Table of Contents

Editorial 1
Research Articles
• HUMANistic Caring: An approach for meeting the care needs of Filipino gay and lesbian older persons 3
Jed Patrick Montero Catalan, MN, RN and Evelyn Acas Luna, MN, MPH, RN
• Perceived Social Support from Family, Friends and Spiritual Experiences as Correlates of Depression 14
Louie Roy E. Catu, PhD, RN
• Spiritual Well-Being of Filipino Patients with Cancer 22
Alyssa Jenny E. Tupaz, MA, RN, and Araceli O. Balabagno, PhD, RN
• Sexual Health Intervention for Couples with Difficulty in Sexual Abstinence 29
Daisy H. Alberto, PhD, RN
• Knowledge and Compliance to Standard Precautions and General Self Efficacy 36
among Nurses in a Tertiary Hospital
Crisanto D. Gatbunton, MAN, RN
• Transition Experience to Professional Nurse: A Phenomenological Approach 44
Jo-Ann F. Cummings, PhD, RN, Stephanie M. Chung, PhD, RN, and Lisa D. Wardle, MA
• Development and Effect of the Online HIV Prevention and Care Training (HPCT) Program for Student Nurses 51
Ryan Q. De Torres, MA (Nursing), RN, Rose Zuzette M. de Leon, MAN, RN,
Conchita Aranil-Palencia, MN, RN, and Gracielle Ruth M. Adajar, MA (Nursing), RN
• Health Promoting Lifestyle Behaviors of University Employees in Work-From-Home Arrangement during the 60
COVID-19 Pandemic
Naressia D. Seludo-Ballena, RN, MAN, EdD, Mary Joan Therese C. Valera-Kourdache, RN, MPH,
Jorel A. Manalo, PTRP, MPH, Alexandra Belle S. Bernal, RN, Mary Joy C. Tiamzon, BS,
and Raymund Kernell B. Mañago, RN
Concept Analysis
• Developing a Professional Identity in Nursing through Reflection 69
Charmaine T. Co-Enarsico, MN, RN, CHSE
• Reintegration: A Concept Analysis 74
Rock Billaco Tubaña, MAN, RN
• A Concept Analysis of Role Modeling 79
Bhert Keane Q. Pugrad, MAN, RM, RN
• Fitness Nursing: A Concept Analysis 83
Anthony James Almazan, MAN, RN
• Stigmatization of Nurses: A Concept Analysis 87
Mark Joseph Fagarang, MAN, RN
• Family caregiver: Caring on family carers 91
Sherwynn Lloyd Javison, MAN, RN, CLSSGB, CHA

Nurses’ Voice from the Field

• Nurturing Responsive Learning Environment in the Nursing Academe Amid COVID-19 96
Iris C. So, PhD, RN
• Website Innovation for Nursing Student Learning during the COVID-19 Pandemic 99
Fandro Armando Tasijawa, [Link]., Ns., [Link].
• Scarred Heroes 102
Roison Andro Narvaez, MSN, RN

Guideline for Authors 103

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Abstracts and articles may may accessed at the following links: [Link]
This publication is not for sale
[Link] and [Link]
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EDITORIAL

Supporting Health Care Workers

beyond COVID-19
I n the past two years, the COVID-19 pandemic has disrupted
people's lives, affecting health, socio-economic and cultural
aspects. The impact is not only limited to the current time but is
efficacy. However, there was no significant relationship between
the level of knowledge, level of compliance in standard
precautions, and general self-efficacy.
expected to make ripples into the future. As we cope with the
challenges brought by COVID-19, the fact remains that the Nurses working in reproductive health services were also part of
previous health problems and concerns pre-pandemic still exist. the study of Alberto who implemented a sexual health intervention
These challenges need to be addressed even as we face an for couples with difficulty practicing sexual abstinence in natural
uncertain future, with possible new variants of COVID-19, health family planning. Results showed that change of sexual scripting,
workforce shortages, mental health issues, workplace safety, and coupled with mind setting plus communication, facilitates
the threat of emergencies and disasters. partnership and adherence leading to successful sexual
abstinence. Further, the study concluded that enhanced sexual
This issue of the Philippine Journal of Nursing gives us a chance to intercourse happens if there are acceptance and openness to life,
look into existing health and social concerns that impact the health full trust in the observation, and recording of fertility, as well as
and lives of Filipinos. There are eight original research papers in respect to self and spouse.
nursing. These research papers contribute to nursing literature by Some studies were focused on college students.
providing new perspectives from a developing country and offering
new insights and possible solutions to old problems. Catu looked into perceived social support from family, friends, and
spiritual experiences as correlates of depression. Statistically,
Some interesting research studies that look into special significant relationships were found between depression and
groups are featured. perceived support from friends and spiritual experiences, but no
significant relationship between depression and support from
Catalan and Luna presented humanistic caring - an approach for family. The study concluded that supporting freshmen students is
meeting the care needs of Filipino gay and lesbian older persons important, especially peer support and spiritual experience. De
emphasizing the need for extensive gender-care training for Torres et al. studied the development and effect of the online HIV
gerontological nurses. It was suggested to be incorporated in the prevention and care training program for student nurses. The
nursing curriculum to address gender-care disparities in the caring online HIV Prevention and Care Training (HPCT) program
dynamics. showed positive effects on student nurses' knowledge, attitude,
Tupaz and Balabagno explored the association of spirituality and and perceived practices. The study concluded that there is a need
quality of life among Filipino patients with cancer. Filipino patients to highlight and integrate the basic HIV concepts and
in the study had high spiritual well-being despite the presence of developments in the education of student nurses.
cancer, showing their highest spiritual well-being in the Some studies are about professional nurses and their
transcendental domain which describes one's relationship with workplaces.
God. Patient characteristics, especially their illness profile, are
recommended to be considered in developing nursing As students become professional nurses, there is still a need to
interventions that may improve their spiritual well-being. support their journey to professionalism.

Studies among professional nurses are also shared. Cummings et al. describe the lived experience of new graduate
registered nurses as they transition to become professional
In a tertiary hospital, Gatbunton evaluated the level of knowledge nurses. They revealed that new graduate nurses continue to feel
and compliance of nurses on standard precautions and their overwhelmed and they need structured guidance in their
general self-efficacy. Findings reveal that nurses have a good professional transition training programs. The study showed that
knowledge and high compliance concerning standard transition programs, such as structured residency and prolonged
precautions, and they have a moderate level of general self- orientations assist them to adjust to the work environment.

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Working from home has been the norm in the COVID-19 The family caregiver concept is also presented by Javison to
pandemic. Selludo-Ballena et al. conducted a survey on health- clarify the idea of caring for family carers and identify family
promoting lifestyle behaviors among university employees in a caregivers' vulnerability in inpatient care. The collaboration
work-from-home arrangement. The study showed that the between nursing, multidisciplinary teams, and family carers is
majority of the respondents practice good health-promoting seen to contribute to the immediate recovery of patients and
lifestyle behaviors such as social and coping skills, but with smooth transition to home care.
limitations on opportunities for a more active lifestyle, availability of
nutritious food, and access to health care. There is a need for Another important segment in this journal is the Nurses'
health promotion and protection strategies such as nurse-led Voices From the Field – from the academe to practice. Two
health programs in the aspects of nutrition, physical activity, and reflections on important issues in nursing education and practice
health responsibility. are featured in this journal.

This journal issue also features concept analyses from nurses So shared how the nursing academic environment nurtured a
who are giving us glimpses of future research in nursing. responsive learning environment with technological caring,
Concept analysis is done to determine the defining attributes or relational practice, and professional resilience, thereby preparing
characteristics of the concept/s under study. It helps in refining and students to be responsive to an ever-changing work environment.
clarifying concepts, in theory, practice, and research towards
Tasijawa also shared their web-based learning platform as classes
defining a conceptual framework and/or instrument development
shifted online in Indonesia emphasizing the need for faculty to
for full research proposal preparation.
keep updated with technology.
One of the concepts presented is the reintegration of patients
A special poem, entitled Scarred Heroes, is offered by Narvaez.
requiring different modalities of care and treatment programs as
It is a fitting tribute to nurses and other frontline health care workers
they journey towards recovery. Tubaña points to the need to define
who continued to serve and care for patients amidst the COVID-19
reintegration and measure its attributes as a contribution to
pandemic.
literature to improve nursing care and health outcomes.
COVID-19 has made a tremendous impact on the health system.
Role modeling is another important concept as nurse educators,
It has disrupted health services in hospitals and the community. It
staff nurses, and managers act as the primary role model of
has exposed weaknesses in the health system including poor/
neophyte nurses. Pugrad identified that the antecedents of role
unsafe work environments, inadequate staffing levels, low pay,
modeling are the role of aspirants' ideas and perspectives and the
and lack of career opportunities. The impact of COVID-19 will
role model's experiences.
certainly be continuously felt in the coming years.
Stigmatization of nurses as they care for patients, especially
There is a need to review the impact of COVID-19 on nursing
during the COVID-19 surges, add to the psychological stress of
education and evaluate the innovations in teaching and learning
nurses. Fagarang states that this merit further study to support
that many schools adopted to continue the lessons amidst the
nurses to improve patients' health, longevity, and quality of life
lockdowns and lack of face-to-face classes. Nursing practice has
through the provision of patient-centered care.
been dealt with even more stresses with the surge in cases and the
Reflection on developing a professional identity traces the high burden of illness, prompting changes in the types of services
systematic development of professional nurses as they advance in provided and new challenges to the health workforce. Nurses have
practice from the undergraduate to the graduate programs. Co- experienced a high level of stress due to workload, demands, and
Enarciso's paper asserts that transformation in power and infection risks. More researches with multiple perspectives need
responsibility requires the development of needed competence in to be encouraged to determine the actual needs and challenges in
nursing, knowledge, skill, attitude, including ethical grounding that the field.
will directly affect the care provided to individuals, both sick and well. As we recover from the COVID-19 pandemic, there is a need,
The concept of fitness nursing, according to Almazan, has not more than ever, to conduct and support health and nursing
been fully defined in the nursing profession but has slowly research. We hope that as we create a new normal in nursing
emerged due to the increasing interest of people in a healthy education and practice, we learn from our research and base our
lifestyle. He defined fitness nursing can be defined as the actions on the implications derived from them.
combined science of nursing with the art of personal training that
focuses on health promotional activities and disease prevention
through physical fitness. Sheila R. Bonito, DrPH, RN
Guest Editor
The defining attributes are physical training and health coaching and Dean, College of Nursing
outcomes can be measured at the individual or community level. University of the Philippines Manila

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RESEARCH ARTICLE

HUMANistic Caring: An approach for meeting

the care needs of Filipino gay
and lesbian older persons
Jed Patrick Montero Catalan, MN, RN1 and Evelyn Acas Luna, MN, MPH, RN2

Abstract
Quality care is a basic human right and a core foundation for a patient's health, recovery, and well-being. In the current Philippine
context, gay and lesbian older persons face gender-care disparities in the caring dynamism. Until now, their care needs are not
articulated in the country's basic nursing curriculum. Consequently, the care approach is incongruent, biased, and risky. In
response to this gender-care disparity, participatory action research (PAR) was used to identify this cohort's care needs and their
meaning by developing a nursing care hub called the ‘Gay Care Center’ for older gays and lesbians. This paper focuses on
describing: (a) the current situation of nursing care among the gay and lesbian older persons; (b) the meaning of care needs from
their perspective; and (c) the Gay Care Center's tailored approach and services to meet their care needs. Multiple sources were
utilized to collect data: focus group discussions, in-depth interviews, and observations. Data were then analyzed using Mayring's
qualitative content analysis. Findings revealed that caring practices for older gays and lesbians could only be effective, satisfying,
and holistic when the meaning of their individual needs are sensitively listened to, understood, and met. This led to the coined term
HUMANistic caring, a new approach that emerged as their preferred mode of care. It is recommended that extensive gender-care
training be conducted among gerontological nurses, and this be incorporated in the nursing curriculum to ensure that the provision
of care is safe, respectful, humane, and just.
Keywords: Humanistic caring, gay-friendly care hub, gerontology nursing, gender-care disparity, care approach, PAR

Introduction

T he annual increase of aging individuals worldwide denotes

an emergent demand for fundamental preparation and new
health challenges (Badana and Andel, 2018). Regardless of
The care provided is incongruent, biased, and risky (Cohen et
al., 2018; Pearlberg, 2004). This substandard care and
treatment jeopardize the older gays and lesbians' goals to
age, socioeconomic status, ethnicity, gender orientation, or achieve healing, causing significant stress and potential health
religion, every person deserves health care. As the WHO risks (Kuan, 2015).
acknowledged, this may seem ambitious, but it is worthwhile
pursuing and must be realized to create "a healthier and more On the broader concept of care needs, these G.L.s are often
equitable world" (WHO, 2019). overlooked, misunderstood, or ignored. Consequently, the
unique concerns and realities of this under-reported minority
One reality in the context of caring is the older gays and lesbians' within the aging population, the elderly G.L.s are not mentioned
(G.L.s) invisibility that can lead to adverse health outcomes in the curriculum of basic nursing education. This raises
(Fenge and Hicks, 2011; Cohen et al. 2018). Their unique care legitimate concerns about whether the care provided to this
needs are still unknown, placing vague and confusing aging cohort is holistic and equitable.
responsibilities on nurses expected to provide appropriate care
approaches (Eliason, Dibble, and DeJoseph, 2010). Despite the available record of the 5 million Filipino senior
Practitioners treat this elderly group as homogenous and hetero- citizens (POPCOM, 2019), G.L.s are not statistically
stereotypical, thus, hampering the formulation of accurate, represented. In Republic Act 9994, also known as the Expanded
caring strategies to meet their actual needs (Cohen et al., 2018). Senior Citizen Act of 2010, their specific needs are not
1 Corresponding author; Doctor of Science in Nursing – Gerontology, Cebu Normal University, Cebu City, Philippines; catalan_jedpatrick@[Link];
[Link] 0000 – 0002 – 6042 – 0061
2 Lecturer, Faculty of Nursing – Universitas Pelita Harapan, Indonesia
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mentioned. With the existing law's failure to recognize their

rights and protection, they might be denied health services and Methodology
face harassment from service providers or other elders. The
2017 curriculum memorandum order (CMO) for nurses lacks Pilot Study
teaching-learning strategies for gender-care sensitivity.
The study was conducted in the ‘Gay Care Center’, developed
There is a dearth of local nursing literature that explores the care using a participatory action research (PAR) methodology. PAR is
needs of this cohort (Guevara, 2016). Instead, researchers focus the collection, reflection, and analysis of data involving people
on young LGBTIQ+ and HIV/AIDS care experiences. This who will act and bring about social change (MacDonald, 2012).
underscores that this aged G.L.s is an underserved population This method allows concerned individuals with knowledge and
with disparities in healthcare. Compared to their younger experience to decide and take responsibility for the contents and
counterparts who actively express their health rights, many senior the delivery of the actions to be performed (Blair & Minkler,
G.L.s remain quiet and either avoid or delay accessing healthcare 2009). The pilot care hub project also followed the key steps of
services out of fear of being stigmatized, mistreated, disrespected, the nursing process – assessment, planning, implementation,
and emotionally harmed by healthcare providers (Stanton, 2013). and evaluative analysis, done continuously to determine the
These may be rooted in their exclusion in the healthcare agenda effectiveness of the planned activities. Evaluating the entire pilot
and historical experience of discrimination (Eliason et al., 2010; implementation was executed through in-depth interviews and
Nadal and Corpus, 2012). This has created mistrust in the care focus group discussions (FGDs). These were then used as
offered for their needs (Eliason et al. 2010; Hillman, 2016) and analytical support to revise activities and remodel training
they continue to suffer various forms of injustice (Stanton, 2013), modules.
which have implications in the caring system.
Selection of participants
The senior Filipino G.L.s, just like those from other countries, are
deprived of a safe space in the healthcare setting. Even though The study used passive snowballing technique to recruit
the Philippine Health Agenda (2017-2022) has the goal of participants. In this method, the researchers did not obtain
improving geriatric health, policymakers excluded the older gays identities/contact information of potential participants. Instead,
and lesbians in the mainstream, further marginalizing them. the researchers tapped the City Social Welfare of Bislig City to
Their specific needs and experiences of care turned out to be recruit the potential participants within their network using the
silenced. Thus, a nursing care hub model, called 'Gay Care research's recruitment inclusion guidelines. The potential
Center,' the first for gay and lesbian older persons in the country, participants then directly contacted the researchers for more
was developed and piloted. information if they were interested. The reason for this is to
protect the potential participant's identity/confidentiality.
This paper describes the process through which the care hub
was developed and the emergence of a tailored caring approach With this strategy, ten non-institutionalized GL (five gays and five
evolved based on the gay and lesbian older persons' lesbians, predominantly 'who came out') ages 60 and above,
identification and meaning of needs. It can be a guideline for and ten heterosexual geriatric nurses (five males and five
future program development efforts. It would shed light on the females) volunteered. Nurses were selected because of their
underlying phenomenon of care dynamism among older gay and particular experience caring for an elderly G.L. and identified self
lesbian persons, hence, the goal of 'Healthy Aging for All' is as exclusively heterosexual). All participants were based in
realized to assist G.L.s in growing old with security, dignity, and Bislig City in the province of Surigao del Sur, Philippines.
live meaningful lives.
Table 1. Profile of Participants

Legend: P – G.L. participant(s); N – Nurse participant(s)

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Data Collection hired care specialist before being performed. Expectations,

contents, and types of activities, competency assessment,
This study used two phases to collect data. policies, experiences, and feedbacks were parts of the core
context of the discussions. The interviews with older G.L.s and
Phase one: Development of hub's activities and training
the focus groups among trained nurses were audio-recorded
module and transcribed verbatim. The duration of the data gathering
Data were gathered through a plenary FGD. It was a critical first sessions lasted not over 60 minutes.
step in developing the care hub since there was no Philippine-
based literature to serve as a model for starting it. It enabled the Observations were done allowing the researcher to monitor the
G.L. participants to define their current situation and its meaning nurses and the nursed older G.L.s’ interactions as these could
as they and the nurses shared experiences and reflected on past not be captured from interviews and FGDs. The participants were
incidences in healthcare as patients and care providers, keenly observed on their individual responses, gestures, and
respectively. All activities and the program's name were overall behaviors. This happened during the project meetings
extracted from the initial assessment when asked about their and prior or actual nurse-client care hub activity sessions.
expectations of a gay-friendly care hub.
Data Analysis
Consultative meetings were conducted before finalizing the pilot
Analysis was accomplished alongside data collection and
program's activities and training module. The first author
through an iterative process. Textual data were coded,
developed the initial set of activities based on what appeared to
categorized, and synthesized manually using Mayring's
be significant and consistent aspects during the FGD and
Qualitative Content Analysis (QCA). In this analytic approach,
supported by published literature. Once drafted, the training
the central tool is its system of categories, where every unit of the
module was made. The module involved various instruments,
analysis must be coded and allocated to a system of categories.
including brochures, slides, videos, booklets, posters, and
Content coding techniques were based on meaningful segments
questionnaires. The research team reviewed and pre-tested
and patterns (Mayring, 2014). These were divided into macro-
these, which comprised three academicians, four clinicians, four
categories and subcategories following a tree-chart or matrix.
advocates, a researcher, a social welfare specialist, and two
The macro-categories referred to the main themes that were
local government officials. Finally, a care specialist in
included in the interview guide. The subcategories were the
gerontology was hired to validate and scrutinize the final draft of
direct results from the interviewees' thoughts.
the model pilot project.
Data analysis was carried out by the first author and audited by
Phase two: Implementation of the hub and its module the hired gerontology specialist, who was also the project
After the model pilot project was finalized, the care hub was supervisor. For each interview, the author carried out the steps
organized. This was intended as a shelter for the older G.L.s and of content analysis by Mayring, followed by cross-case analysis,
served as a training facility for professional nurses. Moreover, while developing the emerging themes was done separately.
this was conceptualized to improve the caring strategies parallel The thematic analysis began with open coding of the transcripts,
to the care needs for this specific age group. This was piloted for and the overarching thematic codes were discussed. The
32 days in the Barangay Mangagoy Senior Citizens Shelter. participants' accounts were meticulously observed to ensure
that the analysis was grounded on actual collected data.
Random in-depth interviews and day-to-day observations Summaries that contained brief descriptions were attached to
followed by weekly FGDs were utilized. Reports were done substantiate the codes.
before, during, and after every post-conference in the
implementation phase of the study. Audio and video materials, Identified parts of the interviews with emerging themes and
minutes of meetings, respondents' feedback on activities, and meaningful patterns, as agreed by the researchers, were
recorded dialogues supplemented the reports and added details included. The authors also added unique phrases from the
and substance to the data collected. The technical working interviewees enhancing the richness of thematic coding. At first,
group conducted regular post conferences to discuss and reflect both authors independently created macro-category themes
on their observations, and the participants' comments were based on the individual thematic coding for each case. This was
shared with the hired care specialist. This expert also acted as followed by a series of meetings to discuss and reflect on the
the project supervisor and process evaluator. codes and macro-categories throughout the analysis process,
thereby, increasing the level of trustworthiness. The macro-
Open-ended questions followed by probing questions were category themes identified by researchers were then combined.
used in both in-depth interviews and FGDs. Both guide These became the bases of the search for cross-case, sub-
questions were discussed between the research team and a category themes.

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Before coding was finalized, two independent referees were childhood experiences (N1, N3, N7, N8) and exposures (N2,
hired to ensure congruence and concreteness of the overall data N5). Their attitudes in caring for older gays and lesbians may
management process. It included cross-checking between have been based on either gender-orientation preference where
macro-category themes, sub-category themes, and the male nurses showed negative attitudes for gays, or female
transcripts. To further enhance the rigor of the analysis, other nurses had the same negative attitudes for lesbians (N1, N4, N6,
members of the research team conducted an audit trail of the P3, P4). Another attitude may have been based on relatedness,
initial findings. Last, a linguist was consulted when complexities wherein nurses showed a positive attitude when the patient was
requiring immediate language intervention occurred. related to or known (N1, N3, P2, P7, P8).

Limitation of the Study 'Nothing special, what should we expect. Never was it
taught. Remember, we don't have nursing books that
The participating older G.L.s in this study identified themselves specify an approach for them.' (N6, male nurse)
as such based on sexual orientation as gay or lesbian. Given the
limited representatives, experiences and issues in nursing care 'I felt that the female nurses were afraid of me. There were
faced by senior bisexuals and transgender people were instances when they were uneasy or even unfriendly with
excluded from the current study's analysis. The G.L.s were me.' (P2, lesbian patient)
identified through contact with key informants from the local
offices of the senior citizens’ association. Demographic data, Several nurses believed that care provided for older G.L.s must
other than age, occupation, and sexual orientation among these be heteronormative or gender-care blinded, where care needs
older persons, were not collected since the study tried to between them and their heterosexual counterparts do not differ
understand their respective meanings of care and inclusivity and gender-orientation should not be the primary focus (N1, N2,
care, which will then be used to develop the care hub. N5, N8). Three nurses assumed (assumptive or gender-care
tampering) that senior gays should be provided with a feminine-
Ethical Consideration care-type and masculine-care approach for lesbians (N1, N4,
N7). One nurse said that caring should be selective (gender-care
The protocols for this study were reviewed and approved by the swing), quality care is appropriate for influential or wealthy (N6).
City Social Welfare Development Office of Bislig City before the One out of the ten nurses verbalized that a carer must sensitively
pilot project started. The principles set by the National Ethical acknowledge gender differences (gender-care sensible) (N3).
Guidelines for Health Research of the Philippines (2011) were
followed. Before data collection, invitation letters were sent to 'It depends on the nurse's discretion. To be safe, I usually
each participant enclosed with research consent reemphasizing provide female-type care to a gay patient, and male-type
their rights as respondents of the study. Questions from the care to a lesbian. (N1, male nurse)
participants were answered and clarified, and the settings for the
interview were selected per participants' preferences and Nurse participants have difficulty in providing essential care for
convenience. Pseudonyms and special coding were assigned to these elderly patients because of limited knowledge (N5, N6,
de-identify the respondents for confidentiality and avoid N8). First, the fitting care: the concept of sensitivity in nursing is
potential risk. broad and not clearly defined (N1, N2, N4, N5, N7). The nurses
emphasized that no literature guides prioritizing the older G.L.s'
Findings needs (N2, N4). Second, the fitting approach: the prefixes that
can be used in addressing them as nurses initiate the nurse-
patient interaction (N2, N5, N8). Last, the fitting communication:
This section summarizes the descriptions of the current nursing language competency in 'gay-lingo' (N6).
care situation for senior gays and lesbians, the meaning of their
care needs, and the center's tailored approaches and services to 'Why do male nurses treat us as males, when we are still
meet their care needs. females?' (P2, lesbian patient)

The Situation: Knowledge Gaps in the Philippine Nursing 'It is really difficult to provide essential care for these
Curriculum patients when in fact I really don't understand their real
needs, their "gay – lingo", and the right approach for
The Philippine nursing curriculum has specific knowledge gaps them.' (N6, male nurse)
in caring for senior G.L.s. A review of the old and the new CMOs
showed that both did not have structured teaching-learning The absence of specific guidelines in caring for older G.L.s
strategies of gender-care sensitivity. In the absence of these threatens the care outcomes for both the care providers and the
critical guidelines, providers based their care on personal cared for. This can lead to psychological distress (P3, P4) care

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mistrust (P2, P3), and care dissatisfaction (P6, P8) on the Three of the gays were financially stable compared to the lesbian
patients causing immediate care termination or going home participants. Two gay respondents were college teachers (P1,
against medical advice. P3), and another owned a beauty salon (P4). In contrast, a
lesbian respondent was forced to retire as a security guard
'I need comfort but I felt belittled. I was emotionally because of her age and had to work as a low-paid laborer in a
disturbed. With no second thoughts, I left the hospital market (P7). One of the lesbian participants verbalized her
even against medical advice.' (P4, gay patient) difficulty in finding a job as work opportunities for aged lesbians
is lower compared to senior gays (P2). Additionally, their single
'I believe that social and personal status matter. Some status exacerbated their poverty as they did not have children to
nurses are just good to those they know.' (P3, lesbian support them in their old age; thus, they rely on charity for their
patient) necessities, including drug maintenance (P1, P2, P7, P10).
Nurses, too, can be affected, leading to psychological distress Support Needs
(N2, N3) and trauma (N1, N5) when they hear sarcastic and
demeaning statements, especially from aggressive patients Despite sacrifices for their respective biological family, the G.L.s
dissatisfied with the care they received. had little support, and two were rejected by their siblings/parents
(P3, P7). Filipino society is still largely conservative.
'I am hesitant in caring for them because they say harsh Acceptance of a G.L. family member remains difficult because of
words that insult me.' (N1, male nurse) the perception that this may bring shame to the family. Some of
Unspoken Meaning of Care Needs of Filipino Gay and them either lived alone and were unsure who would care for
Lesbian Older Persons them (P2, P3), stayed with friends/other older persons in a
sibling-like relationship (P1, P8, P9), or depended on the help of
The identified needs of the older G.L.s are similar to the general strangers (P10).
population, but their unique definition of every need must be
sensitively heard, understood, and met. Their identified needs 'Acceptance should start at home… our homophobic
are as follows: health needs, financial needs, support needs, family must understand this.' (P4, gay patient)
legal and protection needs, recreational needs, spiritual needs, Older G.L.s in this study have a limited social circle, unlike the
and trust needs. younger LGBTQI+. They dissociate themselves from the
Health Needs existing community-based elderly association (P7). For them,
invisibility and silence were their only options of protection from
Among the elderly respondents, gays were more health- homophobic victimization and discrimination (P4, P7).
conscious in seeking preventive care than lesbians (P2, P3, P6).
The older lesbians said that they were diagnosed as having 'Our world [older G.L.s] and their world [heterosexual
cardiovascular diseases (P7, P8), diabetes mellitus (P6, P9), counterparts] are like water and oil. We never mix.' (P7,
osteoporosis (P8), and breast/cervical cancers (P1, P3), while lesbian patient)
the gays verbalized that they were diagnosed with hypertension
The question of same-sex marriage yielded varied viewpoints.
(P2, P3), HIV+ (P9), and anal/prostate cancers (P4, P5).
Half of them have not considered it due to trauma from past
Almost half of the older G.L.s in this study were active smokers abusive relationships (P1, P8), age reasons (P9), the choice to
(P1, P6, P7, P8) and occasional drinkers (P2, P3, P7). These be single (P7), and financial instability (P10). The other half was
lifestyle practices contribute to their overall poor health in a relationship with live-in partners for more than five years. For
outcomes compared to the rest of the aged population. them, the legalization of same-sex marriage would provide the
opportunity to be officially recognized as a couple (P2, P4),
'Been an alcoholic since I left home at age 15. And, I was express intimacy (P5), and become eligible for social security
diagnosed with HIV+ in my late 50s.' (P9, gay patient) benefits (P6).

Financial Needs Legal and Protection Needs

Three of the gay respondents were forced to quit their jobs when The problem of same-sex partnership abuse exists in this cohort,
they were younger to care for their sickly aging parents (P1, P3, particularly in relationships between older G.L.s and younger
P9) or young nieces/nephews (P6, P8). Meanwhile, two partners who financially exploited, blackmailed, and
financially supported their younger siblings in school (P2, P7). In physically/verbally abused them (P1, P8). Aside from this, the
turn, five of them could not build up their savings. older G.L.s also experienced poly-victimization from their family's

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non-acceptance (P3, P7), sibling rivalry (P4), discrimination (P2), understand the meaning of inclusivity, gender-care needs, and
and poor standards of healthcare (P2, P8, P9). One of the older quality care (P1, P5, P7, P8). Third, (M) maintain
G.L.s said he did not know where to go (P10). privacy/preserve dignity: create a trusting environment that can
protect their being, physicality, and intimacy (P3, P6). Fourth, (A)
'In my bruises and deep wounds, who will protect me? attentively and sensitively listen to understand their unique
Nobody cares. I don't know where to go. We have no needs/feelings as an individual, provide quality person-centered
space in the Office of the Senior Citizens Association of the nursing and involve them in the care planning (P2, P4, P7). Last,
city.' (P1, lesbian patient) (N) nurturing their inner being and offer a positive interfaith
building that is accepting and affirming of their sexuality (P2, P9).
Recreational Needs
'All I need is care that does not discriminate, sincere, can
Besides the rejection from their families, the internalized
understand and respect me for who and what I am. I am
homophobia and limited funds contributed to their preference to
also human, created by God with equal rights and similar
spend most of their time at their abode (P3, P9). Two of the G.L.
needs for care, love and sensitivity.' (P2, lesbian patient).
respondents expressed their need for a fun recreational program
that considers their current condition (P3, P4). Despite leisure Five out of the ten respondents said they do not want to be cared
activities planned by local offices for the general elderly for by LGBTIQ+ nurses. In their experience, the LGBTIQ+
population, none was tailored fit for the G.L.s (P5). nurses, especially the younger ones, are more homophobic than
the heterosexual nurses (P2, P3, P5, P7, P9). The senior
Spiritual Needs
lesbians want to be cared for by female nurses as they have
In a predominantly Roman Catholic country like the Philippines, feminine needs (P2, P3); while gender preference was not an
homosexuality is taboo. Participants believed that churches issue for the gay participants (P4, P6).
should stop 'homosexual-church-phobia' (P8) and stop giving
'My nurse was also gay, but he had no empathy for me.'
homonegative sermons (P6). Instead, it should start to be
(P9, gay patient)
spiritually welcoming as they too have spiritual needs (P3, P4)
and are also searching for hope in the remaining years of their Addressing Care Needs for Filipino Senior Gays and
lives (P9). Lesbians
'We're created by God, and churches cannot deny that.'
(P9, gay patient) 'HUMAN-istic care' as a caring approach was the overarching
concept generated from the assessment phase of the study.
Trust Needs Participants believed that the coined term encompasses the
concept of inclusive elder care. They wanted to capitalize on the
Trust is a vital component of the nurse-patient relationship, and importance of the 'HUMAN' concept in contrast to the traditional
two G.L.s expected their caregivers to provide them with gerontological nursing because they believed it was the missing
emotional support, yet they verbalized their anxiety over possible element that was also often misunderstood, causing gender care
discriminatory care (P3, P4). One was anxious about the care disparities. Moreover, they also verbalized that if this element will
providers' naiveté in meeting their care needs or possibly be incorporated into the future care hub, the hub will be
harboring hidden gender biases (P5). transformed into a 'healing nest' (P3, P4). In this place, holistic
needs, not only the basics, are addressed, and nurse-patient
Caring Approach Needs interaction is meaningful (P2).
When older G.L.s were asked about the type of care they 'More than the basic needs that anyone can imagine, we are also
needed, they verbalized that they were looking for a care type persons who need care as a patient and as human beings with
that is comfortably welcoming and trusting from the beginning to rights.' (P2, lesbian patient)
the end. More important to them than alleviating physical
complaints is a caring strategy with a human touch. This new caring approach was the basis for developing the
training module of the pilot project. The primary authors for the
The care can be summarized in the acronym HUMAN. First, (H) service structure in the training module were the care recipients
humanely accepting and welcoming, where they can be and the care providers.
themselves, freely and safely express their sexuality as an
individual/couple, and where nurses are non-judgmental, non- The care hub was intentionally crafted with four mechanisms,
malicious, respectful, do not discriminate and say colored jokes, namely (1) Rescue, (2) Support, (3) Refer, and (4) Care. These
and use gender-neutral language (P1, P2, P3, P4). Second, (U) mechanisms were integrated from the G.L.s identified

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interrelated care requisites and directed the formulation of a clear hesitant to speak out during the nurse-patient interactions. On
service pathway. the other hand, the nurses verbalized their doubts, the by-product
of their lack of knowledge and understanding of the term
The first mechanism, rescue, provided temporary shelter for 'sensitivity' which is vaguely defined in nursing. As a result,
elderly G.L.s abused in their homes. A 24/7 hotline was activated defensiveness and distancing were shared between the carers
to respond to emergencies like first aid or transportation to a and the cared during the initial implementation phase. A
hospital. A trauma care package was prepared that included reorientation/open forum was purposely conducted to neutralize
materials for wound care, counseling, legal support, and post- the tension. This was followed by setting boundaries specifying
trauma rehabilitation. the role of the nurse, defining the nurse-patient relationship, and
clarification of daily expected outcome.
The second mechanism, the support, provided extensive training
courses for nurses and caregiver volunteers in handling older In depth-interviews and FGDs were conducted during post-
gays and lesbians. The module used was generated from the conferences. In a separate interview, both the senior G.L.s and
assessment of participants and refined by a multi-professional trained nurses were asked to describe their experiences in the
workgroup in consultative meetings that considered findings hub. Their inputs were incorporated updating and revising the
retrieved from the literature review. A gender care nursing module based on daily lessons learned. Self-reflections and daily
strategy was also developed and integrated with the training informal dialogues were also used as elements in the evaluation
module. Family members or guardians were included in the hub's process. Some participants reported that the training inside the
activities, a hallmark and salient project component. This hub was more than an experience and affected their lives (N1,
enhanced their participation, bolstered awareness and N3, N6). The project turned out to be an eye-opener for the
understanding of their ethical and caring responsibilities toward trained professionals and student nurses, helping them reshape
older gays and lesbians in the family. This created a positive caring practices and become advocates for the provision of
attitude in the older G.L.s' concept of aging gracefully when they equitable gender-sensitive care equitable. Applying the new
saw family members participating in selected hub activities. knowledge care approach yielded high patient satisfaction and
overwhelming positive appreciation from the nurses reported
'Seeing my nephew actively join the hub's sessions made during the evaluation phase. To ensure sustainability, ongoing
me happy and gave me hope for the future.' (P10, gay monitoring and evaluation of the project were conducted to
patient) confirm that the needs of the G.L.s were heard, understood, and
met. Analyses of the implemented project became the basis for
Refer, the third mechanism of the hub was included to create a further internal and external consultations, and plans were
potential network and possible funding sources from diverse discussed for possible replication in the nearby municipalities.
agencies, ensuring that the needs of this specific elderly group
were supported and addressed. This was managed by a 'I have never been to a place like this before where I feel
volunteer social worker who assessed their financial, loved and respected despite my gender orientation.' (P9,
psychological, legal, and spiritual needs. The G.L.s were referred gay patient)
to appropriate agencies and local government offices. The hub
was also working closely with an HIV treatment clinic where ‘This is the start of a meaningful nurse-patient relationship
identified HIV+ older G.L.s were referred for treatment and where we can work together in resolving this unspoken
monitoring. gender care disparity among our older gay and lesbian
constituents.' (N1, male nurse)
Care, the fourth mechanism, provided care services in either
center-based or homecare settings. Nursing services were The interactive sharing of experiences between the care
implemented according to how they defined the care. To ensure recipients, the care providers, and the research team helped to
sensitivity, some approaches were added in operation like (a) understand better the concept of care appropriate for the older
gender-neutral approach; patients were called according to "their G.L.s' needs. The new caring knowledge, HUMAN, helped
name of choice" without prefixes (unless requested); (b) special correct the nursing strategy mismatch in gerontology nursing.
sections were added to the information sheet: sexuality (gender
stratification) and types of relationship (living with others); and (c) Discussion
care provision according to age cohort (young-old to oldest-old).

At first, the older G.L.s, volunteer care providers, and nurses The findings of the study highlight the dearth of knowledge on the
expressed discomfort and varied 'what ifs' prior to the project's needs of older G.L.s' in nursing education and literature not only
implementation at first. For the elderly G.L.s, their historical in the Philippines. Other studies revealed that nurses lack
experience of discrimination in life made them hyper-vigilant and specific knowledge, skills, and values in identifying and caring for

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the needs of older G.L.s as this was not included in their and various forms of abuse (Frediksen-Goldsen et al., 2014).
education (Eliason, Dibble, and DeJoseph, 2010; Fenge and They are not safe in their own houses because they also
Hicks, 2011; Frediksen-Goldsen et al., 2014). There is experience domestic violence in the form of battery, verbal
uncertainty in the care providers' approach towards gays and abuse, and worse, being thrown out from home (Nadal and
lesbians (Fenge & Hicks, 2011; Mitchel, 2016). There is also Corpus, 2012; Guevara, 2016). Older gays and lesbians are
difficulty implementing gender-based care because of limitations forced to have limited social circles and dissociate themselves
in their nursing education and personal biases (Fenge and Hicks, from others, even from elderly community groups. (Martos,
2011; Frediksen-Goldsen et al., 2014). This situation is Wilson and Meyer, 2017). Many of them are victims of sexual
compounded by the scarcity of researches addressing the needs orientation attacks but chose not to report nor seek legal help
and concerns of older gays and lesbians that could guide (Guevara, 2016; Choi & Meyer, 2016; Westwood, 2018),
practitioners in meaningfully caring for this cohort (Montilla, believing that there are no laws related to their protection (Tan,
2008; Badana and Andel 2018). 2012; Guevara, 2016). This caused their further distancing from
other people (Choi & Meyer, 2016) without recognizing that the
Lim and Berstein (2012) pointed out that nurses' beliefs about more they disengage themselves from others, the higher the risk
older G.L.s' care needs reflect their societal attitudes. This belief of becoming socially isolated, lonely, depressed, and developing
influenced by their societal attitude causes a struggle to reconcile mental problems (Hughes, 2009; Frediksen-Goldsen et al.,
their reservations with professional responsibilities in providing 2014; Guevara, 2016).
quality care (Kentlyn, 2011; Lim and Pace, 2013). Their non-
recognition of the older G.L.s' sexuality in their nursing care The discrimination older G.L.s' experience is also manifested in
planning often leads to inappropriate care service deliveries and, the spiritual realm. One study showed that some religious groups
worse, discriminative gender care (Fenge and Hicks, 2011). All asked the G.L.s to leave the church (Beagan & Hattie, 2015).
these have contributed to this cohort's discomfort and negative Conflicts between sexuality and religious teachings can
experiences in the healthcare milieu, raising serious bioethical significantly damage the psychological and emotional well-being
concerns that contribute to the erosion of a sense of safety and of older gays and lesbians (Ibid, 2015), and condemnation from
trust in the healthcare system (Harbin, Beagan, and Goldberg, church members marginalizes LGBTIQ+ in faith communities
2012). As Nadal and Corpus (2012) disclosed, they have (Frediksen-Goldsen et al., 2014).
developed distrust towards healthcare providers having
experienced discrimination in the past. Their lack of trust in As stated earlier, the needs that the older gay and lesbian
caregivers results in negative consequences in the caring flow respondents identified from health, financial, support, legal and
(Frediksen-Goldsen, 2015), affecting their ability to cooperate in protection, recreational, spiritual and trust are similar to their
the caring process (Choi & Meyer, 2016). heterosexual counterparts and the general population. But, the
pivotal difference lies within their unique and distinctive definition
In several general population-based aging studies, older G.L.s of care needs and how every need must be sensitively heard,
had an overall higher risk of poor physical health, alcoholism, understood and met.
smoking substance abuse, nutrition deficiency, poor mental
health such as depression, anxiety, and suicide (Brotman et al., There are avenues where G.L.s' needs can be incorporated into
2007, Guevera, 2016; Frediksen-Goldsen et al. 2014; Cohen & the current nursing curriculum. Describing and explaining the
Cribbs, 2017; Cannon, et al., 2017). This may be due to their phenomenon in this participatory action research provides a
mistrust in the current healthcare system (Cannon et al., 2017). clear although partial LGBT cultural competency for gerontology
The rate of STDs, including HIV/AIDS is now increasing among nurses. The Gay Care Center and its discovered care approach
older G.L.s due to having had multiple partners in the past appear significant in the curriculum framework development of
(Frediksen-Goldsen et al., 2015). Despite this, there is still a lack the pilot project implementation as a gender-care mismatch and
of sexual and reproductive health support programs particularly silencing care-discrimination are recognized but remain largely
on HIV/AIDS for senior LGBTIQ+ (Choi & Meyer, 2016). neglected.

Another concern of the older Filipino gays and lesbians is their Its hub development went far beyond merely understanding the
financial needs. Usually, they could not invest at their younger care needs and providing care for older gays and lesbians. The
age because of the career and self-sacrifices for their families hub served both as a temporary service center and a home for
(Guevara 2016). Since same-sex marriage is illegal in the the older G.L.s where they could safely and freely express their
country, they could not access benefits from life insurances from sexuality. It also revealed the mandatory element of a meaningful
their deceased live-in partners (Choi & Meyer, 2016). relationship of interconnectedness between the cared client(s),
the nurse(s), and the care center. Nurses who were part of the
As Tan (2012) pointed out, older G.L.s are voiceless regarding project learned that they needed to understand this group's
their rights. They are victimized by ageism and by homophobia, meaning and care needs as persons with HUMAN needs. As

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carers, they should understand the importance of allowing the nurses should be prepared to provide settings and services that
care recipients to speak out and decide for themselves. The are culturally congruent, competent, safe, inclusive, and
incongruence of care occurred when they failed to listen with sensitive. Furthermore, nurses need to change their attitudes
sensitivity or insisted on their heteronormative care strategy. and biases to meet the caring demand holistically and respond to
Therefore, nurses must understand the importance of sensitivity their calls for greater inclusivity. Therefore, including gender-
and confidentiality and demonstrate these in their practice care sensitivity content in the basic nursing curriculum is time to
(Brotman, 2007; Barrett, et al., 2014). To deliver this, they must educate and raise nurses' competency in addressing the needs
recognize their personal biases (Cannon, et al., 2017). The care of one of the diverse population groups.
recipients, older G.L.s must be assertive and express their caring
needs to be heard. It is essential that both sides keenly listen to The newly identified care practice and needs of the Filipino gay
each other's viewpoints, mindful that each side's attitudes and and lesbian older persons, in this study, are only scratching the
behaviors are consistent with their definition of their respective surface from among real macro-needs. It is crucial to conduct
role in the caring dynamism inside the hub. further studies on a bigger scale to meaningfully understand the
holistic context of needs among this population. Nevertheless,
The care recipients viewed the hub specifically as a 'healing nest' the findings can be utilized in crafting evidence-based guidelines
where both they and the nurses could HUMAN-istically, safely, to address the shortage of materials for this specific aggregate in
and meaningfully interact. Thus, the intention of addressing the nursing education. In addition, much more still needs to be done
care mismatch and ending the disparities within the caring circle to make the older gays and lesbians' needs visible. On top of the
of the nursed, the nurses, and the hub, equally important rigorous studies recommended to reinforce the findings of this
components, contributed to a meaningful flow of connectedness. pilot project, the challenge of harnessing this initiative to its
optimum level and getting the policymakers' commitment to
Conclusion support and embrace it remains a priority.

____________________
The richness of the method used does not discount the other
care needs of G.L.s that must be explored and discovered. In References
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Philippines Country Report.” UNDP. [Link]

sites/default/files/documents/ 1861/[Link]. Ms. Evelyn Acas Luna recently finished
Westwood, S. (2018) “Abuse and Older Lesbian, Gay, Bisexual a three-year teaching stint at Universitas
and Trans (LGBT) People: A Commentary and Research Pelita Harapan - Faculty of Nursing in
Indonesia prior to her retirement this July.
Agenda.” Journal of Elder Abuse & Neglect. doi:
She is currently a part-time faculty
10.1080/08946566.1543624. member at the Philippine Christian
University - Mary Johnson College of
Nursing. She earned her Master in Nursing major in Public
ABOUT THE AUTHORS Health from Silliman University College of Nursing in 2013 and
a Master in Public Health from UP Manila in 1994. Studies in
public health, primary health care, environmental changes
and their effects on populations, and gender care are among
Mr. Jed Patrick Montero Catalan is
her interests.
currently a neonatal/pediatric intensive
care unit nurse in Adela Serra Ty
Memorial Center and a freelance
research consultant to various Acknowledgments
international and national research-
based funded projects. He earned his Special thanks go to all the older gays and lesbians who
Master in Nursing major in Nursing Administration Services, participated and shared their experiences. The researchers
minor in Psychiatric Nursing from Liceo de Cagayan would also like to thank the Philippine Nurses Association,
University. Now, he is working on his dissertation for the Inc., - BIBAHILITA Chapter for their support in the realization
degree Doctor of Science in Nursing specializing in of the project. And to the late Suhaini Nasher Pagadilan.
Gerontology at Cebu Normal University. Most of his research
works were focused on health-caring equity, social Declaration of Interest
empowerment, and sexual/reproductive health rights.
The author declares no competing interest.

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RESEARCH ARTICLE

Perceived Social Support from Family, Friends and

Spiritual Experiences as Correlates of Depression
Louie Roy E. Catu, PhD, RN1

Abstract
Depression is the origin of ill health problems in college students. It advances as one of the leading causes of mental health issues.
During their college life, freshmen encounter many firsts. These include a new environment, friends, exposure to social norms and
culture. The students may struggle and experience difficulty if they cannot deal with these challenges. They can become a
vulnerable population. Therefore, the overall purpose of this study is to conduct a baseline assessment of college students'
experiences in the university. More so, this study 1) describes the characteristics of a sample of freshmen allied medical sciences
students, 2) describes the levels of perceived social support from family and friends, spiritual experiences, and depressive
symptomatology among allied medical sciences freshmen; and 3) to assesses the possible association among described positive
influences (spirituality, family support, peer support) to depressive symptomatology. The study utilized a cross-sectional analytic
quantitative design. In selecting respondents, a consecutive sampling technique was utilized. Respondents eligible to participate
included first-year full-time students in the university taking up Bachelor of Science in Nursing (BSN), Bachelor of Medical
Technologist (BSMT), and Bachelor of Science in Radiological Technologist (BSRT). A total of 110 undergraduate students
participated in the study. Most of the students were females younger than 20 years old. The overall perceived social support from
family and friends yielded average scores. The higher the scores, the greater the perception of social support from family and
friends. For their spirituality, it showed that participants scored lower, indicating a high level of spiritual experiences. Lastly, the
depression scale yielded high scores indicating that the participants had signs of severe/major depression, as based on the Center
for Epidemiologic Studies Depression (CES-D) scoring. The relationships between Depressive Symptoms and Perceived Social
Support from Family (PSS-Family) and Friends (PSS-Friends), and Spirituality Experiences were also evaluated. It showed that
Depression and PSS-Friends yielded a statistically significant relationship. However, there was no statistically significant
relationship between Depression and PSS-Family. For the spirituality experiences, the test revealed that there is also a statistically
significant relationship with depression. Overall, the study concludes that college life is a period of increased challenge for young
allied medical health students. Their courses accompany complex and challenging responsibilities that increase tensions and
anxiety. The results from these processes may cause or worsen stress when not given priority and could lead to depressive
symptomatology. It was reflected that freshmen students' peer support and spiritual experiences appear to be closely associated
with depressive symptomatology.
Keywords: Allied medical sciences students, perceived social support, spirituality, depression

Introduction

A ttending university and adjusting to college life can be a

stressful experience for incoming freshmen. Adapting to
these life changes, the challenges they need to face in their
last 12 months of their university experience. They also
verbalized that it was difficult for them to function and study,
thereby, affecting their individual academic performances
college life put students susceptible to developing depressive (American College Health Association, 2015). A high level of
symptomatology. The occurrence of depression and other anxiety was associated with depressive symptoms
mental health problems like anxiety and stress are common and development (Reed et al., 1996), and depression rates in
have been increasing among college students. Kumaraswamy undergraduate students have been reported to increase over
(2013) presented that 25% of the college student population time (Ibrahim et al., 2013). Students with symptoms of
report symptoms of anxiety at any given time. College students depression expressed a high level of emotional suffering that
reported feelings of overwhelming anxiety and depression in the accounts for undesirable events in the lives of college students.

1 Faculty (Assistant Professor) in the School of Nursing and Allied Medical Sciences, Holy Angel University, Angeles City Pampanga; lrcatu@[Link]

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This experience may affect their life satisfaction academic pressure can lead to mental distress and hurts cognitive
performance, and worst, suicide (Brown & Schiraldi, 2004). functioning and learning (Dahlin et al., 2005). College life
experiences entail a major adjustment that could partially lead to
Globally, depression is considered the most common mental depressive symptomatology. Several factors that affect
disorder (Cooper, 2018) with a prevalence of 2% to 15%. students' adjustment include their abilities to perceive support
Because of this, the risk of committing suicide increases from their social network (e.g., family and friends) and
gradually making it an important public issue. An estimated 264 spirituality experiences. To start with, having robust social
million people suffer from depression (Cooper, 2018) and over support with their university experience is an important factor
48,000 are dying by suicide each year (Centers for Disease that leads to success with their academic experiences and lives
Control and Prevention [CDC], 2018). In 2015, the American in general. According to Hall et al. (2004), Rayle and Chung
College Health Association (ACHA) survey reported that 50% of (2007), Reed et al. (1996), Saltzman and Holahan (2002), Way
students in universities (42% of men and 53% of women) have and Robinson (2003), the higher a person's discernment of
hopelessness feeling any time in the past 12 months, 65% felt support from a conducive campus environment, together with
gloomy (55% of men and 70% of women), and 35% (30% of men their friends and family social support, the lower the prevalence
and 37% of women) described that they feel so depressed that it of symptoms of depression in university students. On the other
affects their daily function. The World Health Organization hand, studies have reported that there is an inverse association
(WHO) foresees that in the year 2030 signs of depressive between depressive symptoms and spirituality of university
symptomatology will upsurge. Thus, depression would be the students. This high level of spirituality may be an indicative
top cause of disease burden worldwide (WHO, 2011). In the defense aspect in mitigating the development of depression
Philippines, 3.3 million Filipinos were reported to suffer from symptoms in their campus life (Muller & Dennis, 2007; Turner-
depression, with suicide rates in 1.7 females and 2.5 males per Musa & Lipscomb, 2007; Young et al., 2000).
100,000 (Department of Health, 2019). According to the study of In general, the perception of support from family and friends,
de Wit et al. (2011) and Wang et al. (2016), the incidence of and spirituality is noteworthy to have a defensive aspect in the
depressive symptoms is more likely to females than to males. In development of symptoms of depression in college students.
addition, Pratt and Brody (2014), reported the survey done in However, there is a lack of concurrent evaluation of these
2009–2012 by the National Health and Nutrition Examination factors. To better understand the perception of social support
that 7.6% of individuals aged 12 and older experienced and spirituality, they may be examined together, to provide
moderate to severe depression. In 2015, around 16.1 million evidence, and identify what are the important roles of these
people aged 18 years or older had experienced at least one factors that might affect the development of depressive
major depressive symptomatology (National Institute of Mental symptoms. In addition, the reporting of symptoms of depression
Health, 2017). or its diagnosis varies with other countries because of cultural
differences. Majority of studies were done in North America,
Though stress is an inevitable part of life (Blanco et al., 2008), it Europe, and other Western developed countries. Few studies
becomes more prevalent among college students (Prince, could be found in Southeast Asia, that is why there is a need to
2015). University students encounter stressors inherently put the focus on a different perspective of the world.
unique with the educational system, which varies with their
contemporaries who did not enroll in college. According to Therefore, this study aimed to assess the depression level of
Dyson and Renk (2006), there is a consistent finding with the college freshmen and explored multiple factors (e.g., family and
correlation of the progression of symptoms of depression and friends social support, and spirituality) and their association.
stress among students in the university. Specifically,
professional courses with close interaction with people, Methodology
affective involvement with the client, such as allied health
courses like nursing, medical technology, and radiological The study utilized a cross-sectional analytic quantitative design
technology, are highly demanding courses. Thus, the that conducted a baseline assessment of college students'
development of stress and burnout syndrome is common experiences in the university, and factors possibly associated
(Moreira & Furegato, 2013). Allied health education is perceived with depressive symptomatology (i.e. social support from family
to be stressful and it is categorized to have different affectation and friends, spiritual experiences) through a research survey
on students' psychological development (Abdulghani, 2008). questionnaire. For the selection process of respondents, a
Studies have noted that allied medical students experience consecutive sampling technique was utilized. The sample
increased occurrences of stress during their college included full-time first-year university students taking up
undergraduate courses. This increased level of stress may Bachelor of Science in Nursing (BSN), Bachelor of Medical
potentially harm mastery of the academic curriculum. This Technologist (BSMT), and Bachelor of Science in Radiological

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Technologist (BSRT). This study utilized four different for the last 2-weeks which causes an impairment of the
questionnaires namely Perceived Social Support from Friends individual's life (American Psychiatric Association, Diagnostic
(PSS-Fr) and Family (PSS-Fa) by Procidano (1992), Daily and statistical manual of mental disorders [DSM-5], 2013).
Spiritual Experiences Scale by Underwood (2006), The Center
for Epidemiological Studies Depression Scale (CES-D Scale) The researcher sent out an electronic invitation to participate in
by Radlof (1977). Permissions to use were sought and granted the study. The invitation to participate, cover letter with
from their original authors. information of the study, the electronic consent form, and the
survey instruments were hosted by Google Form, a free web-
Perceived Social Support from Friends (PSS-Fr) and Family based survey application. Through the invitation and cover
(PSS-Fa) measures the degree to which an individual perceives letter, the students were informed of what is required from their
support from them. Both questionnaires contain 20 items participation in the research and assured that their grades in the
answerable by “yes”, “no”, or “don't know”. “Yes” answers are university would not be affected. Students who agreed to
given 1 point while “no” and “don't know” responses are given no participate were asked to complete the questionnaire. All the
merit. The overall scores range from 0 to 20. The higher the data collected were treated with the utmost confidentiality. Data
scores the better the perception of support. The reliability and collection was done from March 2020 to April 2020. The
validity of these scales were tested with college undergraduate invitation was posted on the social media website (Facebook).
students and generated Cronbach's alpha of .88 and .90 Participants were given a month to return their completed
(Procidano & Heller, 1983). For the factor analyses, the survey form. After receiving, it was then processed for validation
orthogonal factor rotation in a separate study verified that the to check if it was filled up completely and that the respondents
scales were composed of a single factor, which was expected qualified the inclusion criteria). The target was 100%
from the method of the final selection of items and their internal participation of 152 students (BSN 84 student, BSMT 39
consistency (Procidano, 1992). Hence, the scales were students, BSRT 29 students; verified with the Registrar office of
computed separately. the University). The researcher garnered a 72% (110 students)
response rate, wherein 74% (62 students) were from BSN, 95%
Daily Spiritual Experiences Scale (DSES) is a 16-item scale (37 students) were from BSMT, and 38% (11) were from BSRT.
developed by Underwood (2006) that quantifies a person's All their returned questionnaires were valid and subjected to
spiritual experiences examining health, both physical and analysis. Data from the survey were electronically stored in a
emotional. The scale reflected strong psychometric properties password-protected cloud. Quantitative data were analyzed
and demonstrated a high level of validity and reliability. The inter- using IBM SPSS software. The characteristics of the sample
item correlations of the tool ranged from .60 to .80, with an overall were presented using descriptive statistics (e.g., mean,
Cronbach's alpha of .94. The initial investigations exploratory frequency, standard deviation) and chi-square for the possible
factor analysis reported by Underwood and Teresi (2002), relationship of the variables.
generated that the 14 items are loading on one factor (.69 to .93)
and two items loading on a second factor (.77 and .78). The study was subjected to an IRB clearance with protocol
number (2020-013-LECATU-DEPRESSIVE SYMPTOMATOLOGY)
Center for Epidemiological Studies Depression Scale (CES-D before the data collection. The well-being of the participants is
Scale) was created by Radloff (1977) to measure depressive the primary concern of the researcher. Electronic consent was
symptomatology in the general population. The foremost scale obtained from the participants before the administration of the
developed is used in the general population to quantify the survey questionnaires. The research minimized duress through
epidemiology of depressive symptoms. The predecessors of the electronic means of data collection. The students’ autonomy
this scale were established to measure signs and symptoms of was respected. Knowing that this inquiry contains a degree of
depression in the hospital setting. It is a 20-item self-report scale inherent risk, individuals participating may feel personal and
that focuses primarily on the level of existing depressive emotional disturbances interrelated in their discovery of oneself
symptoms of a person's experience (Radloff, 1977). It is while completing the questionnaires. A debriefing statement with
described with high reliability, with a Cronbach's Alpha of .85 in contact details of the researcher and the university's guidance
the general population, and .90 in the patient sample. The score office was given out. The variables in this study may contain
ranges from 0 to 60, the greater the score reflects a great sensitive issues for some individuals. Respondents who
presence of symptoms of depression. Indicative of risk for encountered personal and emotional disturbances during the
depression is a score equal to 15 or higher. Though depression completion of the survey were instructed to coordinate with the
is a multifaceted process, a score of 15 or higher on the CES-D University Guidance Counseling. The investigator asked for the
scale should be furtherly screened for depression. The assistance of the University Guidance Counseling to provide a
symptoms suggestive of a Major Depressive Disorder should standby channel for the anticipated psychological need of the
have at least 5 of the symptoms and the person experiences it students and it was acknowledged. The participants' age and

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Table 1. Participants' Profiles

Table 2. Descriptive Factors

Table 3. Depressive Symptoms per Category

sex were collected from their personal information. Electronic for Perceived Social Support from Friends (PSS-Friends) was
mail was not required. The results were reported only as 14.45 (±3.55). As to their Daily Spiritual Experiences, the mean
aggregate data to ensure the anonymity of the participants. After score of the sample of health sciences students was 30.59
the completion of the survey, the storage of the information will be (±12.45). Lastly, the depression scale reflected a mean score of
kept for up to two years, after which it will be deleted. 29.51 (±9.38). Furtherly, Table 3 showed the CES-D Scale who
scored 16 or greater per category of the participants.
Results
Table 4 showed the cross-tabulation of the sample's mean
Table 1 presented the profile of the 110 undergraduate students scores of the independent variables perceived social support
(62 BSN students, 37 BSMT students, 11 BSRT students) who from Family, perceived social support from Friends, and
participated in the study. Most of the students were younger than Spirituality Experiences with Depressive Symptoms. Looking at
20 years old (n=85, 77%) and were female (n=89, 81%). Depression and Perceived Support from Friends (PSS-
Friends), the analysis showed a statistically significant
Table 2 illustrated the mean scores for each of the variables relationship (X[540] = 599.63, p = .04). However, Perceived
assessed. The mean score for Perceived Social Support from Support from Family (PSS-Family) investigation (X[720] =
Family (PSS-Family) was 11.58 (±5.90), while the mean score 751.43, p = .20) yielded no statistically significant relationship

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Table 4. Cross-tabulation of Depressive Symptoms and independent variables PPS-Family, PSS-Friends, Spirituality Experiences

Note: * = Significant relationship (p < .05)

with depression. For the spirituality experiences, the test who feel that their family would be there to help them in time of
revealed that there is also a statistically significant relationship need and felt that they matter to friends, significantly have
(X[1296] = 1439.93, p = .00) with depression. lesser academic-related stress compared to those who
expressed the feeling of no support (Rayle & Chung, 2007).
Discussion Similar to the study of Auerbach et al. (2011) that described
increased perceived social support from friends were more
The overall purpose of this study is to conduct a baseline likely to experience fewer depressive symptoms.
assessment of college students' experiences in the university.
More specifically, this study 1) described the characteristics of a For their spirituality, it showed that the participants have lower
sample of freshmen allied medical sciences students; 2) scores indicating a high level of spirituality. Thus, a high level of
described the levels of perceived social support from family and spirituality may indicate a protective aspect in contradiction to
friends, spiritual experiences, and depressive symptomatology the development of depressive symptoms in college students
among allied medical sciences freshmen; and 3) assessed the as reported by previous studies (Muller & Dennis, 2007; Turner-
possible association among described positive influences Musa & Lipscomb, 2007; Young, et al., 2000). Freshmen year is
(spirituality, family support, peer support) to depressive the time when their spiritual growth increases as they become
symptomatology. Most of the participants in this study are less young adults who start to search for meaning in their lives.
than 20 years old and most are females. According to Demaray Similar to the study of Bryant et al. (2003), it reported that during
and Malecki (2002), Rueger et al. (2010), females and younger freshmen it is where the students begin to examine their religion
adolescents' (Bokhorst et al., 2010) perceptions of social and spiritual beliefs. This is the phase students develop their
support are far greater when compared to males and older ability to have hypothetical thinking and utilize abstract
adolescents. The study of Bokhorst et al. (2010), reported that concepts to serve as the foundation of their faith. It was
12-year-old children rely mostly on their parents rather than remarkable to find out that there is a substantial association
friends for support. However, when children reach the age of 18 between spirituality and depression. The stress students face
onwards, they become more sociable with friends; hence, the during the time of transition with their university life could be
scores are then inverted. handled or faced successfully with increased spirituality.
Spirituality has fostered considerable curiosity in the literature.
Perceived social support from family and friends, overall, It has been associated with an improved physical and mental
yielded average scores. The higher the scores the greater the well-being of students (Salsman et al., 2005). This may indicate
perception of social support from family and friends. Support in that when a person's level of spirituality increases, the
freshmen students played an important component in the development of depressive symptomatology decreases.
development of social relationships and psychological well- Synonymous to the study of Alorani and Alradaydeh (2018), it
being in their college life (Rayle & Chung, 2007). The data reported that there is a significant association between
reflected that students perceived social support from their family perceived social support and spirituality in college students. In
and friends. It was noteworthy that the perceived support from addition, optimistic health habits have also been consistently
friends yielded better scores when compared to family social associated with spirituality. However, findings on spirituality and
support scores. Because of the participants' age group, this is mental health association still have mixed results. Some
the time of their college experiences where they interact more studies found positive associations, while others reported a
with their friends and their confidants. Hence, it may be the negative association between spirituality and depression
reason why support from friends reflected better scores. Having (Koenig, 2001). Despite the inconsistencies, the study reflected
a social support network from family members and friends that a that spirituality and depressive symptomatology are closely
student can go in times of need especially in their beginning associated. The same was true with the research output of
college life is indeed essential. Furtherly, the scores from PSS- Salsman et al. (2005), which reported a significant connection
friends were seen to be associated with depression. Freshmen between psychological functioning, spirituality, and depression.

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It was noted from the literature that when a person faces a almost five decades. As early as the 1930s, healthcare
stressful encounter they often turn to spirituality. However, the professionals and students in the allied medical field were being
efficacy of coping with spirituality in resolution to stressful events polled about the challenges and difficulties related to training
still has a diverse standpoint (Ano & Vasconcelles, 2005). With (McKay, 1978). Many of the stressors identified in those early
an increased multidisciplinary care focus, psychologists are years of education are analogous to the stressors on allied
being called to closely work with students' well-being. Spirituality health students today (Moreira & Furegato, 2013).
is a noticeable aspect of a person and has a noteworthy
implication concerning psychological functioning. especially Allied medical professions education programs like nursing,
with freshmen students (Moss & Dobson, 2006). It is at this medical technology, and radiological technology are among the
stage where the grasp of their spirituality strengthens and stressful professions. From the academic preparations,
furtherly developed and it was observed that spirituality may training, and related learning experiences, the student runs into
affect individual psychological well-being. Overall, support from circumstances that require them to take important decisions that
family members, friends, and spirituality have been described to could impact the patient's well-being. These processes may
serve as a defensive aspect in mitigating the development of result in stressful events in their college experiences. When not
depressive symptoms in university students. given priority, it could lead to depressive symptomatology.
These attributes of proactive disposition, adept attitude, and
Lastly, for the depression scale, it yielded high scores indicating high level of cognitive skills are regularly required both among
that the participants had signs of severe/major depression, allied health students and health professionals in practice.
based on the Center for Epidemiologic Studies Depression Stress and depression may greatly affect the performance of
(CES-D) scoring, however, the scale was not intended to be used students and qualified health professionals (Moreira &
as an individual diagnostic tool for clinical depression. Therefore, Furegato, 2013). Students who experience depressive
the participants' average group score can be an indication that symptomatology, disturb the amount and quality of social
they are susceptible to severe/major depression. The emerging interactions within the University. Thus, special attention may be
adulthood developmental perspectives of mental health, given to these students that may reduce depressive symptoms.
interpersonal relationships, and social functioning appear to be a This may lead to the improvement of students' college life
period of the strained and challenging part of college students' experiences, and an overall improved social functioning and
university life (Arnett, 2000). It is consistent with others' findings academic performance.
for depressive symptoms (Galambos et al., 2006), that freshmen
year is a time of intensified stress (Goff, 2011). For young students – as with the allied medical health students
– their courses involve the experience of the transition from
College life experiences, as explored in the study, showed secondary school to university academic life, which is
intertwined with stress and depressive symptomatology. This accompanied by a surge in complex challenging
stress or crisis the student faces with their experiences in the responsibilities, increasing tensions and anxiety (Dweck et al.,
university showed a major risk of developing depression in 2014). Seeing this, the acknowledgment of stress in students is
freshmen students. It was important to note that facing personal essential, so that preventive measures that mitigate the
stress with university life at times needs immediate assistance. predisposing factors of stress may be strategized and put into
Having strong social support keeps the student able to handle this action, ensuring its consequences to a bare minimum, to
college life experience challenges. This relationship that provides improve students' health and performance in the university.
support plays a critical role in how students function in their day-
to-day life. Psychologists emphasized that having a strong Depression is the origin of ill health problems in college
foundation of social support networks is important. When faced students. It advances as one of the leading causes of mental
with a crisis or reaching a goal, professional experts say that most health issues (Mokrue & Acri, 2015). During their college life,
people overcome this with the support of their family and friends. freshmen encounter many firsts. These include a new
Studies have provided research data on the link between various environment, friends, exposure to new social norms and culture.
aspects of health, social relationships, and well-being (American The students may struggle and experience difficulty if they
Psychological Association, 2019). It is the support from family and cannot deal with these challenges and can become a vulnerable
friends that builds people up giving that extra boost during a time population.
of distress. The strength to carry on and move on, often comes
from these networks of social support, for an individual to thrive, In summary, the present study concludes that college life is a
especially in college (Feeney & Collins, 2015). period of increased challenge for young allied medical health
students. Their courses are accompanied by complex
The stressors in the allied medical professions educational challenging responsibilities, increasing tensions and anxiety. The
system have been constantly recognized in the literature for result from this process may cause or worsen stress. When not

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given priority, it could lead to depressive symptomatology. It was Brown, S. L., & Schiraldi, G. R. (2004). Reducing subclinical
reflected that freshmen students' peer support and their spiritual symptoms of anxiety and depression: A comparison of two
experiences appear to be closely associated with depressive college courses. American Journal of Health Education, 35(3),
symptomatology. 158-164.
Bryant, A. N., Choi, J. Y., & Yasuno, M. (2003). Understanding the
Therefore, it is deemed important to assess the beginning phase of religious and spiritual dimensions of students' lives in the first
the students' university life experiences. One of which is through year of college. Journal of College Student Development,
research; therefore, the replication of the study for future research 44(6), 723-745.
with a wider-range and diversified population is recommended. Centers for Disease Control and Prevention (CDC), (2018).
National Center for Health Statistics. National Vital Statistics
Limitations of the present study are the use of a self-report System – Mortality Data via CDC WONDER
questionnaire and limited homogenous sample. Replication of Cooper, C. (2018). Global, regional, and national incidence,
these findings in diverse samples is needed. prevalence, and years lived with disability for 354 diseases and
injuries for 195 countries and territories, 1990-2017: a
____________________ systematic analysis for the Global Burden of Disease Study
2017. The Lancet, 392(10159), 1789-1858.
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Use and Health. [Link]/health/statistics/
Adolescent Research, 18(4), 324-346.
prevalence/[Link]
Pratt, L. A., & Brody, D. J. (2014). Implications of two-stage World Health Organization. (2011). Global burden of mental
depression screening for identifying persons with thoughts of disorders and the need for a comprehensive, coordinated
self-harm. General hospital psychiatry, 36(1), 119-123. response from health and social sectors at the country level.
Prince, J. P. (2015). University student counseling and mental health Young, S. J., Cashwell, C. S., & Shcherbakova, J., (2000). The
in the United States: Trends and challenges. Mental Health & moderating relationship of spirituality on negative life events
Prevention, 3(1-2), 5-10. and psychological adjustment. Counseling and Values, 45(1),
Procidano, M. E. (1992). The nature of perceived social support: 49-57.
Findings of meta-analytic studies. In C. D. Spielberger & J. N.
Butcher (Eds.), Advances in personality assessment, 9, 1-26. ABOUT THE AUTHOR
Procidano, M. E., & Heller, K. (1983). Measures of perceived social
support from friends and from family: Three validation studies.
American Journal of Community Psychology, 11, 1-24.
Radloff, L. S. (1977). The CES-D scale: A self-report depression Louie Roy E. Catu, PhD, RN, is a faculty
scale for research in the general population. Applied (Assistant Professor) in the School of
Psychological Measurement, 1(3), 385-401. Nursing and Allied Medical Sciences, Holy
Rayle, A. D., & Chung, K. Y. (2007). Revisiting first-year college Angel University, Angeles City Pampanga,
students' mattering: Social support, academic stress, and the Philippines. He earned his Bachelor of
mattering experience. Journal of College Student Retention: Science in Nursing (2008), Masters of
Research, Theory & Practice, 9(1), 21-37. Science in Nursing (2014), and doctoral
Reed, M. K., McLeod, S., Randall, Y., & Walker, B. (1996). degree (2019) from Holy Angel University, Angeles City
Depressive symptoms in African-American Women. Journal of Pampanga, Philippines. He acquired his Emergency Medical
Multicultural Counseling and Development, 24(1), 6-14. Technician - National Certification (2010) under Technical
Rueger, S. Y., Malecki, C. K., & Demaray, M. K. (2010). Relationship Education and Skills Development Authority. He is a former
between multiple sources of perceived social support and clinician who started his journey as an Operating Room Volunteer
psychological and academic adjustment in early adolescence: Nurse (October 2008 October 2009) at Angeles University
Comparisons across gender. Journal of youth and Foundation Medical Center, Angeles City Pampanga,
adolescence, 39(1), 47. Philippines. Then, he continued his clinical experience at Sacred
Salsman, J. M., Brown, T. L., Brechting, E. H., & Carlson, C. R. Heart Medical Center, Angeles City Pampanga, Philippines, as
(2005). The link between religion and spirituality and an Operating Room–Delivery Room Complex Staff Nurse (May
psychological adjustment: The mediating role of optimism and 2010 - November 2015). In the same hospital, he was recognized
social support. Personality and social psychology bulletin, and promoted to Head Nurse (November 2015 - July 2016),
31(4), 522-535. Nurse Supervisor, and Nurse Training Officer (July 2016 -
Saltzman, K. M., & Holahan, C. J. (2002). Social support, self- October 2018). His research work focuses on nursing academics
efficacy, and depressive symptoms: An integrative model. and clinical practice—looking into the theoretical foundation with
Journal of Social and Clinical Psychology, 21(3), 309-322. consideration of the human aspect of nursing from student to
Turner-Musa, J., & Lipscomb, L. (2007). Spirituality and social professional nurses and how these academic experiences
support on health behaviors of African American translate to the clinical practice.
undergraduates. American Journal of Health Behavior, 31(5),
495-501.

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RESEARCH ARTICLE

Spiritual Well-Being
of Filipino Patients with Cancer
Alyssa Jenny E. Tupaz, MA, RN1, and Araceli O. Balabagno, PhD, RN1

Abstract
Cancer is a serious disease that leads to physical, psychosocial, and spiritual difficulties. Filipinos' high reverence to God can affect
their health-related behaviors and responses to illnesses like cancer. Though studies have shown the association of spirituality and
quality of life, very few have been conducted in Filipino cancer patients. This study aimed to describe their spiritual well-being in
terms of the personal, communal, environmental, and transcendental domains; and compare spiritual well-being across different
patient characteristics (i.e. type of cancer, stage of cancer, type of treatment, and the period since first symptoms are felt) as input to
determining patients at risk for spiritual distress. A descriptive cross-sectional design was utilized with 87 conveniently sampled
respondents. A researcher-developed questionnaire and the Spiritual Health and Well-being Measure© (SHALOM) instrument
were used to collect data. Data were analyzed using descriptive statistics and Kruskal Wallis H Test. Majority of the respondents
were below 50 years old, female, married or with a common-law partner, had at least a high school education, unemployed, did not
have enough income to support basic needs, Catholic, and an active member in the church. Most of them had colorectal cancer,
were in Stage III, first felt symptoms 6 months to 1 year prior to the conduct of the study, and received a combination of treatments.
In terms of personal state, the patients had the highest spiritual well-being in the Transcendental Domain which describes one’s
relationship with God. The second-highest spiritual well-being level was found to be the communal domain followed by personal,
and environmental domains. Significant differences were found in the spiritual well-being scores in the 4 domains across the types
of cancer, with the lowest scores among those with head and neck cancer. Filipino patients in the study had high spiritual well-being
despite the presence of cancer. Patient characteristics, especially their illness profile, should be considered in developing nursing
interventions that may improve their spiritual well-being.
Keywords: spiritual well-being, cancer, nursing, Filipinos

Introduction

C ancer is one of the leading causes of morbidity and mortality

in the world. In the Philippines, it is the second leading cause
of death after cardiovascular diseases (Philippine Statistics
one's identity, meaning, and purpose. Communal Domain is
demonstrated through love, trust, hope, forgiveness, and faith in
humanity. Environmental Domain is seen through care, nurture,
Authority [PSA], 2021). In Globocan 2020, there are 153,751 and being in awe of the physical environment. Lastly, the
new cases, 92,606 deaths, and 354,398 prevalent cases (5- Transcendental Domain is demonstrated through faith,
year) in the Philippines (Globocan, 2020; PSA, 2021). Studies adoration, or worship of something or some-One beyond the
suggest that spiritual well-being improves the health outcomes human self (Fisher, 2016). Many factors had been found to
of patients with cancer (Feng et al., 2021; Martins et al., 2019; contribute to spiritual well-being. Among them are sex, age,
Zare et al., 2019). The positive outcomes related to the quality of religion, educational attainment, employment status, marital
life, mental health, and death anxiety generated interest and status, phase of care/hospitalization, stage of illness, and
numerous research on the subject. In Fisher's Spiritual Health prognosis (Hiratsuka et al., 2021; Martins et al., 2019; Rohde et
and Life-Orientation Measure, spiritual well-being (SWB) is an al., 2017). Greater SWB was found among females, older
indication of one's spiritual health and an important indicator of adults, Catholics, with lower educational attainment, employed,
health-related quality of life. It can be expressed in four singles and widows. Lower SWB was found in those with greater
domains― personal, communal, environmental, and adversities in their cancer experience. They were more likely to
transcendental. The Personal Domain pertains to the search for experience spiritual distress (Hiratsuka et al., 2021).
1 College of Nursing, University of the Philippines Manila; Sotejo Hall, College of Nursing, Pedro Gil St., Ermita, Manila 1000 Philippines;
Corresponding author, Email: aetupaz@[Link]
2 College of Nursing, University of the Philippines Manila

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Though studies have shown the association of spirituality, quality which asked about the patient's age, sex, civil status,
of life, and patient factors, very few have been conducted in educational attainment, occupation (with work or unemployed),
Filipinos with cancer (Cariñgal et al., 2020). There is also a lack of family income (whether enough or not enough to support basic
role clarity and uniform approach among nurses in providing needs), religious affiliation, type of cancer that is based on site of
spiritual care because there is no agreed definition of spiritual origin, stage of cancer, cancer treatment, and length of time
need (Zehtab & Adib-Hajbaghery, 2014). Hence, this study since first symptoms were felt. The second questionnaire used
aimed to describe Filipino cancer patients' spiritual well-being in with permission from the developer was the Spiritual Health and
terms of the personal, communal, environmental, and Life-Orientation Measure (SHALOM). The SHALOM
transcendental domains. It also aimed to compare spiritual well- questionnaire, which was developed by Dr. John Fisher to
being across different patient characteristics (i.e., type of cancer, assess spiritual well-being, consisted of 20 items on a Likert
stage of cancer, type of treatment, and period since first scale (1-lowest score, and 5 – highest score) reflecting each of
symptoms are felt) as input to determining patients at risk for the 4 domains of spiritual well-being: personal, communal,
spiritual distress. environmental, and transcendental. The definitions of each
domain were provided in the earlier section of this paper. The
Method average score was taken per domain, and higher scores meant
higher spiritual well-being. The personal state of the adult
Research design Filipinos with cancer is reported in this study.

A descriptive cross-sectional design was utilized in this study. The instrument has been used in different countries and among
different populations such as students, teachers, doctors,
Sample and Setting nurses, abused women, and troubled youth. It has also
undergone rigorous statistical testing and was used in different
The study was conducted in the cancer center of a tertiary languages (Fisher, 2016; Riklikienė et al., 2018) and has a
hospital. It was a 48-bed capacity unit with 40 beds allocated for Cronbach's alpha of 0.886 (Eksi & Kardas, 2017). Before the
the adult patients and 8 beds in a separate room for the pediatric questionnaire was used on the sample population, it was
patients. There were 38 to 40 cancer patients, who were translated to Filipino by the Sentro ng Wikang Filipino. The
admitted for cancer treatment (i.e., chemotherapy, and radiation Filipino version was back-translated to English and the authors
therapy), in the unit daily. reviewed the back-translation. The Filipino translation also
underwent pilot testing wherein Filipino nurses and patients
Convenience-purposive sampling was used to select
answered the tool and were asked for comments. The
participants who met these inclusion criteria: 1) patients with
Cronbach's alpha of the translated version is 0.915.
cancer aged 19 to 60 years old admitted in a cancer center of a
tertiary hospital at the time of the study; 2) diagnosed with either Data Collection
stage III or IV (or its equivalent since there are cancer types like
blood cancers that do not use the TNM [Tumor-Nodes- The selection of participants was done through chart review.
Metastasis] cancer staging system). Participants were excluded After selection, the nature and purpose of the research were
if they had exhibited signs of cognitive problems such as explained to the patients who met the inclusion criteria. Then,
confusion, disorientation, or emotional imbalance that could informed consent was obtained to complete the recruitment
affect their decision-making. They were also excluded if they had process. It was emphasized that participation in the study was
not been able to provide informed consent, or they had been in voluntary, and a patient could stop participating in the research at
cardiorespiratory distress at the time of the data collection. Using any time with the withdrawal criteria as follows: verbal refusal to
2
G*Power with an effect size of f 0.25, 0.8 power, α of 0.05, and 4 continue participation, the onset of cardiorespiratory distress
groups/categories to be compared, the target sample size was during the data collection, and inability to finish the research
180. However, the target sample size was not met and only 87 questionnaires due to fatigue, pain, and/or any discomfort. The
respondents were able to provide data completely. Many of the questionnaires were self-administered, and the researcher
patients in the hospital did not meet the inclusion criteria, and collected these upon completion which was usually after 15 to 30
some of the respondents were not able to complete due to minutes. Data collection was conducted from August to October
difficulty in reading, understanding, and answering the 2017.
questions, and pain.
Data Analysis
Instruments
Patient characteristics and their spiritual well-being were
Self-administered questionnaires were used in the study. The summarized through descriptive statistics. Since the spiritual
first questionnaire used was the Filipino Cancer Patient Profile well-being scores were not normally distributed and the sample

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JULY-DECEMBER 2021

size was limited, the Kruskal-Wallis H test was used for the married or had common-law partners and most of them (42.53%)
comparison across different patient characteristics. The small reached high school level. Most of the participants (74.71%) did
sample size was considered in the analysis and is a limitation of not have work or any means of income, and more than half
the study. (56.32%) perceived that their family income was not enough to
support their basic needs. As for the religious affiliation, the
Ethical Considerations majority of the participants (86.21%) were Roman Catholics.
This study with protocol code UPMREB 2017-153-01 was For the disease profile, most of the participants (43.68%) had
reviewed and granted ethical clearance by the University of the colorectal cancer. Half (50.57%) had Stage III cancer, and most
Philippines Manila Research Ethics Board (UPMREB) Review (39.08%) had first felt the symptoms of the disease for the period
Panel 2. Then, the permit to conduct research in the cancer of 6 months to 1 year. Almost half of the participants (48.28%)
center was given by the Philippine General Hospital Expanded already received more than one cancer treatment modality,
Hospital Research Office (PGH EHRO). During recruitment, which could be a combination of chemotherapy and surgery,
informed consent was solicited from all participants of the study. chemotherapy and radiation therapy, or all of these.

Results Spiritual Well-being of Patients with Cancer

Profile of Respondents To assess the personal state of their spiritual well-being, the
participants were asked how frequently each item reflected their
A total of 87 adult Filipino patients with cancer participated in the personal experience given their circumstances at the time of data
study. The respondents had a mean age of 46 years old. The collection. The transcendental domain had the highest mean
youngest participant was 20 years old and the oldest was 60 score (x̄=4.61) while the environmental domain had the lowest
years old. Almost half of the participants (44.83%) were part of the mean score (x̄=3.99) as shown in Table 1. The following items
older age group which was above 50 years old. Majority of the received the highest mean scores: peace with God, oneness with
respondents (57.47%) were females. Most (67.82%) were God, worship of the Creator, and personal relationship with the

Table 1. Personal state of spiritual well-being scores of cancer patients according to the disease profile

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Divine/God. These four items were from the transcendental Considering their life-threatening conditions, praying to a divine
domain while one (i.e., respect for others) was from the communal being is one of the usual coping strategies (Lagman et al., 2014;
domain. The following items had the lowest mean scores: a sense Oliveira et al., 2020). However, this result is in contrast with
of 'magic' in the environment, oneness with nature, connection studies done in Lithuania and Portugal that had the lowest
with nature, and awe at a breathtaking view. These four items scores in the Transcendental domain (Martins et al., 2019;
were from the environmental domain while one (i.e., trust Riklikienė et al., 2018). Other countries such as in the West have
between individuals) was from the communal domain. experienced a decline in church attendance and related
religious practices (Brenner, 2016). This may indicate that
Spiritual Well-being and Type of Cancer country-specific and cultural factors affect the expressions of
spiritual well-being among cancer patients.
Patients with head and neck cancer (HNC) had the lowest SWB
scores across all domains as shown in Table 1. Significant The communal domain shows that Filipinos with cancer place
differences were found across the types of cancer in the personal value on others first before thinking of themselves. Filipinos
(H=10.849, p=0.013), communal (H=10.291, p=0.16), have strong family and social ties that are also partly interlinked
environmental (H=10.757, p=0.013), and transcendental with their religious beliefs of being good. The cancer experience
domains (H=12.006, p=0.007). also brings uncertainties that patients want to spend more time
with their loved ones, and feelings of love, kindness, trust, and
For the personal, communal, and transcendental domains, forgiveness towards other people may have been amplified.
differences were found between HNC together with colorectal Family, friends, and religious communities may also be a source
cancer and others (i.e., bone marrow, blood-related cancers). In of prayer and hope for the patients (Ginter & Braun, 2019;
the environmental domain, it was found only between HNC and Lagman et al., 2014). Having cancer can change how patients
colorectal cancer. view themselves as they experience physical symptoms,
feelings of vulnerability, body image disruption, depression, and
Spiritual Well-being and other patient characteristics
anxiety as reflected in the personal domain (Benson et al.,
The lowest SWB scores in the 4 domains were found in 2020). It can also trigger existential issues such as the search for
participants with Stage 3 cancer as shown in Table 1. The SWB one's purpose and meaning of life (Hassankhani et al., 2017;
scores were also found to be lowest in those who were receiving Krok & Telka, 2018). If left unresolved, these spiritual-related
combination therapy and in those who had first felt the cancer concerns can result in suffering and distress. Despite scoring
symptoms for the past 6 months to 1 year. Given the limited lowest in the environmental domain, a score greater than 3
sample size and the results of the Kruskal Wallis H test, there was means that they continue to have a high sense of
no sufficient data to determine whether there were significant connectedness to nature and the mystical energies in the
differences in SWB scores across different stages of cancer, environment. The hospital environment where the patients were
types of treatment, and periods since symptoms were first confined may also not be conducive to their spiritual well-being
experienced. as the location of the cancer center is in the middle of an urban
city that lacks green space.
Discussion
Certain patient characteristics and disease profiles cause
The results of the study show that adult Filipinos with cancer distress and anxiety that may lead to lower spiritual well-being
have high spiritual well-being in the four domains. These are (Hiratsuka et al., 2021). Patients with head and neck cancers
consistent with published studies that cancer patients have experience body image disturbances and self-esteem issues
good spiritual well-being (Cariñgal, 2020). Patients had the that can affect their view of themselves and their relationship
highest spiritual well-being in the Transcendental Domain which with others. These patients have a high risk for distress and
describes one's relationship with God. This is followed by coping problems and decreased faith in God can lead to greater
communal, personal, and environmental domains. Significant suffering and despair (Popescu et al., 2017). For those with
differences were found in the spiritual well-being scores in the 4 Stage 3 cancer, where the tumor is bigger and the cancer cells
domains across the types of cancer, with the lowest scores have spread to the lymph nodes and the surrounding tissues,
among those with head and neck cancer. patients need to adjust to the challenges of undergoing cancer
treatments, presence of complications, understanding the
The study suggests that adult Filipinos with cancer place the irreversible nature of the illness, and facing the possibility of
highest importance on building their relationship with God. Many cancer coming back even after therapy. Patients who had first
aspects of the daily life of Filipinos are highly influenced by the felt the cancer symptoms for the period of 6 months to 1 year
teachings of the Catholic Church (Lagman et al., 2014). were recently diagnosed and had already received single or

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multiple treatments. It may be early to tell if the patient had respondents were diagnosed with advanced cancer. Hence,
undergone remission, so the uncertainties in the treatment caution is needed when generalizing the findings to other
results can place them at risk of being in distress. The patients cancer patients.
who already received combination therapy may experience
distress associated with the adverse effects of cancer Conclusions and Recommendations
treatment (Hiratsuka et al., 2021). Receiving different
treatment modalities also requires patients to visit the hospital The adult Filipino patients with cancer in this study had high
or healthcare institution more often, be hospitalized for a spiritual well-being despite the presence of cancer. They had
longer period, or even be placed in reverse isolation to avoid the highest SWB scores in the transcendental domain and
acquiring infection. This can cause the patient to be lowest SWB scores in the environmental domains. Significant
temporarily separated from loved ones and live in a care differences were found in the SWB scores across the types of
setting different from the home environment. cancer, and SWB scores were lowest among those with head
and neck cancer. Though there was insufficient data to
The lower spiritual well-being of patients with advanced determine whether there were significant differences in SWB
cancer highlights the need to integrate spiritual care in cancer scores across different stages of cancer, types of treatment,
management (Martoni et al., 2017). Since cancer patients and periods since symptoms were first experienced, these
spend the most time with nurses, recognizing spiritual distress patient characteristics and disease profiles can still guide
is important (Martoni et al., 2017). The findings imply the need nurses in planning and implementing interventions that may
for nurses to consider the patient characteristics and illness improve their spiritual well-being. Future research should
profile in assessing, planning, and implementing spiritual care involve a bigger sample size and actively recruit those with
interventions. While his study found high spiritual well-being early-stage cancer as respondents to get a more
among the study respondents despite the cancer diagnosis, representative picture of the spiritual well-being of Filipino
nurses can enhance the patient's spiritual well-being by adults with cancer. A qualitative study is also needed to help
supporting current spiritual beliefs, values, and practices explain the findings of this study and to further explore
(Highfield, 2000). Nurses can collaborate with the clergy, spiritual well-being in this patient group.
pastoral care services, or other religious leaders in providing
spiritual care (Azarsa et al., 2015). In supporting patients'
____________________
spiritual well-being, nurses must also be aware that spiritual
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ABOUT THE AUTHORS

Alyssa Jenny Tupaz is currently an

Assistant Professor and Chair of the
Faculty and Students Relations
Committee at the University of the
Philippines College of Nursing. She was a
former charge nurse at the Department of
Medicine of the Philippine General
Hospital. She is also active as an officer of the Philippine
Oncology Nurses Association. Her areas of research are
spiritual well-being, oncology, and adult health nursing.

Dr. Araceli O. Balabagno is a Professorial

Lecturer and former Dean of the UP Manila
College of Nursing, and a former Chair of
the PNA National Department of
Research. Her research interests are in the
areas of adult health and cardiovascular
nursing and geriatric nursing

Acknowledgment:

The author would like to express her heartfelt gratitude to all the
people who helped her in this research: Ms. Cecile Pena for
being the research critic and mentor; Sr. Letty Kuan, Prof. Rita
Ramos, and Prof. Loyda Amor Cajucom for comprising the
thesis panel; Prof. Peter James Abad, Prof. Erwin Leyva, and
Prof. Jo Leah Flores for their valuable inputs in the research
paper.

Conflict of interest: The authors declare no conflict of interest. ICN

International
Council of Nurses

On the World Day of

#SocialJustice, ICN calls for
decent, fair, and just working
conditions for #nurses.
#Humanrights are
#healthcareworker rights -
they must be protected, safe,
and free from discrimination.
#genderequity #VaccineEquity

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RESEARCH ARTICLE

Sexual Health Intervention for Couples

with Difficulty in Sexual Abstinence
Daisy H. Alberto, PhD, RN1

Abstract
Purpose: Nurses in the forefront of reproductive health services face the challenge of motivating clients to adapt fertility
awareness-based methods, or making them continue with the method due to concerns about handling sexual abstinence. To assist
nurses and other reproductive health providers, a sexual health intervention was developed. Thus, this study aimed to determine
the effectiveness of the sexual health intervention called Kalabit-kalabit (sexual desire), Irap (abstinence), and Sanggang-dikit
(shared behavioral plan) (KIS) on the sexual scripts, motivation, and behavior of couples with difficulty in sexual abstinence in
natural family planning. Specifically, it aimed to identify the sexual scripts on pagkatao (personhood), pagkalalaki (manhood),
pagiging lalaki (masculinity), pagkababae (womanhood), pagiging babae (femininity), pagtatalik (sexual intercourse), and
pagpipigil (abstinence), as well as the sexual motivation and behavior of couples with difficulty in abstinence before and after KIS.
Methods: Embedded multiple-case study with purposive sampling using the replication logic was used to satisfy the inquiry. Four
couples qualified using the assumption that difficulty with abstinence is caused by illogical sexual scripts, and inappropriate sexual
motivation and behavior of either one or both spouses as a template to determine KIS’s effectiveness. Pattern matching, cross-
case synthesis, and logic model were used for analytic generalization. Prior to the conduct of the study, the research protocol
underwent scrutiny by the Independent Ethics Committee of De La Salle Medical and Health Sciences Institute.
Result: KIS was found to be effective in (a) decoding and denouncing illogical sexual scripts and inappropriate sexual motivation
and behavior, (b) reframing them to logical sexual scripts and appropriate sexual motivation and behavior, and (c) sharing mutual
behavioral plans if accompanied with openness and full acceptance of self and spouse coupled with conviction, cooperation,
commitment, and determination.
Conclusions: Decoding, challenging, reframing, and sharing mutual behavioral plans facilitate couples' competence in achieving
sexual abstinence with ease.
Keywords: Sexual scripts, motivation, behavior, abstinence, natural family planning.

Introduction

M odern natural family planning (NFP), also known as fertility

awareness methods, was based on research. Couples
observe and record signs of fertility while they adjust their sexual
episodes of use of periodic abstinence with emphasis on
calendar method in 43 countries for a 12-month period.

intercourse based on their intentions to postpone, stop or Enhancing the sexual abstinence and intercourse experience of
achieve pregnancy. Thus, abstinence is required during the couples as they practice NFP is necessary in the practice of the
fertile days if the couple intends not to have a child. Cooperation, fertility awareness method because sexuality is entwined in daily
communication, and shared commitment are necessary. If life. There may be situations that may lead to a degree of
instructions are not carefully followed, natural family planning is misunderstanding: “Lalaki ako, may pangangailangan,” (I am a
less effective (Billings & Westmore, 2011; Kaiser Family man with a sexual needs) and/or “'Pag 'di napagbigyan,
Foundation [KFF], 2018; National Health Service United sasabihin, may pinaglalaanan ng iba o 'di naman kaya, mainit
Kingdom [NHS UK], 2021; United States Conference of Catholic ang ulo,” (Every time I don't feel like making love, my husband
Bishops [USCCB], 2021). Polis, et al. (2016) reported that there gets annoyed thinking I might have another man). Skeptic
were 13.9 pregnancies (method and user-related) in 100 audience will often comment “Imposible ang NFP sa mga

1 Chair, Research and Development; Faculty Member, College of Nursing De La Salle Medical and Health Sciences Institute; dhalberto@[Link]

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lalaking mahihilig. May kilala ako,” (NFP is not applicable to the individual look into their feelings, and challenge the negative
males with a high desire for sex. I know someone who is like that). appraisals and substitute them with logical suppositions.
These are examples of statements that a natural family planning Moreover, the Reticular Activating System (RAS) or the
teacher, like the researcher herself, hears from some NFP subconscious mind can be programmed and reprogrammed.
practitioners and skeptical audiences. The programming of the RAS, belief system, and commitment,
when put together, result in achieving the goal (Pax, 2021;
Reflected in the statements are common archetypes the society Goodyear, 2020; Hallbom & Hallbom, 2016; [Link],
and culture have inculcated in the very fiber of the person's being. 2013; Sanders, 2012). Likewise, the concept of cognitive
These paradigms become the ethos, which most probably are dissonance suggests that where two or more conflicting
the by-products of the conventional knowledge on sexual urges conditions exist, particularly when two options are both alluring, it
suggesting that men are easily aroused, have very strong sex can only be removed if the person reduces or eliminates the
drives, and want sex more than women do. Enough sex keeps importance of the conflicting beliefs (Festinger, 2015; Travis,
the relationship together (Baumeister, 2010; David & Webber, 2014).
2013). The researcher believes that these long-standing beliefs
are the reasons why some couples and skeptics do not accept The researcher, thus, proposed an intervention that will enable
and endorse NFP. These even are the ascribed reasons for the couples to appraise the interplay of the levels of scripting (cultural
difficulty in abstinence, which may eventually lead to scenario, interpersonal scripting, and intrapsychic scripting) as
disengagement from NFP practice. logical (positive appraisal) or illogical (negative appraisal) and
that negative appraisal will be replaced with logical suppositions,
In 2013, the Philippine statistics on NFP showed that there is guided by the perspective that Reticular Activating System can
1.0% adherence to modern natural family planning methods, with be reprogrammed (See conceptual framework in figure 1).
9.3% of them using the rhythm method (Marquez et al., 2017).
Rivera (2009) reported that among the modern NFP, there is Statement of Purpose
0.1% usage of both Billings Ovulation Method and Standard
Days Method but none for Sympto-thermal Method. The study determined the effectiveness of KIS on the sexual
scripts, motivation, and behavior of couples with difficulty in
The researcher also found out that the available program that abstinence. Specifically, it determined the: (1) sexual script on
addresses the issue of abstinence both globally and locally are personhood, sexual intercourse, and abstinence, manhood,
for adolescents' education. Nothing was found on changing the masculinity, womanhood, and femininity; (2) sexual motivation
interplay of sexual scripts, motivation, and behavior that may and behavior and; (3) chain of outcome namely, (a) change from
assist couples in their abstinence practice while exercising illogical to logical sexual scripts (immediate outcome), (b) shared
natural family planning. In fact, Tandico (2007), in his study, sexual behavioral plan (intermediate outcome), and (c)
suggested that by virtue of Mcdonaldization, males were left appropriate sexual motivation and behavior (ultimate outcome)
uninvolved in the Philippine family planning program. of couples with difficulty in abstinence before and after employing
the KIS intervention.
As such, to assist nurses and reproductive health workers
providing NFP services as well as their clients, the researcher Assumption of the Study
contemplated that by identifying, decoding, challenging, and
reconstructing these sexual paradigms, both sexual intercourse The assumption of the study was difficulty in sexual abstinence is
and abstinence will be more meaningful and life-giving. The idea caused by illogical sexual scripts and inappropriate sexual
of sexual paradigm is apparent in the theory on the sexual script motivation and behavior of either one or both spouses.
while the process of challenging and substituting illogical to
logical supposition may be done using the principles of Rational Methodology
Emotive Behavior Therapy. Simon and Gagnon (1984)
contended that sexual script constructs the sexual conduct as An embedded multiple-case study by Yin (2009) was used to
dictated by the culture of the society since human sexuality is satisfy the inquiry.
responsive to both socio-historical processes and necessary
understandings that preserve a sense of an individual's The study contended that couples' conscious and/or
experiences in life. Thus, the script is defined as a “metaphor for unconscious pattern of negative beliefs about one's own and
conceptualizing the production of behavior within social life” (p. spouse's personhood, manhood/womanhood, sexual
53). Kimmel (2007) furthered that sexual script is the heart of intercourse, abstinence, and masculinity/femininity (sexual
sexuality in identity formation. On the other hand, Ellis (n.d), script/s) brought difficulties/challenges either within the self or
Cormier and Hackney (2008), and Rosner (2011) explained that with his/her relationship, thus, resulting in illogical sexual scripts.
to change one's behavior, the treatment must focus on helping Otherwise, couples have logical sexual scripts. Moreover,

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Figure 1. Conceptual Framework inappropriate sexual motivation.

Otherwise, couples have
appropriate sexual motivation.

Further, couples with any or a

combination of the following: (1)
negative description about
sexual intercourse and sexual
abstinence as reflected either in
the pagtatasa (evaluation) and
sexual meter stick or as part of
the narrative during the
processing of KIS or in their
individual journal or all of them,
(2) presence of violations of the
rules of NFP, (3) inconsistency
with the expressed sexual
motivation, and (4) negative
description or positive but
inconsistent reflection on
Discerning Applicable Sexual
Behavior were classified with
inappropriate sexual behavior.
Otherwise, couples have
appropriate sexual behavior
(kalabit-kalabit – sexual desire
and irap- abstinence).

KIS has three parts. The first part

(Phase 1 to 2) is to decode the
sexual scripts through various
worksheets, interviews,
journals, NFP charts, and
reports of NFP teachers, as well
as through activities like
symbolic representation; sexual
lifeline – a recollection and
narration of their sexual history;
sexual scripting process – a
recollection of the most
memorable sexual experiences
(both happy and sad); and
decoding which entails
couples may have either (a) conscious or unconscious rejection identification of their sexual scripts which need change.
of the need to examine the purpose of postponing pregnancy in
reference to health, economic, socio-cultural, and moral aspects The second part (Phase 3 to 5) is to challenge the couples with
without losing sight of the accountability and responsibility to illogical sexual scripts and inappropriate sexual motivation and
humanity as they exercise prudence and generosity; or (b) behavior to denounce and reframe their sexual scripts, as well as
conscious or unconscious acceptance of the need to examine to develop and implement the shared sexual behavioral plans.
the purpose to postpone pregnancy in reference to health,
economic, socio-cultural, and moral aspects but has lost sight on The third part (Phase 6) is to decode once more the sexual
the accountability and responsibility to humanity, thus, failing to scripts on personhood, manhood/womanhood, masculinity/
exercise prudence and generosity, which is categorized as femininity, sexual intercourse, and abstinence through the same

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process in Phases 1 and 2. The couples were again classified participant. The order of the session - whether male or female -
whether to have logical or illogical scripts by identifying the sexual depended on the readiness of each participant. The participant
scripts and whether the sexual intercourse and abstinence who finished first was instructed to keep silent about the activities
experiences were appropriate or inappropriate. A group sharing to maintain the spontaneity of the partner who would undergo the
is included in the last part of Phase 6. same session in a separate room. The thoughts and feelings
during the conduct of the session were elicited by the
Ethical considerations were reviewed by the Independent Ethics investigator. Then, a journal was handed to each participant
Committee of De La Salle Medical and Health Sciences Institute. every after the session for insights. After the individual sessions,
the couple met for a sharing session. Sessions on Phase One to
Participants of the Study Two decoded the individual's sexual scripts and sexual scripting.
Among the many couples practicing NFP, only four prequalified The Phase 3 session worked on the sensitivity of each spouse to
were able to finish the study due to problems with their schedule. one's own and to his/her partner's sexual nature and desire in
The participants were all married, within the age range of 26-40, relation to appropriate sexual motivation and with a short input
with 33 as the average. Except for one participant being Born about communicating and listening skills.
Again Christian, the rest were Roman Catholic. Most of them
graduated from high school except for Female 4 (F4); Female 3 Phase 4 evaluated the couples' sexual motivation: kalooban.
rd
(F3) graduated from college while Male 2 (M2) reached 3 year Couples looked into the reasons for sexual intercourse and
college. Couples 3 (C3) and 4 (C4) have four children. Couple 1 sexual abstinence by reflecting on the basis for practicing natural
(C1) has two, while Couple 2 (C2) has seven. The breadwinners family planning, and their accountability and responsibility to
among Couples 1, 2, and 4 are male, while Couple 3 is female. humanity as social beings with prudence and generosity.
The length of NFP practice among the participants varies from at
least three weeks to ten years at most with normal cycles. All four Phase 5 guided the couples in denouncing old script and sexual
couples had difficulty in abstinence and had illogical sexual scripts in session one and assisted in integrating the role of the
scripts, inappropriate sexual motivation, and behavior, new script and sexual scripts in their sexual behavioral plans in
specifically: Female 1 (F1), Male 2 (M2), Female 3 (F3), and session two. They were tasked to develop a meaningful conjugal
Male 4 (M4). Meanwhile, Male 1 (M1), Female 2 (F2), and Male 3 script and sexual behavioral plans to work on for the next three
(M3) were tolerant of their spouse's sexual behavior, while weeks.
Female 4 (F4) was sometimes forced.
Phase 6 was conducted after three weeks. To validate the
Data Gathering Instruments effectiveness of the newly developed shared and meaningful
sexual behavioral plans, all four couple participants
Instruments used were miniature toys for introspection, accomplished the same worksheets and activities. The last
disclosure, and articulation of feelings and connection within the session was the sharing of experiences including the process of
self as they target to represent the person's sexual script. implementation, its success, and failure.
Candles provided a stimulus for cultivating the senses and
sensitivity of the person to describe how the body, mind, and Findings
motivation work together in relation to script and sexual script.
Other forms are various worksheets, e.g., sentence completion, KIS's effectiveness was determined using the logic model from
checklist, and questionnaires, namely, demographic profile, the cross-case analysis as a chain of outcomes, namely, (a)
pagtatasa (evaluation), Scripts and Sexual Scripts (SSS), change from illogical sexual script to logical sexual script
Sexual Intercourse Meter Stick (SIMS), Sexual Abstinence (immediate outcome), (b) shared sexual behavioral plan
Meter Stick (SAMS), Decoding Sexual Script Guide (DSSG), (intermediate outcome), and (c) appropriate sexual motivation
Sensing, Feeling, Thinking (SFT), Discerning Applicable Sexual and behavior (ultimate outcome).
Behavior (DASB), and Scripting and Plans for Sexual Behavior
(SPSB). Journal writing was also employed. All these were A. The Immediate Outcome
answered individually by both male and female participants.
In terms of the first chain of evidence, immediate outcome, all the
Data Collection four couple participants had illogical sexual scripts prior to KIS.
These sexual scripts were manifested as the interplay of cultural
Selection of participants, consent signing, and administration of scenarios, interpersonal, and intrapsychic scripting. The
the worksheets for the first session marked the start of KIS. interplay of these three shows the following: (a) the cultural
Almost all sessions were conducted on a one-to-one basis for scenario of sex as a stress reliever or pampatulog (sleep
more or less an hour depending upon the pacing of the inducer), and obligation and abstinence as difficult; (b)

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interpersonal scripting of being tough (negative light) and couples show consistency, commitment, and determination to
satisfier of the sexual need of the spouse; and (c) intrapsychic triumph the plan.
fear of impregnating the wife, compelling sexual desire, being
selfish and being insensitive creating a couple scripting of C. The Ultimate Outcome
Challenge-abide (C1), Conform-nonchalant (C2), Pamper me-I
will (C3), and Compelling husband-reluctant wife (C4). For the third chain of evidence, the ultimate outcome is the
appropriate sexual motivation and behavior leading to without
This interplay was challenged, reframed, and replaced by (a) the difficulty in abstinence. Couples 1, 3, and 4 were able to
cultural scenario of sex as proper timing while abstinence as immerse their sexual desire in their intention to avoid pregnancy
easy, if with communication and mind setting; (b) interpersonal and consciously communicated during abstinence, hence
scripting of being tough (positive light), being sensitive and with a without difficulty in abstinence. However, the presence of fear of
sense of respect; and (c) intrapsychic scripting of being open to impregnating on M1's part, though conquered once, could
life, being sensitive, being good follower, being partners, and possibly induce another episode of withdrawal during the marital
employing a wait-and-see approach. These changes in the act. Couple 1 needed time. Couple 2 failed to immerse their
cultural scenarios, interpersonal, and intrapsychic scripting sexual desire in their intention to avoid pregnancy, hence still
created couple sexual scripts of We are partners (C3 and C4), I having difficulty in abstinence. Therefore, the assumption that
started to trust - I started to adjust (C1), and Your goal could be difficulty in abstinence is caused by illogical sexual scripts, and
my goal and I am starting to be sensible but wavering – He leads, inappropriate sexual motivation and behavior is indeed true.
I will follow (C2).
Hence, the changes in sexual scripting paired with sensing,
After KIS, decoding, challenging, and reframing in terms of feeling, thinking, abdominal breathing, and adequate
abstinence were effective to Couples 1, 3, and 4 but not in terms communication are the main elements in KIS that are
of enhanced sexual intercourse in Couple 1 where M1 was able responsible for its effectiveness in facilitating ease in sexual
to challenge the fear once but still needs more experience of the abstinence and enhanced sexual intercourse. Together with
same essence. Meanwhile, Couple 2 was starting to digest the these aforesaid elements, conviction, cooperation,
new couple script on abstinence. commitment, and determination of the participants contribute to
KIS effectiveness. Lack of ownership and acceptance, coupled
B. The Intermediate Outcome with inadequate conviction, commitment, cooperation, and
determination, makes KIS less effective.
For the second chain of evidence, intermediate outcome, only
Couples 3 and 4 had a coordinated and congruent intention of Simon and Gagnon (1984) contended that social meanings
avoiding pregnancy, prior to KIS. Couples 1 and 2 had an explain sexual behavior rather than physiological processes.
individualized uncoordinated intention. Couple 2 had a different This is because the inhibitory regions in the temporal lobes,
primary reason. Only F2 showed eagerness to avoid another anterior cingulate cortex (ACC), and ventromedial prefrontal
pregnancy. The concept of the partnership was well verbalized cortex (vmPFC) make an individual behave appropriately
by F3 but lacked execution as manifested in the adjustments (Clark, 2014). Furthermore, the reticular activating system
made by M3. C4, on the other hand, had very good teamwork in works as a gatekeeper to help an individual to be more focused
terms of fulfilling the daily needs of the family. But in terms of and achieve his/her set goals (Reticular Activating System:
avoiding another pregnancy, M4 showed inconsistency as a Definition & Function, 2016).
team player. After KIS, all four couples did their best to follow
their plans. Couple 2 partially met their goal as manifested by the Analytic Generalization (Expanding the Theory of Simon and
reduction in the frequency of sexual intercourse from three to five Gagnon)
times per week to five times a month, though some days of Sexual scripting in the sexual abstinence and intercourse in the
abstinence were unintentional and were due to marital fertility cycle continuum in natural family planning practice can
arguments. Sexual intercourse on a possible fertile day indicates be best explained as the belief-in-action-interaction mode of
non-adherence to their plan. Also, C2 lacked good each spouse which can either be reciprocated or rejected or
communication aside from the fact that they still have illogical sometimes tolerated by the spouse. This belief-in-action-
scripting. Moreover, M2 lacked ownership of and commitment to interaction scripting of the husband-and-wife results in couple
their own plan while F2 was tolerant of M2's behavior. Hence, scripting that is either logical or illogical which influences their
inconsistency during the execution is a manifestation of a lack of sexual motivation and behavior to be either appropriate or
determination and commitment. Couples 1, 3, and 4 were able to inappropriate, hence with or without difficulty in abstinence and
achieve a shared and well-executed behavioral plan. All three enhanced sexual intercourse.

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The couple's sexual scripting (belief-in-action-interaction) can handling extreme fear of pregnancy. Thus, reproductive health
be decoded, challenged, and reframed. Moreover, the couple's providers/NFP teachers are encouraged to be equipped with
sexual scripts influence sexual motivation, and behavior. Based skills in surfacing the scripts and sexual scripts, motivation, and
on the reprogrammed scripting, a couple can create a shared behavior and assist couples to create a shared mutual
sexual behavioral plan that may facilitate sexual abstinence and behavioral plan. Sexual health intervention may be used. Also, a
enhanced sexual intercourse. However, the resulting sexual phenomenological study on couple scripting on sexual
behavior depends on the degree of internalization of the intercourse as pampatulog or as a form of stress reliever might
emerging values and goals. (See analytic generalization in interest the researchers.
figure 2 below).
____________________
Discussion
Effective decoding, challenging, reframing, and sharing mutual References
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Cultural Scenario Cultural Scenario Cultural Scenario

Sex is an expression of love, marital bond, Cultural Scenario
Sex is a stress reliever, an expression of Sex is a stress reliever, an obligation, Sex is an expression of love, marital bond,
love, marital bond, and God’s blessing an expression of love, marital bond, and sacred God’s blessing for married persons and done
at the right time proper timing, sacred
Abstinence is difficult, an expression Abstinence is difficult, closed for Abstinence is a challenge, easy with mind
of love, and avoidance of pregnancy intercourse, discipline Abstinence is easy with communication,
avoiding of increase in family size, We are partners setting, self-discipline, partnerhip
Interpersonal Scripts Interpersonal Scripts partnership I started to trust - I started
Being husband, jolly, sweet, Interpersonal scripting Being sweet and tough for pagkatao; responsible, to adjust
of tolerance – sweetness, Interpersonal Scripts Interpersonal Scripts
and soft for pagkatao, husband, sweet, beautiful, and sexy, and satisfier
beautiful, and sexy; Jolly, sweet, responsible, team player, Tough (on a positive light) responsible,
responsible, patient, honest, of sexual need of spouse both for Your goal could be my goal
sexualneeds fulfillment, problem fighter, and adaptability for pagkatao; God-loving for pagkatao; attitude,
and satisfier of sexual need pagkababae and pagiging babae; also, being
sweetnessgiver – receiver; trust, sensibility, respect, good follower, responsible, sensitive, complete, happy,
of spouse both for pagkalalaki submissive for pagiging babae I’m starting to be
and play – do not play decision maker, wise and team player respected for pagkababae and
and pagiging lalaki sensible but pagiging babae
Intrapsyshic Scripting Intrapsyshic Scripting Intrapsyshic Scripting wavering -
fear of impregnating for pagkalalaki Compelling sexual desire, jealous, and Wait and see mode, open to life He lead I will
and pagiging lalaki, compelling insensitive for pagkatao and pagkababae follow Intrapsyshic Scripting
Fear of impregnating related to pregnancy
sexualdesire and insensitive for Wait and see mode
while doing NFP.
pagkataoand pagkalalaki, and
jealous for pagkatao Gecko; challenge

KlS
Phase 1; The Sexual Scripts
Phase 2: Sexual Scripting
Phase 3: Sexual Motivation: Sexual Nature and Desire Figure 1. Analytic Generalization
Phase 4: Sexual Motivation: Kalooban
Phase 5: Redefining Sexual Intercourse and Abstinence and Sharing of Sexual Behavioral Plans (Expanding the Theory of Simon and Gagnon)
Phase 6: The Sexual Scripts. Motivation and Behavioral Plans

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ABOUT THE AUTHOR
[Link]
National Health Service United Kingdom (2021). Natural family
planning (fertility awareness) your contraception guide. NHS
[Link] Daisy Huelva Alberto, PhD, RN is a
faculty member of the College of Nursing
planning/ in De La Salle Medical and Health
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Singh, S. (2016). Contraceptive failure rates in the Research Development of the College of Nursing. She is one
developing world: An analysis of demographic and health of the pioneers and the Vice President of the Philippine
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[Link] President of the World Organization of Ovulation Method
rates-in-developing-world Billings Philippines (WOOMB PHIL) from 2003 to 2007. She is
Reticular Activating System: Definition & Function. (2016). a Fertility Awareness practitioner, teacher, and trainer since
the 1990s. She obtained her Master's Degree in Nursing in De
[Link] [Link]
La Salle Medical and Health Sciences Institute while her
[Link]. Doctor of Philosophy Major in Counseling Psychology in De
Rivera, M. (2009). Natural family planning in the Philippines. In La Salle University – Dasmariñas where she received an
Echavez, R. and Borja, E. (Eds). Natural family planning Outstanding Dissertation Award. She is taking her Doctor of
values, issues, and practices. Cagayan de Oro and Manila: Science in Nursing Major in Gerontology Nursing at Cebu
Philippine Center for Population and Development. Normal University. Her research interests include fertility,
Rosner, R. (2011). Albert Ellis' rational emotive therapy. sexuality, family, and older persons.
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Seven keys to creating the life you want now. WestBow Acknowledgments
Press.
Scott, S. (2019). The multiple link between sex and stress. A heartfelt gratitude to all those who have been part of this
study, namely; the respondents, research assistants,
Verywell Mind. [Link]
transcriptionists, proofreaders, editors, technical reviewers,
stress-management-technique-3144601 IEC, and especially to De La Salle Medical and Health
Simon, W. & Gagnon, J. (1984) Sexual script. Department of Sciences for the financial grant.
Sociology, University of Washington in Society, November-

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RESEARCH ARTICLE

Knowledge and Compliance to Standard

Precautions and General Self Efficacy among
Nurses in a Tertiary Hospital
Crisanto D. Gatbunton, MAN, RN1

Abstract
Purpose: This study aimed to evaluate the level of knowledge on Standard Precautions, level of compliance to Standard
Precautions, and General self-efficacy of nurses in a tertiary hospital. Also, this study aimed to identify the relationship between
those variables.
Design and Methods: A descriptive correlational research design was utilized in the study. 168 nurses from the tertiary hospital
from Nueva Ecija, Philippines were recruited to complete a questionnaire about their knowledge and compliance to Standard
Precautions and their General self-efficacy. The data was coded, encoded, and statistically analyzed using PSPP 1.2.0 (GNU
Project. New York City, New York, USA).
Results: Findings indicated that nurses have good knowledge and high compliance concerning standard precautions; also,
findings showed that nurses have a moderate level of general self-efficacy. However, there was no remarkable relationship
between the level of knowledge, level of compliance in Standard Precautions, and general self-efficacy.
Conclusions: Although the researcher concluded a high level of knowledge among nurses, statistical analysis showed no
relationship when correlated with compliance. This concluded that knowledge of Standard Precautions does not necessarily
influence compliance and its application. Also, findings inferred that a moderate level of general self-efficacy did not act upon the
level of compliance of nurses to Standard Precautions.

Keywords: Standard Precaution, Compliance, Knowledge, General Self-efficacy.

Introduction

S
“ tandard Precautions are minimum infection prevention
practices used for all patient care, regardless of infection
status and setting where health care is delivered. It prevents the
Standard Precautions, most importantly now that there are a lot
of emerging deadly diseases like COVID-19. Low compliance in
Standard Precautions enables the transmission of infection
transmission of diseases that can be contracted by exposure to from patients to health care workers and other patients (World
blood, non-intact skin, body fluids, and mucous membranes. Health Organization, 2011). At any given time, seven percent in
Standard Precautions are composed of the use of personal developed and ten percent in developing countries, including
protective equipment, hand hygiene, respiratory hygiene/cough the Philippines, will acquire at least one healthcare-associated
etiquette, safe injection practices, sharps safety, sterile infection. Death from healthcare-associated infection occurs in
instruments and devices, and cleaning and disinfected about ten percent of affected patients (World Health
environmental surfaces” (Centers for Disease Control and Organization 2011). Also, low compliance in Standard
Prevention, 2019). Precautions places healthcare workers at high risk of acquiring
infectious diseases like HIV infection, Hepatitis B, and Hepatitis
Compliance with Standard Precautions guidelines has been a C following occupational exposure(Centers for Disease Control
problem for the health care system universally. A break in the and Prevention, 2002). At times, it may also be a cause for an
principle of Standard Precautions threatens the welfare of the outbreak in the community(World Health Organization, 2011).
patients and health care providers. It is indeed vital to adhere to

1 Staff Nurse, Dr. Paulino J. Garcia Memorial Research and Medical Center; crisantogatbunton@[Link]

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Knowledge and compliance with standard precautions and scale (GSES) was pioneered by German psychologist
general self-efficacy are crucial to protect not only the patients Schwarzer and colleagues in 1981 which gives a good
but also medical workers from exposure to communicable representation of self-efficacy in different settings.
diseases. The relationship between these variables may predict
the success in compliance with Standard Precautions in The researcher sorted and checked the questionnaires for
preventing hospital-acquired infections. completeness to determine their usability. A total of 168 copies of
the questionnaire were distributed and were returned to the
This study aimed to evaluate the level of knowledge on and level researcher garnering a 100% return rate.
of compliance to Standard Precautions, and the level of general
self-efficacy among nurses working in a tertiary hospital. Also, it The data was encoded and statistically analyzed using PSPP
aimed to uncover relationships between those variables. 1.2.0 (GNU Project. New York City, New York, USA). Frequency
and percentage distribution were used in the presentation of the
Methodology demographic profile of the respondents. The mean scores were
computed for the level of knowledge, general self-efficacy, and
A descriptive correlational research design was utilized to compliance, and were categorized from low to high. Pearson's
identify the relationship between level of knowledge on Standard correlation was utilized for the analysis of the relationship
Precautions, level of compliance to standard precautions, and between knowledge and compliance with Standard Precautions,
level of general self-efficacy among nurses in a tertiary hospital. and general self-efficacy. The researcher observed ethical
approaches in all areas of research by taking into consideration
The researcher used simple random sampling by securing a list ethical issues related to data collection such as confidentiality,
of the member of the population. Each member was marked with risks, and benefits. The research locale issued the ethical
a specific number and randomly chosen by the use of random clearance after a thorough evaluation.
number generator software (Stat Trek). Sample population of
168 nurses of a tertiary hospital was calculated through Results and Discussion
OpenEpi, with an assumption prevalence of 50, a study
population of 295 nurses, a confidence level of 95%, and an Demographic Profile of the Respondents
allowable error of 5.
Table 1 showed the distribution of the respondents' answers to
The researcher started the data collection from August 10 to the demographic question. The age of respondents was
October 30, 2020, after securing ethical clearance. The predominantly between 20 to 29 years old (42.86%) and aged 30
researcher conducted data collection in an empty room in the to 39 years old (41.68%). Of the sample of 168, 108 were female,
nursing office without any person except the respondents and and 60 were male with a corresponding percentage distribution
the researcher who administered the questionnaire after the of 64.29% and 35.71%, respectively. Out of 168 nurses, 33.93%
informed consent was presented. Respondents completed the were master's degree holders, and one nurse has a Doctorate
questionnaires encoded in Google Docs. The link to the (0.6%). The respondents mostly comprised of 4-6 (42.29%)
questionnaire was sent to their emails. The researcher made years of experience. Most of the respondents were from the
himself available throughout the study to explain the procedure, Operating Room (11.31%) Emergency Department (11.31%),
maintain privacy and confidentiality of the study, and cater to Female Medical Ward (9.52%), Pediatric Ward (8.93) Surgical
further concerns and queries. Complex (8.33%). 122 (72.69%) of the surveyed nurses have
training on Standard Precaution.
The researcher utilized a validated self-report questionnaire
used by Lou, et al., (2009) in their study "Factors affecting Age of Respondents
compliance with Standard Precautions in nursing, China." The
researcher had a minimal revision on the respondents' profile Data revealed that out of 168 nurses surveyed, 42.86% of nurses
part. The researcher did not conduct pretesting and pilot study aged between 20 to 29 years old, 41.68% of nurses aged
since it was already validated. A letter through e-mail was sent to between 30 to 39 years old, 8.33% of nurses aged between 40 to
previous researchers to ask permission to use the 49, and 7.14% of nurses aged above 50 years old. The sample
questionnaires. Pasay et al (2015). also utilized the said set of population was dominated by nurses aged between 20 to 29
questionnaires excluding the general self-efficacy scale in their years old (42.86%) and aged 30 to 39 years old (41.68%). It
study 'Compliance with Standard Precaution among Hospital implied that most of the respondents are part of the millennial
Nurses in Ozamiz City, Philippines”. The general self-efficacy generation. “Millennial generation exhibits a capacity for high-

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Table 1. Respondents' Demographic Profile level cooperative work, confidence, ambition,

optimism, conventionality and at the same time,
they can be easily stressed out" (Wilson & Gerber,
2008). Understanding generation differences allow
leaders to enhance and sustain a culture of
compliance. Studies showed that older nurses
have higher compliance in standard precautions
(Pasay et al., 2014), while 20-30 years old nurses
ranked lowest on compliance, similar to the findings
of Chan et al. (2002). However, the studies of
Gebresilassie, et al. (2014), say that older nurses
have a higher resistance to behavior change in
compliance to standard precaution. According to
their reports, it is because of the experiences and
training attended.

Sex of Respondents

Most of the respondents were female (64.29%),

while 35.71% were male. World Health
Organization (2015) said that women were a
significant part of healthcare in many countries
since they comprise 75% of the workforce.
Concerning gender, Pasay et al. (2015) reported
that male nurses have better compliance with
standard precautions, same with the findings of
Efstathiou et al. (2007). While in the studies of
Yassi, et al. (2007) and Creedon (2008), female
nurses are more compliant with standard
precautions.

Educational Attainment of Respondents, Year

of Experience, Training on Standard Precaution

Out of 168 nurses, 33.93% were master's degree

holders, and one nurse has a Doctorate, which
mostly comprised of respondents with 4-6 years of
experience (42.26%). 122 (72.69%) of the surveyed
nurses have training on Standard Precaution.
Education is an essential element in the training of
healthcare workers, particularly in countries where
there is a lack of infection control programs. Lack of
understanding and training are factors affecting
compliance with Standard precautions. Lou et al.,
2009 concluded that nurses who undergone
training had greater precaution compliance than
those without Standard precautions training.
However, a study in Iran showed that nurses with a
Master's degree despite having higher scores in
knowledge in Standard precautions did not reach a
satisfactory score for compliance in Standard
Precautions(Askarian et al., 2007).

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Level of Knowledge on Standard Precautions infectious disease. Respondents' knowledge was also deficient
when it comes to diseases' mode of transmission, especially
Table 2 presents the answers concerning the knowledge of the those diseases transmitted airborne.
respondents on Standard Precautions.
Findings indicated that nurses have good knowledge concerning
Success in the implementation of Standard Precautions standard precautions in comparison with the previous studies.
guidelines depends on health care workers receiving continuing 99.40% of the respondents know what is Standard Precaution,
education. A good level of knowledge with Standard Precautions and 91.67% were aware that the main objective of adherence to
was observed throughout the study, which is an excellent Standard Precautions is not only to protect the healthcare team
indicator of the possible decline in healthcare-associated but also other patients. However, 29.17% of nurses have not
infections; however, some areas need to be reinforced. Standard recognized that Standard Precautions should be used not only in
precaution's primary goal was severely neglected by the patients diagnosed with infection or patients suspected of the
respondents and believed that Standard Precautions was solely infectious disease but also to all patients regardless of their
used in patients diagnosed with infection or patients suspected of diagnosis.

Table 2. Responses to Questions Regarding Knowledge on Standard Precautions

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Table 3. Level of Compliance of Nursing Personnel

All respondents wash their hands immediately in case of contact There were respondents (7.74%) who still thought that bending
with blood or any other potentially contaminated materials, and or recapping needles was not forbidden.
98.21% believed that hand hygiene should be performed before
and after providing care to different patients. Some respondents (18.45%) thought that it was not necessary
to adopt the Standard Precautions measures when providing
Data showed that 12.5% of the respondents thought that glove nursing care to patients with hepatitis B or syphilis, which is very
was not mandatory when performing procedures with the dangerous since syphilis and hepatitis B can be acquired
patient's mucous membranes. Moreover, respondents thought through contact with infected blood. Measles, Tuberculosis and
that it was not necessary to wash hands after removing gloves. Varicella, can be acquired via airborne transmission, and
However, 99.40% of the respondents recognized that gloves 80.36% of the respondents thought that only Standard
should be changed when caring for one patient to another; also, Precaution in addition to the Droplet precautions was the
respondents were aware that in blood collection or venipuncture necessary measure to avoid those diseases.
procedures and contact with secretion or excretion, the use of
gloves was required. According to Mahony (1998), gloves do not Level of compliance of nursing personnel on Standard
eliminate 100% contamination of pathogens because fluids are Precautions
still capable of passing through the microscopic holes in the
gloves. The finding showed that nurses were compliant with Standard
Precautions contradicting several previous studies. Table 3
Most of the respondents were knowledgeable about the proper presents the answers concerning the compliance of the
use of personal protective equipment. Data showed that 97.02% respondents on Standard Precautions.
of respondents believed that PPE should not be shared and
contact with objects, materials, equipment, clothing, and Compliance with handwashing was extremely high. It can be
individuals with contaminated Personal Protective Equipment associated with the posters/signage and daily reiteration from
(PPE) should be avoided (93.45%). infection control nurses. Respondents were compliant in using

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Table 4. General Self-Efficacy of Nurses

gloves when performing procedures involving the possibility of These findings equated to an average level of perception in
contact to urine, feces, non-intact skin, mucosa, blood samples, individuals' capabilities to organize and apply the courses of
and secretions. However, the researcher investigated that nurse action needed to accomplish a specific goal. Bandura's (1997)
tend to forget to use gloves during the intramuscular and social cognitive theory considers self-efficacy as one of its core
subcutaneous injection, possibly because, during training, concepts. Also, it was considered as an influential parameter
lecturers reiterated that gloves are usually not necessary if there affecting the quality of clinical practice and nurses' perceived
was no bleeding that could result in hand contact with blood. professional benefits (NPPB) (Cheng et al 2020). “People who
Compliance with the use of an apron, protective glasses, are low in self-efficacy tend to see difficult tasks as threats they
disposable hats, and surgical shoes when there was a risk of should avoid and tend to avoid setting goals and have low levels
splashes or spray of blood and body fluids was relatively low. It of commitment to the ones they do make” (Bandura, 1997).
can be associated with the unavailability of materials, or nurses Several studies have evaluated the effect of self-efficacy in
were unaware of the availability of the material in the facility. This maintaining an optimistic attitude, reducing job burnout, and
finding is similar to the study conducted by Labrague, et al., increasing positive emotion (Stajcovic et al. 2018). “Some
(2012), Luo (2009), et al., and Sadoh, et al. (2006). Compliance researchers have reported that self-efficacy can improve an
in the disposal of sharps and used needles in a specific container individual's confidence to provide nursing practice in a complex
was relatively high. However, the researcher observed that the situation” (Pike et al., 2010)
respondents have low compliance when it comes to active
recapping of used needles or perform passive recapping of Relationship between Knowledge in Standard Precautions,
needles with only one hand, which resulted in needle stick injury Compliance in Standard Precautions, and General Self
among respondents. Needle-stick injury was prevalent and Efficacy.
usually unreported.
The data shown in Table 5 correlate the level of knowledge and
Level of General Self-efficacy of Nurses compliance in Standard Precautions to self-efficacy.

Nurses described their confidence in perceived situations and Although the researcher concluded a good level of knowledge
how they behave in different situations as average (see Table 4). among nurses, statistical analysis (Pearson r value of 0.279)

Table 5: Relationship between Knowledge, Compliance, and General Self Efficacy.

*Significance level, a = 0.05, N=168

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showed no relationship when correlated with compliance. This implementation of the protocol and strict audit in compliance
denotes that knowledge of Standard Precautions does not with Standard Precaution. Also, training in standard
necessarily influence compliance and its application. These precautions must be communicated not only to nurses but also
findings supported Pasay et al.'s (2015) study while to other health care workers. The infection control committee of
contradicting studies of Lou et al. (2009) and Lambrague et al. different institutions should strictly implement Standard
(2012), which reported that lack of knowledge is the primary Precaution protocol and do routine surveillance. Moreover, they
reason for non-adherence to standard and isolation precautions. should revisit the existing protocol and revise with the present
The coefficient of correlation obtained using Pearson r Is 0.492 status quo, availability of materials, and several workforces in
when the level of compliance was correlated to level general self- their facility.
efficacy. This statistical analysis showed an average level of
general self-efficacy has no relationship when correlated with Since no correlations were found with knowledge, level of
compliance with Standard Precautions. This finding denoted that compliance with Standard Precautions with self-efficacy when
self-efficacy did not necessarily influence the compliance of using a self-administered questionnaire, a follow-up study that
nurses to Standard Precautions. These findings sided the study incorporates actual observation in data collection is
of Lou et al. (2009) which proved that general self-efficacy recommended. Actual observation is a direct method for
cannot consider as a crucial determinant to skill performance in collecting data best for the study of human behavior. Moreover,
compliance with Standard Precautions. the data collected is accurate in nature and improves the
precision of the research result.
Conclusions
Even though it was found out that nurses have a very high level
The majority of the respondents were female and aged between of compliance with standard precautions, leaders and
20 to 39 years old. The age denoted that most nurses belonged educators should also create an effective compliance program
to the Millennial generation. A great number have worked in the to ensure that their workforce is following written policies and
hospital mostly for 4-6 years with Standard Precaution training. code of conduct that the institution set.
Most of the respondents hailed from the Operating Room,
Emergency Department, Female Medical Ward, Pediatric Ward, The future researcher might also consider hours of duty as a
and Surgical Complex. factor that may affect compliance with Standard Precautions
since limited attention has been paid to the prolonged hours
A good level of knowledge and high-level compliance with worked by nurses or the effects of these hours on patient safety.
Standard Precautions were observed throughout the study. This
is an excellent indicator of the possible decline in healthcare- ____________________
associated infections; however, some areas need to be
reinforced. References
Nurses described their self-efficacy as an average which
denoted an average level of perception in individuals' Askarian, M., Memish, Z., & Khan, A. (2007). Knowledge,
capabilities to organize and apply the courses of action needed Practice, and Attitude among Iranian Nurses, Midwives,
to accomplish a specific goal. and Students Regarding Standard Isolation Precautions.
Infection Control & Hospital Epidemiology, 28(2), 241-244.
Although the researcher concluded a high level of knowledge DOI: 10.1086/510868
and the average level of general self-efficacy among nurses, Bandura A. (1997) Self-efficacy: TheExerciseofControl.
statistical analysis showed no relationship when correlated with NewYork: WH Freeman and Company Centers for Disease
compliance. This concluded that knowledge and general self- Control and Prevention (2019). Standard Precautions for
efficacy do not necessarily influence compliance and its All Patient Care, [Link] infectioncontrol/
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Recommendations Surveillance of healthcare personnel with HIV/AIDS, as of
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very high among respondents; however, certain areas need to Chan, R., Molassiotis, A., Eunice, C., Virene, C., Becky, H.,
improve specifically in using a glove, eye shield, and apron Chit-Ying, L., & Ivy, Y. (2002). Nurses' knowledge of and
during a procedure. The researcher recommended the strict compliance with universal precautions in an acute care

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hospital. International Journal of Nursing Studies, Stajkovic, A. D., Bandura, A., Locke, E. A., Lee, D., & Sergent,
39(2),[Link]: [Link] [Link]/10.1016/S0020 K. (2018). Test of three conceptual models of influence of
7489(01)00021-9 the big five personality traits and self-efficacy on
Cheng L;Cui Y;Chen Q;Ye Y;Liu Y;Zhang F;Zeng W;Hu X; academic performance: A meta-analytic path-analysis.
(n.d.). Paediatric nurses' general self-efficacy, perceived Personality and Individual Differences, 120, 238–245.
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benefits from Class A tertiary hospitals in Jilin province of World Health Organization. (2015). Infection prevention and
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Creedon, S. (2008). Hand hygiene compliance: Exploring control/background/en.
variations in practice between hospitals. Nursing Times, World Health Organization; (2011) .Report on the endemic
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Efstathiou, G., Papastavrou, E., Raftopoulos, V., & Merkouris, A. [Link]
(2011). Compliance of Cypriot nurses with standard 241501507_eng.pdf. Accessed September 20, 2019.
precautions to avoid exposure to pathogens. World Health Organization (2004): Practical Guidelines for
Nursing & Health Sciences, 13(1), 53-59. Infection Control in Health Care Facilities. SEARO and
[Link] WPRO Publication No. 41. 2004, New Delhi: India and
Gebresilassie, A., Kumei, A., & Yemane, D. (1970, January 1). Manila: The Philippines
Table 2 from Standard Precautions Practice among Health Wilson, M., & Gerber, L. E. (2008). How generational theory
Care Workers in Public Health Facilities of Mekelle Special can improve teaching: strategies for working with
Zone, Northern Ethiopia: Semantic Scholar. undefined. the “Millennials.” Currents in Teaching and Learning, 1(1),
[Link] paper/Standard- 29-44.
Precautions-Practice-among-Health-Care-in-Gebresilassie-
Kumei/a81660659c637819cb35fc79c41068444babed87/
figure/1. ABOUT THE AUTHOR
Labrague, L. J., Rosales, R. A., & Tizon, M. M. (2012).
Knowledge and Compliance of Standard Precautions
among Student Nurses. International Journal of Crisanto De Guzman Gatbunton
Advanced Nursing Studies, 1(2). [Link] MAN, RN, earned his nursing degree at
10.14419/ ijans.v1i2.132 Our Lady of Fatima University College
Lou, Y., PingHe, G., WeiZhou, J. (2009, March). of Nursing, Valenzuela City in 2012 and
Factors impacting compliance with Standard finished his Master's Degree in Nursing
Administration at Dr. Gloria Lacson
Precautions in nursing, China. Retrieved from
Foundation Colleges, Inc. in 2020. He
[Link] is a COVID-19 Ward Nurse/ Mental Health Nurse at Dr.
S1201971210025014#! Paulino J. Garcia Memorial Research and Medical Center .
Mahony, C. (1998). The need for a clear policy on glove use. His research interests include patient safety, infection
Nursing Times, 94(17), [Link] control, and mental health.
9625988/.
Pasay, J. M., Robles, C. J., Awa, A. L., & Enguito, M. R. (2015).
Compliance with Standard Precautions Among Hospital Acknowledgment
Nurses in Ozamiz City, Philippines. Journal of
Multidisciplinary Studies, 4(1). [Link] The author wishes to acknowledge the guidance of
jmds.v4i1.855 Dr. Alexander Tiongson and Mrs. Pinky Miriam Canlas
Pike, T., & O'Donnell, V. (2010). The impact of clinical MAN, RN.
simulation on learner self-efficacy in pre-registration
nursing education. Nurse Education Today, 30(5),
405–410. [Link]
Sadoh, WE, Fawole, AO, Sadoh, AE, Oladimeji, AO &
Sotiloye, OS. (2006). Practice of universal precautions
among health care workers. Journal of the National
Medical Association 98(5): 722–6.

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RESEARCH ARTICLE

Transition Experience to Professional Nurse:

A Phenomenological Approach
Jo-Ann F. Cummings, PhD, RN1, Stephanie M. Chung, PhD, RN2, and Lisa D. Wardle, MA3

Abstract
Purpose: Transition programs have been adopted by many healthcare institutions to assist the new graduate nurse as they adjust
to the work environment. The use of structured residency programs and prolonged orientations are considered best practices to
ease the new graduate nurse into their role. This study aims to describe the lived experience of new graduate registered nurses as
they enter the workforce.
Design: Using a qualitative research design, Van Manen's phenomenological inquiry, study participants were selected using non-
probability purposive sampling. Data were collected between December 2018- September 2019 with in-depth interviews using
semi-structured questionnaires. The sample (N=7) consisted of participants born between the years 1986-1996, graduated within
three years of the study, and practice in the northeastern region of the United States.
Method: A modified Colaizzi approach allowed the researchers to return to the study participants to validate themes.
Findings: The experience and perceptions of new graduate registered nurses are unified in two major themes discussed within
this article: emotional ambivalence and the need to escape.
Conclusion: New graduate nurses continue to feel overwhelmed and need structured guidance during their professional transition
training programs. In the absence of strong support by the institution, new graduates leave the bedside.
Keywords: new graduate registered nurses, transition shock, phenomenology, Colaizzi Method, organizational issues, residency
programs, turnover

Introduction

T he impact of nurse turnover at the bedside is a global

concern that extends beyond the United States. Turnover
rates and factors influencing turnover have been examined
conflict, and reality shock (Garcia-Martin et al., 2020; Kramer,
1974; Riegel, 2013).

locally and abroad. Common factors include concerns related Previously, newly graduated nurses have been reported to
to the work environment, staffing, and resources (Alijohani & leave their first job or have left the profession (Kovner et al.,
Alomari, 2018; Chen et al., 2018; Lyu, Li, & Li, 2016; Park & 2014). The reported turnover rates for new graduates range
Ko, 2020). from 30% in the first year of practice to as high as 57% in the
second year (Lippincott Solutions, 2017). Attrition rates for new
Various research articles have been written on the transition of graduate registered nurses are higher when compared to
nurses during the first year of practice (Asber, 2019; Cadmus & experienced registered nurses (RNs). In 2019, over 22.9% of all
Wurmser, 2019; Hofler & Thomas, 2016; Jones-Bell et al., 2018; new RNs left within a year (NSI, 2019). In the US, the average
McInnes et al., 2019; Pasila, Elo, & Kääriäinen, 2017). It has hospital loss ranged from 4.4 million to 6.9 million, with the
been well documented as a major period of adjustment average cost of turnover for a bedside RN $52,100 (roughly
(Duschscher & Cowin, 2004; Duchscher, 2008; Duschsher, PHP2.7 million) (NSI, 2019).
2009; Duchscher &Windey, 2018; Kramer, 1974). The transition
of a graduate nurse from student to professional has been In 2010, The Institute of Medicine (IOM) Future of Nursing
recognized as a time of stress, role adjustment, interpersonal Report provided recommendations to create, fund, and
1 Jo-Ann F. Cummings, PhD RN Associate Professor, School of Nursing, Georgian Court University, jcummings@[Link];
Corresponding author, School of Nursing, Georgian Court University, 900 Lakewood Avenue, Lakewood New Jersey 08701 United States
2 Stephanie M. Chung, PhD RN Assistant Professor, School of Nursing, Georgian Court University, schung@[Link]
3 Lisa D. Wardle, MA Program Coordinator, School of Nursing, Georgian Court University, lwardle@[Link]

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implement transition-to-practice programs to develop skills and nurse manager, and nurse educator collaborate and evaluate
reduce turnover rates. The retention of nurses is a priority for the NGRN for strengths and weaknesses.
healthcare organizations. Higher productivity, reduced
employee turnover, succession planning are all benefits Method
realized with the achievement of this goal. The development of
nurse residency programs has been identified as a key strategy To investigate new nurse graduates' experiences, interpretive
to support their successful transition into practice. phenomenology (Van Manen, 1990) was the framework used to
uncover and describe the internal meaning structures of the
Lin, Viscardi, and McHugh (2014) conducted a systematic lived experiences. The investigators conducted multiple
review that examined factors that influence job satisfaction of readings of the text considering each sentence and sentence
nurse residency programs. The review was based on 11 studies; cluster to further understand the experience. A modified Colaizzi
seven domains found to influence new graduate nurses' (1978) approach was used to systematically analyze the data.
satisfaction included: extrinsic rewards, scheduling, interactions This is a unique method that includes returning to the study
and support, praise and recognition, professional opportunities, participants to validate themes.
work environment, and hospital system. The authors concluded
the literature demonstrates benefits associated with nurse Participants and setting
residency programs.
Approval for the study was obtained through the Institutional
Letourneau and Fater (2015) conducted an integrative review of Review Board at the university where the researchers work. The
the literature for articles published from 2006 to 2013 to explore qualitative study was conducted between December 2018-
nurse residency programs and evaluate the evidence September 2019. Recruitment advertisements were placed on
supporting their use. The findings demonstrate increased social media websites and distributed to local hospitals.
retention and decreased 12-month turnover rates and offer Participants were selected based on purposive, convenience,
evidence to support nurse residency programs for newly and snowball sampling. Inclusion criteria included: graduation
licensed nurses. in 2016 or more recently; license to practice in the United States
as a registered professional nurse; and willingness to share
In 2019, Wildermuth and colleagues conducted a experiences about transitioning into professional practice. In
phenomenological study to explore the lived experiences of a this study, nurses were born between 1986-1996, a sample of
cohort of nurses as students and new graduate nurses during seven volunteers included a mix of graduates from associate,
the transition in the nurse residency program. Using Meleis' accelerated, and traditional baccalaureate nursing programs.
(2010) Transition Experience Theory as a theoretical framework The participants included two males and five females all working
three major themes emerged which included: feeling on the Northeastern Coast of the United States (Table 1). Four
overwhelmed, feeling supported, and feeling confident. The Caucasian females, one African American female, one
study findings were consistent with Meleis' theory that transition Caucasian male, and one Asian Filipino male immigrant. Most of
can be facilitated or inhibited by personal, community, or societal the participants are United States citizens. The seven
conditions (Wildermuth et al., 2019). participants effectively communicated and provided strong
quality experiences this allowed for data saturation and
The study aims to follow up on individual new graduate additional cases were not necessary.
registered nurses as they transition into the practice setting. The
questions posed were “What are the experiences and Data collection and analysis
perceptions of new graduate registered nurses' (NGRN) as they
transition into the work environment?” and “What is it like to be To ensure participants met the criteria, individuals were
an NGRN?”. contacted by either the primary or secondary researcher over
the telephone. For those who qualified, a description of the study
In this study, a formal residency program is defined as a year- was provided. For those who did not meet the criteria, the
long program that consists of six months of didactic and clinical researchers used the approved script to thank and decline
orientation with an assigned experienced preceptor. In the last individuals. Written consent to participate was obtained from
six months of the program, the NGRN is taken off orientation and each participant prior to the start of the interview. Semi-
functions independently with an assigned clinical unit mentor for structured interviews were performed by the primary (JC) and
ongoing mentorship and support. secondary researcher (SC). JC is trained as a qualitative
researcher and SC in mixed methodology. Both are registered
An orientation program is defined as the NGRN working with an nurses. Interviews were approximately one to one and a half
assigned preceptor for 90 days. During this time frame, the hours in length and were conducted via Skype, phone, and in-
NGRN is guided through orientation while the preceptor, unit person. Face-to-face interviews were conducted in mutually

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Table 1. Demographics

agreed-upon public locations with conference space. As part of the data, four of the seven participants reviewed the exhaustive
the research protocol and ethical considerations, a contact description of what it is like to be an NGRN. The results of the
number for free counseling services to a local community health study include numerous quotes that are transcribed verbatim to
center was provided should participants need to further discuss capture the essence of experiences.
any concerns or want mental health support. A semi-structured
interview guide was developed for this study with seven The dependability and confirmability of the study are supported
demographic and nine open-ended questions centered on by coding checks that show agreement within and among the
participants' experiences as a new nurse in practice. The list of concepts and themes. An intersubjective agreement was
questions was not tested before implementation. Preparation of achieved at each phase of data analysis. Peer debriefing and
the questions considered topics to be covered with each exhaustive audit trails include memos and journals that record
participant that the interviewer would encourage participants to researchers' thoughts, reflections, and decisions about the data
talk freely and tell stories in their own words. Field notes were and coding procedures.
taken during and after interviews. During the interview, the
researchers made notes of statements then revisited
Findings
statements to further explore and clarify. The transcripts extracted 195 significant statements regarding
The interviews were digitally recorded and transcribed to the transition experience. Significant statements and their
produce typed verbatim accounts. Microsoft Word and Excel corresponding formulated meanings were identified.
(2007) were used for the management and analysis of data. The Categories for emotional ambivalence include self-doubt, fake
modified Colaizzi (1978) steps were followed to analyze it, and validation. Categories for the need to escape include
participant responses: a) read all transcripts; b) extract leaving the bedside and returning to school. This article
significant statements; c) formulate meanings; d) organize discusses two major themes: emotional ambivalence, and the
meanings into cluster themes; e) integrate to exhaustive need to escape.
descriptions; f) formulate an exhaustive description of the Serendipitous findings found that nurses who started in a non-
phenomenon; and g) participants were invited to review findings hospital setting developed firmer confidence in acclimating to
(not all participants returned feedback and two repeat interviews the role of the registered nurse. With low acuity clients,
were conducted). Two main coders JC and SC coded the data, repetition of skill and task allowed for better delegation and
the third member of the team LW provided an outside advocacy of client care in knowing what to expect. In addition,
perspective to assist with generating deeper insights and new nurses who came from families with nurses such as parents
understandings. The consolidated criteria for reporting or siblings were better able to navigate their concerns and
qualitative research (COREQ) recommendations were followed insecurities through levity and strong social support. Social
when the study was conducted (Tong, Sainsbury, & Craig, 2007). support allowed for discussions on the affirmation of the NGRN
role, how-to better handle a situation, and how to process and
Trustworthiness of Data reflect on experiences.
Using a phenomenological reductionistic technique, JC and SC Emotional Ambivalence
employed bracketing to make clear their own understandings,
beliefs, and assumptions of experiences to limit potential bias A common theme noted among the participants was the
prior to data collection and analysis. To ensure the credibility of onslaught of positive and negative emotions. The role transition

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and multiple responsibilities of work led participants to examine Validation

their thoughts, feelings, and choices. Participants felt
vulnerable, struggling, and working beyond their capacity. This There was a need to validate that what they were doing was
manifested in physical symptoms such as feeling shortness of constantly right. It helped to motivate them to move forward.
breath, inability to sleep, and crying uncontrollably either at Acceptance of questions, predictability, positive feedback, and
home, work, or both. Participants questioned whether to stay or flattery went a long way.
leave their current jobs, with any unfavorable event easily
pushing them to leave. “…not to get like a millennial… but [say] you did that right,
you're doing a good job…maybe just like hey, that was
“Internally, I was struggling immensely and I didn't know great, you did the proper technique, you were sterile during
what to do, or how to deal, with this struggle....I felt the technique, you followed the policy…stuff like that, it's
constantly defeated" Participant 1 huge…” Participant 3

Self-Doubt Besides wanting feedback from the preceptor, managers,

physicians, and others, the participants informally questioned
Fearful that they were being judged as having zero critical their peers asking about their own experiences to compare if
thinking skills there was constant uncertainty and hesitation, a their situation was better or worse. The participants wanted to
stream of endless questions. With the number of questions hear that they were not alone in this journey and that they were
asked, NGRNs worried about how other nurses viewed their not the “worst” nurse in the world.
abilities. They were worried about making mistakes and would
pause, review, and revisit tasks frequently. This insecurity limited The Need to Escape
them from moving forward from even the most basic of tasks. Many participants were dissatisfied with their current position. To
They needed to stop and think of a procedure step-by-step. take control of the situation, they planned to either leave their
“I would question, double-check, triple-check everything current jobs, go back to school, or leave the nursing field to
escape the unfavorable conditions.
because I didn't want to make a mistake, or I felt like, did I
do this right, even go home and think [sic did I] chart that “ After multiple times of being disappointed, feeling I was
right, did I sign the MRI checklist right... did I even write being taken advantage, defeated, the first opportunity to
patient is a full code, something as simple as that... I leave, I took it…words cannot paint the horrors of the
definitely felt insecure” Participant 3 hospital, thinking that I would be there longer, I could not
wait to get out” Participant 1
Not knowing what to expect, their thoughts even on days off
gravitated towards work and would cause a great deal of anxiety. “I think for me it's more of looking for a job that won't
The anticipation of returning to the unit would cause a visible decentralize your other aspects of life...I don't want my job to
change in their demeanor noticeable to family and friends. Some be my life, I want a job that can help my life be better.”
participants adopted unhealthy behaviors such as drinking Participant 7
alcohol and binge eating.
Leaving the bedside
“Fake It”
For participants, the thought of staying long-term in nursing,
The NGRN had to pretend they had the knowledge and the especially at the bedside, did not seem realistic, the work was
ability to deal with situations and to care for clients and their viewed as arduous and taking a physical and psychological toll.
conditions though they had no experience. They had to fake they
had done a task or procedure a hundred times before; but, “I'm done with nursing, there's plenty of other jobs and I could
internally, they were filled with anxiety. They did their best to probably make more money. I wasn't eating. I was losing
apply what had been learned but reverted to being reactionary weight that's why I left…I could go somewhere else and have
versus analytical and systematic. a good time” Participant 3

“...every day still feels like I'm brand new … but then, you Going back to school
got to walk into the room you have to act like, you've been
doing this your whole life and it's like I've only been alive 24 Working beyond their capability and never feeling the work was
years, I haven't seen ... it gives me such anxiety, thinking I completed― these excessive burdens would cause nurses to
have to walk into a room and not know what I'm doing" resolve the conflicts by running away from it. Viewed as a haven,
Participant 4 the academic environment offered NGRN the ability to stay

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connected with nursing without withdrawing completely from moral outrage, and 4) conflict resolution. The findings of this
nursing practice. study highlight similar features noted in phase three (moral
outrage) and phase four (conflict resolution).
“Some days I come home out of desperation looking at
master's programs, I can't do this, I'm burned out…” In this study, the theme “emotional ambivalence” and Kramer's
Participant 5 moral outrage are characterized by feelings of tremendous
upheaval and turmoil, which usually encompasses anger,
Discussion frustration, and intense discomfort (Kramer, 1974, p. 158).
Emotional turmoil and shock have also been noted in previous
The findings of this article discuss two main themes: emotional studies (DeGrande et al., 2018; Hussein et al., 2017; Martin &
ambivalence and the need to escape. As previously noted, Wilson, 2011; Olson, 2009: Pellico, Brewer, & Kovner, 2009;
themes were not identified in advance to allow for a more Wildermuth, Weltin, & Simmons, 2019).
unbiased approach to the data, and to accept the information
without overlying assumptions from the literature. For this study, the need to escape was initially thought of as a
unique finding. However, a review of the literature uncovered
Garcia-Martin et al. (2020) conducted a qualitative study on the that Kramer's conflict resolution explains the phenomenon from
transition of new nurses to the emergency department during the a broader perspective. Kramer (1974) explains that the conflict
COVID-19 pandemic. In the results, three major themes resolution phase is characterized by evaluation and choice.
emerged from the data: Fears and concerns, organizational Conflict resolution has different aspects that may present as
issues, and support for novice nurses. The theme “fears and nurses who withdraw from nursing practice or who retreat to the
concerns” were specific to the COVID-19 pandemic. This is a Ivory Tower of school (Kramer, 1974, p. 159). Martin and Wilson
unique aspect of nursing practice that was not present during the
(2011) conducted a phenomenological study of newly
completion of the current study.
registered nurses' experience in the first year of practice. They
In the literature, reality shock has been used to describe “the discussed the resolution phase as a point where participants
shock-like reactions of new workers when they find themselves decided about the future which included changing positions,
in a work situation for which they have spent several years returning to school, or leaving nursing altogether.
preparing and for which they thought they were going to be
prepared, and then suddenly find that they are not” (Kramer, Limitations
1974, pp. vii-viii). Reality shock used as a construct
encompasses “the total social, physical, and emotional response Limitations of this study include the small sample of seven
of a person to, the unexpected, unwanted, or undesired, and in participants from one geographic location in the Northeastern
the most severe degree the intolerable” (Kramer, 1974, pp. 3-4). United States. The results of this study may not be
More recent studies have noted reality shock (Hoare, 2016; generalizable to a broader audience. However, the specific
Duchscher & Windey, 2018; Martin & Wilson, 2011). However, it context may be applicable to other NGRN transition
is the theoretical construct of transition shock by Duchscher experiences. Despite the small sample size, the rich text and
(2009) that captures the physical, intellectual, and emotional saturation of data were clearly associated with previous
factors experienced by participants in this study. Duchscher and literature on the experiences of recently registered nurse
Windey (2018) posit that transition shock is a dynamic process graduates. Both the primary (JC) and secondary researcher
that consists of various stages: doing, being, and knowing. In (SC), interviewed participants familiar with them, which allowed
stage one, “doing” encompasses the first three to four months for interviews that contained both positive and negative views.
post orientation and is marked by a wide range and fluctuation of However, participants may have withheld comments given the
emotions as the new nurse works through discovering, learning, perceptions of authority and power. Last, the COVID-19
performing, concealing, adjusting, and accommodating pandemic has added a new facet to the practice setting of new
(Duchscher, 2008). Based on the results of this study, the NGRN nurse graduates, a condition that was not present during the
did not stay in the field or position long enough to pass the doing conduct of the present study. This study further supports
phase. Approximately, three of the seven participants, at the time organizations to continuously assess and evaluate transition
of the interview, were already in their second job or seeking their support programs to address new nurses' perceptions and
third job. Four of the seven had applied or enrolled for further experiences.
education, not necessarily in nursing.
Recommendations
Kramer (1974) describes Postgraduation Nurse Socialization:
An Emergent Theory. In the emergent theory there are four The NGRN enters the workforce with limited practical nursing
phases: 1) skill and routine mastery, 2) social integration, 3) experiences and only basic clinical and work-management

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skills. The health organization is tasked with the responsibility to Sciences, 5. 396-402. [Link]
recognize these initial limitations, but then actively design and [Link].2018.09.012
implement successful transition programs. The participants in Colaizzi, P. (1978). Psychological research as the
this study experienced feelings of being overwhelmed and these phenomenologists views it. In R. Valle & M. King (Eds.).
findings contribute to our understanding and can inform Existential phenomenological alternatives for psychology (pp.
interventions to close the preparation and practice gap. 48-71). New York, NY: Oxford University Press.
Transition models that build in and demonstrate feelings of DeGrande, H., Liu, F., Greene, P. (2018). The experience of new
support that facilitate prolonged engagement with a preceptor graduate nurses hired and retained in adult intensive care
will aid in the retention of NGRNs. The NGRN must be nurtured units. Intensive & Critical Care Nursing, 49, 72-78.
into the role. The increased acuity of patients equates to an [Link] 10.1016/[Link].2018.08.0005
increase in responsibility and demands of the nurse to provide Duchscher, J.B. (2008). Becoming: The stages of new nursing
safe effective patient care. graduate professional role transition. The Journal of
Continuing Education in Nursing, 39(10),441-480.
Conclusion Duchscher, J.B. and Windey, M. (2018). Stages of transition and
transition shock. Journal for Nurses in Professional
The findings of this study present the lived experience of NGRNs Development, 34(4), 228-232.
post the IOM recommendations in 2010. With some participants Duchscher, J.E. B. (2009) Transition shock: The initial stage of role
graduating in 2016 and licensed in 2017, transition programs adaptation for newly graduated registered nurses. Journal of
should be well-developed seven years after the IOM Advanced Nursing, 65(5), 1103-1113.
recommendations. The evidence suggests that NGRNs Duchscher, J.E.B. and Cowin, L.S. (2004). The experience of
continue to feel overwhelmed and need structured guidance marginalization in new nursing graduates. Nursing
during their professional transition training programs. This Outlook,52(6),289-296.
includes resources and support from organizational leadership, Garcia-Martin, M., Roman, P., Rodriguez-Arrastia, M., Diaz-
nurses, and well-rounded training experiences. The Cortes, M., Soriano-Martin, P.J., & Ropero-Padilla, C. (2020).
development and implementation of structured nurse residency Novice nurse's transitioning to emergency nurse during
programs are exemplary accomplishments for the profession. COVID-19 pandemic: A qualitative study. Journal of Nursing
Organizations should continue to implement ongoing Management, 29(2), 258-267. [Link]
surveillance of transition programs to evaluate the quality and jonm.13148
outcomes (Cadmus & Wurmser, 2019). Hoare, K.J. (2016). Retaining new graduate nurses in practice;
under-pinning the theory of reciprocal role modeling with
What is it like to be an NGRN? To be a new graduate registered routinization theory and transition shock. Social Theory &
nurse is an overwhelming experience filled with emotional Health 14(2), 224-238.
exhaustion and uncertainty. The preoccupation to provide Hofler, L., &Thomas, K. (2016). Transition of new graduate nurses
competent safe care leads to feelings of insecurity and anxiety, to the workforce: Challenges and solutions in the changing
that if left unchecked, result in graduate nurse turnover. health care environment. North Carolina Medical Journal,
77(2) 133-136.
Hussein, R., Everett, B., Ramjan, L.M., Hu, W., &Salamonson, Y.
____________________ (2017). New graduate nurses' experiences in a clinical
specialty: a follow up study of newcomer perceptions of
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Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria

Kovner, C.T., Brewer, C.S. Fatehi, F., Jun, J. (2014). What does for reporting qualitative
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Politics, & Nursing Practice, 15 (3-4) 64-71. DOI groups. International Journal for Quality in Health Care,
10.1177/1527154414547953 19(6), 349-357. [Link]
Letourneau, R.M., & Fater, K.H. (2015). Nurse residency
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ABOUT THE AUTHORS
Lippincott Solutions. (2017, October 18). Recruiting & retaining
new nurse grads [Web log post]. Retrieved from
[Link]
8/recruiting_retainiiysQ.html Jo-Ann Cummings, PhD, RN is an
Lyu, L., Li, G., Li, J., & Li, M. (2016). Nurse turnover research in Associate Professor of Nursing at
China: A bibliometric analysis from 2000-2015. International Georgian Court University. Dr. Cummings
Journal of Nursing Sciences, 3, 208-212. [Link] is the current governance chair Psi Psi 549
10.1016/[Link].2016.04.008 Chapter of Sigma Theta Tau International
Martin, J., and Wilson, C.B. (2011). Newly registered nurses' Nursing Honor Society. Her research areas
include pediatric care and practice in the
experience in the first year of practice: A phenomenological
emergency department setting, nursing education, and role
study. International Journal for Human Caring, 15(2), 21-27. development.
McInnes, S., Halcomb, E., Huckel, K., & Ashley, C. (2019).
Experiences of registered nurses in a general practice-based Stephanie Chung PhD, RN is an Assistant
new graduate program: a qualitative study. Australian Journal Professor of Nursing at Georgian Court
of Primary Health, 25, 366-373 University. Dr. Chung is the faculty adviser
Meleis, A.I. (2010). Transitions theory: Middle range and situation to the student nursing club. Her main areas
specific theories in nursing research and practice. New York: of teaching are medical-surgical and
NY: Springer. fundamentals. Her research areas include
NSI Nursing Solutions INC. (2019). 2019 NSI national health care generations of nurses, specifically
retention & RN staffing report. Retrieved from millennials, transcultural nursing, and transgender clients.
[Link]
I_National_Health_Care_Retention_Report.pdf Lisa Wardle, MA holds a master's degree
Olson, M.E. (2009). The “Millennials”: First year in practice. in holistic health. With over 10 years of
Nursing Outlook, 57, 10-17. experience in higher education, Mrs.
Wardle is the Accelerated Bachelor of
Park, B., & Ko, Y. (2020). Turnover rates and factors influencing
Nursing Program Director of Georgian
turnover of Korean Acute Care Hospital Nurses: A Court University School of Nursing.
retrospective study based on Survival Analysis. Asian
Nursing Research, 14 293-299. [Link]
[Link].2020.09.001
Pasila, K., Elo, S., &Kääriäinen, M. (2017). Newly graduated
nurses' orientation experiences: A systematic review of Acknowledgment
qualitative studies. International Journal of Nursing Studies, Data collection and preliminary analysis were sponsored by a
71, 17-27. Mini-Faculty Grant by Georgian Court University. We have no
Pellico, L.H., Brewer, C.S., & Kovner, C.T. (2009). What newly conflicts of interest to disclose.
licensed registered nurses have to say about their first
experiences. Nursing Outlook, 57, 194-203.
Riegel, E.M. (2013).Orienting a new generation of nurses:
Expectations of the millennial new graduate. Open Journal of
Nursing, 3, 461-466.

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RESEARCH ARTICLE

Development and Effect of the

Online HIV Prevention and Care Training (HPCT)
Program for Student Nurses
Ryan Q. De Torres, MA (Nursing), RN1, Rose Zuzette M. de Leon, MAN, RN2,
Conchita Aranil-Palencia, MN, RN3, and Gracielle Ruth M. Adajar, MA (Nursing), RN4

Abstract
Student nurses must be competently prepared to address the rising human immunodeficiency virus (HIV) epidemic in the
Philippines. This article presents the development and effect of the online HIV Prevention and Care Training (HPCT) program for
student nurses. The Iowa Model-Revised guided the development of the program. Literature review, student and faculty
engagements, advocate participation, resources and protocol assessment, and pre-HPCT survey analysis were systematically
performed to determine the contents and delivery of the program. The participants were 2nd and 3rd year level student nurses who
were asked to answer the pre- and post-HPCT online surveys containing sociodemographic, HIV knowledge, attitudes, and
perceived practices, and program evaluation questionnaires. Descriptive and inferential statistics were performed using SPSS
version 23. Student nurses in the post-HPCT survey obtained significantly higher HIV knowledge scale mean scores (mean=18.22,
SD=4.138) than those in the pre-HPCT survey (mean=15.01, SD=4.069) (p=.000). Pre- to post-HPCT survey revealed significant
decreases in the proportions of student nurses who agreed on the following: HIV-positive patients should not be put in rooms with
other patients when admitted to hospital (44.3%, 31.6%; p=.004); the need to worry about putting family and friends at risk of
contracting the disease when caring for a person with HIV/AIDS (39.7%, 26.4%; p=.002); and healthcare workers are worried of
getting HIV/AIDS from caring for a person with HIV/AIDS in their work environment (47.2%, 37.5%; p=.011). Significantly, more
student nurses in the post-HPCT survey agreed in all the items of the HIV practice scale than those in the pre-HPCT survey. The
online HPCT program was acceptable with beneficial effects on student nurses' HIV knowledge, attitudes, and perceived practices.
There is a need to highlight basic HIV concepts and integrate HIV developments in the education of student nurses.
Keywords: evidence-based nursing, HIV, program development, student nurses, online learning

Introduction

D espite multiple efforts exerted on prevention, treatment,

and management, human immunodeficiency virus (HIV)
remains a national and global public health concern. To
international global funds (UNAIDS, 2020). The approval of
Republic Act 11166 (Philippine HIV and AIDS Policy Act) in 2018
aims to strengthen the delivery and access of comprehensive
eradicate the acquired immunodeficiency syndrome (AIDS) and multi-sectoral HIV prevention, education, treatment, and
epidemic by 2030, the Joint United Nations Programme on care programs. The use of pre-exposure prophylaxis (PrEP)
HIV/AIDS (UNAIDS) (2015) set the global HIV targets of 95-95- and HIV self-test kits has been rolled out (UNAIDS, 2021).
95. This target means that 95% of persons living with HIV Despite the availability of services and allocation of resources
(PLHIV) will know their status, with 95% of them on treatment for HIV prevention and treatment, the Philippines fell short in
and 95% virally suppressed among treated. Comprehensive reaching global HIV targets, with only 73% of PLHIV knew their
and intensified efforts are being exerted to fight the burgeoning status, and 61% of them on treatment in 2019 (UNAIDS, 2020).
impact of HIV in the Philippines. The country's total financial
expenditures for HIV in 2013 were around USD 10.3 million, with Health professionals are vital resources to improve HIV
most of the finances coming from domestic public and prevention and care service delivery. However, they must
1 Corresponding author, Assistant Professor, Ph.D. in Nursing Student, College of Nursing, University of the Philippines Manila; rqdetorres@[Link]
2 Ph.D. in Nursing Student; College of Nursing, University of the Philippines Manila
3 Ph.D. in Nursing Student, College of Nursing, University of the Philippines Manila; Associate Professor, Bicol University
4 Ph.D. in Nursing Student, College of Nursing, University of the Philippines Manila; Staff Nurse, Lung Center of the Philippines

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possess the competency to provide evidence-based and this step, we identified salient topics and teaching strategies in
culturally congruent care for Filipinos at risk of HIV and those HIV education. Finally, we synthesized it by creating an initial
living with HIV. It has been reported that health professionals outline of topics and the related activities and ways of delivering
exhibit stigma that discourages people from accessing and using them.
HIV prevention and care services (Arias-Colmenero et al., 2020;
Ingram et al., 2019). HIV-related stigma is negatively associated Student and faculty engagement and preferences
with PLHIV's medication adherence and quality of life (Ingram et
al., 2019). To address this concern, HIV-related training and Initially, we planned to implement the program in one nursing
educational programs can increase the capacity of health school. However, we decided to open it to student nurses from
professionals to meet the varying and complex needs of different nursing schools based on the recommendations by a
populations at risk of HIV and PLHIV (Feyissa et al., 2019). In a dean of a nursing school, a student nurse organization, and
cross-sectional study, doctors with formal HIV/AIDS training were faculties. We interviewed course coordinators and faculties
less likely to show discriminatory intent at work (Vorasane et al., involved in HIV education to examine the contents and delivery of
2017). Nurses with formal HIV/AIDS training were less likely to HIV lectures and discussions. It helped review the units and time,
have feelings of not providing good care for PLHIV (Vorasane et duration and coverage, and teaching strategies for HIV
al., 2017). Different modes, activities, and platforms to deliver HIV education.
education have significant effects on recipients' HIV knowledge,
Assessment of resources and protocols
attitudes, and perceptions (Feyissa et al., 2019). Basic and
updated HIV-related education and training can eliminate or We examined various resources like teaching plans, materials,
reduce HIV-related stigma in healthcare, thus, promoting optimal and protocols on HIV education. We reviewed current literature
delivery of HIV-related services to individuals and communities. on HIV in the Philippines, including policies and programs of
This article reports the development and impact of the online HIV different agencies such as the Department of Health (DOH),
Prevention and Care Training (HPCT) program for student nurses World Health Organization (WHO), and UNAIDS. We examined
as part of a doctoral course in Nursing and Health Program the Nursing curriculum from the Commission on Higher
Development. Education (CHED) and other nursing schools to further identify
the scope and components of the program.
Program Development and Implementation
We used the frameworks by McNairy and El-Sadr (2014) and Fox
We used the IOWA Model-Revised (Iowa Model Collaborative et
and Rosen (2017) to refine and broaden the initial outline of the
al., 2017) to guide the program's development, implementation,
program. McNairy and El-Sadr's (2014) framework focused on
and evaluation. The model provides a systematic and evidence-
four main points of the HIV prevention continuum, while Fox and
based approach to organizing a team to create, implement, and
Rosen's (2017) focus on salient points of the HIV care continuum.
evaluate an intervention. We followed the six steps of the model.
Develop and implement the program and create an
Program team creation and setting identification
evaluation plan
We created the online HPCT program with guidance from an nd
expert in Nursing science, adult health, and health program To be included in the program, student nurses should be 2 and
development. Our team was composed of four Doctor of 3rd year level and agree with the participation agreement form. At
Philosophy in Nursing students with varying work experience and these levels, participants were expected to have taken
educational backgrounds. The conceptualization of the program fundamental courses in Nursing, making the program appropriate
started in December 2020, and then succeeding meetings were to them. We sent the program invitation and Zoom link to
made to plan the program. participants who registered and met the criteria. To recruit
participants, we sent emails to respective heads, coordinators,
Search and synthesis of body of evidence faculties, and student nurse organizations of different Nursing
schools. Flyers were also posted on Facebook and shared with
In search of the current guidelines, best practices, and training possible links to target participants.
materials on educating student nurses on HIV prevention and
care, online databases were used that included CINAHL, The online HPCT program was conducted in April 2021 using
ProQuest, PubMed, and ScienceDirect. The keywords combined Zoom to reach student nurses located in various locations in the
and used for the literature search were HIV, AIDS, nursing, Philippines. This mode of delivery removed the risk of COVID-19
competency, training, and education. Each of the implementers transmission by preventing direct contact among the program
conducted a literature search. Eventually, we discussed and implementers and participants. Two weeks before the program, a
compared the literature that we found during meetings. Through pre-analysis of student nurses' sociodemographic characteristics

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Table 1. Outline of the Online HIV Prevention and Care Training (HPCT) Program

and HIV knowledge, attitudes, and perceived practices were school location, and prior HIV education attendance. With
performed to modify some of the program's contents, activities, permission from the primary author, the HIV/AIDS Knowledge,
and delivery methods. Table 1 presents the outline of the Attitude and Practice (KAP) questionnaire (Delobelle et al.,
program's topic, time, and activities. The first two hours focused 2009) was used to measure student nurses' HIV knowledge,
on topics about HIV prevention continuum while the following two attitudes, and perceived practices. In the study of Delobelle et al.
hours focused on topics related to HIV care continuum. (2009), the questionnaire was validated by a public health and
nursing expert. Its reliability was assessed by computing the
We implemented several activities, including lecture Cronbach's alpha coefficient with a value of 0.77 for the
discussions, video presentations, short case scenarios, knowledge scale and 0.63 for the attitude scale. The practice
workshops, and question and answer portions. In addition, we scale was modified to capture student nurses' perceived present
presented short videos of the experiences of an HIV nurse, an and future practices in HIV prevention and care.
HIV program manager, and a PLHIV. Adjustments were made at
the time of the program because of technical issues The knowledge scale has 28-items about HIV-related
encountered. The program was done for 4 hours instead of the knowledge and scored as 'true,' 'false,' or 'don't know.' The
initial 3 ½ hours. At the end of the program, student nurses were attitude scale was used to measure attitudes toward PLHIV. This
requested to answer the same pre-HPCT questionnaires and the scale has 10 items rated on a five-point Likert scale (1 as
program evaluation questionnaire. Certificates of attendance 'strongly disagree,' 3 as 'neither disagree nor agree,' and 5 as
were given to those who completed the program. 'strongly agree'). The practice scale was used to measure HIV-
perceived practices. This scale has 10 items scored as 'yes,' 'no,'
Data collection was done using online surveys. Student nurses or 'not applicable.' We used a program evaluation questionnaire
were requested to read and accomplish the participation rated on a five-point Likert scale (1 as 'strongly disagree' and 5
agreement form which contained information about the as 'strongly agree') to determine student nurses' perceptions of
objectives, mechanics, and nature of participation in the the program's duration, content, speakers, delivery, and impact.
program. It was explained to them that participation in the We added open-ended questions to identify student nurses'
program was voluntary, and they had the right not to participate or perceptions about the strengths and points for improvements of
withdraw their participation without any repercussions. They the program.
were informed of how the data they provided would be protected,
used, and discarded. This program was offered to student nurses Program Evaluation
at no cost.
Responses in the survey were entered into an Excel file to
The sociodemographic questionnaire collected student nurses' examine the completeness of the data. SPSS version 23 was
age, sex, gender identity or sexual orientation, year level, nursing used in the data analysis. Descriptive statistics (mean, SD,

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frequencies) were used to describe student nurses' responses level student nurses were excluded from the analysis. After the
on the sociodemographic, HIV knowledge, attitudes and program, 298 survey submissions were received, with ten
perceived practices, and program evaluation questionnaires. submissions by 4th-year level student nurses excluded from the
Inferential statistics (independent t-test, paired t-test, analysis. The final analysis of the post-HPCT survey involved
McNemar's test) were used to compare student nurses' 288 student nurses, which is 6.2% lower than the number of
characteristics and HIV knowledge, attitudes, and perceived student nurses in the pre-HPCT survey (n=307).
practices before and after the program. An alpha level of .05 was
used to determine significant findings. Summative content Most student nurses who submitted the pre-HPCT survey were
analysis was used to analyze responses to open-ended aged > 21 years (50.8%), female (83.4%), heterosexuals
questions. Qualitative responses were counted and grouped (84.7%), 3rd-year level (50.5%), studying in nursing schools
according to identified categories. Tables were used to present within the National Capital Region (52.1%), and without prior
summaries of the evaluation of the program. HIV education attendance (74.9%) (Table 2). These
characteristics were also similar to post-HPCT student nurses
Student nurses' sociodemographic characteristics except that there were an equal number of those aged 18 to 20
nd
A total of 324 student nurses agreed and registered in the years (50.0%) and > 21 years (50.0%), while more 2 -year level
program. However, 17 pre-HPCT surveys submitted by 4th-year student nurses (54.2%) and studying in nursing schools outside

Table 2. Comparisons of student nurses' characteristics in the pre- and post-HPCT surveys

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the National Capital Region (57.6%). Significantly more student observed among student nurses aged > 21 years (p=.001), in
nurses from nursing schools outside the National Capital region the 3rd year level (p=.000), studying within the National Capital
responded in the post-HPCT survey (57.6%) than in the pre- Region (p=.000), and with prior HIV education attendance
HPCT survey (47.9%) (p=.007). (p=.001). These findings were similar in the post-HPCT survey
except having no significant difference in the HIV knowledge
HIV training attendance scale mean scores between those with and without prior HIV
education attendance (p=.107).
Student nurses reported that the hours of HIV training or lecture
they received ranged from 30 minutes to 6 hours. The focus of HIV attitudes
the training or lecture they attended were commonly on
awareness and prevention (26.2%) and pathophysiology From pre-to post-HPCT surveys, significant decreases were
(11.5%), and minimally on safe sex practice (4.1%), HIV observed in the proportions of student nurses who agreed on
transmission (3.3%), the myths and facts of HIV (1.6%), and the items: 'patients who are HIV-positive should not be put in
nursing considerations and care (1.6%). rooms with other patients when admitted to hospital' (44.3%,
31.6%; p=.004); 'the need to worry about putting family and
HIV knowledge friends at risk of contracting the disease when caring for a
person with HIV/AIDS' (39.7%, 26.4%; p=.002); and 'healthcare
Table 3 shows that student nurses in the post-HPCT survey workers are worried of getting HIV/AIDS from caring for a
obtained significantly higher HIV knowledge scale mean scores person with HIV/AIDS in their work environment' (47.2%,
(mean=18.22, SD=4.138) than those in the pre-HPCT survey 37.5%; p=.011). The rest of the items in the attitude scale did not
(mean=15.01, SD=4.069) (p=.000). In the pre-HPCT survey, show significant differences in the proportion of student nurses
significantly higher HIV knowledge scale mean scores were who agreed or disagreed (Table 4).

Table 3. Comparisons of student nurses' HIV knowledge scores in the pre- and post-HPCT surveys

Note: *significance at α level of .05 using independent t-test, +significant at α level of .05 using paired t-test, HPCT=HIV Prevention and Care Training,
NCR= National Capital Region

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Table 4. Comparisons of student nurses' HIV attitudes in the pre- and post-HPCT surveys

Table 5. Comparisons of student nurses' HIV perceived practices in the pre- and post-HPCT surveys

HIV perceived practices

differences were observed in the proportions of student nurses
Table 5 presents the comparisons of HIV perceived practices of who agreed and disagreed in all items of the practice scale pre-
student nurses in the pre- and post-HPCT surveys. Significant and post-HPCT.

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Table 6. Student nurses' evaluation of the online HPCT program

HPCT evaluation way prevents them from developing stigmatizing attitudes and
discriminatory behaviors that could be barriers in performing
Table 6 shows the mean rating scores of the items in the comprehensive assessment, establishing nurse-patient
program evaluation questionnaire. Most student nurses interactions, and implementing nursing interventions which are
commented that the top three strengths of the program were the critical components toward compassionate care for PLHIV.
knowledge and expertise of the speakers (n=126, 43.8%), Fundamental and updated topics in HIV prevention and control
followed by the content of the program (n=62, 21.5%), and might not have been covered or emphasized in the classes of
program delivery and flow of presentation (n=34, 11.8%). The student nurses (Suominen, 2015), considering that the
top three comments of student nurses on how to improve the commonly reported learning about HIV focused on HIV
program were about time management (n=43, 14.9%), more awareness, transmission, prevention, and pathophysiology.
engagement of the participants (n=21, 7.3%), and technical These possible reasons may build a gap for student nurses to
preparation (n=18, 6.3%). provide assistance for those needing HIV testing and
counseling, use infection control measures efficiently, and
Discussion promote access to PrEP and post-exposure prophylaxis (PEP)
(Khan et al., 2021; Nigatu et al., 2021; Vorasane et al., 2017).
The online HPCT program significantly improved student
nurses' HIV knowledge, attitudes, and perceived practices. The The program was acceptable with high evaluation scores given
Iowa Model-Revised (Iowa Model Collaborative et al., 2017) by the participants. Our varying clinical experience and
helped make the program systematic, meaningful, and setting- education and the extensive literature review were vital points
based, aligned with the needs of student nurses and the to incorporate and interrelate updated and salient topics for the
pressing HIV situation in the Philippines. Collaborative program, emphasizing critical roles and responsibilities in HIV
engagements, consultations, and pre-program survey analysis nursing. Our use of frameworks helped us in the selections and
were essential steps undertaken to identify current gaps in HIV transitions of the topics of the program. Although we performed
education among student nurses and how the program should technical rehearsal before the program, technical issues using
be promoted and implemented. The presence and participation an online platform could happen (Al-Balas et al., 2020); thus, we
of advocates provided student nurses to hear stories about the adjusted the program's time. Possible consideration on this
realities and challenges in HIV prevention and care. matter is increasing the duration of the program to allow more
discussions and activities while weighing its effect on student
The findings indicate that the program helped increase further nurses' active participation and internet connection when using
the HIV knowledge of student nurses and equalize it between an online platform. An interprofessional approach can enhance
those with and without prior HIV education attendance. this program for student nurses to learn from different
Informing student nurses about basic HIV concepts is professions, thereby promoting positive learning experiences
fundamental in helping them lessen their fear and anxiety and (Bunting et al., 2019).
implement comprehensive and sensitive care for PLHIV. This

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There are considerations when it comes to the results of the Arias-Colmenero, T., Pérez-Morente, M., Ramos-Morcillo, A. J.,
evaluation of the program. Most student nurses who responded Capilla-Díaz, C., Ruzafa-Martínez, M., & Hueso-Montoro, C.
to the pre- and post-HPCT surveys had no prior HIV training (2020). Experiences and attitudes of people with HIV/AIDS:
attendance. Immediately after the program, student nurses A systematic review of qualitative studies. International
were asked to answer the post-HPCT survey. The HIV practice Journal of Environmental Research and Public Health,
focused on student nurses' perceptions which may not reflect 17(2), 639. doi:10.3390/ijerph17020639
their actual practice. We did not implement strict screening and Bunting, S. R., Saqueton, R., & Batteson, T. J. (2019). A guide for
monitoring of student nurses who entered the Zoom link in designing student-led, interprofessional community
comparison with the list of those who registered. There are education initiatives about HIV risk and pre-exposure
possibilities that those who have registered did not attend the prophylaxis. MedEdPORTAL: The Journal of Teaching and
program, and others who did not register had entered the Zoom Learning Resources, 15, 10818. [Link]
meeting. Technical difficulties, internet connection problems, 10.15766/mep_2374-8265.10818
and other external distractions encountered by student nurses Centers for Disease Control and Prevention (2021). HIV stigma
can affect their learning and participation during the program. and discrimination. Retrieved from [Link]
hiv/basics/ hiv-stigma/[Link]
Conclusion Delobelle, P., Rawlinson, J. L., Ntuli, S., Malatsi, I., Decock, R., &
Depoorter, A. M. (2009). HIV/AIDS knowledge, attitudes,
Following the steps of the Iowa Model-Revised (Iowa Model practices and perceptions of rural nurses in South Africa.
Collaborative et al., 2017), we developed, implemented, and Journal of Advanced Nursing, 65(5), 1061–1073.
evaluated the online HPCT program in a systematic, [Link]
collaborative, and scientific-based approach. Active Feyissa, G. T., Lockwood, C., Woldie, M., & Munn, Z. (2019).
consultations among educators, student nurses, and advocates Reducing HIV-related stigma and discrimination in
helped us conceptualize the program meaningfully and healthcare settings: A systematic review of quantitative
creatively. We found gaps in HIV-related education and evidence. PloS One, 14(1), e0211298.
competency among student nurses that are potential barriers to Fox, M. P., & Rosen, S. (2017). A new cascade of HIV care for the
effective HIV prevention and care service deliveries. Variations era of "treat all". PLoS Medicine, 14(4), e1002268.
exist in student nurses' exposure to HIV education, knowledge [Link]
on developments, guidelines and services in HIV, and perceived Ingram, L., Stafford, C., Deming, M. E., Anderson, J. D.,
practices and attitudes in the care of PLHIV and HIV at-risk Robillard, A., & Li, X. (2019). A systematic mixed studies
populations. review of the intersections of social-ecological factors and
HIV stigma in people living with HIV in the U.S. South. The
The program was acceptable and beneficial to student nurses' Journal of the Association of Nurses in AIDS Care, 30(3),
HIV knowledge, attitudes, and perceived practices. Further 330–343. [Link]
evaluation is needed to assess the translation of learning into Iowa Model Collaborative, Buckwalter, K. C., Cullen, L.,
actual clinical practice, and an interprofessional approach can Hanrahan, K., Kleiber, C., McCarthy, A. M., Rakel, B.,
be integrated to promote positive learning experiences. There is Steelman, V., Tripp-Reimer, T., Tucker, S., & Authored on
a need to strengthen basic HIV concepts and integrate HIV behalf of the Iowa Model Collaborative (2017). Iowa Model
developments in the education of student nurses. Shaping HIV- of Evidence-Based Practice: Revisions and validation.
related competencies of student nurses would contribute to Worldviews on Evidence-based Nursing, 14(3), 175–182.
strengthening the health workforce in the Philippines to achieve [Link]
global HIV targets. Joint United Nations Programme on HIV/AIDS (UNAIDS) (2015).
Understanding fast-track: Accelerating action to end the AIDS
epidemic by 2030. Retrieved from [Link]
____________________ sites/default/files/media_asset/ 201506_JC2743_
Understanding_FastTrack_en.pdf
References Joint United Nations Programme on HIV/AIDS (UNAIDS) (2020).
UNAIDS data 2020. [Link]
Al-Balas, M., Al-Balas, H. I., Jaber, H. M., Obeidat, K., Al-Balas, documents/2020/unaids-data
H., Aborajooh, E. A., Al-Taher, R., & Al-Balas, B. (2020). Joint United Nations Program on HIV/AIDS (UNAIDS) (2021).
Distance learning in clinical medical education amid COVID- Community-led HIV services stepped up in the Philippines
19 pandemic in Jordan: current situation, challenges, and during the COVID-19 pandemic. Retrieved from
perspectives. BMC Medical Education, 20(1), 341. [Link]
[Link] ories/2021/may/20210511_philippines

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Khan, R.S., Tariq, T., Tahir, F., Ahmad, A. (2021). Knowledge,

attitude and practices (KAP) of non-medical staff regarding Rose Zuzette M. de Leon, MAN, RN is a
HIV/AIDS in teaching hospital, Dera Ghazi Khan, Pakistan. graduate of the University of Santo
Pakistan Journal of Medical and Health Sciences 15(1), pp. Tomas, Cum Laude. She obtained her
170-173. [Link] master's degree in Nursing major in Adult
McNairy, M. L., & El-Sadr, W. M. (2014). A paradigm shift: Focus Health from the University of the
on the HIV prevention continuum. Clinical Infectious Philippines Open University in 2018. She
is pursuing Doctor of Philosophy in
Diseases, 59 Suppl 1(Suppl 1), S12–S15. [Link]
Nursing at the University of the Philippines Manila College of
10.1093/cid/ciu251 Nursing. Currently, she is a faculty member of the University
Nigatu, M., Kabeta, T., Taye, A., & Belina, M. (2021). HIV of Santo Tomas College of Nursing. Her research interests
voluntary counseling and testing uptake and associated include drug dependence, nursing informatics, and HIV.
factors among Ethiopian youths: Evidence from the 2016
EDHS using multilevel modeling. BMC Infectious Diseases, Conchita A. Palencia, MN, RN is an
21(1), 334. [Link] Associate Professor at the Bicol
Philippine HIV and AIDS Policy Act of 2018. Retrieved from University College of Nursing, Legazpi
[Link] City. She obtained the degree of Master
html in Nursing in 2012 at the Bicol
Suominen, T., Laakkonen, L., Lioznov, D., Polukova, M., University, Legazpi City, and Bachelor of
Science in Nursing in 1995, in the same
Nikolaenko, S., Lipiäinen, L., Välimäki, M., & Kylmä, J.
institution. She is taking Doctor of Philosophy in Nursing at
(2015). Russian nursing students' knowledge level and the University of the Philippines Manila College of Nursing.
attitudes in the context of human immunodeficiency virus Her research interests include nursing education and
(HIV) - a descriptive study. BMC Nursing, 14(1), 1. leadership and management.
[Link]
Vorasane, S., Jimba, M., Kikuchi, K., Yasuoka, J., Nanishi, K., Gracielle Ruth Adajar, MA (Nursing),
Durham, J., & Sychareun, V. (2017). An investigation of RN, is an intensive care unit nurse at the
stigmatizing attitudes towards people living with HIV/AIDS Lung Center of the Philippines, where
by doctors and nurses in Vientiane, Lao PDR. BMC Health she received the Career and Self-
Services Research, 17(1), 1-13. DOI 10.1186/s12913-017- Development Award in 2020. She is a
2068-8 Certified Pulmonary Nurse Level III by
the Department of Health. She obtained
her Bachelor of Science in Nursing degree at the University of
ABOUT THE AUTHORS Perpetual Help System-Laguna, Cum Laude in 2009 and her
Master of Arts in Nursing (Major in Nursing Administration)
degree from the University of the Philippines Manila, where
she is also taking her doctoral degree. Her research interests
Ryan Q. De Torres, MA (Nursing), RN is include nursing management and leadership, critical care
Assistant Professor at the University of the nursing, and caring for patients with Covid-19.
Philippines Manila (UPM) College of
Nursing, where he is pursuing his doctoral
degree and finished his master's degree in
Acknowledgments
Nursing major in Adult Health. He
completed his bachelor's degree in Nursing The authors are grateful to Dr. Araceli O. Balabagno and Dr. Bethel
at the Trinity University of Asia, Cum Laude. He attended the Buena Villarta for their guidance and motivation. Appreciation to Dr.
Brown University and UPM Training Program for the Prevention Sheila Bonito, UP Nursing Student Council, Mr. Arnold B. Peralta,
of HIV in Vulnerable Populations in 2021. His research interests and Dr. Jenniffer T. Paguio for their support. The authors are also
are HIV Nursing, Sexual and Gender Minority Health, Adult thankful to all the deans, faculties, and student nurses who
Health, and Transcultural Nursing. In addition, he is a volunteer supported and joined the program.
HIV counselor and educator at The LoveYourself Inc.
Conflict of Interest: The authors declare no conflict of interest.
Funding: The program did not receive any financial grant.

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RESEARCH ARTICLE

Health Promoting Lifestyle Behaviors

of University Employees
in Work-From-Home Arrangement
during the COVID-19 Pandemic
Naressia D. Seludo-Ballena, RN, MAN, EdD1, Mary Joan Therese C. Valera-Kourdache, RN, MPH2,
Jorel A. Manalo, PTRP, MPH3, Alexandra Belle S. Bernal, RN4, Mary Joy C. Tiamzon, BS5, and Raymund Kernell B. Mañago, RN6

Abstract
Since the COVID-19 emerged, a work-from-home (WFH) arrangement was implemented as an infection containment measure among
employees. This lifestyle change is bound to affect health-promoting behaviors. The study aims to determine the health-promoting
lifestyle behaviors of university employees in a WFH arrangement during the COVID-19 pandemic. This study utilized a quantitative
descriptive research design. After consecutive sampling of employees of a state university in Manila, the response rate was 33.1% (395
out of 1, 195 eligible respondents), but only 31.8% or 380 respondents completed the validated online questionnaire through Google
Forms™ from August to October 2021. The instrument was based on the Health Promoting Lifestyle Profile (HPLP) survey by Walker
and Hill-Polerecky (1996). Descriptive data analysis was done via IBM® SPSS® Statistics v22. Majority were females (70.3%) and
single (51.8%). Approximately 70% were staying at home with their family. The mean scores for the subscales of inner development,
interpersonal relations, and stress management were 3.08 (SD±.24), 3.00 (SD±.30), and 2.70 (SD±.30), respectively. These were
observed to be higher than other HPLP subsets. Subscales garnering the lowest mean scores were physical activity at 2.32 (SD±.21),
nutrition at 2.68 (SD±.31), and health responsibility at 2.56 (SD±.12). The mean HPLP score of faculty members was the highest at
2.74 (SD±.36) as compared to administrative staff and research extension and professional staff (REPS) with mean scores of 2.73
(SD±.36) and 2.71 (SD±.39), respectively. Overall HPLP scores suggested that the majority (60.8%) practice “good” health-promoting
lifestyle behaviors. These findings indicate that the WFH arrangement allows employees to develop social and coping skills while
staying in their residences. Whereas limitations to opportunities for a more active lifestyle, availability of nutritious food, and access to
health care also contribute to the low HPLP scores. Health promotion and protection strategies such as nurse-led health programs
must be instituted to improve and develop the knowledge, skills, and attitude among employees working from home in the aspects of
nutrition, physical activity, and health responsibility. Nurses must also use this opportunity to promote occupational health among
employees through lifestyle programs in coordination with universities and colleges or other workplaces of similar nature. Health
programs must capitalize on the increase in the utilization of social media and the Internet during the pandemic. There is a need for
further research to examine associations between the variables in various institutions and settings.
Keywords: health promotion, lifestyle behaviors, work-from-home, COVID-19 pandemic

Introduction

I n December 2019, a novel coronavirus disease (COVID-19)

emerged as a pandemic with over 60 million confirmed cases
and over 1.4 million confirmed deaths (as of November 26,
to mitigate the transmission of infection (World Health
Organization [WHO], 2020). Policies of most governments
focused on allowing the home to be the workplace for many
2020); and, the numbers are rising steadily. This caused the employees in a setup known as work-from-home (WFH)
majority of the workforce to seek alternative work arrangements arrangement (Vyas & Butakhieo, 2021). The term WFH has

1 Assistant Professor, College of Nursing, University of the Philippines Manila, Ermita, Manila, Philippines; Corresponding author; nsballena@[Link]
2 Assistant Professor, College of Nursing, University of the Philippines Manila, Ermita, Manila, Philippines, mcvalera@[Link]
3 University Researcher III, Human Resource Development Office, University of the Philippines Manila, Ermita, Manila, Philippines, jamanalo1@[Link]
4 University Research Associate II, College of Nursing, University of the Philippines Manila, Ermita, Manila, Philippines, asbernal1@[Link]
5 Administrative Assistant II, College of Nursing, University of the Philippines Manila, Ermita, Manila, Philippines, mctiamzon@[Link]
6 Research Assistant, College of Nursing, University of the Philippines Manila, Ermita, Manila, Philippines, rbmanago@[Link]

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been described in different terms, such as telework, inner development, interpersonal development, and stress
telecommuting, remote work, or e–working. Work-from-home management; and, determine dimensions of health-promoting
setup refers to the capacity of workers to execute their jobs at lifestyle behaviors that can be developed into a wellness
flexible workplaces, especially at home, by using technology program. This would provide significant information on whether
(Gajendran & Harrison, 2007; Grant et al., 2019) the academic institution has a culture of health and can promote
the well-being of the employees.
As a result, the work of employees usually left in their offices and
workplaces now tend to be incorporated into the daily household Background of the Study
and personal activities, causing unclear boundaries between
private life and work. This lifestyle change has an unavoidable Health Behavior and Healthy Promoting Lifestyle Behaviors
effect on the health-promoting behaviors of most employees
(Palumbo et al., 2020). Individuals adopting healthy lifestyle behaviors are capable of
improving and sustaining their well-being. To acquire health-
Health behavior is understood to be an individual practice, and it promoting behaviors, individuals need to have self-control and
is based on how a person believes and values health to achieve should be inclined to consistently perform these behaviors
health and wellness. Çelebi et al. (2017) described health because positive health behaviors should be acquired and
behavior as any performed activity or behavior believed to be maintained to promote health (Çelebi et al., 2017).
beneficial to one's well-being. The health behavior of individuals
can be influenced by the kind of family health practices, Health behaviors differ among the social and organizational
socioeconomic status, physical environment, and workplace environments, and they are influenced by gender, race, age,
environment. The development of healthy lifestyle behaviors is income, and worksite size. The social environment and
the basis of health maintenance and disease prevention, organizational culture of a person are related to health behaviors
especially non-communicable diseases (NCDs). on nutrition, physical activity, and weight control (Tabak, 2015).
Employees' behaviors of a healthy lifestyle are at a medium
The NCDs are cancer, heart disease, diabetes, stroke, and level. In terms of physical activity, males are more active
chronic respiratory diseases, accounting for 68% of all deaths in compared to females in displaying healthy lifestyle behaviors.
the Philippines (WHO, 2019). These diseases have been shown Likewise, displaying healthy lifestyle behavior is inversely
to negatively impact the population's health, as well as the proportional to age because positive health behaviors should be
economy. The national economy spends an estimated P756.5 acquired and maintained to promote health. Activities, done
billion per year, equivalent to 4.8% of the country's annual gross apart from the working hours, have effects on employees'
domestic product (WHO, 2019). displaying healthy lifestyle behaviors and their engagement in
sports (Aynur et al., 2016). The lack of opportunity and time
One of the common workplace environments is an academic constraints may also affect the practice of health behaviors
institution where all kinds of stress and challenges are (Paudel et al., 2019).
encountered. A “Health-Promoting University” concept
encourages universities to incorporate health into the university The Concept of a Health Promoting University (HPU)
culture, processes, and policies to promote the health of the
academic community (Suarez-Reyes et al., 2019). Promoting Major universities worldwide have adopted the approach. A
the health of the university community can be done through framework for action has been developed guiding universities to
annual physical examination, laboratory tests, and the presence become health-promoting. Results demonstrated that
of a health service clinic with health programs. Employees are, universities implement the HPU framework for action with
thus, expected to avail these health benefits (Suarez-Reyes et diverse approaches to become a Health Promoting University
al., 2019). (Suárez-Reyes et al., 2019).
The purpose of the study is to determine the health-promoting Work-from-Home Arrangement during the COVID-19
lifestyle behaviors of university employees in a WFH Pandemic
arrangement during the COVID-19 pandemic. Specifically, this
study aims to determine the profile of the participants in terms of In the Philippines, guidelines on the implementation of flexible
age, sex, marital status, city/municipality, annual income, work arrangements as a remedial measure due to the ongoing
employee category, employee type, and years of service in the outbreak of COVID-19 were released (Department of Labor and
university; identify the risk factors in terms of tobacco use, Employment, 2020). Before the pandemic, a WFH arrangement
alcohol intake, comorbidities, and family history; determine is considered not feasible for heavily populated cities, which
health-promoting lifestyle behaviors in terms of the following includes Manila, because home working requires a dedicated
dimensions: health responsibility, physical activity, nutrition, quiet space to execute work duties (Vyas & Butakhieo, 2021). As

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a health and safety measure to prevent crowding and curb the employed in the university, in a WFH set-up for at least a month,
spread of the coronavirus, many governments around the world and between the ages of 21 years old to 59 years old. This study
have directed employees to work remotely. did not include personnel who were on long-term leave (e.g.,
study, maternity, or sabbatical leave), visiting and adjunct
In the international scene, the change of work arrangement professors, and employees from the affiliated teaching hospital
showed contrasting results. The home environment was seen to and affiliated institutions in rural areas. The set inclusion and
be counter-productive because of exposure to a lot of exclusion criteria intended to capture the health-promoting
distractions, and an increase in blurring of work-life boundaries behaviors of university employees with continuous WFH
negatively impacts the lifestyle, subjective well-being, and experience while living in an urban setting where the Internet is
productivity of a person (Pluut & Wonders, 2020). Employees considered to be more accessible.
struggled to manage their time between performing domestic
responsibilities and workplace duties (Pluut & Wonders, 2020). Variables and Instrumentation
Conversely, in some instances, WFH was noticeably
advantageous for employers and employees because of greater A survey questionnaire was utilized for data collection through a
flexibility, reduced commuting time, avoidance of office politics, web-based platform, i.e., Google Forms™. The tool was
lesser use of office space, increased motivation, women adopted from the Health Promoting Lifestyle (HPLP-II) which
empowerment, less absenteeism and turnover, and higher job measured health-promoting behaviors as a multidimensional
satisfaction and productivity (Laegran, 2008; Mello, 2007; pattern of self-initiated actions that maintain or enhance the level
Robertson et al., 2003). In another study, results suggested that of wellness of the individual (Walker & Hill-Polerecky, 1996).
a WFH setup increased quality of life but decreased work
productivity (Weitzer et al., 2021). The instrument was composed of three parts, namely: (1) the
personal data, (2) risk factors, and (3) health-promoting lifestyle
The Workplace Health Model (HPLP) behaviors. The HPLP section was a 52-item
questionnaire with a 4-point Likert scale with assigned
The study uses the workplace health model as an overarching responses: 4-Routinely, 3-Often, 2-Sometimes, and 1-Never.
framework. This is a systematic and comprehensive approach to The score of 4 was considered the highest, whereas the score of
developing an effective health promotion program in the 1 was the lowest. A total sum of scores was interpreted as
workplace which includes assessment of employee health, follows: Excellent: 169-208, Good: 130-168, Moderate: 91-129,
planning and implementation of employee health programs, and and Poor: 52 to 90. This tool was used to measure the domains
systematic evaluation of impact and significance of these of health-promoting behaviors, i.e., health responsibility,
activities (Centers for Disease Control and Prevention, 2016). physical activity, nutrition, inner development, interpersonal
The implications of this study will affect the work of nurses, relations, and stress management. Items in the questionnaire
especially occupational health nurses, in developing innovative were modified to fit into the context of the research setting and
strategies to promote desirable lifestyle habits among university study participants.
employees.
The survey questionnaire was pretested on 20 respondents in a
Methodology public higher education institution. A Cronbach's α of 0.93
indicated that the data collection tool has excellent internal
Research Design consistency and reliability.

This study utilized a quantitative descriptive research design. Procedure for Data Gathering
The study population was employees of a state university in
Manila through its eight (8) colleges and two (2) non-academic Data collection was conducted from August to October 2021 in
units. Participants were faculty members, administrative staff, two phases, pretesting phase for the survey questionnaire and
and research extension and professional staff (REPS) with actual data collection for quantitative data. For the first phase,
corresponding positions as regular employees and non-regular pretesting of the survey questionnaire was conducted in one of
employees, such as lecturers and contractual workers. the selected higher education institutions. Treatment of data
was done to determine the reliability of the survey of the
Sampling and Population questionnaire and to determine the applicability of the 60
minutes allotted time to answer the survey.
Consecutive sampling technique was used to cover all
respondents who voluntarily participated to improve the study The second phase, actual data collection, was an internet-based
validity and minimize selection bias. The participants in this Google survey. A 52-item questionnaire was composed of three
study were based on the following inclusion criteria: currently (3) sections, namely: 1) the personal data, 2) risk factors of non-

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communicable diseases and co-morbidities which include then exit. The Google survey forms that followed the page of the
personal health history on tobacco, alcohol and health problems Informed Consent marked the start of the data collection.
and family history, and 3) the health-promoting lifestyle
behaviors. All data collected in this online survey were stored in a computer
that is password-secured and could only be accessed by the
Data Analysis researchers. If there would be a physical copy of the survey
questionnaires, these were kept in a cabinet with a lock in the
Data analysis was done via IBM® SPSS® Statistics v22. To researcher's room in UP Manila College of Nursing. In publishing
analyze the demographic profile and risk factors, percentage and the findings of this study, the anonymity of the respondents was
frequency distribution were used. For health-promoting lifestyle maintained. Computers used for analysis were not connected to
behaviors, measures of central tendency were used for data the internet and no information of the respondents was uploaded.
analysis. The soft and physical copies were scheduled for deletion and
shredding five years after publication.
Ethical Considerations
Results
Ethics approval was obtained from the UP Manila Research
Ethics Board (UPM REB) with protocol approval code, UPM REB The response rate was 395 (33.1%) out of 1, 195 eligible
2020-403-01. The researchers sought administrative approval respondents, but only 380 (31.8%) respondents completed the
and coordinated with the Human Resource Department for the survey. The demographic profile is presented in Table 1. Majority
list of selected participants to be invited to participate in the study. of the participants were females (70.3%). In terms of marital
The researchers proceeded with the recruitment of participants status, the proportion was highest for single at 51.8%, while
by seeking permission from the Chancellor's Office and the 43.2% were married. Approximately, 71.1% of the respondents
Human Resources Department (HRD) for the dissemination of were staying at home, while 27.1% were renting a condominium
the link to the survey. unit, apartment, or dormitory. For the employment category,
49.7% were administrative staff, 28.9% were faculty members,
The invitation was sent via email, and the survey was accessed and 21.3% were from REPS.
through their UP mails. Once accepted, the participants obtained
access to the Google survey. The participants' email addresses In terms of employment-related profile, the average length of
were collected by the researchers and changed into a code to service at the university was 10.8 years (SD±9.7). Based on the
ensure their privacy. distribution of participants according to the annual income,
majority had an income of less than PHP500,000 as 33.9% of
The participants' informed consent was obtained with the first them reported receiving an annual income of PHP250,000 to
page of the survey tool containing an explanation of the purpose, PHP499,999, and 27.6% responded that their yearly income
significant ethical concerns and other important details about the ranges from PHP100,000 to PHP249,999.
study, and the extent of their participation while ensuring them
that their responses will be kept private and confidential. The The characteristics of the respondents based on lifestyle-related
researchers adhered to the Data Privacy Act of 2012. Any risk factors, presence of morbidity within the last 12 months, and
identifiable information from the encoded data was anonymized family history of morbidity are presented in Table 2. Only 13.4%
when transformed into a written document. reported having smoked cigarettes or tobacco products, and
68.9% had experienced consuming alcoholic beverages at one
The Informed Consent emphasized that the participation was point in their lives.
voluntary and that it would be their choice not to continue with the
survey, or to stop answering at any point during the survey, and Within the past 12 months, 243 (63.9%) did not experience any
their responses would not be recorded and counted. Aside from disease. Among those who have comorbidities, NCDs seemed to
reiterating the eligibility criteria, it was stressed that there would be more common as hypertension was the most frequently
be no time limit in answering. The participants were provided reported condition at 20.3%, followed by asthma, diabetes, heart
access to the survey if they wish to continue after an hour, and disease, and cancer at 10.8%, 5.8%, 1.6%, and 1.3%,
follow-up notifications were sent as reminders. Likewise, the respectively. Communicable diseases such as pneumonia
participants were informed that access to the study results would (1.3%), pulmonary tuberculosis (0.5%), and COVID-19 (1.1%)
be given upon contacting the principal investigator by email. The have also been reported.
details of the principal investigator and the chair of the UPM REB
Panel could be found at the end of the Informed Consent page, Majority of the participants have a family history of NCDs.
before the statement of consent, wherein they would have to click Hypertension (74.5%) was the most common condition in the
“YES”, if participants agree, or “NO” if they decide otherwise, and family, followed by diabetes mellitus (51.1%), heart disease

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Table 1. Demographic Characteristics of the Respondents (N=380).

Table 2. Distribution of the Respondents According to Presence of Risk Factors (N=380).

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(33.2%), bronchial asthma (32.6%), and cancer (31.6%). highest mean HPLP scores, followed by the administrative staff.
Communicable diseases such as pulmonary tuberculosis The REPS group has the lowest mean HPLP score among the
(12.1%) and pneumonia (11.1%) among participants' relatives three groups, which yields an implication that this group needs
were also reported. stronger support in terms of improving lifestyle choices and
health promotion. The high mean scores of faculty members
The summary of responses according to the HPLP subscale is could be attributed to their preexisting knowledge of desirable
shown in Table 3. The subscale for inner development had the health behaviors, especially since the university where the study
highest mean score at 3.08 (SD±.24) followed by interpersonal was conducted offers health science programs.
relations at 3.00 (SD±.30). Subscales garnering the lowest mean
scores were physical activity at 2.32 (SD±.21), nutrition at 2.68 Among the subscales of HPLP, results reveal that respondents
(SD±.31), and health responsibility at 2.56 (SD±.12). These have the highest mean scores on inner development and
findings indicated that the WFH arrangement allowed employees followed by interpersonal relations. These scores indicate that
to develop social and coping skills while staying in their during the work-from-home arrangement, respondents
residences. Whereas limitations to opportunities for a more demonstrate high levels of inner peace by welcoming
active lifestyle, availability of nutritious food, and access to health possibilities of creating new options for becoming something
care also contributed to the low HPLP scores. more and going beyond who and what they are. High levels of
interpersonal relations during the pandemic indicate that the
Furthermore, the data also revealed that the mean HPLP scores respondents can sustain or improve communication skills that
of the faculty members was 2.74 (SD±.36), which indicated that involve sharing thoughts and feelings with others (Walker & Hill-
this group had the highest HPLP scores. As shown in Table 4, the Polerecky, 1996).
administrative staff garnered a mean score of 2.73 (SD±.36),
whereas the REPS had a mean score of 2.71 (SD±.39). The In contradiction, other reports suggest that quarantine measures
REPS group had the lowest HPLP scores. induce problems with mental health and coping abilities. An
increase in stress and anxiety is observed among the
Overall HPLP scores revealed that majority (60.8%) practice participants during the lockdown period (Chopra et al., 2020).
“good” health-promoting lifestyle behaviors. This was followed by Participants at risk for clinical depression, as well as the
“moderate” HPLP levels at 25.8% and “excellent” at 12.4. Only 4 incidence of depression, increased throughout the pandemic
(1.05%) showed “poor” lifestyle behaviors from March to July 2020 (Giuntella et al., 2021). The containment
measures represented a substantial impact on human health
Discussion with social and economic repercussions (Ammar et al., 2020a,b;
Deschasaux-Tanguy et al., 2020; Reyes-Olavarría et al., 2020).
This study examines the health-promoting lifestyle behaviors of Negative health outcomes, especially unhealthy lifestyle
employees of a state university in Manila in a work-from-home behaviors and significant increases in the prevalence of
arrangement during the COVID-19 pandemic. Among the psychosocial and emotional disorders were observed (Ammar et
employee categories, data show that faculty members garner the al. 2020b; Di Renzo et al., 2020).

Table 3. Summary of Responses to the HPL Scale (N=380).

Table 4. Distribution of the Respondents according to HPLP Scores (N=380).

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Lower mean scores are noted in the HPLP subscales of physical These observations have potential implications in terms of
activity, nutrition, and health responsibility, with physical activity health programs to support weaker areas of HPLP.
being the lowest. These scores indicate that the respondents Recommendations include instituting health promotion and
require interventions and health programs that will boost their protection strategies such as nurse-led health education
skills and commitment in paying attention to their own health, programs to improve and develop the knowledge, skills, and
engaging in regular participation in light, moderate, and/or attitude among employees working from home in the aspects of
vigorous activity for fitness and health, and planning and nutrition, physical activity, and health responsibility. Nurses must
executing a diet regimen using a knowledgeable selection and also use this opportunity to promote occupational health among
consumption of foods for healthy sustenance (Walker & Hill- employees through lifestyle programs in coordination with
Polerecky, 1996). universities and colleges or other workplaces of similar nature.
Noting that most of the respondents are middle-aged adults,
In support of the study findings, other studies similarly report a health programs must capitalize on the increase in the utilization
negative change in lifestyle, decrease in physical activity, and an of social media and the Internet during the pandemic to
increase in daily screen time are observed particularly among disseminate knowledge, develop positive attitudes, and provide
men and in upper-socioeconomic classes (Chopra et al., 2020; specific nursing action points to support healthy lifestyle habits
Pluut & Wonders, 2020). Average daily steps also significantly amidst the global situation.
dropped, and daily screen time increased (Giuntella et al., 2021).
Perception of noticeable weight gain was also noted (Di Renzo, Declaration of Conflict of Interest.
2020). There is reduced accessibility to grocery shopping that
resulted in decreased consumption of fresh foods, in favor of The researchers declare no conflict of interest. .
highly processed convenience foods and “comfort food” rich in
sugar and fat (Yilmaz & Gökmen, 2020; Rodríguez-Martín & ____________________
Meule, 2015).
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World Health Organization (2020). COVID-19 Public Health

Emergency of International Concern (PHEIC) Global Alexandra Belle S. Bernal, RN is a
Research and Innovation Forum. World Health University Research Associate II of the
Organization: [Link] College of Nursing, University of the
item/covid-19-public-health-emergency-of-international- Philippines Manila. She is currently
concern-(pheic)-global-research-and-innovation-forum pursuing her Master of Health Research
Yilmaz, C., & Gökmen, V. (2020). Neuroactive compounds in Ethics degree at the University of Malaya,
foods: occurrence, mechanism, and potential health Malaysia - a collaborative master's
program offered between the Faculty of Medicine, Universiti
effects. Food Res. [Link] Malaya and the Johns Hopkins Berman Institute of Bioethics
(with the support of the U.S. National Institutes of Health,
Fogarty International Center). Her research interests revolve
around nursing informatics, perioperative nursing, and ethical
ABOUT THE AUTHORS conduct of research. She hopes to promote ethically sound and
responsible research culture among future undergraduate and
graduate students.
Naressia S. Ballena, RN, MAN, EdD is
the lead principal investigator of the Mary Joy C. Tiamzon, BS is an
research project and a former faculty of the administrative assistant of the Research
University of the Philippines Manila (UPM) and Creative Writing Program at the
College of Nursing. She was appointed as University of the Philippines College of
the ISO Lead QMS Internal Auditor of Nursing. She is currently taking her
UPM. During her stay in the UPCN, she Diploma in Public Management at UP
was a member of the Maternal and Child Health Nursing NCPAG with a specialization in
specialty group. At present, she is a faculty member of Centro organization studies. She hopes to promote research that will
Escolar University Manila. Her research interests include health benefit the employees and organizations through collaboration
promotion, maternal and child nursing, and nursing leadership, efforts.
management and governance. She presents papers solely and
collaboratively authored in international research fora. She Raymund Kernell B. Mañago, RN is an
published research articles. anaesthetic and recovery nurse at the
Royal Victoria Infirmary in Newcastle
Mary Joan Therese C. Valera- upon Tyne, United Kingdom. He
Kourdache, RN, MPH obtained her graduated from the University of the
Bachelor's degree in Nursing and Master Philippines College of Nursing as cum
of Public Health with a major in Health laude and Class Valedictorian. He is the
Promotion and Education from the board topnotcher of the Nurse Licensure Examination in
University of the Philippines Manila (UPM). November 2017. His collaborative research work is focused on
She survived five brain surgeries to innovations in nursing care and health promotion. He
remove a brain tumor in 1997 and continues to teach at UPM internationally presented a project on telemedicine for children
College of Nursing and supervise students in the wards of the with cancer which he coauthored.
Philippine General Hospital and in the community health
centers. She is a published writer and researcher.
Acknowledgment
Jorel A. Manalo, PTRP, MPH is currently
the Supervising Administrative Officer of The authors recognize the substantial support of the University
the Human Resource Development Office of the Philippines Manila – National Institutes of Health as the
(HRDO), UP Manila. He provides funding agency of this study under grant number NIH 2021-03.
comprehensive quality services in terms of
recruitment, development, and welfare.
His research interests are on workplace
bullying and organizational development. He co-authors several
articles published in peer-reviewed journals with topics on health
financing schemes and pharmacy DOTS Initiative. He hopes to
contribute to a Healthy University workplace that applies Work-
Life Balance.

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CONCEPT ANALYSIS

Developing a Professional Identity

in Nursing through Reflection
Charmaine T. Co-Enarsico, MN, RN, CHSE1

Abstract
PProfessional identity is the nurse's collection of beliefs about what it “means to be” and to “act like” a nurse. This represents his/her
“philosophy of nursing” and it has a direct influence on how actual “roles and responsibilities” are followed. In other words,
professional identity is the “foundational reference” in the nurse's cognitive process to which decisions are being made. Moreover,
these are the values and beliefs held by the nurse as guiding principles in thinking, behaving, acting, communicating, and
interacting with patients, the patient's family, and other members of the healthcare team.
As a practical science, nursing education has introduced the importance of reflective learning in the clinical setting when providing
care to patients and in building nurse-patient relationships. This means that there is a developing awareness of assisting,
encouraging, and teaching both students and professional nurses to become thoughtful individuals, capable of critical thinking and
analogy to come up with innovative ideas. Reflection in this mode of instruction is considered as a tool for the analysis of nursing
practice nurturing both the understanding of professional nursing and the building of important thoughtful approaches essential for
providing nursing care in multifaceted and dynamic working conditions. As a result, reflection, as an instructional method, has been
included in many nursing curricula.
However, the concept of reflection within the context of developing a professional identity has scarcely been defined to adequately
identify research and educational indicators. This concept analysis aims to describe attributes, antecedents, and consequences of
reflection in the development of professional identity in nursing and to provide clear evidence for nursing educators/faculty that
support the systematic development of professional nurses as they advance in practice from the undergraduate to the graduate
programs.
Keywords: Reflection, Professional Identity, Professional Nursing

Introduction

P atient-centered care (PCC) is identified to be at the heart of

every healthcare provider. There is a need for healthcare
professionals to empower patients (and their families) and to
stages. The “shift” of caring decisions toward the patient and
their family requires a change in responsibility, thus changing
the dynamic that plays in a nurse-patient relationship. This
select and own their healthcare needs (Tashiro, Shimpuku, transformation in power and responsibility requires the
Naruse, & Matsutani, 2013). In modern times, the concept of development of needed competence in nursing, knowledge,
PCC encourages people to attain and maintain wellness skill, attitude, and ethical grounding that will directly affect the
through working closely and building professional relationships care provided to individuals, both sick and well. Competence is
with healthcare professionals. It entails shifting from a very acquired through collaboration, socialization, and integration to
“paternalistic” and “traditional” focus to a “people-centered” internalize values, norms, and ethical standards of the
focus in healthcare. Moreover, patients are now more informed professional culture into one's behavior and self-conception.
through technology and the worldwide web. With a click of a
button, those needing medical attention can learn about their Professional identity is the nurse's collection of beliefs about
health and management of diseases. what it “means to be” and to “act like” a nurse. This represents
their “philosophy of nursing,” and it has a direct influence on
Nurses are on the medical frontlines, working continuously and how actual “roles and responsibilities” are followed (Fagermoen
closely with patients needing help to cope with the impact of 1997). In other words, professional identity is the “foundational
health deficiencies or the effect of changes in the nuances of life reference” in the nurse's cognitive process in decision making.
1 Saint Louis University School of Advanced Studies, ctco888@[Link]
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The nurse equips the said values and beliefs as guiding subject to change rather than following fixed conditions with rigid
principles in thinking, behaving, acting, communicating, and rules that are not always appropriate for examining reflective
interacting with patients, the patient's family, and fellow learning in a new context. This paper then followed Rodgers's
healthcare team members. evolutionary concept analysis to analyze reflection towards
developing professional identity among nurses. The purpose is
As a practical science, nursing education has introduced the not to elicit a conclusive answer but to identify a unanimous
importance of reflective learning in the clinical setting when concept. As Rodgers (1989) suggested, the process of concept
providing care to patients and building a nurse-patient analysis is to explore the context on how the concept was used,
relationship (Pierson 2001). The dynamic between both parties retrieve data from different concept resources and references,
means a developing awareness of assisting, encouraging, and and identify antecedents, attributes, and consequences of the
teaching both students and professional nurses to become concept. In addition to how the investigation was designed, the
thoughtful individuals capable of critical thinking and analogy to dispositional theory of concepts is adopted as described by
develop innovative ideas. Reflection in this mode of instruction Rodgers. “Reflection” as a context used in this concept analysis
formed in the relationship is considered a tool for analyzing is in its scientific use as it appears in the published work
nursing practice, nurturing both the understanding of contrasting to the familiar terms used in everyday
professional nursing and the building of essential and thoughtful conversations. The concept of reflection is chosen as it is
approaches essential for providing nursing care in multifaceted defined and studied within the nursing educational contexts
and engaged working conditions. As a result, reflection has been being delineated in search of published work.
included in many nursing curricula as an instructional method.
However, the concept of reflection in developing a professional Data Source
identity has scarcely been defined to identify research and
educational indicators adequately. The search for electronically published work is from five
databases: Google Scholar, EBSCO, Cochrane Library,
This concept analysis aims to describe attributes, antecedents, Science Direct, and Scopus using a combination of the
and consequences of reflection in developing a professional keywords “reflection,” “nursing,” “nursing education,” “critical
identity in nursing and surrogate terms and is a model case to reflection,” “reflection in practice,” “critical thinking,” “reflection
inform nursing students and nurses both in the academe and in in action,” “nursing student journaling/journal writing,”
the clinical area about developing reflective skills. Further, the “blogging,” “service learning,” and “e-learning.” The articles
findings of this study also aim to provide clear evidence for used are written only in English. Duplicates, non-academic, and
nursing educators/faculty that supports the systematic unavailable articles were disregarded for use. Articles
development of professional nurses as they advance in practice containing concepts of reflection including attributes,
from the undergraduate to the graduate programs. antecedents, consequences, surrogate terms, and essential
aspects in nursing education are included, while articles with
Study design none are not. Fifty articles were chosen based on the
abovementioned inclusion and limitation criteria. Rodgers
In unfolding, exploring, and clarifying the base of knowledge, pointed out that including at least 30 articles reach the common
concepts are important because as the concerned healthcare use of the concept (Tashiro, Shimpuku, Naruse, & Matsutani,
professionals gain criticism, it encourages acceptance by 2013). The sampling, therefore, of this current concept analysis
building critical consensus. Thus, this feedbacking method was adequate based on the guideline set by Rodgers.
fosters understanding, and as research develops, the
definitions of concepts evolve and eventually concretize (Morse Data Analysis
1996). In other words, concepts must first be adequately defined
and described as it becomes the foundation and grounding of The 50 electronic articles were reviewed and analyzed using
further exploration to develop valuable and updated knowledge thematic analysis as suggested by Rodgers. The language used
in nursing science. Numerous methods and approaches for in the included published work was thoroughly examined to
concept analysis were introduced to advance nursing theory determine a trend by having the question in mind: What is similar
and practice. Wilsonian (1963/1969) methods of concept in using the word? The following concepts are chosen from the
analysis adopted and further developed by Walker and Avant description of “reflection” in the selected published works: (a)
(1983/1998/1995), Chinn and Jacobs (1983/1987), Chinn and antecedent are the events that happen prior to the concept); (b)
Kramer (1991), and further reformed by Schwartz-Barcott and attributes are the traits related to the definition of the concept; (c)
Kim (1986/1993) and Rodgers (1989/1993). consequences are the results that are happening because of the
antecedents and the attributes. These were then are placed in a
Rodgers (2000) upholds that concepts are dynamic and develop table to evaluate similarities among the published articles.
over time depending on context. Therefore, concepts are always Cohesive contexts were continuously organized and

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reorganized to develop a comprehensive and relevant analysis ideologies, values, and ethical principles brought about by
of the concept. these concerns. Reflective learning is an important strategy to
promote critical thinking and self-inquiry regarding their cultural
Results values and how to adapt demands of the patient and their family
without compromising their values and beliefs.
Antecedents
Advancement in Education and Learning
Gap between thought and action
The development of more complex assessments and evaluation
In the clinical setting, nurses often experience situations where in nursing education that is leaning towards knowing oneself and
the ideal option they have in mind is not clear and readily others to build a professional identity makes the positivist
available (Parissopoulos 2019). These problematic situations traditional educational approach less effective. This is due to
prompt the nurse to analyze what they have experienced and nurses being able to understand the process of caring through
what they thought they knew. A cognitive thought and an their inner self with others. Hence, they can attain a sense of
emotional awareness have sparked an uncomfortable feeling accomplishment and self-actualization. Reflection as a tool can
brought about by the realization that the knowledge being enhance self-effectiveness and respect of self and others.
applied during their performance of patient care was not
enough to explain what had transpired. Attributes of Reflection
Deliberate process of experience analysis
Through this, nurses can improve their critical thinking and
problem-solving abilities. Therefore, nurses can identify their An extensive number of authors describe reflection as a tool to
strengths and weaknesses to identify the need for growth and allow learners to reflect on their experiences freely. In turn, it
learning and adopt viable alternative workarounds to solve helps the learner deeply understand what has transpired in their
clinical dilemmas in the future. experiences to improve their decision-making, behavior, and
practice approach. This leads to the reflection of a plan for
Gap Between Theory and Practice changing and having new actions in taking necessary steps to
As nurses transcend from the schools to the clinical area, they change their thinking, perceptions, and their practice as shown
soon face a break between what they learned and what they see in the cyclic process below:
in reality (Contreras, Edwards, Hall, & Lee, 2020). A vast pool of
studies has mentioned the need for reflection to integrate theory Figure 1: Cycle of Reflection
and practice. Reflection is progressively acknowledged in
nursing practice because of its contribution to the learning
process and expansion of the body of nursing knowledge
(Edwards 2017).

Advancement in Knowledge and Technology

As healthcare expands and becomes increasingly advanced
and more accessible to people, there is an expansion and
shifting of roles in advanced practice, which demands nurses to
act more autonomously and make reasonable clinical
judgments. These developments entail that nurses are now
required to apply their specialized knowledge in dealing with
well and sick clientele in collaboration with other professionals
in the healthcare team. The changes also bring about the need
for reflection in practice and nursing education.

Values and Cultural Differences

As nurses interact with other people, they get exposed to
dilemmas from the diversity of culture, beliefs, and values.
These problems may be rooted in differences in practices and
multiplicity of beliefs as influenced by upbringing depending on Spiritual, Emotional Quest and Examination of Inner Self
one's country or place of origin; this poses a challenge for Through internally assessing and reflecting on past decisions,
nurses to develop transcultural competencies and sensitivity one can use reflection to identify uncomfortable feelings that
(Siles-González & Solano-Ruiz 2016). Nurses must think about made them think over the situation. The process, in turn, makes

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one critically appraise and analyze the situation from different Surrogate Terms
perspectives, thus developing new insight from experience.
Life-Long Learning
Thought Process Relying Mostly on Memory Although life-long learning is more than reflective learning,
At the end of reliving and describing a situation, students are reflection as a daily activity will continuously help enhance
required to internally examine their feelings and thoughts, from knowledge and skills to address immediate problems and
their memories, considering their thoughts and emotions about participate in the process of self and professional development.
the situation described. To form new understandings and Transformative Learning
appreciations, learners need to draw learning from experiences
that are poorly defined, complex and influenced by many factors. The term is the same as a perspective transformation where an
Thus, it is imperative to assess and analyze what happened individual can recognize the valid reason for a problem. This
deeply and the influences in the issue of concern. produces critical awareness where the cognitive process changes
an outlook, behavior, or practice.
Consequences
Experiential Learning
Increased Critical Thinking Skills
Learning through reflection is the processing, analyzing, and
Reflection brings a learner to critically analyze situations, be aware evaluating experiences where concepts are grasped, resulting in
of one's own beliefs, values, strengths, and weaknesses, and change or transformation. Thus, as Dewey (1933) proposed,
decide what to accept as guiding principles. Learners can formulate “experience and reflection will result in learning.”
questions, hypothesis alternatives, and plans to test principles by
either experimenting or making mental maps. Through this Discussion
process, the students will become more aware of their personalities
and learn more about themselves, their roles, and responsibilities The author identified antecedents, attributes, consequences, and
as nurses and members of a larger institution. surrogate terms of reflection in nursing in developing a
Facilitate Communication and Collaboration professional identity. The cycle of reflection is a circular model
(Figure 1). The consequences of reflection to develop
Learners explore in reflecting their values and feelings and how professional identity are seen as an overall linear upward trend.
these factors influence others around them. Reflection brings the
means for professional nurses to realize knowledge and Proposed Definition:
theoretical underpinnings in nursing by either accepting,
In the development of professional identity, reflection is a
challenging, or changing knowledge to meet the need of the
continuous and deliberate process triggered by the gap in thinking
present circumstance. As a result, nurses can contribute to the
and action. Following the definition, the nurse is to describe and
multidisciplinary team their enhanced knowledge to improve
analyze experiences, identify and process their deepest
practice, thus improving patient care outcomes as a whole. emotional feelings, examine their thoughts, critically look at their
Development of the Meaning of Nursing behavior and the situation, and thus plan for more effective action.
Through the cycle of reflection, they become more aware of their
There are five identified consequences of reflection in the caring skills and be ambassadors of the profession to better
development of personal meaning in nursing: 1) Identifying gaps communicate with patients, colleagues, and other healthcare
in their knowledge and thus opening the need for improvement of team members. As a life-long learner in the process of reflection, a
self; 2) Identifying opportunities of growth as a person and as a nurse can acquire self-directed learning skills leading to obtaining
nurse; 3) Awareness of one's roles and responsibilities as a professional maturity.
member of a profession; 4) Recognizing support for finding
solutions in deciding during uncertainty; 5) Analyzing reasons of Model Case
embracing the nursing profession as one's calling; & 6) Reflexivity Cristopher is a newly hired nurse in his 1st year working in the
in practice where nurses can see the interconnectivity in the lives Emergency Room. It was another work day for him and another
of people, acknowledging and taking the responsibility of their shift to conquer as an orientee nurse. Fresh from passing the
presence in the lives of the different patients they are caring for board exams, he was left to decide for himself and rationalize
through the reflective lens (Palaganas et. al 2017). In the journey nursing interventions being done to his patients. He could cope
of reflection towards reflexivity, nurses can put meaning in every with difficulties through guided reflection with his mentors at the
aspect of their experiences in caring for patients, guided by the end of every shift. Reflecting on his actions made him appreciate
principle that their involvement in the lives of patients have an more the role of nurses in the healthcare system. This gives him
overall effect on the patient's decision-making for their health. strength and pride in his chosen profession.
(Palaganas & Estacio 2021)

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Conclusion Morse, J. M., Hupcey, J. E., Mitcham, C., & Lenz, E. R. (1996). Concept
analysis in nursing research: a critical appraisal. Scholarly Inquiry
This global, dynamic, ever-changing society brings about for Nursing Practice, 10(3), 253-277.
changes in nursing care, shifting from traditional to people- Oates, J., Weston, W. W., & Jordan, J. (2000). The impact of patient-
centered care on outcomes. Fam Pract, 49(9), 796-804
centered care. The shift requires increased responsibility and
Olsen NC. Self-reflection: Foundation for meaningful nursing practice.
autonomy from a professional nurse. In this concept paper, Reflections on Nursing Leadership. 2013;39(2):1-4. Accessed
reflection is identified as a potential tool for a nurse to find their October 26, 2020. [Link]
identity where reflection helps them look into their perspectives. In [Link]?direct=true&db=rzh&AN=104206515&site=ehost-live
this matter, they can enhance communication within themselves, Palaganas, E. C., Sanchez, M. C., Molintas, V. P., & Caricativo, R. D.
their patients, and colleagues. As a result, they can find their (2017). Reflexivity in qualitative research: A journey of learning.
identity as professionals dealing with patients and all aspects of Qualitative Report, 22(2).
life and thus improve the quality of care. Palaganas, E.C. & Estacvio, J. (2021). Reflexivity And Research
Methodology: A Second Glance. Philippine Journal of Nursing. Vol.
____________________ 91. [Link]. 87-96.
Parissopoulos, S. (2019). Reflection and reflective practice: a
cornerstone value for the future of nursing. Rostrum of Asclepius /
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and critical reflection. Nursing Philosophy, 7(4), 216–224.
Nusantara Studies, 5(1), 54–79. [Link]
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Burton AJ. (2000). Reflection: nursing's practice and education
panacea? Journal of Advanced Nursing (Wiley-Blackwell), 31(5), Siles-González, J., & Solano-Ruiz, C. (2016). Self-assessment,
1009–1017. [Link] reflection on practice and critical thinking in nursing students.
Nurse Education Today, 45, 132–137. [Link]
Contreras, J. A., Edwards, M. S., Hall, A., & Lee, M. A. (2020). Effects of
[Link].2016.07.005
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Anxiety and Competency: An Integrative Review. Worldviews on Tashiro, J., Shimpuku, Y., Naruse, K., & Matsutani, M. (2013). Concept
Evidence-Based Nursing, 17(3), 239–245. [Link] analysis of reflection in nursing professional development. Japan
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Cotton, A. H. (2001). Private thoughts in public spheres: issues in Tofthagen, R., & Fagerstrøm, L. M. (2010). Rodgers' evolutionary
reflection and reflective practices in nursing. Journal of Advanced concept analysis–a valid method for developing knowledge in
Nursing (Wiley-Blackwell), 36(4), 512–519. [Link] nursing science. Scandinavian journal of caring sciences, 24, 21-31.
10.1046/j.1365-2648.2001.02003.x
dos Santos Martins Peixoto, N. M., & dos Santos Martins Peixoto, T. A. ABOUT THE AUTHOR
(2016). Reflective practice among nursing students in clinical
teaching. Revista de Enfermagem Referência, 4(11), 121–131.
[Link] RIV16030
Edwards, S. (2017). Reflecting differently. New dimensions: reflection- Charmaine Co-Enarsico, Master in Nursing,
before-action and reflection-beyond-action. International Practice Major in Nursing Administration in Education;
Development Journal, 7(1), 1–14. [Link] is a Certified Healthcare Simulation Educator
ipdj.71.002 (CHSE) working at the Simulation and Skills
Epstein, R. M., & Street, R. L. (2011). The values and value of patient- Development Center (SSDC), Princess
centered care. Nourah Bint Abdulrahman University (PNU),
Fagermoen, M. S. (1997). Professional identity: values embedded in Riyadh, KSA. She is a member of SSDC
meaningful nursing practice. Journal of advanced nursing, 25(3), Curriculum Review Committee and the Coordinator for Simulation of
434-441. the College of Medicine and Dentistry. She is a Basic Life Support
Fejes, A. (2008). Governing nursing through reflection: a discourse (BLS), Advanced Cardiac Life Support (ACLS), & Pediatric
analysis of reflective practices. Journal of Advanced Nursing Advanced Life Support (PALS) Instructor of the American Heart
(Wiley-Blackwell), 64(3), 243–250. [Link] j.1365- Association (AHA).
2648.2008.04800.x
Hannigan B. (2001). A discussion of the strengths and weaknesses of She is passionate about lifelong learning and teaching and is in the
“reflection” in nursing practice and education. Journal of Clinical field of education since 2005. Starting young as a faculty in Saint
Nursing (Wiley-Blackwell), 10(2), 278–283. [Link] Louis University, School of Nursing, Baguio City, Philippines, her
2702.2001.00459.x10.1111/j.1365-2702.2001.00459.x humble beginnings made her believe that education must be more
Moloney J, & Hahessy S. (2006). Using reflection in everyday nurturing than torturing. She was given the “Innovative Idea Award”
orthopaedic nursing practice. Journal of Orthopaedic Nursing, in the 1st SimGhosts Conference 2020 held at Princess Nourah Bint
10(1), 49–55. Abdulrahman University, Riyadh KSA.

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CONCEPT ANALYSIS

Reintegration: A Concept Analysis

Rock Billaco Tubaña, MAN, RN1

Abstract
Reintegration is an integral part of nursing care. Nurses play a critical role in contributing support, dependence, and continuity of
care from rehabilitation to reintegration. While the reintegration of patients is a concept often used in nursing, its theoretical origin
has remained unclear. This article aimed to conduct a concept analysis of reintegration for the development of nursing as a
discipline and improve nursing care and health outcomes. The evolutionary strategy to concept analysis of Roger was utilized,
which resulted in the characteristics of reintegration as to its attributes, antecedents, consequences, and exemplar in nursing
practice in the context of COVID-19. The capacity to adapt, reorganize, offer support, and build a network of resources are
attributed to the concept of reintegration. Antecedents include rehabilitation, survivorship from illnesses, trauma, and injuries, and
disruption of social and physical functional performances and activities. The identified consequences include transition to recovery,
quality of life, independence, successful adaptation, job satisfaction, holistic care, and continuity of care. The new conceptual
definition of reintegration emerged. Reintegration is a process of nursing care among patients who demand assistance and support
before transitioning to regain normality or on their way to being restored to the community in the presence of adaptation from health
adversities. The patient in all areas is cared for holistically, offering support to meet his needs and overcome challenges in terms of
physical, mental, social, and emotional aspects. Concept analysis is as essential as operationalizing a concept in the nursing
discipline.

Keywords: reintegration, quality nursing care, COVID-19

Introduction

E very patient requires different modalities of care and

treatment programs towards recovery. To achieve faster
recovery and optimal health, sometimes nursing care is
of consensus definition for reintegration has created deep
nuances in the understanding of what comprises reintegration.
It makes it challenging to utilize it in nursing care without the
demanded, especially by patients with debilitating effects of reliability to measure it. Hence, understanding and clarifying the
illnesses or diseases requiring intensive considerations, concept and describing its attributes are necessary.
support, and dependence. From rehabilitation to reintegration,
both of these processes have been an integral part of nursing Materials and Method
care.
Concept Analysis Method
While the reintegration of patients is a concept often used in
nursing, its theoretical origin has remained unclear. One There are several approaches in conducting concept analysis in
definition says that reintegration “is closely allied to functional nursing science. The evolutionary strategy to concept analysis
performance” (Wood-Dauphinee & Williams, 1987), which of Rodger viewed it as a systematic method that clarifies,
suggests an association on physical health, (i.e., wellness). describes, and explains concepts central to nursing science
There are also various issues and definitions related to several based on the review of a chosen concept as used within the
aspects of living and across fields, such as psychosocial health, discipline or other health sciences (Tofthagen & Fagerstrom,
social, education, and legal. 2010).

It is essential to study this concept for the development of The method of analysis is more focused, and the context of the
nursing as a discipline and improve nursing care and health concept varies over time (Cutcliffe & McKenna, 2005; Grove et
outcomes. Moreover, across several works of literature, the lack al., 2012). Since reintegration is changing in context, Rodger's

1 PhD STUDENT, Saint Louis University, Baguio City; 2206602@[Link]

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evolutionary concept analysis was utilized for analyzing this includes “comprehension, creative adaptation, and
concept following the different stages: naming the concept of reintegration processes for adapting to losses at the end of life.”
interest, identifying surrogate terms and relevant uses of the
concept, determining data samples for analysis, identifying the On the other hand, reintegration is also defined in several
attributes, antecedents, consequences, and other concepts perspectives of physical health, such as in the presence of injury
related to the concept, and creating a model case for the concept (i.e., brain injury, cancer, stroke, and burn). In the course of
(Utley et al., 2017). recovery from a burn, it was identified that reintegration is one of
the stages of psychological adaptation during recovery from
Data Source burns (Cash, 2012; Rosenberg et al., 2018). Furthermore, in the
context of patients following brain injury, Reistetter and Abreu
The following databases, such as Scopus, Science Direct, (2005) defined reintegration as a dynamic process of adapting
PubMed, Google Scholar, EBSCO, and Cochrane Library, were that is culturally bound, personal, and multidimensional. Ore
utilized for the review of the literature electronically. The process and Foli (2019) conducted a conceptual analysis on
of gathering data included a rigorous search on different reintegration as a concept among cancer survivors, and they
literature within health sciences using keywords such as defined it as a dynamic process that involves the restructuring of
“reintegration,” “community reintegration,” “social former self abilities concurrent with re-evaluating them.
reintegration,” “integration,” “rehabilitation,” “patient
reintegration,” “readjustment,” “transition,” and “holistic care” in Attributes
title and abstract. Abstract and full-text articles in the English
language were the inclusion criteria. After evaluating the Based on the definitions of the concept, the capacity to adapt,
definitions of the concepts and repetitive features in various reorganize, offer support, and build a network of resources is
literature, the description of reintegration evolved. The search attributed to the concept of reintegration.
yielded also relevant attributes, consequences, empirical
referents, and a specific model case of the concept. Adaptation. Patients with serious illness, trauma, and injuries
may have the ability to adapt. As a result, it is manifested that the
Results level of acceptability to a particular disease enables a person to
cope and improve himself (Smedema et al., 2009; Chan et al.,
2013; Walsh et al., 2015). Adaptation entails a realization of
Surrogate Terms and Relevant Uses of the Concept transitioning from normal to the new normal living of a patient
In this part of the study, the surrogate terms were identified such (Knight & Emanuel, 2007; Olano et al., 2020), which facilitates
as family reintegration (Eggenberger et al., 2011; Bello-Utu & participation in rehabilitation and recovery. The curiosity of a
DeSocio, 2015; Faria et al., 2018), community reintegration patient with regards to his self-care and health outcomes
(Walsh et al., 2015; Olawale et al., 2018; Rosenberg et al., 2018; generates the level of acceptability of the disease and the
Glickman & Chimatiro, 2018; Critchfield et al., 2019), readiness to achieve faster recovery (Livneh & Antonak, 2005).
rehabilitation (Glickman & Chimatiro, 2018), and rebounding
(Earvolino-Ramirez, 2007). Reorganization. The assessment of the strengths and
weaknesses of the patient gives a significant impact on the
With the vast and fast-growing development of literature and restoration of independence; for example, a negative perception
concepts, reintegration is defined from different views and other of one's self limits the ability to recover (Huang et al., 2015).
relevant uses, such as in psychology and psychosocial aspects. Restructuring of one's self encompasses the redefining and
The word reintegration refers to “the process of reorganizing regaining of roles and performances along with the re-
mental processes” (APA Dictionary of Psychology, n.d.) of evaluation of abilities (Suddick et al., 2009; Ore & Foli, 2019). A
mental activity after psychological disturbance, and “action of revised self-concept is related to reconstructing and
integrating back to society” (Oxford Dictionary, n.d.). reassessing the self to regain normality (Ruan & Zhou, 2019).

Several authors have examined the common use of the term Offering Support. One of the most important things a nurse
“reintegration” in an attempt to uncover its meaning. When it does is to provide patient support. This entails addressing the
comes to the psychological health perspective, specifically post- emotional, physical, mental, spiritual, and social needs of a
deployment, Currie et al. (2011) defined reintegration as “the patient (Gardner, 1979), who is experiencing higher physical
process of transitioning back into personal and organizational distress (Sanders et al., 2010). Nurses do patient care
roles following deployment.” In palliative care in nursing, (Knight extensively that can significantly contribute to a patient's
& Emanuel, 2007) developed reintegration into a model, which is recovery (van Weeghel et al., 2019). The interrelationship of
primarily focused on the interventions for terminally ill patients. each aspect of care contributes significantly to a patient's
Knight and Emanuel (2007) further described the model that speedy recovery.

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Building a Network of Resources. One of the factors fear of social challenges, e.g., stigma, rejection, trauma. The
associated with the patient's faster recovery is the resources nurse, while alleviating the patient's fears and anxiety, assisted
and support they will receive from the hospital and until returning the patient in identifying actions to deal with those challenges
home. According to Yates (1995), the identification and (offering support). As the interactions went on, the nurse
development of a network of resources are perceived to affect a identified agencies or people who could help him back to
patient's recovery directly. The quality of support enhances society and resume his previous roles and activities (identifying
better behavioral and emotional outcomes among patients resources). It was at this moment that the patient also
(Villain et al., 2017). mentioned several people who could help.

Antecedents Rehabilitation and Community Reintegration

The literature revealed several antecedents of reintegration that Several studies defined community reintegration as a process
were specifically based on rehabilitation, survivorship from of involvement in the community activities, engaging in one's
illnesses, trauma, and injuries, and disruption of social and previous roles and responsibilities, and relationships within the
physical functional performances and activities. community (Obembe et al., 2013; Herndon, 2012; Esselman et
al., 2001; Dijkers, 1998). This implies further that integrating the
Due to the incapacitating effects of illnesses or disorders, the patient into the community signifies social interactions that
level of functioning of a patient or individual as to social and enable social support from individuals around him, making the
physical is compromised, resulting in rehabilitation. transition (reintegration) easier (Herndon, 2012).
Rehabilitation maximizes the health potentials of patients after Rehabilitation, to a higher degree, can also be attributed to
experiencing trauma, injury, or illness, which is vital in the patient reintegration. According to World Health Organization
reintegration of a patient to functional performance (Obembe et (n.d.), “rehabilitation is a set of interventions needed when a
al., 2013). Also, being a survivor from impactful adversities in person is experiencing or is likely to experience limitations in
one's health initiates and underpins the concept of reintegration everyday functioning due to aging or a health condition,
of patients transitioning from normal to new normal living (Currie including chronic diseases or disorders, injuries or traumas.”
& Kelloway, 2011; Ore & Foli, 2019;). Reintegration also Moreover, Waddell and Burton (2004) defined rehabilitation as
requires nurses to assist patients due to the disruption of their a secondary intervention to restore patients as far as possible to
activities and lifestyles. their previous condition after disease or injury (within limits
imposed by pathology and impairments).
Consequences
Discussion
The consequences of reintegration are obvious and
encompassing, where it gives positive impacts on both the The result of the concept of analysis on reintegration is
patient and nurse. In the part of the patient, several outcomes comprehensive and remarkably precedent in social,
were identified, such as the transition of recovery, improved psychosocial, and psychological aspects from various
quality of life, independence, health status, and successful literature. Based on the findings, the identified attributes are the
adaptation. The nurse is also benefited from the interaction with capacity to adapt, reorganize, offer support, and build a network
the patients, especially in the context of assisting and facilitating of resources. The adaptability of patients is integral, and it
reintegration, such as job satisfaction, enhanced holistic care, denotes the readiness of someone to progress from
and continuity of care. disablement to enablement while there is acceptance of
specific health adversity (Nalder et al., 2013). Reorganization
Model Case indicates the restructuring of the patients' self-concept. It
serves as the opportunity for the patient to reorganize the
Andy, a 34-year-old man, was about to be discharged after former roles towards normality. Nursing care offers support that
being confined at a critical care unit for a month due to COVID- also assists the patient in overcoming challenges related to
19 (survivorship from illness). As the nurse was preparing the physical, mental, social, and emotional aspects, which
discharge plan for the patient, the patient suddenly got anxious influence holistic care (Turner et al., 2009; Kidd et al., 2016).
and worriedly asked the nurse about the things he could do to Lastly, identifying support systems and resources reveals a vital
prevent COVID-19 recurrence, and circumstances await him role in the continuity of care.
after hospitalization (adaptation capacity). The nurse provided
health teachings and assisted the patient in making informed Based on these attributes to the development of the concept,
decisions, especially in redefining his roles, beliefs, and reintegration can be defined as follows: “Reintegration is a
activities while the nurse was accessing his strengths and process of nursing care among patients who demand
weaknesses (reorganization). The patient also verbalized the assistance and support before transitioning to regain normality

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nursing science. Scandinavian journal of caring sciences, 24

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CONCEPT ANALYSIS

A Concept Analysis of Role Modeling

Bhert Keane Q. Pugrad, MAN, RM, RN1

Abstract
Role modeling is a strategy used to teach attitudes and behaviors. It is a modality that may be consciously and unconsciously
executed by the role model. This concept is used interchangeably with mentoring. Thus, requires further clarification and
understanding. The Walker and Avant method was adopted as the main tool of analysis in understanding this concept. The
identified antecedents of role modeling are the role of aspirants’ ideals and perspectives and the role models' [Link]
attributes that have emerged are facilitating learning, embodiment, inspiring, transforming, reinforcing, connecting, and caring. The
consequences are transforming, reinforcing motivation and goals, and the conception of new role [Link] implies that role
modeling is a cyclical and interactive process. It is continuously constructed both by the role aspirants and role models. Nurse
educators, staff nurses, and managers act as the primary role model of neophyte nurses. Thus, they should remain cognizant in
their practice. The way they interact with their subordinates greatly influences their role aspirants' motives and ideals, who will later
assume the responsibilities of a future role model.

Keywords: Role modeling, role model, concept analysis

Introduction

R ole modeling is widely used in the academe and social

sciences. It is a traditionally accepted approach in teaching
attitudes and behaviors (Bidwell & Brasler, 1989). The term 'role
Role modeling and mentoring are used interchangeably; role
modeling may be imitative and passive. It may cover a vast
audience limiting the interaction between the mentor and the
model', coined by Merton (1968), pertains to a reference mentee. On the other hand, mentoring requires long-term and
individual where roles, behaviors, and values are adopted for individualized relationships. Mentors may serve as models and
emulation. Ibarra and Petriglieri (2008) described role models as participate in the mentee's advancement (Bidwell & Brasler,
successful in the field and are imitated by role aspirants who will 1989).
later assume a professional role (cited in Morgenroth et al.,
2015). Role modeling is viewed as a way of instilling aspirations, Role modeling remains critical and associated with mentoring.
stimulating motivation to achieve their goals (Morgenroth et al., This calls a need to examine the elements surrounding the
2015). Bandura (1977) also described modeling as one of the concept of role modeling and its application to nursing.
constructs in his theory and proposed that human behaviors can
be learned through observational learning and symbolic Method
representation.
This paper critically examines the concept of interest through
In nursing education, role modeling is proposed as a teaching concept analysis. Schiller (2018) defined concept analysis as “a
strategy for sharing practitioners' knowledge (Perry, 2008) and a systematic process that allows one to examine and articulate
tool for translating theory into practice (Prince as cited in Perry, the most basic element of a given concept, including its
2008). Modeling is a skill beyond human nature, an instrument structure and function" (p.1). Walker and Avant's method was
beneficial to the role models and observers. This can facilitate an adopted as the main tool of analysis commencing with selecting
atmosphere for good and open communication. Moreover, role a concept based on the review of nursing theory and literature
modeling humanizes learning. It offers a stable and strong followed by a literature search covering both nursing and non-
foundation for teaching-learning, allowing students to nursing resources.
appreciate this knowing (Lamb, 2005).

1 Saint Louis University, Baguio City; 2170658@[Link]

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Attributes of Role Modeling learners. The role models' ability to influence novice individuals to
explore their potentials would promote a positive outcome in the
Attributes are considered the hallmark of a concept. The learners' performance.
identified attributes were processed from an in-depth analysis of
the retrieved literature. Key criteria were compiled and pulled Connecting. Connectedness draws back to humanism; role
from each definition. Use of those combined terms with similar modeling is the primary method that demonstrates humanism
terms was examined if they truly exist as a defining criterion of the (Weissmann et al., 2006). In education, role modeling
concept (Schiller, 2018). establishes a genuine connectedness. It launches an
atmosphere of communication. This constitutes an interpersonal
The concept of role modeling contains the following attributes: attraction or humor, having a sense of collaboration, and making
facilitates learning, embodiment, inspiring, transforming, role models readily reached for the learners (Bandura, 1977;
reinforcing, connecting, and caring. Perry, 2009; Baldwin, 2014; & Lamb, 2005).
Facilitates learning. This attribute reflects the crucial role of Caring. Caring qualities are essential to nursing, and role
educators as role models. An educator does not only provide modeling conveys genuine interest to role aspirants. Caring
information and instructions, but they also transmit attitudes and qualities are: showing respect, valuing patients, colleagues, and
values and act as a behavioral model (Bandura, 1977; Bidwell & students, compassion, being available in times of adversities,
Blasler 1989; Baldwin, 2014; & Morgenroth et al., 2015). The respecting opinion, and being a student advocate (Baldwin,
transfer of learning using role modeling has been an effective 2014; Perry, 2009; Cruess et al., 2008).
learning tool; it allows students to remember concepts and skills
to acclimate to real-world experiences (Lamb, 2005). Model Case

Embodiment. Embodiment means an epitome. It is a person The model case is defined as a type of case where all the defining
admired because of his/her principles and values, like honesty, attributes of the concept are present (Schiller, 2018). Nursing is
integrity, and morality. Role models are being respected because one of the most challenging programs. It demands you to bend
of the ideal qualities they possess. These are the qualities that the and bow. For me, level 2 nursing was one of the most challenging
role aspirants like students and novice nurses would like to parts of the undergraduate. Since our program was a ladderized
emulate or adopt. Aside from their personal qualities and program, we need to attend to 20 actual normal deliveries, have
characteristics, their achievements, attained goals, and levels of five perineal suturing, intravenous (IV) insertion, and internal
success in the profession, enthusiasm, and uncompromising examinations to be qualified to take the midwifery licensure
quest for excellence are symbolically viewed by most of the role exam. We also need to pass the board exam before admission to
aspirants (Bandura, 1977; Bidwell & Blasler, 1989; Baldwin, level 3 of the nursing program. As a novice nursing student, I am
2014; Merton, 1968; & Morgenroth et al., 2015). Efficacious quite anxious and excited about our delivery room exposure
qualities of role models would be tagged as a reference individual (DR). Before entering the delivery room, my clinical instructor
(Merton, 1968) by the role aspirants who would attempt to conducted a micro-teaching to make a concept easy to
assume professional roles in the future (Ibarra & Petriglieri as comprehend and demonstrated exceptional skills in maternal
cited in Morgenroth et al., 2015). and newborn care. I was attending my first case. My clinical
instructor (CI) noticed that I am tense. Despite being anxious, he
Inspiring. Reflecting on the achievements of a role model, he showed belief in me and uttered words that guided me to perform
may overtly or covertly influence role aspirants. One of the distinct the task. Every time I asked what to do next, he responded
functions of role models is being an inspiration. Inspiration could compassionately and gently tapped my back. He make me feel
impact the aspirants' expectations of success and contribute his presence that boosted my confidence. After my first case, my
more to their reinforcement (Morgenroth, et al., 2015). CI congratulated me on doing a great job. After this exposure, he
told me that I could perform better and asked me to continue
Reinforcing. Reinforcement is the application of a stimulus learning to enhance my skill. Those experiences may occur for a
resulting in a strengthened behavior (Bastable, 2003). In the short while, but it is life-changing. My CI is truly an embodiment of
literature analysis, reinforcers are discharged from role models to a character that most of us, his learners, wanted to emulate.
their role aspirants in the form of motivation, conveying belief, and
confidence to their strength and ability. Morgenroth et al. (2015) Borderline Case
state that role models send messages to the aspirants that they
can successfully execute the task and improve their A borderline case contains some but not all of the defining
performance. attributes compared to a model case. Kulas was a newly hired
nurse in the government hospital in their locality. He undergoes
Transforming. Role models can promote students' potential by apprenticeship in their assigned unit for two weeks. Domz, his
refocusing and reframing their perception, especially novice nurse supervisor, assisted kulas. Every time Kulas will perform

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complex tasks like IV insertion, Domz would demonstrate it first worked long-term. Her adviser teaches her what to do, examined
before allowing him to perform the task. For every successful her output, and provided feedback and constructive criticisms.
attempt, he was praised by his supervisor. Within their apprentice Whenever Fhats feel so down, Dr. Ester counseled her towards
session, Domz shared his experiences telling Kulas to be refocusing on their goal.
steadfast because patients' lives are crucial in their unit. After two
weeks, Kulas felt more confident and carried the task Antecedents
independently. However, he noted that his supervisor lacks
interpersonal connection with their patients and focused too Antecedents are defined as the events occurring or being in
much on the piled work and procedures. place before the concept can exist (Schiller, 2018). The
antecedents of role modeling can be viewed as the role of
Contrary Case aspirants' ideals and perspectives and the role model's
experiences. Role models do not exist without role aspirants
A contrary case does not contain the identified attributes of the (Morgenroth et al., 2015); therefore, role models are perceived
selected concept. Bhert was a pediatric staff nurse who was just mainly by the role aspirants. They are created and selected
transferred to the medical unit. During his first day of duty, Bhert
based on their ideals and preferences. Janis (2012) stated that
was quite anxious since this will be his first time to be assigned to
students select role models based on their personality, clinical
the unit. He expected that he will be oriented and assisted by the
nurse supervisor; however, his co-staff told him it would be a skills, competence, and teaching abilities. On the other hand,
different case since they were outnumbered. Instead, his role modeling qualities are not innate but crafted from
colleague gave their unit's manual of procedures and asked him experiences. Today's present role models were once an
to go through it and familiarize himself with the unit's different apprentice from their role models in the past witnessing “the
processes. force of prestigeful modeling” (Bandura, 1977 p. 88) transforming
their lives and perspectives.
Related Case
Consequences
A related case is described as similar to the concept and may
mimic its characteristics, but it is different from the study concept A positive experience of role models can transform their learners,
(Schiller, 2018). Role modeling is always interchanged with build their confidence, and strengthen knowledge, skills, and
mentoring, but they are not the same in all instances. Fhats is a values. Jarvill et al. (2018) stated that exposure to an expert role
PhD student currently writing her dissertation, through the model significantly improved students' performance. Moreover,
guidance of her adviser, Dr. Ester, an expert in the field of experiences in role models enhance students' innate values
qualitative research. During their first meeting, Fhats and Dr. (Wear & Zarconi, 2007). This results in the conception of a new
Ester briefly examined their desirable characteristics since they generation of models in the arena. Being acquainted with models

Figure 1. Relationship of the antecedents, attributes, and consequences of role modeling

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is strongly associated with their protégé's selection of field as they Janis, A. T. (2012.). Role Modeling: The Forgotten Influence.
will later assume professional roles like their models (Morgenroth Retrieved from [Link] 2012/11/role-
et al., 2015 & Wright et al., 1997). [Link]
Jarvill, M., Kelly, S., & Krebs, H. (2018). Effect of Expert Role
Empirical Referents Modeling on Skill Performance in Simulation. Clinical
Simulation in Nursing, 24, 25-29. doi:10.1016/
Empirical referents or indicators are measures of the attributes of [Link].2018.08.005
the concept. Role modeling exists from interaction, stories, and Lamb, P. D. (2005). Application of the modeling role-modeling
experiences. This concept can be explored using a qualitative theory to mentoring in nursing (Unpublished master's
method of inquiry, particularly phenomenology. Aside from thesis). Montana State University.
qualitative methods, there are available tools to measure some Merton, R. K. (1968). Social theory and social structure. New
but not all of a role model's critical attributes. The tools available York: Free Press.
are the Clinical Instructor Characteristics Rating Scale by Raun Morgenroth, T., Ryan, M. K., & Peters, K. (2015). The Motivational
(1974), the Clinical Teaching Evaluation Instrument by Fong, and Theory of Role Modeling: How Role Models Influence Role
the Role Model Appreciation Tool (RoMAT) by van der Leeuw, H. Aspirants' Goals. Review of General Psychology, 19(4), 465-
G. A. (2014). The concept could also be explored using a mixed- 483. doi:10.1037/gpr0000059
method, particularly the sequential exploratory method. Perry, R. B. (2009). Role modeling excellence in clinical nursing
practice. Nurse Education in Practice, 9(1), 36-44.
Nursing Implication doi:10.1016/[Link].2008.05.001
Schiller, C. J. (2018). Teaching concept analysis to graduate
Role modeling is interactive process and cyclical. They are both nursing students. Nursing Forum, 53(2), 248-254.
constructed by role aspirants and models. Nurse educators, staff, doi:10.1111/nuf.12233
and managers should remain conscious and reflective in their Wear, D., & Zarconi, J. (2008). Can Compassion be Taught? Let's
practice. Their interaction with their subordinates significantly Ask Our Students. Journal of General Internal Medicine,
influences novice staff and students who seek models to pattern 23(7), 948-953. doi:10.1007/s11606-007-0501-0
their ideals and goals. Weissmann, P. F., Branch, W. T., Gracey, C. F., Haidet, P., &
Frankel, R. M. (2006). Role Modeling Humanistic Behavior:
Conclusion Learning Bedside Manner from the Experts. Academic
Medicine, 81(7), 661-667. doi:10.1097/
As individuals, we always identify someone to emulate and serve [Link]
as our models who reflect our own ideals. Role modeling is the Wright, S., Wong, A., & Newill, C. (1997). The Impact of Role
method of guiding and showing how to act in a complex and Models on Medical Students. Journal of General Internal
taxing nursing structure. It ensures the sustainability and survival Medicine, 12(1), 53-56. doi:10.1046/j.1525-
of the profession. Distinct from mentoring, role modeling may not 1497.1997.12109.x
entail specificity to establish a personal relationship with nurses.
However, the way they interact and embody their idealism and
philosophies contribute a significant impact on the role aspirants' ABOUT THE AUTHOR
lives.

____________________
Bhert Keane Q. Pugrad, MAN, RM, RN
References is an instructor in Ilocos Sur Community
College, Health Science Department. He
obtained his Bachelor's degree and
Bandura, A. (1977). Social learning theory. Englewood Cliffs, Master of Arts in Nursing major in
New Jersey: Prentice Hall. Maternal and Child Nursing from the
Bidwell, A. S., & Brasler, M. L. (1989). Role Modeling versus University of Northern Philippines . At
present, he is completing his PhD in Nursing at Saint Louis
Mentoring in Nursing Education. Image: The Journal of University, Baguio City. His research interest includes caring,
Nursing Scholarship, 21(1), 23-25. doi:10.1111/j.1547- nursing education, and community and public health.
5069.1989.tb00093.x
Cruess, S. R., Cruess, R. L., & Steinert, Y. (2008). Role
modelling—making the most of a powerful teaching strategy.
B m j , 3 3 6 ( 7 6 4 6 ) , 7 1 8 - 7 2 1 . d o i : 1 0 . 11 3 6 /
[Link]

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CONCEPT ANALYSIS

Fitness Nursing: A Concept Analysis

Anthony James Almazan, MAN, RN1

Abstract
The concept of fitness nursing has not been fully defined in the nursing profession but has slowly emerged due to the increasing
interest of people in physical fitness and a healthy lifestyle. Hence, this analysis aims to add Fitness Nursing to the body of nursing
knowledge that is currently undefined. Walker and Avant's framework for concept analysis will be used to discover the concept.
Definitions of the concept are presented along with related terms. Antecedents, attributes, and consequences of the concept are
presented in detail. Model, borderline, related, contrary and invented cases are presented to provide a rich representation of the
concept. Empirical referents and nursing implications are presented. The concept of Fitness Nursing can be defined as the
combined science of nursing with the art of personal training that focuses on health promotional activities and disease preventive
measures through physical fitness. The defining attributes are physical training and health coaching. The consequence of Fitness
Nursing may be presented in two aspects, Individual aspect includes increased vitality, a better body shape, higher self-esteem,
better fitness overall, and most importantly, avoidance of chronic illnesses. As for the community, the outcome would be a
healthier community with increased productivity and increased lifespan.

Keywords: Fitness Nursing, Physical Fitness

Introduction

E xercise is good medicine. Nowadays, physical fitness has

become increasingly popular as part of health promotional
activities and disease preventive measures due to the rising
skills. That way, they effectively assist patients in meeting and
achieving the goal of living a healthy lifestyle (Llewellyn, 2014).

number of lifestyle-related diseases. Some researches revealed This analysis of Fitness Nursing will add to the body of nursing
obesity, cigarette smoking, or chronically stressed individuals knowledge that is currently undefined. The aims of this analysis
are more likely to suffer from health conditions such as comprise of identifying possible uses of the concept,
hypertension, and heart diseases. This posed negative impacts antecedent, attributes, definitions, and consequences, and
on their well-being. Hence, nurses are given an imperative role constructing model, borderline, related, and contrary cases.
to the community to assist them in the performance of those Walker and Avant's framework for concept analysis was used.
activities contributing to the health and to help them alleviate Empirical referents and nursing implications were presented.
occurrences of illness or injuries through physical fitness. Many Definition and Uses of Concept
people think nurses are limited in the type of work they do. Some
believe that nurses only take vital signs or run routine check-ups Physical fitness is a set of attributes that people have or
with patients. However, a wide variety of exciting options are achieve. Being physically fit has been defined as “the ability to
available to nurses today like the freshly emerging concept of carry out daily tasks with vigor and alertness, without undue
Fitness Nursing. fatigue and with ample energy to enjoy leisure-time pursuits and
to meet unforeseen emergencies”. The health-related
The nursing profession has yet to officially develop a specialty in components of physical fitness are a) cardio-respiratory
“fitness nursing” or “sports nursing” on either the professional or endurance, b) muscular endurance, c) muscular strength, d)
academic level. But a growing number of nurses are becoming body composition, and e) flexibility (Caspersen et al., 1985).
involved in these areas (Minority Nurse, 2015). Nurses are in a
unique position to become part of this growing practice. By Whereas nursing includes the promotion of health, prevention of
combining the art and science of nursing, this new career path illness, and the care of ill, disabled, and dying people. Advocacy,
offers nurses the opportunity to draw upon their knowledge and promotion of a safe environment, research, participation in

1 Saint Louis University, Baguio City; antoniusrn@[Link]

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shaping health policy and patient and health systems provide an appropriate routine exercise. They are also tasked
management, and education are also key nursing roles. (ICN, with helping individuals execute a fitness care plan and make any
2002). Further, nurses are cognizant of factors that influence additional behavior modifications necessary to improve
physical health as they provide care to support the optimal conditions. Patients' conditions and their responses to the
physiologic function of the patient. Efforts to restore, maintain or exercise or dietary regimen are monitored by the fitness nurse.
improve function include measures that address a client's need Another antecedent is the patient's willingness to achieve fitness.
for nourishment, comfort, and activity (Kozier et al., 2004). The patient shows interest and readiness to achieve fitness and
According to Guide to Nursing Degree (2016), a fitness nurse is communicates with the fitness nurse regarding lifestyle changes
someone who recognizes a strong connection between physical and physical exercises. People nowadays are getting more
fitness, a state of wellness, and the prevention of disease. health-conscious, and are aware that getting fit can help
decrease the occurrence of lifestyle-related illnesses.
On the other hand, sports medicine is a sub-specialty of
orthopedic medicine, largely involving injuries or traumas Critical Attributes
suffered as a result of training for or competing in an athletic
event. Sports medicine nurses are typically nurse practitioners For the critical attributes, engagement in Physical Training and
that help physicians care for patients experiencing various provision of health coaching was identified as important
musculoskeletal injuries, including muscle strains, joint sprains, characteristics to understand the concept of Fitness Nursing.
torn ligaments, bone fractures, and dislocations (Collora, 2016). The first attribute is Physical Training which involves the
systematic use of exercises that promotes bodily fitness and
Antecedents strength with the assistance of the fitness nurse. The overall
condition of the patient is assessed first such as signs, activity
The following are the identified antecedents based on the tolerance, bone or joint problem, heart medications, and
reviewed literature: a. Health Promotion/Awareness; b. Health nutritional status. The fitness nurse determines the goal of the
Consciousness; and c. Patient's willingness to achieve fitness. patient and prescribes the exercise program of the patient. The
WHO defines health promotion as the process of enabling fitness nurse will assist the patients during the exercise program
people to increase control over, and to improve, their health. and monitor their conditions. During and after physical training,
Nursing is an appropriate profession to implement health the level of fitness is assessed and documented to determine the
promotion which is the basis of the first antecedent, the Health intensity and the outcome of the exercise program followed by
Promotion/Awareness. According to Kemppainen et al. (2012), the patient.
nurses can be considered general health promoters, with their
health promotion activities based on sound knowledge and Another attribute is health coaching which is done to guide and
giving information to patients. Nurses can use their medical motivate patients to make lifestyle changes such as losing
knowledge and clinical skills in providing nutritional education, weight, curbing tobacco use, managing stress, following a proper
information, and sessions of physical activity during exercise or diet, and increasing physical activity. By addressing the range of
sports, and holding workshops on effective stress management physical, emotional, and environmental factors that influence
techniques. people's behavior, health coaching is tailored to an individual's
specific needs and challenges. It can result in measurable, goal-
In fitness nursing, nurses predominantly focus on encouraging oriented outcomes (Llewellyn, 2000).
and ensuring adherence to regular exercise, proper diet, and
healthy lifestyle. Similarly, the Center for Disease Control and Synthesized Definition of Term
Prevention (1999), mentioned that “health care settings offer an
opportunity to individually counsel adults and young people Fitness nursing is the combined science of nursing with the art of
about physical activity as well as other healthful behaviors, such personal training that focuses on health promotional activities
as dietary practices.” and disease preventive measures through physical fitness to
endow patients with the optimum level of wellness.
Prevention is better than cure denotes the second antecedent
which is being health conscious. The fitness nurses in Consequence
preventative health care are tasked with improving the health of
patients through evidence-based recommendations while The consequence of fitness nursing includes has two aspects,
encouraging individuals to receive preventative services such as the individual and the community. Individual aspect includes
screenings, counseling, and precautionary medications. The increased vitality, a better body shape, higher self-esteem, better
fitness nurse may play the part of an educator that offers fitness overall, and most importantly, avoidance of chronic
information and counseling that encourage positive health illnesses. As for the community, the outcome would be a healthier
behaviors, provides regular screening of patients to develop, and community with increased productivity and increased lifespan.

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Model Case and Additional Cases fitness center. Nurse Hem has no more appointments so he is
set to go home. On his way home, he dropped by the mall to buy
Model Case some stuff. But sadly, he saw Rico seated in an ice cream shop
It is Wednesday afternoon. Nurse Jack is expecting only one eating a large cup of sundae.
patient for a fitness session. Mike is 29 y/o, a health-conscious This contrary case lacks the attribute of health coaching. Nurse
bank manager. Mike occasionally drinks liquor and never Jack just reminded Rico of his diet which is why Rico did not
smoked. He frequently visits the fitness center 2-3 sessions per
demonstrate the behavioral change that results in a little
week. On Mike's initial consultation about two years ago, he
improvement in Rico's fitness.
wanted to decrease his body mass. He was 210lbs that time and
gets tired easily even in a short distant walk. Based on Mike's Related Case
statement, Nurse Jack determined that he needs to improve his
cardio-pulmonary endurance and weight loss and recommended Nurse Marga is a public health nurse for less than a year. She is
sets of cardio and muscle endurance exercises. This time, Mike visiting her patients who are members of the Hypertensive and
enjoys his weight at 165 lbs, 5'9”, and with a normal BMI of 24.36. Diabetic Club once a month in the barangay to give their monthly
As a routine, Nurse Jack checked first his BP- 120/80. Overall, supply of anti-hypertensive medication and to monitor her
Mike is physically fit and eager for today's physical training. Mike patients' response to their medical regimen by checking their
is set for cardio exercises in combination with treadmill and blood pressure and blood sugar. During her visit, she gave a
weights exercises alternately. They started with a 15-minute lecture to the patients regarding the importance of lifestyle
warm-up. Nurse Jack is on his side to check him out. Mike has modification and exercise. The effect of cigarette smoking was
completed the cardio exercise for an hour and a half and emphasized in her discussion because she has observed that
appeared very tired. Nurse Jack reassesses him and found out most of her patients are smokers. Afterward, Nurse Marga
that Mike is just doing fine. After the exercise, information on a initiated a 20-minute aerobic exercise with her patients. Her next
healthy lifestyle was relayed to Mike. Nurse Jack has observed visit will be next month.
that Mike portrayed consistent behavior change towards
achieving fitness since he started. Mike's cardio-respiratory This is an example of a related case. It exhibits the ideas that are
endurance has improved after a series of cardio exercises based similar to fitness nursing but looks different when examined
on the record of Nurse Jack. Mike will return on Saturday for closely. Nurse Marga provided health education to her patients
another session. about healthy lifestyles and physical activities and initiated
aerobic exercises. However, Nurse Marga is a public health
This model case shows all the attributes of the fitness nursing nurse who is implementing a health program for a patient with
concept. Nurse Jack determined the fitness goal of mike, made non-communicable diseases.
the necessary assessments, and prescribed him an appropriate
exercise. Nurse Jack assisted Mike throughout the fitness Contrary Case
session and checked Mike's level of fitness. Nurse Jack also
provided Mike with health coaching regarding his diet and Chad is a friend of Nurse Gab. Chad is 34 y/o, a smoker, and
healthy lifestyle. obese. His father died 2 months ago due to a heart attack. This
made him decide to ask for help from his friend. Nurse Gab had a
Borderline Case busy day so he just provided instructional videos of different
exercises and brochures about proper diet and nutrition. Three
Nurse Hem has been assisting Rico patiently on his exercise weeks after, Nurse Gab have learned that Chad was
program for 3 months now. Rico is 27 y/o, overweight. Rico's goal hospitalized due to chest pain with a diagnosis of Angina
is to decrease his weight from his initial weight of 82kg to 72kg in Pectoris. According to his informant, Chad overexerted to his
a three-month regular exercise program. Today, Rico weighs exercise program but continued smoking and consumed a lot of
80kg which Nurse Hem is very concerned with. Based on his diet food.
review on the previous month, Rico has been compliant with his
low carbohydrates diet. Rico is in good condition today according This is an example of a contrary case because the attributes
to the routine assessment of Nurse Hem, aside from that Mike's were not shown in the story. Nurse Gab did not make any
body fat has little improvement. They are set for 1 hour and 45 assessment to Chad, no presence and assistance of the nurse
minutes of mixed cardio and muscle endurance exercises in a during the exercise, and health coaching is not also done.
treadmill and weight exercises wherein Rico has survived. After
the session, Nurse Hem made a reassessment and noted that Invented Case
Rico was doing well. Nurse Hem reminded Rico about his diet
program that he must lessen the intake of foods rich in Hercules was sailing along the Aegean Sea when he knew that
carbohydrates and glucose. Rico just nodded and went out of the the gods and goddesses in Mt. Olympus are feeling weak

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because of the food and liquor they had consumed during the References
month-long festival. He immediately called the Pegasus so he
could visit them. He was horrified by what he saw. The gods and Caspersen, C. J., Powell, K. E., & Christenson, G. M. (1985).
goddesses have lost their fitness which greatly affects their Physical activity, exercise, and physical fitness: definitions
power. Hercules had a great idea of how to help them. He and distinctions for health-related research.
proposes to his father, Zeus to conduct an Olympic game among [Link]. Retrieved August 28, 2016, from
the gods and goddesses after three months and Zeus affirmed. [Link]
For this reason, the other gods and goddesses were eager to Collora, C. (2016). Sports Medicine Nurse: An Advanced Practice
train with Hercules. The following day, Hercules gave them Role. [Link]. Retrieved on September
various exercises. There were restrictions to their diets too. The 2, 2016, from [Link]
Olympian gods and goddesses are good in sports. Poseidon and careers/ortho-nurse/
Hades are excellent swimmers so they preferred swimming Guide to Nursing Degree (2016). What is Fitness Nurse?.
exercises. Artemis, Apollo, and Eros train and compete in [Link]. Retrieved August 31, 2016, from
archery. Athena and Ares are excellent swordsmen, so they train [Link]
and battle in fencing events. Day by day, the gods and International Council of Nurses (2002). Definition of Nursing.
goddesses were gradually regaining their fitness and power. [Link], Retrieved September 1, 2016, from
Until the day of the Olympics has come, the gods and goddesses [Link]
have totally recovered their fitness. They rewarded Hercules for Kemppainen V., Tossavainen K., and Turunen H. (2012). Nurses'
a job well done. roles in health promotion practice: an integrative review.
[Link]. Retrieved on September 2,
This is an example of an invented case. It is a fictional story of 2016, from [Link]
Hercules and the Olympian gods and goddesses who went early/2012/08/10/[Link]
through different physical exercises to regain their power. This Kozier B., Erb, G., Berman, A., and Snyder, S. (2004).
fictional story contains all the attributes of fitness nursing. Fundamentals of Nursing: Concepts, Process, and Practice
(7th Edition). Singapore: Pearson Education South Asia PTE
Empirical Reference
LTD., 2004 pg 1057
There are only a few studies on the concept of fitness nursing. Llewellyn A. (2014). Nursing Beyond the Bedside:
Hopefully, the analysis of this concept will open up a new door in Health/Wellness/Fitness Coach. [Link]. Retrieved
nursing research and practice. Kemppainen et al. (2012) stated August 28, 2016, from [Link]
that nurses can be considered general health promoters, with beyond-bedside-healthwellnessfitness-coach
their health promotion activities based on sound knowledge and Minority Nurse (2015). The Wide World of Sports/Fitness
giving information to patients. Nursing is an appropriate Nursing. [Link]. Retrieved August 28, 2016,
profession that implements health promotion activities. But, from [Link]
several barriers are associated with organizational culture and sportsfitness-nursing/
have a marked effect on delivery.
ABOUT THE AUTHOR
Implication

The lifestyle of people has been greatly affected by technological

advancement. Many people have developed lifestyle-related Anthony James F. Almazan, MAN, RN,
diseases such as heart disease, diabetes, and hypertension. the Project Development Officer IV -
Fitness Nursing can be a way to alleviate the increasing number Program Manager of the Newborn
of these chronic diseases through physical fitness for both the Screening Center – Northern Luzon in
nurse and the patient. Mariano Marcos Memorial Hospital and
Medical Center, is taking his Ph.D. in
Nursing at St. Louis University, Baguio
Conclusion City. He earned his Bachelor of Science in Nursing at Lorma
Colleges, San Fernando City, La Union, and his Master of Arts
Fitness Nursing is not yet fully defined in the nursing profession. in Nursing at University of Northern Philippines, Vigan City.
The concept analysis utilizing Walker and Avant's framework has
provided new insight into this phenomenon. Thus, further His research interest revolves around public health, maternal
and child nursing, and disaster management.
exploration, understanding, and development of this concept
should be done to fully recognize the role of nurses in promoting
physical fitness

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CONCEPT ANALYSIS

Stigmatization of Nurses: A Concept Analysis

Mark Joseph Fagarang, MAN, RN1

Abstract
For the past months, a new strand of Coronavirus, SARS-CoV-2 has been challenging our health care systems worldwide.
Healthcare workers especially nurses are not just at risk of adverse physical symptoms but may suffer from psychological stress.
This is one scenario of a stigmatized nurse.
The goal of primary care is to improve patients' health, longevity, and quality of life through the provision of patient-centered care.
To do so healthcare providers must overcome any stressful activities or circumstances like stigma. This concept focused mainly
on a stigmatized nurse. For this concept analysis, the framework of Walker and Avant was used. Definitions of terms are
discussed. Cases were also identified for a better representation of the concept. Empirical referents and implications to nursing
are also presented.

Keywords: Nurse, Stigma, concept analysis

Selection of a concept Identify uses of the concept

Stigma can happen to anyone and can truly affect individuals Walker and Avant (2005) recommended using dictionaries,
negatively. It can happen to an individual, to a family, community, thesauruses, knowledge from colleagues, and any possible
or within an organization. Stigmatization of nurses has been an literature to identify the use of the concept. According to “The
issue in recent years which has a great impact on the delivery of American Heritage Dictionary (2012), Stigma is a relationship of
health care, therefore it is necessary to understand nursing disgrace or public disapproval with something, such as an
stigma or a stigma affecting the nurse to reduce not only social action or condition”. There are three types of stigma; structural
and emotional distress on their part but also promote stigma, public stigma, and stigma by association. First,
competence, improve quality services, and increase self-esteem structural stigma refers to the imbalance and injustice seen in a
and restoration of functioning as a health care professional. Thus social institution. An example of this could be the poor quality of
this study clarified the concept of stigma in nurses by using a healthcare services delivered by stigmatized healthcare
concept analysis method, defined the construct of nursing professionals, specifically the nurse towards an individual.
stigma, and provided a general theory that explains the Public stigma describes the negative attitudes of the general
conditions under which stigmas are likely to arise, how this population, that could be the patient/client or the colleagues,
process unfolds and the initial effects stigma inflict to a nurse. towards a stigmatized nurse. Lastly, stigma by association
means discrimination due to being involved with an individual or
Aims of Analysis specifically a nurse who is stigmatized (Larson and Corrigan;
Werner, Goldstein and Heinik, 2011).
Walker and Avants' (2005) framework for concept analysis was
used to elaborate and exhaustively explain the concept of Determine the defining attributes
stigma. The aims of this analysis include (a) identifying or
determining related terms and uses of the concept; (b) These attributes provide insight into the concept. It is being
identifying all antecedents; (c) identifying all defining attributes noted that all attributes must arise before a phenomenon can be
and explaining them relatively; (d) identifying consequences; (e) labeled stigma. The following attributes were identified after an
constructing and giving examples of a model, related, analysis of articles about stigma and were simultaneously
borderline, contrary and invented cases; and (f) identifying refined and tested by analysis of the cases and related
empirical referents. concepts.

1 School of Advanced Studies, Saint Louis University, Baguio City; mmmhmcresearchcommittee@[Link]

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a. Other's negative perceptions, attitudes, emotions, and a. Model Case

avoidant behaviors towards the nurse because of
unusualness including the negative situations, events, Story of a 52 years old nurse who recovered from a stroke.
behaviors, problem or disease associated with the nurse or Carolina is a 52-year-old staff nurse currently working in a
because of unordinary characteristics. private clinic and hospital for 32 years. She is a trained
b. Other's beliefs that the unusualness of the nurse is operating room nurse and an emergency room nurse.
somehow harmful, dangerous, unhealthy, capable of
affecting them negatively or different from general social Carolina was diagnosed with hypertension stage II when she
norms. (Brickley et. al 2009, Hinshaw 2005 and Pirutinsky was 40 years old. One night shift they had 6 cases of
et. al 2010) and; exploratory and laparotomy which made Carolina exhausted
c. Other's beliefs that the other members of the organization or and tired. When she got home from duty, Carolina complained
the colleagues of the nurse are directly or indirectly of chest heaviness, dizziness, and numbness of extremities
contaminated by the stigmatized nurse so that every that prompted her to consult a doctor. So, her husband rushed
member of the organization is also considered as harmful, her to the hospital. She was admitted to the intensive care unit
dangerous, unhealthy, capable of having a negative effect with a diagnosis of CVD infarct, stroke new-onset.
on others, or different from general social norms (Corrigan et Immediately after recovering from a stroke, she went back to
al, 2010). work. But consequently, changes in her routine or functioning
were noticed. Carolina admitted that some of her knowledge
Antecedents was lost believing that this is because of the stroke she
suffered recently. She was consciously unaware of what she
• 1st antecedent - overall unusualness of an individual or is doing. The incident became viral to the public and marked a
organization. One example of unusualness is the occurrence negative impression. All of the people in that place and even
of highly negative events to a nurse. Specifically, this refers to her colleagues viewed Carolina as incompetent. They see
the occurrence or history of negative situations, events, Carolina as a threat and harmful to the public.
incidents, problems, or diseases happening to a nurse who
affects either the whole organization or one member of the This model case shows all of the three attributes of stigma.
organization. This can include being involved in a scandal, Carolina is experiencing others' negative attitudes, emotions,
being affected by COVID-19, or having a very ill member. and avoidance because of Carolina's incompetence brought by
(Dever C. and Dewette T, 2014). memory loss from a stroke. Most people talk about her
nd
• 2 antecedent – the spread of information about that negatively at her back. Other people outside or within the
individual or organization to the wider public. In this matter, organization believes that her unusual attitude makes her
other people come to know the supposedly negative aspects incompetent, dangerous specifically to clients/patients,
of that individual or organization, such as the negative unhealthy to the public, and capable of affecting them negatively
incident that they were involved in, the unordinary or different from general social norms. And lastly, other people
characteristics or structure of that individual or organization. see the entire clinic or her colleagues as incompetent as being
influenced by Carolina, so people tend not to consider that clinic
Consequences for consultation.
The emotional consequences of a nurse experiencing a stigma b. Borderline Case
are typically the feeling of disregard, disrespect, and
incompetency. They feel shame, fear, anxiety, intense concern, Angela is a 25 years old nurse who transferred from a public
and loss of trust. Related to that, the quality of healthcare to a private hospital. One employee named Rizza, who is her
services decreases (Brickley et. al 2009, Larson and Corrigan college friend, finds out the reason why Angela transferred. It
was found out that Angela was dismissed from the public
2011, Werner et al 2010).
hospital because of consecutive medication errors, recurrent
Organizational consequences include clients'/customers' absences without official leaves, and attitude problems like
complaints because of mistrust leading to the possibility of being bossy and aggressive. From then on, Angela seems to
dismissal of the institution, and possible resignation of isolate herself away from others.
personnel that may lead to understaffing resulting in poor One morning during her 7-3 shift at the OB-Gyne ward,
delivery of healthcare services (Goffman E., 2005). Angela was assigned to one patient named Claudia.
However, Claudia heard the rumors about nurse Angela, so
Cases she does not want her to be her nurse. She requested another
nurse to take care of her.
The concept analysis method described by Walker and Avant
(2005) used case studies to clarify or to picture out the concept So Angela leaves the room quietly. She was traumatized.
and its attributes. Every time she handles a patient, there is that feeling of

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stigma. There is that fear, the fear that it might happen again. nurse Ria immediately get her vital signs and revealed blood
She was irritable and preoccupied with that incident. pressure of 140/90, PR: 32 beats per minute, RR: 32 breaths
per minute, and temperature of 36.2 degrees Celcius. She
After two months Angela recovered from stigma. She does referred the patient to Dr. James during his rounds and
her functions well. In fact you cannot see any more in her face ordered 12 lead ECG, and eventually, the patient was
the feeling of fear, shame, and doubt. Angela shared what she intubated.
experienced with other nurses, how such an incident affects
her life most specifically being a provider of care. On the other hand, patient Hallen at room B complained that
why his 10:00 AM antibiotic medication is still not yet
This is a borderline case. This story has two out of the three administered and the time is already 10:30 am. So when
attributes of a stigmatized nurse. Patient Claudia had a negative nurse Ria came in. He scolded her in front of other patients.
perception, attitudes, and emotions to nurse Angela since she
knew her negative background. Thus, Claudia does not want After administering the medication, the patient became calm
Angela to be her attending nurse so she asks for another nurse. and come to realize how busy the nurse was, that she
attended an emergency.
c. Contrary Case
The case is an example of a related case. It demonstrates ideas
Leah is a 24 years old pediatric nurse of a tertiary hospital for that are very similar to the main concept but differ when
almost 3 years. Leah is gorgeous. As time passed by, she examined closely (Walker and Avant, 2005). From the story, it's
became uncomfortable hanging out with girls. So, she knew in just like stigma happened to nurse Ria, stigma-like aroused
herself that being a woman is not her gender preference. because of an arrested patient that delays the medication of
Eventually, Leah became passive in her work. She does not patient Hallen. So stigma here came not from Ria's real attitude
want to handle patients, specifically female patients, because but came from the nature of her work.
of the fear that they will stigmatize her. Later on, other nurses
and even her supervisor noticed the change in her behaviors e. Invented Case
and attitudes. She now confessed to her supervisor, her
family, workmates, and friends that she is a lesbian. The main Arjay is a 22 years old nurse working in a hospital of princes
concern of Leah at first was the fear of discrimination, and princesses named Disney Hospital. One night, he was
disrespect, rejection, immorality, and the feeling of mistrust drunk and had a hung-over on his 7-3 shift duty so his mind
from her patients. She might lose her family, her friends, or was floating, and cannot focus to work. During his duty, he
even her employment because of the fear that everybody administered the wrong medication to Princess Fiona, so
would stigmatize her for her preferred gender. She feels that Shrek, her watcher, was very angry and scolded Arjay in front
her self-esteem was decreased which compromised her of other patients.
duties and responsibilities as a nurse. However, Leah's family,
friends, co-workers, and even her patients accepted her. It seems that all the patients of Arjay don't trust him. Other
Actually, one patient told Leah that she was very nice because patients thought that other nurses are like him so they tend to
of her uniqueness and this attitude increased the patient's transfer to another hospital. He was depressed which lead to
self-esteem and confidence. They told her that it does not consecutive absences.
matter what her decision was, and they did not care about her
preferred gender. This story is an example of an invented case since it was a
The case is an example of a contrary case, as it contains none of fictional story but contains all of the attributes. It was depicted in
the attributes of stigma. Leah confessed that she is a lesbian. the story the existence of princes and princesses from Disney
Despite her revelation, her family, friends, co-workers, and even land.
her patients did not express any negative emotions, attitudes, or
Empirical Referents
behaviors toward her. In addition, they did not think that being a
lesbian would be harmful, unhealthy, or in any way affect them Empirical referents are essential because they support the
negatively, most especially to her patients. As such, Leah concept's validity by providing ways to evaluate the existence of
continued to get along with her friends and continued her service the concept. Once identified, the empirical referents are useful
as a competent nurse. with developing the instrument since they were developed based
on theoretical analysis of the concept (Walker and Avant 2005).
d. Related Case
Ria is a 23 years old nurse assigned to the medical ward. She So far, there is no measurement specifically measuring stigma in
handles a maximum of 20 patients a day. One time during her nursing or a stigmatized nurse. The majority of studies found in
7-3 shift, when she was preparing for her 10:00 AM the literature have used qualitative methods for examining
medications of her patients, suddenly a patient in room A individual subjective stigma experiences. However, more
named Soledad complained of sweating and chest pain. So quantitative measures were employed by others. Most of them

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adapted existing measurements and those scales were particular stigma will hopefully not only extend awareness to healthcare
to certain conditions. For example, they evaluated nursing stigma professionals but also for them to realize how stigma greatly
due to mental illness. Corrigan et. al (2006) utilized the first seven affects their functions most especially in the delivery of
items such as blame, anger, pity, help, dangerous, fear, and healthcare to patients.
avoidance from the attribution questionnaire measuring primary
stigma related to mental illness. ____________________
In terms of measuring a general stigma related to nursing based
on the attribute from this analysis, the empirical referents seem References
to be very diffused and complicated. For example, others'
negative perceptions and beliefs are critical parts of the concept Houghton Mifflin Harcourt Publishing Company, Dictionary of the
of stigma related to nurses. However, those parts are hard to English Language, 5th edition Copyright 2011.
measure and sometimes hard to guess from the individual's Walker K.C. and Avant L.O. 2005, Strategies for theory construction
position, since they involve others' invisible emotions to in Nursing; Pearson Education, Upper Saddle River, NJ 4th
uncertain attitudes and behaviors. Thus, it seems to be more edition.
appropriate to measure both attributes and consequences at the Brickley et al. ,2009, Community, Family and Partner related Stigma
same time when quantifying the phenomenon of stigma to experienced by pregnant and postpartum women with HIV in
nurses. Thus, more in-depth study is needed in this area. Vietnam, Volume 13.
Hinshaw, 2005, The stigmatization of mental illness in children and
Impact on Patients parents, developmental issues, family concerns, and research
needs.
Experiences of discrimination, disrespect, and awareness of Larson and Corrigan, 2008, The stigma of mental illness, Academic
stigmatized social status can cause nurses to experience stress Psychiatry Volume 32.
and have other acute reactions that may compromise their duties Nisus Thesaurus, 2006, version 1.1, Computer software.
and responsibilities most specifically in the delivery of quality Pirutinskyet. Al, 2010, Do medical models of mental illness. The
healthcare services regardless of how compliant the patients are. journal of nervous and mental disease. Volume 198.
The American Heritage Dictionary of the English Language 2012, 5th
The effect of stigma can be immediate, long-term, or both. The edition, Houghton Mifflin Boston, MA.
direct effects of provider attitudes on patient-centered care may Vandam, 2004, Mothers in two types of lesbian families, Stigma
reduce the quality of the patient encounter, harming patient experiences, supports and burdens.
outcomes and reducing patient satisfaction. It may also affect the Rickin Baltimore 2016. Wikipedia.
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is employed. Identity.
Devers C. and Dewett T., 2014. Organizational Stigma.
Conclusion
This study analyzed the concept of stigma by using the concept ABOUT THE AUTHOR
analysis method. The stigma merely focused on an individual
who is the nurse and how it affects her functions, especially in the
delivery of health care services. The defining attributes,
antecedents, and consequences of stigma were discussed. The Mark Joseph Fagarang, MAN, RN,
received her BSN in Mariano Marcos State
use of cases, such as model, borderline, contrary, related, and University, City of Batac Ilocos Norte in 2012
invented cases, helps better illustrate stigma as a concept. and his Master of Arts in Nursing Major in
Maternal and Child Nursing at University of
Stigma on the part of the provider affects the patient in both
Northern Philippines, Vigan City Ilocos Sur in
measurable and immeasurable ways. It can reduce the quality 2015. He is currently studying Doctor of
and even the quantity of patient-centered care and can signal to Philosophy in Nursing at Saint Louis University, Baguio City.
the nurse that he/she is being perceived by the patient in terms of
his or her stigmatized identity which in turn may affect the At present, he is working as a Nurse Supervisor of the Outpatient
patient's perception of, and compliance with provider's Department under the Department of Family and Community
recommendations. Medicine in Mariano Marcos Memorial Hospital and Medical
Center, City of Batac Ilocos Norte. He is also the executive
Healthcare providers including nurses meet numerous patients assistant of the Hospital Research Committee of the same
daily and tend to focus only on their patients' medical condition institution. He has the determination and eagerness to make
that they tend to forget sometimes their personal status, most positive contributions to the nursing arena amidst the pandemic.
especially their functions as a nurse. The result of my analysis of

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CONCEPT ANALYSIS

Family caregiver: Caring on family carers

Sherwynn Lloyd Javison, MAN, RN, CLSSGB, CHA1

Abstract
This study was conducted to clarify the idea of caring for non-professional family caregivers and identify their vulnerabilities while
caring for their patients. This concept was developed because of the non-availability of structured caregiving programs for non-
professional family caregivers in the hospitals and community. This issue might lead to potential health and safety hazards for
patients and caregivers. Nurses and non-professional family caregivers can co-create a safe and loving environment ideal for
patient care. Nurses are essential to upholding the health and safety of non-professional family caregivers while developing their
confidence and care performance. Moreover, training the non-professional family caregivers in the hospital and communities
would promote safe and effective nursing practice in preparation for a smooth patient transition at home.
Keywords: family caregiver, non-professional family caregivers, nursing, caring, work-related hazards, collaboration

Background

H arvey Picker (1987), as cited in Rawson & Moretz (2016),

has listed eight principles of patient-centered care: (1)
respect for patients' values, preferences, and expressed needs;
professional family caregivers capable physiologically and
mentally to become such? How could they provide quality care
when nobody cares for their health and safety at work? This
(2) coordination and integration of care; (3) information, concept analysis brings the idea of integrating love and care for
communication, and education; (4) physical comfort; (5) Family Caregivers because patient safety starts from them. The
emotional support and alleviation of fear and anxiety; (6) principal objective of this paper is to enlighten the concept of
involvement of family and friends; (7) transition and continuity; caring for Family Caregiver and understand their vulnerabilities
(8) access to care. Articles agreed that the patients are always at through Walker and Avant's concept analysis methodology.
the center of care. However, direct carers should also deserve to
share a space in the center too. The manifestation of close Definition
family ties among Filipinos is seen from birth to death (Miralao,
1997). Reinhard et al. (2008) and Henson (2020) referred to a Walker and Avant (2019) included the analyses of each
Family Caregiver as an unpaid non-professional Family terminology to understand the conceptualization process of
Caregiver, either a family, friend or neighbor willing to provide Family Caregiver Focused Care.
care to a family member. A Family Caregiver may act as a direct
carer, a decision-maker, and a liaison between the The Merriam-Webster dictionary defines family as a “basic unit
multidisciplinary team. Family Caregiver is one of the significant in society traditionally consisting of two parents rearing their
people who could influence a patient's ongoing and future children.” The Medical online dictionary described the family as
treatments; hence, a potential entity that would realign the “a group of people related by blood or marriage or a strong
patient back to the center of care (Li, Hu, Dong, & Arao, 2013). common bond, such as those descended from a common
ancestor, or a husband, wife, and their children." Moreover,
Despite the challenges, there is no known taste of caring for [Link] defines the term according to the family type―
Family Caregivers in most articles. Not everyone could acquire traditional and single-parent family. The traditional family is "a
good vitality forever. Being selfless for a long time makes their basic social unit consisting of parents and their children,
body weak in addition to physical strain and emotional considered a group, whether dwelling together or not ."While
challenges they have experienced, like moral distress and the single-parent family is “a social unit consisting of an adult
compassion fatigue (Henson, 2020). These factors could with the children they care for.” Family is the relatedness of
gravely affect the tasks expected from them (Schulz & Beach, individuals not merely in the consanguinity of blood but also in
1999). However, despite various articles related to such a topic, social relationships (Miralao, 1997).
the following questions have not been answered yet: Are all non-

1 Saint Louis University School of Advanced Studies; 2197484@[Link]

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On the other hand, the Cambridge Dictionary defines a caregiver systems and find accessible resources (indicators: access social
as “someone who takes care of a person who is young, old, or support timely; make referrals if needed; work on overcoming
sick.” Also, the NIH National Cancer Institute (2012) deeply obstacles). Sixthly, nurses and Family Caregivers enhance the
defined the term as “a person who gives care to people who need culture and context of care (indicators: recognize stigma and
help taking care of themselves. Examples include children, the discrimination; introduce caregiving models; assist in self-
elderly, or patients who have chronic illnesses or are disabled. reflection). In addition, the seventh dimension might include
Caregivers may be health professionals, family members, Nurses ensuring Family Caregivers promote safety on their
friends, social workers, or clergy members. They may give care patients and themselves.
at home or in a hospital or other health care setting.”
To promote a loving and caring atmosphere towards the Family
To fuse the two terminologies, the Family Caregiver is “informal, Caregivers, nurses must identify and resolve the intrinsic and
unpaid family member, friend, or neighbor who provides care to extrinsic vulnerabilities in the workplace (Reinhard, Given,
an individual who has an acute or chronic condition and needs Petlick, & Bemis, 2008). Lexico defines vulnerability as the
assistance to manage a variety of tasks, from bathing, dressing, "quality of being exposed an active or possible attacked or
and taking medications to tube feeding and ventilator care harmed, either physically or emotionally.” Meriam-Webster
(Reinhard, Given, Petlick & Bemis, 2008).” Family Caregivers in dictionary referred to as “capable of being physically or
a clinical setting have to be selected accordingly to maximize emotionally wounded” and “open to attack or damage.”
their role (Feinberg, 2008). Furthermore, [Link] added to the definition as
“susceptibility to criticism or persuasion or temptation.” Relating
The expression of tender loving care is usually associated with to the concept, these vulnerabilities in Family Caregivers include
Nursing; hence, the only way to raise the value of a Family being susceptible to the effect of physical and mental hazards
Caregiver is to collaborate their work with Nurses. The term such as moral distress and compassion fatigue that may cause
nursing is defined as “the duties of a nurse (Merriam-Webster, medical errors, poor work performance secondary to declining
n.d.) that concerned with the provision of services essential to health behaviors such as not taking maintenance prescriptions,
the maintenance and restoration of health by attending the no exercise and healthy diet leading to further sickness
needs of sick persons (MedicineNet dictionary, n.d.).” (Reinhard, Given, Petlick, & Bemis, 2008; Lynch & Lobo, 2012;
Furthermore, the International Council of Nurses (2002) added, Rodrigo, 2005). Social isolation is a hazard that confuses a
“Nursing encompasses autonomous and collaborative care of Family Caregiver's life priorities over their role as a mother to her
individuals of all ages, families, groups, and communities, sick or children and a wife to her husband or vice versa (Lanier and
well and in all settings. Nursing includes the promotion of health, Brunt, 2017). A safety hazard is the number one risk among them
prevention of illness, and the care of ill, disabled, and dying because they are untrained non-professionals prone to self-
people …." For the Family Caregivers to function well, a injurious activities in the work environment such as issues in
collaborative nursing pathway must exist to pursue the Family body mechanics related to patient care or equipment, the
Caregiver role. The Covenant Health (2019) deciphered six unfamiliarity of hospital set-up, and with little less idea of general
interdependent competency domains of a Family Caregiver guidelines on workplace safety (McNeill, Schuyler, & Ezrachi,
Competency Framework, which would allow functional 1997; Wardell, 2007).
collaboration between the Nursing Team and Family Caregiver.
Firstly, Nurses would guide a Family Caregiver to recognize their Defining Attributes
roles (indicators: understanding their value and contribution;
knowledge of caregiving; identifies their roles and Defining attributes are characteristics of a concept that
responsibilities on patient care). Secondly, nurses to have direct frequently appears in the literature, distinguishing one from the
communication with a Family Caregiver (indicators: other related concept immediately bringing the concept to mind
communicate with respect, empathy, and compassion; listen (Walker & Avant, 2019). There are three defining attributes of a
actively; convey information in a timely and straightforward Family Caregiver: Caring on Family Carers concept analysis.
manner; support care coordination/engagement). Thirdly, Firstly, the Family Caregiver has little or no known knowledge of
Nurses partner with a Family Caregiver (indicators: understand basic patient care. Secondly, the Family Caregiver is vulnerable
benefits; create a collaborative environment; recognize their to health hazards such as physical, mental, social, and safety.
assessments and planning; spot conflict and countermeasures). Thirdly, Family Caregiver needs a collaborative effort from the
Fourthly, Nurses foster resilience among Family Caregivers nursing team to avoid work-related hazards and optimize their
(indicators: assess their needs and daily goals; understand role potentials. Finally, a Family Caregiver needs to be loved and
relationship dynamics between nursing-caregiver-patient; cared for by the family support system and people around them-
educate to enhance skills and abilities; promote health and they need to be treated with dignity and respect both as a family
wellbeing). Fifthly, Nurses help navigate the health and social member and a caregiver.

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Model Case and Analysis doing so. After a few minutes, Kellan shouted for help because of
severe pain in his back. Diagnostic investigation revealed spinal
A model case comprises all defining attributes integrated into the fracture due to wrong body mechanics.
concept (Walker & Avant, 2019). Below is an example of a model
case for caring for Family Caregivers. This model of care This event is an example of Family Caregiver neglect. As
involves Nurse Kessa, who is working on a project about nurses, we need to empower the Family Caregivers to get
Caregiving Program intended for adult cancer patients with involved in the care required for the patient (as long as they are
functional disabilities. She asked for the help of Nursing assisted), making them active participants in inpatient care. The
Education, Quality Improvement, Patient Relations, Social multidisciplinary team should identify possible hazards to
Worker, Nursing, and the Medical teams. After brainstorming, the caregivers. Institutions should not tolerate neglect and cancel
Nursing Education representative voiced out, "How can we take culture in the workplace.
care of our Family Caregivers while maximizing their potentials?"
All have participated in the brainstorming activities and started b) Contrary Case and Analysis
drafting a structured program. The team's ultimate goal was to
maintain a caring and supportive environment for Family A patient is about to transfer from full code to do not resuscitate
Caregivers to attain patient safety and quality care. There was a (DNR) status. Before making this decision, the medical team
strong collaborative partnership between Family Caregivers and needs a patient and family meeting (PFM) to comply with the
the nursing team, including classroom-based and actual patient hospital policy. Nurse Joshua informed Dr. Paul, the primary
care demonstrations. Another member suggested, "we need to consultant, that the Family Caregiver B would be coming
do light class sessions for Family Caregivers for them to spend tomorrow. He suggested rescheduling the PFM as the current
more time with their patients." The team then developed a new Family Caregiver A is working 24/7 for five days. But because Dr.
virtual education platform for Family Caregiver and set a Paul's schedule will be hectic starting tomorrow, he decided to
schedule for a practical demonstration on basic care and the conduct the PFM on that day with the presence of Family
elimination of workplace-related hazards. Caregiver A though the person appears sleepless and
exhausted. After the PFM, the multidisciplinary team accepted
The example shows a strong collaborative partnership between and signed the DNR form in the presence of Family Caregiver A.
Family Caregivers and the nursing team to uphold the caregiving Family Caregiver A left the hospital and could not update the rest
role. The nursing team has expressed their care and love for the of the family and Family Caregiver B about the DNR status
Family Caregivers by understanding their burdens and making because of complete exhaustion. The family noticed that no
them their strong points. When Family Caregiver has received medical interventions were given to their gasping patient on the
these attributes, they could empower themselves even more. same day. They clarified to nurse Joshua and responded,
"patient is placed on DNR, weren't you informed?" The family
Additional Cases became hysterical and violent after hearing the statement.

The cases under this category are the borderline and contrary That event is an example of communication failure secondary to
cases. Walker & Avant (2019) defined a borderline case as the the mishandling of family meeting sessions. Dr. Paul is not
existence of most defining attributes, but not all of them. considering the impact of his abrupt decision even he knew that
Meanwhile, the contrary case is the reciprocal of a model case Family Caregiver A appeared sleepless and exhausted. Also, he
where all listed attributes are not present. The following underestimated the family's participation and decision-making
examples below are formulated as a sample scenario. capabilities, which led to aggression. Also, he should have
pondered the suggestion of Nurse Joshua, as this is shared
a) Borderline Case and Analysis care, and Nurse Joshua's reason is valid. The multidisciplinary
team must carefully assess the Family Caregiver and family
A patient is hemiplegic caused by Cerebrovascular Accident. He representative's ability to decide though they are legally
is undergoing physical therapy twice weekly, and tomorrow is his competent.
last session in preparation for his discharge. The Physical
Therapist taught the patient's brother Kellan on the previous Antecedents and Consequences
courses and advised him to coordinate with the nurses whenever
he needed further teaching and assistance. On that day, Kellan The antecedents are the triggering events or attributes before
asked the nurse to call the therapist for some clarifications in bed forming a concept, and the consequences are the outcome that
turning, but the nurse said, “the Physical Therapist will be coming occurred as a result.
here today.” Four hours had passed, but the Physical Therapist
still had not come. He followed up with the nurse again and said Selecting the Family Caregiver is the primary antecedent of this
with a loud voice, “I already called the therapist!” despite not concept analysis. Family Caregivers tend to present themselves

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because of family and a financial burden (Collins & Swartz, home care transitions would improve. Family Caregiver is the
2011), but selecting a Family Caregiver should not be voluntary best co-partner for nurses when maximizing potentials and the
but appointed with careful deliberation considering the level of caring, loving, and sustaining culture are worthy for them.
resiliency (Collins & Swartz, 2011). The absence or incomplete
family caregiving direction is another antecedent. There are few ____________________
institutions not embracing contemporary caregiving programs,
and it leaves the non-professional Family Caregiver to "do it References
yourself" activities Reinhard, et al., (2008). Another antecedent is
the lack of professional supervision among medical teams. Barnsteiner, J., Disch, J., & Walton, M. (2014). Person and family
centered care, 2014 AJN award recipient. Sigma Theta Tau.
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Caregivers affects decision-making. It compromises the safe Caregiver. (n.d.). In the National Cancer Institute. Retrieved from
care and self-care process, leading to medical errors and work- [Link]
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caregiver activation in transitions (FCAT) tool: a new
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family physician, 83(11), 1309. Retrieved from
The lack of knowledge on basic care can be measured [Link]
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through practical demonstration. Practical demonstration is the Dykes, P. C., Stade, D., Chang, F., Dalal, A., Getty, G., Kandala,
best knowledge retention activity (Lanier and Brunt, 2017). R., Lee, J., Lehman, L., Leone, K., Massaro, A., Milone, M.,
Vulnerability from a work-related hazard can be assessed McNally, K., Ohashi, K., Robbins,K., Bates, D., & Collins, S.
through risk assessment results conducted by Risk Management (2014). Participatory design and development of a patient-
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professional guide to maximizing potential. Once performed comparison of concepts. Medsurg Nursing, 29(2).
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Li, G., Hu, H., Dong, Z., & Arao, T. (2013). Development of the Schulz, R., & Beach, S. R. (1999). Caregiving as a risk factor for
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(2016). Families caring for an aging America. 10.1177/216507990705501003
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QAAQBAJ&oi=fnd&pg=PR1&dq=Families+Caring+for+an
+Aging+America&ots=_Nk72ZWAun&sig=aDc4SrCXlRVW ABOUT THE AUTHOR
H8GuVMod4qZI3XQ&redir_esc=y#v=onepage&q=Familie
s%20Caring%20for%20an%20Aging%20America&f=false
Nursing. (n.d.). In International Council of Nurses. Retrieved Sherwynn Lloyd Javison, MAN, RN,
from [Link] CLSSGB, CHA is working as a Shift
Nursing. (n.d.). In Medicinenet. Retrieved from Manager at King Fahad Medical City-
[Link] Comprehensive Cancer Center (CCC)
y=4601 Nursing Administration based in Saudi
Nursing. (n.d.). In Merriam-Webster Dictionary. Retrieved from Arabia. He is a Quality Improvement
Specialist, a chairman of Nursing Quality
[Link] Link and CCC Nursing Regulatory Documents.
Rawson, J. V., & Moretz, J. (2016). Patient-and family-centered
care: a primer. Journal of the American College of Radiology, He is pursuing his Doctoral studies in Nursing at Saint Louis
13(12), 1544-1549. [Link] University, Baguio City. He promotes the application of the
[Link].2016.09.003 evidence-based nursing process through Quality Improvement
Reinhard, S. C., Given, B., Petlick, N. H., & Bemis, A. (2008). projects across the hospital and upholds research culture for
Supporting family caregivers in providing care. In-Patient nurses working in the oncology setting.
safety and quality: An evidence-based handbook for nurses.
Agency for Healthcare Research and Quality (US).
Retrieved from [Link]
NBK2665/

“Violence, discrimination, and racism have a direct impact on determinants of health,

exacerbate health inequities, and can lead to long-term trauma. We strive to utilize nursing
leadership, innovation, and science to promote policies that will achieve health equity.”
- American Academy of Nursing, 2022

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NURSES’ VOICE FROM THE FIELD

Nurturing Responsive Learning Environment

in the Nursing Academe Amid COVID-19
Iris C. So, PhD, RN1

When the Commission on Higher Education (CHED) canceled face-to-face classes as a safety measure against COVID-19 and
schools shifted to remote online learning, educators, including me, had to turn to technology to assist us in its delivery. Study and
work from home arrangements drove us to improvise learning resources as an alternative to actual campus, clinical, and
community exposure. Schools have also taken steps to assist their academic community in varied ways, such as lending out of
laptops, provision of internet allowance, purchase of low to high fidelity mannequins and simulators, integration of learning
management systems, and the likes.
With the abrupt change in teaching methods, we found ourselves asking: “How do we do it?” “How do we conduct virtual class
sessions in a way that engages and connects with students?” “How do we design clinical simulations to bring out essential nursing
skills and values from our students?” “How do we make authentic assessments with the confidence that our students will observe
academic integrity and honesty?”
Technology should no longer be new to us as we enter the fourth industrial revolution (FIRe). Still, we ponder if we can embrace a
new teaching-learning milieu in the context of FIRe and our present socio-economic situation. We contemplate if e-learning and
borderless education can facilitate student development from “becoming” a nurse to “being” a nurse. We also reflect if digital
technology may one day take on, if not take over, the functions of teaching our future nurses, given the dearth of qualified nurse
educators.
In response, let me share three concepts to consider as we modify our nursing academic environment amid COVID-19.

Technological Caring

I n his Theory of Technological Competency as Caring in

Nursing, Locsin (2013) described technological competency
as “the skilled demonstration of intentional, deliberate, and
As contemporary health care continues to be dependent on
technology, Locsin and Ito (2018) asserted that viewing nursing
and nursing practice in terms of predictive health care activities,
authentic activities by nurses who practice in environments predetermined skills, or prescribed procedures may reduce
requiring technological expertise” (p. 2). He posited that caring nursing into simple automation, easily replaceable by robotic
and technology can co-exist in nursing (Locsin, 2017) and that technology. Therefore, it is crucial to rethink who nurses are and
nurses should be able to use technology not only to complement what nursing is to affirm the science of caring that is unique for
and supplement their tasks, but more so to enhance knowing nursing and crucial for health and wellness.
patient (or nursed person) as caring, designing caring mutually
with the patient (or nursed person), and engaging patient (or Applying Locsin's theory, technological caring can exist in the
nursed person) participation in caring (p. 162). Nursing care nursing academe by using technology as a medium for caring.
involves the whole person, and nurses can maximize technology In our shift to online, we need to be mindful in laying out and
towards providing care holistically, actively, inclusively, and aligning our instructional designs with intended student learning
collaboratively with the patient (Locsin, 2013). outcomes. Similarly, we can use technology to reach out to

1 Professor and Dean, College of Nursing, at Chinese General Hospital Colleges, Manila, Philippines. The author has no conflict of interest to report. This article was presented
virtually via zoom during the Philippine Nurses Association National Capital Region Zone 1 Manila Chapter 40th Annual Convention and Scientific Meeting on November 28,
2020. Correspondence concerning this article may be addressed to Iris C. So, Chinese General Hospital Colleges, 286 Blumentritt St., Sta. Cruz, Manila 1014, Philippines.
Email: irischuaso@[Link]
[Link]

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students to know them fully, determine their learning needs, and This pedagogy involved reflection, dialogue, and enactments
elicit their participation in learning at home, within their that allow students to develop their capacity for relational work
community, and among their online classmates. Through digital and their ability to be with people in real, profound, and
platforms, we seek to develop their 21st century skills (i.e., meaningful ways. Likewise, as educators, we may use case
communication, critical thinking, collaboration, and creativity) scenarios, case studies, or case exemplars, maybe stories
that they would need to navigate through nursing practice in the shared by nurses and patients themselves, to stimulate
context of FIRe. Lastly, we can take advantage of unlimited e- reflexive thinking, cultivate empathy for complex emotions, and
resources to expand theory and research base in the field and hone relational skills. Consequently, we hope that the
guide students towards understanding the nature and core of outpouring of relational teaching-learning in the nursing
nursing that is integral and distinct to the profession. academe will produce a responsive nurse being, endowed with
true purpose, passion, and perspective, and equipped with a
Relational Practice sense of professional identity.
COVID-19 has pushed people apart with social distancing and Professional Resilience
quarantine. We have become “people phobic” for fear of getting
infected or infecting others. Even in the hospital setting, COVID- The Philippines continues to be susceptible to outbreaks of
19 patients are isolated from others. Testimonies from patients emerging infectious diseases, such as COVID-19, which
who have recovered from COVID-19 and nurses assigned to challenge the health care system, impact health care burden,
COVID-19 wards have highlighted expressions of going through increase mortality and morbidity, disrupt life activity, and affect
the disease process alone. In those moments, a nurse's the economy. Facing these threats in the forefront are the health
dynamic presence and deliberate engagement with the patient care providers, particularly nurses. The uncertainty and
made a difference in the patient's illness experience towards unpredictability of novel diseases, tension between health care
either recovery or death. Through relational practice, a nurse demand and resources, complicated and bureaucratic health
can listen perceptively and impart hopeful courage (or in Filipino care environment, state of health care financing and
terms, “lakas ng loob”). I have heard stories from recovered compensation, or patient acuity, staffing, and workload all
patients about how nurses were able to uplift their downhearted contribute to anxiety, stress, and burnout in the workplace.
spirits at a point when they have lost all hope to survive COVID- Inability to cope or ineffective coping have led some nurses to
19. Families who were separated from their confined loved ones quit their jobs or take prolonged leave of absence. Likewise, in
have shared how nurses served as a bridge to impart their last the nursing academe, given the effect of COVID-19 on the
words and accompany their loved ones in the dying hours. It is a radical transformation of the teaching-learning environment,
practice that goes beyond the performance of skills and students who cannot catch up with the new learning set-up have
provision of physical care. It is an encounter that patients either deferred enrollment or dropped out of the undergraduate
remember most about nursing. nursing program. Even educators are not spared from being
overwhelmed with adapting to a new teaching modality in a
Doane (2002) defined relational practice as an approach in short span of time. Through these challenges, the concept of
which the nurse builds therapeutic relationship with the client, resiliency often stands out.
based on trust, respect, and empathy, through intentional
interaction and genuinely interested inquiry into the client's lived Resilience is important in nursing education for students to
experiences (p. 401). It allows the nurse to know the client in a succeed in the program. It is associated with perseverance,
humanistic and holistic process and understand how personal- determination, hope, optimism, assertiveness, empowerment,
interpersonal, socio-cultural, and ethico-moral factors shape the and adaptability. It is viewed either as a personal capacity or a
client's health and illness experience. DeFrino (2009) stated that process of using protective factors to withstand challenges or
significant nursing knowledge of the patient stems from overcome adversities. These protective factors include
relational work. Relational work, in turn, results in professional personal attributes, self-efficacy, availability of resources, and
satisfaction which buffers the nurse from distress and burn out in supportive relationships (Reyes et al., 2015). Enhancing
a high pressure care environment. resilience in students equips them to handle stressors inherent
in future professional nursing practice. Resilience is linked with
Hence, relational teaching-learning in the nursing academe is the potential to turn demanding situations into learning
something we need to refocus on, all the more with our students opportunities. It is related to the ability to respond appropriately
confined in their homes, having only their gadgets to interact and recover from difficult circumstances (Amsrud et al., 2019).
with. We wonder what kind of relational skills we can draw out Building student resilience is the foundation to professional
from them in that state. Doane (2002) advocated for a pedagogy resilience in nursing (Hodges et al., 2005).
of interpretive inquiry to advance relational practice in nursing.

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JULY-DECEMBER 2021

In a systematic qualitative review and thematic synthesis of Commission on Higher Education. (2020). COVID-19 Updates.
studies, Amsrud et al. (2019) found that establishing an [Link]
educational culture of trust and readiness to care were means DeFrino, D. (2009). A theory of the relational work of nurses.
for nurse educators to enforce student resilience. A caring Research and Theory for Nursing Practice: An International
supportive relationship can encourage students to believe in Journal, 23(4), 294-311. [Link]
their ability to transcend negative events. Recognition of 6577.23.4.294
students' resources and capacity to endure can assist students Doane, G. (2002). Beyond behavioral skills to human-involved
to persevere. Acknowledging students' struggles and focusing processes: Relational nursing practice and interpretative
on help-seeking behavior can make students feel safe to stand pedagogy. Journal of Nursing Education, 41(9), 400-404.
their ground. Redefining perceived burdens into possibilities for [Link]
growth can give students insight into coping positively and Hodges, H., Keeley, A., & Grier, E. (2005). Professional
healthily. Finally, adjusting the learning process and resilience, practice longevity, and Parse's theory for
environment can boost students' confidence to meet learning baccalaureate education. Journal of Nursing Education,
tasks and move forward. By immersing students towards a 44(12), 548-554.
deeper understanding of the real world of professional nursing, Locsin, R. (2013). Technological competency as caring in
exploring personal meanings and philosophies of caring, and nursing: Maintaining humanity in a high-tech world of
creating strong professional discipline, nurse educators can nursing. Journal of Nursing and Health Sciences, 7(1), 1-6.
foster resilience, stamina, and career longevity in nursing [Link]
(Hodges et al., 2005). [Link]
Locsin, R. (2017). The co-existence of technology and caring in
Conclusion the theory of technological competency as caring in nursing.
Journal of Medical Investigation, 64, 160-164.
Amid COVID-19, an educational environment focused on [Link]
technological caring, relational practice, and professional Locsin, R. & Ito, H. (2018). Can humanoid nurse robots replace
resilience can be achieved by innovative pedagogy and role human nurses? Journal of Nursing, 5(1). [Link]
modeling. Stepping away from conventional teaching-learning 10.7243/2056-9157-5-1
methodology, educators can create avenues for students to Reyes, A., Andrusyszyn, M., Iwasiw, C., Forchuk, C. & Babenko-
learn how to be intentional, deliberate, authentic, and Mould, Y. (2015). Resilience in nursing education: An
humanistic in caring; how to work confidently, committedly, and integrative review. Journal of Nursing Education, 54(8), 438-
connectedly with people; and how to practice in unpredictable, 444. [Link]
stressful, ambiguous, and technological health care
environment. By modeling professional attributes, educators
inspire and influence students to demonstrate the same in their ABOUT THE AUTHOR
nursing practice. Even through remote online learning, students
can continue to acquire not only the knowledge and skills to
“becoming” a nurse, but more importantly, imbibe the core Iris Chua So is the Dean of the College of
values and essential character inherent to “being” a nurse. If we Nursing and concurrent Officer in Charge
bring to light what nursing truly is, its identity, philosophy, and for Academic Affairs at the Chinese
discipline, educators can nurture valuable qualities that General Hospital Colleges. Prior to joining
the academe, she worked as a pediatric
students eventually contribute to nursing practice and the
cardiology nurse at the Philippine Heart
nursing profession. As such, if we prepare our students now to Center. She obtained her Bachelor of
address their line of work in the future, we equip them with the Science in Nursing degree, magna cum laude, at the University of
tools they would need to be responsive to an ever-changing Santo Tomas. She pursued her graduate studies at the University
work environment and to promote their own welfare and that of of the Philippines Manila where she earned her degrees on
other Filipino nurses, even beyond COVID-19. Master of Arts in Nursing and Doctor of Philosophy in Nursing.
She is a member of the Philippine Nurses Association and an
____________________ officer of the Association of Deans of Philippine Colleges of
Nursing. She has recently been appointed as member of the
References Commission on Higher Education - Technical Evaluator for
Nursing Program and also assigned as evaluator and monitor for
the Professional Regulation Commission - Continuing
Amsrud, K., Lyberg, A., & Severinsson, E. (2019). Development
Professional Development Council for Nursing. Her areas of
of resilience in nursing students: A systematic qualitative interest include adult health nursing, pediatric cardiology nursing,
review and thematic synthesis. Nursing Education in nursing education, and nursing research.
Practice, 41. [Link]

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NURSES’ VOICE FROM THE FIELD

Website Innovation for Nursing Student Learning

during the COVID-19 Pandemic
Fandro Armando Tasijawa, [Link]., Ns., [Link].1

C OVID-19 became a severe threat to education (Daniel, 2020)

like in Indonesia, resulting in the government issuing policies
that institute learning/working from home arrangements. With the
during the pandemic. Even though each college has its own
website, I recommend a suitable website for the lecturer. Why is
this so important? Because with a personal website, the lecturer
anticipation of the virus spreading widely, universities are can fully control and regulate the entire content. These include
burdened to innovate their arrangements, such as admissions, student consultations, lecture schedules connected to the Zoom
learning activities, examinations, and even graduations. The use platform or Cloud X, real-time examinations using the
of online platforms such as Google Meet, Zoom, and CloudX [Link]/quizziz platform, lecture materials, learning videos,
becomes massively utilized to support these policies. tasks, and books that students can download.

The conversion of conventional learning methods from face-to- As a developing country, the main question of the lecturers will
face to online has a positive and negative impact on students and be “How much would it cost?”. Many platforms offer their
lecturers. I found that students and lecturers who carry out services for free with the site name's requirement (domain)
various learning activities in front of laptops or smartphones for following the original domain of the web. This, however, comes
more than six hours feel the harmful impacts. These impacts with many limitations. Thus, this experience I am sharing is a
include physical, psychological, and socio-economic aspects. free website.
The physical impacts– weight gain because of the low physical
activity, neck strain due to the poor posture facing the laptop The individual websites made by lecturers can be linked to the
screen, less sleeping time due to the effects of looking at the faculty's main website so that students can easily access the
screen for a long time– are mostly felt. Psychologically, it has also lessons in the main portal. This system becomes a breakthrough
led to increased stress and anxiety. Economically, pockets are in faculty lecture management. Nursing lecturers in developing
easily emptied by merely buying an internet. In fact, the students countries can utilize this system most especially now where
are required to spend money to buy internet credit – which, when several media is used and more attention is needed to monitor
totaled for two weeks, could go as high as IDR100,000,00 - all activities.
IDR200,000,00 (roughly PHP360- PHP720; USD7-USD14)
The website "Media Edukasi Keperawatan Jiwa" consists of
Lecturers under this arrangement had to use several media to several menus such as lectures, student grades, examination,
support learning activities such as WhatsApp, Google Classroom teaching materials, learning videos, and member areas that can
(GCR), Zoom, Google Meet, and other platforms. Lecturers have be accessed through laptops or smartphones. The learning video
many responsibilities such as teaching, doing community menu is an innovation in this pandemic because the students can
services, conducting research, and engaging in office work. This learn independently by playing videos repeatedly to understand
can lead to overwhelming tasks on hand. The best way to these materials (Stuckey & Wright, 2020). The other menus were
overcome that problem is to build a teaching management system put in place to help students in the lecture process. Lecturers can
for lectures that can be accessed through one gate system but set up when the information is published, activate/disable the
connected to various media. Thus, I propose one integrated link, and set a password for a particular class.
system to overcome the obstacles of using many platforms.
As an example, the website "Mental Nursing Media Education"
The web-based media that is very suitable for them are has been accessed 3,607 times by 999 users for the past three
WhatsApp, Zoom, Google Forms, Cloud X, [Link]/quizziz, months. The site has received both satisfactory and
and other applications connected to the website. This innovation dissatisfactory feedback from students. Nursing students from
received a positive response from students as a learning medium the mental nursing course were asked to evaluate the site based

1 Lecturer
at the Faculty of Health, Universitas Kristen Indonesia Maluku, Indonesia; fandrotasidjawa@[Link]; [Link]
Scopus Author ID: 57286855300
PJN VOL. 91 | NO. 2
100
JULY-DECEMBER 2021

Figure 1. Website "Media Edukasi Keperawatan Jiwa" (very satisfied 55.1 %, satisfied 43%, not satisfied 1.9%).
in supporting mental health nursing lectures. Overall, students were very satisfied in the websites' accuracy.

For the format, students graded the website's design with

regards to the attractiveness of the color settings (very satisfied
44.1%, satisfied 52.9%, not satisfied 2.3%, very dissatisfied
0.8%), layout's user-friendliness (very satisfied 49, 4%, satisfied
46.4%, not satisfied 4.2%), and easily understandable menu
structure and link (very satisfied 56.3%, satisfied 41.8%, not
satisfied 1.9%). Overall, students were very satisfied with the
user-friendly layout and easy to understand menu structures and
link, and were satisfied with the color settings.

Regarding the website's ease of use, students graded it in terms

of its user-friendliness (very satisfied 50.2%, satisfied 48.7%, not
satisfied 1.1%) and accessibility anytime and anywhere (very
satisfied 54.8%, satisfied 43.7%, not satisfied 1.5%). Overall, it
showed that most students were very satisfied with the website's
ease of use.

The timeliness of the website was evaluated based on how

quickly the lectures were posted (very satisfied 44.5%, satisfied
52.5%, not satisfied 3%) and updated (very satisfied 42.6%,
satisfied 54.8 %, not satisfied 2.7%). It revealed that most
students feel satisfied with the timeliness of the website.

Overall, those evaluation showed students' satisfaction with the

on its content, accuracy, format, ease of use (user-friendly), and web-based media. In addition to quantitative evaluations,
timeliness (Fitriansyah & Harris, 2018). Their responses can qualitative responses also showed students' satisfaction about
range from very satisfied (SP), satisfied (P), dissatisfied (TP) up the website. Sample responses were “In my opinion, what we
to very dissatisfied (STP). They were also enquired to give inputs use during the learning process, especially the mental nursing
on how to develop the site further based on their expectations as course is very good, and I become happy to learn about the
users. Out of 277, only 263 students accomplished the website
satisfaction evaluation. Students were assured that their
evaluation shall not affect their grades and will remain
anonymous to the lecturers.

Students evaluated the website's content in terms of its method

of delivery, and whether the site is easy to understand, complete,
and clear. For the learning needs, 54.4% were very satisfied,
45.2% were satisfied, and 0.4% were not satisfied. Whereas, in
terms of whether the website is easily understandable, 46.8%
were very satisfied, 51.3% were satisfied, and 1.9% were not
satisfied. Meanwhile, in terms of completeness of the website for
learning, 44.1% were very satisfied, 55.1% were satisfied, and
0.8% were dissatisfied. Lastly, in terms of clarity of the content,
47.1% were very satisfied, 51.7% were satisfied, and 1.1% were
not satisfied. Overall, students were very satisfied with the
method of delivery and were satisfied with the contents being
easily understandable, complete, and clear.

In terms of accuracy, students rated their satisfaction level on the

correctness and accuracy of the displayed information on
lectures (very satisfied 51.7%, satisfied 47.1%, not satisfied
1.1%) and appropriateness of the links showed on the webpage Figure 2. One of the learning videos at the
3rd meeting of the mental health nursing course
PJN VOL. 91 | NO. 2
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JULY-DECEMBER 2021

Figure 3. Website Traffic on "Media Edukasi Keperawatan Jiwa" for the past 90 days
mental treatment.” and “Thank you for
the education nursing education
media's media website, because it
was easier for me in the learning
process.” Student satisfaction with the
website is an illustration that using
website is an effective medium in the
learning process.

Website development is not without

criticisms. One of the responses in
terms of receiving technical
instructions before using the web-
based media was “I have many
obstacles when just starting, my
advice, [students] must be trained
well, or there is a guide to accessing
the website.” Other responses
included reconsidering design
templates or adding images to lessen
boredom. Lecturers need to develop
an effective, efficient, and exciting
website to lessen students'
dissatisfaction.

In addition to evaluating students' satisfaction, lecturers also References

found several obstacles during the teaching process. Some
obstacles include: Daniel, J. (2020). Education and the COVID-19 pandemic.
Prospects, 49(1), 91–96.
1. Students must be oriented on the website, which requires a Fitriansyah, A., & Harris, I. (2018). Pengukuran kepuasan
considerable amount of time for a first meeting. pengguna situs web dengan metode End User Computing
2. Most students come from villages that are not familiar with Satisfaction (EUCS). Query: Journal of Information
the internet. When taught, however, they can get used to Systems, 2(1).
operating it easily, and get new insights related to the use of Stuckey, L., & Wright, A. (2020). Innovations in Education in
the internet. Response to COVID-19: Online Medication Commercials.
3. The pandemic has made students to return home because Nurse Educator, 45(4), 197.
of parents' worries or expensive living costs in the city. Thus,
in rural villages they must install an internet network to have
access to online learning materials. ABOUT THE AUTHOR
4. Using a website is very easy for students in urban areas, but
students in rural areas have limited internet connection. The
website-based test makes it easy for lecturers to evaluate
Fandro Armando Tasijawa, [Link]., Ns.,
student cognitive abilities. As an alternative, students who [Link]. is a Lecturer at the Faculty of
have a connection problem can use an essay collected Health, Universitas Kristen Indonesia
through the website. Maluku. His research interests include
recovery of schizophrenia, schizophrenia
In conclusion, I recommend nursing lecturers in developing and its relationships, adolescent
countries to be active in continuing education related to distance reproductive problems, violent behavior,
learning during a pandemic; practice consistently to be able to and counseling for HIV-AIDS.
get used to new platforms; and collaborate with their institutions'
Information Technology (IT) teams in developing efficient and
effective learning methods and platforms.

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JULY-DECEMBER 2021

Scarred Heroes
Roison Andro Narvaez, MSN, RN

A year full of tragedy, we encourage despite ugly sides,

the world was shaken fully, we light up the dark times with a smile,
with death and poverty, even we can't hide,
that killed our fantasy, that we are broken inside.
to live happily,
without any calvary. We passionately served,
but also being discriminated,
Death was all around,
everyday we face defeat,
making our hearts pound,
the world was shut down, like a broken radio on repeat,
with a deafening sound, it shattered what we built,
without water, we drowned, crashing down our guilt.
such a moment of breakdown!
It's not easy to be one of us,
We are starved with hunger; we got backlashes from our past,
that make us madder, we got scratches on our backs,
draining our will-power, like a scar that lasts,
to be hopeful believers, failure maybe always strikes,
but we faced great endeavors, but we remain strong like rocks.
that made us survivors!
We don't receive,
Yesterday still make us shake,
what we always give,
stabs painfully like a stake,
keeping us at night awake, but we strive and live,
restless but never hopeless, to bring aid and relief,
even inside, we slowly break, we continue to breathe,
making our hearts ache. to fight for our oath and belief.

So fight as we flight, Not all heroes wear capes,

with all our might, some wear scrubs and coats,
through day and night, not all heroes have weapon and power,
giving our best shot, some wield stethoscopes to save other,
even death pains a lot, that make them stronger like a diamond so bright.
right exactly at the heart.

Life is surely uncertain, ABOUT THE AUTHOR

tomorrow could be a pouring rain,
or like a leaving train, Roison Andro Narvaez acquired his BSN
passing in a memory lane, from Manila Doctors College and earned his
everyday is a hope to keep us sane, MSN from St. Paul University Philippines.
even uncertainty could only bring us pain. He began his career at Cancer Prevention
Center-Philippine General Hospital and
We are not sure, about the future, Manila Doctors Hospital as a Staff Nurse.
we are not sure, if we're still secured, At present, he is currently a Clinical Case
but one thing is sure, Manager at Ace Home Health and Hospice and is pursuing his
PhD in Nursing Science at St. Paul University Philippines. Rois is
that we'll continually endure. currently maintaining a website called "[Link]" and his
mission is to encourage hope and devote well-being by inspiring
We heal though we're scarred; professional nurses and aspiring nurses through his literary
we comfort though we're scared, pieces and blog posts.

PJN VOL. 91 | NO. 2

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JULY-DECEMBER 2021

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PJN VOL. 91 | NO. 2

 BOARD OF GOVERNORS 2021
EDITORIAL BOARD
• MR. GEORGE MICHAEL P. LIM Erlinda Castro-Palaganas, PhD, RN
Chairperson Editor-in-Chief
Governor, PNA Region X
• MR. JED PATRICK M. CATALAN Members
Corporate Secretary Cora A. Añonuevo, PhD, RN
Governor, PNA CARAGA Cecilia M. Laurente, PhD, RN
• MR. MELBERT B. REYES
President
Governor, PNA Region IV Editorial Assistant
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Vice President for Programs & Development
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Vice President for Finance
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Governor, PNA NCR ZONE 1 TERESITA I. BARCELO, PhD, RN
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Governor, PNA NCR Zones 4 & 5 HELEN M. BRADLEY, PhD, RM, RN
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Governor, PNA Region V
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