TEORI MODEL KEPERAWATAN

KOMUNITAS
Setyoadi
 DEFINISI MODEL & MODEL KEP

a. Model adalah gambaran yang mendekati

kenyataan dari konsep (Riehl and Roy, 1980).
b. Model Konseptual merupakan sintesis dari suatu
kumpulan konsep dan pernyataan yang
menginterpretasikan konsep-konsep tersebut
menjadi suatu kesatuan.
c. Model Keperawatan adalah kerangka pikir,
sebagai suatu cara melihat keperawatan, atau
satu gambaran tentang lingkup keperawatan
• Model konseptual praktek keperawatan
adalah suatu kontruksi yang sistematik,
berdasarkan ilmu pengetahuan dan logika,
berkaitan dengan konsep yang diidentifikasi
pada komponen yang nyata pada praktek
keperawatan (Riehl and Ray, 1980)
• Model keperawatan sebagai acuan dalam
Proses Keperawatan
• Empat konsep sentral pada disiplin
Keperawatan :
– Manusia
– Lingkungan
– Kesehatan
– Keperawatan
• Keempat konsep tersebut didefinisikan secara
umum untuk membangun Fondasi Model
 Teori Model
Keperawatan Komunitas
1. Community as client or partner
2. Cognition social model
3. Health belived model
4. Transtheoritical model
5. Health promotion model
The Community as Client
pendahuluan

Perawat kesehatan masyarakat bekerja pada

beberapa tingkatan klien: sebagai individu,
keluarga, kelompok, subpopulasi, populasi,
dan komunitas. Komunitas sebagai klien
merujuk pada konsep kelompok masyarakat
luas sebagai fokus layanan keperawatan
 Characteristics of Community Health
• Focus on:
– The health of the population
– Health promotion and disease prevention
– Creation of a healthy environment
– The health of all residents
– Using limited resources effectively to promote
health
• Involves collaboration among residents
Community Assessment Wheel
 General Community Survey

(Source revised “Learning about the community on foot,” which incorporates all aspects of the assessment wheel from
Anderson ET, McFarlane JM, Community as Partner: Theory and Practice in Nursing, 5e. Phila., PA: J.B. Lippincott; 2008:172-4.)
Community Survey cont’d
Community Survey cont’d
Community Survey: Perceptions
SOAPE Framework: Individual vs.
Community
 Dimensi komunitas sebagai klien
Komunitas memiliki 3 komponen:
(1) lokasi,
(2) populasi, dan
(3) Sistem sosial.

Komponen tiga dimensi ini sangat

sesuai untuk pertimbangan komunitas
lokal, yang bervariasi berdasarkan
batas geografis
 Location variables
Every physical community carries out its daily
existence in a specific geographic location. The
health of a community is affected by location of
health services, geographic the features, climate,
plants, animals, and the human made environment.

In assessing the health of any community, it is

necessary to collect information not only about
variables specific to location but also about
relationships between the community and its
location.
Location variables

(1) Community boundaries

Community boundaries serve as basis for measuring
incidence of wellness and illness, and for determining
spread of disease.

Where is the community located?

What is its boundary?
Is it a part of a larger community?
What smaller communities does it include?
(2) location of health services
Use of health services depends on availability and
accessibility.

Where are the major health institutions located?

What necessary health institutions are outside the
community?
Where are they?
(3) geographic features,
Injury, death, and destruction may be
caused by floods, earthquakes, volcanoes,
tornadoes, or hurricanes.

What major landforms are in or near the community?

What geographic features pose possible threats?
What geographic features offer opportunities for
healthful activities?
(4) climate,
Extremes of heat and cold affect health
and illness. Extremes of temperature and
precipitation may tax community’s coping
ability.

What are the average temperature and precipitation?

What are the extremes?
What climatic features affect health and fitness ?
Is the community prepared to cope with emergencies?
(5)flora and fauna, and
Poisonous plants and disease- carrying animals
can affect community health Plants and
animals offer resources as well as dangers.

What plants and animals pose possible threats to health

(6) The human-made environment
All human influences on environment (housing,
dams, farming, type of industry, chemical
waste, air pollution, and so forth) can
influence levels of community wellness

What are the major industries?

How have air, land, and water been affected by
humans? What is the quality of housing? State health
department
Do highways allow access to health institutions?
II. Population
The total population of community is the second
dimension to be examines. The health of any
community is greatly influenced by the attributes of
its population.
 A healthy community has leaders who are aware of
the population’s characteristics, know its various
needs, and respond to those needs.
Community health nurses can better understand any
community by knowing about its population variables:
size, density, composition, rate of growth or decline,
cultural characteristics, social class structure, and
mobility.
Population variables:

(1)Population Size:
The number of people influences number and
size of health institutions.
Size affects homogeneity of the population and
its needs

What is the population of the community?

care community? Census data
Is it an urban, suburban, rural community?
(2) Density
Increased density may increase stress
High and low density often affect the
availability of health services

What is the density of the population per square

mile?
(3) Composition
Composition of the population often
determines types of health needs.

What is the age composition of the community?

What is the sex composition of the community?
What is the marital status of community members?
(4) Rate of growth or decline
Rapidly growing communities may place
excessive demands on health services
Marked decline in population may signal a
poorly functioning community

How has population size changed over the past two

decades?
What are the health implications of this change?
(5) Cultural differences
Health needs vary among sub-cultural and ethnic
population
Utilization of health services varies with culture.
Health practices and extent of knowledge are
affected by culture.

What is the ethnic breakdown of population?

What racial groups are represented?
What subcultural populations exist in the
community?
Do any of the subcultural groups have unique health
needs and practices?
Are different ethnic and cultural groups included in
health planning?
(6) Social class
Class differences influence the utilization of
health services
Class composition influences cost of public
health services.

What percentage of the population falls into each

social class?
What do class differences suggest for health needs
and services?
(7) Mobility
Mobility of the population affects continuity
of care. Mobility affects availability of
service to highly mobile populations

 How frequently do members move into and out of the

community?
 How frequently do members move within the
community?
 Are there any specific populations, such as migrant
workers, that are highly mobile?
 How does the pattern of mobility affect the health of
the community?
 Is the community organized to meet the health needs
of mobile groups?
III. Social System .
The various parts of a community’s social system that
interact and influence the system are called social system
variables.
Whether assessing a community’s health, developing new
services for the mentally ill within the community, or
promoting the health of the elderly, the community health
nurse needs to understand the community as a social
system.
A community health nurse working in a small village in SA
needs to grasp the social system of that village no less
than a nurse working in Capital City.
Social System variables include:
Health system
Family system
Economic system
Educational system
Religious system
Welfare system
Political system
Recreational system
Legal system
Communication system
The CHN needs to understand the community as
a social system
 asocial system consist of parts, such as the
local government , families and hospitals that are
linked together. The parts interact and influence
each other
 each of the ten major systems of a community
includes a number of subsystems that are made up
of organizations. Member of the community
occupy roles in these organizations
 The Health Care Delivery System as Part of the
Social System
Community health nurses must examine all the systems
in a community and must understand how they interact,
the health system is of particular importance.
Studying the health system in a community can be
compared with assessing an individual client.
The major function of the health system is to promote
the health of the community. Community assessment
asks not merely whether, but also how well, the system
is functioning. What is the level of health promotion
carried out by the health system of a community?
Teori Kognitif Sosial
 Pokok bahasan

• Teori kognitif sosial

• Pembelajaran
▫ Pembelajaran dari mengamati
▫ Pemodelan
▫ Pembelajaran dengan bertindak
• Self efficacy
• Self regulasi
Asumsi dasar dari teori kognitif sosial
1. Manusia memiliki karakteristik yang menakjubkan adalah
keplastisannya.
2. Manusia memiliki kapasitas untuk mengatur hidup mereka
sendiri
3. Manusia memiliki kapasitas untuk melatih atas alam dan
kualitas hidup mereka sendiri
4. Manusia mengatur kehidupannya dipengarui dengan faktor
internal dan eksternal
5. Manusia menemukan dirinya dalam situasi yang ambigu
secara moral.
Pembelajaran

Observasional
Learning

Pemodelan

Enactive Learning
 1. Observasional Learning

Manusia belajar dengan

mengamati perilaku orang lain
hal ini bertolak belakang
dengan teori skiner bahwa
perilaku manusia dilakukan
sendiri.
Bandura juga menyatakan
bahawa penguatan bukan
merupakan esensi dari
pembelajaran.
 2. Pemodelan

Pemodelan melibatkan
proses kognitif jd tidak
hanya meniru lebih dari
sekedar menyesuaikan diri
dgn tindakan org lain karena
sudah melibatkan
presentasian informasi
secara simbolis &
menyimpannya utk
digunakan di masa depan
next

Pertama Kedua
1. Karakteristik model. 1. Konsekuensi perilaku
2. Cenderung yg dimodelkan
menyukai model yg 2. Semakin besar nilai
statusnya lebih
tinggi. yang diberikan
pengamat, makin
3. Menyukai pribadi yg
kompeten drpd yg besar nilai diserap
tidak menyukai
pribadi yg kuat drpd
lemah.
next
Proses Pembelajaran Pemerhatian/Pemodelan

Proses 1 Proses 2 Proses 3 Proses 4

Perhatian Representasi Reproduksi Motivasi

Pengamatan Presentasi Menghasilkan Subjek dapat
secara selektif simbolis sebuah termotivasikan
dari banyaknya disimpan perilaku untuk
pengaruh si dalam memori melakukan
model perilaku yang
dimodelkan
 3. Enactive Learning
• Bandura berpendapat perilaku yang kompleks dapat
dipelajari ketika manusia memikirkan dan mengevaluasi
konsekuensi-konsekuensi dari perilakunya tersebut.
• Konsekuensi memiliki tiga fungsi:
1. Efek dari tindakan
2. Memotivasi perilaku kedepan
3. Memperkuat perilaku (Skiner)
 DETERMINISME TIMBAL BALIK (RESIPROK)
DETERMINISME TIMBAL BALIK
Perilaku
(RESIPROK)  Bandura
menyatakan konsep
resiprokalitas triadik :
PERILAKU, FAKTOR KOGNITIF
dan PRIBADI, serta
LINGKUNGAN semua bekerja
Keprbdn Lingkn
secara interaktif/saling
mempengaruhi  tindakan
manusia mrpkn hasil interaksi 3
variabel tsb
 Self Efficacy

Keyakinan manusia
pada kemampuan
mereka untuk
melatih sejumlah
ukuran pengendalian
terhadap fungsi diri
mereka dan kejadian-
kejadian
lingkungannya.
 Pembentuk self efficacy
Pengalaman-pengalaman tentang penguasaan
• Performa yang dilakukan pada masa lalu

Pemodelan sosial
• Pengalaman-pengalaman yang tidak terduga dr orang lain

Persuasi sosial
• Seseorang harus percaya kepada sang pembicara

Kondisi fisik dan emosi

• Emosi yang kuat biasanya menurunkan tingkat performa
 Collective Efficacy
Keyakinan bersama
manusia terhadap
kekuatan kolektif
mereka untuk
menghasilkan
perilaku yang
diinginkan.
Regulasi Diri
Dalam regulasi diri
manusia akan terjadi
strategi reaktif dan
proaktif.
Strategi reaktif digunakan
untuk mencapai tujuan
sedangkan strategi proaktif
digunakan mencapai
tujuan yang lebih tinggi
next
Beberapa faktor mempengaruhi regulasi diri

• Observasi diri
Faktor • Proses penilaian
Internal: • Reaksi-diri

• Standart evaluasi
Faktor tingkah laku
Eksternal: • Penguatan
(reinforcement)
HEALTH BELIEF MODEL

(Teori Kepercayaan Kesehatan)

 HEALTH BELIEF MODEL (HBM)
Rosenstock 1966, Becker 1970, 1980

• HBM dikemukakan pertama oleh Rosenstock, 1966

kemudian disempurnakan oleh Becker, dkk 1970 dan
1980
• HBM digunakan untuk memprediksi perilaku
kesehatan preventif dan juga respon perilaku untuk
pengobatan pasien dengan penyakit akut dan kronis
• Namun akhir-akhir ini HBM digunakan untuk
memprediksi berbagai perilaku yang berhubungan
dengan kesehatan
 Health Belief Model (HBM)
• Termasuk dalam pendekatan intrapersonal
• Pendekatan yang dilakukan menekankan
pada aspek kognitif atau model kognitif
• Digunakan untuk meramalkan perilaku
peningkatan kesehatan.
• Perilaku kesehatan ditentukan secara
langsung oleh dua keyakinan:
– Ancaman yang dirasakan (perceived threat of
injury or illness)
– Pertimbangan keuntungan dan kerugian
(benefits and costs)
Penilaian tentang Ancaman
(Threat)
• Penilaian tentang ancaman ditentukan oleh:
– Ketidak-kekebalan yang dirasakan (perceived
vulnerability)
– Keseriusan yang dirasakan (perceived of severity)
– Petunjuk untuk berperilaku (cues to action) seperti:
media masa, kampanye, nasehat orang lain, penyakit
dari anggota keluarga yang lain, dll
• Ancaman, keseriusan, ketidak-kekebalan dan
pertimbangan keuntungan dan kerugian,
dipengaruhi oleh:
– Variabel demografis: usia, jenis kelamin, latar
belakang budaya
– Variabel sosiopsikologis: kepribadian, kelas sosial,
tekanan sosial
– Variabel struktural: pengetahuan dan pengalaman
tentang masalah
 Health Belief Model
PERSEPSI INDIVIDU FAKTOR PERUBAH KEMUNGKINAN MELAKUKAN

Variabel Persepsi hambatan (cost)

kependudukan mengenai pencegahan
Variabel Persepsi merasakan manfaat
Perilaku sosial (benefit) dari sebuah
pencegahan

Persepsi/pandangan Persepsi terhadap Kemungkinan mengambil

kerentanan (susceptibility) ancaman (threat) tindakan preventif kesehatan
terhadap penyakit ‘ x ‘ penyakit ‘ x ‘ telah direkomendasikan
Persepsi/pandangan keseriusan
(severity) terhadap penyakit ‘ x
‘

Isyarat untuk bertindak (cues to action) :

Iklan
Saran dari orang lain
Artikel koran dan majalah
Pengalaman dari keluarga
 HBM memperkirakan perilaku sebagai hasil
keyakinan/kepercayaan yang merupakan persepsi individu
terhadap :

• Susceptibility to illness
• The severity of the illness
• The cost involved in carrying out the
behaviour
• The benefits involved in carrying out the
behaviour
• Cues to action
– Internal
– External
 Susceptibility to illness (Kepercayaan ttg
kerentanan terhadap penyakit)

• Merupakan persepsi seseorang tentang resiko

terkena penyakit
• Seseorang yang merasa mungkin terkena
penyakit akan lebih merasa terancam
• My chances of getting lung cancer are high
 The severity of the illness (kepercayaan tentang
keparahan penyakit)

• Persepsi seseorang tentang tingkat keparahan

suatu penyakit akibat perilaku tertentu
• Jika seseorang yakin penyakit makin berat
akibatnya maka akan makin merasa terancam
• Lung cancer is a serious illness
The cost involved in carrying out the behaviour
(Pengorbanan yang dikeluarkan untuk berubah
perilakunya)

• Pengorbanan yang dikeluarkan tidak hanya

finansial tapi juga hal-hal yang bersifat
psikologis seperti khawatir, malu, rasa sakit,
dll
• Stopping smoking will make me irritable
 • Susceptibility to illness
• The severity of the illness
• The cost

Percieved of Threats
(Persepsi tentang Ancaman)
 Threats (ancaman)
• Ancaman mendorong individu melakukan
tindakan pencegahan atau penyembuhan
penyakit
• Namun ancaman yang terlalu besar malah
menimbulkan ketakutan yang menghambat
melakukan tindakan karena merasa tidak
berdaya (pasrah)
• Guna mengurangi ancaman, ditawarkan suatu
alternatif tindakan oleh petugas kesehatan
• Apakah individu menyetujui atau tidak
alternatif tindakan tersebut tergantung
persepsi tentang manfaat dan hambatan
pelaksanaannya
The Benefits Involved in Carrying Out the
Behaviour (persepsi tentang manfaat yang dirasakan jika
berubah perilakunya)

• Seseorang tidak akan menerima tindakan kesehatan

yang dianjurkan kepadanya kecuali bila ia yakin
bahwa tindakan tersebut dapat mengurangi
ancaman penyakit atau menguntungkan.
• Stopping smoking will save me money
 Cues to action
(Isyarat terhadap Tindakan

• Mempengaruhi seseorang dalam mendapatkan

pengertian yang benar tantang kerentanan, kegawatan,
dan kerugian dari tindakan pencegahan dan
pengobatan yang dilakukan, bisa berasal dari faktor
internal maupun eksternal.
• Cues to action
– Internal ( The symptom of breathlessness)
– External ( Information from leaflet)
Kesiapan Individu untuk Melakukan Tindakan

• Kesiapan individu tinggi bila

– Manfaat > hambatan
• Kesiapan individu rendah bila
– Manfaat < hambatan
• Jika manfaat dan hambatan tinggi, konflik
akan sulit dipecahkan
Variabel lain: Demografi, Psikologi Sosial dan
Struktural

• Peran : Menyiapkan kondisi, baik persepsi

individu maupun manfaat yang dirasakan
dari tindakan preventif.
Transtheoretical
Model
 Pengertian
• Model teori perubahan perilaku, yang telah dasar untuk
mengembangkan intervensi yang efektif untuk
mempromosikan perubahan perilaku kesehatan.
• Transtheoretical Model dikenal juga the Stage of Change
Model, dikembangkan oleh Prochaska & Diclemente
(1982;Green, Rossi, Reed, Willey, & Prochaska, 1994)
• Transtheoretical Model memiliki nilai dalam memfasilitasi dan
mengakselerasi perubahan perilaku yang berkaitan dengan
kesehatan, baik untuk perilaku adiktif maupun non-adiktif.
• Inti dari model ini : bahwa individu terlibat dalam berbagai
perilaku yang baru, mereka berpindah melalui suatu
rangkaian perubahan yang terdiri dari lima tahap.
 Model ini sebelumnya telah diterapkan
pada berbagai masalah perilaku seperti

• berhenti merokok,
• olahraga,
• diet rendah lemak,
• pengujian radon,
• penyalahgunaan alkohol,
• mengontrol berat badan
• mengontrol berat badan,
• penggunaan kondom untuk perlindungan
HIV,
• perubahan organisasi,
• penggunaan tabir surya untuk mencegah
kanker kulit,
• penyalahgunaan obat,
• kepatuhan medis, skrining mamografi,
• dan manajemen stres.
 Tahapan Perubahan
• Precontemplation : "orang tidak berniat
untuk mengambil tindakan di masa
mendatang, biasanya diukur sebagai 6 bulan
berikutnya"
• Kontemplasi : "orang yang berniat untuk
perubahan dalam 6 bulan mendatang"
• Persiapan : "orang yang berniat untuk
mengambil tindakan dalam waktu dekat,
biasanya diukur sebagai bulan berikutnya"
• Aksi : "orang telah membuat modifikasi
terbuka tertentu dalam gaya hidup
mereka dalam 6 bulan terakhir"
• Pemeliharaan : - "orang yang bekerja
untuk mencegah kambuh," tahap yang
diperkirakan terakhir "dari 6 bulan
sampai sekitar 5 tahun"
• Pemutusan : "individu memiliki nol
godaan dan 100% self-efficacy ...
mereka yakin mereka tidak akan kembali
ke kebiasaan lama yang tidak sehat.
Maintenance
 TRANS THEORETICAL MODEL OF
BEHAVIOUR CHANGE

1. Precontemplation
Not intending to make any changes

2. Contemplation
Considering a change

3. Preparation
Make small changes

4. Action
Actively engaging in a new behaviour

5. Maintenance
Sustaining the change overtime
• Precontemplation
– Tidak ada niat berhenti merokok
• Contemplation
– Menimbang2 manfaat berhenti merokok
• Preparation
– Mencoba tidak merokok
• Action
– Tidak merokok dalam waktu ttt
• Maintenance
– Tidak merokok selamanya
Perokok yang
tidak tertarik
untuk berhenti
dalam enam bulan
kedepan.
Gambar Dimensi Temporal sebagai
Dasar bagi Tahapan Perubahan
 Pender’s
Health Promotion Model
 Pender’s Health Promotion Model

Revised Health Promotion Model. (From Current Nursing (2010) Health Promotion Model. Retrieved from
http://currentnurisng.com/nursing_theory/health_promotion_model.html )
• Influences of Pender’s philosophy
– Personal experiences
As a young girl observed professional nurses caring for her aunt and developed a belief
that “the goal of nursing was to help people care for themselves”
– Educational experiences
• Master’s degree in human growth and development helped her to develop a
holistic approach to health over the human lifespan.
• PhD in psychology and education led to ideas about how individual’s thoughts
influence behavior.
 Information and Concepts
•Eleven major concepts of Nora Pender’s Health Promotion Model (2006).
Pender recognized that there are particular behaviors that promote individual ownership of
prevention of illness and continued awareness of personal health. The Health Promotion Model
focuses on prior behavior and personal factors that contributed to the
outcome.
– Prior related behavior
A similar behavior in the past that can be direct or indirect effects of health promoting behaviors.

– Personal factors
Biological, psychological, and socio-cultural are personal factors considered that are predictive of
target behavior being addressed.

– Personal biological factors

Age, gender, body mass index, pubertal status, menopausal status, aerobic capacity, strength, agility
and balance are considered variables.

– Personal psychological factors

Personal self-esteem, self-motivation, competence, perceived health status, and definition of health
are analyzed variables.

– Personal sociocultural factors

Race, ethnicity, acculturation, education and socioeconomic status are included variables. Also
considered are behavioral-specific cognitions and affects that are indicative of nursing actions.
 Information and Concepts
– Perceived benefits of action
Anticipated positive outcomes from actions resulting in healthy behavior are perceived benefits.

– Perceived barriers to action

Anticipated, imagined or real blocks from actions are perceived barriers. Also considered is
personal cost of the given behavior.

– Perceived self-efficacy
Personal capability to organize and execute a health promoting behavior is perceived self-efficacy.
An ability to analyze personal barriers and creating action for these barriers demonstrates this
capability.

– Activity-related affect
Subjective positive and negative feelings that occur before, during and following behavior based on
the stimulus properties of the behavior itself.

– Interpersonal influences
Influential cognitions are concerning behaviors, beliefs, or attitudes of others that directs ones
thoughts. Some influences include norms, social support, and modeling.

– Situational influences
These are personal perceptions and cognitions of any given situation or context that can facilitate or
impede behavior. The perceptions can be available options, demand characteristics, and aesthetic
features of the environment that health-promoting behaviors are proposed to take place. Situational
influences can be direct or indirect.
 Information and Concepts
– Commitment to a plan of action
A description of commitment of intention and identification of a planned strategy the leads to
implementation of healthy behavior.
– Immediate competing demands and preferences
Competing demands are alternative behaviors over which individuals have low control. Competing
preferences are alternative behaviors over which individuals exert relatively high control.
– Health-promoting behavior
The end point or action outcome that is directed toward attaining positive health outcomes such as
optimal well-being, personal fulfillment, and productive living.

• Global concepts
The four global concepts are addressed in the Health Promotion Model as follows:
1. Human-being- Pender ascertains in her theory that individuals are responsible to create healthy
choices for their own human health potential. These persons must be able to reflect on their behaviors.
2. Environment- The individual creates an environment to pursue and maintain for optimal health.
3. Health- Pender encourages healthy prevetive behaviors throughout the lifespan.
4. Nursing- Nursing provides interpersonal influence to aid in commitment to healthy behaviors
 Implication
Helping people change their lifestyle and move
toward a state of optimal health. This sums up the
health promotion model (HPM). It is a simple model
to comprehend although it involves complex
variables of behavior, biological and sociocultural
factors. The potential beneficial effects are not
disputable. The difficulty lies in finding methods of
drawing people away from their risky behaviors and
instilling healthy ones.
• Four Global Concepts
– An individual to an entire nationality is its targeted population.
– Environment acknowledged as a variable.
– HPM works best in a community health care setting. Here they can
focus on activities that can improve the well-being of people.
– Nurses help identify factors which work against participation in healthy
lifestyles and analyze factors in their life that contribute to their
participation.
• Narrow or Wide View
– HPM has a broad application base. This includes those with no current
health problems and those who have chronic diseases.
• Examples
– Geriatrics - “Older adults may underestimate their
capabilities, inadvertently leading them to engage in
risky health habits such as stress, poor nutrition, and
physical inactivity (Byam & Salyer, 2010, p. 115)”.
Meals on wheels is an excellent example of promoting
better nutrition for this group.
– Low income families - Instruction about a balanced
diet, exercise and the importance of early detection of
illnesses might even be added to food pantries in the
community.
– Obstetrics – Increase in prenatal care.
– Pediatrics – Well child checkups.