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NCM 104

Module 12 : ETHICAL CONSIDERATIONS IN COMMUNITY HEALTH NURSING

(2 HOURS)
This module aims to Explain the Ethical Considerations in Community Health Nursing

Topic 1: Ethical Approaches to Public Health

Topic 2: Public Health Laws

Topic 1: Ethical Approaches to Public Health

Learning Targets: 1. Distinguish a moral community from a population.
2. Apply different ethical approaches to specific
community/public health (C/PH) nursing issues.
3. Discuss healthcare disparities and identify populations at risk.
4. Analyze communicable disease-related ethical issues.
5. Identify ethical issues and questions that are outcomes of the
human genome project.
6. Explain what it means for a nurse to be a servant leader.

Concept/Digest
• In their own way, community/public health (C/PH) nurses are contributors to the building
of the world. Although the terms community health nursing (CHN) and public health
nursing (PHN) ideally are differentiated .
• “Public health nurses integrate community involvement and knowledge about the entire
population with personal, clinical understandings of the health and illness experiences of
individuals and families within the population” (American Public Health Association, PHN
Section, 2007, Para 1).
• “The practice is population- focused with the goals of promoting health and preventing
disease and disability for all people through the creation of conditions in which people
can be healthy”.
• The community health nurse experiences and many ethical conflicts are existing in health
care delivery system. As we began professional practice, it is essential to understand the
law that defines the nurse’s responsibility and duties. Especially the community health
nurse must be very careful while doing services in the community because; there is a team
of people working in the hospital. Whereas, in the community health nurses are alone
and most of the time she is in position of to implement the services at home. So, she must
be more careful and she should have enough knowledge on legal issues.
• The purpose of this topic is to analyze traditional ethics and professional nursing and
apply these principles to the practice of community health nursing.

Population is the term used to describe the recipients of the health promotion and disease and
disability prevention care that is the primary focus of C/PH nursing.
 • In this module, a population is defined as a group of people who share at least one
common descriptive characteristic but who do not necessarily have a collective
commitment to a common good.
• The name used to denote a population is often related to the common characteristic(s)
of the people who make up the population, such as male alcoholics or pregnant
teenagers.
• The word community means different things to different people .

Community is a group of people who have a shared interest in a common good, and members of
the group have the potential to share in a collective dialogue about their common good.
• Membership in the community forms some part of each member’s identity.
• The sharing in a commitment to promote the community’s well-being, which transcends
individual interests and goals, makes personal relationships within the community moral
in nature.

Moral community is formed by members who care about collectively alleviating the suffering
and facilitating the well-being of other members of the community and who may take action in
doing so. Individual persons may be active or inactive members of a moral community.
• A moral community can be as large as the global community whose members are
generally committed to the common good and prosperity of the inhabitants of the earth
or as small as a community of senior nursing students at a university.

ETHICAL APPROACHES TO PUBLIC HEALTH

• As it is with all sorts of ethical considerations regarding nurses’ personal and professional
beliefs and behaviors, it is difficult to limit one’s philosophy to only one ethical theory or
approach in public health practice.
• At varying times and in varying situations one of a number of important ethical
approaches and theories may help guide nurses’ actions and the development of public
health policies.

DEFINITIONS
‘’ Ethics is a system of moral principles, and rules of conduct recognized in respect to a particular
class of human actions or to a particular group of people.’’
Or
Ethics is a branch of philosophy dealing with values related to human conduct with respect to
the rightness and wrongness of certain actions and to the goodness and badness of the motives
and ends of such actions.

PRINCIPLES OF THE ETHICAL PRACTICE OF PUBLIC HEALTH

1. Public health should address principally the fundamental causes of disease and
requirements of health, aiming to prevent adverse health outcomes.
2. Public health should achieve community health in a way that respects the rights of
individuals in the community.
3. Public health policies, programs, and priorities should be developed and evaluated
through processes that ensure an opportunity for input from community members.
4. Public health should advocate and work for the empowerment of disenfranchised
community members, aiming to ensure that the basic resources and conditions necessary
for health are accessible to all.
5. Public health should seek the information needed to implement effective policies and
programs that protect and promote health.

1. The Precautionary Principle

• The concept known as the precautionary principle is based on the German word,
vorsorgeprinzip, which means the principle of forecaring. The word forecaring conveys
more than being cautious. It means that one uses foresight and preparation, and it is
aligned with the principle of “first do no harm” (nonmaleficence) and the adage “better
safe than sorry” (Science & Environment Health Network [SEHN], n.d. a).
• The participants at the Wingspread conference developed a statement to guide actions
by governmental and nongovernmental agencies. The group stated: “When an activity
raises threats of harm to the environment or human health,
• Minimum standards for citing evidence of cause and effect relationships via traditional
science are usually very high (SEHN, n.d. a).
• The type of science needed to support the precautionary principle has been called
appropriate science, as distinguished from traditional science (Kriebel, Tickner, &
Crumbley, 2003). Appropriate science is based on the context of the problem at hand
rather than requiring that scientific pursuits be forced into a preconceived idea of
necessary rigor.

2. Kantian Ethics (Deontology)

• Kantian ethics emphasizes that all rational persons are autonomous, ends-in-them- selves
and worthy of dignity and respect.
• Kantianism is highly valued in Western medicine because of the focus on individual rights
and informed consent.

3. Utilitarianism (Consequentialism)
• Utilitarianism is an ethical approach based on maximizing the good or moral
consequences of one’s decisions and actions. Although there are variations in utilitarian
theories, when utilitarianism is used in health care, the goal or intended consequence
generally is to produce the greatest good for the greatest number of people.
• Because of the emphasis on population-focused care, utilitarianism is one of the most
widely used ethical approaches in public health practice.
• The second distinguishing element of public health nursing outlined in the ANA’s (2007)
Public Health Nursing: Scope and Standards of Nursing is that “the primary obligation is
to achieve the greatest good for the greatest number of people or the population as a
whole” (p. 8). This directive for public health nurses is a classic example of utilitarianism.

4. Communitarian Ethics
• Communitarian ethics is based on the position that “everything fundamental in ethics
derives from communal values, the common good, social goals, traditional practices, and
cooperative virtues” (Beauchamp & Childress, 2001, p. 362).
• Communitarian ethics is relevant to moral relationships in any community, and this
ethical approach is particularly useful in the practice of PHN because of the focus on
populations and communities rather than on the care of individuals.
 • Nussbaum (2004) suggested that people often develop an “us” versus “them” mentality,
especially when violence occurs among various groups and significant ethnic and cultural
differences separate them.

5. Social Justice
• Social justice is related to the fair distribution of benefits and burdens among members
of a society. However, in our U.S. society, market justice is the dominant model
(Beauchamp, 1999).
• Market justice is based on the principle that the benefits and burdens of a society should
be distributed among its members according to the members’ individual efforts and
abilities.
• In a market-justice system, money for health care tends to be invested in technology and
curing diseases rather than in health promotion and disease prevention.

Health Disparities
• Health disparities are inequalities or differences in health care access and treatment that
result in poor health outcomes for persons and populations. Health disparities occur
because of some characteristic(s) of the persons or population affected.
• After the first goal of aiming to “increase quality and years of healthy life” (U.S. DHHS,
2000, p. 8), the second goal of Healthy People 2010 “is to eliminate health disparities
among segments of the population, including differences that occur by gender, race or
ethnicity, education or income, disability, geographic location, or sexual orientation” (p.
11).
• Eliminating health disparities is a moral issue for C/PH nurses because social justice and
communitarian ethics are based on building flourishing communities that sup- port the
common good of all community members.

6. Virtue Ethics: Justice and Generosity

• Pieper (1966) proposed that “the subject of justice is the ‘community’” (p. 70). Jus-
tice can be viewed in terms of what rights or resources should be accorded or
distributed to persons or populations or what is their due. However, there is another
conception of justice that is communitarian in nature.
• This approach is based on virtue ethics and emphasizes the virtue of just generosity,
which is a conception of justice that highlights human connections and not
separateness. Indebtedness is the hallmark of this type of justice, and although the
concept of justice as a stand-alone virtue is important to public health ethics, the
combination of the virtue of justice with the virtue of generosity expands the scope
of justice.
• People are accustomed to thinking of justice in limited terms, and they are
accustomed to separating the individual virtues of justice and generosity. Thinking
and acting in terms of the comprehensive virtue of just generosity sometimes requires
the use of one’s moral imagination to envision “what could be.”

CLIENTS RIGHTS AND PROFESSIONAL RESPONSIBILITIES IN COMMUNITY HEALTH CARE

CLIENTS RIGHTS
• It is one of the earliest recognitions of clients rights concerning health were made by the
national convention of the 1973. Undergoing the theme of basic human rights, the leaders
of the revolution declared that there should only be one patient to a bed in hospitals and
hospital beds were to be placed at least 3 feet apart(Annas,1978).
• This kind of direction by a government or legislating body in the recognition and assertion
of clients right has continued to be prominent in consideration of thought to health and
 the right to health care as extensions of basic human rights such as rights to informed
consent to refuse treatment or to privacy have apparently been aided by consumer
groups and health care providers.

BASIC HUMAN RIGHTS RELATED TO HEALTH

American Hospital Association was studied and issued the results of its study, entitled ‘’ the
Patient’s bill of rights.’’ The document says that the traditional physician- patient relationship
takes on a new dimension when care is rendered within organizational structure.’’ The basic
rights includes the following:
1. Considerate and respectful care
2. Obtain complete medical information
3. Receive information necessary for giving informed consent
4. Refine treatment
5. Consideration of privacy
6. Confidential treatment of personal information and medical records
7. Request services
8. Information on other institution and individuals related to care and treatment
9. Refuse participation in research projects
10. Expect reasonable continuity of care
11. Examination and explanation of financial changes
12. Know institutional regulations

SOCIETAL OBLIGATIONS
The ‘Presidents’ commission for the study of ethical problems reached several conclusions
concerning current patterns of access to health care and made significant recommendations for
changes. The commission concludes that:
1. Society has an ethical obligation to ensure equitable access to health care for all.
2. The societal obligation is balanced by individual obligation.
3. Equitable access to health care requires that all citizens be able to secure an adequate level of
1.
4. When equity occurs through the operation of private forces, there is no need for
government involvement, but the ultimate responsibility for ensuring that society obligation is
met, through a combination of public and private sector arrangements, rest with the federal
government.
5. The cost of achieving equitable access to health care ought to be shared family
6. Efforts to certain nursing health care costs are important but should not focus on limiting the
attainment of equitable access for the least well served portion of the public.

PROFESSIONAL RESPONSIBILITIES
In response to client’s rights, health care professionals incur particular duties or responsibilities
which are supported by professional code of ethics and are correlative to basic liberty rights of
patients.

PROFESSIONAL CODE OF ETHICS

Professional code of ethics is statements encompassing rules that apply to persons in
professional role there are some professional ethics
1. Professional etiquette good manners based on loyalty.
2. Knowing the lines of authority and responsibility.
3. Each person should be treated with dignity.
4. When death occurs, they need empathy, support and understanding. More practice is
needed in an isolated area.
5. Should know what others are doing and be faithful in supporting each other.
6. Coordinate with all.
7. Have partnership and cooperate with physician.
8. Good communication based on giving and receiving.
9. The nurse relates in the community as a worker and to improve health standards.
10. The nurse relates in the community as a worker and to improve health standards

ETHICAL PRINCIPLES IN COMMUNITY HEALTH

Relationships of ethical rules, principles and theories
• Rules state that certain actions are to be performed because they are right (or wrong). An
example would be that ‘’ nurses always ought to tell the truth to the clients.’’ Principles
are more abstract than rules and serve as the foundation of rules. For example, the ethical
principle of autonomy is the foundation for such rules as ‘’ always informed consent’’, tell
the truth, and protect the privacy etc. theories however are collection of principles and
rules.
• They provide theoretical foundations for deciding what to do when principles or rules
conflict. Ethical principles simply suggest which ethical principle will more likely to happen
generally when moral decisions have to be made.

PRINCIPLE OF BENEFICIENCE
• It states ‘’we ought to do good and prevent or avoid doing harm.’’ It includes the idea that
beneficence is a duty to help others gain what is of benefit to them but does not carry the
obligation to risk one’s own welfare or interiors in helping others.

Application of theories in community health The principle of beneficence can be applied for:
1. Balancing harms and benefits to client population
2. In the use of cost benefit analysis in decisions affecting client population

COST BENEFICIAL ANALYSIS

It is a specific application of the principle of beneficence. To measure the benefits and costs of
alternative approaches to a problem or to decide how to distribute health program funds.

PRINCIPLES OF AUTONOMY: autonomy refers to freedom of action, as chosen by an individual

person who are autonomers and capable of choosing and acting on plans they themselves have
decided on.
Application in community health nursing principle of autonomy is applied in community health
through considerations with:
1. RESPECT FOR PERSONS: the client should be given a choice or even considered in a treatment
plan. The elderly have the right to determine their life and health plans as they have the capacity
to do so.
2. THE PROTECTION OF PRIVACY: since the relationship between client and nurse is built on trust,
the nurse has a responsibility to protect the privacy of clients and their families as for as clients
health is concerned.
3. THE PROVISION OF INFORMED CONSENT: the elements are essential for adequate informed
consent information, comprehension and willingness. Informed consent is not valid without all
elements and no contract between client and nurse is ethically acceptable without valid,
informed consent.
4. FREEDOM OF CHOICE INCLUDING TREATMENT REFUSAL: in community health nursing,
respect for the client’s or guardian’s right to refuse treatment may depend on nurse judgment of
the competency of the client to make such choices.
5. THE PROTECTION OF DIMINSHED AUTONOMY: the person who is having diminished
autonomy whether from physical or psychological incapacities or immaturity are not considered
purely to be autonomous persons. Yet respect for the principle of autonomy requires that
practitioner recognize when persons back the capacity to act autonomously and therefore an
entity to protection in health care delivery.

PRINCIPLE OF JUSTICE
It claims that equals should be treated equally and those who are unequal should be treated
differently according to their differences.
Application as theories in community health: different theories may be may be appealed in
deciding how to distribute health care resources. These theories include:
1. ENTITLEMENT THOERY: the entitlement theory claims that everyone is entitled to whatever
they get in the natural lottery at birth and there is no responsibility for government or its agencies
to improve the lot of those less fortunate than others. In this theory, inequalities between
individuals in matters of health, position and wealth are tolerated. Only aggression or harms
against others and the unjust acquisition of goods are prohibited.
2. UTILITARIAN THOERY: this theory of justice claims that the best way to distribute resources
among citizenry is to decide how expenditures or the use of resources will achieve the greatest
net of good and serve the largest number of people. In this theory the needs and wants of some
individuals will not be satisfied, and they may indeed, be harmed in this process. This would be
considered unfortunate but this is distributing resources so that, the greatest good for greatest
number is achieved.
3. MAXIMIN THOERY: this theory of justice first identifies the least advantaged number of
community. For example, the economically poor, the elderly the mentally retarded and children
under one year of age and decides they might be benefited rather than deciding or greatest not
aggregate benefit. Obviously this will create problems in case of limited resources. Thus, it is
possible that technologically advancement and the development of more sophisticated health
care goods cannot be made widely available to the public in times of limited economic resources.
The result is that interest and needs in matters of health may not be satisfied within the system
of justice.
4. EQUALITARIAN THOERY: the equalitarian theory of justice claims that justice requires the ‘’
equality of net welfare for individuals.’’ In this theory, the distribution of good in
community takes the needs of all citizens into equally. Thus everyone would have to claim to an
equal amount of all goods and resources, including health care. It requires
a. Establishing priorities for the distribution of basic goods and health services in the community.
b. Determining which population or individuals shall obtain available health goods and nursing
services.

ETHICAL PRINCIPLES IN DECISION MAKING

1. RESPECT: treating people as unique or equal
2. AUTUNOMY: freedom of choice and exercise of people’s right- for careful consideration.
3. BENEFICENCE: doing good or benefitting others (accessible to all).
4. NON-MALFEASANCE: avoiding and preventing harm to others.
5. JUSTICE: irrespective of age, sex, caste, urban or rural- equal treatments.
6. FIDELITY: Keeping promises should be kept confidential. If not, may lose faith and interest.
7. VERACITY: telling the truth-actual information.

NURSES RESPONSIBILITIES
• Practice within scope of nurse practice acts.
• Observe agency policies and procedures.
• Establish standards by using evidence based practice.
• Always prefer patient’s welfare.
• Be aware of relevant law and understand limits.
• Practice within the area or individual competence.
• Upgrade technical skills by attending continuing nursing education and seeking
certification. Following the standards of care and referral services.
 • Ensure patient safety.
• Proper action for needs and problems and appropriate treatment.
• Monitor the program and proper reporting.
• Verify the medication errors and reactions.

LEGAL SAFEGUARDS OF CH NURSES

1. INFORMED CONSENT: granted freedom, written or oral form (procedures, expected outcome,
complication, side effects, and alternative treatment.
2. CONTRACTS: exchange of promises between two parties. Agreement may be written or
oral(e.g. patient and his family and health care team)
3. COLLECTIVE BARGAINING: policies, legal procedures, up-to date knowledge.
4. COMPETENT PRACTICE: it is most important and most legal safeguard. Institutional
policies and procedures should be adopted.
5. RESPECTING INDIVIDUAL RIGHTS: developing rapport and working relationship with
the community. Keeping careful documentation of every activity.
6. PATIENT FAMILY EDUCATION: discuss with family members. Tentative plans
7. EXECUTING PHYSICIAN ORDER: attempt to get order in writing/verbal order.
8. DOCUMENTATION: actual , accurate, complete and essential.
9. ADEQUATE STAFFING: under staffing is a problem that will reduce quality of care.
10. RISK MANAGEMENT PROGARM: identify analysis and treat the condition avoid taking risk.
11. INCIDENT, VARIANCE, AND OCCURRENCE PROGRAM: incident program for quality
improvement for our safety.
12. SENTINEL EVENTS: expected to play in a critical role in sentinel event( death or any other
incident)
13. BILL OF RIGHTS: quality of care, decision making, privacy and financial information
14. GOOD SAMITARIAN LAWS: laws are designed to protect health practitioners while giving care
in emergency situations.
15. STUDENT LIABILITY: legal responsibilities of student nurses include careful
preparation by instructors.

LEADERSHIP ROLES AND MANAGEMENT FUNCTIONS ASSOSIATED WITH LEGAL ISSUES

• Serves as role model by nursing care.
• Updates of knowledge and skills in field of practice.
• Reports substandard nursing care to higher authority.
• Respectful relationship, caring and honest and reducing the possibilities of future lawsuit.
• Prioritizes patient’s right and welfare of the family.
• Demonstrate vision risk taking and energy in determining appropriate legal boundaries.
• Increases knowledge, regarding sources of law that affects nursing practice. Minimize the
risk using appropriate equipment and products.
• Monitor and supervise subordinates increases staff awareness of intentional torts to see
that written protocols, policies, and procedures to reduce liability. Provides educational
and training for staff on legal issues affecting nursing practice.

APPLICATION OF ETHICS TO COMMUNITY HEALTH NURSING PRACTICE

THE PRIORITY OF ETHICAL PRINCIPLES
• In community health nursing, ethical principles direct and guide nursing actions with
individuals and aggregate groups. The professional ethic, in general, places a greater
emphasis on the observance of the principles of autonomy and beneficence than the
principles of justice in most nursing actions.
• The ethical principle of beneficence is given slightly less emphasis in the code for nurses.
The principle of justice is not strongly emphasized in the professional code of ethics. it is
noted in passing that nursing practice is not influenced by age, sex, race, color, personality
 or other personal attributes or individual differences in customs, beliefs, or attributes.
The cod estates that ‘’ nursing care is delivered without disease detection and prevention
and in health maintenance.

ACCOUNTABILITY IN COMMUNITY HEALTH NURSING

• Moral accountability in nursing practice means that nurses are answerable for how they
promote, protect, and meet the health needs of clients while respecting individual rights
to self-determination in health care. In community health nursing, where the greater
emphasis is on aggregates rather than individual clients, moral accountability means
being answerable for how the health of aggregate groups justice are still important in
community health nursing.
• Yet they are less important than the principle of beneficence .in community health
nursing the emphasis of the professional ethic is slanted toward benefit to aggregates,
which implies following a rule of utility in planning, implementing, and evaluating
community health nursing services.

FUTURE DIRECTIONS
• Expanded role of nurse has increased the legal accountability of the nurse practitioner
who is certified to function as an independent care giver. Thus, there is a current and
future need for periodic assessment of the moral and legal requirements of accountability
in community health nursing services.
• There is also the need to determine how existing programs and services will be evaluated
to determine the effectiveness of various nursing services in meeting accountability
requirements. There is task that has yet to be accomplished by today’s community health
nursing leaders

SCOPE OF COMMUNITY HEALTH NURSING PRACTICE

WHAT IS COMMUNITY HEALTH?
‘’Community health refers to the health status of the members of the community, to the problem
affecting health and to the totality of health care provided for the community.’’

COMMUNITY HEALTH PRACTICE

• Community health practice is application of community health concepts to prevent
diseases and promote health and efficiency and prolong life of people at large through
organized community efforts.
• It implies making systematic assessment and diagnosis of health status of people and their
problems, planning and implementing comprehensive health care services for the entire
community with their active co-operation and participation.
• In community health practice, the whole community is the client and its objective is to
provide need based comprehensive health care services which include primary level
prevention i.e. health promotion and provide specific protection; secondary level
prevention i.e. early diagnosis and treatment and control of further spread of diseases;
tertiary level prevention i.e. control of disabilities and rehabilitation; evaluation research
and training and education of health personnel.
• Community health practice requires the skills of many different disciplines e.g. Nursing,
Medicine, Social Work, Nutrition, Preventive medicines, Epidemiology, Biostatics,
Demography, Engineering etc. functioning together as demographic team. so that they
are knowledgeable and skillful. They need to acquire knowledge about community’s
epidemiological aspects of health problems, health planning, administration and delivery
system that they are knowledgeable and skillful. They need to acquire knowledge about
community’s epidemiological aspects of health problems, health planning, administration
and delivery system.
SCOPE OF COMMUNITY HEALTH NURSING PRACTICE
The community health nursing practice encompasses: the goals and aim of community health
services, the priority practices/services, the focus of these priority practices and practice levels.
1. THE GOALS AND AIM
• Community health nursing, which is nursing aspect of organized community health
practice, is committed to the goals and aims of community health. The goals of
community health are to promote and preserve health, to restore health when it is
impaired, minimize suffering and distress and to promote quality living.
• These goals can be achieved by providing comprehensive health and nursing services as
mentioned to the entire community and by working with individual, families and groups
in the community with an aim of self care.
• Self care is an appropriate strategy. It makes individual self dependent in promoting and
preserving their own health, preventing diseases and health problems, controlling their
illness and health problems and restoring their health. Self care activities include practice
of wholesome personal habits and life style, following of specific protective measures,
reporting early when sickless, undertaking treatment and precautions for spread of
disease to others and for occurrence of relapse.
2. THE PRIORITY PRACTICES
• The community health priority practices are based on the concept of levels of prevention.
These are as follows:
PRIMARY LEVEL OF PREVENTION: it is in the prepathogenesis phase of disease or health
problems and includes all those measures which promote general health and wellbeing of people
and protect them from specific diseases and health problems e.g. healthful living, environmental
sanitation, wholesome diet, immunization and control of air pollution etc.
SECONDARY LEVEL OF PREVENTION: includes all those measures which help in arresting the
disease process, restore health and control further spread of disease e.g. early diagnosis and
treatment, health education, immunization of population at risk, safe disposal and disinfection
of infected excrements, infected equipments and supplies etc.
TERTIARY LEVEL OF PREVENTION: includes all those measures which help in minimizing suffering
, reducing or limiting the impairments and disabilities and promoting adjustment to disabilities,
medical rehabilitation, vocational, social, and psychological rehabilitation etc. in community
health practice, highest priority is given to primary level preventive measures because these
measures promote health and prevent diseases and health problems and less emphasis is given
to secondary and tertiary level prevention at the primary level infrastructure

3. THE FOCUS AND PRACTICE LEVEL

• Community health nursing which is aspect of organized community health practice is
committed to goals of community health i.e. to promote and preserve health, to restore
health when impaired, to minimize discomforts and to promote quality skills. It helps in
achieving these goals by providing comprehensive health and nursing care services to the
entire community. Thus community is the focus of community health nursing services.
• Nurses in the community work with individuals, families and groups and lay major
emphasis on primary health care and less emphasis on secondary and tertiary level of
health care. The aim of such care is to make individual, family and community self reliant
in dealing with their own health problem in the long run. The scope of community health
nursing practice determines the modes of delivery of health care services and its
approaches.

MODES OF DELIVERY OF HEALTH CARE SERVICES AND NURSING INTERVENTIONS

Two modes of delivery of health services are identified by ANA, 1980. These include
1. SERVICE TO INDIVIDUAL , FAMILIES AND GROUPS
The community health nurses work with individuals, families and groups in the community and
provide direct health care service to promote health, prevent disease and injury, to apply
therapeutic measures, to reduce or minimize discomforts and restore health and promote quality
living. The ultimate aim of such care is to develop competencies for self care. This is attained
through appropriate application of nursing interventions related to comprehensive health care
which are as follows:
SUPPLEMENTAL INTERVENTIONS: supplemental interventions are those actions which the
individuals / families are not able to do for themselves and the nurse does for them but educate
them and prepare them to do for them e.g. care of child with high fever or any other problem.
FACILITATIVE INTERVENTIONS: these are those interventions which will help to remove barriers
which interfere with to providing self care. The barriers could be related to resources available,
cultural practices and environmental conditions e.g. helping family to procure or develop
resources, creating awareness regarding harmful cultural practices etc.
DEVELOPMENTAL INTERVENTIONS: these include education, supervision, guidance and
counseling to help individuals and families gain knowledge and develop competencies to
promote and preserve their health problems, seek medical care, give care when required and
restore health.
SERVICES TO THE COMMUNITY AS A WHOLE: These modes of delivery of health care services
include services which are planned to deal with various aspects of community that affect the
health of entire community. In this, community health nurse works with community and its
subgroups, help them recognize their health problems, set priorities, help them utilize and
develop their resources, self help groups etc. such services ultimately affect the health of
individuals, families and groups within the community.
Role of community health is not limited only to sick but has equal responsibility to prevent the
disease and to preserve and promote the health of people.
1. Home care: nursing practice is applied in meeting the health needs of communities, families
and individual s in their normal environment such as at home.
2. Nursing homes: community health team which provides nursing care, treatment to the the
sick and health counselling given in nursing homes.
3. MCH and family planning: the public health nurse plays a major role in the MCH and family
planning services. it comprises antenatal, postnatal and child health services.
4. School health nursing: school health nurse provides services to promote and protect the
health of school children. she provides services like early detection of diseases, immunization,
first aid and dental health, maintenance of health records, school sanitation, health education,
follow up and referral services.
5. Health care services: the purpose of health care services is to improve the health status of
population. It aims at mortality and morbidity reduction, increase in expectation of life, decrease
in population growth rate, improvement in nutritional status, provision in basic sanitation,
health, manpower requirements and resource development an certain other parameters such as
food production, literacy rate, and levels of poverty.
6. Industrial nursing services: the nursing services at industrial area include periodic health
checkups, care of sick, first aid, health counseling, industrial sanitation, and safety, organization
of services to women and children, rehablitation of the ill and disabled workers and
administration.
7. Domiciliary nursing services: community health nurse focused at domiciliary nursing services
includes maternity services health supervision and disease prevention and service for illness and
accidents.
8. Geriatric nursing services: community health nurse should take care of old people in the
community. The need of geriatric nursing care is different and they need more care than the
younger age groups.
9. Mental health nursing services: this includes early diagnosis and treatment, rehabilitation,
psychotherapy, use of modern psychotropic drugs, and after care services.
10. Rehabilitation services: community health nurse provides care, in rehabilitation units.
Nursing is an important component in the rehabilitation of the disabled.
Topic 2: Public Health Laws
Learning Targets: 1. Distinguish a moral community from a population.
2. Apply different ethical approaches to specific
community/public health (C/PH) nursing issues.
3. Discuss healthcare disparities and identify populations at risk.
4. Analyze communicable disease-related ethical issues.
5. Identify ethical issues and questions that are outcomes of the
human genome project.
6. Explain what it means for a nurse to be a servant leader.

Concept/Digest

LAWS AFFECTING COMMUNITY HEALTH NURSING PRACTICE

HEALTH SERVICES

EO 851 Reorganizing DOH, integrating components of health care delivery into its field
operations and for other purposes
PD 568 Restructured Health Care Delivery System (RHCDS)
RA 1891 Strengthening Health and Dental Services in Rural Areas
RA 1082 Employment of More Health Personnel in Rural Areas (Rural Health Unit Act)
RA 1054 Free Emergency Medical and Dental Treatment for the Employees
LOI 949 Legal basis for the adoption of PHC
EO 105 Providing for the Creation of a National Health Planning Committee (NHPC)
and the Establishment of Inter Local Health Zones (ILHZ) throughout the
country and for other purposes
EO 102 Redirecting the Functions and Operations of the DOH
RA 7875 National Health Insurance Act of 1995
RA 7305 Magna Carta of Public Health Workers
RA 7432 Senior Citizen’s Act of the Philippines
RA 9257 Expanded Senior Citizen’s Act of 2003
RA 7876 Senior Citizen’s Center Act of the Philippines
RA 7160 Local Government Code of 1991
RA 1939 An act prescribing the appropriate share of the national, provincial, city, and
municipal government in the financial contributions for the operations and
maintenance of free beds in government hospitals and establishment of
additional wards or hospitals in the Philippines
RA 7719 National Blood Services Act of 1994
RA 7883 Barangay Health Worker Benefits and Incentives Act of 1995
Batas Pambansa Accessibility Law
344
EO 958 National Healthy Lifestyle Advocacy Campaign, Declaring year 2005 to 2015 as
the Decade of Healthy Lifestyle

ENVIRONMENTAL HEALTH

PD 856 Code of Sanitation

RA 9211 Anti-Tobacco/ No Smoking Campaign
PD 1160 Barangay Captain to enforce pollution and environmental laws
PD 825 Penalty for improper disposal of garbage/ refuse waste and other forms of
uncleanliness
RA 9003 Philippines Ecological and Solid Waste Management Campaign
PD 1181 Prevention and Control of Air Pollution for Motor Vehicles
RA 8749 Clean Air Act of the Philippines
RA 6969 Prohibits the entry of hazardous an nuclear wastes in the country and provides
a mechanism to monitor and regulate the production and release
COMMUNICABLE DISEASES
RA 3573 Reporting of Communicable Diseases
RA 4073 An Act of Liberalizing the treatment of leprosy
PD 384 Amending RA 4073 by amending and repealing certain sections of the Revised
Administrative Code
RA 1136 TB Law, reorganizing the division of Tuberculosis control in the DOH
RA 8504 An act promulgating policies and prescribing measures for the Prevention and
Control of HIV/ AIDS in the Philippines

FAMILY PLANNING
RA 3753 Civil Registry Law
PD 651 Registration of Birth/ Death in the Philippines from January 1, 1974 thereafter
PD 79 Revised Population Act of 1971
PD 1204 Amending Certain sections of PD 79 Revised Population Act of the Philippines
PD 166 Amending the Revised Population Act 1971
PD 965 Requiring applicants for marriage license to receive instruction on family
planning and responsible parenthood
EO 209 (as amended by EO 227) Family Code of the Philippines
RA 8187 An act granting paternity leave of seven days with full pay to all married male
employees in the private and public sectors for the first four deliveries of the
legitimate spouse with whom he is cohabiting and for other purposes

MATERNAL AND CHILD HEALTH

Proclamation # 6 Implementing a United Nations Goal on Universal Child Immunization by 1990
P 46 Reaffirming commitment to the goal of Child Survival Program thru
Immunization on Polio Eradication
PD 996 Providing Compulsory Basic Immunization for all infants, and children below 8
years of age
RA 7846 An act requiring compulsory immunization against hepatitis B for infants and
children below 8 years old
RA 9288 Newborn Screening Act of 2004
PD 603 Child Youth Welfare Code
PD 148 Amending Republic Act 679, Women and Child Labor Law
EO 51 Milk Code of the Philippines
RA 8980 Early Childhood Care and Development Act of the Philippines
RA 7600 The Rooming In and Breastfeeding Act of 1992
RA 7610 Special Protection of Children Against Abuse, Exploitation, and Discrimination
Act
RA 9262 Anti-Violence Against Women and Their Children Act of 2004
RA 8353 Anti-Rape Law
RA 7877 Anti-Sexual Harassment Act of 1995

NUTRITION
PD 491 Nutrition Act of the Philippines
PD 1569 Barangay Nutrition Scholar Decree
RA 8172 An act promoting Salt Iodization Nationwide or Asin Law of the Philippines
RA 8976 Philippine Food Fortification Act of 2000
EO 472 Transferring the National Nutrition Council from the Department of Agriculture
to the Department of Health
MEDICATIONS
RA 6675 Generics Act of 1988 Safe Medication
RA 6425 Penalties for Violations of the Dangerous Drug Act of 1972
RA 9165 Comprehensive Dangerous Drug Act of 2002
RA 8423 Traditional and Alternative Medicine Act of 1997

PROFESSIONAL CONCERNS
PD 223 Creation of the Professional Regulation Commission (PRC)
RA 8981 PRC Modernization Act of 2000
LOI 149 Convention concerning the employments and conditions of work and life of
nursing personnel
RA 6758 Salary Standardization Law
RA 1080 Conversion of bar and board examination as Civil Service Eligibility
LOI 1000 Compulsory membership of professional association accredited by the PRC
RA 7164 Philippine Nursing Act of 1991
RA 9173 Philippine Nursing Act of 2002
RA 5921 An act regulating the practice of pharmacy and setting standards of
pharmaceutical education in the Philippines and for other purposes
RA 7392 Philippine Midwifery Act of 1992

*Reference: DAVID, E., et al. Community Health Nursing: An Approach to Families and Population
Groups. 2007

Learning Activity
Ethical Reflections
• To what communities do you belong? What can be identified as the common good of each of
these communities?
• Have you noticed “us” versus “them” thinking among members of the nursing community?
Among members of the larger community of health care professionals? If so, what effect has this
thinking had on relationships among members of the particular community?
• Can a community exist when there is “us” versus “them” thinking among the members? Why
or why not?
• What patient populations might be particularly susceptible to having people approach them as
“us” versus “them”? What evidence did you use for your answer? How can nurses change this
type of separatist thinking?