion. This is in congruence with the current statistics on
maternal mortality ratio and nutritional status in the country.
However, despite being cited as needing most training in other
municipalities, nutrition promotion and maternal and childcare was
deemed by other municipalities as knowledge requiring the least
training along with environmental sanitation. Workshop was the
preferred method of training by most of the administrators. An
administrator suggested the use of videos to address age
variations.
Table 6 shows the skill scores of the personnel in terms of the
elements of primary health care as perceived by the
administrators. The skill scores of personnel mirrors the knowledge
scores except in some areas to be discussed in succeeding
sentences. In terms of health education and maternal and child
care, four out of five administrators rated their personnel as
needing minimal support.
Table 6. Skills of personnel on primary health care according to administrators
Table 7. Attitudes of personnel on primary health care according to administrators
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JULY - DECEMBER 2019
Despite having two municipalities rate its skill in environmental
sanitation as expert, one (1) municipality rated its skill in this
component as needing whole process guidance; the same
municipality who rated the same on knowledge on essential drugs
and nutritional promotion.
In terms of the most required skill in their current setting, two out of
five (2/5) administrators identified maternal and child care. Other
administrators identified appropriate treatment of common
diseases and injuries and nutritional promotion. In terms of the least
required skill, most of the administrators identified environmental
sanitation because it is usually delegated to the rural sanitary
inspectors. In the perspective of administrators, their personnel
need the most training in maternal and child care, health education,
and nutritional promotion. However, despite being cited as needing
most training in other municipalities, nutrition promotion and
maternal and childcare was deemed by other municipalities as
knowledge requiring the least training along with environmental
sanitation. Workshop was the preferred method of training by all of
the administrators.
Table 7 shows the attitude scores of the personnel in delivering
primary health care as perceived by the administrators. In terms
of immunization and control of locally endemic diseases, most of
the administrators rated themselves as proficient. Compared to
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JULY - DECEMBER 2019
Table 8. Distribution of PHC providers according to demographic characteristics
knowledge and skill scores, most of the municipalities (4 out of 5)
have higher rating on attitudes except for one (1) municipality
whose attitude scores decreased from being rated itself as
expert in knowledge and skills part.
In terms of the most required attitude in their current setting, two
out of five (2/5) administrators identified all components,
nutritional promotion, health education and maternal and child
care. One municipality shared that attitudes specifically on
intrapartum care needs training. In terms of the least required
attitude on the elements, most of the administrators identified
environmental sanitation. In the perspective of administrators,
their personnel need the most training in maternal and child care,
health education, and nutritional promotion. Attitudes on
environmental sanitation need the least training according to
most of the administrators because they see it as adequate (3/5).
Workshop was the preferred method of training by all of the
administrators.
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Part 2. PHC Provider
A total of 87 PHC providers composed of doctors, nurses,
midwives, and barangay health workers (BHWs) were
interviewed for this study.
Table 8 shows the demographic characteristics of the 87 primary
health care providers who agreed to participate in this study. In
terms of age, the mean age of the providers falls at 49.78 ± 11.61
years old indicating that the workforce is already at middle
adulthood. Majority of the health care providers in the area are
female. A large fraction of the providers are barangay health
workers who are auxiliary health workers in the grassroots level
and are usually elementary or high school graduates. Second to
barangay health workers in frequency are midwives (n=15)
followed by nurses (n=10). The average number of years working
in the field shows long-term retention of human resources in their
respective departments.
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JULY - DECEMBER 2019

Table 9 shows the current work and frequency expressed in
number of hours per week of providers. The highest mean
number of hours per week is allotted to functions outside primary
health care such as administrative work although only three out
of five municipalities indicated this. Vaccination and health
education are among the components by which providers allot
the most number of hours per week. Rehabilitation, in all
municipalities, were not being allotted time for by the providers.
Table 10 shows the training and learning activities of primary
health care providers. Workshop is the most commonly used
method of teaching for the providers averaging for about twice a
year. The training and learning activities conducted to RHU
personnel are mostly through workshops. It was found out in a
study that although doctors and nurses have sufficient education,
continuing education and training were still helpful (Zuellig Family
Foundation, 2011).
Table 11 shows the perceived level of knowledge of providers on
the elements of primary health care. The highest score given was
in terms of maternal and child care followed by immunization and
environmental sanitation. These results are somehow congruent

Table 9. Current work and frequency of PHC Providers

Table 10. Training and Learning Activities of PHC Providers

Table 11. Knowledge on Primary Health Care of PHC Providers

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JULY - DECEMBER 2019
with the ratings given by administrators wherein maternal and
child care was among the highest. Health education however
was the lowest among the components. Ratings by providers
were higher than ratings provided by administrators on the
different components. Most of the ratings were proficient
compared to the administrators' wherein ratings dwelled on
needing minimal support.
In the perspective of the providers, the most required knowledge
for them include almost all the elements of primary health care
(32 out of 87), appropriate treatment of common diseases and
injuries (20 out of 87), and maternal and child care ( 17 out of 87)
in contrary to the ones identified by administrators such as health
education and nutritional promotion. Only maternal and child
care were the common components identified by most
municipalities. Environmental sanitation was identified as the
least required knowledge. Providers identified maternal and
child care (28 out of 87) and all of the components (27 out of 87)
to be needing the most training. Environmental sanitation (7 out
of 87) was identified to be needing the least training. Workshop
was the preferred method by most of the providers (65 out of 87).
Table 12 shows the perceived level of skills of providers on
primary health care. The skill ratings almost mirrored the
Table 12. Skills on Primary Health Care of PHC Providers
Table 13. Attitudes on Primary Health Care of PHC Providers
PJN VOL. 89 | NO. 2
knowledge ratings but with higher ratings. In terms of skills, the
components with the highest ratings include sanitation and
water, immunization, and maternal and child care. Treatment of
common diseases and injuries had the lowest rating although it is
already at the proficient level. Ratings for skills by providers are
higher than ratings provided by administrators.
Providers identified skill on appropriate treatment of common
diseases and injuries (30 out of 87) and all components (30 out of
87) to be the most required and needing the most training. As
identified in the knowledge part, environmental sanitation was
deemed to be the least required skill. Workshop (68 out of 87) is
the preferred method of training.
In a publication released by the Zuellig Family Foundation (2011)
on the adequacy and competency of selected rural health
workers, results revealed that health care providers such as
doctors, midwives, and nurses all identified comprehensive
maternal care and basic emergency obstetrical skills as one of
their training needs. The admission by the providers coincides
with the country's MMR that is still high. In terms of skills, both
administrators and providers identified the treatment of common
diseases and injuries as the most required (aside from
identifying all components). But on the skills needing the most

training, the administrators identified that skills on maternal
and child care, nutritional promotion, and health education
as needing the most training although providers identified
skills on treatment of common diseases and injuries (aside
from identifying all components). It can be said that the
perspective of the administrators is largely on the health-
promotive side while the providers were mainly on the
curative aspects.
Table 13 shows the attitudes of providers in delivering
primary health care. Environmental sanitation and
immunization both occupy the highest ratings, which was
also identified as proficient by administrators. Treatment of
common diseases and injuries had the lowest rating
although it is already at the proficient level. All municipalities,
on average, rated themselves on the components to be at
least proficient.
Providers identified that good attitudes on all components,
health education, and appropriate treatment of common
diseases and injuries were the most required. Likewise,
attitudes on environmental sanitation and provision of
essential drugs were the least required. Workshop is the
most preferred method of training.
Conclusion
In comparison with the ratings given by the administrators
and the providers in all the components, the providers rated
themselves higher (mostly proficient) than the
administrators (mostly needing minimal support). In terms of
knowledge on the elements of primary health care, most
administrators rated the knowledge on health education and
maternal and child care of their personnel as needing
minimal support. However, in the providers' perspective,
they believe that they were proficient in terms of maternal
and child care followed by immunization and environmental
sanitation but lowest on health education. For both
administrators and providers, knowledge on maternal and
child health care was deemed as the most required and
needing training in their setting.
Moreover, current work and frequency for providers
revealed that in majority of the municipalities (3/5), functions
outside primary health care, such as administrative work
demand most of their time. Vaccinations and health
education came second and third. At the time of data
collection, the country was facing an epidemic on measles.
Thus, it is not surprising that the recall of workers are
affected by this; because in days without epidemics,
immunizations are done on a scheduled basis (weekly)
.Another factor is that majority of the providers interviewed
were barangay health workers. The role of BHW in
vaccination is to perform house visits to remind mothers to
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JULY - DECEMBER 2019
have their children vaccinated thus, getting more of their time.
They also accompany midwives in vaccination activities during
epidemics.
Recommendations
It is highly recommended that further training has to be
conducted to PHC providers in all elements of PHC, especially
in maternal and child care and treatment of common diseases
and injuries, which really need to be reinforced throughout the
country. Despite the high perceived levels of knowledge, skills,
and attitudes of the PHC providers and despite the efforts of the
government in primary health care, health outcomes of the
country still serves as better indicators in which currently MMR
in the country is high.
As community health providers, there is also demand for quality
and continuous care especially in this time of urbanization and
lifestyle changes that have brought about notable change in the
health status of the country. In 2016, hypertension is the second
top leading cause of morbidity in the country. Deaths related to
noncommunicable diseases (NCDs) are attributed to:
cardiovascular diseases (33%), cancer (10%), diabetes (6%),
and chronic respiratory diseases (5%). Thus, each health care
provider must be trained and oriented to assume his/her
redefined functions and roles.
Moreover, PHC providers need to have focus on their job and
not be diverted to other else like the administrative functions.
Duties and responsibilities among PHC providers need to be
well delineated. Additionally, hiring of more PHC providers
would be beneficial not only to the primary health care sector
itself but also to the public being served.
____________________
References
Action for Economic Reforms (2014). Citizens' Report Card on the
Sponsored Program of the National Health Insurance Program
(Philippines). Action for Economic Reforms (http://saatlas.org/
uploads/files/AER_Final_CRC_Paper_%28Aug_
2014%29.pdf, accessed 17 July 2018).
Corpuz, A. M., Ladia, M., Garcia, R., Facun, R., &Nool, N. (2012,
April 2). Assessment of the Implementation of Maternal and
Child Health Services of Rural Health Units in Tarlac City.
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Technology, 3(2).
Department of Health (2015). The 2015 Philippine Health Statistics.
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Nutrition Survey. Food and Nutrition Research Institute.
Joint DOH and WHO News Release on 8 April 2019. DOH, WHO
highlight need for primary health care in UHC
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https://www.who.int/ philippines/news/detail/08-04-2019-doh-
who-highlight-need-for-primary-health-care-in-uhc.
Pambid, R. (2015). Factors Influencing Mothers' Utilization of
Maternal and Child Care Services. Asia Pacific Journal of
Multidisciplinary Research, 17-28.
Srivastava, A., Avan, B., Rajbangshi, P., & Bhattacharyya, S. (2015).
Determinants of women's satisfaction with maternal health care:
a literature review from developing countries. BMC Pregnancy
and Childbirth, 12.
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Washington DC, World Bank (http://documents.worldbank.org/
curated/en/583391468758964883/Philippines-Filipino-report-
card-on-pro-poorservices, accessed 18 July 2018).
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Geneva, Switzerland, World Health Organization
(http://apps.who.int/iris/bitstream/handle/10665/112738/
9789240692671_eng.pdf, accessed 28 March 2019).
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Review.
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Status and Implication on Service Delivery and Health
Outcomes.
ABOUT THE AUTHORS
Irma Imaculata-Almoneda, MAN, RN is an
Assistant Professor at the University of the
Philippines Manila College of Nursing
(UPM-CN). She obtained her bachelor's
degree from the West Visayas State
College now a State University and her
Master of Arts in nursing from the UPM-CN. She has finished
the Medical Strategic Leadership Program Course 6-250C1
(International) from Fort Sam Houston, Texas, USA. She is a
nurse anesthetist and a retired military nurse. She is currently
a student in the PhD in Nursing and is involved in the
leadership and management program and quality assurance
of the college.
Sheila R. Bonito, DrPH, RN is a Professor
at the University of the Philippines Manila
College of Nursing (UPM-CN), and at the
University of the Philippines Open
University (UPOU). She obtained her
bachelor's degree and master of arts in
nursing from the UPM-CN and her Doctor of Public Health
major in Epidemiology from UPM College of Public Health.
She is involved in researches that focus on nursing
workforce, disaster nursing, education and technology.
The character of a nurse is as important
as the knowledge she possesses.
- Carolyn Jarvis
PJN VOL. 89 | NO. 2
Luz Barbara P. Dones, MPH, RN is an
Associate Professor at the University of the
Philippines Manila College of Nursing
(UPM-CN). She received her degrees in
Bachelor of Science in Nursing and Master
of Public Health in the University of the
Philippines Manila. Her involvement is in the community
health nursing and her research interests are focused on
Human Resources for Health. She is one of the contributors of
the book "Nursing Practice in the Community", a textbook
reference for nursing students in the Philippines. She was the
Project Director of the Cambodia Nurse Bridging Project, a
bridging program to upgrade Associate Degree in Nursing to
Baccalaureate Degree.
Josefina A. Tuazon, DrPH, RN is a
Professor at the University of the
Philippines Manila College of Nursing
(UPM-CN). She obtained her bachelor's
degree and Master of Arts in Nursing from
the UPM-CN and her Doctor of Public
Health major in Health Promotion and Education from UPM
College of Public Health. She was past dean of UPM College
of Nursing and head of WHO Collaborating Centre for
Leadership in Nursing Development 2004 - 2010. She was
appointed to the Philippine Commission on Higher Education
(CHED) Technical Committee on Nursing Education
regulating nursing education in the country in 2011- 2013. She
is currently the UPCN Program Head for Research and
Graduate Program Chair and Graduate Program Coordinator.
She also headed the Secretariat of the Asia Pacific
Emergency and Disaster Nursing Network (APEDNN) for
2013 – 2015 where she is a founding member and continues
to be an active core member. She is an advocate for health
promotion and the prevention of non-communicable
diseases.
Acknowledgment
This study was originally part of the international study
entitled, "Capacity-building of primary health care providers in
10+3 Southeast and East Asia Nursing Education and
Research Network (SEANERN) countries led by Fudan
University and Chiang Mai University". The data collection
tools were adopted from this international study which was
published in 2018. The study was conducted in coordination
with the University of the Philippines Manila Community
Health and Development Program.
 21

RESEARCH ARTICLE

FROM TESTING TO COPING:

THE VOICES OF PEOPLE LIVING
WITH HIV/AIDS
Mark Gilbert S. Milallos, RN, LPT, MSN1 and Jezyl C. Cutamora, RN, MN, PhD2

Abstract
This study aimed to explore the lived experiences of people living with HIV/AIDS in Cebu, Philippines. The study utilized Husserlian
qualitative phenomenological design. Ethics clearance was acquired from Vicente Sotto Memorial Medical Center – Ethics Review
Committee.
There were 7 informants that were recruited through purposive sampling and research referral techniques. The researchers used an
open ended interview guide where interviews were audio recorded, transcribed and analyzed using Collaizi’s method. Three (3) themes
have emerged in this study. The first emerging theme is, (1) Why get tested? With the following subthemes of, (a) Presence of Risky
Behavior; and (b) Knowledge that lead to testing. The second theme is, (2) Challenges after diagnosis with subthemes of, (a)
Psychosocial challenges; and (b) Physical Challenges. Lastly, the third theme is, (3) Response and Coping with HIV/AIDS with the
following subthemes, (a) Establishing old and new networks: Support systems; (b) Socio-spiritual changes: lifestyle changes and being
more religious; and (c) Moving Forward.
High risk sexual patterns, knowing that a partner is HIV positive and the presence of some signs and symptoms are the factors
considered for testing. PLWHA’s compliant of their treatment regimen despite the undesirable side effects and opportunistic infections.
Stigma results to non-disclosure of status and mental health issues are common. The presence of support groups is essential; PLWHA’s
are willing to adapt a healthy lifestyle; and they become advocates of the disease.
There is a need to increase the promotion of safe sex practices and health education about HIV/AIDS. Continuous support is needed in
order to increase visibility of support groups, and the development of self-advocacy skills of PLWHA’s. Mental health should also be
given attention.

Keywords: People Living with HIV/AIDS; PLWHA; HIV; AIDS; Lived Experiences

Introduction

B eing infected with HIV does not only constitute physiological

problems but also psychosocial ones. It should be common
knowledge that being diagnosed with HIV can in fact, cause
distress, anxiety and depression (National Health Services–UK
[NHS], 2017). PLWHA's are also very vulnerable to stigma and
discrimination as they may be rejected by their communities,
including family and friends. They may also experience
unpleasant treatment from their education and work settings.
Others have even been denied healthcare services (Averting HIV
and AIDS [AVERT], 2017).
However, despite the steady rise of affected individuals, there is
still limited number of qualitative studies in the Philippines tackling
the lives of PLWHA's. This study aims to expand the research field
on this subject, and also to address what commonalities and
differences are present between the Philippine settings versus
the international settings. Moreover, this study aims to uncover
other issues that have not yet been addressed, as treatment hubs
are more focused on the medication distribution and adherence.
If certain issues are uncovered, this may lead to a reevaluation of
the programs on HIV/AIDS by the DOH and that other issues can
already be addressed in new programs. Overall, this aimed to
explore the lives of PLWHA's from the start of their journey or from
when they submitted for testing, why they did, and what
underwent thereafter.

1 UM Nurse, Cognizant Technology Solutions Philippines, Inc. | Graduate School Student, Cebu Normal University, Osmeña Blvd, Cebu City, Cebu | markmilallos@outlook.com | +639275646200
2 Faculty, College of Nursing, Cebu Normal University, Normal Osmeña Blvd, Cebu City, Cebu | cutamoraj@cnu.edu.ph

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Methodology
The study utilized the Husserlian qualitative phenomenological
design that centers on the lived experiences of people, which is
this study's main inquiry. The study was conducted in Cebu,
Philippines and the informants of this study were people living
with HIV/AIDS (PLWHA's) who are taking Anti-Retroviral
medications for at least 6 months and are of legal age regardless
of gender, sexual preference and economic status. Data
saturation was attained on the 5th informant and added two more
for validation.
Purposive sampling and research referral techniques were used.
This study also utilized a researcher made semi-structured
interview guide with open-ended questions, since it allows the
informant to narrate what happened in his life (Hesse-Biber,
2017). The first part contained a brief profile while the second part
contained the main questions of the interview. An audio recorder
was used during interviews that were later transcribed. Field
notes were taken down which includes all verbal and non-verbal
cues during the interview.
The primary researcher underwent bracketing and examined
personal biases, experiences and any knowledge about the topic.
A note was kept for these biases and recognized these all
throughout the interview process and analysis stage which aided
in minimizing the contamination of biases. Rigorous analysis of
data constitutes the second component of the descriptive
phenomenological investigation and used Colaizzi's (1978)
method to guide the analysis (Shosha, 2012). Triangulation
techniques were applied to establish the rigor of the study which
includes, transferability, dependability; confirmability, credibility,
and (Castell, 2000 and Billups, 2014).
Ethical Considerations
The study protected the interests of the information in terms of
bodily, psychological and cultural integrity and observed the
informants' right to self-determination and the right of full
disclosure (Loiselle, et al., 2010). The study was granted approval
by Vicente Sotto Memorial Medical Center – Ethics Review
Committee with approval number of VSMMC-ERC-O-2017-036.
Findings
Profile of the Informants
Found below is the profile of the informants of this study utilizing
pseudonyms.
Andrew is a 28 year old who identifies as a homosexual man. He
is single and denies being in any romantic relationship. He is a
bottom or participates in receptive anal intercourse. He is a
nursing graduate and is currently working in the BPO industry as
a workforce manager. He was diagnosed with HIV on March
2016.
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Bertha is a 29 year old transsexual woman. She is single and not
involved in any romantic relationship. She is a bottom or
participates in receptive anal intercourse. She is a college
undergraduate finishing 3 years in nursing. She is currently
unemployed but was formerly working as a call center agent. She
stints as a freelance make-up artist at times and invests in some
farming businesses. She currently volunteers in an LGBTQ
organization mainly focusing on those diagnosed with HIV/AIDS.
She is also a community based screening motivator for
HIV/AIDS. She was diagnosed on May 2017.
Carlos is a 34 year old homosexual man. He has a long term
partner of 9 years who is also HIV positive, wherein they met prior
to both being diagnosed. He is a versatile or participates in both
insertive and receptive anal intercourse. He only finished 1 year in
college taking fine arts. He is currently unemployed and has
worked as a call center agent previously. He was diagnosed on
January 2017.
Darryl is a 32 year old homosexual man. He is single and is not
any romantic or sexual relationship. He is a versatile or
participates in both insertive and receptive anal intercourse. He is
a Registered Nurse working as a Utilization Management Nurse.
He was diagnosed on February 2018.
Eduard is a 36 year old homosexual man. He is in a relationship
with another HIV positive man for 2 years. He is a top or
participates in insertive anal intercourse. He currently works as a
hairdresser in a salon. He was diagnosed with HIV infection on
September 2015.
Felix is a 36 year old homosexual man. He is in a relationship with
another man for almost 2 years who is also living with HIV, whom
he met 2 years after being diagnosed. He is a bottom or
participates in receptive anal intercourse. He is a licensed
Physical Therapist. He currently works as a call center agent and
as a reviewer for international English examinations. He was
diagnosed to be HIV positive on October 2014.
George is a 24 year old homosexual man. He is single and denies
being in any form of romantic relationship. He is a bottom or
participates in receptive anal intercourse. He is an IT graduate
and currently works as a call center agent. He was recently
diagnosed on April 2018.
Thematic Analysis
This presents the findings of the study wherein distinct and
common experiences of each informant are also characterized. A
total of 197 significant statements were extracted from the
transcripts and then a total of 26 formulated meanings. Three
themes have emerged with the first emerging theme as, (1) Why
get tested?, with the following subthemes of, (a) Presence of
Risky Behavior; and (b) Knowledge that lead to testing. The
second theme is, (2) Challenges after diagnosis with subthemes
of, (a) Psychosocial challenges; and (b) Physical Challenges.

Lastly, the third theme is, (3) Response and Coping with
HIV/AIDS with the following subthemes, (a) Establishing old and
new networks: Support systems; (b) Socio-spiritual changes:
lifestyle changes and being more religious; and (c) Moving
Forward.
Theme 1: Why Get Tested?
This theme tackles the reasons why the informants submitted to
HIV testing. It was mentioned by the informants that knowing a
former partner being diagnosed with HIV would prompt one to
seek answers. Self-awareness on one's own actions and risks for
HIV infection would push one to submit for testing; while others
have prior knowledge of the early signs of HIV infection. Cianelli,
et al. (2015) mentioned that people submit for HIV test if they have
knowledge on the disease, prior testing, knowing someone who
died from the complications of HIV/AIDS and their own
perceptions of their own personal risks. These personal risks
include high risk sexual behaviors (Sivaram, et al., 2008). This
clustered theme has two subthemes that are discussed below.
Subtheme 1: Presence of Risky Behavior
This discusses the presence of the risky behaviors as to why
people get tested for HIV. The awareness of one's sexual activity
and the usage of injectable drugs are factors that the informants
were aware of in terms of getting HIV infection. Below are
statements made by the informants regarding the presence of risk
factors in HIV testing.
Andrew mentioned; (SS3) “I practice safe sex. Sometimes
yes, sometimes not because there is really some... I don't
know, but there's really an urge sometimes like for example
not to use like condoms. I don't know. For me, it's a
pleasure. It's a satisfaction with me not using that. I am
aware that there are some risks, but at the time when you
are into that situation already then probably you can't think
of that anymore. All that you're thinking is how to 'palami' or
how to get pleasure.”
Carlos on the other hand mentioned about the use of
injectable drugs; (SS70) “There were only 2 syringes. We
were 6 of us using. So we had to share the syringe, and I
think it was at that time….”
Darryl also narrated the following, (SS108) “Well cause I
am promiscuous. Yes, I have a lot of sexcapades and I
usually got those partners from Grindr and other dating
sites, and when we have sex, I don't usually use condom.”
Precipitating factors include those of high risk sexual behaviors,
like promiscuity and unprotected sex (Sivaram, et al., 2008); and
prior knowledge and perceptions of HIV can lead to testing
(Cianelli, et al., 2015). People at risk also include people who
inject drugs most especially those who practice needle sharing
(CDC, 2018; AVERT, 2018; Challacombe, 2018).
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JULY - DECEMBER 2019
Subtheme 2: Knowledge that leads to testing
This discusses what people knew or what they will know that
would ultimately prompt one to take an HIV test, such as the
informants knowing that a former partner was infected with HIV
and the signs and symptoms experienced that are presumptive of
HIV infection. The narratives below will show statements made by
the infomants as what prompted them to get tested.
Bertha said that, (SS35) I had Syphilis that prompted me to
open my twitter to contact a volunteer (to get tested).
Eduard also narrated the following, (SS137) “I had myself
tested because my partner at that time was diagnosed with
HIV so he encourages me to have myself checked. He didn't
know that the red spots on his skin were the start already. He
was advised by his friend who is a nurse to have himself
tested in Cebu Plus. So he had himself tested and the results
were positive. He sent me a text message to inform and
advise me to have my self-tested. So, I went to Cebu Plus
and found out that I am also positive.”
Lastly Felix mentioned that, (SS153) “It was during 2014, I
was taking my review for NPTE (National Physical Therapist
Examination) and there was 1 week where I have really high
fever which can't be relieved by any anytipyretics and on the
4th or 5th day, I had violet pressures on my shoulders which
was hallmark of HIV which then prompted me to visit the
clinic for check.”
Knowing that a former or current partner was diagnosed with HIV
is a factor that will urge one to get an HIV test (Brown, et al., 2012).
Prior knowledge about HIV, including the mode of transmission,
risk factors and early signs and symptoms would give someone
the desire to have oneself checked but at the same time wary of
the possible result (Cianelli, et al., 2015; Scott-Sheldon, et al.,
2013).
Theme 2: Challenges after Diagnosis
Being infected with HIV imposed challenges on one's life ahead
that vary from adjusting to medications; mental and physical
health issues; and stigma (Ntseane, et al., 2010; de Jesus, et. al.,
2017; Dejman, et al., 2015; and Rao, 2016). Identifying and
addressing such challenges are vital in the treatment of PLWHA's
(Dejman, et al., 2015). Specific challenges of the informants are
discussed below.
Subtheme 1: Psychosocial Challenges
Psychosocial challenges refer to the psychological health issues
and social challenges that PLWHA's have encountered, including
battling with stigma and discrimination. Stigma and discrimination
was experienced by the informants as they have discussed about
people leaving them, rejection from future employers and the
spreading of rumors about them being HIV positive. One pressing
concern is their mental health.
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JULY - DECEMBER 2019
The informants have expressed that they have undergone
depression, isolation and even suicidal thoughts as seen on the
statements below.
Andrew stated that, (SS9) “I actually isolated myself for a
week because I'm so depressed at that time. I don't know
what to do, but yeah, I went to Sotto to try and get a
medication.”
Bertha also said, (SS46) “I also got depressed. I even had a
suicide attempt. I had mood swings. I get angry easily. That
happened to me. If I am alone in my room, I always think of
how productive my life was before. I earn a good amount of
cash then HIV happened.”
Darryl mentioned, (SS122) “Yes and actually I was
depressed because of being my life getting over soon, but
with that idea or with those people that I know in the hub, it
really helped me because I can still live longer as long as I
take the medication religiously. There are times, especially
when I'm alone, there are times that I can regret those days
having unprotected sex and I was also… there was some
suicidal thoughts that came into me.”
PLWHA's undergo emotional distress like depression, isolation
and suicide which can be related to stigma and discrimination
(Dejman, et al., 2015; and Rao, 2016). Concerns on mental health
have been experienced by the informants.
Stigma and discrimination were also discussed as part of the
social challenges experienced by PLWHS's. Found below are
statements regarding stigma and discrimination that were
experienced or perceived.
Andrew has stated his concerns about stigma as follows,
(SS28) “My co-workers, the people around me, the people
who knows me. You really don't know what people will tell
about you having a person with HIV cause like for example
in our office, I heard people talking about HIV so they got
misconceptions about it so me asking myself how would I
tell them if they knew that I have HIV? How will they accept
me? So I am scared that there is a big chance that I will lose
some people in my life.”
Bertha experienced discrimination as she verbalized the
following, (SS49) “They (the neighbors) emphasized that I
was sick and I was rotting. I am a type of person that does
not really care but I do have a limit; especially, when they are
already stepping on my dignity. There was a time when I
was walking alone and someone approached as asked how
I was. I asked Why” Do you know? I said I have HIV and told
him to mind his own business. I even told him If I was asking
money from them for my medications. I said you shouldn't
care about me.”
Felix narrated, (SS170) “Yeah even if let's say I'm in a new
environment and people would know that I'm HIV positive
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because I would tell them right away I'm the kind of person
who's like that. They would initially be friends but then in a
few weeks, they would not be friends anymore.”
Social stigma is one of the biggest challenges PLWHA's have to
experience (de Jesus, et. al., 2017; Dejman, et al., 2015; and Rao,
2016). PLWHA's will often experience social stigma or the fear of
being stigmatized that may result to non-disclosure of status
within his circle of family and friends and become a barrier for
treatment (Oskouie, et al., 2017 and Turan, et al., 2017).
Subtheme 2: Physical Challenges
Physical challenge accounts on the physiological changes
encountered in relation the medication side effects and
occurrence of opportunistic infections. PLWHA's take
antiretroviral medications that have side effects which the
informants describe as distressing and includes nausea and
vomiting, hot flashes, upset stomach, and nightmares as shown
on the statements below.
Andrew mentioned the following things, (SS12) “Yes, it's
very uncomfortable with the side effects of the medication.”
And, (SS13) “There is. There are hallucinations. There is
also dizziness feeling.”
Bertha also narrated the following, (SS50) “When I first took
my medications, I was really dizzy. I was do dizzy that it
almost felt like I was high on drugs but in a bad way….”
Next, (SS51) “The medication side effects were really bad
on the first month. On the second month, it felt like nothing
anymore.” And lastly, (SS52) “For the first month of
medication, I always feel hot but not anymore today.”
Carlos mentioned the following side effects, (SS102) “I had
vivid dreams. There are times I would wake up in the middle
of the night thinking what happened was real. But you really
can't sleep well with ARV.”
It takes time adjust to the side effects of ARV's. Headache,
dizziness, nausea, vomiting, tiredness, lack of energy, difficulties
in sleeping, digestive discomfort, skin rashes, nightmares are
some of the common side effects of ARV treatment (Renju, et al.,
2017 and Chen, et al., 2013).
Also, the occurrence of opportunistic infections are one of the
physical challenges PLWHA's encounter as narrated.
Bertha was diagnosed with pneumonia and syphilis and
was able to verbalize the following, (SS37) Then I had
pneumonia starting February. (SS41) “My body was weak. I
felt weak and I was mentally unwell.”
Carlos, who was already diagnosed with COPD (Chronic
Obstructive Pulmonary Disease) said, (SS94) “I also
noticed that I always get tired easily. I cannot do the all the
things I used to do. I can no longer cook my own food. You
can never leave me alone because I might black out….”

The infection of HIV continually causes suppression of the
immune system; someone with a weak immune system is highly
susceptible to opportunistic infections (Takalkar, et al., 2012). The
most common opportunistic infections are pulmonary
tuberculosis, pneumonia and oral candidiasis (Low, et al., 2016;
Khanal, et al., 2014; and Solomon, et al., 2018). All three common
infections have been narrated by the informants of the study. In
addition to that, syphilis, herpes, and COPD (Chronic Obstructive
Pulmonary Disease) were mentioned.
Theme 3: Responses and Coping with HIV/AIDS
A person with HIV would adhere to what can help them live longer.
This discusses the responses and coping of PLWHA's to the
disease. The presence of social networks, specifically support
systems show a positive impact to the lives of PLWHA's toward
their treatment and coping (Forouzan, et al., 2013; da Silva and
Tavares, 2015; and Bateganya, et al., 2016). Lifestyle
modifications were discussed as an important factor in moving
toward the positive spectrum of life (Derman, et al., 2010).
Spirituality also aids in the coping of PLWHA's (Szaflarski, 2013).
The advocacies that address HIV/AIDS like stigma, treatment and
control are helpful aspects against discrimination and the further
spread of disease (Mutchler, et al., 2011; and Tumwine, et al.,
2012). Three subthemes are discussed further below.
Subtheme 1: Establishing old and new networks: Support
systems
The importance of networking has been established and the
informants have narrated how support groups have helped them
or how they are important. The statements below stated the
importance or presence of a support system, which includes
either of the following; family, friends, or fellow PLWHA's.
Bertha mentioned that, (SS44) “My mother knows little
about HIV so I have to educate her about it before I came
home. My family motivated me to come home so they can
take care of me. I lived alone for 10 years.”
Carlos narrated, (SS105) “I told myself that I have a horrific
attitude. But I think I recovered because of the support of
my family. A support system is really important.”
Darryl also said that, (SS121) “Since I attended with this
support group, they really help me a lot. There are a lot of
people now that I know that they have been taking the
medication for 5 years or more and I was surprised
because they're still alive.”
In connection to family as the support system, Bertha and Felix
were the only ones who were able to immediately disclose their
status to either parent as discussed on the statements below.
Bertha said, (SS43) “I called my mother to tell her about my
status. I am only an adopted son and I don't know who my
real parents are but I am very lucky to have my parents as
they have accepted me.”
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JULY - DECEMBER 2019
Meanwhile Felix narrated the following, (SS162) “I told my
dad after a month. I told my dad after a month and then I
slowly told my siblings but my mom only knew about it after a
year. Yeah because my mom is a worrywart. Even until now,
she still doesn't understand it. I didn't really tell my mom. It
was my siblings who told her about it.”
In contrary, other informants were able to only tell siblings or no
family members at all regarding their HIV status or did have
challenges related to familial issue related to the illness.
Darryl strongly verbalized, (SS124) “cause I know my family
and my family have this close mind and I think if they know
I'm HIV positive cause they don't know that I'm gay so
maybe they'll find out my sexuality. Yes and also being an
HIV positive, they might 'itakwil' or disown me.”
Eduard mentioned the following statements, (SS139) “I am
actually afraid to tell my family of my status. I don't know
what will be their reaction but I am really scared. I don't know
but I know I still can't do it. I am scared because of all the
discriminations and my family might disown me. I still hope
they will support me still but I am not yet ready.” And,
(SS140) “I think it will be a relief if I am able to tell my family. I
am just not ready. I still don't know what opinions other
people have. I am still in fear.”
Even George, the last informant mentioned sentiments on
disclosing status to his parents on, (SS197) “…And how to
tell my parents about my status. This is something I haven't
figured out yet.”
A social network can be a source of support for individuals
diagnosed with HIV and family networks have been highly
emphasized on the adherence of treatment (Forouzan, et al., 2013;
& da Silva and Tavares, 2015). This is in contrary to what the
informants of this study have narrated; majority of the informants
has initially informed friends and other PLHWHA's in their social
circle in terms of seeking support.
Subtheme 2: Socio-spiritual changes: lifestyle changes and
being more religious
This describes the lifestyle changes they did in response to being
diagnosed with HIV/AIDS, including the cessation of high risk
sexual activities, avoidance of alcoholic beverages and smoking.
There is also a discussion about establishing a relationship with a
higher being. Transcripts were able to capture the changes the
transpired in the lives of the informants pertaining to their lifestyle
and being religious.
Andrew mentioned that, (SS15) “No more hookups. No
casual hookups. No more dating with people.”
Bertha verbalized the following, (SS60) “I already stopped
drinking but I was drunkard when I was in Manila.” And,
(SS61) “I do smoke. I can't stop it yet. I am trying to stop
because the program coordinator would always remind
me.” She also added, (SS57) “I was almost promoted as a
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trainer when I was working in a BPO company. Then, I was
infected with HIV and had to quit my job. I will definitely go
back to work. Not now, not tomorrow, not the other day, but
God's perfect time, I will.”
Carlos added, (SS104) “Immediate changes I really had to
stop what I'm used to do I can no longer smoke.”
Eduard mentioned that, (SS146) “I leave everything to the
Lord.” And, (SS147) “I didn't say that I stopped drinking but I
really can't tell what will happen. I admit I was a drunkard
before but not now. I stopped and only drink in moderation.”
George said, (SS194) “I have learned to be more
responsible with my health and the people around me. I
learned to accept the consequences of my actions and live
a life of positivity in mind and body. I'm still trying to restore
my faith with God and be more religious like before.”
Lifestyle issues can affect the adherence of treatment for HIV and
can increase presence of opportunistic infections and death (Katz
and Maughan-Brown, 2017). Lifestyle changes are necessary and
are considered a part of the management of patients with HIV,
which include alcohol intake and drug use (Derman, et al., 2010). In
addition, physical activity and a proper diet can aid the PLWHA's in
achieving optimal health status (Somarriba, et al., 2010).
Spirituality and religion on the other hand can help improve health
and quality of life through optimism and this also helps PLWHA's
cope up stressors through praying and believing in a higher being
that has helped increased their faith (Szaflarski, 2013).
Subtheme 3: Moving Forward
This is about what PLWHA's have learned about their condition
and tackles the actions that support the willingness to move on,
such as forming advocacies and developing self-advocacy skills.
This is also about the goals they have, like staying healthy despite
the diagnosis. The narratives are further shown below.
Andrew was able to discuss the following, (SS33) “Lessons
learned. We have to be extra careful. We have to be very
responsible. You know that there's a risk. Do more research
about it? Do not engage into things like for example the
casual hookups or one night stand because you do that,
there is really conscience. That is a gift, I'm telling you,
inside that, that is bad, don't do that, before you engage to
that, I mean, before you satisfy yourself. It can end into like
for example troubles.”
Bertha also stated, (SS53) “I told myself that this mistake
change my life. I said that I also need to be positive in life
because of my family and the people around me. I wanted to
become an HIV advocate and a support system for others.”
George emphasized to use of social media in spreading
awareness as stated, (SS195) “Yeah. I still use that gay
dating app Grindr but changed my profile name portraying
my status to raise awareness in the app and to find friends
and other poz (HIV positive) people. I already stopped doing
meet ups just to give blow jobs and the like. I kinda do
friendly meet ups only now.”
PJN VOL. 89 | NO. 2
Advocacies on HIV/AIDS are present to promote health education
and de-stigmatization, safe sex practices, regulation of injectable
drug use, regular testing, and encouragement of treatment against
the infection (Mutchler, et al., 2011; and Tumwine, et al., 2012). It
was noted that PLWHA's can gain self-advocacy skills as they
promote health education, prevention and treatment and building
self-advocacy skills help empower PLHWA's (Mutchler, et al.,
2011; and Tumwine, et al., 2012). The informants were able to
discuss the importance of advocacies and verbalized what the
public needs to know and were also clear in stating their goals.
Exhaustive Description
PLHIV's are usually aware of the behaviors that put them at risk for
HIV infection and that pushed them to submit for testing, which
includes the presence of high risk sexual activities and injectable
drug use; presence of presumptive signs and symptoms; and
having a former partner diagnosed with HIV. There were medical
and health professional informants who have knowledge about HIV
including transmission and risk factors. All informants admitted to
having high risk sexual patterns, while two who were injectable drug
users discussed an instance of needle sharing. Sivaram, et al.
(2008) highlighted that risky sexual patterns are the common cause
of HIV transmission. Furthermore, it is also known that HIV can be
transmitted through needle sharing between those people who
inject drugs (CDC, 2018; AVERT, 2018; Challacombe, 2018). Three
of the informants mentioned that they had a partner that was
diagnosed with HIV, which also prompted them to get tested. Brown,
et al. (2012) said that there is number of people who submit for
testing because a partner, current or former is HIV positive.
The challenges encountered while being diagnosed with HIV
ranged from coping with medication side effects, mental and
physical health, and most especially the stigma (Ntseane, et al.,
2010; de Jesus, et. al., 2017; Dejman, et al., 2015; and Rao, 2016).
Depression and suicidal thoughts also posed as threats. There
were at least two informants who have had suicide attempts. One
informant mentioned that he took 10 tablets of ARV medications,
which sent him to the emergency room.
Stigma was another issue the informants experienced that led most
of them to not disclose their status to the public and their family for
fear of being discriminated or disowned. Disclosure was avoided as
they mentioned how their peers judge PLWHA's including the
misconceptions of HIV/AIDS. One disclosed his status to his peers
and potential employers that resulted to rejection and
discrimination. The social stigma seems to be the biggest
challenge PLWHA's would experience (de Jesus, et. al., 2017;
Dejman, et al., 2015; and Rao, 2016); and is a barrier to one's
disclosure of status (Oskouie, et al., 2017; and Turan, et al., 2017).
PLWHA's need a lifelong treatment to maintain one's health and are
initially challenged with medication side effects. One informant
deferred taking ARV's because of the known side effects. Nausea
and vomiting, hot flashes, stomach upset, and nightmares were
side effected noted. Low, et al., (2016); Khanal, et al., (2014); and
Solomon, et al., (2018) have narrated that pulmonary tuberculosis,
pneumonia and oral candidiasis are the top 3 opportunistic

infections that PLWHA's experience. At least one or two of the said
infections were experienced by each informant. Others mentioned
to have syphilis and herpes.
Everyone has the will to survive that they create a conscious effort
to do so. The presence of support groups will have positive impact
on the lives of PLWHA's, including lifestyle changes, coping and
adherence to treatment (Forouzan, et al., 2013; da Silva and
Tavares, 2015; and Bateganya, et al., 2016). Most support groups
that were mentioned are composed of fellow PLWHA's. Forouzan,
et al., (2013); and da Silva and Tavares, (2015) mentioned that a
supportive family is vital in the treatment adherence but the
informants stated the opposite. One informant even mentioned
that medication compliance issues due to the lack of holistic family
support.
If the goal is to be healthy and to live longer, lifestyle changes are
necessary. Derman, et al. (2010) and Somarriba, et al., (2010)
mentioned that lifestyle changes are part of the management of
HIV/AIDS. Spirituality and religion are present factors that aid in the
coping and increased optimism of PLWHA's (Szaflarski, 2013).
Most informants have acknowledged the presence of a higher
being that they pray for help and guidance
The presence of HIV/AIDS advocates are important factors as they
aid to health education and de-stigmatization, safe sex practices,
regulation of injectable drug use, regular testing, and treatment
adherence (Mutchler, et al., 2011; and Tumwine, et al., 2012). The
informants developed self-advocacy skills and have expressed the
need of education to the public to battle stigma. Mutchler, et al.,
(2011); and Tumwine, et al., (2012) mentioned that PLWHA's can
gain self-advocacy skills as they promote health education,
prevention and treatment.
Implications
High risk sexual patterns is a factor that would make one consider
HIV testing but knowing that a former or current partner and the
presence of some signs and symptoms would ultimately push one
to get tested.
PLWHA's are compliant of their treatment regimen, which includes
ARV medications, prophylaxis and treatment of opportunistic
infections regardless the undesirable side effects experienced.
The physical and physiological health of PLWHA's is well
addressed by the government; however, the mental health status is
not given much attention.
PLWHA's acknowledge the importance of support groups. They
are willing to adhere to changes that will help them to become
healthy including change of lifestyle and sexual patterns. They
desire to have a close relationship to a higher being.
In general this tackles on the importance of health education in the
nursing profession. Nurses are professionals that face PLWHA's
before, during, and after diagnosis. This implies the importance on
educating the public about the prevention and transmission on
HIV; taking care of newly diagnosed clients both physically and
psychologically; and assisting the clients towards recovery and
health.
27
JULY - DECEMBER 2019
Recommendations
There is a need to increase the promotion of safe sex practices and
health education about HIV/AIDS and information dissemination
should be delivered on a wider scope so that more people would be
aware of their own risks. To increase the visibility of testing centers,
community based advocates, and the advertisement of personal
testing kits is recommended.
The government must continue the provision of ARV and
prophylactic medications against opportunistic infections and
educating on the importance medication compliance, its
undesirable side effects, and possible handling strategies should
be reinforced. Mental health of PLWHA's should also be addressed
as depression and suicide risk is present.
Response and coping with HIV/AIDS have also been dealt with
which includes networking, socio-spirituality and advocacy.
Religious sectors can acknowledge the desire to be closer with a
higher being as enhancing spiritually provides optimism in one's
life. There is also a need to continue building self-advocacy skills as
this leads to empowerment, promotion of health education, safe
sex practices, regular testing, treatment adherence, and support to
fellow PLWHA's especially those newly diagnosed.
ABOUT THE AUTHORS
Mark Gilbert S. Milallos is a Utilization
Management Nurse at Cognizant Technology
Solutions Philippines, Inc. He is currently
pursuing a Doctor of Science in Nursing
degree (Major in Gerontology Nursing) at
Cebu Normal University and completed his
Masters of Science in Nursing (Major in
Medical-Surgical Nursing) from the same institution. He finished
his Diploma in Professional Education at Cebu Technological
University and his BS Nursing degree at the University of Cebu –
Banilad Campus. He is active in both local and international
research conferences and has received awards for presentation
of research articles
Dr. Jezyl Cempron-Cutamora is a former
dean and program chair of Cebu Normal
University–College of Nursing and is
currently a professor who handles both
undergraduate and graduate school courses.
She obtained her Bachelor of Science in
Nursing from Cebu City Medical Center –
College of Nursing. She finished her Masters in Nursing (Major
in Medical-Surgical Nursing) and Doctor of Philosophy in
Education (Major in Research and Evaluation) from Cebu
Normal University. She has authored and co-authored
published researches in several international and national
refereed journals. She received research awards for publication
and presentation of research articles.
PJN VOL. 89 | NO. 2
28

RESEARCH ARTICLE

ASSESSMENT OF KNOWLEDGE AND

SKILLS OF BARANGAY HEALTH WORKERS:
BASIS FOR DIABETES EDUCATION
PROGRAM FOR LAY PERSONS
Joylyn L. Mejilla, MAN, RN1, Anjanette S. De Leon, MAEd, MAN, RN, Ana Leah D. Esguerra, MAN, RN,
Josefina E. Florendo, EdD, RN, Leyden V. Florido, MAN, RN, Mercerose P.J. Puno, MAN, RN,
Ray Justin M. Reyes, RN and Eleonor C. Tangkeko, PhD, RN

Abstract
This study aimed to determine the level of knowledge and skills of the barangay health workers (BHW) about diabetes management. A
descriptive correlational design that included 121 BHWs in Bustos, Bulacan was utilized in the study. A test and skill demonstration
checklist was utilized to determine the knowledge and skills of BHWs about diabetes management. Categorical variables such as the
respondents' profile were described using frequencies and percentages. Continuous variables such as level of knowledge and skills
were summarized using central tendency measures (mean) with standard deviation. Pearson correlation test for association was used
to test for relationship between level of knowledge and skills. Pearson Chi square was used to test association between demographic
variables and level of knowledge and skills. A p value of <0.05 was considered significant in the analysis of the results. Results showed
that the overall level of knowledge of the BHWs was satisfactory but varied in many aspects of diabetes management. The BHWs level
of knowledge in determining signs and symptoms and diagnosis of diabetes was high but low in determining types of diabetes mellitus.
The level of skills of the BHWs was high in blood pressure measurement but low in blood glucose monitoring. BHWs have varied
knowledge and skills in diabetes care management. There is a need to train the BHWs further to develop their knowledge and skills. The
nurse diabetes educators must provide diabetes education program for BHWs that are focused on competencies to deliver safe and
appropriate health teaching activities utilizing the basic concepts and principles of diabetes management.

Keywords: Diabetes Management Self Education, Diabetes Type 1, Diabetes Mellitus, Diabetes Nurse Educator

Introduction

D iabetes is a worldwide epidemic that accounts for 422 million

adults living with diabetes as of 2014. The global prevalence
of diabetes has nearly doubled since 1980, rising from 4.7% to
8.5% in adult population. Diabetes is no longer just the problem of
high income countries but cases have also, in fact, risen faster in
low and middle income countries (WHO, 2016). The Philippines is
one of the world's emerging hotspots, ranking in the top 15th of
the world's diabetes prevalence. Philippines is home to more than
4 million people diagnosed with diabetes and a large unknown
number of people do not know that they have diabetes (IDF,
2016). Diabetes health education is vital in its management.
Health care providers in different settings are pushing for diabetes
education to people with diabetes to lessen the burden of this
worldwide problem.
Primary health services in the Philippines are delivered in the
barangay health stations, health centers and at hospitals. The
health care providers are doctors, nurses and midwives with the
help of the barangay health workers. The Barangay Health
Worker (BHW) is a category of health care provider in the
Philippines. They undergo training from government and non-
government institution and render primary health care services.
According to the Philippines Department of Health (DOH), as of
2009 there were 196,562 active accredited BHWs. They are
considered the backbone of government health service delivery in
the Philippines and their role as health educators in diabetes care
is important to consider (Paz-Pacheco & Jimeno, 2015). Thus,
their level of knowledge and skills in providing diabetes care and
education is vital to assess.

1 Corresponding author: Association of Diabetes Nurse Educators of the Philippines ( ADNEP); email address: jlmejilla@ceu.edu.ph

PJN VOL. 89 | NO. 2


A training workshop aimed to enrich local government healthcare
staff's knowledge and skills in diabetes care by Ku and Kegels
(2014) revealed that the level of knowledge increased and the
self-assessed skills also improved. The same diabetes training
was conducted for community health workers by Aponte in 2015.
Aponte's (2015) findings showed that the diabetes knowledge of
the BHWs increased after the diabetes training. Aviles et al
(2015) assessed the BHWs knowledge and skills in providing
diabetes health education and revealed that the level of
knowledge and skills varies on different areas of diabetes. BHWs
as lay persons, have high knowledge in medical nutrition therapy
and lowest in the diagnosis of diabetes. In terms of the level of
skills, the highest average percentage score of the BHWs is
height measurement while the lowest is blood glucose
monitoring techniques.
This study aims to assess the level of knowledge and skills of the
BHWs in Bustos, Bulacan to serve as basis for the development
of Diabetes Education Program for Lay Persons. This Training
Program will be used as a tool to train BHWs in diabetes health
education process in Bustos, Bulacan.
Research Design
The study utilized descriptive correlational research design in
determining the level of knowledge and skills of the barangay
health workers in diabetes education in Bustos, Bulacan. The
outcome of the study will be the basis for the development of the
lay diabetes education program.
Setting of the Study
The study was conducted at Bustos, Bulacan. The Municipality of
Bustos sits in the Midwest of the Province of Bulacan and about
50 kilometers from Metro Manila. It is a 2nd class semi-urban
municipality with 14 barangays namely Bonga Mayor, Bonga
Menor, Buisan, Camachilihan, Cambaog, Catacte, Liciada,
Malamig, Malawak, Poblacion, San Pedro, Talampas, Tanawan
and Tibagan. The setting was chosen because of the
investigator's affiliation with the municipality as a diabetes health
educator.
Subjects of the Study
Out of 251 barangay health workers in Bustos, Bulacan, 121
were included. They were purposively selected and had
voluntarily consented to become the respondents of the study.
The study included barangay health workers who are presently
rendering services to various Barangay Health Centers in
Bustos, Bulacan for at least 6 months regardless of their age, sex
and number and area of focus of previous trainings attended. All
chosen barangay health workers voluntarily participated in the
study as they are encouraged by their respective midwives,
nurses and Municipal Health Officer.
29
JULY - DECEMBER 2019
Instrumentation
The data collection utilized adopted test and skill demonstration
checklist from Aviles et al. (2015), which was further modified to
attain the objectives of the study. The test consisted of fifty (50)
items that included assessment of the level of knowledge of the
barangay health workers on the following 1) overview of diabetes
(definition and types of diabetes), 2) types of diabetes mellitus, 3)
risk factors 4) signs and symptoms, 5) diagnosis of diabetes, 6)
management/ treatment of diabetes, 7) exercise management, 8)
smoking cessation, 9) stress management, and 10) complications
of diabetes management. The research test was validated by
expert diabetes educators. Some words used in the test were
changed to simpler one to facilitate understanding of the question.
In addition, items were classified accordingly as mentioned
above.
The skill demonstration checklist consisted of fifty-nine (59) items
that were used to assess the level of skills of barangay health
workers on the following: 1) anthropometric measurements
(weight, height, waist and hip circumferences), 2) blood glucose
monitoring, and 3) blood pressure monitoring. The checklists are
standard tools used in the Diabetes Education Training (DET)
conducted by Philippine Association of Diabetes Educators
(PADE) and Association of Diabetes Nurse Educators in the
Philippines (ADNEP).
Data Gathering Procedure
The conduct of the study was approved by the Municipal Health
Officer of Bustos, Bulacan. Proper coordination process to the
different barangay health centers in Bustos, Bulacan was done to
facilitate the conduct of the study. After selection of participants
based on inclusion criteria, data gathering process were
initialized. The participants were given one (1) hour to accomplish
knowledge test and two (2) hours for skills demonstration, which
consisted of four (4) stations including height and weight, waist
and hip circumferences, blood pressure and blood glucose
monitoring accordingly. One evaluator was assigned for each
station and the participants were in pair and took turns in
performing the skill/s assigned to each station.
Statistical Treatment of Data
Descriptive and inferential statistics were used in the study.
Descriptive statistics were used to interpret and describe the
nature of the data, general and specific trends. Categorical
variables such as the respondents profile were described using
frequencies and percentages. Continuous variables, such as
level of knowledge and skills were summarized using central
tendency measures (mean) with standard deviation. Pearson
correlation test for association was used to test for relationship
between level of knowledge and skills. Pearson Chi square was
used to test association between demographic variables and
PJN VOL. 89 | NO. 2
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JULY - DECEMBER 2019

level of knowledge and skills. A p value of <0.05 was considered
significant in the analysis of the results.
Results
The profile of the Barangay Health Workers (BHW) in Bustos,
Bulacan were described according to age, sex, educational
attainment and years of service.
A good proportion of the respondents belong to age group 51-60
years old (n=37, 30.6%), while only few belong to 71-80 years old
(n=8, 6.6%). There is only one respondent for both 20-30 years
old and 81-90 years old age group (n=1, 0.8%). (Figure 1). All of
the respondents are female (n=121, 100%).
Figure 1. Age of the Respondents Figure 2. Respondents' Educational Attainment
The respondents' educational attainment shows that almost half
of the respondents are elementary graduate (n=58, 47.9%).
However, a few of the respondents are undergraduate (n= 10,
8.3%), college graduate (n= 5, 4.1%), and vocational graduate
(n= 4, 3.3%). (Figure 2)
More than half of the respondents have worked in the health
center for 0-10 years (n=69, 57%). A good proportion of the
respondents worked for 11-20 years (n=36, 29.8%). Only few of
the respondents worked for 21-30 years (n=10, 8.3%) and 31-40
years (n=6, 5.0%). (See Figure 3)
The level of knowledge of the respondents in diabetes mellitus
and its management was determined by the test questions
Figure 3. Respondents Years of Service

Age Educational Attainment Years of Service

Figure 4. Level of Knowledge of the Respondents

Level of Knowledge

LEGEND
Level of Knowledge - 50-40: Excellent | 39-40: Very Satisfactory | 29-20: Satisfactory | 19-10: Unsatisfactory | 9-0: Poor
PJN VOL. 89 | NO. 2

Figure 5. Level of Skills of the Respondents
Level of Skills
LEGEND
Level of Knowledge - 100-80: Excellent | 79-60: Very Satisfactory | 59-40: Satisfactory | 39-20: Unsatisfactory | 19-0: Poor
administered to them. Respondents' knowledge was interpreted
from “excellent” to “poor”. Figure 4 presents that the overall level
of knowledge of the respondents were “satisfactory” (M=29.80,
SD= 7.26). Respondents' knowledge in signs and symptoms of
DM were “very satisfactory” (M=4.02, SD= 1.0) which ranks first.
However, respondents' knowledge in Types of DM (M=1.73, SD=
0.96) and in diagnosis of diabetes (M=2.25, SD= 1.31) were
“unsatisfactory”. The level of knowledge of the respondents
shows “satisfactory in knowledge in diabetes definition, stress
management, smoking cessation, treatment, complications, and
risk factors of DM”.
The level of skills of the respondents in Blood Glucose Monitoring,
Blood Pressure measurement, and Anthropometric
measurements, which includes height, weight and hip and waist
circumference were determined through their total scores in the
return demonstrations. Respondents' skills were interpreted from
“excellent” to “poor”. The Figure above shows that the level of
skills of the respondents in BP measurement were “very
satisfactory” (M=70.99, SD= 66.68). The level of skills in
anthropometric measurement shows “satisfactory” results in the
skills return demonstration scores (M=53.95, SD= 5.46). While
the BGM measurement skills shows “unsatisfactory” scores in the
level of skills (M=37.51, SD= 30.95)..
The relationship between the knowledge and skills in BGM, BP
measurement and anthropometric measurement were
determined using Pearson correlation statistics (See Table 1).
The skills of the respondents in BGM shows significant weak
positive correlation (r= 0.21, p=0.02) in the respondents overall
31
JULY - DECEMBER 2019
scores in the knowledge test. Significant weak negative
correlation was also obtained between respondents' skills in BP
measurement and overall scores in knowledge test (r= -0.27,
p=0.00). However, no significant correlation was obtained
between respondents' skills in anthropometric measurement and
overall scores in knowledge test (r= -0.03, p=0.700).
Table 1. Relationship between knowledge and skills
The correlation between the respondents' level of knowledge to
demographic profile were determined using chi square. Table 2
revealed that the respondent's level of knowledge was
significantly related to age, in particular knowledge to diabetes
(r=38.54, p=0.31), smoking cessation (r=47.59, p=0.02), stress
management (r=55.81, p=0.003), and complications of diabetes
mellitus (r=44.08, p=0.04). The respondents' level of knowledge
in smoking cessation was significantly related (r=41.46, p=0.003)
to education. In terms of the respondents' year of service, it was
significantly related (r=25.62, p=0.042) to their knowledge in
stress management in DM.
No significant correlation was obtained between skills and
demographic profile of the respondents (Table 3).
PJN VOL. 89 | NO. 2
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JULY - DECEMBER 2019
Table 2. Relationship between Knowledge and Demographic profile of the Respondents
*Chi square goodness of fit
**P-value: the correlation between the means is considered statistically significant if the p-value is <0.05
Table 3. Relationship between skills and Demographic Profile of the Respondents
*Chi square goodness of fit
Discussion
Assessment of knowledge in diabetes is vital in diabetes health
education process (Cavanaugh, 2011, Powers, 2015). The
BHWs must be knowledgeable enough to conduct diabetes
health education process to patients with diabetes mellitus.
Results of this study revealed that the BHWs overall level of
knowledge were satisfactory. The level of knowledge was
highest in signs and symptoms of diabetes and lowest in types
and diagnosis of diabetes mellitus. A pilot study in Sweden by
Smide and Nygren (2013) was conducted to determine diabetes
level of knowledge of health workers in nursing home. The study
determined the general level of knowledge in diabetes and found
out that the health workers knowledge in diabetes varied. The
health workers in the nursing homes considered symptoms of
patients related to hyperglycemia, while others were uncertain.
The results of the Sweden study was in contrast with the results
of the present study in which BHWs level of knowledge were
highest in determining signs and symptoms of diabetes mellitus.
The level of skills of the BHW's in the study were very satisfactory
in BP measurement, however, they have unsatisfactory level of
knowledge in blood glucose monitoring. The same results were
obtained by the study of Aviles et al. in the Philippines (2015).
The BHWs level of knowledge in diabetes varied. However, the
level of knowledge of the BHW in the study of Aviles (2015) were
highest in medical nutrition therapy. In terms of skills, the BHWs
level of skill were highest in height measurement and lowest in
PJN VOL. 89 | NO. 2
Note: Sex is excluded in the cases because it is constant
Note: Sex is excluded in the cases because it is constant
blood glucose monitoring. The study of Aviles (2015) included
BHWs who were high school graduate. Compared to the results
of this study, the respondents were elementary graduate.
Differences in the level of knowledge from this study and that of
Aviles (2015) may be attributed to the respondent's level of
education.
The BHWs or Community Health Workers' (CHWs') function as
level 1 diabetes educator associate according to Diabetes
Educator Practice Level Guidelines (AADE, 2014). As discussed
in the position paper of AADE (2014), the role of the BHWs in
diabetes management and prevention can be expected to have
varied activities in the community such as basic assessment
skills. Basic assessment skills included measurement of vital
signs and anthropometric data. They can also provide support,
general information and guidance regarding accessing care,
available diabetes care offerings and financial assistance. The
current update of literature on the role of BHWs in diabetes
showed areas of advancement (Shah, Kaselitz, Heisler, 2013).
BHWs are used to implement and evaluate interventions in
diabetes that were included in Community-based participatory
research (CBPR). The need to train and empower that the role of
the BHWs is the work of the nurse diabetes educators. BHWs
must be provided trainings that are suitable to their role in the
health care and as support in diabetes education. The
assessment of knowledge and skills is then necessary to come
up with a structured program for BHWs.

Conclusions & Recommendations
BHWs have varied knowledge and skills in diabetes care
management. There is a need to train the BHWs further to
develop their knowledge and skills. The nurse diabetes
educators must provide diabetes education program for BHWs
that are focused on competencies to deliver safe and appropriate
health teaching activities utilizing the basic concepts and
principles of diabetes management.
Based on findings of the study, a program must be developed
based on the relevant competencies to effectively deliver safe
and appropriate health teaching activities to individuals, families,
population group and community utilizing the basic concepts and
principles of diabetes care management. In the training design,
the knowledge on the different types of diabetes mellitus and
diagnosis of diabetes must be emphasized in the training
program. Case scenarios is strongly suggested to be part of the
methodology to ensure better understanding of these content.
On the other hand, skill on Blood Glucose measurement must be
strengthened by providing more time allotment for return
demonstration. Guided practice must be part of the training
design as well to ensure that competencies are attained.
Lastly, age, educational attainment and years of service must be
considered in choosing Barangay Health Workers who can
participate in the Diabetes Education Program for Lay Persons to
maximize the outcome of the training.
____________________
References
American Association of Diabetes Educators (AADE) (2014). Diabetes
Educator Practice Levels.2014. http://www.diabeteseducator.org/
export/sites/aade/_resources/pdf/general/PracLev2014.pdfAcce
ssed March 15, 2017.
Aviles, N. Jr., Clutario, B., Diaz, AD., Goyen, ND, Gubatan, C. III.,&
Ignacio, DL. (2015). Knowledge and Skills of Barangay Health
Workers in Providing Diabetes Health Education: An Assessment.
Unpublished research study. Association of Nurse Educators of
the Philippines (ADNEP).
Cavanaugh, K. (2011). Health literacy in diabetes care: explanation,
evidence and equipment. Diabetes Manag (Lond). 2011 Mar; 1(2):
191–199. doi: 10.2217/dmt.11.5.
Department of Health (DOH) Philippines. (2009).What is the number of
BHWs nationwide. Retrieved in www.doh.gov.ph › Frequently
Asked Questions › Barangay Health Workers on March 22, 2017.
International Diabetes Federation (IDF) (2016). Bridging research in
diabetes to global environments and systems- Philippines.
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Ku, GM. Kegels, G. (2014). Integrating chronic care with primary care
activities: enriching healthcare staff knowledge and skills and
improving glycemic control of a cohort of people with diabetes
through the First Line Diabetes Care Project in the Philippines.
33
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Glob Health Action. 2014; 7: 10.3402/gha.v7.25286. Published
online 2014 Oct 21. doi: 10.3402/gha.v7.25286
Paz-Pacheco, E. &Jimeno, C. (2015). Diabetes Care in the Philippines.
Journal of the ASEAN federation of Endocrine Societies. Vol 30,
No 2 (2015).
Powers, M., Bardsley, J. Cypress, M.,Duker, P., Funnell, M., Fischl, A.,
Maryniuk, M. Siminerio, L. &Vivian, E. (2015). Diabetes Self-
management Education and Support in Type 2 Diabetes: A Joint
Position Statement of the American Diabetes Association, the
American Association of Diabetes Educators, and the Academy of
Nutrition and Dietetics.Diabetes Care 2015 Jul; 38(7): 1372-1382.
https://doi.org/10.2337/dc15-0730.
Shah, M, Kaselitz, E. &Heisler, M., (2013). The Role of Community
Health Workers in Diabetes: Update on Current Literature. –Curr
Diab Rep. 2013 Apr; 13(2): 163171.. doi: 10.1007/s11892-012-
0359-3.
World Health Organization (WHO) (2016).Global Report on Diabetes.
Retrieved from apps.who.int/iris/bitstream/10665/204871/1/
9789241565257_eng.pdf on March 22, 2017.
ABOUT THE AUTHORS
Joylyn L. Mejilla, MAN, RN (principal
investigator and corresponding author), is an
Assistant Professor and currently the
Assistant to the Dean for Instructions of the
Centro Escolar University -School of
Nursing. She earned her Master of Arts in
Nursing at Pamantasan ng Lungsod ng Maynila. She is the
immediate Past-President and currently the Chair of the Ethics
Committee of the Association of the Diabetes Nurse Educators
of the Philippines (ADNEP). She was one of the authors of the
Career Progression and Standards of the Diabetes Nursing
Practice in the Philippines. Her interest in research is on
Diabetes Nursing and Critical Thinking Skills.
Anjanette S. De Leon, MAEd, MAN, RN, is
an Assistant Professor at Centro Escolar
University and currently the community
coordinator of the School of Nursing. She
earned her Master of Arts in Education at De
La Salle, Manila and Masters of Arts in
Nursing at Centro Escolar University, Manila. At present, he is
a active member of the Board of Directors of the Association of
Diabetes Nurse Educators of the Philippines. Currently, she is
a lecturer and facilitator in the Diabetes Education Training
Program for health care professionals.
Ana Leah D. Esguerra, MAN, RN is a
Diabetes Nurse Educator at the AFP V Luna
Hospital and currently a member of the
Board of Trustees of the Philippine
PJN VOL. 89 | NO. 2
34
JULY - DECEMBER 2019
Association of Diabetes Educators, Inc. (PADE). She earned
her Masters of Arts in Nursing at Philippine Christian
University, Manila. To date, she is an active member of the
following organizations: Association of Diabetes Nurse
Educators of the Philippines, Philippine Nurses Association
and Diabetes Philippines.
Josefina E. Florendo, EdD, RN, is currently
the Treasurer of the Philippine Association
of Diabetes Educators, Inc. (PADE). Took
her Pre-Med at the University of the
Philippines but pursued Nursing as her
profession. She earned her Master of Arts in
Nursing at Philippine Women University, Quezon City and her
Doctorate Degree in Education at Far Eastern University,
Manila. Among her active membership are with the Diabetes
Philippines, Association of Diabetes Nurse Educators of the
Philippines, Inc. (ADNEP), Philippine Nursing Research
Society and the Philippine Nurses Association (PNA).
Leyden V. Florido, MAN, RN, is currently
the elected Executive Board, International
Diabetes Federation- Western Pacific
Region and President of the Philippine
Association of Diabetes Educators, Inc.
(PADE). She earned her Masters of Arts in
Nursing at the Philippine Womens University, Quezon City. A
Board of Director/Trustees of various organization involved in
educating and caring for persons with diabetes and the health
care professionals. The organizations are as follows:
Rainbow Camp Foundation Philippines, Diabetes Philippines
and Association of Diabetes Nurse Educators of the
Philippines. A faculty and volunteer diabetes nurse educator
at the Institute for Studies on Diabetes Foundation. A
lifetime member of the Philippine Nurses Association.
Mercerose P.J. Puno, MAN, RN is Team
Leader for Diabetes Education & Clinical
Research at Novo Nordisk. Experienced
Team Lead with a demonstrated history of
working in the pharmaceuticals industry.
A nurse is not what you do.
It is what you are…
I am a nurse. It’s not what I do,
it’s what I AM.
PJN VOL. 89 | NO. 2
Skilled in Diabetes, Biopharm and Obesity Project
Management, People Management and Coaching, Clinical
Research, Hypertension, Nursing Education, and Medical
Devices. Strong education professional with a Masters of
Science in Nursing focused in Administration from
Concordia College.
Ray Justin M. Reyes, RN is an active
volunteer of the Rainbow Camp
Foundation Philippines' Annual Summer
Camp for Type 1 persons with diabetes. He
earned his Nursing Degree at the Centro
Escolar University, Manila. Currently, he is
holding a position as Assistant Unit Manager in Pru Life UK.
Mr. Reyes is also a Registered Financial Planner and
Chartered Wealth Advisor. A member of various organization
such as Association of Diabetes Nurse Educators of the
Philippines, Philippine Nurse Association, Life Underwriter
Association of the Philippines, WFP Foundation and Kiwanis
International.
Eleonor C. Tangkeko, PhD, RN is an
Associate Professor and former Dean of
the College of Nursing and Health Sciences
at Jose Rizal University, Mandaluyong City.
She earned her Doctorate in Philosophy
and Master of Arts in Nursing at Philippine
College of Health Sciences, Manila, and Bachelor of Science
in Nursing at Martinez Memorial Colleges, Caloocan City,
and Bachelor of Science in Medical Technology at Centro
Escolar University, Manila. At present, she is the President
and member of the Board of Trustees of the Association of
Diabetes Nurse Educators of the Philippines, Inc. (ADNEP).
She is one of the resource speakers and facilitators at
ADNEP and PADE Diabetes Education Training Program for
health care professionals. She is a lifetime member of the
Philippine Nurses Association (PNA) and an active member
of Philippine Association of Diabetes Educators (PADE) and
Diabetes Philippines (DP).
 35

RESEARCH ARTICLE

NORMALIZING ADVANCED PRACTICE

IN PUBLIC HEALTH NURSING
IN THE PHILIPPINES:
A FOUCAULDIAN ANALYSIS
John Joseph Posadas, RN, MSAHP1, Luz Barbara P. Dones, MPH, RN
and Peter James B. Abad, MSc, RN

Abstract
This study provides a closer look to the possibility of having advanced practice in public health nursing by analyzing the power relations
between nursing practice and social structures. Representatives from the public health sector, national authorities, and the private
sector were invited in a round table discussion. Transcriptions were coded and later on categorized and analyzed drawing upon the
concepts of Foucault. Foucauldian analysis hands an important insight on how social structures and institutions can steer the creation of
an advanced practice in public health nursing in the Philippines. Various social institutions view the relevance of a master's prepared
nurse according to their societal roles and functions. Requisite competencies of a master's prepared nurse in public health nursing
include fulfilling the role of a clinician, leader and manager, supervisor, and a researcher. PRBON, CHED, DOH, and nursing schools
need to work together to define the knowledge of an advanced practice in public health nursing, to implement appropriate surveillance
mechanisms, and to establish a compliant practice.

Keywords: advanced practice nursing, public health nursing, Foucauldian analysis, professional roles

Introduction

I n the Philippines, the minimum requirement to be a registered

nurse is to have a Bachelor of Science degree in Nursing.
According to the National Nursing Core Competency Standards
(2014), the expectations of an entry-level nurse is technically a
generalist who can be deployed in hospitals or clinics, and public
health facilities. They fulfill beginning roles as clinician,
researcher, and as leaders and managers. Currently, there are no
professionally recognized advanced practice nursing or nurse
practitioner tracks in the country.
Nurses comprise the top cadre of institution-based health workers
in the Philippines. In 2017, the DOH Health Human Resources
Development Bureau computed that there are 8.6 nurses for
every 10,000 population. However, only 26% of the 90,308 nurses
in the country are employed in primary care facilities in
communities (Dayrit et. al., 2018). Hence, the number of nurses
serving populations in non-hospital primary care facilities might
actually be lower.
In order to support local health systems development, the DOH
implemented deployment programs of human resources of health
(HRH) to various local government units (LGUs). From 2011 to
2017, an average of 15,953 nurses have been deployed with a
high of 21,929 nurses in 2013 under the Registered Nurses
Health Enhancement and Local Service or RNHEALS program
(DOH, 2015) and 17,538 nurses under the Nurse Deployment
Program or NDP (Dayrit et. al 2018).
The World Health Organization (WHO) has called for the
transformative scale up of health professional education in 2011.
In a seminal published work, equal emphasis was placed on
increasing health human resource and at the same time
increasing their impact on population health (Frenk et. al., 2011).
The severe global workforce crisis was acknowledged along with
its contributing factors such as critical shortages, imbalanced skill
mix, and uneven distribution of health professionals (WHO, 2011).

1 Corresponding author: Assistant Professor of Nursing, University of the Philippines College of Nursing, Sotejo Hall, Pedro Gil Street, Ermita, Manila City, jbposadas@up.edu.ph;

PJN VOL. 89 | NO. 2

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In order to meet population health needs, health professional
education should direct the increase in the quantity, quality, and
relevance of health providers. (WHO, 2011). Advanced practice
in public health nursing can be one of the strategies to enhance
the quality and relevance of health providers for the populations
being served. This is all the more important as the Philippines
transitions to a health system that provides for universal
coverage (Universal Health Care Act of 2019). Advanced
practice in public health nursing will equip the BSN-prepared RN
to fulfill the role of a primary care provider under the
implementation of UHC law. This will also enable public health
nurses to participate as important actors in systems
strengthening to ensure primary health care and achieve
universal coverage.
However, advanced practice nursing in public health remains to
be a prospect as there is no enabling law that provides for this.
This would also entail reforms in education that are informed by
community health needs and respective responses. Strong
collaboration between education and health sectors, other
national authorities and even private sector is needed in order to
realize this prospect. An analysis of the power relations between
and among these key players in health using a Foucauldian
analysis can help situate such reforms. As such, the aim of this
paper is to analyse power relations between and among societal
structures that govern the practice of public health nursing in the
Philippines. It is against this background that the relevance of a
master's prepared nurse with specialization in public health
nursing as well as the requisite competencies for master's
preparation will be discussed.
Methodology
A qualitative descriptive design was used. Six (6) experts were
purposively invited to participate in a round table discussion
(RTD) essentially to examine the current Master of Arts
(Nursing), Community Health Nursing track offering of the
University of the Philippines College of Nursing. Participants
represented key institutions that can provide substantial input
and direction for an advanced public health nursing program.
The Department of Health, a local health department from Metro
Manila, and a non-government organization (NGO) represented
the potential employer of the graduates. The Professional
Regulatory Board of Nursing and Commission on Higher
Education Technical Committee on Nursing Education were
invited to provide input regarding the regulation of nursing
practice and of nursing schools, respectively.
The session lasted for about 4 hours. It began with an
introduction of participants, a review of objectives, sharing of
insights, discussion of issues, and finally, a summary of
important points. The RTD was guided by the following
questions: 1) What are the current roles of the Public Health
Nurse? 2) What is the added value of a BS Nursing prepared
PJN VOL. 89 | NO. 2
nurse to have a masters degree in Public Health Nursing? 3)
How should advanced nursing practitioners and clinical nurse
specialists be regulated or credentialed? 4) What reforms are
needed to establish an advanced practice in Public Health
Nursing?
The consent of the participants were solicited for the publication
of the results of the RTD. Responses of the participants were
transcribed. Transcriptions were coded and analyzed using
Foucauldian discourse analysis.
Results
As mentioned, the participants of the RTD came from various
sectors, which are also stakeholders, in the advancement of
public health nursing in the Philippines. Six of the seven
participants are nurses while the only non-nurse participant is a
medical doctor who represents the Department of Health.
The participant who works as a public health nurse in one of the
cities in Metro Manila described the roles and responsibilities of
public health nurses based on their rank. Their local government
only accepts registered nurses with several years of relevant
nurse experience for the entry level positions. This is due to the
fact that in their setting, nurses are in the frontline of health
systems.
Nurses are basically expected to provide primary care through
the implementation, monitoring and evaluation of health
programs. Promotion to higher ranks means they are expected
to perform more complex roles such as providing school health
services, coordinating a health program for their entire local
government setting, managing the health facility and supervising
health personnel, and providing capacity building activities for
other health personnel.
Post-graduate degrees are required for a public health nurse to
be promoted to the highest possible rank. Currently, these
positions are filled by nurses who have non-nursing
postgraduate degrees.
Schools in the Philippines are now offering a Bachelor of Science
in Midwifery. Entry of BS Midwifery graduates can create a
conflict in the tasks of health human resources who are in the
public health setting.
The participant from a non-government organization (NGO)
shared her experience on employing community-based health
and wellness nurses (CBHW nurses). The nurses of the NGO
are assigned to low resource communities or geographically
isolated and disadvantaged areas (GIDA) where the
organization has built barangay health centers or birthing
homes. These facilities are endorsed to respective LGUs after
construction.

The identified roles and responsibilities of CBHW nurses include
1) conducting clinical assessments, 2) providing appropriate
community interventions 3) organizing wellness clusters in the
community, 4) training Barangay Health Workers to become
leaders, teachers, and health workers, and 5) preparing
innovative and culturally sensitive learning materials, 6)
providing nursing care, 7) evaluating and monitoring program
outcomes, and 8) managing health projects.
There is a general need to train registered nurses on 1) program
development, 2) Filipino traditional medicine, 3) cultural
competencies for indigenous knowledge and resource
management in the community, 4) adapting to the realities of
community health nursing practice, 5) adapting educational
materials for the local setting, 6) community-based approaches,
and 6) research in the community setting.
The participant from the Department of Health described the
leadership and development framework for rural health units.
The discussion included the general functions, mission, and
mandate of rural health units since the devolution of healthcare
in the Philippines back in 1991. Core competencies of public
health workers such as municipal health officers, public health
nurses, and rural health midwives were also discussed.
A task analysis of public health based on health systems
management was presented. Tasks were classified as both
overlapping and specific to public health workers in local health
units and identified as part of the building blocks of health
systems – health service delivery, health regulation, health
human resource management, health information systems,
health financing and health governance.
Priority setting and management were identified as the key core
competencies of public health workers. Beyond the provision of
care, public health workers should participate in systems
strengthening and health systems management.
The participant from the Professional Regulatory Board of
Nursing (PRBON) explained the practice standards and career
progression of Public Health Nurses. She made the distinction
between Community Health Nurses and Public Health Nurses.
Both practices have the same goals but the approaches to
achieve their goals are different based on theories and concepts
used.
Currently the nursing profession is primarily regulated by the
Philippine Nursing Act of 2002. It is also influenced by other laws
such as Continuing Professional Development Act of 2016 and
PQF (Philippine Qualifications Framework) Act of 2017. The
former was intended to advance professional knowledge, skills,
and ethical values while the latter sets the professional
standards and nursing education outcomes. These laws have
led to the creation of national policies that enforce quality
assurance frameworks and mechanisms.
37
JULY - DECEMBER 2019
The recommendation to have a clear career pathway in nursing
was emphasized. This means that nursing practice standards
should be upheld and updated especially for post-licensure
specialization. Another important recommendation was to shift
nomenclatures and respective curricula and trainings to Public
Health Nursing as it already includes community health
nursing.
The participant from the Commission on Higher Education
(CHED) Technical Committee on Nursing Education informed
the group that there will be a new CMO (CHED Memorandum
Order) governing graduate education that will soon come out. As
soon as this new Policies, Standards and Guidelines (PSG) for
Graduate Education is published, the TCNE plans to release a
new memorandum governing graduate education in nursing.
This proposed memorandum will primarily address the current
graduate nursing education scenario wherein post graduate
nursing courses are seen in various curricular programs as in
Master of Arts in Nursing, Master of Nursing, and Master of
Science in Nursing for the master's level and PhD in Nursing,
Doctor of Nursing Science and Doctor of Nursing Practice for the
doctorate level.
It was clarified that equivalencies of nursing education should be
facilitated by the Commission on Higher Education (CHED) and
credentialing be performed by the Professional Regulatory
Board of Nursing (PRBON). Professional, research, and
academic post graduate tracks for nurses should be clearly seen
in educational outcomes and curricula.
Advanced practice in public health nursing can only be created
with clear nursing education guidelines from the CHED and
credentialing by the PRBON. The latter should be assisted by a
professional society of public health nurses.
The participant from the UP College of Nursing presented the
Bachelor of Science and Master of Arts (Nursing) curriculum.
Particular attention was given to undergraduate community
health nursing courses and the proposed Master of Science in
Nursing Public Health Nursing track. Health systems thinking
and systems strengthening were recommended to be
emphasized in the proposed curriculum.
Issues regarding professional opportunities for nurses with
graduate preparation on public health nursing were raised.
Specifically, if the government would provide positions for the
graduates of the program. The current transition to Universal
Health Care provides such opportunities.
For the first objective, the participants highlighted the following
roles of the masters-prepared public health nurse: 1) clinician, 2)
manager and supervisor, and 3) researcher. These roles are vital
in caring for the various clients in the public health setting.
Nurses, through these identified roles, can enable the transition
of the Philippine Health Care towards Universal Health Care.
PJN VOL. 89 | NO. 2
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JULY - DECEMBER 2019
For the second objective, the relevance of a masters-prepared
public health nurse was viewed based on an academic,
institutional, industry, professional, and social lens.
The current epidemiological shifts and complex health problems
require advanced knowledge in public health to ensure the care
of communities and population groups. With such preparation,
nurses can be better equipped to deliver primary care and to
work with wider health systems that are people-centered. In
order to realize this, educational institutions are expected to
include global and public health issues, universal health care
and other relevant topics in the master's curriculum. A
mechanism to bridge formal and informal training should be put
in place. DOH should engage the Commission on Higher
Education to recognize not just academic postgraduate degrees
but also informal, professional development trainings that can
be recognized for equivalencies.
Specialization in public health nursing should be covered by
law. Legal implications of having an advanced practice in public
health nursing is comparable with independent nursing
practice. This can also affect the current scope of practice and
harmonization among and between nursing and other health
professions. The advanced practice in public health nursing
requires a collaborative arrangement with public health
physicians. Instead of creating another professional silo, this
should be seen as an opportunity to work with other health
professionals.
Issues surrounding the possibility of a having a nurse-led public
health clinic and nursing clinics for wellness were discussed. This
would require advanced, complex, multiple interventional skills
and financial literacy for the nurse. With the Universal Health
Care, these clinics must be certified as part of the health care
provider network. Likewise, nurses should be certified as primary
care providers. These certifications are required to ensure that
nurses and their clinics contribute to Universal Health Care and
that their respective clients are covered by PhilHealth. This
model can be piloted in one of the state university systems.
Discussion
The relevance of a masters-prepared nurse in public health
nursing is subject to the same control of social structures and
institutions that look after the profession. The powers of such
institutions, that includes their influence and reach, ultimately
determine the relevance of a masters-prepared nurse in public
health nursing. State and social apparatuses were represented
by the participants who have shown the mandate, the interest,
and the power of the entity they represent. They exert power
directly to the nursing profession and indirectly to other nursing-
related structures and institutions.
In the creation of a new norm for nursing, it is imperative that
power relationships are analyzed through a Foucauldian lens.
PJN VOL. 89 | NO. 2
This would particularly look at notions of surveillance, notions of
knowledge, and ultimately, notions of docility. Power is always
related to knowledge. Knowledge is the exercise of power and
power is the application of knowledge (Foucault, 1977).
Surveillance is a normalizing force in society based on the fear of
being seen to be doing something wrong. Here, there is constant
inspection. The inspecting power is visible yet unverifiable.
Notions of docility pertain to passivity and non-resistance to
societal structure and control achieved through the
internalization of disciplinary surveillance.
Masters-prepared public health nurses can consume social
spaces where they are deemed relevant along with their
identified requisite competencies if they can be equipped and
backed by knowledge and a form of surveillance. Power is
gained by a person to practice the profession by gaining
knowledge through medical training specific to the nursing
practice. Hence, the more degrees or training a registered nurse
has, the wider their practice becomes.
The Commission on Higher Education plays a key role in
ensuring that advanced practice public health nurses have
enough knowledge, competencies, and skills to consume and
deliver public health services in social spaces. Their
surveillance activities cover academic institutions that offer
nursing related courses. A certain level of docility among public
health nurses can be achieved if they work closely with the
professional regulatory commission in harmonizing education,
credentialing, and equivalencies of educational outcomes
specific to this field.
Literally, on the basis of one's knowledge, the professional
regulatory commission allows a board passer to practice
nursing. In the same way, the institution should create
mechanisms to open, and to prepare the field for public health
nurses and implement a form of surveillance or monitoring of
activities based on one's level of knowledge. Hence, providing
trainings for specialization and adhering to the Philippine
Qualifications Framework is not enough. To create an advanced
practice in public health nursing entails establishing the
knowledge into the field of nursing practice. The state and social
apparatuses of the field should be internalized in every
advanced practice public health nurse.
The input of the Department of Health and practitioners from the
field show how spaces for health are consumed by health human
resources. They described the current norms in public health
citing the different health professions to include public health
nurses. The current structure of public health systems is an
intersection of knowledge coming from the expected roles and
functions of public health workers. To disturb the current public
health structure by creating a precept of a norm as in an
advanced practice in public health nursing is to deconstruct this
intersection of knowledge. The power and influence of other

health professions, especially the medical profession, and their
particular reaction to this change and how it will affect their
professional practice should be considered. Social spaces for
health curated by the knowledge held by social structures such
as DOH, PRBON, and CHED and the social relations of its
actors.
Educational institutions adhere to the prescriptions of PRBON
and CHED. The latter regulates them while the former provides
the industry standards (Dayrit et. al, 2018). Educational
institutions open the gateway for an individual to acquire
knowledge that gives them agency to consume greater social
spaces in health. DOH is the main industry that employs nurses.
It relates with other institutions in a way wherein its social
structure is consumed and defined by the products of all the
other institutions.
Nursing schools transform individuals from disciplinary objects
of the nursing profession to docile bodies that can navigate the
healthcare system according to the boundaries set by the social
apparatuses of nursing education that they have internalized.
Schools implement DOH, CHED and PRBON recommendations
and their powers are directed toward their students.
State control of the mechanisms of power in the nursing
profession are not absolute. Despite strategies to enforce
PRBON and CHED regulations, educational institutions can use
social stature and positions as a form of strategy as defined by
Bourdieu (1998) and or a form of resistance to power (Foucault,
1977). Institutions can also take advantage of gaps in social
structures through tactics, the weapons of the weak (De
Certeau, 1984). This is especially true for underperforming
nursing schools or those who comply to the bare minimum of the
industry, academic, and professional standards. Advanced
practice in public health nursing can be taken advantage at the
onset by institutions who are not really equipped with the
requisite knowledge for the specialization.
The activities of non-government organizations is a glimpse of
the mismatch between the state set-up and the actual practice of
public health nursing. Gaps are filled by NGO's that contribute to
innovations that transform the profession. Once categories of
new norm making (Foucault, 1975) are satisfied, the recognition
of these transformation can lead to state-imposed normality
(Lefebvre, 1991). Nurses who engage in public health, however,
cannot be automatically considered as public health nurses as it
is a field yet again, defined by knowledge.
The recommendations and insights on the relevance of a
masters-prepared nurse in public health nursing and its
requisite competencies by participants represent the power of
their respective institutions. From their responses, changes in
the nursing profession happen when these flow from the
PRBON and CHED down to nursing schools. PRBON regulates
39
JULY - DECEMBER 2019
professional nursing practice and CHED sets the standards for
nursing education programs and institutions of higher learning.
Nursing schools can capitalize such changes by updating their
curricula or by using creative ways to prompt the prescribed
structure. DOH has power and control over the health industry
and serves the main employer of nurses and other health
professionals. DOH also defines the social spaces of health and
transforms them into places where various actors of the health
industry perform their duties and responsibilities and relate with
one another.
Successfully creating an advanced practice in Public Health
Nursing requires a power, based on knowledge, exerted by
these institutions to the nursing profession. A masters-prepared
nurse is only as relevant as how these institutions would give
value and define the need for such knowledge in the field. The
requisite competencies that is expected from them, will follow
from this definition.
The nursing profession is a social product. The creation of
advanced practice in public health nursing requires a
deconstruction of current intersections of knowledge from social
institutions. To create a new track for nurses is to shift this
intersection of knowledge to be acknowledged and supported by
social institutions and health professionals as actors of the
health industry whom these advanced practitioners will
potentially work with.
Advanced practice in public health nursing will provide additional
agency to nurses. This challenges social norms and powers and
at the microlevel, power of other actors in the health industry
cannot be discounted. With the devolved health care set up in
the Philippines, actors can follow, resist, and interpret structural
prescriptions at the national and the local level. Social structures
provide agency to the nursing profession and the nursing
profession in turn can also shape social structures (Bourdieu,
1998).
Summary
Foucauldian analysis provides an important insight on how
social structures and institutions can steer the creation of an
advanced practice in public health nursing in the Philippines.
Various social institutions view the relevance of a master's
prepared nurse according to their societal roles and functions.
Requisite competencies of a master's prepared nurse in public
health nursing include fulfilling the role of a clinician, leader
and manager, supervisor, and a researcher. PRBON, CHED,
DOH, and nursing schools need to work together to define the
knowledge of an advanced practice in public health nursing, to
implement appropriate surveillance mechanisms, and to
establish a compliant practice. To normalize advanced
practice in public health nursing is to recognize that social
structures shape the capacity of nurses to function.
PJN VOL. 89 | NO. 2
40
JULY - DECEMBER 2019
Conversely, nurses contribute to the transformation of social
structures by practicing their profession and by exerting their
agency.
____________________
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Foucault, M. (1977). Discipline and Punish, Panopticism. Discipline and
Punish: The Birth of the Prison, 195–228.
https://doi.org/10.2307/2065008
ILO. (2014). National Nursing Core Competency Standards Training
Modules. Makati City: ILO Country Office for the Philippines.
Lefebvre, H. (1991). The Production of Space; translated by Donald
Nicholson. Urban Studies. https://doi.org/10.1080/
00420989220081001
Philippine Nursing Act of 2002, Republic Act 9173, 2002.
PQF Act of 2017, Republic Act 10968, 2017.
WHO. (2011). Transformative scale up of health profession education:
An effort to increase the numbers of health professionals and to
strengthen their impact on population health. Retrieved from
https://apps.who.int/iris/handle/10665/7057
Universal Health Care Act, Republic Act 11223, 2019.
..........
Acknowledgment
The authors would like to thank the following participants of
the round table discussion for their participation and
invaluable insights:
Hon. Cora A. Añonuevo, RN, PhD
Member, Professional Regulatory Board of Nursing
Professional Regulatory Commission
PJN VOL. 89 | NO. 2
Marilou De Leon, RN
Public Health Nurse
City Health District VI, Manila Health Department
Pretchell P. Tolentino, MD, MCHM
Division Chief, Learning and Development Division
Health Human Resource Development Bureau
Department of Health
Remedios L. Fernandez, RN, PhD
Member, Technical Committee for Nursing Education
Commission on Higher Education
Rebecca M. Galvez-Tan, RN, MAN
Executive Director, Health Futures Foundation Inc.
Wenefreda A. Udtujan, RN
Nurse Training Officer
Training Office, Manila Health Department
Arnold B. Peralta, RN, MAN, MHPEd
Head, Teaching Program
UP College of Nursing
ABOUT THE AUTHORS
John Joseph B. Posadas, RN, MSAHP is
an Assistant Professor and Coordinator of
the Public Health Nursing specialty group at
the College of Nursing, University of the
Philippines Manila. His research interests
include Filipino and Chinese traditional
medicine, and medical anthropology. He is currently enrolled
under the Doctor of Philosophy (Anthropology) program of the
University of the Philippines Diliman.
Assoc. Prof. Luz Barbara Dones is a
faculty of the UP College of Nursing under
the Public Health Nursing specialty group.
She is currently the Coordinator of
International Linkages of the College of
Nursing. Her research interests are on family
health nursing, community mobilization and development, and
human resources for health.
Peter James B. Abad, RN, MSc is Assistant
Professor at the College of Nursing,
University of the Philippines Manila. He is
part of the Public Health Nursing and
Maternal and Child Nursing specialty
groups. Aside from genetics and genetic
counseling, his research interests include human resource for
health issues as well as professional development and skill
mix.
 41

RESEARCH ARTICLE

PROMOTION OF SAFE MOTHERHOOD

IN THE NURSING COMPETENCY-BASED
CURRICULUM
Arnold B. Peralta, RN, MAN, MHPEd1, and Erlyn A. Sana, PhD

Abstract
Purpose: Nurses play a significant role in maternal health. The nursing competency-based curriculum prepares students for this role.
This study identified the competencies on safe motherhood expected of graduating nursing students, determined the degree of
integration of these competencies in the curriculum, and described students' perceived levels of proficiency in performing said
competencies.
Design: This is a descriptive cross-sectional study. The authors deduced concepts and principles of safe motherhood in nursing based
on the 2006 standard competencies. A complete enumeration of 55 graduating students of a college of nursing in a state university in
Manila participated in the study.
Methods: Students rated the competencies from A: “concepts were merely introduced” to D, “threaded through” in selected courses.
The level of proficiency ranged from 1: “can perform well without supervision” to 4 “cannot perform despite supervision.” Ratings were
analyzed using frequency counts, mode, and percentage distributions.
Findings: Seventy competencies on safe motherhood were derived. Cognitive and affective competencies on the basic nursing
processes were threaded through in foundation, intervention, and intensive nursing process courses. Students could perform the
cognitive and affective competencies without supervision but required assistance in performance of skills.
Conclusion: The nursing curriculum prepares students to promote safe motherhood; however, students need to improve their clinical
skills to be fully competent.

Keywords: safe motherhood, nursing education, competency-based curriculum

Introduction

I n 1987, the World Health Organization (WHO) launched the

Safe Motherhood Initiative aiming to ensure that all women are
educated, aware of, and are able to utilize access to care during
pregnancy, safe childbirth, and postpartum period (WHO, 2011).
WHO identified the important roles of health sciences schools in
reducing maternal and infant mortality rates.
Since 1978, a state-subsidized college of nursing in the
Philippines has been adapting the competency-based curriculum
(CBC). Abarquez in Sana, editor. (2013) explains that CBC starts
with defining the professional competences of graduates in the
health professions and translating these into specific knowledge,
skills, and attitudes (KSA) for students to learn in different course
objectives, how they should be learned and in what settings, and
how they should be assessed. CBC ensures a systematic
approach in developing competence in nursing practice at the
staff level position in both hospital and community settings as well
as beginning opportunities for nursing research, leadership and
management (Maglaya, Abaquin, et al., 2006).
In the nursing CBC, concepts on caring for the mother, child, and
family across the life span are consciously embedded in courses
across all year levels (Commission on Higher Education
Memorandum Order [CMO] No. 14, 2009; CMO 15, 2017).
Expanded opportunities to apply these concepts are also in the
curriculum in form of didactics, simulations, and related learning
experiences in various workplace settings (Maglaya, Abaquin, et
al., 2006). This study described the nursing competencies on safe

1 Corresponding Author; Assistant Professor and Head, Teaching Program, College of Nursing, University of the Philippines Manila; email address: abperalta1@up.edu.ph

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Table 1. BSN courses where competencies on safe motherhood are taught
motherhood, how graduating students perceived them to be
integrated in the curriculum, and their levels of proficiency in
performing them. Results of this study reflect how students can
meet the competencies required of them before they start
professional practice (Professional Regulation Commission,
2014). A good match reveals that the learning experience
provided by the school transformed the students and led them to
respond to population health needs (Frenk, Chen, et al., 2010).
Methodology
This was a descriptive research design. Schutt (2004) explained
that descriptive research defines and describes a particular social
phenomenon of interest. In this study, students described how
they experienced the BSN curriculum in terms of their perceived
levels of integration and proficiency in performing the
competencies on safe motherhood. The study was conducted at
the national training hospital in Manila, where the graduating
students of the state university nursing school were having their
internship. A complete enumeration of fifty-five fourth year nursing
students was done. Administrative clearance was secured from
the college administration. Informed consent was obtained from
all students before requesting them to participate in the study.
The study used a survey questionnaire derived from the list of
competencies stipulated in UPCN SKA 2006 for safe motherhood
standards. The participants rated the competencies (1) according
to their perceived degree of integration and (2) level of proficiency.
The degree of integration was rated according to (A) concepts
were merely introduced, (B) thoroughly integrated, (C) concepts
were used as an example not only in the course but also on other
courses, and (D) concepts were threaded through in all major
courses (Option D). Perceived level of competence was
evaluated from (1) can perform well without supervision, (2) with
minimum supervision, (3) with full supervision, and (4) cannot
perform despite supervision. Both ratings were summarized
using frequencies, mode, and percentage distributions.
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Results
The standard competencies on safe motherhood were identified
in eight courses in the BSN curriculum from second to fourth
years. Table 1 lists these courses, their corresponding units, year
levels, and semesters where located. The competencies are in
fundamental, community, and intervention nursing courses.
A total of seventy competencies on safe motherhood were
derived from the curriculum. Table 2 presents the first 21
antenatal care competencies composed of six constructs
distributed according to the courses, mode perceived degree of
integration, and level of proficiency of respondents. Results show
that integration was strongest in Construct 4 across all courses.
However, no level of proficiency was recorded in these areas. The
researchers verified that Construct 4 included routine activities
performed by students in all settings. They explained this
instance as an example of unconscious competence where the
performance of certain skills became natural that there was no
need to be consciously aware that they were being done (Atienza
in Sana, 2013).
Table 3 presents the next 26 core competencies in management
of clients on labor and due for delivery, mode degree of
integration, and perceived degree of proficiency. Results show
that students recognized the concepts and principles promoted in
selected Nursing courses but not to the point of being “strongly
threaded through” in each of the courses. Compared to the
results in antenatal care, respondents reported relatively low
levels of perceived proficiency in performing clinical procedures
for those in labor and delivery.
Table 4 presents the last 23 core competencies in post-partum
care. Figures show that competencies are clearly threaded
through in all the courses enumerated. The students also rated
themselves strongly in these competencies except in Construct 3
which includes actual delivery of the baby. Further analysis of the
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Table 2. Competencies in antenatal care, mode perceived degree of integration in the curriculum, and level of proficiency of students (n=55)

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Table 3. Competencies in managing clients in labor and delivery, mode perceived degree
of integration in the curriculum, and level of proficiency of students (n=55)

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JULY - DECEMBER 2019

Table 4. Competencies in managing clients in post-partum care, mode perceived degree of integration
in the curriculum, and level of proficiency of students (n=55)

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JULY - DECEMBER 2019
curriculum, duration of rotation, and nature of activities explained
that students perceived themselves able to perform these skills
not only because they have been doing them since they were in
second year but also because concepts and skills related to safe
motherhood were iteratively learned in several courses.
Discussion
The study identified 70 basic competencies in the promotion of
safe motherhood in the nursing competency-based curriculum.
Competencies related to interpersonal communication skills and
rapport building with client from antenatal to post-partum care,
including family planning were constantly threaded through in
Nursing Foundations I and II, Maternal and Child Nursing,
Community Health Nursing I, Nursing Interventions I, Nursing
Research, Intensive Hospital and Community Nursing. These
competencies are stipulated as programs outcomes for
nurses (Maglaya, Abaquin, et al., 2006; CHED, 2017) affirming
respondents' acquisition of knowledge, skills, and values required
in the PQF (PRC, 2014). On the other hand, clinical procedures
requiring evaluation and appropriate technology were integrated
in few courses. Consequently, to the perceived levels of
proficiency, students reported they could perform these
psychomotor and affective competencies well but with
supervision. These results are consistent with Fitts' cognitive
phase of skills acquisition where the basic concepts and
procedural knowledge of a given competence are known by
learners. In terms of actual execution, respondents needed
stronger conceptual links with practice to reach the associative
phase where they can perform the skills in real setting (McCarthy,
2012). Results suggest that graduating students have acquired
the “what to know” but need reinforcement on “what to do with
what they know” (Fitts as cited in Patrick, 1997). This further
means that respondents were not able to reach adaptation
referring to the stage where students should perform a given
clinical procedure accurately, gracefully, within the expected
allowable time, and across all clinical conditions, and settings
(Sana, ed., 2013).
Conclusion and Recommendation
Graduates of nursing schools in the Philippines are trained to
achieve target competencies especially addressing maternal and
child health. This study described competency-based curriculum
in nursing that is especially designed to prepare nurses for this
transformative role. However, this goal could not be completely
achieved if nurses are only proficient in their intellectual and
attitudinal role expectations.
The study recommended that students are given more expanded
opportunities, from words and images, online resources,
simulations, and performance in workplace settings with real
technology to master clinical procedures. Christie, Carey, et al.,
(2015) and Tripathy and Sinha (2016) in their separate studies in
India and Australia trained health care workers using practical
PJN VOL. 89 | NO. 2
knowledge with technology in their workplace settings and
reported marked improvement in their safe motherhood
competencies.
____________________
References
Christie, M, Carey, M., et al, (2015). Putting Transformative Learning into
Practice. Australian Journal of Adult Learning. Vol. 55, No. 1, April.
Commission on Higher Education (2009). CHED Memorandum Order No.
14 s. 2009. Quezon City.
Commission on Higher Education (2017). CHED Memorandum Order No.
15 s. 2017. Quezon City.
Frenk, J, Chen, L, et al. (2010). Health professionals for a new century:
transforming education to strengthen health systems in an
interdependent world. The Lancet, 376, 1923-58.
Maglaya, A. S., Abaquin, C. M., Anonuevo, C. A., Balabagno, A. O.,
Dones, L. B., Lao-Nario, M. B., Villarta, B. B. (2006). SKA
Competency-Based BSN Curriculum: A Model. Manila: UP College
of Nursing.
McCarthy, B. (2012). The Learning Cycle, the 21st Century and Millennial
Learners. Wauconda, IL: About Learning, Inc.
Patrick, J. (1997). Training: Research and Practice. San Diego, CA:
Academic Press.
Professional Regulation Commission (2014). Philippine Qualifications
Framework at https://pqf.gov.ph
Sana, E. A., editor. (2013). Teaching and Learning in the Health Sciences.
Quezon City: University of the Philippines Press.
Schutt, RK. (2004). Investigating the Social World. CA: SAGE
Publications, Inc.
Tripathy, J., Sinha, S., et al. (2016). Improving quality of home-based
prenatal care by microteaching of multipurposed workers in rural and
urban settings. Advances in Medical Education and Practice: Dove
Press, Inc.
World Health Organization. (2011). Monitoring maternal, newborn and
child health: understanding key progress indicators. Geneva,
Switzerland: WHO Press.
ABOUT THE AUTHORS
Arnold B. Peralta is an Assistant Professor
and Head of the Teaching Program of the UP
College of Nursing. He is the Project Leader
of the Embedding and Spreading of the 2012
National Nursing Core Competencies
Standards in the BSN Curriculum as part of
the UPCN's role as CHED Center of Excellence in Nursing
Education.
Erlyn A. Sana is a full-time professor of
health professions education at the National
Teacher Training Center for the Health
Professions, University of the Philippines
Manila. She is the editor and principal author
of the book "Teaching and Learning in the
Health Sciences," the 2011 Most Outstanding Book given by
the National Academy of Science and Technology.
 47

RESEARCH ARTICLE

A FIVE-YEAR TREND ANALYSIS OF THE

PHILIPPINE NURSE LICENSURE EXAMINATION
(2014-2018)
James Montegrico, MSN, RN1

Abstract
Purpose: This study analyzed the trend of the Philippine Nurse Licensure Examination (NLE) results from 2014 to 2018.
Design: A retrospective research design was used to describe the five-year trend in the NLE. It determined the association between
NLE outcome (pass/fail) and the type of examinee (first time vs. repeat examinees) and timing (month) of taking the exam (May/June vs.
November).
Methods: Trends in NLE results were examined to determine the pass and fail rates over five years as an indication of the quality of
nursing education. Secondary data analysis was conducted after collecting publicly available NLE data. Odds ratios were estimated to
express whether the odds of passing differ for the type of examinee and month of taking the NLE.
Findings: The overall pass rates indicated a decreasing trend over the past five years (47.5% to 41.3%). The first-time pass rates
showed an increasing trend (70.6% to 77.3%) while the repeat pass rates revealed a decreasing trend (31.6% to 28.2%). The odds of
passing the NLE among first-time examinees is 7.01 times the odds of passing the NLE compared to repeat examinees [OR = 7.01
(95% CI = 6.86, 7.12)]. The odds of passing the NLE in November is 1.32 times the odds of passing in May/June [OR = 1.32 (95% CI =
1.29, 1.34)].
Conclusions: Despite the increasing first-time pass rates, a large number of nursing graduates still fail the NLE, especially among the
repeat-takers. The results of this study can be used to improve nursing programs by developing measures to increase the NLE passing
performance through assisting at-risk first-time examinees prior to taking the NLE and developing programs to assist graduates who will
retake the NLE.

Keywords: nurse licensure examination, first-time pass rates, nursing education, Philippines

Introduction

m ost countries require graduates to pass a licensure

examination prior to entry into the nursing profession. In the
Philippines, graduates are required to pass the Nurse Licensure
Examination (NLE) prior to starting nursing practice (BON, 2017).
Republic Act 9173 mandated the Board of Nursing (BON) to
administer the NLE to measure the entry-level competencies of
new nurses.
One way to measure the quality of a nursing program is the
performance of graduates in the licensure examination (Banua,
2017; CHED, 2017; Rosales, Arugay, Divinagracia, & Castro-
Palaganas, 2014). The first-time pass rate on the licensure exam
is regarded as a primary criterion in measuring the quality of
nursing programs (Taylor, Loftin, & Reyes, 2014). RA 9173 or
Philippine Nursing Act of 2002 mandated the Professional
Regulation Commission through the BON to administer the NLE
to graduates of Bachelor of Science in Nursing (BSN) programs
to determine eligibility for professional practice (Rosales et al.,
2014).
The NLE blueprint, “Philippine Nurses' Licensure Examinations
Covering Nursing Practice (NP) I, II, III, IV, and V” was based on
the provisions of RA 9173 and the BSN curriculum mandated by
the Commission on Higher Education (CHED) (BON, 2017;
Rosales et al., 2014). The NLE is a five-part 500-question paper-
and-pencil test given over two days twice a year, in May or June
and in November. Each part of the NLE consists of a 100-item

1 Corresponding Author: Lecturer/Lead Faculty, School of Nursing at University of North Carolina at Charlotte, 9201 University City Blvd., Charlotte, North Carolina, USA 28223-0001;
jmontegr@uncc.edu
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multiple choice test that covers Basic Foundations of Nursing
and Professional Nursing Practice (NP I), Community Health
Nursing and Care of Normal and High-risk Mother and Child (NP
II), and Care of Clients with Physiologic and Psychosocial
Alterations A, B, and C (NP III, IV, and V, respectively). An
examinee must achieve an average rating of 75% in all five areas
with no rating below 60% in any area in order to pass the NLE
(BON, 2017).
A review of the literature revealed only two published national
studies analyzing the Philippine NLE results for the past 12
years, where both studies reported a deteriorating quality of
nursing education in the country. Rosales et al. (2014) analyzed
NLE trends from 2006 to 2010 while Bautista, Ducanes, & David
(2018) studied NLE results from 2010 to 2016. In their studies,
the NLE overall pass rate (OPR) from 2006 to 2016 was 44.0%.
The lowest NLE OPR was in 2013 (37.1%) and the highest OPR
was in 2015 (51.8%). In a study by Banua (2017), the five-year
NLE passing rate for graduates in one university was 57.9%.
These findings are significant because both the BON and CHED
use NLE results as a major criterion to monitor the quality of
nursing schools. In 2013, CHED, as a government regulatory
body with its effort to maintain quality nursing education in the
country, issued warnings to nursing schools that only achieved
46-55% OPR, ordered probations for phase-out for 31-45%
OPR, and the gradual phase-out for less than 30% OPR (CHED,
2017). CHED's actions on imposing moratorium on the opening
of new nursing programs, warnings to 152 nursing schools, and
ordering closures of 218 out of the 491 nursing schools in the
Philippines were concrete indicators of the quality of nursing
education in the country (Bautista et al., 2018).
Bronfenbrenner's socioecological model (SEM) provides a
conceptual framework in understanding the multidimensionality
of individual, interpersonal, organizational, and environmental
factors that impact an examinee's performance on the licensure
exam (Hickey, Harrison, & Sumsion, 2012). Individual factors,
such as students' demographics and academic performance,
and contextual factors that include interpersonal variables can
affect academic success and outcome of the NLE. Academic
factors such as college grade point average (GPA), college
entrance test, and nursing courses have significant association
with NLE ratings (Banua, 2017; De Leon, 2016; Ong, Palompon,
& Banico, 2012). First-time examinees have higher pass rates
and chances of passing the NLE than repeat examinees
(Rosales et al., 2014). Organizational factors such as
accreditation status (Rosales et al, 2014), school type and size,
location, ownership, and year of establishment were also
associated with NLE pass rates (Bautista et al., 2018).
Environmental factors, such as increased demand for Filipino
nurses in the global market, overcrowded nursing curriculum to fit
global employer needs, and the proliferation and
commercialization of nursing schools, were identified to
contribute to the deterioration in quality nursing education
(Masselink & Lee, 2010; Ortiga, 2014).
PJN VOL. 89 | NO. 2
Analyzing the trend in licensure examination results is significant
for three reasons. First, it is an objective valid measure of the
quality of nursing education in an institution (Bautista et al., 2018;
CHED, 2017; Taylor et al., 2014). Second, it provides information
about the comparability of Philippine nursing education with
global nursing standards (Lurie, 2016; Xu, 2010). Third, it has
implications for the global nursing workforce since the Philippines
is the world's leading supplier of migrant nurses to over 50
countries (Ortiga, 2014). Nursing demand in the United States
(U.S.) significantly affects the enrollment in Philippines nursing
schools (Arends-Kuenning, Calara, & Go, 2015) since the U.S. is
the preferred destination of Philippine-educated nurses (Marcus,
Quimson, & Short, 2014). Morover, more than half of the
internationally educated nurses in the U.S. are from the
Philippines (Spetz, Gates, & Jones, 2014).
Thus, the study sought to analyze the overall trend in NLE results
from 2014 to 2018 to enhance knowledge of this understudied
area that has important implications for nursing education and
nursing workforce in the Philippines and internationally. The
concerning status of the Philippine nursing education based on
NLE results (Bautista et al.; Rosales et al., 2014) is a major
impetus to conduct the study and to continuously monitor the
trend of NLE results. This study adds to the limited NLE studies
by analyzing the trends in NLE results from 2014 to 2018. This
study provides new knowledge on the NLE and a new
perspective on the odds of passing the NLE based on the type of
examinee and the timing of taking the examination.
Research Questions
This study aimed to answer the following research questions: 1)
What is the overall pass rate (OPR) in the Philippine NLE from
2014 to 2018? 2) What is the trend among the first-time pass rate
(FPR) compared to repeat examinees pass rate (RPR)? 3) What
are the odds of passing the NLE according to the type of
examinee (first-time vs. repeat examinee) and timing (month) of
taking the exam (May/June vs. November)?
Methods
This study used a retrospective research design to describe the
trend in the NLE from 2014 to 2018 and to detect associations
between passing the NLE with first-time examinee vs. repeat
examinee and timing of taking the exam (May/June vs.
November). Trend analysis was used as a method to determine
the NLE pass rates over a period of time and across different
samples. Trend analysis is commonly used in educational policy
research as a means to provide a broad perspective about
educational data over several years (Griffore, Phenice, & Hsieh,
2014). The use of trend analysis in analyzing NLE results provides
a rich source of educational research information from 166,717
Philippine examinees over a five-year period. An institutional
review board (IRB) approval was not sought since data was
collected from a publicly available source, the official website of
 49
JULY - DECEMBER 2019

the PRC-BON. The results from each NLE cohort, for Figure 1. Overall trend of NLE results from 2014 to 2018
May/June and for November, were manually entered
into a Microsoft Excel spreadsheet for data analysis.
Frequency and percentage distribution described
the number of examinees and NLE passing rates.
Odds ratios were estimated to express whether the
odds of passing differ for the type of examinee and
timing of taking the NLE.

Results

NLE Overall Pass Rate (OPR)

Note: OPR-overall pass rate; FPR-first-time pass rate; RPR-repeat pass rate
The OPR slightly increased from 2014 (47.5%) to
2015 (51.7%) and then steadily declined from 2016 Table 1. Overall pass rates of NLE examinees from 2014 to 2018
(45.7%) to 2017 (40.6%). It had a slight increase in
2018 (41.3%). As shown in Figure 1, the first-time
pass rate (FPR) had a positive trend with a steady
increase from 2014 (70.6%) to 2018 (77.3%). On the
contrary, the repeat pass rate (RPR) had a consistent
negative trend from 2015 (37.6%) to 2018 (18.0%), a
52.1% reduction within a four-year period.
Table 1 presents the number of examinees,
frequency of passed, failed, and conditional
examinees, and OPR from 2014 to 2018. Of the
77,151 new registered nurses (RN) who passed
within the five-year period, most passed in 2014
(N=26,517) and this steadily decreased each year
through 2018 (N=9,037). There was a consistently
decreasing trend from 2014 (N=55,873) to 2018
(N=21,904), accounting for a 60.8% reduction in the
number of examinees. The five-year OPR was
46.3%. Examinees in 2015 had the highest OPR
(51.7%) while 2017 had the lowest OPR (40.6%).
Years 2017 and 2018 both had lower OPR (40.6%
and 41.26%, respectively) compared to the 2014,
2015, and 2016 OPR (47.5%, 51.7%, and 45.7%, Note: NLE-nurse licensure exam; OPR-overall pass rate
respectively). The Nov. 2014 NLE had the highest Figure 2. The overall trend of FPR in 10 NLE examinations from 2014 to 2018
OPR (57.3%) while June 2017 NLE had the lowest
OPR (34.7%).
First-time NLE Examinees' Pass Rates
Figure 2 and Table 2 show the trend in first-time
takers' pass rate (FPR) from 2014 to 2018. The five-
year FPR is 74.5%, which indicates that one in four
first-time examinees did not pass the NLE.
Note: FPR-first-time pass rate; NLE-nurse licensure examination
Examinees in 2017 had the highest FPR (77.4%),
followed closely by 2018 (77.3%), while examinees respectively). Both 2016 NLE (77% and 77.2%) had higher FPR while the 2014
in 2014 had the lowest FPR (70.6%). The June 2018 NLE had lower FPR (75.0% and 66.4%) than the five-year FPR.
NLE produced the highest FPR (83.0%) while May
2014 NLE had the lowest FPR (66.4%). Five NLE Repeat NLE Examinees Pass Rates
periods (Nov. 2018, June 2017, Nov. 2015, Nov.
2014, and May 2014) had lower than the five-year Table 3 and Figure 2 show the repeat pass rates (RPR) within the five-year
FPR (73.8%, 73.4%, 73.7%, 75.0%, and 66.4%, period. The five-year RPR is 29.5%, which means that only three out of ten

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repeat examinees passed the NLE. The highest RPR Table 2. First-time pass rates of NLE examinees from 2014 to 2018
was in 2015 (37.6%) while the lowest RPR was in
2018 (18.0%). The two most recent years had the
lowest RPR pass rates. These low RPR in 2017
(21.7%) and 2018 (18.0%) accounted for low OPR of
2017 (40.6%) and 2018 (41.3%) examinees. The Nov.
2014 NLE produced the highest RPR (44.1%) while
the Nov. 2018 had the lowest RPR (12.8%).
Odds of Passing the NLE Based on Type
of Examinee and Month of NLE
The odds of passing the NLE is seven times higher for
first-time examinees compared with repeat
examinees (OR = 7.01, 95% CI = 6.86, 7.12). In the
same way, the odds of passing the NLE is 1.32 times
more likely to be during the November timing of the
exam (OR = 1.32, 95% CI = 1.29, 1.34).

Discussion
The findings in this study showed that despite the
increase in first-time NLR pass rates, there was a
decline in the number of total NLE examinees and Note: NLE-nurse licensure exam; FPR-first-time pass rate
over-all NLE performance within the years of 2014 to
Table 3. Repeat-pass rates of NLE examinees from 2014 to 2018
2018, which can be attributed to the low pass-rates of
repeat examinees. The decreasing enrollment trend
in nursing schools in recent years is attributed to the
reduced demand for nurses in the U.S., a major
determinant of Philippine nursing school enrollment
(Arends-Kuenning et al., 2015) and introduction of the
K-12 curriculum in basic education, which significantly
reduced college enrollment (Bringula, Balcoba, Alfaro
& Merritt, 2018).
In this study, the majority of first-time NLE examinees
passed the exam while most repeat examinees failed.
Only three out of four new nursing graduates passed
the NLE the first time. These findings support the two
studies (Bautista et al., 2018; Rosales et al., 2014)
about the concerning quality of nursing education in
the country. Although the FPR increased from 2014 to
2018, one in four first-time NLE examinee failed the
exam. FPR is a major criterion used to measure the
quality of nursing programs (Taylor et al., 2014). It is
used by the BON and CHED in monitoring the
Note: NLE-nurse licensure exam; RPR-repeat pass rates
performance and quality of nursing schools in the
country and is used in making decisions for closing Table 4. Odds of NLE passing based on the type of examinee and month of NLE*
BSN programs (CHED, 2017). This study supports
Rosales et al.'s study (2014) that being a first-time
examinee improves the chances of passing the NLE
and taking the NLE in November slightly increases the
odds of passing the exam.
A limitation of this study is the focus on NLE as a
measure of quality education. Using the SEM as a Note: NLE-nurse licensure examination; OR-odds ratio; CI-confidence interval; *From 2014 to 2018 data

PJN VOL. 89 | NO. 2


conceptual framework, individual factors (college GPA, college
entrance tests, and nursing courses), organizational variables
(school characteristics and curriculum overload), and
environmental factors (global nursing supply and demand) are
identified in the literature that affect NLE performance (Banua,
2017; Bautista et al., 2018; Masselink & Lee, 2010; Ong, 2012;
Ortiga, 2014; Rosales et al., 2014). These factors need to be
considered in understanding the multidimensionality of factors
affecting licensure examinations and quality of education.
Conclusion, Implications, and Recommendations
Using a retrospective design, it was found that the overall trend on
passing the Philippine NLE from 2014 to 2018 decreased. First
time examinees had an increasing trend in NLE pass rates and
had increased odds of passing the NLE. Repeat examinees had a
decreasing trend in NLE pass rates and lower odds of passing the
NLE. Taking the NLE in November slightly increases the odds of
passing the NLE.
These findings support other studies about the concerning quality
of nursing education in the Philippines. Nursing programs should
review admission, retention, and promotion policies that affect
NLE performance. Remediation measures for at-risk students
and for those who retake the NLE are needed. There is a need to
further evaluate the factors affecting the NLE outcomes as this
has been greatly understudied. Research on individual and
institutional factors that affect NLE performance is needed to
address the deterioration of nursing education in the country.
____________________
References
Arends-Kuenning, M., Calara, A., & Go, S. (2015). International migration
opportunities and occupational choice: a case study of Philippine
nurses 2002 to 2014. Paper presented at the Institute for the Study of
Labor. Bonn, Germany.
Banua, A. (2017). Determinants of performance of nursing graduates in
licensure examinations.
Bicol University Research & Development Journal. 20, 135-141.
Bautista, J., Ducanes, G., & David, C. (2018). Quality of nursing schools in
the Philippines: Trends and evidence from the 2010-2016 Nurse
Licensure Examination results. Nursing Outlook, 00, 1-11.
doi.org/10.1016/j.outlook.2018.12.012
Board of Nursing (2017). Syllabi of the Nurse Licensure Examination.
Professional Regulation Commission, Republic of the Philippines.
Retrieved from www.prc.gov.ph/nursing
Bringula, R., Balcoba, A., Alfaro. L. & Merritt, J. (2018). Managing the
perceived impact of K to 12 implementation on academic tenure and
financial stability: evidence from five higher education institutions in
the Philippines. Educational Research for Policy and Practice.
doi.org/10.1007/s10671-018-9239-1
Commission on Higher Education (2017). (Memo) Memorandum Order
No. 15. Quezon City.
De Leon, J. (2016). Academic and licensure examination performances of
BSN graduates: Bases for curriculum enhancement. International
Journal of Educational Policy Research and Review. 3(4). 64-72.
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Griffore, R., Phenice, L., Hsieh, M. (2014). Trend analysis of educational
investments and outcomes. Journal of Research in Education. 24(1).
154-161.
Hickey, N., Harrison, L., & Sumsion, J. (2012). Using a socioecological
framework tounderstand the career choices of single- and double-
degree nursing students and double-degree graduates. International
Scholarly Research Network, 748238. doi: 10.5402/2012/748238
Lurie, L. (2016). Strategic planning for future delivery of care: onboarding
foreign-educated nurses. Nurse Leader, 427-432.
Marcus, K., Quimson, G., & Short, S. (2014). Source country perceptions,
experiences, and recommendations regarding health workforce
migration: a case study from the Philippines. Human Resources for
Health, 12(62), 1-10.
Masselink, L. & Lee, S. (2010). Nurses, Inc.: expansion and
commercialization of nursing education in the Philippines. Social
Science & Medicine, 71, 166-172.
Ong, M., Palompon, D., & Banico, L. (2012). Predictors of nurses'
licensure examination
Performance of graduates in Cebu Normal University, Philippines. Asian
Journal of Health. 2, 130-141.
Ortiga, Y. (2014). Professional problems: The burden of producing the
“global” Filipino nurse. Social Science & Medicine. 115, 64-71.
Rosales, A., Arugay, Y., Divinagracia, C., & Castro-Palaganas, E. (2014).
Analytical study of the nurses' licensure examination performance of
graduates of Philippine colleges of nursing.Philippine Journal of
Nursing, 84 (1), 4-23.
Spetz, J., Gates, M., & Jones, C. (2014). Internationally educated nurses in
the United States: their origins and roles: Nursing Outlook, 62, 8-15.
Taylor, H., Loftin, C., & Reyes, H. (2014). First-time NCLEX-RN pass rate:
measure of program quality or something else? Journal of Nursing
Education, 53(6), 336-341.
Xu, Y. (2010). Is transition of internationally educated nurses a regulatory
issues? Policy, Politics, & Nursing, 11(1), 62-70.
..........
Acknowledgment
Special thanks to Kelly Powers, PhD, RN, School of Nursing,
University of North Carolina at Charlotte and Thomas McCoy,
PhD, APS, School of Nursing, University of North Carolina at
Greensboro for assistance in preparing the manuscript.
ABOUT THE AUTHOR
Jhordin James C. Montegrico, MSN, RN, is
currently a Lecturer and a Lead Faculty at the
School of Nursing of the University of North
Carolina at Charlotte. He is a graduating PhD
(Nursing Science) student at the University of
North Carolina at Greensboro. He had his BSN
at the University of Santo Tomas and MSN (Adult Health
Nursing) at Saint Paul University Philippines. His research
interests are measurement and evaluation in nursing education,
international nursing, licensure examinations, and HIV. His
dissertation and current research involve understanding factors
affecting the NCLEX-RN performance of internationally
educated nurses.
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52

FEATURE ARTICLE

COMPASSIONATE NURSE:
A CONCEPT ANALYSIS
Geraldine Y. Ferreras, MSN, RN

Abstract
The purpose of this article is to develop a framework on fostering compassion among nurses, by examining the attributes of the concept
of compassion. This concept analysis utilized the Walker and Avant Framework. A review of literature indicates that compassion in
nursing remains constant throughout the years even with changes prompted by the academe, healthcare and advancement in
technology. Results show the defining attributes of compassion include full acceptance of duties and responsibilities and security in
workplace to develop compassion. To become compassionate, a nurse must (a) be holistically prepared, (b) experience a sense of
personal and professional development, and (c) possess the initiative to fulfill patient's needs. Thus, nurses can provide quality care
and prevent the occurrence of patient neglect. This concept of compassion reveals that self-awareness and security from the
organization can foster compassion among nurses.

Keywords: compassionate, nurse, caring

Introduction

N ursing profession exists to fulfill the essentials of those

who are incapable of doing care on their own. Being a
caring profession (Rolfe, 2014), nursing is exemplified by the
neglect. In this paper, the focus will be on the latter, which
strongly emphasizes the behaviors of nurses.

therapeutic caring relationship with patients and not merely the
technical skills that are routinely delivered. However, reports
conclude that nurses are losing their caring attitude; which led to
growing public concern over patient neglect (Reader &
Gillespie, 2013). Moreover, Bally (2007) identified factors such
as low morale, a general apathy regarding professional collegial
support, heavy workloads, reduced resources, and high patient
acuity, which contribute to job dissatisfaction, poor work
performance, and may be putting positive patient health
outcomes at risk. Thus, more nurses today shift to other
careers: some geared towards medicine and others to different
fields. The occurrence of these circumstances led to the
concept analysis on compassionate nurses.
Is nursing a crumbling career? What transpired in the society
that prompted nurses to be uncaring in some ways? These are
some of the puzzling questions not only to nurses, but most
especially to the patients, whom they serve. Some patients
observe that nurses appear more posh to care (Rolfe, 2014);
and it seems that nurses' image has shifted from caring to less
likely caring. This alteration steered to poor nursing care
leading to neglect. According to Reader and Gillespie (2013),
there are two aspects of patient neglect: procedure and caring
The purpose of this concept analysis paper is to develop a
framework on fostering compassion among nurses to be utilized
as a tool in delivering safe and quality care to patients. Hence, it
will serve as a guide for nurses and organizations to safeguard
the health of the society and bring fulfillment to the nurse, patient
and the organization. Accordingly, preservation of integrity and
identity of the nursing profession remains throughout the years.
Definitions
The word compassion came from late Latin compassionem,
which means a feeling of distress and pity for the suffering and
misfortune of another, often including the desire to alleviate it
(The Free Online Dictionary). During Florence Nightingale's
time, it can be viewed as getting close and empathizing with
clients and assisting them towards recovery. However, with the
progress of modern technology as an aid in health care, nurses'
view on compassion can be different. The speed at which
technology has engulfed the way that care has been delivered to
individuals, communities and populations over the last two
decades can be attested by many nurses (Reed, 2014).
Conferring to Schantz (2007, as cited in Davison & Williams,
2009), compassion is a nurse's most precious asset and one of

PJN VOL. 89 | NO. 2


the strengths of the profession. Compassion is inherently part
of nursing; therefore, it must be constantly present in any
generation of nurses.
Literature Review
In philosophy, Schopenhauer identified compassion or fellow-
feeling as a source and foundation of morals and not merely
knowledge; as an incentive that motivate human actions
(Madigan, 2005). Thus, a compassionate person portrayed as a
part and involved in the suffering world. Elwell (1996) described
compassion as that which produces action to alleviate the
suffering; however, geographical distances or lack of means
prevent people from acting upon their compassionate feelings.
Conferring to Fishman (2002, as cited in Raina, 2006), healing
cannot take place without compassion for self and others.
Accordingly, in psychology, a strong link between compassion
and health, happiness, and joy make compassion as one of the
priorities. Compassion exists in every individual and it remains a
virtue which brings happiness.
In an organization, nurse administrators have the privileged
opportunity to co-create with nurse colleagues a caring
environment (Boykin &Schoenhofer, 2001). Hence, the
opportunity to foster professional development of each nurse in
their institution is upheld. According to Zamanzadeh, Valizadeh,
Rahmani, van der Cingel, and Ghafourifard (2017), a nurse's
capacity to develop compassion will be addressed by providing
organizational support and professional education.
Consequently, nurses are recommended to follow their value and
belief system and to consider their colleagues as role model of
compassionate practice. Schofield (2016) described the
attributes of compassionate nursing: recognition for a need of
care with a wish to do something about it. Compassion in nursing
remains constant throughout the years even with the changes
prompted by the academe, healthcare and advancement in
technology. According to Dempsey, Wojciechowski, McConville,
and Drain (2014), connecting with patients in compassionate
ways to alleviate inherent patient suffering and prevent avoidable
suffering is the key to improving the patient experience.
Therefore, appraising this skill of nurses is fundamental in
upholding the profession's identity as a caring profession.
Defining Attributes
Compassion in nursing is exemplified as having empathy and
contentment in fulfilling the needs of the clients at all times. Thus,
a compassionate nurse must have full acceptance of his duties
and responsibilities and feel cared in his workplace to develop
compassion towards self and fellowmen. To accept one's duty, a
nurse must first be prepared and aware of his roles and it should
not be done against will. Consequently, security in the workplace
brings a sense of being cared to the nurse; therefore, fostering
compassion. According to Bally (2007), to reinstate effective
53
JULY-DECEMBER 2019
healthcare today, fostering collegial relationships, enhancing
nurses' sense of self, promoting professional development, and
encouraging feelings of professional worth are essential.
Antecedents
To develop compassion in nursing, a nurse must first, (a) be
holistically prepared. The nurse must be knowledgeable and
skillful enough in carrying out the responsibilities given to him;
thus, the importance of education is considered. Second, a nurse
must continue to develop to be better, (b) must experience a
sense of personal and professional development. A nurse must
have self-awareness on his values, beliefs, and goals to continue
acting on his career. Additionally, the administration can be a
factor in influencing his actions: a supportive, caring and healthy
environment at work can lead to a motivated and responsible
nurse. A nurturing environment also involves family, peer,
colleagues, and the patients. The continued support, motivation,
respect, guidance, and appreciation can help the personal
development of the nurse. Lastly, the nurse's (c) willingness to
act on the urge to help fulfill the needs of a patient is vital; without
initiative, compassion would not manifest.
Consequences
According to Kapur (2014, as cited in Roberts & Ion, 2014), there
has been widespread occurrence of poor nursing care and worse,
inhumane care. The incidents at Mid Staffordshire portrayed the
oppressive acts of nurses, which has been claimed as outcome of
being oppressed from their work (Francis, 2013). According to
Coward (2013), nurses missed the elements of patient care:
compassion, warmth, and hands-on care, as they focus more on
paperwork and meeting targets. Furthermore, Wiman and
Wikblad (2004) concluded that more aspects of being uncaring
predominated, indicating lack of caring behavior among nurses.
Thus, Francis (2013) recommended recruitment for nurses
focusing on possessing appropriate, values and attitudes. Royal
College of Nursing (2013) also believes that nurses suffer from
“care fatigue” after years of being in a pressurized, constantly
changing system; as their concerns are repeatedly ignored
Contrary to the former, compassion can increase the self-esteem
and self-efficacy of employees in an organization (Choi, Li, No, &
Kim, 2016). Hence, nurses can provide quality care and prevent
the occurrence of patient neglect.
Empirical Referents
Conferring to Fenton and Mitchell (2002, as cited in Davison &
Williams, 2009), compassion is abstract and difficult to measure;
and viewed as an integral part of dignity (Royal College of
Nursing, 2008, as cited in Davison & Williams, 2009). In
determining the compassion of modern nurses, it is best to
evaluate the patient's satisfaction towards the staff care and
experiences in the hospital: including their accommodation,
PJN VOL. 89 | NO. 2
54
JULY - DECEMBER 2019

food, and services by the healthcare team. According to Al-Abri
and Al-Balushi (2014), it is essential to evaluate patient
satisfaction in interpersonal and communication skills and not
merely on the technical competence by nurses. Moreover,
Royal College of Nursing (2013) acknowledged that it is
essential to be positive about getting and using patient feedback
for improvement.
It is required to evaluate the nurse's performance in the area; not
only through written evaluation but also a spontaneous
evaluation through actual observation made by nurse
administrators. Moreover, a Compassion Competence Scale
can be utilized to determine an individual's skill or ability about
understanding and reducing another's suffering (Lee &Seomun,
2016). Various literature suggest that healthy relationship in the
organization occurs when participation is encouraged from the
members of the team. Consequently, harmonious relationship
in the healthcare system can be established.
Implications for Nursing
Being in the healthcare field requires competence. Nurses must
be sensitive enough to identify their patients' needs and to enact
on their responsibility towards them. Thus, it is essential that
nurses be prepared holistically. First, a nurse's self-awareness
on personal beliefs, values, and goals must be highlighted.
Second, one must possess the enthusiasm for the career
chosen: not on the compensation by
it. Lastly, the major motive for nurses
must be the willingness to serve the
society. Conferring to Bally (2007),
mentoring can be utilized as an
effective strategy: implemented
through positive nursing leadership.
C o n s e q u e n t l y, h a r m o n i o u s
relationship will be established not
only towards the employees but also
the patients.
profession can help regain the caring attitude of nurses. One
might be able to apply the theory to practice; but, without the
heart, it is impractical. According to Rolfe (2015, p. 142), “the
cause of the problem is neither too much education nor too high a
level of education but rather an overly technical rational and
evidence-based focus on nursing theory, research and practice.”
Consequently, the caring component of each nurse has been
deemed as diminished.
Caring will always be embedded in nursing. Continuous changes
may affect the duties and responsibilities and can even support in
reducing nurses' workload. Thus, the advancement of
technology should not become a hindrance to reduce a nurse's
compassion; instead, should become an aid to better facilitate
nursing care. The framework on the modern nurse's compassion
will help the profession to recreate the basic and yet most
important skill one must have: compassion. In reality, things must
change, but together with change, the compassion within nurses
must remain constant.
Conclusion
The concept of Compassionate Nurse Framework used in this
paper can be a tool to contemplate in providing safe and quality
care to patients (Figure 1).
Figure 1. Compassionate Nurse Framework

The road to becoming a nurse is

rough. A nursing student might not be
able to surpass the academics
without diligence, patience, and hard
work. Though academics play an
essential role to pass the licensure
examination, it is not enough
assurance to be able to serve the
patients. Conferring to Roberts and
Ion (2014), nursing education
providers can limit future healthcare
failings; while restructuring the
education system and emphasizing
more on the passion for the

PJN VOL. 89 | NO. 2


When helping patients fulfill their needs, it is every nurse's role to
render what is due; however, it is essential for nurses to become
equipped with knowledge, skills, and willingness to serve. The
role of education system is vital in preparing for a relational work;
thus, highlighting the essence of caring must be a priority.
Factors such as values, beliefs, philosophy, significant others,
administration and patients affect the service they may render;
hence, harmony of self and organization is important. To
preserve the dignity and identity of the nursing profession, it is
vital to maintain compassion within. Consequently, when the
nurse feels cared and accepts responsibility, compassion
towards other people can be demonstrated. Conferring to
Burnell (2009), provision of compassionate care is more than a
professional mandate or an attribute of a model, but a result of an
authentic bond between a nurse and a patient. Not only will
nurses live a satisfying and fulfilling career but will be able to
share their lives by continuously serving their fellowmen.
Consequently, nursing will be renowned as a caring profession.
____________________
References
Ahtisham, A., & Jacoline, S. (2015). Integrating nursing theory and
process into practice: Virginia Henderson's Need Theory.
International Journal of Caring Sciences, 8 (2), 443-450.
Al-Abri, R., & Al-Balushi, A. (2014). Patient satisfaction survey as a tool
towards quality improvement. Oman Med J, 29(1), 3-7.
Bally, J. M. (2007). The role of nursing leadership in creating a
mentoring culture in acute care environments. Nursing
Economics, 25(3), 143.
Burnell, L. (2009). Compassionate care: a concept analysis. Home
Health Care Management & Practice, 21(5), 319-324.
Boykin, A., &Schoenhofer, S. (2001). The role of nursing leadership in
creating caring environments in health care delivery systems.
NursingAdministration Quarterly, 25 (3), 1-7.
Choi, H., Lee, S., No, S., & Kim, E. (2016). Effects of compassion on
employees' self-regulation. Social Behavior &Personality: An
International Journal, 44(7), 1173–1190. doi: https://doi.org/
10.2224/sbp.2016.44.7.1173
Davison, N., & Williams, K. (2009).Compassion in nursing: defining,
identifying and measuring this essential quality. Nursing Times,
105(36), 16.
Dempsey, C., Wojciechowski, S., McConville, E., & Drain, M.
(2014).Reducing patient suffering through compassionate
connected care. The Journal of Nursing Administration, 44(10),
517-524. doi: 10.1097/NNA.0000000000000110
Dewar, B. (2013). Cultivating compassionate care. Nursing Standard,
27(34), 48-55.
Elwell, W. A. (Ed.). (1996). Baker's evangelical dictionary of biblical
theology. Grand Rapids, Michigan, USA: Baker Books
Francis, R. (2013). Report of the Mid Staffordshire NHS Foundation
Trust Public Inquiry. London: Stationary office. Retrieved from
www.tsoshop.co.uk
Lee, Y., &Seomun, G. (2016). Development and validation of an
instrument to measure nurses' compassion competence. Applied
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Nursing Research, 30, 76–82. https://doi.org/10.1016/
j.apnr.2015.09.007
Madigan, T. (2005). Schopenhauer's compassionate morality.
Philosophy Now, 52, 16-17.
Raina, K. C. (2006). Compassion and Person Perception: An
Experiment. Retrieved fromhttp://search.ebscohost.com/
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Reader, T.W, & Gillespie, A. (2013). Patient neglect in healthcare
institutions: a systematic review and conceptual model. BMC
Health Service Research, 13(156), 1-15.
Reed, J. (2014). eHealth: A concept analysis from a nursing
perspective. Canadian Journal of Nursing Informatics, 9.
Roberts, M., & Ion, R. (2014). Thinking critically about the occurrence
of widespread participation in poor nursing care. Journal of
Advanced Nursing, 71(4), 768-776.
Rolfe, G. (2014). Foundations for a human science of nursing:
Gadamer,Laing, and the hermeneutics of caring. Nursing
Philosophy,1-12. doi: 10.1111/nup.12075
Royal College of Nursing (2013). Response of the Royal College of
Nursing. London, UK.
Schofield, B. (2016). Compassion in nursing: a concept analysis.
Compassion in Nursing: Theory, Evidence and Practice, 57.
Walker, L. O., & Avant, K. C. (2011). Strategies for theory construction
in nursing (5th ed). Philadelphia, PA: Lippincott Williams &
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&Ghafourifard, M. (2017). Factors facilitating nurses to deliver
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Caring Sciences. doi:10.1111/scs.12434
ABOUT THE AUTHOR
Geraldine Y. Ferreras, is an Assistant
Professor II at Saint Mary's University,
Bayombong, Nueva Vizcaya, where she
finished her Bachelor of Science in Nursing
and a Master of Science in Nursing, Major in
Nursing Administration. She is both a
Clinical Instructor and professor conducting
lectures at the undergraduate and postgraduate level. She is
currently in the Dissertation Writing stage of the Ph.D. in
Nursing program of the Saint Louis University, Baguio City,
Philippines.
Nurses are the heart
of healthcare.
- Donna Wilk Cardillo
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56

NURSES’ VOICE FROM THE FIELD

THE IMPORTANCE OF ENCOURAGING

CHILD DEVELOPMENT
Pimkanabhon Trakooltorwong, RN, MSN1

Abstract
Quality child growth and development are important tools in assisting today's children to become the adults of the future. Hence,
developmental delays in young children have an impact not only on a child's abilities to learn new skills, but also in the opportunities of
the greater community or society. In this regard, parents and caregivers are the most well-equipped to prevent the child from
experiencing developmental delays. Children will learn to trust the person who sensitively interacts with them and this trust provides a
foundation for future learning, growth, and development. This paper looks at the importance of encouraging child development through
the parents or guardians of children, since they are inevitably linked to a child's learning, and they know their own children better than
anyone else. Parents and guardians who do not have the skills required to monitor and encourage the development of young children
can and should be trained by professionals. This research reveals that training parents and guardians to use the Developmental
Surveillance and Promotion Manual in monitoring and encouraging development of young children is a very important way to prevent
future developmental delays.

Keywords: Child development, developmental delays, quality child growth

Introduction

Q uality child growth and development are important tools in

assisting today's children to become the adults of the
future, because as the leaders of tomorrow, they will be
responsible for the country. Unfortunately, some surveys suggest
that developmental delay in young children is increasing in
developing countries (Prime Minister's Office, 2016). According
to data collection by the Department of Health, the survey results
of developmental screening, in children at age 9, 18, 30 and 42,
indicate the rates of developmental delay as 19.84, 24.50, 22.38,
and 25.33 respectively. This survey shows that 32.79% of young
children have gross motor skills delay, 53.21% have fine motor
skills delay, 42.83% have expressive language skills delay,
47.00% have receptive language skills delay, and 32.54% have
personal and social skills delay (Ministry of Public Health, 2017).
The Ministry of Public Health, the Ministry of Education, the
Ministry of Interior, and the Ministry of Social Development and
Human Security have created the Developmental Surveillance
and Promotion Manual to be used to monitor and encourage child
development. This manual is provided free to parents and
guardians. However, studies on the manual's impact reveal that
the majority of parents or guardians, whose children have
developmental delays, do not know how to use it effectively
(Prime Minister's Office, 2016).
Impacts of Developmental Delayed
Developmental delays in young children have an impact on a
child's abilities to learn new skills, resulting in multiple barriers to
healthy development of the child (Piccolo, Segabinazi1, Falceto,
Fernandes, Bandeiral, Trentini1, Hutz1, & Salles, 2016,
Winstona, R. & Chicot, R., 2016). These developmental barriers
include: diminished skills in verbal comprehension, physical
development, eye-hand coordination, learning, thinking, problem
solving, essential skills in communication, social interaction and
self-care in daily living (Sakolsatayadorn, 2016). To help prevent
developmental delays, nurses, doctors, and other specialists in
hospitals and universities can provide effective training
programs. These programs can be used to teach the child's
caregiver how to monitor and encourage development in young
children (Cohen, 2017, Piccolo, Segabinazi1, Falceto,
Fernandes, Bandeiral, Trentini1, Hutz1, & Salles, 2016,
Winstona & Chicot, 2016).
Growth and development are important indicators of a child's
overall health (Ministry of Health and Long-term Care, 2018). The
first few years of life are a crucial period of time and provide the
basis to further a child's healthy development. Specifically, a
child's neurological, and physical development are vital in

1 Correspondence: Ratchathani University, 261, Liang Muang road, Jarama subdistrict, Muang district, Ubon Ratchathani, 34000, Thailand. E-mail: 266334@gmail.com

PJN VOL. 89 | NO. 2


achieving their potential in terms of long-term positive growth and
development. (Piccolo, Segabinazi1, Falceto, Fernandes,
Bandeiral, Trentini1, Hutz1, & Salles, 2016). The Healthy Growth
and Development Guideline concluded that the most important
factor in contributing to successful child development is an active
parent and or caregiver (Ministry of Health and Long-term care,
2018).
The parents are the child's first teachers, and subsequently, a
major influence on their child's learning (Ceka1& Murati, 2016).
Parents and caregivers are role models and are the most well-
equipped to prevent the child from experiencing developmental
delays. They are inevitably linked to a child's learning, and they
know their own children better than anyone else (Moore, 2015,
National Institute of Child Health and Human Development,
2014). As a result, children will learn to trust the person who
sensitively interacts with them. Hence, this trust provides a
foundation for future learning, growth, and development. They
should be observant and provide early detection as well as
encourage the development of their children (Jawad, Sabri, &
Ibrahim, 2017).
Finally, developmental delays have a negative impact on
children's interactions in their environment, and this can affect a
child's ability to learn new skills. Development is dynamic and
involves the maturation of interrelated systems. So,
developmental delays in children can trigger a complex and
damaging cycle for their future development (Piccolo,
Segabinazi1, Falceto, Fernandes, Bandeiral, Trentini, Hutz, &
Salles, 2016). Losatienkit (2015), Director of Health Promotion
Center of Thailand, said that the countries that have more
developmental delays in young children will lose opportunities to
develop. The survey has determined that the average IQ
(Intelligence Quotient) in Thai children aged 9 to 10 is 91.6, lower
than other countries in Asia. This result can be directly related to
developmental delays when they were younger. In fact,
developmental delays cannot be linked to disability until the child
begins attending school (Tepparud, Mukdakasem, Seubnuch, &
Jaturaporn, 2014). The findings show that they were slower in one
or more of the five developmental domains, which includes: gross
motor skills, fine motor skills, receptive language skills, and
personal and social skills (Prime Minister's Office, 2016).
Therefore, early detection and early intervention is the better
solution to decrease developmental delays in young children and
thus, enable them to learn new skills as they grow.
Encouraging Parents and Guardians Towards Child
Development
Parents and guardians who do not have the skills required to
monitor and encourage the development of young children can
and should be trained by professionals. According to Adult
Learning Theory, a good way to learn is to learn by doing. The
reason this works is that adults memorize by training rather than
57
JULY - DECEMBER 2019
just reading. When adults learn and practice, they obtain the skills
and can more readily memorize the contents (Palis & Quiros,
2014). Training programs are the best way to educate parents and
guardians because they provide a two-way dialogue. When
specialists lecture, parents and guardians can listen, ask and
participate with them. Moreover, they can practice in a small
group and repeat until they can monitor and encourage their
young children by themselves. Consequently, childcare
professionals and specialists must supervise and support parents
through individual and group coaching (Beaudoin, Sebire, &
Couture, 2014, Landry, 2014)
Conclusion
Child development is important. Parents and guardians must be
made aware of the importance of monitoring and encouraging the
development of their children in the first few years of life. This is
because the formative years in a child's life are the most important
period of growth and development and are directly related to
learning other skills in the future. Children, who are not monitored
and encouraged during the early developmental period, may
experience developmental delays when they begin attending
school. Children who have a developmental delay in gross motor
skills, fine motor skills, language skills, and personal and social
skills will be lacking in physical development skills, abilities of eye-
hand coordination, abilities in verbal comprehension, expression,
and speech production, abilities to learn, think and solve
problems, communication skills, social interaction, and self-care
respectively (Piccolo, Segabinazi1, Falceto, Fernandes,
Bandeiral, Trentini, Hutz, & Salles, 2016, Sakolsatayadorn,
2016). Therefore, training parents and guardians to use the
Developmental Surveillance and Promotion Manual to monitor
and encourage the development of young children is a very
important way to prevent future developmental delays. This is
because the caregiver can detect any abnormality their children
might exhibit and then they can encourage that specific area to be
developed, before the children experience any developmental
delays. The research has determined that parental knowledge is
a factor related to child development outcomes (Sander &
Morawska, 2014) and educating parents is a way to improve
children's knowledge and skills (Jawad & Sabri, 2017). In
conclusion, professionals should supervise, support, advice, and
empower parents and caregivers to encourage the development
of their children. They should participate in individual and group
coaching programs because they are specialists and they
possess the education, training and experiences that can be
shared with parents.
____________________
References
Beaudoin, A.J., Sebire, G., & Couture, M.. (2014). Parent Training
Interventions for Toddlers with Autism Spectrum Disorder. Retrieved
from http://dx.doi.org/10.1155/2014/839890
turn to page 59
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58
NURSES’ VOICE FROM THE FIELD
MOTIVATORS AND DEMOTIVATORS:
Navigating Self-Care and Silencing Self-Doubt
Gia Laarni Indonto – Simbulan, RN1
“Bago ka ba? (Are you new?)”
I s a question that can be interpreted differently, depending on
whether you are, in fact a novice nurse or a seasoned
professional. I was asked this question today while assisting with
a relatively simple procedure I seldom perform, and my entire
nursing education and experience spiraled into the depths of
humiliation.
For further context, after graduating 10 years ago, I spent three
years working as a nurse, six years as an HR Professional and
now, the prodigal daughter, I returned to the profession and have
been working for almost a year.
I put on headphones on the way home, the sound of calming
music muffled by deafening self-doubt, casting shadows on an
otherwise crisp Sunday morning.
Then the questions snowballed, “Am I a failure? Why didn't I do
better? Why didn't I focus?” From self-deprecation, I then
gravitated to “How can I make it better? Can you train nurses to be
more resilient? Is this stress? Am I allowed to feel stress?”
In every line of work there are demands, but nursing must be one
of the most severe. The pressure that comes with being the most
trusted profession according to Gallup's 2019 poll assessing
ethics and honesty, (Brenan, 2018) comes with expectations we
are groomed to disappoint.
Self-care
For such a caring profession, we are by default indifferent to
disrespect, and because verbalizing stress is synonymous to
weakness, we often retreat within and are left to process feelings
ourselves. There are numerous ways to combat self-care deficit
but the first step is recognizing the signs and overcoming the
stigma. (Blum, 2014)
The ANA in their Health Risk Appraisal in 2016 stated that
“Nurses give the best care to patients when they are operating at
their own peak wellness.” They even list the Nursing Interventions
to remedy this so we owe it to ourselves to initiate self-care
checks and seek help. (American Nurses Association, 2016)
1 Correspondence: E-mail: giaindonto@gmail.com
PJN VOL. 89 | NO. 2
Where I work, stress reduction techniques are offered after five
years in service, already too late for when you actually need them
in my opinion. Stress reduction has become palliative instead of
preventive, a mirror of our own healthcare system. Though ill-
timed, I am considered fortunate to even have stress reduction
programs to begin with.
Hygiene Factors
Other than the stress of work, there is also the feeling of
demotivation. Dissatisfaction lingers among Filipino nurses, but
before crafting surveys and focus group discussions, we must
understand the concept of Frederick Herzberg's Two Factor
Theory. (Herzberg, 2003)
It underscores the two groups of factors motivating employees:
Hygiene Factors (or Dissatisfiers) are pay, quality of supervision,
company rules, physical working conditions, co-worker
relationships, job security.
Motivator Factors (Motivators) are challenging or stimulating
work, status, opportunity for advancement, responsibility, sense
of personal growth/job achievement, acquiring recognition.
It is crucial to underline pay under Hygiene Factors. The
Department of Labor in their website states that nurses earn on
average PHP 13,500.00 a month (as of 2013), hardly enough to
afford honest self-care and not at all enough to settle for, fulfilling
the minimum requirement working experience for abroad
instead. (Department of Local Labor and Employment, 2013)
This is why “The Philippines is the largest exporter of nurses
globally, with roughly 25 percent of all overseas nurses
worldwide” (Philippine News Agency), hence creating a vacuum
of competent nurses and perpetuating the cycle of discontent.
As I reconcile my nursing and HR backgrounds, I discover a
threadbare tapestry of challenges and solutions. The PNA has
been vocal in its move to transform nursing and lift morale,
emboldening us whether we decide to stay or join the 25 percent
that have already left.

While Preparing for my early shift, I am thankful for the
opportunity to practice my first profession again, this time adding
an HR perspective in my arsenal. Every day is a learning
opportunity and today, the most important thing I learned is that
to care for others I have to master the equally daunting task of
taking care of myself.
____________________
References
Brenan, M. 2018, December 20. Nurses Again Outpace Other
Professions for Honesty, Ethics. Retrieved from
https://news.gallup.com/
American Nurses Association. 2016. Executive Summary American
Nurses Association Health Risk Appraisal.
Blum, C. 2014. Practicing Self-Care for Nurses: A Nursing Program
Initiative. ANA Online Journal of Issues in Nursing
Herzberg, F. (2003, January) One More Time: How Do You Motivate
Employees?. Harvard Business Review
The Importance of... (from page 57)
Ceka1, A. & Murati, R. (2016). The Role of Parents in the Education of
Children. Journal of Education and Practice, 7(5), 61-64.
Cohen, S.D. (2017). 3 Principles to Improve Outcomes for Children and
Families. Retrieve from https://46y5eh11fhgw3ve3ytpwxt9r-
wpengine.netdna-ssl.com/wp-content/uploads/2017/10/
HCDC_3PrinciplesPolicyPractice.pdf
Jawad, A. & Sabri, S. (2017). National Strategy for Early Childhood
Development and Intervention 2017-2022. Retrieved from
https://www.unicef.org/oPt/ECD_National_Strategy__Proof_read_
13022017_EN.pdf.pdf
Landry, S.H. (2014). The role of parents in early childhood learning.
Retrieved from http://www.child-encyclopedia.com/parenting-
skills/according-experts/role-parents-early-childhood-learning
Losatienkit, P. (2015). The Situation of Childhood Development in
Thailand. Retrieved from https://hpc03.files.wordpress.com
/2015/09/full-paper-childdev.pdf
Ministry of Health and Long term care. (2018). Healthy Growth and
Development Guideline, 2018. Retrieved from
http://health.gov.on.ca/ en/pro/programs/publichealth/
oph_standards/docs/protocols_ guidelines/Healthy_Growth_and_
Development_Guideline_2018.pdf
Ministry of Public Health. (2017). Prevalence of Development in Thai
Children 2017
Moore, A. (2015). Developmental Delays and Social Skills in Children.
Retrieved from http://www.livestrong.com/article/538274-
developmental-delays-and-social-skills-in-children/
National Institute of Child Health and Human Development. (2014).
Exploring Factors That Influence Child Development. Retrieved
f r o m h t t p s : / / w w w. n i c h d . n i h . g o v / n e w s / r e s o u r c e s /
spotlight/Pages/092914-factors-child-development.aspx
Palis, A.G. & Quiros, P.A. (2014). Adult learning principles and
presentation pearls. Middle East African Journal of Opthamology,
21(2), 114-122.
Piccolo, L.D.R., Segabinazi, J.D., Falceto, O.G., Fernandes, C.L.C.,
Bandeiral, D.R., Trentini1, C.M., Hutz, C.S., & Salles, J.F. (2016).
59
JULY - DECEMBER 2019
Department of Local Labor and Employment. 2013. Nurse
Compensation. Retrieved from http://www.ble.dole.gov.ph/
Cal, B. 2018, January 26. US-based Pinoy Cites Filipino nurses'
contribution to global health. Retrieved from
https://www.pna.gov.ph/
ABOUT THE AUTHOR
Gia Laarni Indonto–Simbulan is currently
working as an Ambulatory Care Facility
Nurse in Asian Hospital and Medical Center.
A Graduate of Far Eastern University in
2009, she worked in Mindanao as a
Pediatric Nurse and briefly in Manila as a
PACU Nurse. She has a diploma in Human Capital
Management from the College of Saint Benilde and was an
HR Manager for 6 years before returning to Nursing. She
hopes to integrate her expansive interests to the profession
and offer a fresh perspective.
Developmental delay in early childhood is associated with visual-
constructive skills at school age in a Brazilian cohort.Retrieved
from http://dx.doi.org/10.1186/s41155-016-0048-2
Prime Minister's Office. (2016). The Twelfth National Economic and Social
Development Plan (2017-2021). Bangkok: Office of the Prime
Minister.
Sakolsatayadorn, P. (2016). Crisis of Thai Child Development. Retrieved
from https://www.hfocus.org/content/2016/06/12324
Sanders, M.R, & Morawska, A. (2014). Can Changing Parental
Knowledge, Dysfunctional Expectations and Attributions, and
Emotion Regulation Improve Outcomes for Children? Australia:
University of Queensland.
Tepparud, S., Mukdakasem, P., Seubnuch, J., & Jaturaporn, J. (2014).
The Factors of child care to child development. Retrieved from
http://hpc4.go.th/rcenter//_fulltext/20140331103024_1551/2014040
3134122_548.pdf
Winstona, R. and Chicot, R. (2016). The importance of early bonding on
the long-term mental health and resilience of children. London
Journal of Primary Care, 8(1), 12-14.
ABOUT THE AUTHOR
Pimkanabhon Trakooltorwong, RN, MSN
received her Master of Nursing Science
degree in Chiang Mai University, Thailand.
She received a scholarship from United
Board to participate in the Intensive English
Language Program conducted by the
Ateneo de Manila University, Quezon City, Philippines, from
June 12 to July 28, 2017. She is currently a lecturer in the
Nursing faculty of Ratchathani University, Ubon Ratchathani,
Thailand. Her areas of clinical expertise and research interests
are child and adolescent care and infectious control.
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JULY - DECEMBER 2019

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