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Community Health Nursing in the Philippines

The implementation of Community Health Nursing in nursing education

and the filling of nursing task fields

Summary of a practical term report

Author: Martina Harking

Student of the faculty of Nursing sciences at the Evangelische

Fachhochschule Rheinland-Westfalen-Lippe in Bochum/

Germany. University of Applied sciences

Institution: West Visayas State University, College of Nursing La Paz,

Iloilo City 5000, Philippines

Supervising by: Prof. Dr. Rosana Grace B. Belo (WVSU Iloilo, Philippines)

Prof. Dr. Merline S. Posecion (WVSU Iloilo, Philippines)

Miss Virgina F. Federiso (WVSU Iloilo, Philippines)

Mrs. Joelah M. Rio (WVSU Iloilo, Philippines)

Prof. Margot Sieger (Evangelische Fachhochschule Rhein-

land-Westfalen Lippe in Bochum/ Germany)

From: 2000-11-13 to 2001-04-12

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Community Health Nursing in the Philippines The implementation of Community Health Nursing in nursing education and the filling of nurs-

ing task fields

Table of Contents

1 The beginning of the practical term project in the Philippines

2 The European concept of Family Health Nursing in the context of German health system

3 Objectives of the practical term project

3.1 Selection of scientific instruments for fulfilment of practical semester objectives

3.2 Course of practical semester

4 Results by selected literature

4.1 The national health situation (in comparison with development and dates of Germany)

4.2 Community Health Nursing in the Philippines

4.3 The task of Community Health Nursing

4.4 The incorporation of Community Health Nursing into the BSN Curriculum

5 Empirical results/ field investigation

5.1 Nursing education- a contribution for a better future of the Filipinos

5.1.1 The situation of nursing

5.1.2 Education for the export

5.1.3 "Philippine nurses are well adapted and can work anywhere"

5.1.4 Attractivity of Community Health Nursing

5.2 The project Community Organizing - a contribution to improve the health situation in the

Community

5.2.1 Acceptance of Community Health Nursing in the Philippine population

5.2.2 Nursing students with versatile abilities

5.2.3 Home visits as an instrument for recording health conditions

5.2.4 We cant afford to get sick

5.3. The self-conception of a Community Health Nurse in the network of Philippine health care

delivery system

5.3.1 The Community Health Nurse as a generalist

5.3.2 Midwifes as front liner of health services

5.3.3 All we have to do is paperwork

6 Final considerations

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Community Health Nursing in the Philippines

- The implementation of Community Health Nursing in nursing education and the filling

of nursing task fields -

1 The beginning of the practical term project on Philippines

Within the framework of post graduated studies of nursing science at the Evangelische Fach-

hochschule R-W-L in Bochum (Germany), the students have to complete a practical semester of ap-

proximately 22 weeks. The purpose of this practical semester is to enable the students to connect the

contents of the nursing studies with the professional practice. To accomplish the objectives, the stu-

dents have to investigate systematically the structures and innovative working concepts of nursing or

other health services in Germany or abroad.

Ms Martina Harking completed her practical semester at the College of Nursing at the Philippine West

Visayas State University in Iloilo from December 2000 until February 2001.Due to her former per-

sonal experiences with Philippine nurses in Germany and her attachment to the Far Eastern culture,

she chose to complete her practical semester in the Philippines. The possibility of communicating in

English enhanced her decision. After establishing the contact with the College of Nursing, structural

and administrative conditions were clarified. The planned objective of the practical semester was the

description of the field Community Health Nursing. This choice of topic was guided from the special

offer of the College, to participate with senior students in theoretical and practical learning experiences

in the field of Community Health Nursing. With regards to German development in nursing, this topic

has a special charm:

In Anglo-American or Asian countries Community Health Nursing has been established since a long

time ago, whereas in Germany it hasnt been existing yet. However in the current health-political dis-

cussions in Germany, there are plans to implement a new professional field the Family Health Nurse.

At the 2nd ministerial conference of the WHO for European countries, all participant states formulated

a common political declaration (June 2000 in Munich). Nursing is supposed to adapt to the changing

social circumstances and take on its responsibility to Public Health, health promotion and prevention

at the living environment of the people (WHO Europe regional office, 2000).

This concept of Family Health Nursing is in Germany still at the beginning of its development. So

far the questions around the training, financing and incorporation of the concept into the existing

health system, havent been clarified sufficiently. Even though the idea of the Family Health Nurse

had at the beginning of the practical semester more of a visionary than an obligatory character, it was

for the german nursing a very interesting challenge to experience in the Philippines the already exist-

ing field of Community Health Nursing.

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2 The European concept of the Family Health Nurse in the context of the german health

system

The german health system is characterized as a progressive and for every citizen accessible curative

oriented health care system. In case of an illness the german population is well protected by curative

and rehabilitative services from their health insurance system. In the 90s a further column of social

insurance was implemented by the government. The Pflegeversicherung (care insurance) offers fi-

nancial help as well as professional nursing in cases of need for long-term care. In the german system

the health oriented services, like health promotion and disease prevention, were lost more and more

out of sight.

In a retrospective view, the health situation in Germany has changed with regard to the demographic

factors. There is a considerable population rise in the agegroups of 65 years and older. This increase is

combined with a large number of chronic illnesses and disabilities, which leads as well to an increase

of the cost of the health care system as well to an increase in the demand for care. In a prospective

view this will lead to a change of focus in nursing in Germany: away from curative aspects to nursing

tasks. Since the nurses and midwifes are the largest group of health specialist in the european region,

the WHO has assigned them a keyrole. They are supposed to be engaged stronger into furthering the

efficiency of the health care systems. Through their special proximity to patients of all age-groups they

are supposed to add in special kind for stabilization and development of health resources in the popu-

lation.

The development of a new profession profile- the Family Health Nurse- is initiated by the WHO

European area. Background for this evolution is the health political framework health for all and the

revised concept health 21. The global health strategy 21 contains twenty one objectives for the 21st

century. It describes public health requirements for the European area and proposed targets and meas-

ures for improvement. The role of the family health nurse is defined in this context as follows:

"The Family Health Nurse will help the individual human being and whole families to cope

with illness, chronic disabilities and to manage stress situations. She spend a big part of her

working time in patients home together with their families. These nursing specialists can give

advice to questions of the way of life and behaviour-conditional risk factors. She already can

recognize in an early stage health problems and guarantee that they treated early. With her

health-scientific and sociological training background and her knowledge about other social

institutions she can identify socio- economic effects to families health and transfer family

member to a responsible place. Through delivery of home care services she can facilitate an

early discharge from hospital, she can be a case- manager between family and physician and

she can step onto the place of the physician if unambiguously nursing expert knowledge is re-

quired" (WHO Europe regional office 2000 pp. 2 EUR/00/5019309/13).

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First of all, the concept of a Family Health Nurse become close to tasks of nurses in home care settings

as it is established in Germany since many years. New at the concept of Family Health Nursing, how-

ever, is the special accentuation on the fields of health promotion, prevention and rehabilitation in

peoples realistic environment over a longer period. In this case become other competencies important

like case-management functions, counselling, nursing education and cooperation with other occupa-

tional groups. Furthermore, the concept of Family Health Nurse requires the perception of the family

as a system. This alteration perspective is new for German nursing. Up to now nursing-relationships

are primarily concentrated onto the dyade patient-nurse. Indeed, health services occur within the

framework of a family. But up to now especially human needs of care are in the foreground, less the

family as whole or quite communities. Measures to health promotion and prevention within a family,

communities or other social settings do not represent an identified field of nursing yet.

For German health service can be stated, that up to now nursing sciences and Public Health still could

not come in any reasonable combination. A positive change in such a way is that with the implementa-

tion of a new professional section - the Family Health Nurse- also in Germany a progress can happen.

In order to perform versatile roles and functions of a Family Health Nurse, German nurses must be

qualified better. Furthermore, they need socially legitimised structures which make admission to fami-

lies and health related dates accessible for her. These fields are protected in Germany particularly by

law. Until now it is not allowed for any authority (with very small exceptions), to penetrate deeper in

family life or to raise personally health related dates and transmit it.

The Family Health Nursing curriculum was created by an European working group of the WHO and is

supposed to be adapted onto each national structures. Currently it is proved in pilot studies at different

places in Europe (WHO Europe regional office 2000 EUR/00/5019309/13).

For Germany can be concluded, that today, almost two years after the Munich declaration a wide cir-

culation of Family Health Nurses idea has occurred but no structural health political conditions were

created.

3 Objectives of the practical term project

Main intention of the practical semester was to widen ones imagination through the experience of the

philippine nursing education and performance in a - at least for the german nursing profession - un-

known professional field. Therefore one objective was to find as many answers as possible to the

question: What characterises Community Health Nursing in particular?

For that purpose the data collection was an explorative procedure with a multiperspective focus. The

centre of interest for the data collection was to be guided onto the fields of nursing education and nurs-

ing practice:

1. Recording the study program of a Community Health Nurse

- the incorporation of the topic (objectives, contents, methods) into the curriculum

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Planned methods were document- and literature analyses as well as expert interviews.

2. Representation of competences and tasks of a Community Health Nurse

- which roles and functions does a Community Health Nurse fulfil within the network of the

Philippine health service?

Planned methods were to be participating observation at a related learning experience project of senior

students in the community, as well as to get insights into the daily work of a Community Health

Nurse.

As further explorative method expert interviews were planned. Experts for example could be college's

teacher or Community Health Nurses.

3.1 Selection of scientific instruments for fulfilment of the objectives of the practical semes-

ter

Two essential conditions led to the selection of the research instruments in order to describe the pro-

fessional field of Community Health Nursing in the Philippines.

On one hand Community Health Nursing is, except from the current european development, a rela-

tively unfamiliar professional field in Germany and on the other hand the research field was in a for-

eign country and therefore in a strange culture.

Foreign understanding means a careful and cautious behaviour in the culture. With regard to this

knowledge an intensive analysis of ethnological research was done before the practical semester

started. An essential realization for a stay in an other culture was for the researcher to keep a maxi-

mally neutral and empirical viewpoint onto the different ways of life. In relation to the practical se-

mester it meant to face the diverse interactions unprejudiced and to let the interpretations of the obser-

vations and events be carried out by the insiders of the culture.

For the project preparation, the fieldwork and the data analysis a combination of qualitative research

methods of the Ethnography and Grounded Theory were chosen. These approaches allowed a finding

out procedure during field work as well as the collection of diverse data from different sources.

3.2 Course of the practical semester

In the beginning of December 2000 the first personal contact with the West Visayas State University

and the college of Nursing was made. In order to be allowed to complete this project it was necessary

to get official permissions and clarifications. In January 2001 the field work started in an indescribable

density and strength. The guest student participated for four weeks in all activities of students related

learning experiences in the community. During this time all observations in the community and con-

current teaching-events at College were done. The interactions were documented by differentiated

conversation- and observation records.

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Furthermore, three intense expert interviews with college teacher were done. The interview guide was

as oriented on the project objectives (nursing education and nursing practice in the community) as

onto sense questions and discoveries of observation processes (which could be explained and interpre-

tated by experts).

To record the professional work of a Community Health Nurse in her daily work a local rural health

unit and an urban health unit were visited. Unfortunately (due to organizational reasons) the observa-

tions could only be done within a limited given time. Expert interviews were executed with a midwife

and two Public Health Nurses (the interview questionnaire was similarly designed as the one before

and extended with the at the time known professional knowledge or the new identified phenomenas).

In the same way 14 students could be interviewed in a written form. They gave informations about

their learning experiences in the community and their future plans as a graduated nurse.

Finally six Barangay members, who had regularly taken part at health classes, reported about their

impressions and experiences during the students activities. Additionally day visits were undertaken to

a regional leprosy village and to a herbal plant laboratory. The latter impressing and emotional experi-

ences were not considered in the description of Community Health Nursing.

All in all for the description of Community Health Nursing in the Philippines there were four tran-

scripted expert interviews, six transcripted conversations with Barangay member, fourteen question-

naires of students, three interviews with a midwife and two Public Health Nurses and documented

observations on a period of approx. seven weeks, numerous records of conversations and recordings of

the field diary. For the description of the educational study program the related learning experiences

conception could be used which is adapted to the Philippines BSN Curriculum as well as various col-

lege internal teaching plans. Furthermore documentation material and literature of the Philippine De-

partment of Health was evaluated which gave information about the national health situation and cur-

rent health programs.

The research manual of the students and their results were used for description of the health situation

in that assigned Barangay. Finally many activities and environmental factors were documented by

photographs.

Reflection on the methodical procedure

As much as the multi-perspective investigation methods were helpful to enrich the sense of identified

phenomena and intention of actors in the Philippine health system and nursing education as much

were they almost unmanageable due to the amount of data collected already after a short time. Con-

tinuously new interesting observation fields that concerned the topic were opened. So it was relatively

soon realized that a state of dense description could only be achieved in a few fields. There were too

many influencing factors which determined the topic whose research used considerably more time.

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Finally it remains to notice critically, that questions formulated in the project planning were too wide

and considered too many investigation fields. Subsequently the concentration on Community Health

Nursing in nursing education alone, or the concentration on professional nursing competences in fields

of her daily work, would have been completely sufficient.

4 Results by selected literature

4.1 The national health situation of the Philippine population

(in comparison with development and data of Germany)

In the mirror of statistics the Philippine population draws an interesting picture in comparison to the

German population. Was the number of citizens in the Philippines in 1995 about 69 million people so

it was 82 million in Germany. The density of population on a square kilometre is 226 people in the

Philippines, in Germany there are 230 persons per square kilometre. The age structure of the Philip-

pine population is characterized through a high part of younger generations: 39% of the population is

younger than 14 years and only 5% is older than 60 years. The number of women in reproducible age

is high so the annual population rate increases rapidly around 2,3% ( on average a Filipina gives birth

to four children) (DOH, 1995 Cruz in Maglaya 2000, p.3).

As in most industrialized countries the age pyramid of German population is marked by a low number

of young generation. By the end of 1999 the number of 15 years old citizens and younger was 15,7%

whereas the percentage of the population being 65 years and older increased to 16,2%. In Germany are

living more people of the age group 65 and older than of the age group 15 years and younger. Accord-

ing to the birth statistics a German woman gives birth to 1,3 children. Nevertheless, the population

growth is in 1999 to 0,2%, a number which is also based on the migration of foreign people to Ger-

many. The average life expectancy of masculine sex is 74 and women 80 years (Statistical Bundesamt

Germany 2000).

At this comparison its obvious that the Philippine population is young and has a rising population.

The German population has a rapid rise of older population and less children. So in this countries

health problems and demands to health care delivery system are completely different.

Poverty is the main reason for health problems in the Philippines (Cruz in Maglaya 2000). According

to the information of the Healthcare Factbook about 40% of the population live below the poverty line.

From that results numerous health problems (infections, malnutrition problems like goitre and general

immundeficiency) that are founded by insufficient environment factors and lacking health explanation.

Missing financial resources hinder both: a healthy way of life in the family and the access to health

services.

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In total the health situation of the Philippine population has improved. Life expectancy has increased

from 57yrs. to65yrs. during the last 30 years. Some illnesses as polio and neonatal tetanus are almost

eradicated. The application of traditional herbal medicine is being practised in parts of the population

and there is a rise in the awareness for prevention and health promotion in families and communities.

Nevertheless, stays as an area of major concern the rapidly growing population with its health prob-

lems for women and children. Also there is to be observed a rapid increase in so called life-style ill-

nesses and road accidents. The number of children mortality in the Philippines is characterized par-

ticularly by illnesses of the respiratory system, complications under birth and nutrition deficits. Mater-

nal mortality is a sensitive indicator for the national health situation. These rates give information on

how a country safeguards the health situation of its growing-up generation. According to information

of the Philippine Department of Health 1995 maternal mortality rate is 1,8 /1000 live birth, that means

180 of 100.000 women die from complications of a birth (Cruz in Malgaya, 2000 pp. 1 - 10).

In comparison for this purpose the German statistical office reported 5,4 maternal morbidity onto

100.000 live birth in 1995 (German Ministry of Health, 1999 pp.217). The health situation of German

population improved especially after the second world war. Health promoting living conditions con-

tributed to an expanded life expectancy. Besides the progress in the medical care, especially the Public

Health strategies helped to correct the health chances of the german population (balanced nutrition,

safe roads and occupational protections, optimisation of water and sanitary hygiene, better access to

family planning methods and to technical headway of medical supply). Infectious diseases with direct

death result became rare in Germany.

However, the health problems only shift into another direction. With the high rate of older generations

there is a drastic increase in chronic diseases. Many of the people in the advanced age have a need for

care. Also mental diseases (Depressions) and life- style diseases like cancer and diabetes are wide

spread.

The national health politic is adapting to the new situation only very slowly. So Public Health as a

scientific discipline could be established in the last two decades of the running out millennium. The

health report as an instrument of Public Health (known in the Philippines as Community Diagnose or

Community Health Assessment) was introduced in the late 90s. Until then existed the bare documen-

tation of factors in medical statistics and Epidemiology. With the health report data available now,

they are to be processed and interpreted, so that they can be used for health politics, health promotion

and health system design. Definitively it can be stated, that currently in Germany there are first ten-

dency to recognize health promotion and prevention to be the subjects of the future. Still it is a rather

small consciousness for this change. An explanation for the small number might be a still functioning

social health system pays for the costs in cases of illness or care. However, this social protection cant

work sufficiently in the future since an immense costs limits the capability of the social security.

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4.2 Community Health Nursing in the Philippines

Community Health Nursing in the Philippines is established as a professional field since many dec-

ades. Conceptually it unites elements of nursing sciences and Public Health. Community Health

Nurses, which are officially called Public Health Nurses are linked into a net of governmental and

non-governmental national health services. The Department of Health practices regulative strength

over the health institutions and the appropriation of health services while their activities are directed

mainly by a centrally controlled framework of action (standards, health plans, laws). With a decen-

tralization of national health service onto regional and local level the Philippine authorities hope to

meet health problems and needs of the clients better on the community level. At last a decree was for-

mulated in 1993 when the local government units were recognized as acting and self- reliant partners

of the DOH in attaining of the national destinations (RA 7160: local government code in Cruz/

Maglaya 2000, pp. 12).

The health requirements of a family or a community are to be determined through a differentiated

manual (Family or Community Assessment, Community diagnosis). From local and regional level the

health data is transmitted to higher health offices where it will be answered by government recom-

mended and supported programmes. This pertains particularly the most frequent and most urgent

health problems (Committee of Community Health Nursing, 1995 pp. 11 ff).

4.3 The task of Community Health Nursing

In the literature Community Health Nursing is understood as a special subject of the nursing practice.

It integrates general aspects and principles of nursing with concepts of Public Health.

Public Health is described by the World Health Organization (WHO) with reference to the definition

of C. Dr E. Winslow as follow: "the science and art of preventing disease, prolonging life and promot-

ing health trough organized efforts of society" (Committee of Community health Nursing 1995, pp.

21). Therefore Public Health has the task to create social systems that safeguard a health receiving

standard of living for every human being, so that his birth right to health and a long life can be ful-

filled. Following this definition Community Health Nursing is understood in the Philippines as an

answer to the health needs of the population. Her specialty is characterized by a population based fo-

cus for example thru working with individuals, families, groups and communities. However the claim

on the practice of this profession is as well general as it is comprehensive, since the work in the Com-

munity pertains to longer time periods and most different requirements in the community. With this

Community Health Nursing is unique and distinguishes itself from other fields of nursing as follows:

it is concerned with the health status of a distinct population rather than focuses on individu-alized care

it addresses the personal and environmental aspects of health while dealing with the commu-nity factors that inhibit or facilitate healthy living

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health services are rendered within the milieu of the client giving priority to care of vulnerable groups through the partnership approach (Cruz in Maglaya 2000, p. 14).

Following Public Health concepts guides the field of Community Health Nursing:

1. emphasis on the importance of the "greatest good for the greatest number"

2. assessing health needs, planning, implanting and evaluating the impact of health services on

population groups

3. priority of health-promotive and disease-preventive strategies over curative interventions

4. tools for measuring and analysing community health problems

5. application of management principles and organization in delivery of health services to the

community (Cruz in Maglaya of 2000 pp. 14)

From the perspective of Public Health results a comprehensive, integrated and multisectorial claim on

the activities of a Community Health Nurse. That is far about the narrow and individualized client-

nurse relationship. In the literature roles and functions of a Community Health Nurse are ascribed as

following:

clinical role when she takes care around sick in theirs homes or in the health office health educator through health teaching classes to the population and education programs to

the employees (midwifes, Barangay Health Worker)

facilitator: she refers clients to other health agencies or facilities supervisor of the midwifes (employees subordinated to her) management functions: as an organizer she coordinates procedures in the health office or mo-

bilize the community to consider peoples foremost health problems

As an advocacy she represents health importance of people (Cruz in Maglaya of 2000 pp. 25).

One important objective of Community Health Nursing is to provide basic health services to individu-

als, families and communities. Furthermore, tasks and responsibilities of Public Health Nurses are

defined by the Department of Health in extracts as follow:

- representation of the Municipal Health Officer in his absence

- assistance in development of Barangay health plans

- check the compliance of Barangay Health Worker with their curricula

- to train hilots

- to control reports of Barangay Health Worker and midwifes (to look for cases in the commu-

nity)

- training midwives in the writing reports

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- Acting cooperation in health programs of the DOH, for example immunization-programs

(EPI)

assists the physician in providing and application of vaccines, writing accomplishment reports,

checking cases of illness)

(Cruz in Maglaya 2000, p. 24)

Considering Community Health Nursing as it is described in the above mentioned literature, it reveals,

that in the Philippines this professional field of nursing has been established since decades. Its obvi-

ous that a governmental framework of action (standards, programs) determines the roles and functions

of a Community Health Nurse. This is to help the nation by the identification, reduction and solving of

the most urgent and most alarming health problems. A successful concept especially in consideration

of the nations small financial resources, the limited staff and physical equipment of its health services

and the numerous complicating settings that accompany them. The family- and community oriented

approach is identified by the application of professional nursing and Public Health instruments. Dif-

ferentiated representations of family care planning and/or community diagnosis show in exemplary

matter, how health influencing factors are identified and used as basis for the development and imple-

mentation of Community Health Nursing interventions and strategies.

Community Health Nurses work according to qualification and status in supraregional or local health

units and cooperate with either, their subordinated employees and the authorities on local, regional

and national level. In presence of the diverse roles and functions that are ascribed to the Community

Health Nurse in the Philippines she is generally equipped with a Master degree in Public Health.

4.4 The incorporation of Community Health Nursing into the BSN Curriculum

Community Health Nursing is an integral component of the Philippine Curriculum of Bachelor of

Science in Nursing (in accordance with memorandum CHED order No. 10 Series of 1998). The objec-

tives of Nursing education is to apply the elementary key concepts: nursing, communication, research

and management in every setting, that means in the clinic and in the community (Laurente, 1993 pp.

4).

By college-internal teaching plans the theoretical study content, that prepare the student for related

learning experiences in the Community, are outlined in the following. Special attention is now directed

to the particular objective of Community Organizing, planned in the level IV, as it represented an es-

sential research component of the practical semester.

In the first semester of the fourth academic year in nursing education the acquisition of management

competences is in the foreground. The students are supposed to apply management theories, concepts

and strategies, as they are needed by nurses in different health settings, when working independently

or in cooperation with others.

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In the field Community Health Nursing these teaching contents are transferred into a concrete practical

experience for the students, when they will plan a term project in a rural community for four weeks,

where they will organize, carry out and finally evaluate all activities by their own. Their task is to as-

sess the health status of a community with multi perspective methods and together with the commu-

nity members identifying health problems, setting objectives and planning activities that will reduce

health problems and can be used for health promotion in the community. The independence of stu-

dents is an educational intention, the realisation and responsibility devolves on students. The project

is continuously accompanied by preceptor. They are available for students questions, however, restrain

themselves in the field.

Preceding the project is about 80 hours of theory for the students. This includes topics of the national

health situation and the importance of health for the evolution of a nation. Roles and functions of the

Community Health Nurse are identified in the structure of the Philippine health system and the con-

cern of the DOH plan is contemplated. Finally they are prepared for the concept Community Organi-

zation and the importance of participation of all community member (College internal Teaching Plan

N- 401 management of clients with altered health pattern).

The related learning teaching plan describes numerous sources and methods in order to determine the

health status and the mode of operation of a local health care delivery systems.

The first task for the students is to record the organisational structures of health care in the assigned

area. They call on the official representatives of the local government unit to be able to get an official

permission for the planned project to the allocated population group. Additionally the students are

supposed to identify the functions of the respective persons of health care. In the next step they will

build up a relationship to the employee of the Rural Health Office. In an open forum students become

acquaintance to tasks and functions of responsible employees: Doctor, midwife, Public Health Nurse

and Barangay Health Worker. In the same way the students are to inform about the objectives and the

content of the planned project and to elaborate possibilities for cooperation. Finally during the entire

time of the project the students will stay together with their perceptor in the community - a selected

rural area of about 100 households. Health data of the community are collect about numerous tools

and sources:

through questioning of local health personnel and/or documents available through selection (accomplishment report)

by drawing up a spot map that is used for recording the geographic situation of households and corresponding family members

home visits represents the main part of investigation, family members are asked with a struc-tured questionnaire about their health situation in the context of economic, ecological and cul-

tural circumstances

Purposeful observations in domestic environment complete the date assessment.

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Finally the collected data show an abundance of demographically, socio-economic, political and health

related data. The results of the community assessments are statistically evaluated by the students. In a

community assembly the results are to be presented to the population and the local health representa-

tives. A common plan for improvement is to be elaborated and will be accompanied by students. In

addition the collected data will help the students to select the topics of health classes, which are to be

continuously offered during the project. The college encourages the students in making family care

plans, as far as they consider it is necessary. Also health service's are supposed to be delivered during

home visits. Finally, back at the College there will be on the last day of the project an evaluation

which is documented by a performance rating scale. (College internal Teaching Plan N- 401 Related

Learning Experience (RLE) Concept Community Organizing).

Summary

The BSN Curriculum is a transparent and educationally valuable curriculum. In the german pedagogic

discussions professional education is understood as the empowerment for current and future situations

of a profession. (Knigge - Demal in Sieger 2001, pp. 43). In this respect the conceptual version of the

BSN Curriculum contributes professional action and ability. Especially successful is considered the

combination of the theoretical with practical educational parts. This will guarantee an optimal use of

practical teaching-learning-situations. Reversely selected practical experiences are transferred as sec-

tions of reality (case studies) to educational learning-situations. The Philippine nursing education pro-

gram prepares students in a scientifically well-founded way regarding the real professional life- situa-

tions of nursing.

5 Empirical results/ field investigation

5.1 Nursing education - a contribution for a better future of the Filipinos

5.1.1 The situation of Nursing

With the abbreviation AIDS (Acute Income Deficiency Syndrome) Philippine college member express

ironically that a considerable part of the population suffers from poverty. Education is considered as

an important chance to improve these poor living-conditions As a governmental institution, the college

feels obliged to provide financially handicapped applicantslace to study. The state pays a scholarship

in specific cases so that at least the tuition fee is free. As a return service the students obliges about a

verbal agreement to remain further two years after examination in the country "to serve the country

first", before they consider to migrate abroad (chapter 5.1.2 education for the export).

The number of unemployed nurses in the Philippines is high. Indeed, hospitals and communities are

complaining about a considerable lack of personnel but the state can not finance any further places of

15

employment. The local Rural Health Unit assesses the health professionals` responsibilities for parts of

the popuation in the community as follows: a doctor is responsible for 20.000, a Public Health Nurse

for 10.000 and a midwife for 5000 people. If graduated nurses find a working place in their own coun-

try this is likely in private institutions. However, in these institutions the salary is smaller than in gov-

ernmental hospitals and there are often temporary limited contracts. Often enough nurses work without

salary (as volunteers) in hospitals in order to gain clinical experiences. This reference promises greater

chances of an application abroad. At present nurses consider themselves as the most exploited profes-

sional group in the Philippines. Therefore, the explicit wish for the future of Nursing is that graduated

nurses receive a paid working place in their own country as well as that the status of Nursing will be

improved. Midwifes request an education financed by the state, more advanced and adapted to the

Bachelor Degree.

5.1.2 Education for the export

College employee estimate that about 60 % of Philippine nurses migrate abroad. Bad working chances

in their own country and a strong family orientation oblige them to use every possibility in order to

support the family financially. As the state also raises taxes onto foreign income Over Sea Worker

contribute considerably to stabilize the domestic economy. Thus, the education of nurses helps to

safeguard the economical situation in the Philippines indirectly, although it rather corresponds to for-

eign demands than to domestic demands. The number of the college students depends highly on the

foreign demand. During last years the number of nursing students varied at WVSU between 400 and

600. In the 80th and 90th USA, Europe, Canada and the middle east recruited nursing students from the

Philippines. In the late 90th the USA set up recruitment foreign nurses. This led to a reduction of study

places at the Philippine colleges. In the last two years more study places were created again, there

were further demands from Canada, Australia, New Zealand, USA, Ireland and England.

This situation - to train for the export is considered with ambivalent feelings by college employees.

They know that nursing knowledge and effectively potentials which is necessary for the improvement

of health situation in their own country migrate abroad. In many conversations it becomes clear how

difficult it is to go abroad or to remain in the Philippines. Filipinos who go tear often a gap, they are

friends, capable nurses and teachers. Also that nurses working abroad miss their culture and family.

5.1.3 "Philippine nurses are well adapted and can work anywhere"

Experiences of numerous professional colleagues working abroad reflect this statements as well as

nursing students and other interlocutors: Philippine nurses estimate themselves as flexible and adapt-

able. So they are equipped with an important condition in order to fulfill professional tasks put onto

them abroad.

16

The student group is asked for their motives for an application abroad. Fourteen questionnaires can be

evaluated by sixteen asked students (N = 14). Thirteen students (93 %) confirm that they want to apply

for a working place abroad, only one student denies this.

The most favoured country is the USA. Eleven students have already concrete plans to work there.

The main reasons are: familiar relations to that country (aunts, uncles, cousins) small language barriers

and advanced medical technology. In two cases Germany is called as desired destination country be-

cause their interest was woken by a communication with a visitor student. In each case once Austria

and England (London) are named as favoured countries because of familiar reasons. In general, stu-

dents estimate recognition of nurses in the USA and Europe as high.

The main reason for an activity abroad is, as already mentioned before the high salary expected. With

it they would like to support their families. They think a stay abroad would provide the chance of

becoming acquainted with other cultures and personal independence.

For a better future of nursing in the Philippines all students request a better salary. So they wouldnt

have to work abroad no more and can provide financial help for their own people. Finally, they re-

quire that the state worries about unemployed nurses and abolish the practice of volunteer work.

Nurses unemployment means stagnation and therefore a four year nursing education does not seem to

be worth while.

These statements speak for a critical estimation of nursing in the own country. They have a self-

confident attitude towards their professional competences and they would like to serve to their own

people unless problematic conditions hindered them.

5.1.4 Attractivity of Community Health Nursing

In first conversations with college employees have already shown, that the field Community Health

Nursing is not as popular for students than hospital work. This assumption would be reasonable be-

cause clinical experiences representing an essential condition for applications on national or interna-

tional level. Also students complained about unpleasant conditions in the community as strong physi-

cal stress and simple rural circumstances.

The students were asked about their actual personal experiences during community exposure. Un-

pleasant concomitants were attached in three cases to dusty streets and cumbersome long distances

"under the heat of the sun". What they have learned concerning human relations ships was sometimes

disappointing: "When families depend on you so much and ask for things for example financially. My

partner and me had one family. We gave them some goods we bought at a store. I think they were

expecting we bring them something everyday. When we didnt bring anything the next day they

werent happy with me and werent so friendly like the day before".

Also they have felt uncomfortable in some situations: "I hate being emotional, like for example the

poor people and you feel pity. This personal involvement was explained by the instructors by the fact

that the students have seldom been confronted with simple rural ways of life. Some of them grow up

17

in good to luxurious urban circumstances and didnt have the occasion before to become acquainted

with simple rural life. However, for majority of the students considered the acitivities in the commu-

nity as beautiful (its nice) and special informative.

In order to understand the attractivity of Community Health Nursing better students were asked

whether they would like to work as a Community Health Nurse after graduation. Five (35,5 %) of

fourteen students answers with a clear refusal. Reasons were plans to work abroad, giving priority to

hospital setting because its more comfortable or other fields like military nurse. Indeed, five (35,5

%) students would work with pleasure as Community Health Nurse know, however, this wish is unre-

alistic since there are not any vacancies in the community and therefore, they prefer the hospital. The

remaining ones four (29 %) students express the explicit wish to work as Community Health Nurse

one day: "Yes, I would like to work as a Community Health Nurse. It would be a privilege for me to

help communities and families in coping with their health problems".

After this questioning students majority (71 %) will not apply for an employment in the community.

This result confirms the assumptions of college teacher. It is less the mission of Community Health

Nursing which prevents the students from working in the Community than rather a question of diffi-

cult conditions e. g. bad chances for places of employment and of planning to safeguard the future by

working abroad.

5.2 The project Community Organizing - a contribution to improve the health situation in

the community

5.2.1 Acceptance of Community Health Nursing in the Philippine population

It was the intention of college teachers to choose a rural area as learning-field for related learning ex-

periences in the community. They wanted students to have success with their project. They have

learned from the past that the urban population is not always so enthusiastic about students activities

than in the rural area. Indeed, the acceptance of a Community Health Nurse is high in all population

groups. Nevertheless, there are differences in relationships. A nurse becomes more close to the com-

munity in rural settings. In larger cities that isnt possible anymore. The Community Health Nurse

cant penetrate more deeply into family life because city population is very busy during a day: "every-

body is catching time". Peoples more involved in their own matters and are not interested in discussing

with students. In a city students reached the population groups in a more difficult way and were some-

times recected. When for example a student knocked on the door of a house (of a city apartment) the

inhabitant replied: "Again, you have to interview us again, are we pissed of". In addition city-dwellers

can contact in cases of health problems hospitals directly because there are enough available. On the

other hand it is very difficult in rural areas. That villages selected by preceptors for project are faraway

from cities. In cases of illness the inhabitants would have to cover a wide way in order to look up a

18

doctor, a nurse or a hospital. In many cases inhabitants income is below the poverty limit so that a

genuine demand for health welfare and primary health services is necessary. So students project can

achieve an additional contribution to improve of the health situation in the community.

These conditions applied to the Barangay selected for the project. The inhabitants described mainly,

that students project was very helpful for them and they learned a lot. It is for example the handling of

a fever thermometer, to care for sick children or to serve first aid like according to dog bites. They

exchange over their experiences with neighbours and spread their knowledge in this way. The students

project represented, so to speak, a highlight in villagers life. The student group was received always in

a friendly manner and supported in their objectives. The health classes were visited by numerous peo-

ple, women, men and children appeared. The well dressed people introduced their children. An old

woman came on a stick supportably daily to take part on lessons. She had to cover a long and cumber-

some way about a mountain. The inhabitants enquired frequently when students would come to home

visits. They wanted to clean their houses it should be seen. For the Barangay member it was something

extraordinary to get in contact with nurses: "I could talk with a really nurse" or simply to get only the

blood pressure that was already something special. They knew also that students support them during

the project according other health problems.

5.2.2 Nursing students with various abilities

During the first days of participation in students project already the course of the project proceeded

automatically. The students knew mainly what to do when, where and how. The preceptors were al-

most in the background and observed students activities. This shows a strictl preparation of project and

a collective responsibility. In teams with changing tasks, students planned, organized and performed

activities within and outside the community.

Their organizational competence was demonstrated by many small and large actions that added to a

mainly harmonious and well managed project.

In the community there were two whereabouts for the project. During first two days official events

occurred in a Barangay Hall. Members of the Rural Health Unit (Doctor, midwife, Public Health

Nurse) as well as the Barangay mayors (Captain) were invited. As in the related learning teaching plan

described informations were given about population health status, tasks and responsibilities of sum-

moned visitors and the students` project planned was discussed. The second place was a private house

with garden. In the following four weeks this place was a continuous stay for students and the com-

munity. Students prepared this places carefully (cleaned grounds and chairs, attached decoration mate-

rial, technical and visual media) served drinks and food and offered entertainment through songs and

games.

Their educational and communicative abilities became clear in the way they had determined topics of

health classes, prepared these in small groups with regard to contents and tools. At the same time child

classes and food plans were elaborated and responsibilities clarified.

19

Usually health classes were given in the afternoon. The topics were announced with the municipality

board or during home visits and read in detail:

Taking vital signs (temperature, respiration, pulse, blood pressure) Handling the fever thermometer, measures at fever Dengue- fever Diarrhea (causes, prevention, interventions) Prevention of cardio- vascular illnesses and cancer Comfort measures First aid

The presentation of topics occurred at vivid examples and illustrative material. Students spoke Taga-

log (Ilongo) the Philippine language in order to synchronize their communication to the community.

Simultaneous to adults` health classes the children were cared for by students with drawing, singing

and movement games as well as small competitions. With that parents could participate without inter-

ference onto health classes. Students provided also health-educational topics in this frame. They

teached children in alphabet, instructed how to the clean of hands, feet and teeth as well as in the

importance of carrying shoes.

Further health services were delivered during home visits. These were required by inhabitants and/or

resulted from the assessment process. The students took vital signs, examined little children, gave

informations about breastfeeding, family planning and measures during pregnancy (Leopolds mano-

ever). Within the framework of home visits students gave advise about disposal refuse, the correct

handling with drinking water sources and health promotion. Some inhabitants had planted a herbal

garden. They were instructed by previous student group. The family members were asked about ex-

periences in application of herbal plants and received further information.

A special emphasis of this project, however, represented Community Organizing. For this purpose the

next chapter describes instruments, steps and results.

5.2.3 Home visits as an instrument for recording health conditions

It took about an hour by jeepney to get from the city of Iloilo to the Barangay which was the object of

the studies. Gigantic sugar cane plantations and rice-paddies are typical for this landscape. The stu-

dents were to visit one part (sito)of this Barangay during the following weeks..

On the first day the student group made a survey. In company of a person familiar with the region a

spot-map was constructed. So they could visit specially selected households and constructed a family

list. First home visits were carried out on the following day. For this purpose students were equiped

with a community bag and a structured questionnaire.

The home visits led to people in most different fields, apartments and furnishings. In order to visit

them students had to walk long distances about rice and sugar cane fields as well as sludgy slopes.

20

Some inhabitants had stone houses with western style equipment mainly however lived in bamboo

huts. Home visits occurred in an open atmosphere. Neighbours or family members were present during

questioning of health state. Results of home visits - presented in extracts- show a first impression of

communities situation:

From the assigned 83 households become 77 visits. The average monthly income of 34 families was

with 500- 1000 Peso below the poverty line. 28 families earned more than 1000- 5000 Peso and 15

families had more than 5000 Peso for monthly living coasts. These dates show that already 44 % of

households lived clearly below the poverty line.

Health problems determined by home visits existed in frequencies' into illnesses as high blood pres-

sure, fever, cough, asthma, tuberculosis and diarrhea. In that particular Barangay was also one death.

Further dates were gathered regarding health promoting- and harmful behaviour as well as environ-

ment factors, state of immunization and family planning methods (results of Survey, done by the CHN

batch III).

Also people reported about effects of last typhoon. One month before a vehement typhoon afflicted

this area. Heavy rain brought floods and many defects. Some people died. Standing water is one rea-

son for spreading of Dengue-fever a dangerous illness transmitted through mosquito bites. Since al-

ready some people fell ill Dengue-fever was included as a topic into the program of health classes.

According to preceptors appraisals the health condition in this community had improved. In this case

they related to investigations and interventions of previous student group last year. The people had

been requested to install toilet bowls sponsored by the local government. Pregnant women were en-

couraged to visit prenatal check-ups in local health unit through midwives and nurses. That also in-

clude immunization, vitamin and mineral supply.

An inhabitant reports that she could oppose an infection successfully through application of herbal

plants. She was directed by the students. A mother reports about the successful instruction of her chil-

dren. She could not convince her children to carry shoes. However, after students health teaching

classes her children are disciplined now.

Results of home visits were presented to the community and all summoned official representatives on

projects last day. The dates were visualized by students rapidly and remained without comment. There

were also no remarks and demands from the community and official representatives. From observer

viewpoint it wasnt clear which consequences were drawn from presented dates for that community.

5.2.4 We cant afford to get sick

The great importance of measures to health promotion and prevention became clear through the fre-

quently expressed statement: "We cant afford to get sick".

So could be made for western Europeans a little strange observation that only a few raindrops caused -

this at tropically warm temperatures- a kind flight reflex. People ran, searched for a protecting place or

covered the head with bags, put over t-shirts or other things. Wet clothing can entail cough or worse

21

infections. A serious illness means to use medical aid which must be paid. These financial additional

expenditures brings to many Filipinos big problems.

Illness keeps on meaning loss working time and with that less income. So a woman of the attended

Barangay reported that their only wish for the future is to receive her strong body in order to do her

daily work. Her husband was sick. So she had to feed her nine children from a low income as a laun-

dry woman.

In students project topics of prevention gained great attention. In a health class for self investigation of

feminine breast the present women were engaged to feel hidden knots in a model and tried to do the

same movements at their own body. The great interest was explained by the drastic results of an ill-

ness. In cases of malicious illness mostly a radical operation is only available to a women. The opera-

tion combined with a hospital stay already brings many families into considerable financial difficul-

ties. A following reconstruction is mostly impossible because people cant afford it. Similarly it be-

haves with intestine cancer. An anus-praetor is seldom laid back. A colostomy can be supplied later on

mostly with simple aids like Nescafe bags.

Also governmental arrangements to offer health services for poor people with small cost or for free

dont work sufficiently. Indeed, there is a law in the Philippines that poor people have a right to free

medicine allocation. Nevertheless, this law doesnt work because there arent any sufficient medicine

deliveries so these cant be spent.

Many Filipinos arent sufficiently protected against individual and economical results from illness.

This becomes clear in the small members of health insurance system. Even the small population part

that has a health insurance get only a payment of 10-20% of the medical expenses. With that illness

always represents an existential risk. For the contributions of a health insurance many Filipinos cant

spare any money. A Filipinos approximately income is low, the living cost rises up, unemployment

rate is high as well as inflation rate. In addition mentality of many Filipinos is more in present situa-

tions and the fulfilment of current needs. If they are healthy they cant imagine that a health insurance

is important: "Why I have to pay? What is that for"? From that nurses find it as absolutely difficult, to

create a changed consciousness for prevention and health promotion although prevention is cheaper

than to cure.

Summary

The analysis of nursing education in the field Community Health Nursing and experiences during stu-

dents project showed in exemplary that nurses in the Philippines are prepared pedagogically excellent

and in a qualified way for her future profession. Key concepts as identified in the curriculum: nursing,

communication, management and research were shown in many students activities. According to

observers appraisal the objectives identified in related learning teaching plan could be mainly fulfilled.

22

With that for visitor student a picture was drawn how Community Health Nursing could be arranged

under ideal-typical conditions. These experiences and findings were shaped, however, through the

situation of nursing in the Philippines. Unfortunately nurses in the Philippines can give their profes-

sional influence only in a limited way to own population because particularly economic conditions

complicate her work. A peculiar situation arises. The Philippines counts actually to developing coun-

tries with the main problem poverty going along with health and social problems. On the other hand

many people show eloquently and world-openly. So nursing education in the Philippines is aligned

onto international standards and graduated nurses have high professional competences. Indeed, this

situation doesnt represent any contradiction, however, it makes sad. For many purposes talented peo-

ple set up their abilities to foreign countries although the own country needs this influence so urgently.

It remains to hope that the strategy of export benefits to the Philippine population on a long-term basis.

So their living and working conditions improve which could be created self-consciously from Filipi-

nos in the Philippines.

5.3 The self-conception of a Community Health Nurse in the net of Philippine health care

delivery system

In many conversations and observations it became clear that students activities did not represent daily

life work of a Community Health Nurse. For nursing education the community is a learning-place at

which students bring the didactic transfer of study contents into a real application under ideal-typical

conditions.

The investigation shows that in fact a Community Health Nurse is responsible for approx. 10.000 peo-

ple and more. So she can be no more or seldom in families and communities. Activities demonstrated

in students project like assessment, health services, health classes take over in daily practice midwifes

and Barangay Health Worker. They are directly in families and transmit information to the Commu-

nity Health Nurse who mainly is active in the office (Health Unit).

5.3.1 The Community Health Nurse as a generalist

A Community Health Nurse in the Philippines is featured as a generalist with her diverse responsibil-

ity and competence fields. She has the nursing scientific background and the practical experience to

teach her subordinates in activities of health promotion, prevention and nursing interventions. Next to

these educational functions she supervises her subordinates (midwifes, Brangay Health Worker), co-

ordinates working processes in health unit and fulfils with that extensive management tasks. A further

essential task of Public Health Nurses daily work is seen in collecting dates about the community,

analysing and submitting these to higher institutions (s. chapter all we have to do is paperwork). In

addition, she works in an interprofessional team and multisectoral linkaged for example with represen-

23

tatives of the Municipalities and of local government unit in order to influence health positively

through acting advocacy commitment in communities.

With that agree role-and function descriptions of Public Health Nurses predominating with that ones

represented in literature. However, the direct contact to clients in their homes is hardly anymore possi-

ble. As later is to read documentation tasks use a considerable part of her working time.

5.3.2 Midwifes as "front liner of health services"

As a Community Health Nurse seldom can render home visits she considers the midwives as "front

liner of health services". Differently to Germany where midwifes have an education equivalent to

nurses and an independent professional field midwives in the Philippines only completed a two-year

training program. Next to her original task as birth helper she fulfils a wide scope of duties. First of all

she is a counsellor for couples in topics of contraception, pregnancy woman and as well delivery tasks.

She cooperates in a team with further midwifes and works in health offices and communities. Her task

is the implementation of government health plan for example weighing children, giving substitute

preparations (vitamins and micronutrients) and distributing of medicines as for example multi drug

therapy against leprosy. For treatment of leprosy the Philippine Department of health pursues since

some years a concept to make a family life in the usual environment for lepers possible. So they hope

for reducing costs of accommodation in leprosy villages and reducing stigmatisation and exclusion.

Home visits were done in every district by midwifes and Barangay Health Worker as a team. They

construct family lists, assess communities health status, give health classes as well as health services.

All gathered dates results and reports must be submitted to the Community Health Nurse who evalu-

ates and transmits these.

However, also midwifes cant achieve a lot of field work so the population is mainly required to come

directly into the health offices (education programs, prevention, immunization). While Community

Health Nurses consider the midwifes as their extended arm, midwifes see this in Barangay Health

Worker. These work with about twenty families usually without salary. They report about health state

in the community. Finally all information and dates meet again in Community Health Nurses office.

Thus the midwife is an important link between the Community Health Nurse and Barangay Health

Worker.

5.3.3 All we have to do is paperwork

Dates and reports are central instruments in the net of the Philippine health system. So as the national

health plan is developed on basis of regional investigations this is also valid for activities on local

level. With the decentralization it`s succeeded that every district pursues own targets and own decision

competences in a given calendar year. The health personnel plan after evaluation of gathered dates

area-particular strategies. The implementation of activities becomes documented in weekly, monthly

or annual reports (accomplishment report; for example number of the immunized children and mothers

24

the occurrence of pneumonia in childhood). After that reports guide onto next higher authorities (for

example Municipal Health Officer).

The asked ones spent a lot of time with production of reports and lamented: "The role of a Community

Health Nurse is really heavy about paper works in our organisation. All we have to do is paper work,

paper work". Unfortunately they cant look up families personally and make itself an own picture of

the community. Although this situation was considered critically by some Public Health Nurses as a

miss conception. They felt exposed to these deficiencies daily. In particular, nurses think that the work

conditions, that is to see many problems in daily work are very hard, however, they are not able to do

anything. They criticize lack of health personal, lack of technical equipment in health offices, inade-

quate deliveries with medicines as soon as the small financial budget. In addition they missed support

through Barangay officials and local government units.

Nevertheless, they described many moments of satisfaction. Peoples` reaction was considered as a best

high-quality feature for delivered health services. If the people cooperate in all programs and activities

of nurses then this shows acceptance. If there arent any complaints in the community and no further

problems do emerge in the fields of mortality and morbidity they fulfilled one of their most important

tasks. Populations contentment will be visible at frequentation of health centre and the friendly faces

of visitors.

Summary

A Community Health Nurse occupies a key position in the net of the Philippine health system. She is

an important link between pretentions of the Department of Health, regional and local authorities,

nursing science and practice as well as the populations possibilities and needs on community level.

Meaningful is the Public Health strategy of the greatest welfare for the greatest number. This comes

up particularly in programs of national and regional health plans. Her roles and functions like man-

agement, teaching, concept development and supervising are mainly oriented at this.

The represented investigation presented partially, results from daily work of a Community Health

Nurse show that she also has to deal with the familiar phenomenon between the idealistic claims from

theory and nursing science and the real possibilities of professional reality (this is not different in

Germany). Because she is responsible for relatively great population groups she provides her profes-

sional influence only limited in direct nurse- client relationships on community level. So she trains her

subordinates in diverse tasks of primary health service and delegate these tasks onto them. Nursing

education is regarded as central part of her management role. This aspect is less developed in Ger-

many. Here many nurses mainly fullfil bed-side nursing tasks. The integration of informal helpers

begins to develop slowly.

25

Also the future Family Health Nurse in Germany will be engaged with other national-health problems

as the Community Health Nurse in the Philippines. In Germany its necessary to gather health related

dates about smaller units as families, communities or quarter districts. Important findings of the practi-

cal semester supplied for this purpose instruments of the Philippine concept Community Organizing.

Nevertheless, German government has to create a structural framework before that legitimises en-

trance to families for investigation and connection of health related dates.

A thrilling finding represented the category "We cant afford to get sick". At beginning the presump-

tion was expressed that in Germany would be a small consciousness for health promotion and preven-

tion because a still functioning social security system in cases of illness or care pays for treatment,

rehabilitation and care. This assumption could be confirmed in part by the Philippine investigations.

Many Filipinos dont have any health insurance. Because they cant afford illness - many either not all

- pay attention as a precaution onto their health.

6 Final considerations The four month stay in the Philippines was accompanied from deep human meetings that made this

time to a touching personal experience. In spite of many differences in type of life and living condi-

tions there were important combining elements. These were basis for one of esteem and acceptance

determined relationship. Particularly combining were the affiliation to occupational group of nurses

and the common confession for the Catholic belief. Many Christian rituals were familiar to visitor

student and could be celebrated with the Philippine hosts together. Next to that filled both topics to

German life and job conditions as also the small and large worries about each nation-particular daily

life many conversations. So a narrow intimacy arose between college employees (Professors, clinical

instructors), the group of the students and to inhabitants of the Barangay. They helped the visitor stu-

dents to get a genuine and deep insight into fields of nursing education, Community Health Nursing

and the Philippine way of life.

Apart from the fulfilment of actual practical semester tasks the visitor-student could admire and visit

the marvellous landscape and sights of the Philippines. Also, the german student had the chance of

doing tropical travels around the country with its wonderful beaches, crystal-clear water, acting volca-

noes and rice terraces. These extensive impressions, experiences made the practical semester to an

extremely enriching experience and let themselves best reflect with words of college member at leave-

taking day: "Hello Stranger, Good bye Friend."

26

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Bundesministerium fr Gesundheit (1999): Daten des Gesundheitswesens. Band 122. Nomos Ver-

lagsgesellschaft, Baden- Baden

Batch of III Nursing Students College of Nursing at West Visayas State University (2001): Results

of the survey done by the CHN batch III. Iloilo City

College of Nursing West Visayas State University: Student- Handbook La Paz, Iloilo City, Philip-

pines

College of Nursing West Visayas State University: Teaching Plan N-401: Management of clients with

altered health pattern. WVSU, College of Nursing, Iloilo City

College of Nursing West Visayas State University: Teaching Plan N-401: Related Learning experi-

ences. Concept Community Organizing. WVSU, College of Nursing, Iloilo City

Committee of Community Health Nursing (1995): Section National League of Government Nurses.

Inc. Service's Community Health Nursing into Philippines the Department of Health

Cruz, R.G. in Maglaya A.S. (2000): Nursing Practice in the Community: An overview. Argonauta

Corporation. Marikina City

Laurente, C.M. (1993): Enrichment of Nursing Courses: A guide (Part II), Association of Deans of

Philippine colleges of Nursing. Inc., Philippines

Knigge- Demal B: (2001) Curricula und deren Bedeutung in der Pflegausbildung. In: Sieger, M: Pfle-

gepdagogik. Hans Huber, Bern

Statistisches Bundesamt. DeSTATIS (2002): Bevlkerungsentwicklung 2000.

www.destatis.de/presse/deutsch/pm20001/p3740022.htm

WHO Europe regional Office (2000): Die Familiengesundheitsschwester. Kontext, Rahmenkonzept

und Curriculum. EUR/00/5019309/1300076. www. who.dk/nursing (1.10.2000)

WHO Europe regional Office (2000): Gesundheitsgipfel europischer Minister macht deutlich: Pfle-

gende und Hebammen- ein Plus fr Gesundheit. Pressemitteilung. Kopenhagen EUR/0900

27