Dunong 2009

DUNONG
Aquinas University Professional Schools Graduate School Research Journal Vol. VI No. 1/April 2009
REDUCING RISK THROUGH DISASTER AWARENESS AND PREPAREDNESS

Jean C. De La Torre, D.B.A. Cenin R. Corral, Ph.D. Edith Rebecca S. Regino, Ph.D.
EDITORS
AQUINAS UNIVERSITY PROFESSIONAL SCHOOLS Graduate School
Legazpi City
Statements of facts and opinions are solely those of the authors. Their publication in Dunong does not imply endorsement by the Editorial Board Publisher Rev.Fr. Ramonclaro G. Mendez, O.P. or the Graduate School. Vol. VI No. 1 April 2009 Editorial Board Editorial Adviser Jean C. De La Torre, CPA, D.B.A. Editors-in-Chief Cenin R. Corral, Ph.D. Edith Rebecca Regino, Ph.D. Layout/Book Design Sherwin F. Seva Cover Design Kaloi Garcia Dunong aims to publish outstanding theses/dissertations on a variety of topics. Dunong does, therefore, give an avenue for the publication of research outputs
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Vita Veritatis et Amoris ex Gratitudine

Vita Veritatis et Amoris ex Gratitudine
TABLE OF CONTENTS
Introductory Essay ...................................................................................................... iv Cenin R. Corral, Ph.D. Contributors ................................................................................................................... vi The Operational Risk Management of Electronic Banking of Universal Banks in Legazpi City........................................................ 1 Luis R. Alamil
Risk-based Information Technology Strategic Plan for Daraga Water District ....................................................................... 90 Elma T. Barbudo
Stress of Nurses Behind Caring Post-operative Patients in BRTTH.....................................................................................................135 Rosario G. Coralde Implementation of the National Policy on Health Emergencies and Disaster Strategies Intervention ..............................................178 Marlyn A. Daguno Diabetes Management, Care and Control at BRTTH .........................228 Mizel D. Guapo Violence Against Women: Their Implications to Nursing Practice .................................................................................261 Bernardita D. Patacsil
INTRODUCTORY ESSAY
REDUCING RISK THROUGH DISASTER AWARENESS AND PREPAREDNESS
Cenin R. Corral, Ph.D.
he Philippines is a country that is at continual risk for a multitude of natural and man-made disasters. The occurrence of disasters causes major damage and destruction to lives and properties. Disasters do not just threaten safety and economic prosperity; they also stretch social cohesion and political order to the breaking point (Kumar et al., 2009). They impede sustainable development by diverting much-needed and scarce resources away from the strategic infrastructure development and gear them toward tactical response and recovery. Nothing could stop the occurrence of certain disaster, but lives could be saved if there were a proactive disaster management in place. Disaster management can minimize the risks through early warning, provide developmental plans for recuperation from the disaster, generate communication and medical resources, and aid in rehabilitation and post-disaster reconstruction. It can be noted, however, that the greatest emphasis of disaster management is continuously placed on response and recovery activities, while little attention is given to proactive measures that would reduce risk and prepare people, communities and economies to better withstand and survive disasters. However, the damages of disasters could also be minimized and lives could be saved by adopting strategies which focus on the grassroots level such as creating awareness and educating vulnerable communities on simple and easy disaster management techniques could be done. Reducing disaster risks and impact should allow for a better balance of social progress, economic growth, and environmental protection. Emergency management should not focus more on response and recovery operations but on mitigation and preparedness. Risk reduction should center on public awareness and community partnerships, better assessments of risks, and preventative action as components that would minimize identified risks. Thus, disaster management should be everybodys business. Everybodys
efforts are required to effectively deal with disasters and more importantly to prevent them from occurring. Disaster management plans must adopt a participatory strategy with an increasing focus on the grassroots level. To have a successful disaster management method, people should be well informed and motivated towards a culture of disaster prevention and resilience. There should be mass participation. People should be made aware about disasters and be educated about their responsibility during disasters. Apart from bringing about mass participation and responsibility, awareness brings about individual preparedness before, during or after a disaster.
Reducing Risk through Disaster Awareness and Preparedness v
References
Kumar, A., Srivastava, J.P., Bhardwaj, P. Gupta, P. (2009). Disaster management: a method of easy survival. The Internet Journal of Rescue and Disaster Medicine. 8 (2). DOI: 10.5580/25f Smith, K. (2009). Environmental Hazards: Assessing Risk and Reducing Disaster, 5th Ed., London: Routledge, Taylor and Francis Group. UN ISDR 2004, Living with Risk: A global review of disaster reduction initiatives (Geneva: UN International Strategy for Disaster Reduction), Retrieved from http://www.unisdr.org/eng/about_isdr/bd-lwr-2004eng.htm
THE CONTRIBUTORS
LUIS RAMIREZ ALAMIL acquired his Masters degree in Business Administration major in Business and Industrial Management in 1993 from Aquinas University of Legazpi. He obtained his Bachelors degree in Business administration major in accounting from the same university in 1977. Alamil resides with his family in Washington Drive, Legazpi City.
ELMA T. BARBUDO is currently working at the Daraga Water District, Daraga, Albay. She obtained her Bachelors degree in Computer Engineering in 1998 from Aquinas University of Legazpi. Barbudo resides with her family in P-6 Penafrancia, Daraga Albay. ROSARIO GAREZA CORALDE is a registered nurse currently employed at the Bicol Regional Training and Teaching Hospital in Legazpi City. She obtained her Bachelors degree in Nursing from Aquinas University of Legazpi in 1974. Coralde is a native of Irosin, Sorsogon but resides with her family in Purok 2, Barangay 38, Barriada, Legazpi City.
MARLYN ALA-DAGUNO is a registered nurse currently employed at the Bicol Regional Training and Teaching Hospital in Legazpi City. She acquired her Masters degrees in Nursing in April 2008 and in Education major in Nursing Education in March 1990 from Aquinas University of Legazpi. She obtained a Bachelors degree in Nursing from the same university in 1980. Daguno resides with her family in Buraguis, Legazpi City. MIZEL GUAPO is employed at the Bicol Regional Training and Teaching Hospital in Legazpi City. She obtained her Bachelors degree in Nursing from Ago Medical Educational Center in 2001. Guapo is a native of Bagaobawan, RapuRapu Albay but resides with her family in Binanuahan West, Legazpi City.
BERNARDITA C. DESCALZO-PATACSIL is a registered nurse currently employed at the Bicol Regional Training and Teaching Hospital of Legazpi City. She obtained her Bachelors degree in Nursing from Aquinas University of Legazpi in 1980. She also finished a Diploma Course in Health Emergency management in the UP College of Public Health in Manila in 1997. Patacsil resides with her family in Bigaa, Legazpi City.
Reducing Risk through Disaster Awareness and Preparedness vii
THE OPERATIONAL RISK MANAGEMENT OF ELECTRONIC BANKING OF UNIVERSAL BANKS IN LEGAZPI CITY
Luis R. Alamil Introduction The new information technology (IT) is becoming an important factor in the future development of service industries. Business companies are faced with a number of important questions, such as how to take full advantage of new technology opportunities, how e-developments change the ways customers interact with producers and services providers, etc. With the current ITs fast rate of development worldwide, all sectors of the society experience the never-ending quest how to effectively adopt it. Business companies adaptations of IT have impact on their costs of operations, time of objectives achievements or quality of service, not to mention the risks involved in their profitability and sustainability. Corporate planners and decision makers are fascinated by the globalization scheme wherein players of commerce and trade can do transactions without time limits and geographical boundaries. For the not so aggressive organizations, the situation becomes their cutting edge but a competitive advantage for the progressive ones. Globalization trend has affected the managerial functions of middle managers. A successful implementation of managements strategic planning, marketing, monitoring, evaluation, controlling, directing, and decision making activities requires them to have adequate information and technological competency. This would make them proficient in their field of endeavors. Managers must first identify and then acquire the necessary information. Historically, they have been the biggest challenges of managers. However, the advent and the maturing of Information Technology have greatly altered not only the availability of information but also the manner by which it is identified and acquired. In reality, todays managers are often burdened, not with lack
2 Dunong Vol. VI No. 1
of information, but rather with information overload. Information overload occurs when managers have so much information that they have trouble distinguishing between the useful and the useless (Iigo, Jr., 1997). Business, to some, means selling of goods and services. But, to others it means production of goods and creation and delivery of services. It is also defined as a social process. It involves the assembly and utilization of resources to produce goods and services in order to satisfy the needs of society. Such process requires the organized efforts and methods of individuals in the production and marketing of goods and services. The purpose of business is to create a customer and to satisfy him, which is a social function since the business enterprise is an organ of society. Peter Drucker asserted that It is the customer who determines what business is, what the business thinks it produces is not of first importance especially not to the future of the business and to its success. What the customer thinks he is buying, what he considers of value is decisive. It determines what a business is, what is produced and whether it will prosper. (Iigo, Jr., 1997). Mr. Druckers idea of business led towards customers satisfaction. However, such status depends on how the producers, marketers and service providers reach and timely meet the demand of their customers. In reality, the outreaching activities necessitate the need for efficient communication means, which the Information Technology could effectively provide. Business organization is not merely a collection of persons working together for a common purpose but is also a system of activity. Management gurus defined business organization as the process of continuing the work which individuals or groups have to perform with the faculties necessary for its execution, that the duties so performed provide the best channels for the efficient, systematic, positive, and coordinated application of the available efforts. (Gutierrez et al, 1998). Gutierrez, et al. (1998) considered the term as the structural relationship between the various factors (men, money, machines, materials, and methods) in the enterprise Information is currently being provided greater emphasis on the material structure of business organization by most managers. The extent and nature of business activities are almost as diverse and comprehensive as the totality of the social and economic interests of man. However, for the business to undertake such activities progressively, the manager should be abreast with the trends of times, for the means of doing business today are also becoming diverse and comprehensive in consonance with the social and
economic interest of man. Undeniably, a business organization should have the five given factors or even more resources for they constitute the inputs of the production of goods and services. It is undeniable, too, that the prime mover of the inputs of production or service is man. Other resources like the methods of communication, processes, machines and information are also necessary. They enable an organization to do borderless and timeless business transactions nowadays. Such is the fascinating effect of computer and the web of information technology (Internet). Hence, electronic business (e-business) and electronic commerce (e-commerce) become the tools of industries globally. The above global developments necessitate a need towards studying the management of e-business of the financial institutions, like banks operating in the locality since banks are part of the value chain system of products and services. A value system is a connected series of organizations, resources and knowledge streams involved in the creation of value to end customers (Handfiled & Nichols, 2008). Furthermore, large-scale production and a high degree of specialization of labor can function only if effective system exists for paying for goods and services, whether they are needed in production or are offered for sale. Business can obtain the money it needs to buy such capital goods as machinery and equipment only if necessary institutions, instruments, and procedures have been established to making savings available for such investment. Similarly, the government units can carry out their wide range of activities on the domestic and international scene only if efficient means that exist for raising money, for making payment, and for borrowing are at hand (Miranda, 1989). Banks have recently been open to historic transformation. The so-called e-developments are emerging and advancing rapidly in all areas of financial intermediation and financial markets like e-finance, e-money, e-banking, ebrokering, e-insurance, e-exchanges, and even e-supervision. Todays information technology (IT) is turning into the most important factor in the future development of banking, influencing banks marketing, operations and risk management strategies. The driving forces behind their rapid transformation like innovations in information technology, innovations in financial products, liberalization and consolidation of financial markets, deregulation of financial intermediation, etc. are influential changes in the economic environment of banks. Such factors also complicate the designed strategy. The process is threatened by unforeseen developments and changes in the economic environment. Therefore, strategies must be flexible to adjust to these changes. The
Reducing Risk through Disaster Awareness and Preparedness 3
question is not any more whether the emergence of Internet has been a threat or an opportunity, for those who have decided to protect themselves from the threats instead of using the opportunities are determined to vanish from the marketplace (Lustsik, 2008). The continuing technological innovation and competition among existing banking organizations and new entrants have allowed for a much wider array of banking products and services to become accessible and delivered to retail and wholesale customers through an electronic distribution channel collectively referred to as electronic banking (e-banking). However, the rapid development of e-banking capabilities carries risks as well as benefits (http:// www.bis.org ). The definition of e-banking varies amongst researches partly because electronic banking refers to several types of services through which bank customers can request information and carry out most retail banking services via computer, television or mobile phone. Burr describes it as an electronic connection between bank and customer in order to prepare, manage and control financial transactions (http://www.bis.org ). The products and services of banking institutions to developing countries are almost as old as modern travel. Even in ancient times, business travelers just as banking institutions have existed for more than one thousand years as ancient market recognized bazaars, seaports and commercial districts. These places have undergone considerable changes for the satisfaction of the affluent and regular customers as well. But the process of change pays. Banking institutions have been one of the most successful wholesale and retail business concepts of the twentieth century. It has become the most powerful and adaptable facility for utilization the world has ever seen. In urban cities, banks have diversified services provided to customers. It could be in the form of safekeeping, money transfer, availing of credit facilities, and many others. Their products and services are not only the means by which to buy the necessary goods. It is also the place to go by people in times of financial needs or to invest hard-earned savings. Thus, banks has become a byword in international and domestic business scenes. Today, they connote business establishments in ordinary form that provide the financial as well as the investment needs of business industry (Miranda, 1989). The implementation of the above cited services makes banks vulnerable to risks. Risks are threats to any enterprise. They come in various forms. Most prevalent are those caused by staff inefficiency, systemic, fraud committed
by staff or external party through robbery, hacking, phishing, spamming or intentional virus infiltration. They become the elements of uncertainties that cause the short-attainment or worst, the non-attainment of the enterprises established objectives. They compelled many managers to consider the necessity to formulate administrative controls and systems strategies, prepare action plans, train people, and implement mitigation and control measures to cushion the impact of anticipated threats that were identified or to be identified (http://www.managementhelp.org/ Risk _ management). The Basel II Committee on Banking Supervision believes that the integration of e-banking applications with legacy systems implies an integrated risk management approach for all banking activities of a banking institution. To facilitate these developments, it identified fourteen Risk Management Principles for Electronic Banking to help banking institutions expand their existing risk oversight policies and processes to cover their e-banking activities. However, it recognizes that each banks risk profile is different and requires a tailored risk mitigation approach appropriate for the scale of the e-banking operations, the materiality of the risks present, and the willingness and ability of the institution to manage these risks. This implies that a one size fits all approach to e-banking risk management issues may not be appropriate (ffiec.gov/ffiecinfobase/booklets/e-banking/ebanking_02-risk_mang.html). Legazpi City is one of the key cities in the Bicol Region that is frequented by domestic and foreign visitors. Its differentiating features from other cities in the region are the natural scenic view of the majestic Mayon Volcano and the active business and commerce transactions everyday. Likewise, it is very much accessible by any means of land, sea, and air transportation, aside from the presence of communication facilities, public services and hospitable people. These have prompted several banker-investors to establish their branch offices in the city. The corporate investors confidence is vividly seen with the presence of 4 government-owned, 2 commercial, 11 universal, 6 thrift, and 3 rural banks. With all the structural evidence above-cited and the corresponding businesses banks offer to the public, a community of bankers the Albay Bankers Association (ABA) was established by several banking institutions in Legazpi City. Since majority of member-banks have also branches in the other localities of Albay and Sorsogon provinces, ABA acquired its status as the two provinces social and quasi-regulatory body of banking networks. Likewise, a cash unit of Banko Sentral ng Pilipinas (BSP) was also established due to the volume of cash transactions of the member-banks. The said unit acts as the cash deposi-
tory and provides cash assistance in times of needs of the ABA members. In the past, the unit also acted as the clearing center for local, inter-regional and regional checks of most member banks. For the past decades, the commercial and universal and some of the thrift and rural bank members of the association have introduced and implemented the electronic banking (e-Banking) system. E-banking transactions are now visibly seen through the automated teller machines (ATM) strategically placed at the banks premises, some busy streets, or inside the shopping centers in Legazpi City. In the long run, electronic banking has evolved into several product designs and strategies. With the introduction of several e-banking services like phone banking, electronic payroll system, electronic card (e-card) and others, it could be surmised that the various banking institutions in the locality are serious about their adoption of electronic banking. The Problem This study assessed the operational risk management activities of electronic banking (e-banking) services of universal banks (unibanks) in Legazpi City. Specifically, it answered the following questions: 1. What is the degree of risk of the operational management activities of universal banks operating in Legazpi City for their e-banking services in terms of: 1.1. Strategic planning, 1.2. Management of information security program, 1.3. Authentication of e-banking customers, and 1.4. Administrative controls? 2. What is the level of effectiveness of operational risk management activities for e-banking services of universal banks in Legazpi City along: 2.1. Monitoring, 2.2. Evaluation, 2.3. Mitigation, and 2.4. Control? 3. What is the level of satisfaction of clients towards the e-banking services of universal banks operating in Legazpi City along: 3.1. Tangible dimension, 3.2. Reliability dimension, 3.3. Responsiveness dimension, 3.4. Assurance dimension, and
3.5. Empathy dimension? 4. What operational risk management strategies maybe recommended to sustain the strengths of e-banking services of universal banks in Legazpi City along the indices mentioned in the level of effectiveness aspect? 4.1. What risk management plan maybe suggested to implement the risk management strategies recommended?
Conceptual Framework The banking sector of Legazpi City is a composition of progressive and dynamic players in the financial industry. It contributes towards the socioeconomic development of the locality. It has implemented the electronic banking to bring out the best effectual considerations along profitability, quality customer service, and total quality management. Likewise, it enables the sector to become abreast with the times through the use of Information Technology. The cited reasons are among the objectives of the banking sector that could lead to the attainment of organizational goals of the member-banks of Albay Bankers Association, and could contribute to the dynamic development of the economic scenario of the locality where these banks are situated. The researcher assessed the operational risk management activities for e-banking services of universal banks operating in Legazpi City. Towards the achievement of the above-cited objective, the study answered five subproblems that are concerned with the above-cited management of e-banking services of the same banks in terms of strategic planning, management of information security program, authentication of e-banking customers, and administrative controls. It also dealt with the level of effectiveness along monitoring, evaluation, mitigation and control; and the level of satisfaction of clients along tangible, responsiveness, reliability, assurance and empathy dimensions. Likewise, the study touched on the management strategies suggested to sustain the strengths; and, an operational risk management plan to implement the recommended strategies for e-banking services of universal banks in Legazpi City along monitoring, evaluation, mitigation and control. In support of the measures provided by the selected respondents, the study likewise developed a risk management plan. The plan would be recommended to universal banks to assist them in furthering their developmental activities towards the attainment of a higher degree of implementation of operational risk management activities. Allied to it is the enhancement of
Degree of Risks due to Operational Risk Management Practices for E-banking Services: Strategic Planning, Management of Information Security Program, Authentication of E-banking Customers, Administrative Controls Level of effectiveness of operational risk management activities for e-banking services: Monitoring, Evaluation, Mitigation and Control Level of satisfaction of clients towards e-banking services: Tangible Dimension, Reliability Dimension, Responsiveness Dimension, Assurance Dimension, Empathy Dimension Management Strategies Suggested to sustain strengths; and, Operational Risk Management Plan to Implement the Recommended Strategies: Monitoring, Evaluation, Mitigation and Control F E E D B A C K
UNIVERSAL BANKS IN LEGAZPI CITY
ENHANCED OPERATIONAL RISK MANAGEMENT ACTIVITIES; CLIENTS SATISFACTION
E-BANKING SERVICES
Figure 3. Conceptual Framework Model
the level of satisfaction of their clients. The said output is deemed a contribution by the study to the enhancement of managing effective, efficient and productive e-banking business approaches in the locality. In order that the findings become meaningful to the identified individuals and institution-beneficiaries, a feedback mechanism is instituted. This means that the results of the study would be communicated to the respective banks management. This gesture would make them become more aware of the customers perceptions and satisfaction level about the operational risk management practices and activities for their e-banking services. In this way, the universal banks would exert more efforts to sustain their strengths that were uncovered by the study.
Methodology This study utilized the descriptive type of research. Such type is deemed appropriate because after gathering the data, collating and presenting them in tabular form, textual narratives were also provided. This means that appropriate interpretations were given in order that the users of the outcome of the study could fully understand the pattern and characteristics of the variables used particularly on the: (1) degree of risk of the operational management activities of universal banks operating in Legazpi City for their e-banking services in terms of strategic planning, management of information security program, authentication of e-banking customers, and administrative control; (2) level of effectiveness of the operational risk management activities for ebanking services along monitoring, evaluation, mitigation and control; (3) level of satisfaction of clients towards the e-banking services along tangible, reliability, responsiveness, assurance and empathy dimensions; (4) management strategies suggested to sustain the strengths of operational risk management practices; and (4.1) the operational risk management plan to implement the strategies suggested to sustain the strengths for e-banking services in terms of monitoring, evaluation, mitigation and control of universal banks operating in Legazpi City. In the above cited process, the method involved in interpretation of meaning or significance of what is described was given emphasis. Thus, description is often combined with comparison and contrast involving measurement, classifications, interpretations and evaluation. The study had two sources of data, the primary and secondary. The primary data were generated from the responses provided by the selected re-
spondents of the study. The secondary data were derived from books, manuals, publications, graduate theses and doctoral dissertations. Most of the foreign literature and studies were tapped from the Internet. The total respondents of the study were 143 as specified in Appendix A. They consisted of two categories. The first type was the selected officers of the banks occupying the position of branch manager or marketing officer, branch operations head or control officer, and branch cashier. They were considered direct implementers of the e-banking services of banks in Legazpi City. The second type consisted of individuals and company account clients who were judgmentally chosen from among the personal and business accounts of the same banks of the study. Judgmental sampling was used due to the sensitivity, accessibility and privacy of information. The researcher utilized a survey questionnaire purposely to gather the responses of the targeted respondents. He, in close coordination with his adviser and the members of the panel, prepared the instrument. The guidelines used in the preparation of the questionnaire were the different problems of the study. Two sets of survey questionnaire were prepared. The first set was for bank officer-respondent. The said survey-questionnaire has three parts. The first part includes the evaluation of the operational risk management activities of universal banks operating in Legazpi City for their e-banking services in terms of strategic planning, management of information security program, authentication of e-banking customers, and administrative control. The second part is for the assessment of the level of effectiveness of the banks activities for e-banking services along monitoring, evaluation, mitigation and control. The third part is the determination of management strategies that may be suggested to sustain the strengths of the activities for the e-banking services by the same banks in Legazpi City. The second set of survey-questionnaire was intended for the clientrespondent. The same type of instrument also has three parts. The first part focuses on assessing the level of effectiveness of the banks activities for e-banking services along monitoring, evaluation, mitigation and control. The second part is for the assessment of the level of satisfaction of clients towards the e-banking services of the same banks along tangible, reliability, responsiveness, assurance and empathy dimensions. The last part deals with the determining of management strategies that may be suggested to sustain the strengths of the activities for the e-banking services of the same banks in Legazpi City.
The primary data that were gathered for Problems 1, 2, and 3 were subjected to a weighted mean computation using the MS-Excel software program. The data gathered for Problem 4 were interpreted using rank. The following numerical scale, range, verbal interpretation and description were utilized in the study to interpret the computed mean for the degree of risks of due to the banks operational risk management practices for ebanking services.
Numerical Scale 5 4 3 2 1 Range 4.50-5.00 3.50-4.49 2.50-3.49 1.50-2.49 1.00-1.49 Verbal Interpretation Very High High Moderate Low Very Low Risk occurrences were enormously sure and their impact threatened the success of banking product/ service offerings to clients. Verbal Description
Risk occurrences were likely with substantial impact on time, costs or quality to product/service offerings of banks to clients. Risk were as not likely to occur if they did, they would have notable impact on time, costs or quality of e-banking service offerings of banks to clients.
Risk might occur but still had minor impact on time, costs or quality of ebanking service offerings of banks to clients. Risk were unlikely to occur and if they did they negligible impact on time, costs or quality of e-banking service offerings of banks to clients.
The following numerical scale, range, verbal interpretation and description were utilized to interpret the computed mean for the level of effectiveness of banks operational risk management activities for e-banking services.

Numerical Scale 5 4 3 2 1 Range 4.50-5.00 3.50-4.49 2.50-3.49 1.50-2.49 1.00-1.49 Verbal Interpretation Very High High Moderate Fair Low Verbal Description
The banks operational risks management activities provided greater than usual results leading to the achievement of their and clients objectives.
The banks operational risks management activities provided usual results leading to the achievement of their and clients objectives. The banks operational risks management activities provided modest but sensible results leading to the achievement of theirs and clients objectives.
The banks operational risks management activities provided impartial results towards the achievement of their and clients goals. The banks operational risks management activities did not provide results towards the achievement of their and clients goals.
To interpret the computed mean along the level of satisfaction of clients on the e-banking services, the following numerical scale, range, description and interpretation were utilized:
Numerical Scale 5 4 Range 4.50-5.00 3.50-4.49 Verbal Interpretation Very High High The banks services extremely exceeded clients expectation. (Extremely satisfied) Verbal Description
The banks services exceeded clients expectations. (Delighted.)

3 2 1 2.50-3.49 1.50-2.49 1.00-1.49 Moderate Fair The banks services matched the clients expectations. (Satisfied) The performance of banks product or serviced extremely did not match clients expectations. (Extremely Dissatisfied)
As to determination of the strengths of the operational risk management activities of the universal banks for their e-banking services, the indicator on the level of effectiveness aspect that had a rating of very high or high was considered strengths, while the indicator that had a moderate, fair or very low rating was considered as weakness. These considerations were utilized in preparing the operational risk management plan aside from those guidelines contained in the Risk Management Plan Template and Guide (El Toolkit), E-Security of the Office of Currency Controller, E-banking Booklet of Federal Finance Insurance and Examination Committee, Implementing Guidelines of Basel II Committee for Banking Supervision , Monetary Board Circular 542 of Banko Sentral ng Pilipinas and the E-Commerce Act of the Philippines (Republic Act 8792).
Very Low
The banks services did not match clients expectations. (Dissatisfied)
Discussion of Results Degree of Risks of the Operational Management Activities of Universal Banks for their E-banking Services Operational risk management is well founded from the principles of operations management and risk management. More closely, operations management reflects the diverse nature of activities to which its concepts and techniques are applied. Stevenson (1999) cited that the production concepts and techniques are implemented to a wide range of activities and situations outside manufacturing; that is, in services such as health care, food service, recreation, hotel management, retail sales, education, transportation.. The essence of operations management functions is to add value during the transformation process of goods and/or services. The methods of doing so through human resource, marketing, finance and operations and control form part of the profitability undertaking of any enterprise especially banks
(Stevenson, 1999). Thus, the above processes necessitate implementing functional and calculated risk, if risk-free activities are not possible. Towards their implementation, several factors affect their effectiveness positively as well as negatively. These situations compelled many managers to consider the necessity to formulate strategies, prepare action plans, train people, and implement mitigation and control measures to cushion the impact of anticipated threats that were identified. The formulation and implementation of the strategies that are appropriate to the organizations needs is called Risk Management. Risk Management is a structured approach to managing uncertainty related to a threat, a sequence of human activities including risk assessment, strategy development to manage it, and mitigate the risk using managerial resources. The objective of risk management is to reduce different risks related to pre-selected domain to the level accepted by society. It may refer to numerous types of threat caused by environment, technology, humans, organizations and politics. It also involves all means available for humans, or in particular, for a risk management entity such as person, staff, and organization (Stevenson, 1999). Once the context of risks is established, prioritization process follows. The risks with the greatest loss and the greatest probability of occurring are handled first. The risks with lower probability of occurrence and lower loss are handled in descending order (Crockford, 1986). In view of the foregoing, operational risk management can be construed to deal with the risk of loss resulting from inadequate or failed internal processes, people and systems; or from external events. They enable an organization track material risks, quantify risk costs, reduce the risk of loss, improve business processes, and empower business process owners by providing greater accountability. The succeeding discussions pertain to the operational risk management activities for the e-banking services of universal banks operating in Legazpi City. Strategic Planning. The Carnegie Mellon University Software Engineering Institute identified seven management principles essential to effective operational risk management. One of these principles is forward-looking view. This principle encourages management to think toward tomorrow, identify uncertainties, anticipate potential outcomes, and manage project resources and activities while anticipating uncertainties (http:// www.hefce.ac.uk/pubs/ hefce/2001/01_24.htm.).
Table 1 Strategic Planning
Indicator 1. Chooses the level of e-banking services to be provided to various customer segments based on customer needs and the institutions risk assessment considerations. The bank
Weighted mean 1.30 1.15 1.21 1.85 2.09 1.79 1.85 1.10 1.21 1.35 2.39 1.64 2.33
Verbal Interpretation
Very High
2. Re-evaluates top management decision to ensure it remains appropriate for the branch's overall business strategy. 3. Decides as to the types and quantity of electronic means on how to deliver the products/services. 4. Decides to implement e-banking products/services based on a thorough analysis of the costs and benefits associated with such action. 6. Designs the appropriate networking architecture, security expertise, and software tools to maintain system availability and to protect and respond to unauthorized access attempts. 8. Uses its flexibility to select the products and services that best meet its e-banking needs. 5. Assigns personnel who have clear understanding of the risks associated with e-banking so that cost considerations are fully incorporated on appropriate risk mitigation controls. 7. Conducts expansion design of MIS to oversee and monitor e-banking vendors (TSP), e-banking security, usage, and profitability towards the success of the branch's e-banking strategy.
Very High Very High High
High
High
High
9. Studies the advantages and disadvantages of supporting technology-based products and services in-house versus contracting for support with a TSP. 10. Reviews whether TSP arrangement continues to meet current and anticipated future needs. 11. Provides sufficient management of service providers activities to identify and control the resulting risks. Overall Mean
Very High
Very High
Very High High High High
12. Establishes clear performance expectations for its MIS to be effective.
The summary of responses of the bank officer-respondents on the degree of risks due to operational risk management activity along strategic planning is presented in Table 1. Based on the finding, it can be surmised that banks had experienced risk occurrences, however, the degree of impact on their cost, time, or quality of services were minor (1.64). In corporate finance, managing risks covers the financial or operational risk on a firms balance sheet. The Basel II framework breaks risks into market risk and credit risk aside from operational risk. Along this line, their impact can be assessed in terms of its effect on time, cost or quality (http://www. Managementhelp .org/risk_mng/risk_mng.htm.). Likewise, the same committee considered that the practice of strategic planning by bank management contributes towards the predetermination of risks together with their possible influences on banks funds, period of objective determination, or quality of products or services offered to public. The process assisted both non-electronic and e-banking implementers became aware of incoming risks. Thus, they can undertake necessary precautions to lessen the impacts (at ffiec.gov/ffiecinfobase/booklets/e_banking/ebanking_02_risk_mang.html). With the findings of the study, the strategic planning activities seemed to contain reputation, legal and financial risks. They also resulted in clients continuous confidence in banks services especially those who were using electronic banking facilities. Strategic planning is one of the main subjects of corporate planning. Progressive companies like banks underwent it periodically. The practice enable them meet the demands of the times as well as the stockholders and stakeholders. Villegas cited that strategic planning is the determination of the future posture of the business with special reference to its product-market posture, profitability, size, rate of innovation, and relationship with its executives, employees, and certain external institutions (ffiec.gov/ffiecinfobase/ booklets/e_banking/ebanking_02_risk_mang.html). It is noted that a strategy can only be implemented by undertaking functional and operative project activities. In this regard, e-banking is an operative undertaking, a project in todays era of information technology by almost all small, medium and large banking institutions. Essentially, e-banking is a set of ideas about desired objectives in the future. It is a broad pattern of attainment for the bank utilizing electronic means like computer, land line phone, mobile phone, automated teller machine, and others. Its services and activities have to be so designed and oriented to meet the desired goals specified in the e-banking strategy as
formulated by banking institution. The sum of the above-cited ideas and the plans of all e-banking operations relative to products and activities now and in the future represent a strategic posture. However, the desired prospect can be vividly seen only if all related risks are defined and given appropriate attention and resources allocation. Hence, the determination of the degree of impact of risk at the earliest possible time is critical. It would enable top management to positively formulate and analyze the courses of actions to look at the probable posture of a specific project on medium and long terms. The banks practice of its flexibility to select the products or services that best meet its e-banking needs paid off in limiting the occurrences of risks (1.10, very low). It may mean that in the strategic planning process some risks were already predetermined and others were known to unlikely occur. However, since risks cause disturbance to the enterprise, good management dictates the formulation of appropriate courses of actions just the same. With this, banks were ever ready to counter risks challenges. That is why most bank managers were comfortable with calculated risk transactions. They could easily contain the impact when they occurred. Hence, the effect on banks and clients in terms of cost, time, or quality of service was deemed negligible. The said finding can also mean that because of the anticipatory management resulting from strategic planning, banks had developed the ability to adapt to changes. This includes selecting products or services to meet clients needs. The same ability placed the banks and clients in an advantage position since the consequences of risk were proven to be very minimal. Thus, bank managements option was to accept risks and positively dealt with them. In deciding how serious a risk is, management should tend to look at the probability, which is the likelihood of the risk occurring, and impact, which is the consequence if risk does occur (at http://www.managementhelp .org/ Qualitative Risk Analysis). With these measurements based on the cited finding it could be gleaned that the management of banks under study were positive that risks would unlikely occur. And, if they occurred, the consequences in terms of cost, time, or quality of product and service offerings would be negligible. With such anticipatory approaches, it is unusual that the management would positively propose and implement counter-measures to ward off risks. If risks were inevitable, the management would always act with utmost agility to contain them thus making the event turn towards their advantage. The banks actions of providing sufficient management to their service
providers (TSP) activities to identify and control the resulting risks were low (2.39). This finding may mean that risks occurred from the service providers activities. However, their consequences on cost, time, or quality of products and services of banks to their clients in utilizing the services of their technology providers were still minor. It is emphasized that banks which offer services that are technology dependent are prone to technical risk (http://www. onlinebusiness.com). This type of risk is more fundamental especially when the organization avails services from technology service providers (TSP), a condition prevalent in the e-banking sector. With the above-cited finding, most managers of banks under study admitted that they had to shell out additional funds to closely monitor and evaluate the TSP control measure management. The situation affected their schedule for there was slight slippage against their targets. And, in terms of service quality, the provision of such to their clients was also affected. One concrete situation was the constant off-line of their servers, which disabled automated teller machines to operate at 24/7 basis. In analyzing further the above computed data for the same activity, it is noted that the activitys weighted mean almost reached the moderate level. In this regard, the bank managements could have been aware of and could have exerted monitoring and evaluation efforts to determine the quality and the manner how the TSPs handled activities on risk identification and consequences management. If bank managements were bias in their analysis and would not undertake immediate corrective measures, the occurrences of risks might have had notable impact on their service quality offering. Perhaps, significant elements of their e-banking scope and functionality would be unavailable in the future (http://www.managementhelp.org/Quantitative Risk Assessmen). If such condition were present, the e-banking services would also be hampered. Listed below are the other activity-indicators that had very low degree of impact of risk due to predetermination activities during strategic planning. It is also worthwhile discussing them for they dealt with re-evaluation of top-management mandates, service delivery mechanisms, TSP versus inhouse technology support, TSP arrangement, and e-banking service system maintenance. They are major activities that could minimize or control risks. The findings for these indicators imply that the management of banks enabled to undertake the variations and made them manageable by veering against internal budget headings (cost benefit assessment), there were slight unfavorable variance against their internal targets (time), and there were also slight
reduction in quality/scope but with no overall impact on usability/standards on the provisions of quality service. The strategic management activities relative to the above findings are: (1) appropriate for the branchs overall business strategy (1.15). It could suggest that the branch management could easily adjust and reckon the needs of the community they are serving. The re-evaluation by the branch of the top management decision during planning was a wise action considering that the main office strategies are based on the general perspective of senior management while the branch office management is in apposite situation for it is in the front line and knows the nature of their clients; (2) Decides as to the types and quantity of electronic means on how to deliver the products/services (1.21). Again, the branch management is the proper body to initiate decision as to the type and quantity of facilities it should use in servicing clients, for it knew very well the demands of clients; (3) Studies the advantages and disadvantages of supporting technology-based products and services in-house versus contracting for support with a TSP (1.21). This particular activity pertains to the management of technology program. Since the branch has a direct hand in servicing clients, it seemed that it recognized the importance of impact of analyzing the benefits of the options to establish own technology service or just have a contract with TSP. (4) Chooses the level of e-banking services to be provided to various customer segments based on customer needs and the institutions risk assessment considerations (1.30). This means that the branch management undertook market segmentation strategy for it to decide the degree of service it should provide to its respective customers. This activity cushions the branch from financial and technical risks; (5) Reviews whether TSP arrangement continues to meet current and anticipated future needs (1.35). This means that the branch management included in its vision the prospect for expansion of market and therefore there is a need for regular assessment of its TSP arrangement to at least minimize technical risks. The other activities under strategic planning were likewise assessed to have low degree of risk due to the strategic planning activities of banks. With this finding, the activities indicated hereunder required banks to put some additional costs, there seemed to be slight slippage against their agreed targets, and they incurred some failures in providing services to customers and other stakeholders. The activities were concerned with layout of networking, security and software maintenance, e-banking product/services cost-benefit analysis, management information system, administrative control, and MIS
effectiveness. They are: (1) Designs the appropriate networking architecture, security expertise, and software tools to maintain system availability and to protect and respond to unauthorized access attempts (1.79); (2) Decides to implement e-banking products/services based on a thorough analysis of the costs and benefits associated with such action (1.85); (3) Conducts expansion design of MIS to oversee and monitor e-banking vendors (TSP), e-banking security, usage, and profitability towards the success of the branchs e-banking strategy (1.85); (4) Assigns personnel who have clear understanding of the risks associated with e-banking so that cost considerations are fully incorporated on appropriate risk mitigation controls (2.09); and (5) Establishes clear performance expectations for its MIS to be effective (2.33).
Management of Information Security Program. Nowadays, the business world is increasingly reliant on technology to supply information and communications facilities to staff, partners, and customers (http://www. businessonline.com). Such situation holds true in the banking sector especially when the bank-members decided to offer e-banking products and implement e-services. However, the introduction and implementation of such electronic marketing strategies require safety nets. Thus, appropriate control measures should be considered by the implementers. Needless to say a product or service that is dependent on information technology carries a certain degree of risk by itself. Once it is operationalized, the level of risk will depend on how the management supervises the service activities and how it deals with risk aversion and control. In this connection, the Monetary Board of the Banko Sentral ng Pilipinas requires banks to establish a security program. At present, securing organizational information and the systems that are used to manage security program for e-banking have become a high profile function. Failure to secure such, it may pose a severe impact on functional credibility of the banking sector. Hence, the practice of management of information security program is a must to all banks which offer both traditional products and electronic services to their clients. In connection with the above-cited need, the bank implements critical analysis of cost, time or quality of products or services including the resources involved in finalizing e-banking service offering. Thus, it is important that at an early stage, the degree of risks should be estimated in advance to mitigate and control the impact on and possible threats to an organizations resources if risks occur.
Table 2 shows the summary of data gathered from the responses of bank officer-respondents along management of information security program of universal banks in Legazpi City. Based on the computed mean, the activities done in said domain resulted in low occurrences of risks (2.0). Banks officers confirmed that with the given level, threats seldom occurred. One reason cited was due to their constant practice and implementation of appropriate activities on management of information security program. In terms of consequences, the threats that occurred allied to the operational practices and activities in securing information of banks through the use of e-banking networks required additional fund allocation. They also caused slight slippage against certain points on published targets. Some commitments by bank to their clients were not also acted upon on time. Table 2 Management of Information Security Program
Indicator 1. Complies with the e-Security and Risk Management provisions of Banko Sentral ng Pilipinas (BSP). The bank 2. Implements its outlined management responsibilities to oversee the protection of customer confidential information. 4. Expands its written information security program to cover the institutions own confidential records and clients. 3. Implements its management responsibilities in overseeing the security of customer information maintained and processed by technology service providers (TSP). 5. Establishes layers of various controls, monitoring, and testing methods towards effective security measures. Weighted mean 1.83 1.94 1.96 2.00 2.09 2.06 2.09
High
High
High
High
6. Ensures that appropriate controls exist internally to exhort sources of attack, equipment, response capability, network access, malicious code, etc. 7. Ensures that appropriate controls exist at its TSP for sources of attack, equipment, response capability, network access, malicious code, etc. Overall Mean
High
High
High High
2.00
Threats to a banking organization that offers e-banking services come in a variety of forms, from hacking to viruses to and simple human errors. The types of threat change constantly, so a bank management must sponsor, design, and implement business and technical processes to safeguard critical business assets and information. To create more secure information of business environment, a bank must: (1) assess business exposure and identify which assets to secure; (2) identify ways to reduce risk to an acceptable level; (3) design a plan for mitigating security risks; (4) monitor the efficiency of security information mechanisms; and (5) re-evaluate effectiveness and security program requirements regularly (http://www.businessonline.com). All of these activities must be coordinated within a well-defined strategy. Bank can manage risk to an acceptable level by developing security policies and making staff and commercial partners aware of their responsibilities within them. Management of information security program can also contribute to an organizations bottom line because customers value the reliability and credibility of any service provider. In terms of specific activity for management of information security program, the banks compliance with the BSPs e-security and risk management provisions had resulted in low occurrences of risks (1.83). From the finding it can be deduced that universal banks strictly adhered with the mandates of the Monetary Board of BSP regarding the same program. However, they still experienced threats although in nominal level. Nonetheless, the same result compelled banks to put up additional funds to cushion the threats impact. Likewise, e-security threats caused their planned targets to move on a slow pace and some of the clients banking needs for information security were not actualized on time. The management of security program is a comprehensive process of formulating and implementing appropriate measures for managing risks of e-banking products and services. Its basis is embodied in BSP Circular No. 542, Series of 2006, which partly states: Effective management oversight encompasses the review and approval of the key aspects of the banks security control program and process, such as the development and maintenance of security control policies and infrastructure that properly safeguard e-banking systems and data from both internal and external threats. It also includes a comprehensive process for managing risks associated with increased complexity of and increasing reliance on outsourcing
The same circular also requires that the Board of Directors (BOD) and banks senior managements take steps in ensuring that their banks have updated and modified, where necessary, their existing risk management policies and processes to cover their current or planned e-banking services. The integration of e-banking applications with legacy systems implies an integrated risk management approach for all banking activities (The Monetary Board, Banko Sentral ng Pilipinas, Circular No. 542, Series of 2006). In this view, the above finding disclosed that all banks of this study complied with the cited provisions. On matters relating to banks compliance with e-Security Act, it appeared from the data in Table 3 that banks also strictly complied with its provisions. However, despite their efforts, they still faced some threats although of minimal degree. Banks with electronic banking facilities and services are required to have additional control measures to help clients ensure that only they can access their bank accounts. The e-security sign is a picture and pass phrase that is a shared secret between the client and the bank. When a client sees the e-security sign, he can be confident that he is at the legitimate bank web site, not at an impostor site (http://www.hse.gov.uk/risk/) Likewise, the need for e-security is important since the manner of doing banking transactions now is borderless and not time-bound. Electronic security is an important mitigation and control feature not only on matters of ensuring the clients bank account but is also protecting him and the bank from legal risks. The law enforced by different countries worldwide is different from each other. Information technology has opened a new area of data transfer, which in turn has developed a new form of criminal element. Offences can now occur across the world, but an incident which equates to an offence in one country may not necessarily equal to an offence in the other. Enforcements have been confronted with inadequate legislation, the requirement to implement new techniques, as well as dealing with cross jurisdictional issues is a must (http:// www.hse.gov.uk/risk/). A recent example is the Love Bug; an investigation was commenced in the USA (where the spread of a computer virus is recognized as an offence) which led to a suspect being tracked in the Philippines. Many problems arose as the country where the suspect was located did not have laws which recognized the spread of a computer virus as an offence.
relationships and third-party dependencies to perform critical ebanking functions (The Monetary Board, Banko Sentral ng Pilipinas, Circular No. 542, Series of 2006).
Moreover, e-security is an enhanced control feature that helps protect a depositor in accessing online account. While the features of Internet banking have increased during this past decade, most clients with e-banking accounts are becoming more aware of increasing security threats like identity theft (http://www.hse.gov.uk/risk/). The diligent efforts to protect password remain their top security defense. However, newer threats like Phishing are prompting them to use new technology measure to help safeguard clients information as well (Republic Act No. 8792, Chapter II). Thus, the situation directs users of the needs and importance in knowing who is really on the other end of the computer. Table 2 also shows that the banks practices in establishing level of control, monitoring, and testing methods for effective security measures had brought low degree of risks occurrences (2.09). The same finding could be construed that the universal banks encountered minimal threats despite doing gradation activities like carrying out trials and dry runs, monitoring the results, and establishing control mechanisms to have operative and effectual security measures. This finding could be interpreted also that banks were necessitated to provide additional financing to control the risks. Since they already acted upon and took care of averting risks, the effect on their targets became minimal or had no bearing at all. Although the risks had minimal impact, it cannot be construed that they did not affect the banks provision of quality service to their clients. The level of tests, observation and data gathering, and taking actions to control occurrences of risks are other important considerations in e-banking. Electronic transactions made through banks networks or linkages with other entities and, vice versa, were deemed consummated when the send bar was clicked on. This is true when the actual dispensing of cash or the debit of one account and the corresponding credit to another, whether such transaction is initiated by the depositor or by an authorized collecting party occurred (Republic Act No. 8792, Chapter II). With this, any inactive and ineffective security measure could result in financial as well as reputation risks for the banks. In terms of the need of banks for guarantee relative to the internal control measures at the level of TSPs to overcome the sources of attacks from hackers, phishers or malicious code (virus) invaders, it also appeared that the universal banks implemented properly the said activity but still experienced risks, although at a low level (2.09). This means that the management of banks under study had provided the much needed attention and supervision on
control measures their TSPs were implementing. However, the containment of the sources of malicious codes and others went on decisively. Without the establishment of the control measures by the bank at their TSPs level, their impact on the services of their clients could be on a high degree. It is also worthwhile discussing the results of the other indicators mentioned in Table 2 specifically the importance of implementing outlined internal management responsibilities to supervise or oversee the protection of customers confidential information (1.94). The same is true with the implementation of banks management responsibilities in looking at the TSPs security measures for the same purpose (1.96). These practices enabled the banks management to contain the degree of risks at low level. However, the results imply that the status was attained only after the banks had employed some additional costs, time and efforts. On the other hand, the practice of expanding the banks written information security program to cover the institutions own confidential records and clients (2.00) enabled the banks management to have minimized the impact of risks up to low degree. All banks are required by law to protect their records and those of clients with utmost confidentiality. The intention of such mandate is to strengthen more the trust and confidence of the market with banking institution. If the market would be keeping its hard-earned savings in banks, a cheaper source of funds for investment purposes for both private and public enterprises would be readily available. The impact would be in the form of employment and socio-economic development in the community, to cite as examples. Likewise, the activity-indicator purported for ensuring that appropriate controls exist internally to exhort sources of attack in affecting their equipment, making their response capability effective, gain efficiency of network access, and cure malicious codes or viruses, and others was also acted upon (2.06). The implementation enabled banks to minimize the impact of risks on their respective institutions and on their clients. Many financial organizations have existed for a long period on the basis of custom and practice in safeguarding their products, services and resources through practical knowledge. However, there is a strong conviction that risks may be involved while their clients use the products or availing of their services. The underlying assumption is that the financial institutions, particularly banks products/services are in everyday use. Hence the institutions accountability to the public is to convince them that there have been no obvious problems they would encounter over time and that they are safe.
Authentication of Bank Customers. Before the entry of wireless banking, one of the tedious tasks, but most important activity of banks, was the manual authentication of signatures of customers. This activity is painstakingly done by bank officers and other personnel designated as signature verifiers. To make them efficient and effective, they were required by management to undergo series of trainings and seminars to scientifically recognize genuine signatures from forged. Banko Sentral ng Pilipinas and the National Bureau of Investigation constantly sponsored signature verification trainings, seminars and workshops to banking community to deter forgery, fake documents and counterfeit money. The activity shows how important authentication of bank customer is. Other means of authentication are clients personal appearance and other forms of documentary and scientific analysis. The advent of wireless banking has also changed the way in which the customers are validated. Accordingly, wireless banking is a delivery channel. It occurs when customers access a financial institutions network(s) using cellular phones, pagers, and personal digital assistants (or similar devices) through telecommunication companies networks. Wireless banking service in the Philippines and around the world typically supplements a financial institutions e-banking products and services (ffiec.gov/ffiecinfobase/booklets/e_banking/ebanking_02_risk_mang. html). The current trend of banking also supplemented the authentication method in a more sophisticated manner. However, in any model, risks are always a distance away much more in e-banking whereby wireless gadgets are constantly utilized. These gadgets have limitations that increase the security risks of wireless-based transactions and that may adversely affect customer acceptance rates. Again, it is necessary that at an early stage, the management should have formulated the activities that more or less mitigate if not control totally the occurrences of risks brought about by the practices of authenticating clients. The summary of responses by the selected bank officer-respondents of the study on the authentication of customer aspect is shown in Table 3. Based on the computed data, the banks practices of the said operational risk management activity consequently lessened the occurrences of risks (1.96). The finding could be interpreted that most managements of banks experienced the occurrences of risks during their authentication of customer activity. But since they have adequately prepared for any eventuality, the level of risks impact became minimal. However, minimal as it was, banks had to allocate additional funds to correct the matter. In view thereof, the banks targets were also affected and they have to undertake stricter control in dealing with their clients.
One of the means towards minimizing the impact of risks was the undertaking of a banks education campaign regarding the customers responsibility in dealing with their bank accounts. The practices of banks in this regard caused the occurrences of risk to become very minimal (1.15). It could be surmised that education campaign activities accorded to clients on matters of self-security and account protection were effective in minimizing the impact of knowledge risks. The resultant effect had caused only a little and manageable variation of budget heading, slight slippage on time, and reduction of quality of service with no overall impact on the usability and service standards of banks. Table 3 Authentication of e-Banking Customers
Indicator 1. Educates customers on their security responsibilities in accessing accounts through e-banking network. The bank 2. Develops a customer identification program (CIP) appropriate to institution size, location and type of business offering. 4. Maintains a written and duly approved CIP by management and incorporated in the institutions Bank Secrecy Act/Anti Money Laundering Program. 3. Implements its customer identification program (CIP) appropriate to the nature of customers and product/service offerings. 5. Establishes procedures that reflect the institutions account opening processes whether faceto-face or remotely as part of the banks e-banking services. Weighted mean 1.15 1.81 1.86 1.69 2.36 2.26 2.61 1.96
Very High
High
High
High
High
6. Authenticates its customers identities each time they attempt to access their confidential on-line information.
7. Ensures that the authentication methods involve confirming one or more of something only the user should know, something the user possesses, and something the user is. Overall Mean
High
Moderate High
In view of the above findings, it also appeared that most clients were inclined to avail of the services of financial institutions like banks that give importance to the campaign for mutual interest and protection of business. While some or maybe few clients were reluctant to follow, for they considered that the authentication task and securing transactions are the banks responsibility, many understood that such responsibility is also that of clients. Likewise, clients were happy to find out that their host banks cared for them and that such made them satisfied with the service. Constant reminder, which is covered by informal education process, made them realize the necessity of their almost forgotten lesson that in any transaction, there are always two parties involved. Hence, both the bank and the client were dutifully bound to protect each others interests. Authentication of bank customers is not an onerous activity but is considered to be multi-disciplinary to protect the account of the client. And, to free the bank from tedious litigation in the future due to legal and reputation risks. It is critical also to understand why a potential client will choose a particular bank or why an existing client chooses to maintain his account with the bank no matter how strict it is. Fundamentally, there are three things evident in a great service practice - a clear business strategy, a point of differentiation, and an operating discipline (Hayes, 2003). The first two practices pertain to marketing strategy, while the last one pertains to control. One of the standard operating procedures of a bank in permitting a client to open an account with the organization is to establish good, mutual and productive relationship. The initial step of these great practices is to personally appear inside the bank while opening an account. In this manner, the bank management as well as the client would see for themselves how serious both parties are in establishing good relationship, in which protection of interest starts. In relation to the above, the banks practice of confirming one or more of something only the client should know, something he possesses, and something he had resulted to a moderate degree (2.61). Analyzing the result, it appeared that banks were relaxed in implementing the required activity. The result was moderate risk level wherein the banks were required to put up significant amount of funds, and possibly caused the loss of confidence by clients in the service quality and reputation of some. In this regard, some banks realized that the procedure was material as internal control mechanism for authenticating clients transactions especially when the ones transacting are walk-in-clients. There is a rising clamor for controlling and marketing work balance in most finance organizations particularly banks. Marketing is now becoming more
organic, natural and integrated into the culture of a service-oriented but profit organizations (Hansen, 2003). These statements virtually provide the situation of a banks management. Most managers would deal mostly with their marketing responsibilities. Some of them enticed clients through the free-for-all strategy without much looking at the value of internal control system like exhaustive client authentication. Such was considered for the performance indicator of marketing manager is more of attaining quantitative targets. However, in operations management, the value added practices to limit risk are always considered. This provides quality accounts for the organization and limited risks. Administrative Controls. Administrative controls pertain to the implementation of policies and practices among the personnel within the organization. Their purpose is to mitigate and safeguard banks assets from fraud and other ineffective activities of the human resource that affect the organizations balance sheet. It calls for the decisive implementation of control measures. The cooperation, integrity and honesty of all organization members to effectively manage and efficiently use their capabilities to protect the enterprises resources and the clientele are required. The same control measures enable the management to protect, on a certain level, the commitance of fraud by personnel. The other end view is to mitigate and control risks from implementing traditional banking or electronic banking practices and activities. The modern banking approach currently implemented by most banks calls for new administrative control requirements and potentially increases the importance of existing controls. Management must evaluate its administrative controls to maximize the availability and integrity of e-banking faculties. Ebanking information can support identity theft for either fraud at the subject institution or for creating fraudulent accounts at other institutions (ffiec.gov/ ffiecinfobase/booklets/e_banking/ebanking_02_risk_mang.html). With this view, institutions should formulate and implement adequate and effective measures. The same should start from internal environment especially with personnel before undertaking control mechanisms with outsiders. In connection with the above premise, the usual activity of bank management before implementing vital project like e-banking is to do initiating activities and evaluate them later as the project progresses. The banks practices along this activity line are summarized in Table 4. Based on the responses of the bank officer-respondents, the operational risk management activities done for administrative controls also resulted to a low degree of
risk occurrences (1.95). Based on the result, it could be surmised also that by administering control measures within a banks environment, the degree of impact of risks became limited. This means that their effect on time, cost and quality of banks services was minor. An organization needs appropriate and applicable administrative control as its starting point in protecting business interests. The furtherance of commitance of fraud within the enterprise can be summed up due to laxity of administrative controls. Whats in a name? The importance of this question always arises when two or more names are almost identical and belong to different persons. For some, if their names were used by others they become elated. However, for corporate identity like banks that embrace risk management philosophy, such should not be the case. That is why they took care and valued the selection of domain names to be used for e-commerce. The premise is that identical business names will create confusion, legal and reputation risks with utmost possibility. Table 4 Administrative Controls
Indicator 1. Implements segregation of personnel duties control. The bank 2. Implements dual control system. 4. Establishes fraud detection controls.
Weighted mean 1.90 2.19 1.88 1.88 1.83 2.10 1.88
High High High High High
3. Ensures that e-banking systems provide sufficient accounting reports for reconciliation activities. 5. Exercises care in selecting its website name/s to reduce possible confusion with those of other Internet sites. 6. Conducts a business impact analysis of ebanking services that define the minimum level of service required and establishes recovery-time objectives. Overall Mean
High
7. Complies with all legal requirements relating to e-banking such as trade name registration, protecting customers data, etc.
High High
1.95
In view of the above, the banks activity of exercising care in selecting its website name/s to reduce possible confusion with those of other Internet sites also lessened the risks occurrences (1.83). This could mean that banks were conscious in setting website names. Hence, it resulted in minor risk consequences along time, cost or quality of a banks products and services. In the age of information technology, websites name may pose risk when it becomes the source of confusion among users. Two or many banks websites with almost similar names cause constant adjustments affecting clients banking transactions. The same nature causes a bank with serious problems if such will not be corrected. Clients would be misled. Things might occur that their business transactions will not be credited to their respective accounts if the website names of their banks appear to be confusing. The same could result in financial and legal risks for the banks. Worst, it becomes an avenue for hacking. Operationally, there are other administrative control measures that deal with risk management. The dual control system is one. Such system provides some material transactions either by a bank or by a client that should be handled by two authorized signatories. There are other transactions, although not material in amount that requires dual control depending on the practice and mandate of the top management. The main point of the system is to minimize risks that may come along if the same would be approved by an authorized officer alone. In the above instance, the indicator that states Implements dual control system had the mean of 2.19 which is verbally interpreted as low in degree. This finding could mean that the universal banks were following the said rule but only in a light manner. Perhaps, the quantity of transactions that call for such policy implementation was minimal or; the authority of a single officer can suffice the handling of regular activities. Summary of Banks Operational Risk Management Activities Figure 5 and Table 5 show the summary of responses on the degree of risks of operational management activities of universal banks in Legazpi City relative to their banking products and services. Based on the computed data, all the cited major activities resulted in low occurrences of risks (1.89). The finding implies that the various practices in this studys given major activities implemented by banks resulted in a run down level of risk occurrences. Consequently, the general impact of such fashion on banks and their clients in terms of time, cost or quality of service was minor.
Figure 5. Summary of Banks Operational Risk Management Activities
Based on the same table, the major activity of strategic planning had a mean of 1.64 (low). The same finding implies that more than the majority of universal banks in the city of Legazpi acceded to the concept and importance of advanced thinking relative to the plan of actions that they will be dealing with in the future of improving the quality of services to their clients. Such actions may also limit their disbursement of additional funds just to correct things in the future. With this, the timeframe that they made and the formulated activities to attain targets would also become practical and adaptable. Table 5 Summary of Banks Operational Risk Management Activities
Activity Weighted mean 1.64 2.00 1.96 1.89 1.95 Low Low Low Low Low
Note: SP = Strategic Planning, ABC= Authenticating Bank Customers, MISP = Management of Information Security Program, AC = Administrative Control
1. Strategic Planning
Interpretation
2. Management of Information Security Program 3. Authentication of Bank Customers 4. Administrative Controls Overall Mean
The management of information security program had a mean of 2.00. The finding implies that the respondents commonly knew the practices included in this major activity, however, they did not have full control of the same especially in supervising the activities of their third party service providers. It is also noted that the major activities of authentication of customers and administrative controls were almost on the same degree (1.96 and 1.95, respectively). It could be deduced that the banks were keen at practicing the various activity-indicators as aforementioned in order to minimize if not totally control risks. Level of Effectiveness of Operational Risk Management Activities of Universal Banks for e-Banking Services The measuring standard for the level of effectiveness of a given organizational risk management activity could be gauged in several manners, one of which is positive result on the enterprise and client. The operational risk management activities implemented by an organization could then be measured according to the favorable contributions they made either through quality of product, quality of service offering, cost benefit results, or viability of undertakings to market their products or services so that the target clients would make repeat or continuous orders. Risk is a measure of the probability and the consequence of an unfavorable event. For it to be minimized and avoided, an organization needs to adopt an appropriate risk management. Risk Management is the total process of identifying, controlling, minimizing and eliminating risks that may affect the achievement of an organizations objectives (ffiec.gov/ffiecinfobase/ booklets/e_banking/ebanking_02_risk_mang.html). Several risk management authors provide steps in establishing the context of risk management as earlier mentioned. They could then be summed up into three categories monitoring, evaluating and mitigating. Since operations and risk management activities and practices necessitate clear direction and forward decision making process, the control function could be added as the fourth category. In enterprise risk management, which is akin to universal banks risk management, a risk is also defined as a possible event or circumstance that can have a negative influence on the enterprise (bank) in question. Its impact can be on the very existence, the resources (human and capital), the products and services, or the customers, as well as external impacts on society, markets, or the environment. In a financial institution, enterprise risk management is
normally thought of as the combination of credit risk, interest rate risk, or asset liability management, market risk, and operations risk (Crockford, 1986). Since this study dealt more with operational risk management activities of universal banks, the discussions in this part of the study are more focused on the operations risk. The continuing technological innovation and competition among existing banking organizations and new entrants have allowed for a much wider array of banking products and services. Banks products or services are now made accessible and delivered to retail and wholesale customers through e-banking. However, the rapid development of e-banking capabilities carries risks as well as benefits (http://www.effiec.go/booklet/ebanking). Thus, for banks to be efficient and make use of the e-banking capabilities in an effective manner favorable to all types of stakeholders, several activities were planned to include risk assessment. Every activity included in the banking program intends to provide benefits. Hence, conducting an assessment of the planned activities, together with how banks practiced them, is of great importance. The Electronic Banking Group of an international committee, the Basel II Committee on Banking Supervision, expects such risks to be recognized, addressed and managed by banking institutions in a prudent manner according to the fundamental characteristics and challenges of e-banking services. These characteristics include the unprecedented speed of change related to technological and customer service innovation, the ubiquitous and global nature of open electronic networks, the integration of e-banking applications with legacy computer systems and the increasing dependence of banks on third parties that provide the necessary information technology (http://www. effiec.go/booklet/ebanking). Monitoring. Monitoring of risks under risk management program could be pre and post activities. Pre activity consists of data gathering and identification of risks. The identified data are then included in a risk repository. Under post activity, once initial risk repository has gone through the Risk Assessment and Handling phases, it is important to keep monitoring risks on a periodic basis. Risk Monitoring is therefore the process that systematically tracks and evaluates the performance of risk handling actions against established metrics (Wideman, 1992). The summary of responses by all types of respondents of the study on the level of effectiveness of operational risk management practices of universal
banks in Legazpi City along monitoring is shown in Table 6. Based on the computed data, the level of effectiveness of the said operational risk management activity was very high (4.79). The finding connotes that the given activityindicators, banks performances along gathering of data and information to be used by them in decision-making process towards the further improvement of their services were very highly effective and of greater than usual worked in favor of the management and their clients. It also connotes that they were able to project seriousness in reducing, if not totally controlling, risks and lessening their impact in terms of costs, time or service quality. Table 6 Monitoring
Indicator 1. Acts in reviewing the security control measures. The bank 2. Delivers required consumers disclosure statements on time. 4. Supervises the payments for third party payments. 5. Screens documents before processing cash advances and payments on e-commerce transactions. 6. Examines authenticity on fund transfer transactions. 7. Applies security source code in all electronic banking transactions. Overall Mean
Weighted mean
Bank Officer
3. Gathers information concerning consumer dissatisfaction.
4.91 4.88 4.85 4.91 4.82 4.94 4.97
Weighted mean
Corporate Account
Very High Very High Very High Very High Very High Very High Very High Very High
4.64 4.85 3.94 4.27 4.64 4.69 4.87
Weighted mean
Personal Account
Overall
Weighted mean Verbal Interpretation
Very High Very High High High Very High Very High Very High Very High
4.84 4.87 4.69 4.65 4.77 4.72 4.82
4.83 4.92 4.55 4.69 4.76 4.89 4.91
4.90
4.56
4.77
4.79
While the concern of monitoring is finding the bases for an effective evaluation, it should be construed as creating inherently new risks. Several government and private committees like the Monetary Board of BSP, Bankers
Association of the Philippines and other local and foreign groups involved in risk reduction and quality assurance have noted that these characteristics increased and were modified. The areas of concern are the traditional risks associated with banking activities, particularly strategic, operational, and legal and reputation risks, thereby influencing the overall risk profile of banking (ffiec.gov/ffiecinfobase/booklets/e_banking/ebanking_02_risk_mang.html.). Effective monitoring involves the right condition for openness and transparency (http://en.wikipedia.org/wiki/Risk_Management.) At this juncture, it requires a timely delivery of the clients record under the position of the bank. Clients record is also known as disclosure statement. The level of effectiveness of universal banks in this regard was very high (4.92). It means that the cited practice had assisted the bank management and clients in most advantageous manner to achieve their objectives. On the part of the bank, such objectives may include maintaining the reputation of the bank in terms of records keeping, and as depository of the monies entrusted them by the depositor-clients. On the part of the clients, they are assured that the bank would be able to provide them with listing of their transactions for reconciliation purposes. Literally, disclosure statement refers to the statement of accounts of clients usually printed by the bank and provided to clients at the end of the month. It serves as an audit trail for both parties. Thus, the finding could also mean that the banks managements were not remissed in their obligation in providing clients with their statements copy according to the period prescribed by Banko Sentral ng Pilipinas. The timely and regular provision of copy (within one week after the end of the month) to client is one way of avoiding risk. This is based on the premise that the client is enabled to have a hard copy for double checking his transactions. Any discrepancy could then be corrected at once. In addition, the existence of clear audit trails for all e-banking transactions should be ensured. Measures to preserve confidentiality of key e-banking information should be appropriate with the sensitivity of such information. Although customer protection and privacy regulations vary from jurisdiction to jurisdiction, banks generally have a clear responsibility to provide their customers with a level of comfort regarding information disclosures, protection of customer data, and business availability that approaches the level they can expect when using traditional banking distribution channels. The level of effectiveness of universal banks operational risk management activity of applying security source code in all electronic banking transactions was very high (4.91). It means that the respective bank management achieved
greater than usual results of effectiveness towards avoiding risks by implementing a codal system in processing clients transactions. On the part of the clients, such practice by banks of imposing the use of the code every time they transact business developed their confidence to maintain their accounts with their particular banking institutions. With the same security feature, they are assured that their bank transactions are treated with utmost confidentiality since they are the only individuals who know of the code. The responses of both types of client-respondents were very close and with a 0.05 variance points for the duly discussed activity-indicator mentioned above. This means that both the corporate and individual bank clients found the cited activity to be very useful in their respective processes of achieving the goals of securing their funds entrusted to banks. The activity of gathering information on consumers dissatisfaction was also very high (4.55) although it was rated the least. The finding can be interpreted that the banks also were very effective in gathering clients reasons for becoming dissatisfied with the services they had. Gathering of information about the feeling and sentiments of customers is also a means of aborting reputation risks. Perhaps, they knew fully well that dissatisfied clients would affect their marketing activities in attracting new depositors, borrowers or investors, for the characteristic and culture of customers in Legazpi City is closely-knit. The perception of the corporate client-respondents (3.94) for the above cited activity was quite different from those of the personal accounts (4.69) Perhaps, they (corporate accounts) had established a well founded relationship with their banks, however, their banking needs and transactions were not similar as those of personal accountholders. Those of corporate accounts are more complex and in every financial transaction that they do, it should also be in accordance with their standard operating procedures. Sometimes, the wants of corporate accounts do not jibe with the policies of the bank. Evaluation. Risk management is a central part of any organizations strategic management. It is the process whereby organizations methodically address the risks attaching to their activities with the goal of achieving sustained benefit within each activity and across the portfolio of all activities. In other words, each time an organization does a new activity or invest money it is taking a risk. But, risks can be weighed versus rewards. This process is risk assessment or evaluation. Risk evaluation involves identifying and analyzing program areas and
key technical process risks to increase the likelihood of meeting cost, performance and schedule objectives. A best practice in terms of evaluation is an idea that asserts that there is a technique, method, process, activity, incentive or reward that is more effective at delivering a particular outcome than any other technique, method, process, etc. The idea is that, with proper evaluation process, checking, and testing a desired outcome can be delivered with fewer problems and unforeseen complications (http://www.managementhelp.org/ risk_mng/risk_mng.htm). An effective evaluation management can result in a better service by encouraging professionals in an organization who serve the clients to think and work together as a team (http://en.wikipedia.org/wiki/Risk_Management). By working in groups that are focused on the clients current and future needs and by developing tailored plans to address those needs, groups can share information and resources. They can use their collective knowledge and experience not only for the clients benefit but also for the organizations. The summary of responses by all types of respondents along the level of effectiveness of the operational risk management activities of banks in Legazpi City is reflected in Table 7. In general, the results of the survey conveyed that almost all of the banks were very highly effective (4.81) in handling their activities along evaluation. The finding can be interpreted that all banks, which were the subjects of the study, already had well established assessment processes. As such, there are effective cross-functional management processes and process stream improvements. It could be that their cultures were more participative. Likewise, basing on the overall mean of responses from all types of clients, it could be that banks management and personnel viewed operational risk management evaluation sincerely to the delight of their customers. The level of effectiveness of banks in confirming authority to access confidential customers information was very high (4.89), and practically this activity was rated the highest among the given activity-indicators. Banks followed the secrecy of deposit as mandated by Republic Act 1405. This Act is the bible of the bankers. As such, no bank personnel should divulge any information unless authorized by the client or by the authority of a competent court. In this end, the compliance of banks may result in a relationship risk, which appears when ineffective collaboration occurs. In this regard, it could be assumed that clients and banks collaboration was very much effective. All clients were agreeable on the performance and effectiveness of their banks in this matter.
Table 7 Evaluation
Indicator 1. Verifies the accuracy of contents in consumers disclosure statements. The bank 2. Confirms authority to access confidential customers information. 3. Checks the accuracy and completeness of information. 5. Confirms unauthorized disclosures of confidential information. 4. Validates inaccurate website content.
Weighted mean
Bank Officer
Weighted mean
Corporate Account
Weighted mean
Personal Account
Overall
4.94 4.94 4.94 4.90 4.91 4.88 4.91 4.97 4.91 4.92
Very High Very High Very High Very High Very High Very High Very High Very High Very High Very High
4.81 4.84 4.85 4.31 4.82 4.60 4.61 4.49 4.65 4.66
4.77 4.83 4.65 4.71 4.62 4.65 4.68 4.73 4.81 4.72
4.87 4.89 4.85 4.71 4.82 4.76 4.78 4.79 4.82 4.81
6. Determines damages to computer systems and customers records due to malicious codes. 7. Proves authentication methods and techniques. 8. Confirms guidelines for person-to-person (e-money) payments.
9. Authenticates Bill Payment Order during presentment and prior to tendering payment. Overall Mean
Process-engagement risk may be an issue when ineffective operational procedures are applied (Crockford, 1986). Related to this, recording and processing of customers ledgers and timely delivering them to the account holders may become futile if the contents of the statement are inaccurate. Disclosure statement is an important document for both clients and banks who use it as their referenced hard copy. It also presents the nature and financial benefits derived by banks. On the other hand, clients use them as bases for their review. The above reasons enabled the banks to attain a very high level
of effectiveness in verifying the accuracy of contents in consumers disclosure statements (4.87). A risk assessment is an important step in protecting workers and business, as well as in complying with law. It helps any manager focus on the risks that really matter in the workplace the ones with the potential to cause real harm. One of the current phenomena in the field of information technology is virus or malicious codes. The effect of virus could be damaging to the organizations files and records unless appropriate protection efforts are acted upon. Banks offering e-banking services are not exempted from virus attacks, for they are using Internet software in their e-banking activities. However, they have proven that precautionary measures have been in place. This is characterized by the very high level of effectiveness of banks in determining damages to computer systems and customers records due to malicious codes (4.76). It means that banks were able to assess and have done appropriate interventions to control the impact of malicious codes and their interferences on the transaction records of clients as well as on the banks themselves.
Mitigation. Risk mitigation is the interplay of operations management, human resource management, and organizational management activities. It involves methods that reduce the severity or the likelihood of the loss from occurring, using available technological, human and organizational resources (http://www.managementhelp.org/risk_mng/risk_mng.htm). In an organizational management perspective, it is viewed that the best way of reducing risk is good management and effective personnel policies. On the other hand, financial management experts deal with insurance and outsourcing to minimize the impact of costs when risk occurs (http://www.palgrave_journals. com/rm/index.html). This study dealt more with goon management and effective personnel policies as expressed in the various indicators in Table 8. The same table also shows the summary of data gathered from all types of respondents of the study. Based on the computed data, the level of effectiveness of operational risk management activities of banks in Legazpi City along mitigation was very high (4.83). The result could be further described that the outcomes of the risk management activities to mitigate threats occurrences and their impact on banks and clients had contributed greatly towards more than usual realization of the achievement of objectives of both parties.
Table 8 Mitigation
Indicator 1. Safeguards customers information. The bank
Weighted mean
Bank Officer
2. Enforces customers authentication policies and processes. 4. Imposes strict identity verification for all types of account transactions. 5. Organizes clients multiple log-ins well. 7. Encourages clients to use their personal users ID, P.I.N., and password.
3. Reviews accounts and documents prior to authorizing customers transactions.
4.97 4.94 4.97 4.91 4.85 4.85 4.91 4.85 4.82
Weighted mean
Corporate Account
4.88 4.78 4.80 4.82 4.51 4.89 4.88 4.87 4.67
Weighted mean
Personal Account
Overall
4.76 4.74 4.72 4.70 4.71 4.67 4.71 4.75 4.74
4.90 4.85 4.87 4.84 4.73 4.82 4.85 4.83 4.77
6. Provides access tools to help customers. 8. Points out to clients the potential of customers liability through disclosures. 9. Tests the efficiency and effectiveness of a software prior to its introduction and use by clients. Overall Mean
4.90
4.79
4.72
4.83
The cited description provides confirmation of two matters. On risk management, the result could be treated that almost all universal banks in the locality have their own structured approach to managing uncertainty. They have already developed a sequence of human and organizational activities to cushion the impact of risks. On risk mitigation approaches, the same banks showed systematic and workable strategies to minimize risk using managerial resources and established collaborative relationships with their clients. It could be construed then that collaboration with existing and prospective
clients added to the value of risk mitigation efforts of banks. The level of effectiveness with respect to the individual activity of banks in mitigating risks particularly in safeguards customers information was very high (4.90). This activity was rated the highest by all types of respondents. The same finding can be construed that banks have attained maturity and have realized greatly their objective in gaining the trust and confidence of clients. Such goal is treated primarily as the base of business not only of financial institutions but also those of manufacturing and other service oriented corporations. Winning clients confidence may mean getting their continuous patronage. Once clients become confident with the banks services, they could become advertisers of the institutions products. This matter can create a chain-reaction and many customers will follow especially when they started pronouncing the very effective reliable treatment of the company towards risks. On the other hand, regular clients were also able to achieve their respective objectives. That is, finding the right financial institution that can be trusted and can provide them the necessary services that would be of great help to their business and trade. The introduction of e-banking allows many organizations to implement some strategies by passing some of their work load like disbursement of payroll and the like to other service providers. However, the firms that accept their propositions for such type of services also like to be assured of some compliance with company rules before undertaking the service to avoid risks and future financial losses on both ends. Banks also provide service of some sort. The end view of this is to establish their competitive advantage with other financial institutions. Personalized ATM is one example. One of the primary activities in safeguarding e-banking account is the system of logging-in. Before one can access his account, he has to use a security feature like password or identification code. In this regard, the banks activity of encouraging clients to use personal users ID, P.I.N., and password resulted in a very high level of effectiveness (4.83). This finding is a realization of the effectiveness of banks in implementing the particular activity. The same finding also shows that both the banks and the clients had worked out their objective on the matter very positively. Banks usually provide the ID and Personal Identification Number or PIN or password for the initial use of clients. However, they all advise ATM card users, Internet banking clients, phone banking clients, and others to change the initial ID or PIN and password given them with their own and personal IDs, PINs and passwords for safety purposes.
Most often, a client has several accounts in one bank. This scenario became a source of inconvenience in his part especially on how to access them without hassle and danger. However, banks had done measures to solve the problem. Their activity of organizing the clients multiple log-ins well proved to be very highly effective (4.73) although the respondents rated the same activity the least. This means that the banks managements achieved their goals in organizing the access of clients to their various accounts with the banks simultaneously in greater than usual manner. Most clients would open several account for various company purposes and control. In Internet banking, just like in surfing and accessing several topics in the web at the same time, clients could also check and analyze their transactions with ease and facility if banks were able to institute organized multiple log-ins. This means that clients can access their various accounts with the bank from the Internet at almost the same time.
Control. Risk management attempts to identify and then manage threats that could severely impact or bring down the organization. Generally, this involves reviewing the operations of the organization, identifying potential threats to the organization and the likelihood of their occurrence, and then taking appropriate actions to address the most likely threats (http://www. palgrave_journals.com/rm/index.html). In this regard, the Monetary Board of BSP in its Resolution No. 999 dated 11 August 2006 outlined and approved various rules and regulations concerning consumer protection for electronic banking (e-banking) products and services by aptly stating that banks, through their Compliance Officer, should ensure that proper controls are incorporated into the system so that all relevant compliance issues are fully addressed. In the risk security management functions, the terms control and controls describe a variety of processes, procedures, or tools for reducing risk to an acceptable level. When a risk is identified, the organization must assess its potential impact, prioritize its importance, identify the options for managing the risk, and assess the business value of introducing a mitigating control. Specifically, controls are security tools, programs, policies, restrictions, and other methods used to mitigate or abort identified risks (http://www.managementhelp.org/risk_mng/risk_mng.htm). Table 9 reflects the summary of responses from all types of respondents of the study along the effectiveness of operational risk management practices and activities along the control aspect. Based on the computed data, the level
of effectiveness of banks on the same major activity was very highly effective (4.77). The finding can be construed that banks were able to attain their objectives in securing and controlling various risk occurrences and the equivalent impact on their organizations with greater than usual value and effectiveness. On the other hand, the clients had also reached their respective objectives with greater than usual use of the banking services that have security and control elements in them. Among the indicators included in Table 9, the enforcement of dual control system in approving transactions involving inactive accounts proved to be very highly effective (4.85). This means that banks were able to comply with the standard rules of the BSP concerning the proper control treatments of inactive accounts. Inactive accounts refer to the deposits maintained by the depositors in the bank that have no movement or transaction (deposit or withdrawal) for the period prescribed by the Monetary Board of the BSP. For savings deposits with or without passbook like ATM account, the time frame is two years or more and one year for checking accounts. They are subject to vulnerabilities of fraud commitance by a banks staff. Mostly the depositors are already dead, no longer residing in the place where their banks are located or simply not anymore interested in their money. Several control measures are prescribed by the Monetary Board in dealing with these inactive accounts. One of which is the enforcement of dual control system in approving transactions involving them. There are several different types of controls that can reduce risk. They are administrative, physical and technical controls. Administrative controls are items like policies, standards, and procedures that set the principles and directives that provide a more secure environment. These controls are subject to rigorous assessment in the same way that technical controls are subject to scrutiny. The administrative controls establish the framework for implementing and managing physical and technical controls and define the limits for physical or technical controls. Physical control or security is an important feature of overall organizational security. Locked doors and restricted locations are important parts of any thorough security program. To achieve a layered defense strategy, physical controls must address physical security of facilities and equipment. Meanwhile, technical controls include the hardware and software devices that protect systems and data. The use of technology is paramount when developing a secure environment that can be readily adapted to changing threats. It is important
Table 9 Control
Indicator 1. Regularly tests its security control measures and procedures. The bank
Weighted mean
Bank Officer
Weighted mean
Corporate Account
Weighted mean
Personal Account
Overall
2. Enforces appropriate administrative controls to deter losses from personnel commitance of fraud. 3. Enforces appropriate operations/transactional control measures to deter losses from customers fraud. 4. Double checks government rules and regulations to avoid customers possible violations of laws (anti-money laundering, anti-terrorism, etc) 5. Enforces rigid validation procedures on clients electronic bill presentment before its payment. 6. Galvanizes appropriate procedures for effective and efficient Wireless Banking transactions. 7. Enforces dual control system in approving transactions involving inactive accounts.
4.94 4.88 4.97 4.85 4.91 4.88 4.97 4.88 4.91 4.91
Very High Very High
4.49 4.49 4.51 4.38 4.49 4.49 4.72 4.52 4.58 4.52
High
4.78 4.82 4.71 4.69 4.72 4.65 4.71 4.75 4.76 4.73
Very High Very High
4.79 4.77 4.79 4.73 4.76 4.73 4.85 4.76 4.79 4.77
Very High Very High
High
Very High
Very High
Very High
Very High
Very High
High
Very High
Very High
Very High
High
Very High
Very High
Very High Very High
High
Very High Very High
Very High Very High
8. Sets up effective countermeasures to avoid the reputation risks due to untoward occurrences of no cash dispense malfunction of ATM. 9. Determines veracity of clients account transactions and balances before providing the disclosures statements to customers. Overall Mean
Very High
Very High
Very High
Very High
Very High
Very High Very High
Very High Very High
Very High Very High
Very High Very High
that security be able to anticipate that threats change. Regular audit of technical controls identifies any circumvention of controls or any ploy to hide an attack from automatic scanning tools. An obvious example is the requirement to keep virus-scanning signatures up-to-date, because an out-of-date virus control may simply not recognize that a virus has infected the host system (http://www. managementhelp.org/risk_mng/risk_mng.htm). The level of effectiveness of the following activities was also very high: (1) regularly tests security control measures and procedures (4.79). Measures and procedures are developed to have effect on the matter why they are instituted. One of the practical means of knowing their practical use and shared value to the organization is by testing them. In this regard, banks were very progressive in testing their measures before implementing them; (2) enforcement of appropriate operations/transactional control measures to deter losses from customers fraud (4.79), which refers to the implementation of the operations or transactional measures to discourage other people to commit crime that would result in financial and other material losses to the bank. In this regard, banks were also very fruitful in attaining their purpose; and 3) determining the veracity of clients account transactions and balances before providing the disclosures statements to customers (4.79), which concerns with the provision statement that is a factual and accurate listing of transactions. The banks were also very productive and effective in this regard. The level of effectiveness of the following activities under control was also very high although they were rated the least by the respondents: (1) double checking of the government rules and regulations to avoid customers possible violations of laws (anti-money laundering, anti-terrorism, etc. (4.73); and (2) galvanizing the appropriate procedures for effective and efficient Wireless Banking transactions (4.73). These two activities could be considered control mechanismseither computer-based or procedure-basedthat limit exposure to vulnerabilities and threats. Summary of Level of Effectiveness of Risk Management Practices and Activities Figure 7 and Table 10 show the summary of responses with respect to the different risk management functions of universal banks covered by the study. It could be gleaned from the said figure and table that the leading activity the banks undertook was mitigation (4.83). Mitigation is the act of minimizing the impact of risks and their occurrences. There are several kinds of risk brought
Figure 6. Summary of Level of Effectiveness of Risk Management Practices and Activities
Legend: Mon= Monitoring, Eval = Evaluation, Mit = Mitigation, Con = Controlling, BO Bank Officer, BC = Bank Client, Average = Sum of BO and BC
about by the use of modern technology which cannot be controlled but can be minimized by way of in-depth defense. E-banking is an example of this nature. Defense-in-depth is a security strategy that focuses on the effective implementation of security controls to minimize, if not totally eradicate risks. Organizations use this strategy to examine and categorize risks in applying the layers of defense. Defense-in-depth provides a framework to apply a combination of people, process, or technology at each layer of an enterprise to prevent a certain threat. This methodology provides a way to reduce risks with overlapping controls to prevent a particular threat. Security professionals consider multiple defensive layers in examining a risk and determining the appropriate mitigation plan (http://en. wikipedia.org/wiki/Risk_management). Examples of controls include such elements as: documented processes and procedures to manage security incidents, an intrusion prevention system, and the configuration of security options and settings for systems or applications, etc. They were very effectively done by banks.
Table 10 Summary of Level of Effectiveness of Risk Management Activities

Bank Officer Corporate Account Personal Account Overall
Weighted mean
Activity 1. Monitoring 2. Evaluation 3. Mitigation
Weighted mean
4.90 4.92 4.90 4.91
Very High Very High Very High Very High
Weighted mean
4.56 4.66 4.79 4.52
Weighted mean
4.77 4.72 4.72 4.73
4.79 4.81 4.83 4.77
4. Controlling
Mean
4.91
Next to mitigation is evaluation (4.81). There is an enormous range of potential controls that can mitigate security issues. It is essential for security policy designers to evaluate and then fully understand that it is important to: (1) implement security controls in response to a perceived and assessed risk; and (2) implement security controls at a number of levels to reduce risk from evolving threats. In this regard, the banks under study were also effective on a greater than usual level. Monitoring was third in rank with a mean of 4.79 (very effective). Monitoring is the data gathering to effect evaluation and formulation of appropriate strategy to mitigate or control risks. It is also undertaken after the activities for evaluation, mitigation and control were done. It means that monitoring activity is not only a one stop shop action but is still prevalent in all the majority functions of risk management. Usually, monitoring activities are done through security audit and review to maintain their effectiveness. Banks also achieved the level of effectiveness in greater than usual status. Controlling was rated last with a mean of 4.77 (very effective) among the other risk management functions. Just as there are different types of controls, the controls that implement security in an e-banking environment have different functions. Controlling usually has a primary function that falls into one of the following categories: protect, detect, defend, recover and manage.
Very High
4.63
Very High
4.74
Very High
4.80
Very High
Generally, securing data with controls that provide multiple functions increases the defense against a particular threat. In this instance, the banks of this study had achieved a greater than usual effectiveness.
Level of Satisfaction of Clients towards the e-Banking Services of Universal Banks Todays companies are facing their toughest competition ever. They can outdo their competition if they can move from a product and sales philosophy. They can go about winning customers and outperforming competitors. The answer lies in doing a better job of meeting and satisfying customer needs (Philip Kotler, 1999). In general, satisfaction is a persons feelings of pleasure or disappointment resulting from comparing a products or services outcome in relation to his expectations (Philip Kotler, 1999). It is clear from the said definition that satisfaction is a function of perceived performance and expectations. If the performance falls short of expectations, the customer is dissatisfied. If the performance matches the expectations, the customer is satisfied. If the performance exceeds expectations, the customer is highly satisfied or delighted. On the other hand, customer satisfaction is a business term that measures how products and services supplied by a company meet or surpass customer expectation. It is seen as a key performance indicator within a business and is part of the four perspectives of a Balanced Scorecard. In a competitive marketplace where businesses compete for customers, customer satisfaction is seen as a key differentiator and increasingly has become a key element of business strategy (http://en.wikipedia.org/wiki/). Organizations are increasingly interested in retaining existing customers while targeting non-customers; measuring customer satisfaction provides an indication of how successful the organization is at providing products and/or services to the marketplace. Customer satisfaction is an ambiguous and abstract concept and the actual manifestation of the state of satisfaction will vary from person to person and product/service to product/ service. The state of satisfaction depends on a number of both psychological and physical variables which correlate with satisfaction behaviors such as return and recommended rate(http://en.wikipedia.org/wiki/). The level of satisfaction can also vary depending on other options the customer may have and other products against which the customer can compare the organizations products.
Because satisfaction is basically a psychological state, several researchers advised that care should be taken in the effort of quantitative measurement. The work done by Berry and Brodeur between 1990 and 1998 defined ten Quality Values, which influence satisfaction behavior. The same values were further expanded by Berry in 2002 and became the ten domains of satisfaction, which are: Quality, Value, Timeliness, Efficiency, Ease of Access, Environment, Inter-departmental Teamwork, Front line Service Behaviors, Commitment to the Customer and Innovation. These factors are emphasized for continuous improvement and organizational change measurement. They are most often utilized to develop the architecture for satisfaction measurement as an integrated model (http://en.wikipedia.org/wiki/). On the other hand, Servqual or Rater is a service-quality framework that has been incorporated into customer-satisfaction surveys to indicate the gap between customer expectations and experiences. It deals more with tangible, reliability, responsiveness, assurance, and empathy dimensions. Practically, the above-cited ten domains are also well-emphasized accordingly in each of the dimensions cited. Considering that this study is also anchored on Servqual concept, the preceding discussions of customers level of satisfaction on ebanking services of universal banks in Legazpi City are aligned thereto.
Tangible Dimension. Tangible dimension is an aspect of measurement that examines the total look of the business like its modern-looking equipment, the physical facilities, the employees, and the materials associated with the services like brochures it provides the customers. Table 11 shows the summary of responses of the two types of client respondents as regards their level of satisfaction on the e-banking services of universal banks in Legazpi City along Tangible Dimension. Based on the computed data, the level of clients satisfaction on the said dimension was high (3.88). This means that clients were highly satisfied with the various structural elements of banks like machine, methods, materials and information. Practically, the cited structural elements are some of the basic ones, aside from man and money, which form part of the expectations clients have in mind in dealing with service enterprise. Facilities, amenities and other tangible assets play a critical part towards making clients feel comfortable, relaxed and happy while they are doing business activities with a bank. Perhaps, this is the reason why the clients were usually satisfied with the banks facilities and amenities (3.99).
Table 11 Tangible Dimension

Weighted mean
Indicator 1. The banks facilities and amenities in making customers feel comfortable. 2. The campaign materials that provide clear information and guidelines on how to avail of the banks products and services.
Corporate Account
3.64 3.83 3.66 3.77 4.02
Weighted mean
Personal Account
Overall
Weighted mean
High
4.33 4.02 3.54 4.33 3.80
High
3.99 3.93 3.60 3.99 3.91
High
High
High
High
3. The convenience of the bank's operation schedule and time.
4. The efficient use of electronic banking equipment in servicing customers transactions. 5. The easy access of ATM, Internet webpage, and telephone banking services. Mean
High
High
High
High
High
High
High High
High High
High High
The introduction of electronic banking necessitates banks to institute machines and equipment to become more effective in their provision of services. The machine and equipments friendly-user characteristic perhaps became the added value in which clients were convinced to avail of e-banking products. This could be the reason why they were also highly satisfied with the banks electronic banking equipment efficiency in servicing their transactions (3.99), which was also rated the highest among the indicators. In the past, when the transactions were still processed manually, the banking period in Legazpi City was limited to six hours, Mondays to Fridays. Thus, the clients transactions received after three oclock in the afternoon, the cut-off time, are processed the next banking day. This was so because the staff would also attend to balancing of accounts and cash on hand, keeping records and summarizing transactions and other matters in preparation for the next banking day. In view of this, some clients had to hurry up in order not to miss the current days validity. However, when electronic banking was introduced, some banks still did not change their banking hours and perhaps
3.78
4.00
3.88
this is the reason why the indicator that states, The convenience of banks operation schedule and time had the lowest mean of 3.60. The other tangible areas like campaign materials (3.93) and ATM, banks webpage, phone banking services, etc (3.91) were found to be highly satisfying also as perceived by the clients. Campaign materials to introduce the various products and services of banks are important means in their marketing activities. They assist prospective and regular clients and guide them how to avail, use and prepare the requirements needed in opening an e-banking account. On the other hand, the use of modern equipment nowadays creates a normal feeling of animosity especially when clients are not accustomed to or have not been dealing with the bank on on-line mode most of the time. However, the banks electronic equipment has a users friendly character that even the first-time users can access them easily at all times. Perhaps this is the reason why majority of the client-respondents were satisfied in availing of the e-banking services of banks.
Reliability Dimension. Reliability dimension is another area that influences customer satisfaction. It looks at the companys commitment to do or fulfill something as promised on a specific and certain time, the sincerity in solving problems of customers, performing the service right at the first time, correcting erroneous records, and other activities that could provide customers with utmost quality service and satisfaction (http://en.wikipedia.org/wiki/). This in turn will give the bank goodwill and, therefore, will gain customers support and patronage. In this study, reliability is more equated with timeliness, efficiency, teamwork, commitment and the front line service behaviors of the banks staff. These traits are likewise considered important ingredients towards establishing customers satisfaction. To become a reliable banking institution, calls for a peculiar feature and attitude that could create an environment for customer to put on his trust in the institution. This means that not only the tangible aspect of the bank can add of satisfaction to clients needs and wants but the concept of reliance as well. The summary of responses by the two types of clients along reliability dimension is presented in Table 12. Based on the computed data, the level of satisfaction of clients on the said aspect was high (3.88). This finding could mean that the expectations of the clients of their respective banks had met the formers requirements for a period that is why they were usually satisfied.
Likewise, the clients were usually satisfied with the banks accuracy in recording their transactions (4.29). In the field of financial management, the accurate information provided to the decision maker is very important. Such information would become a sound basis for formulating a decision that, if it becomes effective, would create an efficient process for implementation. On the aspect of customer service, accuracy of records, particularly the clients financial transactions, would serve them the base of their future investment decision process to a great deal. Table 12 Reliability Dimension
Weighted mean
Indicator 1. The practicality of products offered to customers. 2. The banks compliance to commitment in assisting customers business needs. 3. The banks actions to solve customers banking transactions problems.
Corporate Account
4.09 3.65 3.65 4.39 4.19
Weighted mean
Personal Account
Summary
Weighted mean
High High
4.06 3.67 3.77 4.19 3.73
High High
3.82 3.66 3.71 4.29 3.94
High High
4. The bank's accuracy in recording customers transactions. Mean
High
High
High
Almost all clients wanted to be accorded with services that are very appropriate even though that it was only their first time to deal and transact with the bank. The initial positive and right treatment creates a lasting impression of how the banks also trust the customers. This is considered vital, for the clients concern in opening an account with the bank is to entrust their hard earned savings. Hence, clients expect that they should be treated by the bank management and staff professionally, not only in terms of personal matters but most importantly in business related relationship. In this regard, they were also highly satisfied with the banks provision of service right at the first time (3.94), which they rated the second highest among the given indicators
5. The bank's provision of service right at the first time.
High High High
High High High
High High High
3.99
3.88
3.88
of reliability dimension. The finding could be interpreted that the clients had their expectations on the matter and their respective banks had accorded them with the same gesture that is why they felt highly satisfied. Based on the computed data as reflected in Table 12, the client-respondents were also highly satisfied with the banks gesture in complying with their commitment to assist in the customers business needs (3.66). This means that although the said service was last in rank, it is construed that majority of the clients were usually satisfied with the service activity. In any assistance that the bank commits to its client, it always requires the other party to perform something like submitting documents and the like before it will act on its commitment. Thus, the compliance of the bank to its commitment is not only a one way traffic. This could be the reason why the same service indicator got the lowest mean.
Responsiveness Dimension. This dimension, advises customers exactly when service will be performed, provides prompt service to customers, expresses willingness to help customers and exhibits readiness to respond to customers request. This dimension requires not only commitment value but also the sense of timeliness, efficiency, human consideration and appropriateness of endeavor according to right environment, teamwork, front line service behavior and a sort of innovation. In a deeper sense, responsiveness is a trait that, if regularly practiced would lead to openness, awareness and sensitivity to ones feeling and needs. These are also elements that intensified an in-depth understanding of customers wants and needs to create the formula of gaining and retaining clients by properly implementing the right activities to satisfy customers. The summary of responses by all types of client-respondents on the level of satisfaction in terms of Responsiveness is shown in Table 13. Based on the result of the survey, the clients were usually satisfied with the services along responsiveness of banks (3.95). It can be construed that the respective managements of universal banks in Legazpi City were able to deliver their services to the clients in a timely and appropriate manner. It could also mean that the expectations of clients for banks to assist them in their needs for several occasions were ably met. The above table also indicates that the clients were highly satisfied with the prompt response to their transaction inquiries (4.20) and considered it as the leading activity among the given indicators. It could be deduced that it
is customary for any bank to respond to the valid request of clients especially their transaction inquiries. As such, it became habitual for the staff to be receptive on such requests as long as they pass the standard operating procedure of the bank for transaction inquiry. Aside from the prompt response attitude of the banks to the transaction inquiries of clients, the former also performed well in business and consultancy activity. In this regard, the clients were also usually satisfied with the banking expertise demonstrated to them in solving financial and banking management matters (4.02). It can be surmised that the officers and staff of the banks also performed the consultants role to effect better customer satisfaction. Table 13 Responsiveness Dimension
Weighted mean
Indicator 1. The prompt response to customers complaints and comments.
Corporate Account
2. The banks implementation of "first-come, first-served policy.
3.93 4.00 4.06 4.11 4.28
Weighted mean
Personal Account
Summary
Weighted mean
High
3.64 3.6
High
3.78 3.80 3.95 4.02 4.20
High
3. The technical service provided for customers cope with difficulties in logging e-banking transactions. 4. The banking expertise demonstrated to customer towards solving financial and banking management matters. Mean 5. The prompt response to customers transaction inquiries.
High
High
High
High
3.85 3.92 4.11
High
High
High
High
High
High High
High High
High High
In the process of providing credit facility to a client, a bank management is required to undertake with utmost concern an analysis and review of clients business status and the collateral he is offering. In this regard, the loan officer or the branch manager is obliged to do some counseling for the sake of long-lasting relationship with the client. Included in the counseling activity is the provision of some financial and banking management strategies that
4.08
3.82
3.95
would help the applicant-borrower-client to know and understand his duties and responsibilities. A customers complaint is an avenue of reenergizing the customer service of banks and could also lead towards customer satisfaction. The complaints of the clients could serve as the source of information for proper evaluation then formulation of strategic policies with regard to marketing new clients and retention of the regular ones. On the part of the clients, the response of the management to their complaints and valid comments could provide them the sense of belongingness and valued partnership. The clients were likewise highly satisfied with the banks prompt response to their complaints and comments (3.78). Although the said activity was rated the lowest, it still fell within the range of usually satisfied verbal interpretation. It could be surmised that the bank management always reckoned with the suggestion of clients according to their usefulness and priority activities. It should be understood that banks always act on the complaints of clients with respect to the formers their handling of accounts. However, some comments may necessitate a careful study by the management. Perhaps this is the reason why the cited activity got the least responses from the respondents.
Assurance Dimension. The above-cited dimension pertains to the behavior of the employees whether they are confident in customers and have knowledge to answer their questions. In this view, some of the traits and other elements that are required towards assurance conformance are quality, value, teamwork, commitment, and of course, authority. Assurance can be considered also as a frame of mind wherein one is guaranteed of an actual delivery of a thing or actual performance of an activity to be done by someone in favor of the former. It is a sort of declaration in order that a state of confidence shall be built in a partnership. Such characteristic is one of the bases of customers satisfaction aside from tangible, reliability, responsiveness, and empathy. Table 14 reflects the summary of responses by the two types of respondents along Assurance Dimension. Based on the computed data, the level of satisfaction of clients along the said dimension was high (3.97). Such result could be further described that the clients of the banks in this study were usually satisfied on the various activities towards assuring them of the effectiveness and actual actions they were expecting from their respective banks.
Likewise, the same clients were also highly satisfied with the banks consistency of providing customer with prompt and timely services (4.22). This activity was considered to be the first factor that delighted them. The said finding could be summed up that the banks managements were able to meet the expectations of their clients regarding consistent, prompt and timely provision of services every time the latter needed them. With the cited performance, the banks were able to provide the usual way of satisfying their customers. It could be said that a service may be prompt and timely for the first time. However, if the rest of times it was not, then an organization is not creating an atmosphere of satisfaction but dissatisfaction. Table 14 Assurance Dimension
Weighted mean
Indicator 1. The personnel's behavior in dealing with customers. 2. The banks consistency in providing customers with prompt and timely services. 3. The types of products suggested to customers for their specific banking needs.
Corporate Account
3.60 4.11 3.73 3.97 4.05
Weighted mean
Personal Account
Summary
Weighted mean
High High
4.45 4.33 3.78 3.93 3.75
High High
4.04 4.22 3.75 3.95 3.90
High High
4. The bank's performance of its commitment with clients.
High High High High
High High High High
High High High High
Customer satisfaction measurement must be undertaken with an understanding of the gap between customer expectations and attribute performance perceptions. To clearly understand this situation, the bank management should not only deal with the action of service delivery but also with the manner by which they are delivered. This aspect necessitates the understanding of customer behavior and matches the same with the appropriate attitude by the bank personnel.
5. The bank's reliability in times of additional revolving fund needs. Mean
3.89
4.05
3.97
The above necessity is deemed to be well-articulated by the banks. Thus, their personnels behavior in dealing with customers was rated the second highest factor (4.04) that delighted the clients. This means that the behavioral approaches used by the management and personnel of the banks in dealing with customers had met the expectations of their clients, and, therefore, resulted in the satisfaction of the customers. Competitors that are prospering in the new global economy recognize that measuring customer satisfaction is the key. However, only by offering the right product or service to a right customer in a most effective manner could they hold on to the customers they have and understand how to better attract new customers. Such practice provides the customers sense of assurance that their money would not be put to waste. Perhaps, this is also one of the reasons why the banks types of product suggested to customers for their specific banking needs caused clients to be highly satisfied as well. This could mean that the banks managements were able to tap the confidence and expectations of their clients and the former felt usually satisfied. Empathy Dimension. The above dimension requires the company and its employees to give customers individual attention, provide convenient operator hours, and understand customers specific needs and others. In the past, banking institutions would hardly give individual attention, convenient operator hours and reckoned with the specific needs of their customers. However, as markets shrink, companies are scrambling to boost customer satisfaction and try to keep their current customers rather than devoting additional resources to chase potential new customers (kcacioppo@qualitydigest.com). Thus, most of them shifted from centralized marketing approach to total quality customer satisfaction whereby some of the basic activities are those cited above. The summary of responses by both the corporate and personal accountrespondents on empathy dimension is shown in Table 15. Based on the computed mean, the clients were also highly satisfied (4.00) with the performance of the banks in the said dimension. It could be further interpreted that the clients were usually satisfied by the various activities done to them by their respective banks. Satisfaction itself can refer to a number of different facts of the relationship with a customer. For example, it can refer to any or all of the following: (1) Satisfaction with the quality of a particular product or service; (2) Satisfaction with an ongoing business relationship; (4) Satisfaction with the
price-performance ratio of a product or service; and (5) Satisfaction because a product/service met or exceeded the customers expectations (kcacioppo@ qualitydigest.com). Based on the result of the study, it appears that the second example as earlier cited made the customer-respondents became satisfied. They considered their ongoing business relationship with their respective banks as the reason that made the banks granting of grace period to enable the customers cope-up with their loan repayments without penalty charges made them felt highly satisfied (4.20). Usually, banks would provide their creditor-clients a specified time to repay their loans with no additional charges. Such imposition of short period of time could be hard to the finances especially when business sales are low. Extending a little longer the non-imposition of penalty charges could become a breather for the clients. However, such privilege could only be attained if the business relationship between the bank and the clients had been established already. Table 15 Empathy Dimension
Weighted mean
Indicator 1. The advices to assist customer in dealing with banking business related problems. 3. The confidence accorded by the banks management in accommodating clients with credit facility.
Corporate Account
2. The willingness demonstrated by bank personnel in assisting customers to facilitate their banking transactions. 4. The personalized service accorded by the banks management and staff. 5. The grace period provided to customers to cope-up with their loan repayments without penalty charges. Mean
4.06 4.27 4.39 3.96 4.24
Weighted mean
Personal Account
Summary
Weighted mean
High
3.98 3.69 3.81 3.87 4.16
High
4.02 3.98 4.10 3.92 4.20
High
High
High
High
High
High
High
High
High
High
High High
High High
High High
4.18
3.90
4.00
The granting of credit facility by a bank to its clients is built on trust and higher degree of appraisal of the business needs and capabilities of clients. In this gesture, both the corporate and individual clients agreed that they were highly satisfied of the confidence and the credit facility accorded them by the banks (4.10). In view of the said finding, customer satisfaction becomes a state of mind that customers have about a company when their expectations have been met or exceeded over the lifetime of the product or service. The gesture of the banks in trusting the clients with credit facility could also lead to company loyalty and product repurchase or service reavailment. The most basic objective of a customer satisfaction assessment program is to generate valid and consistent customer feedback. The feedbacking process involves receiving the views and needs of the customers and empathizing with them. The said strategy, which can then be used to initiate other strategy will result in customers retention and thus protect the most valuable corporate asset - loyal customers (kcacioppo@qualitydigest.com). This view is being considered by the banks managements in the study. Thus, they always implement the personalized service to valued clients. In this regard, the clientrespondents were also highly satisfied with this service gesture by the banks.
Summary of Clients Level of Satisfaction on the E-banking Services of Universal Banks The summary of the level of satisfaction of clients on the services of the banks study is shown on Figure 8 and Table 16. Based on the computed data, majority of the client-respondents were usually satisfied (3.93) with the ebanking services of the banks along the given dimensions. This finding could mean that generally majority of clients were usually satisfied with the products and services their respective banks offered to and provided them. Likewise, the computed data reflect that the clients level of satisfaction was high. They considered empathy dimension as the main core and considered tangible dimension the least. However, since customer satisfaction is a subjective and of non-quantitative state, there is a need for business institutions to clearly define their activities for the various dimensions and should be in accordance with their target objectives. Clearly defining and understanding customer satisfaction can help any company identify opportunities for product and service innovation and serve as the basis for performance appraisal and reward systems. It can also serve as the basis for a customer satisfaction surveying program that can ensure
that quality improvement efforts are properly focused on issues that are most important to the customer (kcacioppo@qualitydigest.com). As it determines what needs to be measured and how the data relate to loyalty and repurchase, it becomes important to examine the mind-set of customers the instance they are required to make a pre-purchase (or repurchase) decision or a recommendation decision. Surveying these decisions leads to gauge customer loyalty. In general, the customers pre-purchase mind-set will fall into one of the three categories--rejection (will avoid purchasing if at all possible), acceptance (satisfied, but will shop for a better deal), and/or preference (delighted and may even purchase at a higher price). Figure 7. Summary of Level of Clients Satisfaction
Legend: TD= Tangible, RD = Reliability, RsD = Responsiveness, AD= Assurance, ED = Empathy Dimensions, CA = Corporate Account, PA = Personal Account
This highly subjective system that customers themselves apply to their decisions is based primarily on input from two sources: (1) the customers own experiences--each time they experience a product or service, deciding whether that experience is great, neutral or terrible. These are known as moments of truth; (2) the experiences of other customers -each time they hear something about a company, whether it is great, neutral or terrible. This is known as word-of-mouth. There is obviously a strong connection between
these two inputs. An exceptional experience leads to strong word-of-mouth recommendations. Strong recommendations influence the experience of the customer, and many successful companies have capitalized on that link. Table 16 Summary of Level of Clients Satisfaction
Weighted mean
Dimension 1.Tangible 2. Reliability 5. Empathy
Corporate Account
3. Responsiveness 4. Assurance
3.78 3.99 4.08 3.89 4.18
Weighted mean
Personal Account
Summary
Weighted mean
4.00 3.88 3.82 4.05 3.90
3.88 3.88 3.95 3.97 4.00
Mean
3.98
How does a customer satisfaction surveying manager make the connection between the survey response and the customers attitude or mind-set regarding loyalty? A research conducted by both corporate and academic researchers shows a relationship between survey measurements and the degree of preference or rejection that a customer might have accumulated (http:// en. Wikepedia.org/wiki). When the customer is asked a customer satisfaction question, the customers degree of loyalty mind-set (or attitude) will be an accumulation of all past experiences and exposures that can be indicated as a score from 1 (very dissatisfied) to 5 (very satisfied). It can also be captured with other response formats with an odd number of choices (e.g., 1 to 3 or 1 to 7) to allow for a neutral response. Obviously, the goal of every company is to develop customers with a preference attitude (i.e., we all want the coveted preferred vendor status such that the customer, when given a choice, will choose our company). However, it takes continuous customer experience management, which means customer satisfaction measurement, to get there and even more effort to stay there. The claim that it costs five to eight times as much to get new customers than to hold on to old ones is a key to understanding the drive toward benchmarking and tracking customer satisfaction.
Very High
3.93
Very High
3.94
High
Suggested Management Strategies to Sustain Strengths of the Operational Risk Management Activities of E-banking Services of Universal Banks in Legazpi City Electronic banking is always open to dynamic changes for information technology (IT) constantly evolves in so short span of time. Many IT products and services are introduced to the market every now and then. Most of them promise facility of use, convenience, efficiency and modernization. On the part of the users, these features are treated much to their advantage. However, on the part of the implementers it means new dealings with knowledge, relationship, financial, technical, reputation and legal risks. Hence, management strategies should be formulated and implemented by the bank management to sustain those activities, mechanisms and procedures considered effective. Such process will continuously provide mutual benefits for the bank and client. It will minimize also the impact of financial risk. For, the bank will only deal with the new changes as they come along. The preceding discussions pertain to the various management strategies suggested by the respondents. The indicators in terms of monitoring, evaluation, mitigation and control were partly derived from the summary of various local and foreign literature discussed in this study; and partly from the suggestions of respondents themselves during the validation of the research instruments. Monitoring. The management strategies suggested by all types of respondents on the aspect of monitoring are reflected in Table 17. The need for expansion of audit coverage commensurate to increased complexity and risks inherent in e-banking was prioritized by the respondents. The said finding shows that the corporate and individual clients were aware of and concerned on the needs and importance of an audit activity to closely monitor the proceedings of all transactions in an organization. It is also noted that they wanted to expand the coverage of the activity in those complex areas, which they deemed originators and intrinsic of risks for the e-banking services. The important component of monitoring is the appropriate independent audit function. Financial institutions providing e-banking services should enlarge their audit coverage commensurate to the increased complexity and risks inherent in e-banking activities. Financial institutions offering e- banking services should ensure the audit program expands to include: (1) Scope and coverage, including the entire e-banking process as applicable (i.e., network
configuration and security, interfaces to legacy systems, regulatory compliance, internal controls, and support activities performed by third-party providers); (2) Personnel with sufficient technical expertise to evaluate security threats and controls in an open network (i.e., the Internet); and (3) Independent individuals or companies conducting the audits without conflicting e-banking or network security roles (http://www.effiec.go/booklet/ebanking). The cited areas for audit expansion will enable banks to undertake control management relative to malicious codes (virus), Phishing activities and spamming occurrences. These areas detrimentally caused disturbances and efficiency on the operational activities of both the banks and the clients. Table 17 Monitoring
Indicator 1. Determination of customers compliance with e-sign policy. 3. Expansion of audit coverage commensurate with increased complexity and risks inherent in e-banking.
Frequency
Bank Officer (f=33)
2. Determination of the number and cost per item of bill payment generation. 4. Validation and determination of person-to-person (e-money) transactions. 5. Determination of the number of customers actively using ebanking services.
29 28 32 31 30
Rank
Frequency
Corporate Account (f=55) 48 44 53 50 49

Rank
Frequency
Personal Account (f=55)
Summary (f=143)
Frequency
5 6
3 4
46 41 49 51 50
Rank
4 5
123 113 134 132 129
Rank
4 5
Careful validation and determination of person-to-person (e-money) transactions was the second management strategy suggested by the respondents. E-banking services lessened the customers interaction with banking personnel. As such the banks authentication for various transactions especially cash payments becomes limited. Usually, they only resorted to voice validation.
Thorough determination of the number and cost per item of bill payment generation was the management strategy suggested last. The suggested intervention deals mostly with management needs to effect cost benefit analysis on its ebanking provision of services. However, such strategy would also have an impact on the future dealings of the clients with the bank. Perhaps, it is the reason why the recommended strategy became not so famous with the client-respondents. However, looking at the feasibility of the institution, it is also necessary that such strategy should be undertaken discretely in order that banks could provide total customer quality service. As to relationship of the cost-benefit analysis to level of effectiveness and satisfaction as well as risk management, the provision of service as well as the risk management techniques implementation will be more profound if there is a matching of cost and revenue. Evaluation. The summary of management strategies suggested along the above aspect is shown in Table 18. The strategy to assess and up-grade the facilities effective performance was given priority from, among the suggested management strategies. The finding shows that more than the majority of clients were interested towards the up-grading of the facilities of the banks particularly those that are used in e-banking transactions. Physical resources are always included in risk assessment. This kind of assessment involves identifying and analyzing program areas and key technical process risks to increase likelihood of meeting cost, performance and schedule objectives. When a service system, for example the e-banking, does not get the required people, money, facilities, or equipment, the shortfalls degrade both schedule and morale. However, if the facilities are present but they do not work well accordingly, the need for their up-grading is a must. Identifying this need is an alternative to purchasing new ones, which is costly on the part of the bank management. Any evaluation activity requires concrete data and information for it to provide credible and effective result. There are several sources of information. One of the reliable sources for assessment is the end user of product or recipient of services. Perhaps this is the reason why that next to assessing and up-grading e-banking facility, most respondents suggested that management should conduct constant assessment of the validity of comments and suggestions provided by clients. The cited suggestion can be considered as the customers demonstration of concern and collaboration for better management of the e-banking services of their host banks.
Table 18 Evaluation
Bank Officer (f=33) Corporate Account (f=55) 46 47 51 52 53 50
Rank
Indicator 1. Conduct of benchmarking of actual e-banking acceptance and performance to the institutions goals and expectations.
Frequency
2. Re-assess thoroughly defined measurable goals for e-banking and e-commerce products and services. 3. Consideration of appropriate and effective e-banking policies/procedures. 4. Constant assessment of the validity of comments and suggestions provided by clients. 5. Assessment and up-grading of facilities for effective performance.
27 31 30 32 32 32
Rank
Frequency
Frequency
Summary (f=143)
Frequency Rank
45 48 47 51 52 46
Rank
118 126 128 135 137 128
3.5
1.5
Customers suggestions and comments are important towards further enhancement of services or product development. However, they need to be validated against the overall objectives of the organization. This concern should be taken seriously considering the financial risk the management would face if it would literally and methodically accede to the customers suggestions and comments. But, if customers comments and suggestions were posing advantages that shall result to better customer-management relationship, then the top management should actively implement a thorough analysis of the comments contents. The conduct of benchmarking of actual e-banking acceptance and performance to the institutions goals and expectations was the least suggested by the respondents. The same could be considered as an attempt posed by the bank officer-respondents. However, since most of the client-respondents
6. Instituting a procedure wherein all relevant customers data are disclosed with veracity during enrollment.
1.5
1.5
3.5
were managers themselves of their respective enterprises, they also saw the relevance of the cited intervention strategy as vital to the provision of total quality service. Relative thereto, FFIEC cited that once an institution implements its e-banking strategy, the board and management should periodically do comparison of actual e-banking acceptance and performance to banks goals and expectations (http://www.effiec.go/booklet/ebanking). Some items that might be useful to monitor the success and cost effectiveness of e-banking strategy are revenue-generated, website availability percentages, customer service volume, and number of customers actively using e-banking services, percentage of accounts signed-up for e-banking services, and the number and cost per item of bill payment generated (http://www. effiec.go/booklet/ebanking). Without clear and defined and measurable goals on the given aspects, the management will be unable to determine if e-banking services are meeting the customers needs as well as the institutions growth and profitability expectations. It should also consider whether appropriate policies and procedures are in effect and whether risks are properly controlled. Mitigation. The s3ummary of various management strategies suggested along mitigation is shown in Table 19. Most of the respondents firstly contended that the e-banking system should provide accounting reports for the bookkeeper to reconcile individual transaction to daily transactions totals; and set on-line form that include error checks to identify common mistakes in various fields of e-banking transactions. The said finding declares that most clients were aware of the nature of risks paperless transactions bring to record safekeeping management. To them, the strategies cited should be given priority. The same strategies have bearing on information security. They are essential to a financial institutions ability to deliver e-banking services and to ensure that accountability exists for changes in the information and the processing and communications systems. While e-banking provides fast and efficient service to users and providers alike, the keeping of a hard copy, however, is a way of assuring clients of baseline data when machines malfunction. One important management strategy that the clients suggested was establishing a bank webpage separate from other pages to host sensitive transactions like confirmation of material transactions done by clients through Internet banking. Hence, the indicator, Institute alternative channel for confirmation of sensitive transactions came in third from more than the majority of respondents, specially the clients. The justification of such management intervention strategy could be better explained in the succeeding discussions.
Table 19 Mitigation
Bank Officer (f=33) Corporate Account (f=55)
Rank
Indicator 1 The e-banking system should provide accounting reports for the bookkeeper to reconcile individual transaction to daily transaction totals. 2. Establishment of fraud detection controls to prompt additional review and reporting of doubtful customers transactions.
Frequency
Rank
31 32 30 32 30
Frequency
51 50 48 54 52
Frequency
Summary (f=143)
Frequency Rank
Rank
54 47 49 50 48
136 129 127 136 130
1.5
1.5
3. Constant review of the efficacy of agreements in the contract it formed with customers. 4. Set on-line forms that include error checks to identify common mistakes in various field of e-banking transactions. 5. Institute alternative channel for confirmation of sensitive transactions.
4.5
1.5
1.5
4.5
A large number of financial institutions maintain sites on the World Wide Web. There are two types of websites: (1) Transactional websites provide customers with the ability to conduct transactions through the financial institutions website by initiating banking transactions or buying products and services. Banking transactions can range from something as basic as a retail account balance inquiry to a large business-to-business funds transfer; and (2) Informational websites provide customers access to general information about the financial institution and its products or services (http://www.effiec. go/booklet/ebanking). The suggested strategy may reduce potentials to: (1) provide liability and consumer violations for inaccurate or incomplete information about products, services, and pricing presented on the website; (2) access to confidential financial institution or customer information if the website is not properly isolated from the financial institutions internal network; (3) pose liability
for spreading viruses and other malicious code to computers communicating with the institutions website; and (4) create negative public perception if the institutions on-line services are disrupted, or if its website is defaced or otherwise presents inappropriate or offensive material (http://www.effiec. go/booklet/ebanking).
Control. Table 20 shows the summary of management strategies suggested by the respondents along control. Ensuring compliance of privacy policies and standards according to applicable laws and banking regulations was given top priority. The finding can be deduced that almost all clients and bank officers were aware of the importance of putting into right perspective both traditional and electronic banking practices and activities. And, the best possible way of implementing the suggestion is for the banks to be sincere in complying with the rules and regulations imposed by the Monetary Board of BSP, e-banking Act and the like to protect the privacy of information and personality of the clients. Practically, a client will not be encouraged to put his money in the bank if the same has no implementing rules on the matter. The financial institutions (FIs) are the prime movers of funds through the savings investments of private individuals and groups. A bank, being considered as FI, is one of the active actors in the investment process. The same contributes to the economic development of a community through its lending and investing mechanisms. The government is also benefited by the said mechanism and proven to be advantageous on its part. The aggregate funds from the saving investments of small but numerous working individuals, micro-entrepreneurs, and small and medium enterprises are cheap funds as compared with the credit facilities coming from big and established investment houses. In this regard, small time investors could not be lured to place their hard-earned savings if privacy policy, as mandated by the government, has no assurance. Privacy protects the life of a bank client from physical risks due to robbery, kidnapping and others. In implementing Republic Act 1405 (Bank Secrecy of Deposits) bank also protects clients property from any unjust attachment proceedings. The conduct of test activities to validate if the formulated e-banking policies could effectively control the risks associated to product/service offerings was secondly prioritized by the respondents. The finding declares that todays bank clients were aware of the nature of risks the paperless transactions could bring to their record and safekeeping management. The Y2K phenomenon, which created panic to almost all companies in the world, is a best example.
Table 20 Control
Bank Officer (f=33) Corporate Account (f=55)
Rank
Indicator 1. Conduct test activities to validate if the formulated ebanking policies could effectively control the risks associated with product/service offerings. 2. Immediate validation of clients complaint of utmost concern. 3. Constant analysis of the impact of service outages to prevent risks occurrences.
Frequency
Rank
30 28 28 25 27 30 29 30
Frequency
2.5
49 50 51 49 53 48 47 50
Frequency
Summary (f=143)
Frequency Rank
Rank
50 47 45 45 43 49 50 51
6.5
129 125 124 119 123 127 126 131
6.5
3.5
2.5
5.5
4. Establishment of an effective management information system (MIS).
6.5
5.5
5. Establish functional and efficient feedback mechanism to resolve complaints and problems of clients. 6. Proper disclosure of banks privacy and security policies in its respective websites. 7. Inclusion of clear information of banks legal name and physical location aside from its trade name in the website 8. Ensure compliance of privacy policies/standards according to applicable laws and banking regulations.
2.5
2.5
6.5
2.5
3.5
The proper disclosure of banks privacy and security policies in its respective websites was the least suggested strategy to maintain the strengths of the operational risk management of universal banks for their e-banking services. Although it is the least suggested, it could be reckoned as one of the important interventions a bank offering electronic services should consider. Virtually, every website contains weblinks. A weblink is a word, phrase, or image on a webpage that contains coding that will transport the viewer to a
different part of the website or a completely different website by just clicking the mouse. While weblinks are convenient and an accepted tool in website design, their use can present certain risks. Generally, the primary risk posed by weblinking is that viewers can become confused about whose website they are viewing and who is responsible for the information, products, and services available through that website Operational Risk Management Plan Developed to Implement the Recommended Management Strategies A strategic business plan is the link between strategic thinking and analysis strategy formulation the action or implementation that will be necessary to carry out the strategy. It is the vital, formal documenting of the analysis and the proposed plan of implementation (Beamish, 2008). While a formal, written strategic business plan acts as an important tool, which all organizations should have, an operational risk management plan is equally important alongside with the strategic business plan. An Operational Risk Management Plan (simply referred to as risk management plan) is a document prepared by a project manager or operations manager to foresee risks, to estimate the effectiveness, and to create response plans to mitigate them. It also consists of the risk assessment matrix. The plan contains an analysis of likely risks with both high and low impact. It also contains mitigation strategies to help avoid the services being derailed should common problems arise (http//Wik2pedia). Ideally, the primary goal of Operational Risk Management Plan is to proactively identify and address risks early in the pre-implementation and throughout the implementation of product/service offerings like e-banking in order to avoid surprises ((http//Wikepedia).). Table 21 shows the template of Operational Risk Management Plan developed for this study. Its main purpose is to proactively sustain the various operational risk management activities and practices found to be very effective. The maintenance of effective activities during the course of service provisions of the universal banks in the study with various e-banking facilities may continuously thwart both individual risks and risks that are common to the class of application of the e-banking services on long terms. In view of the above, the Operational Risk Management Plan of the study concentrates only on the top three suggested strategies by all types of respondents. They were deemed likely to control risks with both high and low impact to both the universal banks and clients.
The main components of the studys operational risk management plan are: (1) Objective contains the end result of the action items described; (2) Action Item describes the specific activity necessary to achieve the objective; (3) Person/Office Responsible shows the individual staff, department or committee who will undertake the action item; (4) Outcome illustrates the specific result after undertaking every action; and (5) Assessment - contains reference documents to validate outcomes. The plan is considered as an added tool towards risk management planning and implementation of risk mitigation and control by the respective branchs compliance officer of the universal banks in the study. It will also serves as source documents by their Control Risk Management Committee to validate the performance of the branch as prescribed by the Monetary Board of the Banko Sentral ng Pilipinas for banks offering e-banking products and services. Table 21 Operational Risk Management Plan
Person/Office Responsible
Objective
Action Items
Outcome
Assessment
Monitoring Suggested Strategy No. 1: Expansion of audit coverage commensurate with increased complexity and risks inherent in e-banking. To establish needs of extension audit areas and prioritization process in handling all types of risks. 1. Review banks product/service offerings to markets through strategic planning. 2. Examine planned versus actual targets. Account Officer/ Account Management Group Br. Manager/ Control Officer/ Operations Management Group Br. Manager/ Control Officer/ Operations Management Group/ Comptroller 1. Types of risk are predetermined. 2. Audit coverage formulated and expanded.
1. Risk mitigation history and actual mitigation of risks are planned and documented.
3. Establish data on complexities and risks inherent to increased transactions.
3. Possible risk occurrences and impacts are minimized.
2. For high impact, unanticipated risks, a 24-hour decision turnaround is determined. 3. Summary of risks and transactions log sheets.

Suggested Strategy No. 2: Validation and determination of person-to-person (e-money) transactions. To safeguard transactions under e-money services through validation. 1. Review account holders Information Sheets. Account Manager/Account Management Group 1. All account holders personality and business are established. 1. Risk mitigation history and planned mitigation activities for e-money services are established/ documented. Objective Action Items Person/Office Responsible Outcome Assessment
2. Conduct person-to-person interview and product/service orientation. 3. Analyze account holders e-money transactions.
Account Staff/ Manager/Account Management Group Account Staff/ Control Officer
2. All account holders are oriented on the policies and regulations of the banks on e-money.
Suggested Strategy No. 3: Determination of the number of customers actively using e-banking services. To establish and provide quality assurance services. 1. Conduct assessment of actual number of customers actively using ebanking and traditional banking services Account Executive/Accountant/Br. Manager/Account Management Group 1. Actual number of clients using e-banking and traditional banking services is assessed. 2. The banks facilities and equipment are continuously up-graded. 1. There is an increase in customers availment of e-banking services.
3. Authenticity of all account holders e-money transactions is analyzed.
3. Analysis sheet of account holders transactions.
2. Conduct assessment of the banks facilities and equipment utilized for e-banking and traditional products/services 3. Examine personnel services performance 4. Examine customers complaints/ Suggestions.
Account Management Group/EDP/Br. Manager Personnel Manager/Br. Manager
Account/Br. Manager/Control Officer.
3. Staff development program in place. 4. Customers cooperation is developed.
2. Customers continuously use the banks facilities and e-banking equipment 4. Customers complaints are acted upon.
3. Personnel treat customers with confidence

Objective Action Items Person/Office Responsible Outcome 1. Facilities condition and usability are verified. 2. Facilities current performance is doubled checked. Assessment
Evaluation Suggested Strategy No. 1: Assessment and up-grading of facilities for effective performance. To promote facilities effective performance. 1. Check facilities condition and usability. 2. Conduct assessment of facilities current performance. 3. Analyze/ Evaluate facilities needs for improvement. 4. Institute facilities upgrading. Account Personnel, Control Officer/Accountant, Branch Head Account Personnel, Control Officer/Accountant, Branch Head. Account Personnel, Control Officer/Accountant, Branch Head Account Personnel, Control Officer/Accountant, Branch Head. Account Personnel, Control Officer/Accountant, Branch Head Account Personnel, Control Officer/Accountant, Branch Head Account Personnel, Control Officer/Accountant, Branch Head Account Personnel, Control Officer/Accountant, Branch Head 1. Facilities Performance checklists. 2. Assessment Report of facilities performance. 3. List of duly accomplished facilities work. 4. Lesser customer complaints on facilities performance. 1. Clients better cooperation and feedback.
3.Facilities needs for improvement are evaluated
Suggested Strategy No. 2: Constant assessment of the validity of comments and suggestions provided by clients. To encourage clients cooperation in risk management and assessment process. 1. Install mechanism that could attract clients provide comments. 2. Validate customers comments and suggestions. 3. Assess the validity of the clients comments and suggestions. 1. Clients comments and suggestions are compiled. 2. Clients comments and suggestions are checked versus SOPs.
4. e-banking facilities are upgraded.
4. Formulate appropriate risk management process based on clients validated complaints.
3. Clients comments and suggestions are 3. Clients satisassessed to their faction. importance and authenticity. 4. Appropriate risk management process is formulated from clients valid complaints.
2. Lesser logging of the same nature of clients complaints.
4. Lesser occurrences of risks.

Suggested Strategy No. 3.5: Consideration of appropriate and effective e-banking policies/ procedures. To establish effective ebanking risk assessment policies and procedures. 1. Review the appropriateness and effectiveness of each e-banking policy and procedure. 2. Provide consideration for risk assessment option for each e-banking policy and procedure. Account Personnel, Control Officer/Accountant, Branch Head Account Personnel, Control Officer/Accountant, Branch Head Account Personnel, Control Officer/Accountant, Branch Head Account Personnel, Control Officer/Accountant, Branch Head Account Personnel, Control Officer/Accountant, Branch Head Account Personnel, Control Officer/Accountant, Branch Head Account Personnel, Control Officer/Accountant, Branch Head 1. Appropriate e-banking policies and procedures are established. 2. Various risk assessment options are formulated. Objective Action Items Person/Office Responsible Outcome Assessment
1. Implementation of effective e-banking policies and procedures. 2. Tested risk assessment procedures.
3. Test checks each risk assessment option. 4. Redefine each risk assessment option according to test results, if necessary.
3. Appropriate risk assessment option is validated. 3. Risk assessment option is validated.
3. Functioning risk assessment procedures. 4. Lower rate of risk occurrences.
Suggested Strategy No. 3.5: Instituting a procedure wherein all relevant customers data are disclosed with veracity during enrollment. To establish effective system of customers information. 1. Examine current forms, format and procedures in enrolling clients. 2. Revise forms and format to become simple but useful in gathering verifiable customers data. 3. Take corrective procedure wherein relevant data are provided by customers. 1. Current forms, format and procedures in enrolling clients are evaluated.
2. Forms and format in gathering verifiable customers data are revised.
1. Clients enrolment forms 100% accomplished. 2. New forms and format implemented and used.
3. Corrective procedures wherein relevant data are provided by customers are duly acted upon.
3. Intensive customers data generated.

Objective Action Items Person/Office Responsible Outcome Assessment
4. Implement the duly revised clients enrollment system.
Mitigation Suggested Strategy No. 1: The e-banking system should provide accounting reports for the bookkeeper to reconcile individual transaction to daily transaction totals. To establish effective and functioning reconcilement system. 1. Review existing accounts reconciliation procedures. Account Personnel, Control Officer/Accountant, Branch Head Account Personnel, Control Officer/Accountant, Branch Head Account Personnel, Control Officer/Accountant, Branch Head Account Personnel, Control Officer/Accountant, Branch Head Account Personnel, Control Officer/Accountant, Branch Head 1. Existing accounts reconciliation procedures reviewed.
5. Redefine each risk assessment option according to test results, if necessary.
Account Personnel, Control Officer/Accountant, Branch Head Account Personnel, Control Officer/Accountant, Branch Head
4. Revised system and procedures for clients enrollment are used. 3. Risk assessment option is validated.
4. New and functioning system for clients information installed. 4. Lower rate of risk occurrences.
2. Analyze data generated in preparing accounting report and reconciliation statement.
3. Take corrective measure to generate appropriate accounting reports and reconciliation statements. 4. Test and implement the revised accounting report and reconciliation statement generation.
2. Data for accounting report and reconciliation statement analyzed.
1. Up-dated accounting and reconciliation statements summary. 2. Data needed for reconciliation are easily generated. 1. Easy access to accounting reports and reconciliation statements.
3. Corrective measure to generate appropriate accounting reports and reconciliation statements undertaken. 4. Revised accounting report and reconciliation statement generation tested and implemented. 1. Existing analytical system examined.
Suggested Strategy No. 2: Set on-line forms that include error checks to identify common mistakes in various field of e-banking transactions. 4. To minimize common mistakes in various domain of e-banking. 1. Examine existing analytical system for common mistakes on e-banking services.
2. Easy generation of accounting reports and reconciliation statements.
1. System analyzer in place.

Objective 2. Review the common errors generated from e-banking system. Action Items Person/Office Responsible 2. Common errors from ebanking system reviewed and listed. 3. E-Banking system review guides upgraded. 4. E-banking guides duly tested/ implemented. Outcome Assessment 2. Listing of ebanking service errors at hand. 3. System analyzer in place.
3. Up-grade existing review system according to needs and priority. 4. Test and institute the upgraded system.
Control Officer/ Accountant, Branch Head Control Officer/ Accountant, Branch Head
Suggested Strategy No. 3: Institute alternative channel for confirmation of sensitive transactions. To establish effective confirmation system of clients sensitive transactions. 1. Analyze existing policies and procedures in confirming clients sensitive transactions. 2. Evaluate clients response to the existing channel of confirmation of sensitive transactions. Account Personnel, Control officer/Accountant, Branch Head 1. Existing policies and procedures to confirm clients sensitive transactions are analyzed. 2. Clients response in existing confirmation channel evaluated 3. Channel for confirming clients sensitive transactions is up-graded.
Account Personnel, Control officer/Accountant, Branch Head
4. Functioning system of evaluation. 1. Presence of policies and procedures for analysis. 2. Positive clients responses. 3. Functional channel for confirming clients sensitive transactions. 4. Functional channel for confirming clients sensitive transactions.
3. Up-grade existing channel of confirming clients sensitive transactions.
Account Personnel, Control Officer/ Accountant, Branch Head Account Personnel, Control Officer/ Accountant, Branch Head Account Personnel, Control Officer/ Accountant, Branch Head
4. Test and implement duly up-graded channel.
4. Duly upgraded channel is tested and used.

Objective Action Items Person/Office Responsible Outcome Assessment
Control Suggested Strategy No. 1: Ensure compliance of privacy policies/standards according to applicable laws and banking regulations. To establish appropriate avenue of the banks privacy and security policies websites. 1. Review the existing banks disclosure of privacy and security policies for internet banking versus BSPs. 2. Analyze uses of existing bank disclosure practices of privacy and security policies for internet banking. 3. Get feedback from clientusers on the usefulness of the channel. 4. Relocate existing disclosure domain, if necessary. Control Officer/ Accountant, Branch Head, EDP Control Officer/ Accountant, Branch Head, EDP Control Officer/ Accountant, Branch Head, EDP Control Officer/ Accountant, Branch Head, EDP 1. The banks privacy, security policies versus BSPs are reviewed. 2. Existing bank disclosure practices of privacy and security policies for internet banking are analyzed. 3. Feedback from clientusers on the usefulness of the channel acquired.
Copy of the banks policies and BSP circulars.
2. Copy of Internet policies for disclosure statements of privacy and security. 3. Records of feedback statements from clients.
Suggested Strategy No. 1: Conduct test activities to validate the formulated e-banking policies could effectivelycontrol the risks associated with product/service offerings. To implement risk control effective policies and procedures. 1. Evaluate test activity results if the existing e-banking policies effectively control risks associated with product/service offerings. 2. Review results versus the banks risk management resources and capabilities. Account Personnel, Control Officer/Accountant, Branch Head Account Personnel, Control Officer/Accountant, Branch Head 1. Activity results of existing risk management control for product/ service offerings duly tested are evaluated.
4. Existing disclosure domain, if necessary is relocated.
4. New avenue of privacy and security policies of bank are regularly used by clients.
2. Results versus the banks risk management resources and capabilities are reviewed.
1. Documented results of testing activity. 2. Inventory of the banks risk management resources and capabilities

Objective Action Items Person/Office Responsible 3. Clients actual and practical needs for ebanking product/ service are reviewed. Outcome Assessment 3. Documented actual clients needs for product or service. 4. Clients satisfaction level.
3. Review clients real and practical needs for e-banking product/service. 4. Work out and implement product/ service offerings based on clients needs assessment results. 1.Examine current information mode of banks profile, physical location aside from trade name in its website 2. Reformat information guides according to the banks legal name, physical location, and trade name in the website.
Account Personnel, Control Officer/Accountant, Branch Head Account Personnel, Control Officer/Accountant, Branch Head
Suggested Strategy No. 3: Proper disclosure of banks privacy and security policies in its respective websites. To establish domain website for banks legal name, physical location and trade name. Control Officer/ Accountant, Branch Head, EDP Control Officer/ Accountant, Branch Head, EDP Control Officer/ Accountant, Branch Head, EDP Control Officer/ Accountant, Branch Head, EDP 1. Current information mode of banks profile, physical location aside from its trade name in the banks website is examined. 2. Reformat information guides according to the banks legal name, physical location, and trade name in the website.
4. Product/ service offerings based on clients needs assessment results implemented.
1. Banks legal and trade profile.
3. Provide users and clients with information guides about the new set up. 4. Test and implement new set up if found practical and applicable.
3. Provide users and clients with information guides about the new set up. 4. New set up if found practical and applicable, is tested.
2. Copy of new Information Guide. 3. Clientsfeedback and comments.
Conclusions and Recommendations Based on the above findings, the following conclusions were deduced: 1. The operational risk management activities of the universal banks in Legazpi City for their e-banking services in terms of strategic planning, management of information security program, authentication of e-banking customers, and administrative controls minimized the likelihood of risk occurrences that resulted to minor degree of impact on time, costs or quality of service offerings to their clients. 2. The operational risk management activities of universal banks in Legazpi City for their e-banking services along monitoring, evaluation, and mitigation and control affected greater than usual results towards the achievement of the banks and clients objectives. 3. The clients were delighted and expectations generally exceeded on the performances of tangibility, reliability, responsiveness, assurance, and empathy dimensions of the banks e-banking services. 4. Various management strategies were suggested to sustain the strengths of operational risk management activities of universal banks in Legazpi City along monitoring, evaluation, mitigation and controlling. 4.1. An operational risk management plan can be recommended to become a tool towards implementing operations/risk management strategies by universal banks in Legazpi City to sustain the strengths of operational risk management practices and activities. In view of the above-cited conclusions, the following recommendations are offered by the study: 1. The managements of the respective banks under study should always emphasize a balance treatment of operations management and risk management functional activities for their various product and service offerings to their clients. 2. The senior managements of the respective banks under study should encourage branch managers to implement the herein recommended action plan of management intervention strategies towards sustaining the strengths of their operations/risk management practices and activities for their e-banking producers and services. 3. The implications of the findings of the study should be considered by the management of universal banks operating in the city of Legazpi in enriching their staff and clients of the advantages and consequences of operations
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RISK-BASED INFORMATION TECHNOLOGY STRATEGIC PLAN FOR DARAGA WATER DISTRICT

Elma T. Barbudo
Introduction Information Technology (IT) plays a major role in reengineering most business processes. The speed, information processing capabilities, and connectivity of computers and Internet can substantially increase the efficiency of business processes, as well as communications and collaboration among the people responsible for their operation and management (OBrien & Marakas, 2006). IT can bring about greater efficiency in organizational operations, better working environments, higher quality of service, minimized costs, and effective decision-making. Integration of IT to operate and manage water utilities is a state-of-theart tool for cost and resource-efficient operation and at the same time gives management the necessary overview of the business. Effective utilization of IT can ensure optimal profit, reduce expense and manage the utility with high quality data. A Water District is a local corporate entity established on local-option basis to operate a water supply system in one or more provincial cities and municipalities. Water districts were first considered quasi-private entities until the Philippine Supreme Court handed an en banc decision on 13 September 1991 declaring them as Government-Owned or Controlled Corporations (GOCCs) with original charter (http://www.lwua.gov.ph/primer/primer_body.htm). The Daraga Water District (DAWD), which is the setting of the study, was established on October 1, 1981. The Vision statement of Daraga Water District is We envision to provide 100% water supply requirements to all the people of Daraga. The Mission statement is As an independent and self-sustaining public entity, it aims to promote, manage, and regulate a water supply system operating within its territorial boundaries, according to its capability and competence,
and in harmony with nature, by providing the members of the community with the proper distribution and allocation of potable water supply. The goals are to 1) provide its concessionaires with dependable and affordable potable water supply daily 2) promote full customers satisfaction 3) Uphold and preserve a high standard of public service and 4) maintain and sustain financial viability (Daraga Water District Service Guide, 2006). As a government entity, concessionaires welfare is the top priority especially in promoting full customers satisfaction and high standard of public service. This study made use of Information Technology that was aligned with the vision, mission and goals of the District. Daraga, in the province of Albay has 54 barangays. DAWD presently serves 26 barangays coming from the municipal poblacion to the nearby barangays accessible to prevalent transmission mains. As of August 2008 the total number of connections is 7722. The water supply system is composed of six pumping stations and one spring source operating by gravity flow. These major components of water supply system complement each other to supply the entire service area. Water is distributed via a network, which comprises approximately 47 kilometers of pipe work, ranging from 25mm to 200mm in diameter. The network also includes a 1,450 cubic-meter and 150 cubic-meter capacity reinforced concrete tank at Busay and Penafrancia, respectively. The water from each source receives hypo chlorination. A Filtration system is also operating in Salvacion Pumping Station for the treatment of iron content. The office comprises four divisions, namely Administrative & General Services, Finance, Commercial, and Engineering and Operations. The Administrative and General Services Division, focuses on human resources management, procurement and general services. Finance Division is centralized on collection, disbursement, accounting and budgeting. Commercial Division deals with the customer accounts and everything about customer services. The Engineering and Operations Division handles the planning and design, production, construction and maintenance. While the Board of Directors, consisting of five members serves as the policy-making body. A General Manager has the overall supervision and control over the operations of the Water District. The District has been utilizing Information Technology since 1993 in automating the billing and collection system. From DOS-based to WINDOWSbased system, it is a non-stop process, all for the purpose of delivering readily available information to the management and concessionaires that will be translated into quality service. Presently, the district has an automated
system for billing, real-time tellering, customer service and on-site read-andbill system using handheld computer and thermal printer. This automated system is in client/server architecture composed of eight workstations and a data server. Using MySQL5 as back-end database and Delphi as front-end, these are running on WinXP Professional operating system. The data server is not a high-end server it is running on Pentium 4 processor with 1GB DDRAM. The workstations are in mixture of Pentium 4 and Pentium 3 processor with 256MB and 512MB memory. The handheld computer is PSION Workabout and the thermal printer is EXTECH Printer. The District has separate Local Area Network (LAN) for Internet, stand-alone computers and an out-dated website. There are many ways that organizations may view and use Information Technology. Companies may choose to use information systems strategically, or they may be content to use IT to support efficient everyday operations. If a company emphasizes strategic business uses of Information Technology, its management would view IT as a major competitive differentiator. They would then devise business strategies that would use IT to develop products, services, and capabilities that would give the company major advantages in the markets in which it competes. Daraga Water District is on its way to using IT for its business strategy. The Problem This study determined the use of Information Technology in enhancing the services of Daraga Water District. Specifically, it answered the following sub-problems: 1. What is the status of IT implementation of Daraga Water District in relation to its service requirements? 2. What IT imperatives are most appropriate for Daraga Water District to enhance its services? 3. What are the risks and prospects in the implementation of these IT imperatives in Daraga Water District? 4. What Risk-based IT strategic plan should be established and implemented in Daraga Water District? Conceptual Framework Daraga Water District is a unique government organization whose operation is independent of government financial subsidy. Sufficient to say that DAWD is a self-generating government-owned and controlled corporation
Figure 1 . Conceptual Framework
(GOCC). It is for this reason that DAWD has to explore every option to gain strategic advantage and attain not only stability but also operational growth. DAWD has existing basic Information Technology (IT) systems to start with. With the growing demand for service, the present IT can no longer sustain the growing number of tasks and concessionaires if only to meet the corporate goals of the District. Evaluation of the status of IT implementation in the District in relation to the service requirements of DAWD will determine how far the District is utilizing the benefits of IT in this modern business environment. The District can maximize the use of Information Technology as a tool for improving internal business practices and providing efficient public services. Appropriate IT imperatives that will provide Management and Staff real solution for enterprise-wide improvement are needed. Assessment of risks and prospects in implementing IT imperatives can enlighten the Management of DAWD in balancing the benefits and risk of adapting IT systems. Having been founded on the determination of the status, IT imperatives, and the risks and prospects that are needed in adoption of Information Technology systems, this study will prove that IT can indeed address the clamor for cost efficiency and quality service and thus result in strategic advantage of the District. From here, the Management may start with an IT strategy to be incorporated in its short-term corporate plan. Methodology This study used the descriptive-evaluative method in determining the status of IT implementation in relation to Daraga Water District service requirements. It described IT imperatives that is appropriately needed to enhance its services and its risks and prospects. The data gathered from the target population were described, analyzed and interpreted to be able to recommend a risk-based IT strategic plan relevant and appropriate to its needs. The researcher used the survey questionnaire technique and an informal interview in gathering information. Questions were formulated based on the gathered literature and studies to elicit response on the status and their perception of the IT imperatives that are appropriately needed as well as risks and prospects in implementing these IT imperatives. Syntheses of the responses were made through the processes that will involve gathering, synthesizing, tabulating, and interpreting the meaning and significance of the responses. Data that were collected are presented in tables. The research aimed to establish a risk-based IT strategic plan DAWD may
opt to implement in the future based on problems identified by the respondents along significant and necessary components of an Information Technology System. These methods were deemed appropriate for this inquiry and analysis of the problems, since they helped in the formulation of recommendations. This study has two sources of data, the primary and the secondary. The primary data came from the responses of the respondents to the questionnaire they were requested to accomplish. The information obtained from the interviews were also included as part of the primary data source. The primary data were gathered from two groups of respondents. These were the management and staff with plantilla positions. The secondary data came from the books, publications, journals, unpublished theses and brochures, electronic sources, pamphlets, and articles in journals. Records of DAWD also formed part of the secondary data. Books and other literature related to the study were the main reference in producing a more comprehensive database of the study. The population of this study were the Management and Staff of Daraga Water District who directly knew the need and benefits of using IT to enhance DAWD services. A total of 35 respondents were used in this study. The Management composed of one Acting General Manager and four Division Managers. The 30 plantilla employees are all included in the population of the respondents. A questionnaire was instrument used in this research to gather the necessary information. It is composed of two (2) parts. Part I is a list of IT imperatives that is appropriate to the operation of a water utility that will determine the status and extent of need in relation to its service requirements that will enhance services of DAWD. IT components are composed of Hardware, Software, Networking and Human Resource. Software Components composed of two categories, which are System/Utility/Application Software and Business Application Software for four (4) divisions namely, Administrative and General Services Division, Commercial Division, Finance Division and Engineering and Operations Division. Part II is a list of risks and prospects in implementing IT imperatives for DAWD. The questionnaire was personally distributed to the respondents by the researcher after obtaining the permission of the General Manager. A letter of request was served as the cover letter to the questionnaire that will give the purpose of the study. An instruction on how to answer was provided in the questionnaire.
The first part asked the respondents to identify the presence of IT components mainly in the Hardware, Software, Networking and Human Resource that are currently possessed by DAWD. The respondents answered Present or Missing to each of the listed components. If the respondent answered Present which means the indicator presently exists they have to assess the status by checking functioning well or not functioning or for upgrade. The statistical tool used in analyzing the problem was frequency count and percentage. The same questions were asked in the first part of the questionnaire to determine the extent of need as perceived by the respondents, for each IT component listed. A Likert Scale of 1 to 5 was used to determine their responses together with mean and ranking. The second part listed risks and prospects in implementing the IT imperatives for DAWD. There are twelve (12) listed risks and eight (8) prospects identified and the respondents were asked to encircle their perception on a Likert scale of 1 to 5 for each indicator. Mean values were obtained to two decimal places from the statistical processing of the raw data and mean value was ranked. Analysis of the responses using this Likert scaling method on a five-point scale was interpreted as follows: Scale 5 4 3 2 1 Range of Mean Values 4.50 - 5.00 3.50 - 4.49 2.50 - 3.49 1.00 - 1.49 Urgently/Critically needed Very Strong Agreement Moderately needed Uncertain Highly needed Strong Agreement Adjectival Rating or Interpretation
1.50 - 2.49
The questionnaire provided open-ended questions to each set of questions in all the two parts, and was summarized and consolidated by the researcher. Interviews were also conducted with the respondents to gather more data about the study.
Not needed Very Strong Disagreement
Less Moderately needed Strong Disagreement
The data that were gathered from the respondents were coded for computerization using MICROSOFT EXCEL. The computer statistical printouts were transformed into tables for interpretation and analysis. The frequency count, percentage, mean and rank were applied to describe the variables of the study. Ranking has also been used to arrange the mean values in sequential order to determine the most to the least needed or disagreed statements in the questionnaire.
Discussion of Results As a key part of almost every business and operational solution, Information Technology is often the catalyst for change and the vehicle for enterprise-wide improvement. However, successful solution requires more than technology. Real solutions demand balanced changes involving people, processes, culture, and technology. These solutions must be configured to the present and future demand vis--vis the organizations resources and capability. Daraga Water Districts goal of being competitive in the rapidly changing water service market cannot be met without a modern integrated business software system. The use of Information Technology by water utilities offers a number of benefits including improved customer relations and labor efficiencies. Technical advances in client-server systems have made flexible, user-friendly and powerful systems available at affordable prices. Given the number of available choices for the industry, it is important for water utilities to develop an Information Technology plan that will serve as guide for its adoption and future upgrades (Billings, 1997). Information Technology is now widely used to significantly reduce cycle times, by supporting reengineered processes wherein electronic documents are moved through a shortened set of non-sequential steps, and the intermediate decision-makers have, at their desk, the information needed to complete their task and move the process to the next step. The basic technologies include: workflow system software, electronic imaging hardware and software, combined with electronic document management systems; and ready access to the data needed to process or authorize a procedural step. Daraga Water District has at present a very basic Information Technology system structure. Therefore, IT system is not a new endeavor, however there remains a need for Management to undertake a comprehensive approach to maximize the use of Information Technology as a tool for improving internal business practices and providing efficient public services.
Information Technology at present in DAWD is focused on databasing of customer accounts, computation of monthly billing and account history, locally networked tellering, databasing processes of complaints, and on-site read-and-bill system. Computer hardware components are composed of basic computer unit utilized as MySQL server for the database of the billing accounts of customer that is running on Windows XP operating system. Handheld computers and thermal printers that are being used for on-site read and bill system is on the verge of phase-out product, which means hardware support and parts replacement are hard to find and some units are deteriorating. Commercial Division computers are networked for the information system for billing, tellering, customer service, and on-site read-andbill system. A separate network for Internet connection exists with selected computer units accessing the network for official purposes only. Other than these networked computers, the rest of the computer units in DAWD are stand-alone mainly used for documentary and unit processing purposes. The present organizational structure of DAWD carries no plantilla position for IT personnel but IT functions are included in the job description of a Customer Service Assistant A as added responsibility on top of customer-related tasks. These functions include the jobs of a system/data/network administrator, technical support and IT specialist. An ideal IT for water utilities can be compared to private corporate companies where workflow systems are automated and business application software are utilized for the immediate retrieval of data that are needed for decision-making. Private corporate companies that have a well-established modern IT system, have lesser number of personnel because of automated system. These companies can then do away with tedious and error-prone manual business processes that could result to lost opportunities and profits to the company. DAWD is a government-owned and controlled corporation. It is a utility agency that is customer-serviceoriented where IT is focused on customer-related services like Customer Relation Management, computerized monthly billing system, faster action on customers request on their water maintenance and repair needs, faster and real time access to information through all communication portals, be it through telephone, mobile, Internet and face-to-face system. Further, digitalization of distribution system and pump house monitoring is the only way of minimizing the pressing problems of all water utilities globally that is non-revenue water (NRW).
The need for IT strategy in the District is enormous to attain competitive advantage in this modern day business environment. Management needs to have sharper understanding of how technology empowers innovation. Deciding which technologies will best support IT infrastructure can be daunting, but a solid foundation that rests on reliable platforms and products is the cornerstone of every successful IT initiative. With IT in the business system of the District it will provide a central way for the organization to cut costs, to identify ways on maximizing profit and to minimize the risk of critical processes and decisions to be made. The objective of this study is to come up with a three-year (2010-2012) risk-based IT strategic plan to jumpstart automation of workflow processes and digitalization of distribution line and pump house monitoring of DAWD. This research analyzed the present status, and determined the needs of the current setup, to be able to propose a strategic development plan that considers present and future IT resources requirements of DAWD. This study determines how Information Technology can be used as a tool to provide and enhance services in the operation of DAWD.
Status of Information Technology Implementation of Daraga Water District in Relation to its Service Requirements An important step in the approach towards improvement is to identify and evaluate the current state of an organization. This needs analysis of the current functional and physical characteristics of a system to determine what and where the change configuration process can start. With 52 indicators in hardware, software, networking and human resources components, the respondents replied that 19 (37%) indicators are present and 33 (63%) indicators are missing as shown in Table 1, summary table for status of IT implementation in DAWD. The respondents evaluated the condition of the present indicators whether it is functioning well, not functioning, and for upgrade. It was revealed that out of 19 present indicators 14 (74%) are functioning well, 0 (0%) are not functioning, and 5 (26%) are for upgrade. Missing indicators are the IT components that were perceived by the respondents that are not present in the existing IT system of Daraga Water District, which is basic IT structure.
Table 1 Summary of Status of IT Implementation in Daraga Water District

Total Number of Indicators 14 6 6 9 1 3 7 6
No. of indicator
IT Imperatives A. Hardware Components
Present Indicator 8 2 1 4 0 0 4 0 57 33 17 44 57 0 0 0
Percentage
No. of indicator
Missing Indicator 6 4 5 5 1 3 3 6 43 67 83 56 43
Percentage
No. of indicator
Functioning Well 5 2 0 4 0 0 3 0
Percentage
B. Software Components B.1 System/Utility/ Application Software Administrative and General Service Finance Division Commercial Division C. Networking Components D. Human Resource Components Engineering and Operations Division
B.2 Business Application Software
100 100 75 0 0 0 0
63
No. of indicator
For Upgrade 3 0 1 0 0 0 1 0
Percentage
37 0 0 0 0 0
100 100 100
100
25
Hardware Components. The results revealed that both the Management and Staff have the same perception on what indicators are present and missing. Eight (8) of the fourteen (14) important hardware components are present as follows : MySQL server, workstation, network printers, handheld computers, thermal printers, LCD projector, digital and video cameras, web cam, scanner and other peripherals. Among those that perceived by the 35 respondents to be missing are: high-end server, centralized Uninterruptible Power Supply(UPS), queuing device, input device for material inventory, input device for employee attendance, and devices for leak detection. Only about 57% of the 14 necessary hardware components are present. This indicates that DAWD still has six indicators or 43% of the necessary hardware to accomplish if only to enhance its services. It is an imperative to an enhanced IT of any organization to be responsive and relevant to the need of its sub-units, otherwise, their services given to the customers will only be up to the level and efforts to which their IT department
could sustain. One of the current services that clients of the organization demand pertains to timely and speedy bill and payment transactions, less time in accessing and retrieving information and faster processing of data. The survey found out that DAWD still needs to exert more effort for the development and implementation of an IT program if only to provide its stakeholders the services expected of DAWD. It is noteworthy though that DAWD has already started its way towards IT direction through its initial investments on IT basics as shown in the survey. The status in terms of hardware components, 23 of the 35 (66%) responded that MySQL server is functioning well, while 12 of the 35 (34%) stated that this particular indicator needs upgrade. This implies that the service provided by existing MySQL server is limited to the database for automated billing, tellering and customer service which are the main functions of Commercial Division. MySQL server alone cannot meet the demands of other divisions for IT service for them to be able to provide just and timely service to the clients. Twenty one (21) of the 35 (60%) responded that there is a workstation at present that is functioning well, while 14 of them (40%) said that it needs upgrading. As to the network printers, handheld computers and thermal printers as indicators, majority of the respondents 80%, 83% and 77% respectively, replied that they need upgrading. This implies that the respondents perceived that this hardware equipment are deteriorating and are not providing good service as expected. On the other hand, indicators such as LCD projector, digital cam, video cam and web cam, scanner, and other peripherals, are functioning well as perceived by the majority of the respondents at 89%, 91% and 89% respectively. The result demonstrated that these components already exist and function well and that DAWD can maximize its usability. Software Components. Both the Management and Staff gave the same replies to the indicators as to presence or absence. The indicators are categorized into two: - the system/utility/application software and business application software for every division. Under the first category, the system/ utility/application software, two of the six indicators are present, namely office processing application software, and database back-end. Missing are, licensed network operating system, licensed operating system for workstation, licensed antivirus, and computer-aided design software. Only 33% of the six needed system software were present, and 67% were missing. This indicates
that the number of missing system/utility/application software was more than the present software. Under the second category, business application for every division, only one indicator out of six, was present in the Administrative and General Services Division which is the agency website. Human Resource Management system, computer-based attendance system, computerized record system, and computerized processing of procurement system is missing. Only 17% of the six business application software were present and 83% were missing. This implies that most of the work in the Administrative and General Services Division were still manually done. For the Commercial Division, the result indicated that four indicators were present out of nine. These were the following; billing system, tellering system and on-site read-and-bill system. Missing is online inquiry, online communication, online payment, bank payment transaction system, and on-site read, bill and collection management system. The positive responses constitute 44%. Three of the missing indicators involved bringing the services to online communities. Whereas, the Finance Division has only one indicator that is accounting system, but which unfortunately was not present. The same was true with the Engineering and Operations Division where all three indicators therein were missing. It implies that both Finance and Engineering and Operations Divisions do not have any business application software that can help them enhance the services expected of them. The status of software components of DAWD in relation to its service requirements was evaluated by the respondents as to the softwares responsiveness to the users necessity. Of the 25 indicators, only seven indicators were given evaluation by the respondents as only these seven indicators are present in the current IT system of DAWD. This result implies that 72% of its IT necessity has yet to be provided and only 28% has been furnished. From system/utility/application software category, both indicators-office processing application software and reliable and efficient database back-end, were perceived as functioning well by 26(74%) respondents, while 9(26%) respondents said such indicators are due for upgrade. From business application software category, one indicator in the Administrative and General Services, which is agency website, 32 (91%) of the respondents replied that it is for upgrading, two or 6% said it is functioning well, and one or 3% said that it is not functioning at all. This implies that the
respondents saw the need for giving the agency website some attention by updating the same. For Commercial Division, findings revealed that four indicators were present, to wit computerized billing system, tellering system, customer service system and on-site read-and-bill system. In these indicators, 28 (80%) respondents replied that they were functioning well, and seven or 20% said they were for upgrade. This implies that majority of the respondents says that these automated systems in the Commercial Division were delivering efficient service. Networking Components. As to the presence of networking components and network setup that is appropriate for the IT implementation in relation to service requirements of DAWD, the result showed that the present indicators are as follows: Digital Subscriber Line(DSL), network media, cable and other network equipment, Local Area Network(LAN) for Commercial Division and Local Area Network (LAN) for Internet. Missing indicators are: router, switches, and modems for centralized local area network, wireless technology, and a centralized Local Area Network (LAN). The result implies that 57% was attained and the remaining 43% was for the Management to comply with for purposes of data communication and resource sharing. The result revealed that thirty-three (94%) respondents replied that Digital Subscriber Line (DSL) was functioning well, and two (6%) said it was for upgrade. As to the network media, cable and other network equipment for LAN communication, 25 (71%) replied that these indicators were functioning well, while 10 (29%) replied such were for upgrade. Some of the respondents were experiencing intermittent network connection that is equivalent to network hardware deterioration. As to the Local Area Network (LAN) for billing/tellering/customer service for Commercial Division, 20 (57%) respondents said that these were for upgrade, and 15 (43%) said these were functioning well. This implies that majority of the respondents were experiencing a slow down on local area network for billing/tellering/customer service system. Eighteen (18) or 51% of the respondents replied that Local Area Network for Internet to facilitate Government Electronic Procurement System, and for other online transactions was functioning well, and 17 (49%) said it was for upgrading. This implies that those who responded for upgrading could be due to low signal or intermittent connection with the Internet facilities of DAWD.
Human Resources Components. The existence of human resources components needed by an organization having an IT system was also evaluated. All the respondents replied that all listed indicators under this component were missing. These indicators include Management Information System (MIS) unit, MIS Manager, System and Data Administrator, Network Administrator, Technical Support Staff and Programmer/IT specialist. Those indicated personnel are important key player in MIS/IT unit that handles technical aspects in supporting IT system of the District. Currently there is one personnel whose job description performance of the functions of system/data/network administrator and also as technical support and IT specialist. But in the Organizational Structure of DAWD, there is no plantilla position solely for IT. This implies that DAWD has to carefully review its Organizational Structure and make it suitable to the present and eventual needs of the organization. Since all the indicators in human resource components are missing, the respondents abstained from answering this part. IT Imperatives Most Appropriate for Daraga Water District to Enhance its Services In recent years, small to medium-sized businesses (SMBs) have been topping up IT budgets to increase competitiveness, improve customer service and reduce cost. According to AMR Research, at least 64 percent of SMBs plans to increase IT budgets by an average of 5.3 per cent in 2008. However, despite increased IT budgets, the SMB sector has not really changed its IT imperatives. Their buying decisions will still be influenced by return-on-investment targets, preference for solutions that are easy to manage and deploy, as well as the need to secure access to applications, information, voice and data anytime, anywhere. How do SMBs decide which IT project is most important? Generally, SMBs tend to focus on the areas where they experience the greatest business pains. Today, that need translates to creating an infrastructure that supports diverse workforce needs, from collaboration to telecommuting to simply staying connected in a highly competitive market place where one of the key differentiators is responsiveness to customer and/or market requirements. Customer service is often reactive, but today it is the degree of proactive customer service that sets businesses apart from the competition. The good news is that today, the sales cycles for productivity-enhancing network technologies can be dramatically short (Chai, 2008). This research focused on finding what are the appropriate IT imperatives for Daraga Water District that will literally lift the District technology and will
render a competitive advantage on its operations. Figure 2 illustrates service requirements of Daraga Water District that can be enhanced by using IT as a tool in performing routine tasks.
AGS Daily Attendance Monthly Report of attendance Leave Records 201 files Procurement Property Management Cashiering Human Resource Management
Commercial Customer Service Maintenance Order Service request Application for new service connection, reconnection, transfer of tapping etc. Billing On-site read-and-bill Tellering
Information Technology
Finance Preparation of Financial Report Payroll preparation Disbursement Preparation of payment Budget Accounting
Posting of WM to history card that are brand new, calibrated, retrieved, etc. Planning & Design Production Maintenance
EOD
Figure 2 . Service Requirements of Daraga Water District that can be Enhanced by IT
Administrative and General Services Division is responsible for human resources management, property management, procurement and general services. The survey revealed that all these tasks are manually done in AGS division, which entails errors, and consumes a lot of time in producing a report especially on property management, procurement and human resource. Business application software needed involves automated attendance, records management system, computerized warehouse inventory system, procurement system and human resource system. With these IT system, daily time records and reports will be in real-time, outright computation of leave credits and leave history. Inventory system records will be intact and accurate data can be relied on and reports can be out rightly generated which are very salient in determining the re-order point, and monitoring of supplies. Preparation of Purchase Request, Abstract of Bids, Purchase Order and Tracking of procurement can be properly done without human intervention. Commercial Divisions primary concern is customer service. It takes charge of all consumer-related matters and maintains the customer accounts. This division has existing IT system for billing, tellering, customer service and on-site read-and-bill that is periodically reviewed for enhancement to maintain accurate customer account information. The current IT system in the Commercial Division provides real-time access and retrieval of customer accounts and information is outrightly given to the consumer and to management. Real-time automated tellering makes office collection efficient and orderly getting the consumer payment process done in just a short span of time. On-site read-and-bill system produces statement of account upon meter reading, which gives the consumer information about their bill that results to immediate payment. Customer service can be enhanced further in this Division by having e-services where consumer can avail of the services of the District through the Internet like application for service connection, transfer of tapping, relocation of water meter, service request, and complaints. Online payment can also contribute to higher collection efficiency. Finance Division is centralized on the disbursement, accounting and budgeting. There is no existing information system in this Division. All work activities like preparation of financial report, payroll, disbursement and other accounting activities are manually done. In the preparation of financial reports, a lot of time is spent to produce necessary output in as much as transactions have to be recorded first in the book of accounts, which are posted manually. Payroll preparation is tediously done by referring to Daily Time Record
(DTR) card, checking the overtime authorization and accomplishment, leave of absence without pay, and employees monthly deductions. Disbursement activities like preparation of disbursement vouchers, loan remittance schedule, premium remittance schedule and withholding taxes remittance schedule take time to accomplish. These work activities in the Finance Division involves lot of personnel and time to accomplish. Further, human error and inefficiency are inevitable. IT will dramatically enhance the services of this unit for having a computerized accounting system. Output will be on time and error-free. Books of accounts will now be posted and stored electronically, papers and time utilization will be reduced in accomplishing certain tasks. Personnel can devote their time in analyzing/reviewing their output hence, will greatly improve their efficiency. Data for decision- making needed by the Management and Board of Directors can easily be produced. Engineering and Operations Division handles the planning and design, production, construction, and maintenance. Databasing of water meter history is posted manually in Water Meter History Card ledger. Data acquisition and analysis, planning and design are manually done. IT can automate databasing of water meter history for easy retrieval and access. However, digitalization of distribution line, pump house monitoring and geographical information system will result to further reduction of unaccounted-for-water. This system will efficiently trace leaks and monitoring of pump houses can be done in the office. The information that this system will produce, can maximize the personnel to be deployed to the field with accurate knowledge on where to excavate and what type of system they will deal with. IT as a modern tool in this unit will help the operation of the District in providing uninterruptible water supply to the consumer. Task-Technology Fit theory was used in this study by defining ideal IT system components and comparing it existence to the present system to identify what are necessary IT components are needed to be able to comply with the nature of fitting technology with demands or tasks by the internal and external clients of the system. Diffusion of Innovation Theory was utilized in this research as to adoption of innovation through Information Technology in enhancing services of Daraga Water District. Matching DAWD service requirements with IT system are the main premise of this research. With these two theories IT strategies and development were produced to realize cost-efficient operation and quality service.
The ranking of the indicators revealed the order from highest to lowest mean, it indicates the level of need and the agreement of the respondents in the statement. The researcher did not interpret the responses of the Management and Staff separately because the responses showed similar trend. This is because their average responses to each of the listed indicators showed that all of them are NEEDED. Therefore, the researcher based the interpretation from the total responses of the two sets of respondents. The summary of mean for IT imperatives needed by DAWD as perceived by the respondents is presented in Table 2. Table 2 Summary of IT Imperatives Needed by Daraga Water District Mean 4.14 4.39 4.33 4.34 4.25 4.73 4.39 4.13 4.51
A. Hardware Components IT Imperatives B. Software Components
Interpretation Highly Needed Highly Needed Highly Needed
B.1 System/Utility/ Application Software
Commercial Division Finance Division Engineering and Operations Division
B.2 Business Application Software Administrative and General Services Division
Highly Needed Highly Needed Urgently Needed Highly Needed Highly Needed Urgently Needed
C. Networking Components D. Human Resource Components
Hardware Components. The hardware components are composed of IT devices that are imperative to the operation of DAWD. To extract the information and subsequently analyze which of the listed hardware components are urgently needed, the mean was obtained and became the basis for ranking, as
to which among them are urgently/critically needed and are less needed. Rank one is interpreted as the indicator perceived to be most needed. The survey results showed that from highest to lowest rank, the top three most needed indicator pertains to handheld computers for on-site read-and-bill, thermal printers for on-site read-and-bill, and MySQL Server for Commercial Division billing, real-time tellering and customer service system. The mean is 4.88, 4.85 and 4.52, respectively, or urgently/critically needed. The District at present has these hardware components and are being utilized in the current operation. It implies that these are the priority components as perceived by the respondents to be able to deliver service to the consumers of DAWD. The lowest three indicators that were found needed but were perceived as being given the least priority is: centralized Uninterruptible Power Supply (UPS), digital camera and video camera, and LCD projector. The weighted means for these indicators are 3.70, 3.63 and 3.62 or highly needed. Further analyses showed that all the indicators were found highly needed with mean of 4.14 for all the listed indicators in hardware components. Software Components. For software components the means obtained show the urgently needed indicators in the two categories for each of the four divisions of DAWD. The ranking was established by section from the Urgently Needed to Less Needed in System/Utility/Application Software and Business Software Application in four divisions. Rank one is interpreted as the indicator that was perceived to be the most needed. Under System/Utility/Application Software, respondents perceived that Licensed Antivirus Software is urgently needed with a mean of 4.83. The indicator that received the lowest mean is Licensed Network Operating System, with mean of 3.95 or Highly Needed. It implies that respondents feel the immediate need of having a licensed antivirus to protect their computers from malicious virus that can ruin their files and computer resources. The mean for System/Utility/Application Software category is 4.33 or Highly Needed. This tells us that respondents perceived these indicators as IT imperatives appropriately needed that DAWD should have to be able to support the computer system and protect the data resources. Results in Business Application Software category for Administrative and General Services Division, Computerized Warehouse Inventory System has the highest mean of 4.65 or Urgently/Critically Needed while Computer-based Attendance System with mean of 4.18 or Highly Needed was the lowest. This unit, Agency Website received a mean of 4.32 or Highly Needed which is ranked third. This is the only indicator that DAWD has, but the need to be upgraded
is still imminent. The mean for Administrative and General Services Division was 4.34 or highly needed. This implies that this Division, which is the unit for property and supply, record system, procurement, and human resource, necessitates automation of its present manual processes. This will contribute to an enhanced system for the unit to function efficiently and effectively. The result in the Commercial Division as perceived by the respondents, produced a tie between computerized billing system and on-site read and bill system as rank one, with mean of 4.87 or urgently/critically needed. These two indicators are present and are functioning well. This implies that these systems are very vital in the operations of DAWD and are needing frequent attention as to maintenance and upgrading of the system to cope with the present needs of the District. The indicator with the lowest rank is Accredited Bank Payment Transaction System with a mean of 3.50 or highly needed. Commercial Division is the unit responsible for billing, tellering, customer accounts, and customer service. These systems are essential in the smooth operation of DAWD. The mean for Commercial Division is 4.25 or highly needed. Among the four divisions, Commercial Division is the unit with functioning Business Application Software that is frequently enhanced to cope with the needs of the growing number of customers of DAWD. Missing business application from other units should be synchronized with the present commercial system since all data needed by other application systems would come from the system of the Commercial Division. Finance Division has a sole indicator-computerized accounting system. It earned a mean of 4.73 or urgently/critically needed, as perceived by the respondents. This unit controls the finances, accounting and budgeting of the District. Computerized accounting system is what this unit has been craving for in the past few years. DAWD should closely look into this concern as far as automating the accounting system is concerned for an efficient, accurate, and on-time financial report that are very vital in the decision-making. The findings for Engineering and Operations Division showed that among the three indicators, Computerized Water Meter History got rank one with a mean of 4.32 or highly needed as perceived by the respondents. Respondents were feeling the need for a systematized database records for the Water Meter History, which is very necessary to enhance the services of this unit. This unit is responsible for water sources maintenance, development design, and planning. The mean for Engineering and Operations Division is 4.31, meaning, highly needed. Automating the system for detection of leaks and monitoring of pump
houses and distribution lines using the latest technology present in the water industry will be an innovative way of enhancing the services that this unit can offer which will then be translated into money or profit. The reductions on unaccounted-for water, which is 25%, can be lessened and can be eradicated with the use of the new technology. But since this technology entails big investment, the Management implements the same on a phase-by-phase basis. The mean for the software component as perceived by the respondents is 4.13 or highly needed. This implies that all listed indicators are IT imperatives appropriate for DAWD operation that will enhance its services, which will equate to quality public service. Networking Components. For the networking needs of the respondents perceived that Digital Subscriber Line(DSL) tops among the seven indicators, with a mean of 4.38 or highly needed. This implies that respondents prefer a high bandwidth Internet connection and have their computer units connected to the net. Presently, only selected few computer units are connected to LAN for Internet. Only personnel who are dealing with official online transactions and research are given access. Having a centralized local area network (LAN) should be given priority so that sharing of resources can be maximized. A high-end server to control all these will be a great advantage to the DAWD as data will be much safer. The lowest rank indicator is wireless technology. Respondents perceived that wireless technology has its downtime, but with the rapid technology for wireless, this can be adopted by the District in the future. The weighted mean is 4.13 or highly needed for this indicator. This implies that the indicators listed are needed by the District to have a stable and efficient networking system. Human Resources. A human resource component in IT is very important in an organization that is knowledge-based. An expert in this field would be a good investment of the District if only to fully maximize its IT resources. The result of the survey show a mean of 4.51 or urgently/critically needed. This implies that respondents were able to discern that in DAWD Organizational Structure, there is really no unit or plantilla position for IT and yet the District has an IT system. In case problems arise on the existing IT system, they have to wait for the availability of the person in-charge of IT in the office that belongs to one division handling other workload aside from his functions.
Risks and Prospects Implementing IT Imperatives in Daraga Water District The consequences that DAWD may encounter in not improving its IT system is operational risk which results to inadequate or failed internal processes, people and system failure and uncontrollable external events. System risk such as hardware or software failure, integrity of data and its security, and business operations are at stake. If the District will not enhance its existing IT this will create a void or a vacuum between the services demanded of the clients, the demands of time, responsiveness to customers need and ultimately the call to enhance services. Risk in Implementing IT Imperatives. Implementing change entails many necessary efforts and investments, hence, any organization that entertain the idea of change can expect hindrances or risk from financial, physical and most especially on the human resource aspects of the organization. These organizations therefore must develop strategic plans to acclimate to changes demanded by technology and time. This is because of the need for organizations to evolve, adapt, and sustain their place in the market strategic to implement changes follow that technological innovation (Holt, 1987). Variety of forces from technological advances to human actions can pressure any organization to improve, thus become the risk if the organization is not prepared nor have made any effort to implement improvement programs. DAWD, which is a service-oriented government corporate-type of organization, is not spared from these pressures towards change. The possibility of meeting these pressure or risks is even greater when technology becomes the driving force behind it. This research listed twelve (12) specific risks that an organization involved in water utilities can encounter. The result in Table 3 showed that the respondents expressed strong agreement that DAWD will experience greater risks in implementing the IT imperatives: personnel training in IT; testing of IT system; IT risk management plan, financial constraints, undertaking feasibility study; cost effective IT system; risk of hackers and viruses; tedious procurement system, and wastes generated from IT. The respondents expressed doubts or uncertainty that the following: increased energy consumption and cost; risk of obsolescence; and managements non-conformance to IT innovations, will serve as risks in implementing IT imperatives in DAWD. It implies that the respondents are not aware about the indicators listed that made their responses uncertain.
Table 3 Risks in Implementing IT Imperatives in Daraga Water District Item 2 3 4 5 6 7 10 11 12 8 9 1 Financial constraint IT system should be cost effective Management should conduct feasibility study before acquiring high cost IT system Management should create an IT risk management plan to cushion the effects of fastfaced IT. Personnel should be properly trained in handling the IT system Efficient testing of IT system should be in place Risk of obsolescence Risk of hackers and viruses that can damage IT system Indicators Mean 3.69 2.54 3.79 4.07 4.34 4.29 3.19 3.66 3.62 3.50 3.67 3.48 3.87
Interpretation Strongly Agree Strongly Agree Uncertain Strongly Agree
Management non-conformance to IT innovations
Strongly Agree
Strongly Agree Strongly Agree Uncertain Strongly Agree Strongly Agree Strongly Agree Uncertain Strongly Agree
Political, the need to conform to tedious government acquisition and procurement system Waste Generated from IT supplies and obsolete equipment Increase energy consumption and cost Mean
Results showed harmony in opinion that risk will be encountered and intense perception on what particular risk will be met by DAWD in implementing IT imperatives. Ranking indicates that among the perceived risk, Personnel Development on IT, and Efficient Testing of IT system should be in place. Cre-
ation of IT management plan are ranked highly in order from highly perceived to lowest perceived risks. Personnel feel that they lack the technological skills that are needed for IT-related tasks, which therefore should be given priority if there will be any plan to implement or adapt IT imperatives. The risk for lack of technical skills will contribute to poor information quality due to inability of the personnel to fully optimize the IT system. Since part of the changes will include highly technical and expensive IT equipment, the respondents also demonstrated in their responses the need for DAWD to ensure functionality, capability and maintainability of the IT equipment before acquisition. Moreover, due to the high obsolency rate of IT equipment (software and hardware), DAWD should also prioritize risk management plan to cushion IT investment, and to ensure that IT components are optimized before they reach end-life.
Prospects in Implementing IT imperatives. Prospects in this research refer to the benefits and advantages of using IT. It is becoming clear to the Management that building and sustaining competitive advantage is tightly linked to the superior use of Information Technology. Whether an initiative involves improving supply chain execution, optimizing internal processes, or becoming more intimate with customers, the use of Information Technology is increasingly central to success (http://www.watchit.com/PGDSCR. cfm?c_acronym=MICA). The survey responses indicate a general perception among the Staff and Management that the listed IT imperatives will create a very positive impact insofar as services of DAWD is concerned. The result indicates that all the respondents agree that implementing and sustaining improvements in IT would have a definite effect in information access and retrieval, cost reduction, and on the human resource concerns. The result as shown in Table 4, among the eight (8) listed prospects, the respondents very strongly agreed that implementing IT imperatives in DAWD will result to faster retrieval of data needed for decision-making, and, to revitalize the current operations of DAWD. These indicators ranked first and second, respectively, in terms of computed weighted mean. The remaining six (6) listed prospects indicate that respondents felt a strong agreement as to the resulting effects of implementing the IT imperatives, though not as strong as the previous two (2). Those that were rated by the respondents as strongly agreed to, ranked from highest to lowest were: improved quality and efficiency of customer service; reduction of business processes cost; streamlined workflows; support and facilitate better
human resource system and work-related processes, and provide information and faster services for online access. This implies that among the listed, tangible effects of change will immediately be felt and seen in the access to vital information for decision-making and revitalization of current operations. While the impact of change will take longer time to be perceived. Table 4 Prospects in Implementing IT Imperatives in Daraga Water District 1 2 3 4 5 6 7 8 Reduction of business processes cost Indicators Mean 4.37 4.54 4.72 4.49 3.94 4.07 4.02 4.04 Interpretation Strongly Agree Very Strongly Agree Very Strongly Agree Strongly Agree Strongly Agree Strongly Agree
Item
Revitalized current operations of DAWD Improve quality and efficiency of customer service
Faster retrieval of data that are needed for decision making Provide information and faster services for online access Streamlined workflows, reducing and eliminating paperbased processes Support and facilitate better human resource system and work-related processes Mean
Improved productivity of employee to greater business intelligence and decision-making capabilities
Strongly Agree
Strongly Agree Strongly Agree
All the respondents highly expect that implementing IT imperatives in DAWD will improve the internal operations, thus, enhance the services of DAWD to its consumers. This means that all respondents agreed that IT imperatives must be implemented to respond to the current demand and type of services that customers expect from DAWD.
4.27
Risk-based IT Strategic Plan that should be Established and Implemented in Daraga Water District Daraga Water District needs to have the core and basic functions of technology that is solid and reliable before it can start investing for upgrades and enhancements. That is why it is important that the District has an IT strategic plan that could offer solutions and road maps for growth. The IT strategic plan provides the guiding principles and serve as basic road map for the Daraga Water District. It highlights the business priorities for Information Technology within the District as well as the strategies and expenditures that will be required over the next three years to execute the plan. An overall IT strategic plan should assess and implement hardware, software, and staffing requirements to meet targeted Management, Geographic, and Financial Information Systems developments. The IT function should advise on the selection and procurement of specific computer hardware and software. The Management Information System (MIS) should tie together all the management activities into a computer-based information system. It should enhance Management decision-making processes by grounding them on reliable financial and technical information, and improve the operating efficiency and performance of the water company (Jenny, 2008). IT strategic plan creates the bridge between business strategies and the information systems that support them. This IT strategic plan identifies approach to technology that is carefully aligned with the Districts business goals. At present, DAWD includes a 10 million contingency fund that can be allocated for necessary capital improvements, hence, DAWD can afford and sustain the proposed IT strategic plan. The management can obtain LWUAs grant or loan for IT especially for programs in eliminating non-revenue water. Daraga Water District is committed to provide its concessionaires with dependable and affordable potable water supply daily, promote full customers satisfaction, uphold and preserve a high standard of public service, and maintain and sustain financial viability. To attain these goals IT will be a handy tool by focusing on enhancing the quality of customer care which can simultaneously improve productivity that will optimize operations and reduce cost. Seriously implementing IT strategic plan in the District will tremendously increase process efficiency, increase workforce productivity. Optimize assets and grow revenue. A Three-Year Risk-Based Information Technology Strategic Plan as presented in Table 5 is recommended based on the findings on the status of the
current IT implementation, appropriate IT imperatives that are urgently and highly needed as perceived by the respondents and align it with the risk and prospects in implementing the IT imperatives. This IT strategic plan have nine parts namely Area, Objectives, Strategies, Activities, Time Line, Budget, Metrics, Risk at stake if objectives were not met, and Personnel/Department concern. The area consists of Hardware, Software, Networking and Human Resource these are the key area of the strategic plan. The objectives consist of goals and targets as reflected in this study. Specific strategies were set for each objective that needs to be undertaken to attain the goal by implementing appropriate strategies. Activities are plotted to attain the objective. The basis for time line and budget is the Financial Schedule for IT Investment and threeyear IT acquisition plan that can be found in Appendix C and will guide the management along time management and funds needed in order to successfully implement the IT strategic plan. The sources for the basis of the budget are recent proposal from IT supplier that are carrying products like thermal printers, Handheld Computers, Servers, and other IT equipment forwarded to the General Manager of DAWD. Quotations from Business Software Application Developer were also the basis for budget allocation. Internet sites like amazon, pcexpress, yahoo electronic shopping, etc. , computer magazines, brochures and broadsheet advertisement were additional references in drafting budget in this IT strategic plan. Metrics are the quantifiable measures that the objectives were met. Risks are the adverse situation that may arise if objectives were not met. Personnel/ Department concerns were the point man or department that responsible for ensuring that objectives will be met. The four key result areas of this risk-based IT strategic plan were Hardware, Software, Networking and Human Resource. The main goal is to have an enterprise-wide information system designed to coordinate all the resources, information, and activities needed to complete business processes. Hardware area, enumerates the strategies that will give solution to the management in IT hardware resources that are appropriate in the District operation. Efficient hardware devices are needed to be able to avoid downtime that means interruption of day-to-day business operation. Software area includes attaining faster retrieval of data that is needed for decision-making and streamlined workflows, acquisition of business application. A software to automate system will be the solution. Computerization of all internal system of DAWD can guarantee faster retrieval of vital data that cannot
Table 5 Risk-Based Information Technology Strategic Plan for Daraga Water District (2010 - 2012)
A. Hardware Conduct yearly assessment of units to ensure quality output Purchase three units on the first year then another three units on the following year to eventually eliminate the old units. Prepare project proposal. Solicit proposal from supplier a. 250,000 b. 50,000 c. 50,000 1st quarter 2010 for item a, b, c & d and 1st quarter 2011 for item e Decreased number of manpower involved in Billing/ Reading/ Collection Reduced customer efforts and expenses in bills payment Decreased processing time between billing and collection Increased customer complaint due to inaccurate billing Interruptions of Billing cycle due to non-operational units Increased capability of simultaneous data processing
Area Assess the existing units; units that are serviceable can still be utilized. 1st quarter 2010 and 2nd quarter 2011 700,000 Accurate Read and bill Data; High percentage of erroneous data due to faulty equipment
To replace Handheld computers and thermal printers for onsite read-and-bill with latest units that has superior specification.
Objectives
Ensure that new units should have wireless capability and possess Windows environment capable of on-site collection system
Strategies
Activities
Time Line
Budget
Metrics
Risks
Commercial Division and MIS unit
Personnel/ Department Concern
Maintenance and Repair contract should be implemented.
Acquire these latest units in staggered phase.
To acquire Missing Hardware Devices: a. High-end Server
Provide financial support.
Branded units
Very slow and One at a time data processing therefore longer cumulative cycle times
MIS unit
Area Test devices e. 180,000 Real-time access and retrieval of inventory data and employee attendance Improved processing flow of data Eliminate data corruption and losses due to intermittent power outages 50,000 3,000,000 d. 50,000 In commercial division and reduced transaction times for services required Manual checking of data that takes longer time, more efforts, more cost Need for more personnel that will increase number of errors in the system Reduced printing cost more control in printing jobs 4th quarter 2010; 3rd quarter 2011; Improved maintenance services efficiency &
b. Input device for material inventory
Objectives
c. Input device for employee attendance system
Optimum aftersales service
Strategies Inaccurate inventory data balances that does not reflect on-hand inventory levels
Activities
Time Line
Budget
Metrics
Risks
d. Queuing device
e. Centralized Uninterruptible Power Supply (UPS )
To replace Network Printers Prepare project proposal.
To acquire devices for leak detection, pump house and
Economical and heavy duty laser network printers
Prepare a budget
Solicit proposal from supplier
4th quarter 2011
MIS unit
Digitalization of distribution line
Delayed printing due to breakdown, more costs in printing expected More number of printers needed
Engineering and Operations (EOD) division and MIS unit
Area Conduct feasibility study on District pipeline system Canvass suitable devices that is compatible with the District system Improve savings in Unaccounted Water due to leaks 2nd and 3rd quarter of 2011 Quarterly 100,000 per year 150,000 Lessen number of field personnel Minimize downtime of workstation due to hardware breakdown Inefficient maintenance services Increase field personnel requirements 3rd & 4th quarter 2012 eliminate expensive trial & error approach in leak detection Increase non-revenue water
distribution line monitoring
Objectives
and automation of pump house monitoring requires a feasibility study of current pipeline system if digitalization and automation is possible. Assess all computer units Canvass supplier for computer units Prepare a quarterly maintenance schedule Maintenance schedule should be generated for proper documentation for the status of equipment Increased idle or non-productive time; lesser outputs generated Breakdown problems encountered more often Improved operational efficiency of equipment and personnel Minimize equipment breakdown and personnel idle time MIS unit MIS unit Delays in data processing oftentimes met
Strategies
Activities
Time Line
Budget
Metrics
Risks
To acquire additional workstation or replace obsolete units
Phase-to-phase acquisition
To establish hardware maintenance program for all IT devices
Devices should be branded units that are tested in water industry
More than fouryear older workstation should be replaced to have effective and efficient units.
Conduct quarterly hardware maintenance schedule to eliminate breakdown
Area Double checking of information needed to ensure quality of data generated by system Frequent data corruption and system breakdown MIS unit
Objectives
Strategies
Activities
Time Line
Budget
Metrics
Risks
B. Software Prepare project proposal. Solicit proposal to anti-virus provider Daily back-up of critical and vital data Management should give policies on proper handling of IT system. 1st quarter 2010 100,000 Remove threat of data corruption and system breakdown in all departments Improve operational efficiency of each department through increased number of outputs
B.1 System/ Utility/Application Software
To establish IT risk management security of Data and IT resources by acquiring licensed antivirus, firewall, anti-spam, etc. , system recovery management, and IT policy.
Provide financial support
Licensed antivirus, firewall, anti-spam, etc should be acquired to reputable provider.
Data back-up should be sent off-site.
All IT system should be password protected to trace accountabilty
Reliability and integrity of critical data in automated system will not be protected due to unrestricted system
Provide IT policy and guidelines
Increased exposure to hacking risks
Area Prepare project proposal. Solicit proposal from Licensed Operating System provider Periodicity of Needed Updates in operating systems and software that increases system safety net and integrity of data Maximize time, personnel utilization and productivity in producing designs No opportunity to upgrade software that are periodically provided by system developers in the internet Increased exposure to threats of viruses, hacking and memory system breakdowns 4th quarter 2010; 2nd quarter 2011 and 1st quarter 2011 120,000 1st quarter 2010 50,000 Eliminate the danger of legal issue in software piracy. Violation case (criminal case) will ensue due to utilization of illegal software MIS unit
To acquire Licensed Network Operating System and Licensed Operating System to all Workstation.
Objectives
Strategies
Activities
Time Line
Budget
Metrics
Risks
Licensed OS are for easy recovery and updates support from Operating System Provider and for legal matters.
To acquire Computer Aided Design Software
Licensed Operating System can be acquired in staggered phase. Canvass for latest version 2nd quarter 2011 50,000
Automation of Plan and design for easy modification and retrieval
EOD and MIS unit
Unstable operating system
B.2 Business Application Software For every Division Prepare project proposal. Solicit proposal from reputable developer c. 100,000 d. 100,000 e. 100,000 On-time report generation due to decreased processing times b. 100,000 Inaccurate and unreliable outdated Records and information fed into the organizational system. Eliminate data error Increased personnel productivity 2nd and 3rd quarter of 2010 a. 200,000 Real-time access to inventory, attendance, procurement, records and human resource concern More time, efforts, personnel and costs encountered in Manual manipulation of Difficulties and problems often encountered in services Longer time producing output AGS and MIS unit
Area
Objectives
Strategies
Activities
Time Line
Budget
Metrics
Risks
Administrative and General Services (AGS)
To acquire business application software to automate system in AGS in following order of priority: a. Computerized Warehouse Inventory System b. Computerized processing of Procurement system c. Computer based attendance system
Outsource business application software to the developer that is known in providing solution to water utilities
Synchronize with the other automated system of the District.
Area
d. Computerized Records Management System e. Human Resource Management System Prepare project proposal. Solicit proposal from website developer Solicit compatible application software to the equipment Solicit proposal from website developer Register to PAYPAL or other credit card provider 2nd quarter 2011 a. 50,000 1st quarter 2010 100,000 Minimized time in report generation that will generate accurate data b. 50,000 c. 50,000 2nd quarter 2011 75,000 Real-time and accurate information to external clients Outdated website and posting for procurement as required by RA9184 are not being followed. AGS, MIS unit
Objectives
Strategies
Activities
Time Line
Budget
Metrics
Risks
Upgrade Agency Website
Commercial Division
To acquire business application for on-site readbill-and-collection management system
Incorporate online customer service and online payment
Compatible with latest equipment for on-site readand bill
To provide electronic services to consumer by incorporating to the agency website the following application:
Utilize Internet in reaching online communities
Service request, complaint, and payment can be
Decreased number of field personnel Increase collection and ontime payment Increased customer
Manual monitoring of data for on-site readbill-collection system Outdated in tapping Internet as an opportunity in tapping customer
Area Solicit proposal from Verisign Year-round assessment of existing system Improved operational and personnel efficiency Eliminate manual recording in books of account Real-time & accurate output Increase personnel productivity Inefficiency in Finance Division Year-round 100,000 per year satisfaction due to enhanced customer care and services Software bugs will not be corrected and errors will affect the whole system MIS unit
a. online transaction b. online communication c. online payment
Objectives
received in realtime
Strategies
Activities
Time Line
Budget
Metrics
Risks
Finance Division Solicit proposal from developer
To have software modification/ maintenance to enhance existing automated system Prepare project proposal. 1st quarter 2011 400,000 Long time spent on manual work rather than analysis Lesser personnel Eliminate manual recording in ledger card
Utilize PAYPAL or other credit card provider and Verisign for secure online payment
To automate workflow in finance division by acquiring computerized accounting system
Existing system should cope with the present need of District
Outsource and enterprise with existing automated system
Finance Division and MIS unit
More personnel needed Longer time spent in retrieving data
Engineering and Operations Division (EOD) Prepare project proposal Solicit proposal from software developer Assess for software and hardware compatibility Prepare project proposal. Solicit proposal from supplier of networking equipment 1st quarter 2010 100,000 Reduce or totally eliminate non-revenue water Maximize computer resources limiting number b.3rd and 4th quarter of 2011 and 2012 Increase personnel productivity b. 2,000,000 More personnel needed a. 4th quarter 2010, 3rd quarter 2011 and 3rd & 4th quarter 2012 a. 3,000,000 Real-time information on water distribution system status Maintenance and leak detection are in trial and error process
Area Solicit proposal from developer 1st quarter 2012 100,000 Real-time access and retrieval of data Non-revenue water will be increasing EOD and MIS unit
Acquire Computerized Water Meter History
Objectives
Outsource and enterprise with billing and inventory system
Strategies
Activities
Time Line
Budget
Metrics
Risks
C. Networking
To digitalize water distribution system by acquiring the following application software: a. Detection of leaks, monitoring of pumps and distribution line b. Geographical Information System Redundancy of data backup Lessen time in data back-up
Acquire in staggered phase
Compatibility with the hardware
To maximize access to information and resources sharing by acquiring networking equipment for centralize local area network.
Adopt wired and wireless environment
More computer resources are needed
MIS unit
Area Assess the system and its technical need Prepare project proposal. Review existing organizational structure. Submit new plantilla to DBM,CSC, COA c. 128,000 per year Ensure accountability & responsibility for IT systems Prompt treatment of IT and IT-related problems that may impede smooth data processing flow Before the implementation of new IT system 50,000 per year b. 225,000 per year IT investment will be wasted Start on 1st quarter of 2010 a. 320,000 per year Enhance Management and control systems for IT IT technical need and problems will not be addressed AGS 4th quarter of 2011 and first quarter of 2012 150,000.00 Eliminate need and cost for Networking cables Improve processing and transfer of data Inability to share resources. MIS Unit
To acquire wireless network technology
Objectives
D. Human Resource
Computer unit with wireless LAN can utilize the system
Strategies
Activities
Time Line
Budget
Metrics
Risks
Establish MIS/ IT unit that composed of the following personnel: a. MIS manager b. System & Data admin/Net-work Admin c. Tech Support Staff /Programmer/IT Specialist
Provide budget
MIS unit will be responsible in incorporating all IT system in the District and provide technical support
Merge duties of system & data administrator & network administrator
Suitable IT training for personnel who will handle IT system.
Merge duties of Technical support staff & Programmer/IT specialist Prepare Training Plan and schedule
Train personnel who will handle IT system
Enhanced IT skills of personnel
Improper way of handling IT system
AGS and MIS unit
Area Include training as requirement to the supplier or developer in IT procurement Lessen error in handling IT system Frequent IT technical problem
Objectives
Developer and supplier of IT system and equipment should be required to conduct training for proper deployment.
Strategies
Activities
Time Line
Budget
Metrics
Risks
Proper IT training and preferably cross-training of personnel
of vital data that cannot be done in the present manual system. Acquisition of missing Business Application Software should be synchronized to the current automated system of the District. Outsourcing will also be a sound decision due to the expertise of system developer that are known in providing IT solution to water utilities. The system for digitalization of distribution line and pump house monitoring to eradicate problem on non-revenue water requires a feasibility study since this system entails big investment and implementation will be on a phase-by-phase basis. Networking area, maximize access to information and resources sharing at minimized cost, a centralized Local Area Network(LAN) should be implemented. Networks allow computers, and hence their users, to be connected together. They also allow for the easy sharing of information and resources, and cooperation between the devices in other ways. The benefits of centralized Local Area Network are connectivity, communication, hardware sharing, software sharing, Internet access sharing, and data security and management. To have an uninterruptible LAN connectivity and to avail of the convenience of wireless technology, the District can adopt combination of wired and wireless environment. Human Resource area, establish MIS/IT unit, DAWD should review its existing Organizational Structure. This unit will handle IT concerns within the organization. MIS/IT unit will be the one to carry out this IT strategic plan and provide technical support to several new IT systems. The proposed organizational structure of Daraga Water District that includes MIS Division for information technology management of the District is presented in Figure 6. Having a suitable IT training for personnel who will be the end-user of the IT system, DAWD should have a training program for the concerned end-users most suitable to the IT systems the end-users are holding. A cross-training may also be resorted to so that the IT potentials of the users are maximized. Further, MIS/IT unit personnel should work closely with the developer/supplier on technical aspects. The Risk-Based IT strategic plan for the year 2010 2012 is to be implemented by the District in order to achieve real business goals and objectives, including cost-saving programs, productivity improvements, and proactive management. Conclusions and Recommendations Based on the findings, the following conclusions were derived: 1. Daraga Water District has IT investments and efforts but 63% are still
needed to be able to achieve the objective of providing the quality service it envisions. 2. DAWD needs to give attention to the acquisition of components in the hardware, software, network and human resource. It also showed the need for restructuring the organization that should include a separate unit for IT. 3. Implementing IT imperatives in DAWD will improve the internal operations, thus, enhance the services that DAWD will give to its clients. Risks may arise as the adverse effect in the services of DAWD that would need IT services if IT imperatives were not implemented. 4. Risk-based IT strategic plan was recommended to further enhance services of Daraga Water District. In view of the cited conclusions, the following were the recommendations of the study: 1. DAWD needs to develop a strategic plan for IT and create and establish an MIS/IT unit and hire appropriate personnel that will handle IT system in the District. 2. MIS/IT unit should take charge of the entire project of IT strategic plan in order to ensure that all departments are well served by implementing the solution. By centering the implementation of all IT projects with the IT unit, new and upgraded solutions remain compatible with the enterprises technology, vision and architecture, and IT investments are more likely to meet the desired objectives for enterprise-class information management 3. Risk-based IT strategic plan should be updated on a regular basis to adjust to the inevitable changes in the Districts effective use of Information Technology which should remain focused on providing quality services. 4. Implement the recommended Risk-based IT strategic plan.
A. Books Alex B. Bolanos, Probability and Statistical Concepts, An Introduction, Rex Printing Company, Inc. Quezon City, Phil., 1997, p.36 C.W. Frentzel, & J.C. Frentzel, Management of Information Technology (4th Edition) MA: Course Technology, 2004 David H. Holt, Management, Principle and Practices, Prentice Hall Inc. Eaglewood Cliffs, New Jersey 1987. p. 150 David L. Goetsch & Stanley B. Davis, Quality Management Introduction to total Quality Management for Production, Processing, and Services Copyright 2006, Pearson Eduaction, Inc., Upper Saddle River, New Jersey, Page66 Gary Stoneburner, Alice Goguen, and Alexis Feringa; Risk Management Guide for Information Technology Systems; Computer Security Division Information Technology Laboratory; National Institute of Standards and Technology Gaithersburg MD 20899-8930; Booz Allen Hamilton Inc. 3190 Fairview Park Drive Falls Church, VA 22042; July 2002 James A. OBrien & George M. Marakas, Management Information Systems Seventh Edition, McGraw-Hill Irwin Copyright 2006, page 53 Kalakota, Ravi, and Maria Robinson. E-Business 2.0:Roadmap for Success, Reading, MA:Addison-Wesley, 2001
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Santipat Arunthari, Information Technology Adoption by Companies in Thailand: A Study of Enterprise Resource Planning System Usage, Doctor of Philosophy, University of Wollongong, Australia, 2005 Saritha Kodthuguli, Obtaining business benefits from IT : factors that influence the adoption of benefit realisation methodologies in New Zealand organizations; (unpublished masteral thesis, Master of Computer and Information Sciences; Auckland University of Technology, 1-Jan-2004) Sue Coates, Kevin Sansom and Sam Kayaga ,Customer Relations Management: Part A:Introduction for Urban Water and Sewerage Authorities in Developing Countries A Water and Environmental Health at London and Loughborough study produced as part of Task 514, 2001
Victor William Fazakerley, Critical issues for the future of the Australian urban water supply industry; (Unpublished Dissertation, Doctor of Business Administration; Curtin University of Technology, Graduate School of Business, Australia, 2005) Virginia Reyes, Management Information System in the SLMES-DC Schools, Bicol Region. University of Nueva Caceres, Unpublished Masteral Thesis, University of Nueva Caceres, Naga City, 2001. C. Periodicals and other Materials
Basic Institutional Development Services Course handouts, Public Affairs office, Local Water Utilities, April 2002, p.9 Daraga Water District Service Guide 2006, page 3 Mary Cronin, The Internet Strategy handbook, Boston: Harvard Business School Press, 1997
N. White, M. Jones, M. Brookbanks & J.Douglas, Operational Risk Management and IT: Implications for Financial Services, IBM Global Technology Services, Oct 2006 The New Websters Dictionary of the English Language International Edition, Copyright 2004 by Lexicon Publications, Inc. T.W. Malone & J.F. Rockart , How Will Information Technology Reshape organizations?: Computers as Coordination Technology, in S.P. Bradley, J.A. Hausman and R.L.Nolan (Eds.), Globalization, Technology, and Competition: The Fusion of Computers and Telecommunications in the 1990s, Harvard Business School Press, Boston, 1993 D. Internet Sites Clayton H. Billings The challenge of technology, (the use of information technology by water utilities, Public Works, August 1, 1997, http://www.
Diffusion of Innovations by Everett Rogers; www.stanford.edu/class/symbsys205/Diffusionof Innovations.htm
highbeam.com/doc/1G1-56973740.html
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STRESS OF NURSES BEHIND CARING POST-OPERATIVE PATIENTS IN BRTTH

Rosario G. Coralde
Introduction The caring role of the nurse has traditionally included those activities that preserve the dignity of the individual and those referred as the mothering actions in nursing. However, care involves knowledge and sensitivity to what is important to clients. The caring role is difficult to define specifically. It is the role of human relations. The chief goal of the nurse in this role is to convey understanding about what is important and to provide support. The nurse supports the client by attitude and actions that show concern for client welfare and acceptance of the client as a person, not merely as a mechanical being (Kozier et al, 1997). Nurses are very essential in a workers busiest and highly stressful area, the hospital. They serve as prime movers in the attainment of its goal and objectives. The goal of health care personnel should work toward an understanding of care and the values, health beliefs and lifestyles of different cultures, which will form as basis for providing culture-specific area. A nurse is viewed as a symbol of hope for the sick client and attached to this image is the need to radiate strength in his personality (Kuan, 1992). But looking deeper inside may reveal a person full of stress because he deals with life-and-death situations. In one US study as many as 40% of workers described their jobs as very stressful. While not a specific gauge and not measuring serious stress health problems, this gives some indication as to how prevalent work-related stress is. As regards official health records, in the United Kingdom (UK), the nursing and teaching occupations are most affected by work-related stress, with 2% of workers at any one time suffering from work-related stress, depression and anxiety. Care workers, managers and professionals are the next highest affected occupations, with over 1% suffering from serious work-related stress at any one time. UK work-related stress statistics suggest that work-related stress affects men and
women in equal numbers, and that people in the 45-retirement age suffer more than younger people. Combined with the factors affecting stress susceptibility, it is not difficult to see that virtually no one is immune from stress (Johnson, 1992). An American poll found that 89% respondents had experienced serious stress at some point in their lives. The threat from stress is perceived so strongly in Japan that the Japanese even have a word for sudden death due to overwork, karoushi (Gortner, 1997). Consistent among the psychologists, in general, they use the word stress in at least three (3) ways. First, stress can be referred to as external event or situation that represents a demand or threat. This is in accordance to stimulus definition. Second, according to the respond definition, stress is an organisms reaction to the environmental threat or demand. Third, according to the transactional definition, stress lies neither in environment stimuli nor in reactions to those stimuli but in a particular relationship between the individual and situation. But work-related stress is a natural reaction of people to being put under intense pressure at work for a period of time (Mc Kenchie & Doyle, 1996). The setting of the study is the Bicol Regional Training and Teaching Hospital (BRTTH). BRTTH is a tertiary hospital with 250-bed capacity catering to the people of Albay and to its neighboring provinces. It has 96% bed occupancy rate manned by 365 personnel. The hospital has three (3) departments, namely, Medical, Nursing and Administrative. The Medical department has 32 doctors handling four (4) major services Medicine, Surgery, OB-GYN and Pediatrics serving their clients according their specialties and sub-specialties. They hold specific positions like resident physician, senior resident, consultants and part time consultants. Approximately the doctor-patient ratio is 1:10. The Nursing Department has 114 permanent nursing personnel and out of this three (2.63%) are in the managerial positions, l9 (16.66%) are in the supervisory position, 56 (49.12%) are staff nurses, and 36 (31.57%) are nursing assistants. Due to the exigency of manpower, the administration gave an additional nurse job orders to help in the provision of service to the clients plus some staff detailed from the city government. The hospital has 6 wards and 8 special areas all manned by nursing staff. Inspite of the additional manpower, still it does not follow the standard nurseto-patient ratio. Some general wards have 1: 30 or 1: 50 ratio and 1:5 for special areas. Staff nurses also handle post-operative patients aside from other patients in the ward of varied cases. A newly operated patient needs special care, from
assessment of the level of consciousness, positioning, checking of post-operative site, contraptions, and vital signs, giving of medications and the like. They have to implement all these immediately and other post-operative orders. There is also a need for continuous observation of patients for any complications that may arise. This is not an easy job for a nurse; some have to extend their duty hours just to cope with the needs of the client; others go on 16 hours duty for unexpected absences of the incoming staff. Nurses attend to watchers call, answer information from visitors, attend to doctors rounds and do routine nursing jobs. Insufficient supplies and non-functional equipment add problem to the nurse. Sometimes they have to run to borrow life-resuscitating equipment leaving behind the patient plus attending to some tasks assigned by supervisors. It is in this context that the researcher chose to study the stress encountered by nurses in caring for postoperative patients in BRTTH. The Problem This study aimed to determine the stress of nurses behind caring postoperative patients at Bicol Regional Training and Teaching Hospital. Specifically, it answered the following sub- problems: 1. What are the situations that cause stresses of nurses in selected clinical areas in Bicol Regional Training Hospital (BRTTH) along: a. role, b. interaction, c. communication, and d. transaction? 2. What are the signs and symptoms manifested by nurses under stress in terms of: a. physical, b. emotional, c. behavioral, and d. psycho-social? 3. What mechanisms are instituted by nurses to cope with stress along: a. physical, b. emotional, c. behavioral, d. psycho-social, and e. spiritual?
4. What nursing strategies can be recommended by the study to reduce stress in the work place?
Conceptual Framework The Conceptual Framework, which is shown in Figure 1, shows that the BRTTH nurses experiences some situations that bring about stress in line with their roles, interactions, communication and transactions in caring for post-operative patients. These situations could be interpersonal and social. Moreover, the stresses have signs and symptoms, which could be severe or not. As human beings, nurses may find ways and means to cope with these stresses. The research design used the descriptive one. Data were gathered through a questionnaire while the qualitative data were gathered through a Focused Individual Interview with the nurse-respondents. From whence, strategies to reduce stress were forwarded to the BRTTH nurses.
BRTTH Nurses
Stressful Situations
Signs & Symptoms
Descriptive Design: -Quantitative Data -Qualitative Data
Strategies to reduce stress
Coping Mechanisms Figure 1. Conceptual Framework Model
Methodology The study used the descriptive design. Moreover, it utilized qualitative research using two approaches: the Focus Group Discussion (FGD) and the Focused Individual Interview (FII). Focus Group Discussion (FGD) is an approach to data gathering wherein 6-12 persons guided by a facilitator, during which group members talk freely and spontaneously about a certain topic(Varkevisser et al, l991). In this case, the FGD was utilized to add up to the list of situations under role, interaction, communication and transaction categories made by the researcher. These were needed for the finalization of the research instrument. Focused Individual Interviews of the nurses as interviewees added to the credence of the study. Their statements were taken as is and thus were included in the analysis and interpretation of data gathered. Those uttered in Bicol dialect and Filipino language was translated to English. The quantitative data were sourced from the selected respondents of the study. The qualitative data were taken from the utterances of the same respondents. Both of these were the primary sources of data. The secondary sources were the literature and studies previously reviewed. The respondents of the study were 30 nurses, regardless of position, assigned in different areas of the hospital. They were those who had been assigned and/ or presently assigned in the Post Anesthesia Care Unit (PACU), the Obstetrics and Gynecology Ward (OB-GYN), Surgical ward and the Private and Philhealth Units (PPhU). The total number was 30. The research instruments included a questionnaire and an interview schedule. The first part was for situations regarding role, interaction, communication and transaction. Role included situations where nurses act as caregiver, communicator, teacher, counselor and manager. Each of these roles had 5 situations and using Likert scale, the respondents were made to determine the level of stress they experienced. Similarly, the same scale was used with the other situations under interaction, communication and transaction. These situations were culled from the literature reviewed and from the answers of the respondents from the FGD. This scale is shown below with their descriptions. Scale 4 5 5.00 - 5.50 3.50 - 4.59 Range Verbal Interpretation High Level of Stress (H) Very High Level of Stress (VH)
3 2 1
2.50 - 3.49 1.50 - 2.49 1.00 - 1.49
Moderate Level of Stress (ML) Low Level of Stress (LL) Very Low Level of Stress (VLL)
The next item in the questionnaire was about the signs and symptoms experienced by nurses under stress. There were four factors which were identified. These were physical, emotional, behavioral and psychosocial. Each factor had an enumeration of different signs and symptoms, which were also taken from books. Using the Likert scale, each number was given an equivalent description. This is shown below. Scale 3 2 1 4 3.50 - 4.59 2.50 - 3.49 1.50 - 2.49 1.00 - 1.49 Range Verbal Interpretation Always (A) Sometimes (S) Seldom (SL) Never (N)
The third part of the questionnaire was about coping mechanisms utilized by nurses to overcome work-related stress. There were five factors identified which included physical, emotional, psychosocial, behavioral and spiritual. Each of them had situations where the respondents answered according the description given by the researcher. The weighted mean was used to analyze the data. For qualitative data, an interview was done. Such enabled the researcher to validate, analyze and interpret the data found. Moreover, for the two types of instruments most of the ideas were taken from the literature and studies previously reviewed. Discussion of Results Situations Causing Stress The situations causing stress were identified according to the roles performed by the respondents. Both quantitative and qualitative data described the stress. There were five roles of nurses identified by the researcher in their discharge of nursing care to post-operative patients. These were caregiver, communicator, teacher, counselor and manager. Each of them had 5 situations with an option for the respondents to add some more based on their experi-
ences. These roles were discussed individually. Table 1 depicts the totality of the findings.
Caregiver. Although all 5 situations were marked with high level (HL) of stress by the nurses taking care of post-operative restless patients with no watcher, which got a mean of 4.39 got the highest. The second was taking care of post-operative patients with no medicines, which got 4.12. Then there was one who added a situation which according to her gave her a high level (HL) of stress and this was taking care of post-operative patients with demanding watchers. Table 1 Level of Stress Experienced by Nurses Related to Their Roles
Taking care of 3-4 post-operative patients Situations Mean 3.82 4.08 4.06 4.12 4.39 3.44 3.29 3.35 3.42 3.65 3.40 2.88 0.16 0.16 Description High level (HL) High level (HL) High level (HL) High level (HL) High level (HL) Very low level (VLL) Moderate Level (ML) Moderate level (ML) Moderate level (ML) Moderate level (ML) High level (HL) Moderate level (ML) Very low level (VLL) Moderate Level (ML)
Roles Caregiver
Taking care of post-operative patients with unexpected complications Taking care of post-operative infant/s Taking care of post-operative restless patients with no watchers Others: patient is demanding Over-all Mean Taking care of post-operative patients with no medicines
Communicator
Patient/watcher who hardly follow simple instructions Patient who refuses to talk Demanding visitors
Patient/watcher who refuses to understand suggestions Co-workers who misunderstood suggestions Over-all Mean
Others: Watchers who do not know the consequences for DAMA

Roles Teacher A patient who cannot understand simple health instructions Situations An elderly post-operative patient Others, please specify: Counselor Incoherent post-operative patient Over-all Mean Mean 3.22 3.32 3.37 3.78 3.37 3.56 3.66 2.63 3.52 3.45 3.36 3.39 2.65 3.42 3.65 2.90 0.83 3.35 0 0 3.22 Description Moderate level (ML) Moderate level (ML) Moderate level (ML) Moderate level (ML) High level (HL) Very low level (VLL) Moderate Level (ML) High level (HL) High level (HL) Moderate level (ML) High level (HL) Moderate level (ML) Very low level (VLL) Moderate Level (ML) Moderate level (ML) Moderate level (ML) Moderate level (ML) Moderate level (ML) High level (HL) Very low level (VLL) Moderate Level (ML)
Post-operative patient below six years old Uncooperative post-operative patient
Co-workers with aggressive personality towards post-operative patients Watcher with high demands for postoperative care of his patient Prognosticated post-operative patients Non-cooperative subordinates who refused to care for complicated postoperative patients Co-workers with I dont care attitude towards post-operative patients Others, please specify.
Manager
Non-supportive supervisors Over-all Mean Unfair distribution of duties
Selective in opportunities to staff like sending to trainings/seminars Less prioritization of patients needs Inadequate supplies in the unit Over-all Mean Others, please specify: A supervisor who does not know her job description
When the nurses were asked why it was very stressful to take care of restless post-operative patients without watcher, these were their answers: Pwede kayang mahulog an pasiente. (The patient might fall.) Some of the contraptions might be dislodged because the nurses will not always be around to monitor them or to be at their bedside. A head nurse uttered: Kadakul na pwedeng mangyari sa pasienteng restless na daing bantay. An saro pwedeng haleon nya an dressing kan lugad nya. Ikadua pwedeng bulnoton an indwelling catherter o nasogastric tube (NGT). Ikatolo, pwede siyang magbuhat sa kama
o magtindog. Dakulon pa. (There are so many things that could happen to a restless patient without a watcher. One is she might remove the post-operative dressing. Second is she might pull her NGT or indwelling catheter. Third is she might sit up or stand up from bed. There are more.) In Bicol Regional Training and Teaching Hospital (BRTTH) the total number of surgeries in 2007 was 3,624; out of this number 2,403 were major operations. In other words, there was an average of 6 patients who would need to be monitored very often because they underwent a major surgery. About 1-2% of them, however, were restless. These were those who had trauma and extensive surgeries and those who had general anesthesia. Considering that there are only 56 staff nurses, 13 head nurses and 7 nurse supervisors working in 16 clinical areas of the hospital, taking care of this type of patient would truly give the nurses stress. The staff in the selected areas of the study has the following number of nurses: 4 in surgical ward (SW), 5 in the Operating Room (OR), 5 in the Intensive Care Unit (ICU), 5 in the Private Unit (PU) and only 2 in the Post Anesthesia Care Unit (PACU). Although the BRTTH Nursing Service had been accepting trainees and the city government had been detailing nurses to the hospital, they are not given full responsibilities, especially in terms of taking care of restless post-operative patients. To date, the hospital has been employing job order nurses but just the same they are not allowed to work by themselves without the regular staff nurses at their helm. A restless post-operative patient had to be watched every minute because of the reasons cited above. They are helpless and could not take care of themselves that is why they are classified in the nursing parlance as total care patients. Hence, if there is only one or two staff who takes care of an average number of 40 50 patients in the surgical ward with one or two restless patient/s without a watcher, such situation would bring about high level of stress to them. Taking care of post operative patients with no medicines was second in giving the nurses high level of stress. When asked why, these were what they said: Eh kasi papaano kung kailangan na ng pasyente ang gamot gaya ng para sa post-op pain, saan kami kukuha? Mabuti kung palaging mayroong L.O. (left over) o kaya may doctor na magbibigay ng tulong. Oo mayroon naman na mga doctor na mga matulungin, pero kung wala at wala pang pambili ang watcher, nakakastress talaga. (Eh what if the patient needs medicine like for post-op pain, where will we get them? It is good if we would have left over or if there
is a doctor who would give help. Yes, there are doctors who help but if there are none and the watcher do not have money to buy, it is really stressful.) Another said: There are patients who shout at us or strike us physically when we could not give medicine for pain. But what if this is not available? It gives us butterflies in our stomach. Hindi lang nakaka-stress nakaka-awa pa, (It is not only stressful, it is also pitiful), added another staff nurse from the surgical ward. Post-operative medicines like antibiotics, pain relievers and others are important in the recovery of patients. They heal wounds, relieve pain, prevent complications and generally improve their condition. However, it has been noted by the researcher as well as the staff nurses that many times patients could not afford to buy all of them considering their socio-economic status. It is good if there are medicines available in the hospital pharmacy; such could be loaned to be paid once the patient is about to be discharged or they could be bought at cheaper price. So taking care of post-operative patients with unexpected complications was the third, with a mean of 4.08. One of the factors could be due unavailability of medicines. The fourth stressful situation according to the staff nurses was taking care of post-operative infants with a mean of 4.06. Infants are helpless, are unable to communicate, could possibly have low threshold for pain and would want security from parents. In as much as a parent or any significant adult are not allowed in some clinical areas such as the PACU, ICU and the OR, the nurse is left by herself to take care of the infant. Here are some statements based from real experiences of nurses. An mga aking saraday na maibion pakatapos kan operasyon, deficil papunduhon, deficil atamanon lalong lalo na kun dai an ina. An sarong rason iyo ta bako midbid an nars kaya para bagang dai sindang tiwala, according to a staff nurse from PACU. (Post-operative infants who cry a lot are hard to pacify and cared for especially when the mother is absent. One reason is that she cannot recognize the nurse because she has not yet built trust for others.) One of the OR nurses when asked what makes taking care of postoperative infants highly stressful said, Nakakatakot mag assist sa operasyon ng baby, kasi parang nakikita ko ang sarili kong anak sa kanya. Nakakaawa talaga. (It is frightening to assist in infant operations because I could see my own child in him. It is really pitiful.) Another said, Extubating an infant after surgery was for me highly stressful kasi baka mag aspirate siya. Kaya mas gusto ko na mag-extubate anesthesiologist, hindi nars. ( because he might aspirate.
That is why I would rather have him extubated by an anesthesiologist rather than a nurse.) In the surgical or private unit, some of the nurses said that preparing an infant for surgery was something to contend with. The operative site would ordinarily be very small and very delicate that one would hardly be able to prepare it adequately. Physical, emotional and psychological preparation could hardly be provided for because most of them were fidgety, would cry a lot and could not communicate. There were times too when the parents or the significant adults were so demanding to the point of irking the nurses. The latter was one of the comments under others by one nurse.
Communicator. Seen in Table 1 under the role as communicator, the situation which got high level of stress among the nurses were demanding visitors. The rest of the critical situations got moderate level of stress. Demanding visitors was considered stressful because one patient would ordinarily have sarong barangay na bisita (visitors equal to one village). Many times the nurses call them toxic, meaning high strung or worrisome or demanding. Some nurses said: May mga watchers talaga na mas toxic pa sa pasiente. Ang daming tanong, ang daming hinihingi; minsan wala namang nagagawa. (There are watchers who are really toxic more than the patient. They ask many questions; they ask too much; many times they could not do anything.) When this occurs, the nurses mentioned that they just ignore them or face them squarely. Other times they would tell them frankly to stop demanding too much. However, some nurses said: Ingat na lang madam kasi marami nang marunong mag-complain ngayon. Ibinibigay na lang namin ang kanilang demand kung kaya lang naman. (We are very careful, madam, because many of them know how to complain now. We just give them what they demand if we could.) Pero nakakastress talaga sila para sa amin. (But they are really highly stressful for us.) The researcher being a nurse herself agreed to the observations of the nurses. Many of the demands of visitors were baseless. Because a patient would have plenty of visitors, one by one they would ask the nurse about the condition of the patient. Instructions given to one visitor or watcher were muddled up because the next minute or so there would be another visitor or watcher. This would become stressful to the nurses because they do not have all the time for one post-operative patient alone; they have 50 or so to attend to as well.
One of the nurses added to the critical situations placed by the researcher. This situation was: Patient or watcher does not understand the consequences for discharging the patient against medical advice (DAMA). When asked why this was stressful, the nurse said: There are legal and ethical implications to this, madam. Kasi, madam, kung mag DAMA an pasyente tapos may nangyari saiya sa daan o sa bahay, baka sabihin ng bantay ay hindi namin siya inasikaso o kaya hindi namin na-explain maigi ang consequences ng DAMA.(You know, madam, once a patient goes on DAMA and when something happens to him along the way or at his house the watcher might think that we did not attend to him or that we did not explain to him very well the consequences for DAMA.) That is why we really explain the consequences to them and in fact we asked them to sign that it was their desire to go home against medical advice, added a nurse supervisor. Mahirap na ngayon di ba? Marami nang reclamador ngayon kahit ginawa mo na ang lahat, mayroon pa rin na hindi ma-please kaya palaging paseguro. I-explain na tapos magpapirma pa; may witness pa. (It difficult nowadays isnt it? There are many complainants today even if you did all your best there would still be people who are not pleased that is why we should always be sure. We explain the consequences and again ask them to sign with somebody to act as witness.) But even if you do both, the patient or the watcher would still insist in bringing the patient home, the head nurse at the surgery ward mentioned. She further said that some of their reasons were valid. One was they do not have financial resources to sustain the hospitalization of the patient; the next was they do not have the time to be going back and forth to the hospital, pharmacy, work and home; and the third was that the doctor had prognosticated that their patient is already beyond cure. Communication, is the first step in establishing good nurse-patient relationship. Good communication demands feedback from the receiver. Hence, nurses are expected to be good communicators. Most communication is a two-way process between two or more individuals. Professional or therapeutic communication is one of the means by which nursing process is implemented in order to achieve quality patient care (Kozier, et al, 1997). Communication is the means for building trust, developing therapeutic relationships, providing support and comfort, encouraging growth and change, and implementing patient education. Nurses as health care professionals rely on verbal, written, and electronic or computer communication for sharing information, analyzing data, col-
laborating with other disciplines, and delivering services (Kozier, et al, 1997). The two types of communication are oftentimes used by nurses. Verbal communication, for example, is used for patient and watchers instruction, information and education, referrals and endorsements. Moreover, written communication is used for documentation in the patients chart, and reporting unusual occurrences. Non-verbal communication such as the behavior of patients and watchers or the behavior and attitude of the nurse towards the patient are equally important in caring for post-operative patients. Oftentimes, according to nurses in BRTTH, patients and watchers are makulit (repeated demands) and also they oftentimes misinterpret the behavior or non-verbal communication of nurses. Instructions from nurses are brushed aside or passed to another watcher thus causing conflicts or miscommunication between and among nurses, patients, visitors/watchers and doctors. Teacher. The situation which was considered as highly stressful was uncooperative post-operative patient which generated a mean of 3.78. The rest of the situations got a rating of moderate level of stress. Among the four, however, the two highest critical situations were incoherent post-operative and post-operative patient below six years old, both had a mean of 3.32. Why do some patients not cooperate, was the query of the researcher to the nurses? Some of their answers were: Minsan kasi dai ninda nasabotan an condition ninda asin an mga gigibohon sainda. (Sometimes they do not understand their condition and what will be done for them.) Sometimes also it is the watcher that prods the patient not to cooperate for no reason at all, according to another nurse. One of the supervisors explained that some patients do not cooperate especially in terms of medication or operation itself was because of financial constraint. Minsan nga sabi ng relative, eh, wala man kaming panggastos kaya iuuwi na lang namin ang aming pasyente. (There were times when a relative would say, we do not have money to spend that is why we will just bring our patient home.) Kaya pagminsan delayed ang surgery kasi ang pasyente o kaya ang relative hindi pumipirma ng consent for surgery iniisip ang gastusin, ang maiiwan sa bahay, ang magbabantay sa pasyente at iba pa. (That is why sometimes the operation is delayed because the patient or the relative would not sign the consent for surgery thinking about the expenses, the person who will be left at home, the person who will watch over the patient and others.) There were also times when the patient himself would not cooperate because of his age, fear of the unknown, or because of his personality. Ang very
uncooperative talaga ay ang mga matatanda. Sabi nila bakit pa raw magpaopera mamamatay na rin lang daw sila. (The very uncooperative were the oldies. They asked why they should undergo operation when they will die anyway.) Fear of the unknown is common among those who would be operated on (Dictionary of Nursing, 2005). They fear about what they would receive such that they would think that they would not wake up anymore; they fear about the diagnosis, the procedure that they will undergo and also the prognosis of their illness. Many of them also fear death. Perhaps, this was due to the fact that surgical patients had undergone high level of stress themselves prior and during the surgical procedure. The anesthesia could also be a reason in as much as some of the anesthetics have some residual effects on the brain making the patient become incoherent. Incoherence could also be present in patients whose condition was already serious; or it might be that he is a geriatric patient or a serious complication had ensued post-operatively. Again, a 6 year-old post-operative patient might not be able to cooperate because of his inability to understand what is going on with his condition or his life as a whole. He might not also be able to establish trust and confidence on his caregivers because of his age and might not be able to communicate his needs. Moreover, if patients are uncooperative, incoherent, geriatric or a child, teaching could become stressful and difficult. When the nurses were interviewed concerning the findings, these were what they related: A good nursing care does not only need doing what is needed to be done but cooperation from the recipient of the care would be important as well. Others said: Stressful man talaga ang mag-alaga ng hindi nakakaintindi, ng mga matatanda at mga bata.... dahil para bang ikaw na lang ang gagawa ng lahat, ikaw na lang ang inaasahan para sila gumaling, at iba pa. (It is really stressful to care for those who could not understand, the old, and the children . Because it would seem that you will do everything for them, you are the hope for their recovery, and others.) A teacher is one who tells or shows someone how to do something; causes to learn and to understand; gives lessons and the like. Some of the functions of nurse-teacher include mentor, coach, educator, guide, educator, lecturer, instructor, and pedagogue. As in a classroom, a teacher centers the learning process on the learner. She requires the learner to give a feedback. This could be done by means of a question, a statement or a demonstration or in most cases, a test.
In the clinical setting, most often, instructions, information and education on prevention of diseases, maintenance of health, restoration and rehabilitation are often the center of teaching. Sometimes, demonstration and return demonstration are used as strategies in teaching. Nurses, however, are stressed when performing this function because they do not have enough time or they perform multi-functions. They also had to contend to many watchers and or to watchers who would change as frequently as changing guards. The latter situation would result to repeated instructions to different watchers at different time. Kadificil talaga kun dakul na mga bantay o kaya mga bantay na sigue an liwat ta pagsinabihan mo na an saro may madulok na naman tapos maturo ka na naman. Pag-minsan makauyam kasi nakakaubos ki pasensya asin oras.(It is really difficult when there are several watchers or watchers that change very often because once you have instructed one, another would approach you. Sometimes it is irksome because they consume ones patience and time.) Counselor. Among the counseling roles, the highly stressful was Watcher with high demands for post-operative care of his patient, 3.66 (HL). When the staff nurses were asked why this was so, these were some of their answers: There are watchers who would not believe you that you are taking care of their patient well. Eh kasi huna ninda saro sana an pasyente mo kaya demanding sinda. (It is because some watchers think that you only have one patient that is why they are demanding.) Stressful, it is because they would return to you over and over again demanding from you to monitor or even stay with their patient the whole shift. And most of them would not listen to you that you have other patients to attend to. An iba kaiyan mapa-advise saimo kun ano an gibohon pero dai man matubod. (Others would ask for some advice on what to do but they would not do believe anyway.) Others would argue with you when you counsel them. Isnt it that a counselor does not decide for the counselee instead she presents options for the counselee to choose from, one of them questioned the researcher. On the point of view of the researcher, counseling only becomes stressful if nurses do not know how to do it. Also, if the one being counseled is the problem. Counseling should not be forced; counseling is supposed to be voluntary, meaning the counselee is interested and comes to the counselor himself because he believes that he should be guided towards a better decision or taught on what to do.
The situation that got ML, 2.63, was prognosticated post-operative patients. The explanations of the nurses were: This was not stressful to us because doctors do the prognostication not nurses. What we do was only to follow up what the doctors said to them. Ang stress lang ay kung hindi maintindihan ang prognosis o kaya hindi ko kayang sabihan ang pasyente about the prognosis dahil sa awa. (The stress is when I could not understand the prognosis or if I could not tell the patient about his prognosis because of pity.)
Manager. Along this role, the only highly stressful situation, as shown in table 1 was inadequate supplies in the unit, 3.63 while a supervisor who does not know her job, got 0.83 or very low level of stress. When asked the nurses answered: Ining role hard at nakaka-stress dahil kun daing mga supplies pano ka makagibo kan saimong gigibohon para sa post-operative patient? It is also stressful dahil kun importante nang gibuhon tapos nagpapabakal ka pa sa bantay, hay, sobrang hirap talaga. (This role is hard and stressful because if there are no supplies how could we do our work to the post-operative patient? It is also stressful because if what you would do is important and the watcher is still buying supplies, oh, it is really hard) Any delay in the discharge of nursing care because of lack of supplies could be equated to poor nursing care, that is definitely the perception of postoperative patients and watchers, added one nurse. Nakakainis man talaga kung walang supplies. Pero pambihira man itong mangyari. (It is really annoying when there are no supplies. But it seldom happens.) One nurse added one situation and this was when the supervisor does not know her job. This was a surprise to the researcher. It was quite impossible to believe a supervisor not knowing her job. So the nurse was asked to discuss the matter and this was what she said: Pano kun ihapot dai man nakasimbag kaya an interpretasyon ko kaiyan dai tatao. (Because when asked she could not even answer. So my interpretation is that she does not know.) A supervisor is supposed to be knowledgeable about her work such that she is regarded as the planner, mentor, the coach, the teacher, evaluator and the role model for her staff. But what if the supervisor is the one who does not know? The researcher believes that this could be a great problem especially so when the set up is the clinical area and the clients are people. Nursing is an exact science such that one false move could mean his life; one wrong decision could mean disaster.
Summary of Findings on the Level of Stress Experienced by Nurses according to Roles. Table 2 shows the summary of findings on the level of stress related to the roles performed by nurses. Table 2 Summary of Level of Stress Experienced by Nurses According to Roles n=30
Roles Mean 2.85 3.37 3.36 3.18 2.89 3.44
Caregiver Teacher Manager
Description
Communicator Counselor
Moderate Level (ML) Moderate Level (ML) Moderate Level (ML) Moderate Level (ML) Moderate Level (ML) Moderate Level (ML)
Overall Mean
One could see that all the roles performed by nurses had moderate level of stress. Moreover, the highest among them was being a caregiver. This means the work of the nurse, per se. This could be explained by the fact that nurses had to comply with the standards of safe nursing care. Further, expectations from them by the public, clients, co-workers and administrators are high. They try much to meet these expectations hence stressing themselves, probably. Further, these tasks are the ones observed, supervised and evaluated.
Interaction. Table 3 was the findings along the level of stress experienced by nurses along interaction. Interaction is defined as the observable behavior of two or more persons in mutual presence (www.wikipedia.com.en). As one could see the highly stressful situation experienced by the nurses from BRTTH with a mean of 4.32 was violent post-operative patient and watcher. Why was this so, the nurses were asked? These were some of their responses: Most of the time it was due to communication gap. When the patient or watcher would not allow you to explain further or when they just merely refuse to understand, the situation becomes stressful. One nurse corroborated and added: Kun minsan nagiging irritant an pagsuway kan pasyente o lalo na an bantay sa titaram kan nars. Ini
an pipunan kan violent verbal interaction na nauuli sa stress kan nars asin kan pasyente. Very hard man daw an mga situasyon na siring kaini. (Sometimes it becomes an irritant when the patient or his watcher goes against the nurses instructions. This starts some violent verbal interaction that results to stress of the nurse and the patient as well. It is really hard in situation such as this.) Table 3 Level of Stress Experienced by Nurses Related to Interaction n=30
Uncooperative patients and watchers Situations Restless post-operative patients with no watchers Institutional worker not around when needed Violent post-operative patient and watcher Conflict among staff Uncooperative post-operative patient Mean 3.46 3.92 3.78 3.42 4.32 3.02 3.57 3.06 Description
Interaction
Moderate Level (ML) High Level (HL) High Level (HL) Moderate Level (ML) High Level (HL) Moderate Level (ML) Moderate Level (ML) High Level (HL)
Unsure decision of patient/ watcher for a certain procedure Overall Mean
Pero saro pa man sana an nabalitaan kong nagwala talaga su pasyente. Digdi ito nagpoon sa surgery ward dahil an pasyente naaksidente. Rattled na an mga bantay, mga barkada niya. Pighiling kan nars ta maduguon talaga su lugad sa bitis; rinefer sa doctor sabi kan doctor ipack sana su lugad. Binalikbalikan su nars kan mga bantay; dai talaga sinda naapease. Binalikan uli kan nars su doctor na sinabi na maduguon talaga su lugad kan pasyente maski na ngani pinack na; maabot siya ta nagkaon sana sa luwas na madali. Sabi na naman kan doctor may gigibo pa kaya sa OR. Dai niya aram nagsakat palan su mga bantay ta pighalat kun may maluwas na pasyente ali sa OR. Dai man palang pigoperahan. Dagiton talaga su mga bantay. Hapoton mo na lang su mga nars duman maam. (But I know about one case whose watchers became violent. It started here in the surgery ward. What I know it was about a patient who met
an accident. The watchers who were his friends were rattled. The nurse went to the patient because the affected foot was really hemorrhaging and referred the matter to the doctor who ordered packing of the affected foot. The nurses did it yet they were not appeased. The nurse went back to the doctor to tell him that despite the packing hemorrhaging did not stop. The doctor said to wait awhile because he was just eating outside. Then he said he was operating on somebody at the OR. What he did not know was that the watchers went to the OR to keep watch whether there was really a patient who was operated on. There was no one who was operated on. The watchers were really mad. You can just ask the OR nurses.) The nurses at the OR were asked about the situation. This was what they related. An naromdoman mi iyo su mga pirang lalaki na duroderetcho sa OR ta pighiling talaga kun may operasyon. Pighapot pa ngani su sarong nars kun nagopera. Sabi nya dai man. Talagang dagiton su mga lalaki! As in (What we remember was that there were a group of men who went directly to the OR to find out if there was an operation. They asked a nurse if there was indeed an operation and the nurse replied that there was none. The men became really very mad! As in...) This was just one example of an interaction between nurses and watchers that resulted to verbal violence in the end. If one would analyze the situation the nurses had no fault after all since they had done their responsibilities. But nonetheless, since they are there 7/24 at the bedside or at the nurses station they become the center for abuse. If interaction is not good then stress occurs.
Communication. Communication is one important aspect in the delivery of nursing care. As mentioned in the previous discussions, many of the problems in interaction and role performance were due to gaps in communication. Nursing entails the use of both verbal and non-verbal communications. The term communication has various meanings depending on the context on which it is used. Communication is the exchange of information between two or more people. Thoughts are conveyed to others by spoken or written words and by gestures or body actions. The intent of communication is to illicit response, thus, communication is a process. It includes all the techniques by which an individual affects another. It has two main purposes: to influence others and to obtain information. Communication can be described as helpful or unhelpful. The former encourages a share of information, thoughts or feelings between two or
more people. The latter hinders or blocks the transfer of information and feelings. Nurses who communicate effectively are better able to initiate change that promotes health, establish a trusting relationship between a client and support persons and prevent legal problems associated with nursing practice. Effective communication is essential for the establishment of the nurse-client relationship (Kozier, et al, 1997). Table 4 Level of Stress Experienced by Nurses Related to Communication n=30
Unclear or not readable postoperative doctors orders Situations Referrals to doctors not immediately seen Patients/watchers who have difficulty in understanding instructions Too many orders from doctors and other co-workers Unclear policies Mean 3.87 3.92 3.12 3.02 3.55 3.62 3.72 3.97 3.13 3.13 0.16 Description High Level (HL) High Level (HL) Moderate Level (ML) Moderate Level (ML) High Level (HL) High Level (HL) High Level (HL) High Level (HL) Moderate Level (ML) Moderate Level (ML) Very Low Level (VLL) Moderate Level (ML)
Communication
Patients/watchers inability to follow simple instructions Unclear post-operative verbal orders of physician Language/dialect barriers Telephone post-operative order/s Overall Mean
Post-operative patient below 6 years old No cooperation from other departments like X-ray, laboratory, CT Scan, etc.
The nurses communicate to several people namely the patients, his family, his friends and the like. He also talks to the health team members such as the
3.19
physicians, nursing attendants, medical technologists, cleaners, radiologists, drivers and others. The nurses communicate for several reasons: to teach, instruct, inform or educate. On the other hand the nurse also makes written report such as incidents that happen in the ward, documents her actions and responses of patients and the like. Table 4 presents the findings on the stress experienced by nurses in communicating with post-operative patients. There were 5 situations which the nurses said gave them high level of stress (HL). These were: referral to doctors not immediately seen, 3.92; unclear or not readable postoperative doctors orders, 3.87; too many orders from doctors and other co-workers, 3.55; unclear policies, 3.62; unclear verbal orders of physicians, 3.72 and postoperative patient below 6 years old, 3.97. The latter situation was found to be the highest among them. This could be explained by the reality that children are uncommunicative especially if they do not know the people taking care of them, kaya ngani pipalaog mi an ina o bantay sa Post Anesthesia Care Unit (PACU) para na lang sa aki. Dakul na beses kasi dai man nagtataram an aki kun makolog baga o ano man an namatian sa nars. Usually sa ina iyan minataram. Kun dai man nakataram an ina nakasabot kan mga iro-iro kan aki. (That is why we ask the mother or the watcher to enter the PACU just for the sake of the child. Many times the child would not complain pain or whatever they felt to the nurse. Usually he would tell his mother. If not or if the child is not communicative the mother would understand the behavior of the child.) To the researcher the saying that the mother knows best is true. One nurse added one situation which she said gave her stress and this was no cooperation from other departments like X-ray, laboratory and CT Scan, etc. When she was asked to explain further, this was her reply: Well, it is because when the doctor orders such examination and the other departments would have several reasons why they could not do it such as no reagent, machine is out of order or technician is not around, the burden to explain this to the doctor is on me, on the nurse. Another nurse said: Of course madam, I do not want orders uncarried. I want to endorse to the next shift full implementation of physicians orders. And besides, kawawa man an pasyente, (pity the patient) madam, added another. Pero dahil hindi naman kami ang may kasalanan hindi naman talaga stressful na grabe. (But since we can not be blamed about it, the stress is not really grave.)
Transaction. Transactional theories of stress are based on the work of Lazarus (Kozier, et al, 1997) who states that the stimulus theory and the response theory do not consider individual differences. Neither explains which factors lead some persons and not others to respond effectively nor interpret why some persons are able to adopt over longer periods than others. Response definition refers to state of stress; the person is spoken of as reacting with stress, being under stress and so on. Stimulus and response definition have limited utility, because stimulus gets defined as stressful only in terms of a stress response. These concepts are explained by the findings of the study which is shown in Table 5. The over-all mean was 3.52, meaning high level of stress (HL). Among the situations which were considered highly stressful to the nurses were no supplies for life saving equipment like oxygen, suction Table 5 Level of Stress Experienced by Nurses Related to Transaction n=30
Insufficient medical supplies Situations Malfunctioning equipments Unavailability of laboratory reagents Unexpected power failure Unclear system flow Mean 4.13 4.03 3.55 4.06 3.19 3.32 3.05 3.03 3.36 No supplies for life saving equipments like oxygen, suction catheter, endotracheal tube, etc. No IV fluid and set when badly needed No available blood when in dire need Post-operative diagnostic examination immediately required Demands from high authorities or workers and immediate relatives Overall Mean 3.15 Description
Transaction
Moderate Level (ML) High Level (HL) High Level (HL) High Level (HL) High Level (HL) Moderate Level (ML) Moderate Level (ML) Moderate Level (ML) Moderate Level (ML) Moderate Level (ML) High Level (HL)
3.52
Catheter, endotracheal tube, etc. This could be explained by gusto mo nang gibohon sa pasiente pero dahil dai kang gamit dai ka man na maginibo. Minsan mapabakal ka sa bantay kan pasiente pero kun dai man kuarta na ibakal makaluya; parang dai mo kaya hilingon na sana an pasiente. Kaya an marhay na pakipagtansacsyon sa pasiente o sa bantay kaipuhan na tatao an nars ta kun dai iwal an makua mo.(When you want to do things for the patient but you cannot because there are no adequate supplies, you cannot do anything. Sometimes we ask the watcher of the patient to buy but what if they do not have money to buy you feel helpless; seemingly you cannot just look at the patient. That is why transacting well with a patient or his watcher is needed by any nurse or else fight is what you get.) And according to one of the nurses who just avoid such unhealthy transaction leading to a fight or animosity, this is what they do: Minsan naman minadalangan kami sa ibang ward para magsubli muna kan kaipuhan maitao lang an serbisyo sa pasiente. (Sometimes we ran to another ward to borrow what are needed just so we could already give the service to the patient.) Or, Kadaklan na bes minagibo kami ki paraan. Ingenuity dyan matibay an nars, di ba? (Many times we do what we could. Ingenuity is nurses strength, isnt it?) One way of correcting the situation based on the feedback by nurse supervisor was for them to transact with the supply officer. But most often the response was no money or no available supply. These responses were highly stressful for us, said one of them. Post-operative diagnostic examination immediately required got the lowest among the moderate level of stress. This could be explained by the fact that the role of nurses in diagnostic examinations is as implementers only of the surgeon or anesthesiologists orders. Summary of Findings on Situations Causing Stress. Table 6 below shows the summary of the different situations causing stress for nurses at BRTTH. The over-all mean is 3.37 or moderate level of stress. Moderate level of stress could be considered eustress or normal stress (Kozier, et al, 1997). As mentioned by some literature reviewed, any employed person would have some form of stress. Dr. Hans Selye, for example, who originated the concept of physiological stress in the l930s, makes a distinction between stress that is productive and stress that is harmful (Kozier, et al, 1997). The former is called eutress; the latter he called distress. Regardless of the nature of the stress agent, or stressor, whether it acts on the personality of the individual,
traumatizes body cells, or alters established living patterns on the individual; the bodys responses to stress are the same, according to him. Table 6 Summary of Findings on Situations Causing Stress
Mean 3.57 3.19 3.37 3.52 3.18
Role
Situations
Description Moderate Level (ML) High Level (HL) Moderate Level (ML) High Level (HL) Moderate Level (ML)
Interaction
Communication Transaction Average Mean
To the researcher, as long as stress would not become obstacle to the efficient and effective performance of the nurses and would not become an impediment for his personal and professional growth then such would just be considered as normal. Interaction and transaction were situations which were taken with high level of stress by the nurses. This infers that establishing and maintaining relationships in the workplace were causing high stress among the nurses. The findings proved what Toffler (1997) asserted: any relationship implies mutual demands and expectations. It could be deduced from the findings that many of the nurses stresses were due to relationships and unmet demands and expectations. Maybe there is a need for the administration to look closely on the employees values systems towards their work and their personal self. Perhaps too, there would be a need for them to assess their continuous quality improvement program on matters where employees experienced highly level of stress. Signs and Symptoms Certain reactions observed by Gilmer (n.d.) also served as stress cues. In this study they were termed signs and symptoms. According to Kozier, et al (1997), stress can be manifested physiologically or psychologically. There are also cognitive, verbal and motor manifestations. Physiologic manifestations may or may not occur in clients experiencing stress, depending on the way the client perceives the stressful event and on the effectiveness of the clients coping strategies. The physiologic signs and symptoms are shown on Table 7.
As depicted, the over-all mean was 3.52, described as sometimes. This meant that the nurses at BRTTH were not high strung and if ever they were Table 7 Signs and Symptoms Experienced by Nurses under Stress n=30
Increased heart rate Pounding heart Sweaty palms Headache Diarrhea Constipation Trembling Twitching Nausea Vomiting Fatigue Itching Signs and Symptoms Mean 2.59 1.99 1.93 1.36 2.42 1.49 1.39 1.85 1.50 1.16 1.49 1.36 1.23 2.32 2.82 1.72 1.66 1.93 1.26 1.43 1.76 1.43 0.1 Elevated blood pressure 2.73
Factors Physical
Description
Sometimes (S) Sometimes (S) Seldom (SL) Seldom (SL) Seldom (SL) Sometimes (S) Seldom (SL) Seldom (SL) Seldom (SL) Seldom (SL) Seldom (SL) Seldom (SL) Seldom (SL) Seldom (SL) Sometimes (S) Sometimes (S) Seldom (SL) Seldom (SL) Seldom (SL) Seldom (SL) Seldom (SL) Seldom (SL) Seldom (SL) Seldom (SL) Never (N) Sometimes (S)
Tightness of the chest, neck, jaw and muscles Urinary hesitancy
Stuttering and other speech difficulties Sleep disturbance Cold hands
Shallow breathing
Dryness of the mouth and throat Susceptibility to minor illness Being easily startle Chronic pain Epigastric pain
Unable to concentrate on work activities Overall Mean
3.52

Irritability Hostility Jealousy 2.78 2.29 1.79 2.03 1.29 1.69 1.26 1.73 1.99 1.93 1.26 2.33 1.70 1.82 2.09 1.85 1.84 1.26 2.09 2.02 1.80 1.56 1.59 1.23 1.62 1.50 1.46
Factors Emotional
Signs and Symptoms
Mean
Description Sometimes (S) Seldom (SL) Seldom (SL) Seldom (SL) Never (N) Seldom (SL) Never (N) Seldom (SL) Seldom (SL) Seldom (SL) Never (N) Seldom (SL) Seldom (SL) Seldom (SL) Seldom (SL) Seldom (SL) Seldom (SL) Seldom (SL) Never (N) Never (N) Seldom (SL) Seldom (SL) Seldom (SL) Seldom (SL) Seldom (SL) Never (N) Seldom (SL)
Angry outburst Depression Restlessness Withdrawal Nightmares Impatience Insomnia
Diminished initiative Lack of interest Tendency to cry
Narrowed focus
Reduced esteem
Changing in eating habits Overall Mean Increased smoking Carelessness
Weakened positive response reflexes Behavioral
Teeth grinding or jaw clenching Sleeping too much or too little Eating more or less Overreacting to unexpected problems Picking fights with others Overall Mean
Overdoing habits (ex. Exercising, shopping)

Factors Psychosocial Reduction of personal involvement to other staff Signs and Symptoms Being critical to others Diminished sense of meaning in life Diminished or exaggerated fantasy life Avoid being with other coworkers in the ward Refuse to talk with others Overall Mean Isolating yourself from others Sense of loneliness and isolation Mean 1.63 1.66 1.40 1.29 1.46 1.29 1.63 1.45 1.33 0.13 Description Seldom (SL) Seldom (SL) Never (N) Never (N) Never (N) Never (N) Seldom (SL) Never (N) Never (N) Never (N)
these were only sometimes shown physically. Moreover, gleaned from the table the two highest physical s were fatigue (2.82) and increased heart rate (2.73), respectively. Fatigue could be caused by over activity or exhaustion of strength wherein the capacity or power to respond to stimulation of one cell or organ is lost or diminished. Stress could be due to over activity in performing the nurses roles or could be caused by difficult interactive relationships or gaps in communication between and among employees. Moreover, increased heart rate could also be a physical manifestation of stress due to anxiety and fear of something which could be unknown to the person himself. Sleep disturbance got the lowest among the sometimes responses (2.32).
Increased involvement with others
Emotional. For emotional signs and symptoms, the nurses sometimes experienced irritability (2.78). When they were asked some of the reasons were qualified such: Nakakasuya baga pag palaging ganoon ang situation kahit ibat-ibang pasyente lalo na kung hindi marunong paliwanagan or hindi marunong sumunod ng instructions. Tapos siya pa ang galit. Ah, talagang mararamdaman mo ang pang gigigil. (It was irritating when the situation seemed to be the same even it entailed different patients especially those who do not know how to understand or those who could not follow instructions. Then they are the ones who get mad at you. Ah, so you would have such feeling of uncontrollable desire to bite.)
Three of the signs and symptoms never manifested by nurses of BRTTH were withdrawal (1.26), nightmares (1.26) and jealousy (1.29). Withdrawal could be in a form of absenteeism, not being communicative or ignoring the situation. These might not be true to the nurses in the said hospital because of their sheer commitment to their jobs and or their desire to give the best service they could possibly provide their patients. About nightmares and jealousy, these were their explanations: Diyos ko! Bakit naman ako magnanightmare? Sobra naman iyan! (Why will I have nightmares? That is too much!) Ako tinutulog ko na lang yan pero walang nightmare ha. Ipagdasal ko na lang yan stress-stress na yan. (Me? I just go to sleep but without nightmares. I will just pray for these stresses.) Moreover, the psychological manifestations of stress may include anxiety, fear, anger, and depression, as mentioned in the literature reviewed. Anxiety is a state of mental uneasiness, apprehension, dread, or foreboding or a feeling of helplessness related to an impending or anticipated unidentified threat to self or significant relationships, while fear is a mild to severe feeling of apprehension about some perceived stress (Kozier, et al, 1997). Another manifestation of stress is anger, which is an emotional state consisting of a subjective feeling of hatred or strong displeasure (Kozier, et al, 1997). Depression, on the other hand, is a common reaction to events that seem overwhelming or negative (Kozier, et al, 1997) whereby the individual experiencing depression may have emotional, behavioral and physical symptoms. Emotional symptoms of depression may include feelings of tiredness, sadness, emptiness, or numbness. Behavioral signs of depression include irritability, inability to concentrate, and difficulty making decisions, loss of sexual desire, crying, sleep disturbance, and social withdrawal. Psychosocial. The finding in this research was nurses showed no psycho-social signs and symptoms since the average mean of 1.33 which had a descriptive interpretation of never. While the highest among the situations were reduction of personal involvement to other staff and avoid being with other co-workers in the ward, both had a mean of 1.63. The nurses rationalized that they could not avoid being with or getting involve with other nurses especially if they work in the same clinical area. This was clarified further by Pano man dai ka mainvolve di dai ka na palan makiuron sa kapwa mo. Pano na su pasiente? Iyo na an masuffer. Kaya cool ka na sana. (How can you not get involved? Hence you would not talk to them? How is this to the patient?
He will be the one to suffer. So we will have to stay cool.) Me? I just pray for her said another nurse. Summary of the Signs and Symptoms Manifested by Nurses Under Stress Gleaned from the table the nurses in BRTTH seldom manifested signs and symptoms of stress. Moreover, they would sometimes manifest physical signs and symptoms. Table 8 Summary of the Signs and Symptoms Manifested by Nurses Under Stress
Factors Average Mean 1.84 1.62 2.08 1.33 3.51
Physical
Description Sometimes (S) Seldom (SL) Seldom (SL) Never (N) Seldom (SL)
Emotional
Behavioral
On the other hand, they never manifested psychosocial signs and symptoms. Physical signs and symptoms such as increased heart rate and fatigue are considered normal for as long as they do not end up to serious illness or disease. With regards to psychosocial signs and symptoms, perhaps this could be explained by the fact that nurses ought to be psychologically and socially sound.
Psycho-social
Average Mean
Coping Mechanisms Suffice for one to know that the nurses in BRTTH seldom manifested signs and symptoms of stress. However, for the benefit of the readers of this research, some possible coping mechanisms were herein included in the discussion. The same factors as to the signs and symptoms manifested by nurses under stress were used. Added was spiritual factor. Physical Factor. Table 9 shows that under the physical factor, there were five items which were sometimes used as coping mechanisms. The three highest were eating well-balanced diet 3.12, getting enough good quality sleep 3.08, and listening to music/playing musical instruments 3.03, among others. The nurses were asked to explain their answers further. These were some of their accounts.
An pagkaon ki balanced diet ay dapat lang lalo na kun under stress ka ta an stress baga, madam, nakakapaniwang na tapos kun dai ka pa magkaon ki marhay, ki balanced diet, pano na an lawas mo? Wara, helang an makua ta kaiyan. Table 9 Coping Mechanisms Utilized to Overcome Work-related Stress n=30
Watching television or movie after duty Coping Mechanisms Listening to music/playing musical instruments Overeating Mean 2.83 2.28 2.09 3.03 1.89 2.30 2.75 3.08 2.60 Mean 3.32 1.76 1.43 1.43 2.53 1.46 2.35 3.12 Description Reading books and magazines Involving in physical exercise after duty hours Sometimes (S) Seldom (SL) Seldom (SL) Sometimes (S) Seldom (SL) Seldom (SL) Sometimes (S) Sometimes (S) Sometimes (S) Sometimes (S) Description Sometimes (S) Seldom (SL) Never (N) Never (N) Seldom (SL)
Factors
Physical
Engaging in pleasurable or fun activities Taking a short, shallow breath for 5-10 minutes Getting enough good quality sleep Eating well-balanced diet Overall Mean Factors Emotional Coping Mechanisms
Talking with others (co-workers, friend or superior) Filing a leave Engaging in problem-solving with superior or co-workers
Joining the walk for life with co-workers
Seeking professional counseling Directly attempting to change the source of stress by requesting transfer to other area of assignment Overall Mean
Never (N) Seldom (SL)

Factors Psychosocial Thinking things over Coping Mechanisms Mean 2.56 1.50 2.80 3.06 2.59 2.64 Mean 1.49 1.56 1.75 2.12 2.78 2.66 2.48 2.15 3.63 2.56 2.25 2.96 2.52 2.83 3.03 2.36 2.85 3.09 Description Sometimes (S) Sometimes (S) Seldom (SL) Sometimes (S) Sometimes (S) Sometimes (S) Sometimes (S) Sometimes (S) Description Never (N) Seldom (SL) Seldom (SL) Seldom (SL) Sometimes (S) Sometimes (S) Seldom (SL) Seldom (SL) Seldom (SL) Always(A) Sometimes (S) Seldom (SL) Sometimes (S) Sometimes (S) Sometimes (S) Sometimes (S)
Involving in activities to keep mind-off the problem Isolating self after duty Making plans for handling stressful situations Ignoring stressful situations Overall Mean Throwing things to release tension Blaming others Criticized or lectured self
Thinking of resigning from work Seek out a trusted supervisor or friend Factors Behavioral Coping Mechanisms
Impulsive buying/spending
Talked to someone about his/ her feelings Kept feelings to self Overall Mean Spiritual Attend Novenas
Doubling efforts to make things work Went on as if nothing had happened Always prayed to God when things are complicated Meditate before sleeping
Attend prayer meetings/religious activities Asked others to pray for me Overall Mean
Attend mass before and after duty
Kaya ako pag understress ako dai akong pakiaram, makaon talaga ako. (Eating a well-balanced diet is just right especially if one is under stress, be-
cause stress, you know madam, reduces ones weight and so if you do not eat well, a balanced diet, then what will become of your body? You will get nothing but illness. That is why when I am under stress, I do not care, I just eat.) One nurse also explained about getting enough quality sleep. She related: My difficulty when I am under stress is to get enough sleep. I really have sleep disturbance. Pag minsan nagigising ng madaling araw.; kung minsan matagal naman akong makatulog. Naiisip ko ang mga nangyari sa ward; kung ano ang dapat ko sanang ginawa.(Sometimes I wake up early in the morning; sometimes I could not sleep at once. I think of what happened in the ward; on what I should have done.) Listening to music and or playing musical instruments were also identified by nurses to be one of the best coping mechanisms. Kasi paglalo na kun classical music an nadadangog mo para bagang ialsa an saimong espiritu sa langit kun saen an makua mo katoninongan. Nakakawara kan saimong stress. (Well, especially if one listens to classical music ones soul seems to be lifted to heaven where one finds peace. Then you lose your stress.) Sapolsky mentions that stress upsets the bodys natural means of self regulation (http://www.readersdigest.com.an). Moment to moment the body adjusts its blood pressure, temperature, heart rate, hormone levels and other variables. He said further that these are all controlled by the brain, which tells the endocrine systems what delicate adjustments to make under the ever-changing circumstances of living, including physical disruptions as injury and illness. Wilkinson also said that weakened immunity is related to poor coping ability, reflected in disrupted eating and sleeping habits under stress (Wilkinson, n.d.). This was likewise proved by one trial research. To the researcher this meant that BRTTH nurses know how to cope when they are under stress. Emotional. Under this factor, the nurses revealed that sometimes (3.32) they resorted to talking with others such as co-workers, a friend or his superior. Relating to another person is a good way of relieving stress. Madaling lumuwas an namamatean kun igua kang kahuron. Siempre duman sa taong comportable ka. (It is easy for one to reveal ones feelings to another by talking. Of course, to a person with whom you are comfortable with.) Once you have disclosed your thoughts and feelings you easily become relieved of your stress, stated another. To the researcher, this meant that nurses in hospitals had to have friends with whom they could relate their problems to. She may not always be her
head nurse or supervisor; she may be a doctor, a co-nursing staff or a nursing attendant. In BRTTH this is a common observation and the nursing administration encourages such informal organizations. Moreover, the research also found that nurses never recourse to directly attempting to change the source of stress by requesting transfer to other area of assignment 1.46; filing a leave 1.43; or seeking professional counseling 1.43. This meant the nurses used the fight instead of flight form of coping mechanism. Behavioral. The average mean along behavioral factor was 1.62 or seldom. Along the signs and symptoms experienced by nurses under stress was sleeping too much or too little, 2.09 or SL. When the nurses were asked to explain, this was what they related: ako, kikatrugan ko na sana para malingawan ko an problema na nagpapastress sako (As for me, I sleep much, so that I will forget the problem causing stress to me.) Another nurse said: Ako kabaliktadan. Dai ako nangangaturog pag ako stressed. Minakaturog ako late, minamata man akong atab. An katurog ko kun minsan diiton sana. (For me, it is the other way around. I could not sleep when I am stressed. I sleep late and I wake up very early. My sleep sometimes is very short.) Increased smoking, 1.26 (Never) got the lowest among the signs and symptoms under this factor. This could perhaps be explained by the fact that BRTTH nurses are not cigarette smokers plus there is a Department of Health Order explicitly demanding that all employees of the agency must cease smoking, especially inside the hospital premises. Aside from these, the nurses know that smoking is dangerous to their health.
Psychosocial. Psychosocial is pertaining to or involving both psychological and social factors (McGraw-Hill Nursing Dictionary, 1979). Gleaned on table 8 the average mean for this factor was 2.64 described as sometimes. This meant that nurses sometimes used psychosocial coping mechanisms when they were under stress. Among those which garnered a mean of 3.09 and 3.06 were thinking things over and making plans for handling stressful situations, respectively. The nurses were asked to relate situations that made them use the two identified coping mechanisms. This was what they said: May sarong sitwasyon na su reseta na sinurat kan doctor itinao ko sa bantay para bakalon. Su surat kan doctor dai ko masyadong nabasa. Ipinahiling ko sa kairiba ko. Su pagbasa nya pareho kan pagbasa ko. Su bulong na itinao kan farmasyotica kangaran kan isin-
urat kan doctor na iyo man su sakuyang pagbasa. Ipinainom ko na su bulong. Pero nagpara isip talaga ako kun tama ito dahil iba man su pigmamati kan pasyente na sa paguna ko dai man ito kaipuhan na bulong na ito. Kinaagahan, inapot ko su head nurse ko. An sabi sala daw su basa ko. Pigparaisip ko ito. Kun sala ako pano na ito? Napainom ko na su pasyente. Nadisturb talaga ako. Nagpaaram ako sa head nurse ko para sabihon ko sa doctor nya pag rounds. Sinabi ko naman. An sabi nya dai daw ako nagbabasang marhay.Sala talaga su itinao kan farmaciotica asin sala man su itinao kong bulong. Pigpara-isip ko ito sa haloy na panahon. Marhay ngani ta daing nangyari sa pasyente. (There was one situation where the prescription written by the doctor was given by me to the watcher to be bought. The handwriting of the doctor was not very readable. The pharmacist gave medicine that was similar to what was written by the doctor and what I also read. I administered the medicine. But I kept on thinking if I was right because the patients presenting problem was different and I knew that the medicine was not needed by him. The following day I asked the head nurse. She said that what I read was wrong. I had several thoughts regarding it such that if I was wrong then how would I correct it when I had already administered the wrong medicine to the patient? I was really disturbed. I asked permission from my head nurse to tell the doctor when he makes his rounds. And I did. He told me that I did not read his handwriting well. The pharmacist was wrong and I administered a wrong medicine too. I thought about it for a long time. It was just fortunate that nothing happened to the patient.) The incident was a clear proof that nurses should think things over prior to any action made. It was also a testimony that nurses use deep thinking and making plans for handling stressful situations as coping mechanisms; some thoughts to correct what he felt gone wrong. In the end such would not only benefit the patient under his care but himself as well. According to Bugen18 one way of coping with a situation was to modify the we think about the problem situation. And this was what was exactly done by the nurse about the situation cited above (The New Lexicon Webster Encyclopedia, 1992). What was seldom thought of by nurses was thinking of resigning from work 1.50. This is understandable because employment is scarce nowadays. Unless a nurses has a place to transfer nowadays locally or abroad, he will not give up his job.
Behavioral. The table again shows that nurses sometimes (S) used two from among several coping mechanisms. These were talked to someone about his feelings 2.78 (S) and doubling efforts to make it work 2.66 (S). They were asked to clarify why these were done sometimes. Here are some of their answers:
Sa aking pananaw ang pagkikipagusap sa isang tao tungkol sa nararamdaman mo ay nakakarelieve ng stress. Kagaya ako pag nailabas ko na ang galit o inis ko sa pasyente, kunwari, sa kaibigan ko nawawala kaagad ang stress ko, said one of the nurses. (In my own perception talking to someone about ones feelings could relieve stress. Like me once I release my anger about a patient, for example, to a friend my stress is rightfully relieved.) Tapos, (Also) batted another nurse, maaalis ang sakit ng dibdib mo. Hindi ka pa magkakasakit sa puso. (your chest heaviness would be immediately relieved; you will not also suffer from heart disease.) On the other hand, doubling the efforts to make it work was a behavior explained such: Ako pag under stress, ang behavior ko ay maging workaholic. (For me when I am under stress my behavior is to become workaholic.) Work ako nang work until I am exhausted; madali kang makatulog. (I work and work until I become exhausted; then I can sleep easily.) The researcher thinks that relating with someone is a good form of coping. It would somehow relieve tension and stress at least for a moment. Working is also a good kind of coping, however, not to a point where physical exhaustion would ensue. This is not totally good for the health of the nurse under stress. Again, Bugen says that one way of coping is to modify the way we emotionally respond to the situation (The New Lexicon Webster Encyclopedia, 1992). Throwing things to release tension got a mean of 1.49, described as never. This meant that nurses never used displacement as coping mechanism when under stress. In psychiatry, this is a defense mechanism in which an emotion is unconsciously transferred or displaced from its original object, as a person or situation that is disturbing to the ego, to a more acceptable, less disturbing substitute (Keltner et al, n.d.) Spiritual. The Philippine nursing curriculum, according to Capaque, has recognized the wholeness of man including the spiritual dimension such that responsible nursing calls for competence in giving spiritual care (Shelly, 2004). But what if it is the nurse who needs some form of spiritual consolation because of stress? The nurse can find comfort in St. Augustines prayer: You have made us for yourself, and the heart never rests until it finds rest in you.
God created man to be spiritual beings. This means people who seek after something beyond themselves to find context for their lives. This is most especially
true when a nurse is beset with worries, anxieties and stresses. She tries to seek God for comfort, for consolation and for guidance. The findings in relation to nurses coping mechanisms using the spiritual dimension depicted that nurses always, (3.63) always prayed to God when things are complicated and asked others to pray for me, 3.03, described as sometimes. The lowest among the coping mechanisms was rated as seldom with a mean of 2.25 was attend prayer meetings and religious activities. The nurses explanations were: For me there is only one person who is truly a Friend, a Comforter, a Counselor and a Savior, He is God. God never lets me down. He answers all my prayers in His time. When I am under stress my only recourse is God. Kasi nakikinig Siya; hindi siya tsismoso; hinahayaan niya akong magdecide kung ano ang best sa akin. (Because He listens; He does not gossip; He gives me freedom to decide what is best for me.) Yet through the Holy Spirit He tells me what to do. And so I pray to God when things become too complicated, you know. Several nurses agreed to what this nurse related. Possibly, the reason for this type of spirituality is because in BRTTH many of the nurses are active members of organizations which are the Parish Renewal Experience (PREX) in the Daraga Parish and the Workers of Christ (WOC), which is hospital based. Daily prayer, frequenting the sacraments, reading the scriptures and acts of charity were prescribed and or encouraged for all members. They were also taught to provide spiritual care to patients. And these were ordinarily observed among the nurses. The Filipino cultures current fascination to spirituality should not come as a surprise. The souls deep longing for God is a basic human need. However, the definitions of spirituality in the professional and popular literature today have differed much. Shelly (2004) adds, Any spiritual practice that brings comfort, strength or apparent healing is considered equally good and can be incorporated into health care. Further, she said: If we truly hope to meet the spiritual need of those in our care, our spiritual care must be focused on bringing people to Jesus so they can experience that healing personally. This is one of the objectives of the WOC. In addition, the members conduct Life in the Spirit Seminar for new members of the BRTTH Community with the thought that a health provider who has a good relationship with God would also establish good relationship with patients and colleagues. When one of the nurses has a problem or is under stress, the person could ask the head of the group to group themselves together to pray for the person concerned.
Oftentimes, praying within the group would relieve my tension or stress since my sisters and brothers in Christ would lift me up to Jesus my savior, said one of the nurses. Another said: Ako pag nagkarantahan na ki religious songs, na prayer man baga, minaibi na ako. Pakatapos na kaiyan, wara na an stress. (For me once the members start singing religious songs, which is prayer itself, I cry. After that my stress is gone.) Sa sakuya ang pagpakiuron sa hospital chaplain dakula nang bagay. (As for the me, talking to the hospital chaplain is already a big deal.) Attending praying meetings and other religious activities were seldom done by nurses. Maybe this was due to the bulk of work they do in the hospital which do not jibe with the schedule of these religious activities. Or perhaps responsibilities at home prevent them from attending such. Ako naman pag may time mina attend talaga ako. (As for me if I have time I really attend.) Another nurse explained: If I know the schedule ahead and I was able to arrange my duties in the hospital and the house, I attend prayer meetings and religious activities. In fact, with my family. Summary of Coping Mechanisms Utilized to Overcome Work-Related Stress. The summary demonstrates that the highest among the five factors utilized by nurses as coping mechanism was related to spiritual. Maybe the BRTTH Nursing Service culture was inclined towards the spiritual. This meant further that the nurses had strong faith in God. Psychosocial was the next coping mechanism utilized by them while the lowest was behavioral. Table 10 Summary of Coping Mechanisms Utilized by Nurses to Overcome Work-Related Stress
Over-all Mean 2.35 2.64 2.15 2.08 2.83 2.60
Physical
Coping Mechanisms
Description Sometimes (S) Seldom (SL) Sometimes (S) Seldom (SL) Sometimes (S) Sometimes (S)
Emotional Spiritual
Psycho-social Behavioral Average Mean
Strategies to Reduce Work-related Stresses The following strategies are recommended to reduce work-related stresses based on the findings for all the causes, signs and symptoms and coping mechanisms. 1. Identify stressors. Nurses can make a list of all the things that cause stress in their work. This should be done because nurses could get so stressed with multi-roles and functions given her. Some nurses maybe able to cope while others may not. 2. Stay in control. Nurses should become aware of stressors and the physical, emotional, psychological and behavioral reactions to them. They should determine how the body responds to the stress. Moreover, they should not ignore them nor gloss over them. They should also determine ways and means to stay in control of their reactions. 3. Recognize what can be changed. Nurses can change stressors by avoiding or eliminating them completely. They should reduce the intensity of these stressors by managing them over a period of time instead of on a daily or weekly basis. Nurses can shorten their exposure to stress by taking a break, leaving the physical premises and time management. With regards to emotional and psychosocial reactions to stress, nurses can reduce emotional reactions to stress by praying and asking others to pray, listening to music, talking with friends and not expecting to please everybody. Nurses should not feel that they should always prevail in every situation, hence they should work at adopting more moderate views by, for example, trying to see the stress as something one can cope with rather than something that overpowers them. Moreover, nurses can also try to temper excess emotions by not laboring on the negative aspects and what ifs. 4. Learn to moderate physical reactions to stress. As nurses, they should know how to go slow and to do deep breathing exercises that will bring their heart rate and respiration back to normal. They can do relaxation techniques to reduce muscle tension. Medications, when prescribed by a physician, can help in the short term in moderating physical reactions but nurses must realize that even if they have access to these medications, such should be used as the last resort. They can also learn to build on their physical reserves such as eating well-balanced nutritious meals, maintaining ideal weight, getting enough sleep and avoiding nicotine, excessive caffeine and other stimulants. In addition, nurses can mix leisure with work. 5. Maintain emotional, psychosocial and spiritual reserves. One good
strategy that nurses can do is to be kind and gentle with oneself such as be a friend to yourself. However, they should similarly expect some frustrations, failures and sorrows as part of life. Nurses should develop some mutually supportive friendships and fruitful relationships. Being at peace with God through the Sacraments, keeping ones faith, serving others, such as the patients who are under their care with utmost competence and filial love, being forgiving and trustworthy and cultivating ones personal and professional values could very well help once stress crosses the nurses way. 6. Develop the spirit of hope. Optimism is a good way to look at stress. An optimistic outlook helps people deal better with stress. This will ultimately enable the nurses to think better and feel better about themselves. It would also lower the risk of developing in them stress-related ill health. Conclusions and Recommendations The following conclusions were derived from the findings of the study: 1. Situations related to Role, Interaction, Communication and Transaction can cause moderate level of stress among nurses caring for post-operative patients in clinical areas of the hospital. Transaction and Interaction produce high level of stress among nurses concurring with Lazarus statement that the stimulus and response do not consider individual differences. 2. Nurses who take care of post-operative patients seldom manifested physical, emotional, behavioral and psycho-social signs and symptoms. 3. Working among patients in a hospital can produce stress. There are, however, ways of coping which can be utilized by nurses and most often it is related with spiritual. Authors term this coping mechanism as fight. 4. There are strategies to reduce work-related stresses.
The following are the recommendations of the study: 1. Situations that cause stresses to nurses. This research would like to recommend that the level of stress experienced by nurses taking care of postoperative patients in selected areas of BRTTH should be lowered from moderate to low level of stress. In as much as, among the four factors of stress namely, Role, Communication, Interaction, Transaction, the last two had high level of stress, the researcher would therefore recommend the following measures: Provision of life-saving materials and equipment to facilitate nurses in giving immediate post-operative care; head nurses must see to it that all equipment are functional and available at all times.
Along Interaction, training among nurses and other hospital persons taking care of post-operative patients must be done to improve their dealings with patients, watchers and significant others. Hospital administration should implement stress management programs to help employees cope with their everyday stress. To the hospital administrator, especially the Supply Officer, to see to it that all supplies should be available at all times; To the chairman of the Continuing Education Program to conduct debriefing to nurses 2. Signs and symptoms manifested by nurses when under stress. Among the signs and symptoms manifested by nurses under stress, the physical factors were the highest. In relation to this, the researcher would like to recommend a stress debriefing to be attended by the nurses, as well as their patients if possible and the watchers to help them release their stress and the tension that they feel. Relaxation techniques can also be recommended to the nurses that they can do while on duty or after duty to reduce muscle tension. 3. Mechanisms instituted by nurses to cope with stress. The nurses had high level of faith in God when it comes to coping with stresses while the lowest coping mechanism that they utilized was under behavioral factor. The researcher would then like to recommend some coping mechanisms that they can utilize with regards to their behavior. A weekly or monthly meeting can be done to let the nurses and other co-workers open-up their feelings and share their experiences about the things that happened before and talk about how they can deal with such experience. 4. Nursing strategies that can be recommended by the study to decrease stress in the workplace. There are strategies recommended by the researcher in the previous topics that can decrease stress in he workplace such as identifying stressors, staying in control, recognize what can be changed, learn to moderate physical reactions to stress, maintain emotional, psychosocial and spiritual reserves and deepening the spirit of hope.
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IMPLEMENTATION OF THE NATIONAL POLICY ON HEALTH EMERGENCIES AND DISASTER STRATEGIES INTERVENTION
Marlyn A. Daguno Introduction Major emergencies, disasters and other crises are no respecters of national borders and never occur at convenient times. The magnitude of human suffering caused by these events is huge, and many aspects of peoples lives are affected- health, security, housing, access to food, water and other life commodities, to name a few (Alwan, Risk reduction and emergency preparedness, www.google.com) Disasters are not new. They happen anywhere and anytime. The number of disasters around the world over the past 30 years has doubled. From January to October 2005, an estimated 97,490 people were killed in disasters globally; 88,117 due to natural disasters. The highest recorded fatalities occurred in 2004 with nearly 300,000 deaths (Bulletin of the World Health Organization, January 2006, p. 11, Internet, www.google.com.). Factors identified were not merely caused by natural disasters but some complex mix of factors including climate change, global warming and socio-economic factors. Although most large-scale disasters occur in developing countries, events such as Hurricane Katrina in 2005 and the September 11 terrorist attacks in 2001 are reminders that the United States is not immune to large-scale disasters. Tropical cyclone Nargis hit Myanmar that fateful day of May 3, 2008. In terms of death, the toll may number in the tens of thousands, but the dying, in hundreds of thousands. Nine days after, China was hit by a 7.9 magnitude quake, a powerful earthquake which toppled buildings, schools and chemical plants. The Philippines ranks first in the world in terms of the number of natural disasters. The geographic location of the country makes it most vulnerable to disasters and hazards, natural and man-made. An average of 19 typhoons occur annually resulting to flashfloods in lowland areas (Administrative Order
No. 6-B series of 1999, HEMS Handbook).. The Mount Pinatubo eruption was considered one of the worst volcanic eruptions in the world. Typhoon Reming in Novemver 30, 2006 greatly affected the province of Albay particularly the towns of Camalig, Guinobatan and Sto. Domingo including Legazpi City. After a devastation, more profound problems arise aside from loss of lives. Injuries and debilitation are rife. Shelter is usually gone. Food and supplies are scarce. Displacement, disease, malnutrition and disruption of essential services are more insidious. These are harsh realities which both the victims and people involved in disaster management need to face. The government has the inherent function to protect the lives and properties of the people. To face the challenge in terms of disaster scenarios, Administrative Order No. 168 series of 2004 paved the way to establish the National Policy on Health Emergencies and Disasters (NPHED). This was anchored on Presidential Decree 1566 known as Strengthening the Philippine Disaster Control Capability and Establishing the National Program in Community Disaster Preparedness (Administrative Order No. 168 series of 2004, HEMS Handbook). This institutionalized the disaster management structure from the national government down to the barangay level of which the Department of Health (DOH) is mandated as the primary agency within the National Disaster Coordinating Council (NDCC) to address specific health problems related to emergencies and disasters. In this case, the Health Emergency Management Staff (HEMS) of the DOH is tasked to call and organize all national and local health agencies and organizations to consolidate and solidify their concerted and collective efforts toward efficient and effective health emergency management. Its role in health emergency management is to lead the health sectors preparedness and response based on the existing government structures. Prevention, mitigation, preparedness, response and recovery were the activities that need to be undertaken in order to avoid the adverse effects of disasters. The goal of which is to achieve a satisfactory level in order to save lives and minimize human sufferings. The Bicol Regional Training and Teaching Hospital (BRTTH) a 250-bed capacity hospital and the Bicol Medical Center (BMC) a 500-bed capacity hospital are government tertiary hospitals in the Bicol Region. The former is located in Legazpi City while the latter in Naga City. Guided by the mandate articulated in the said Administrative Order, BRTTH and BMC have to effectively and efficiently carry out the mandate to implement the intended mission of the program.
In response to this call of duty to address emergencies brought about by disasters, both man-made and natural, these health institutions through the HEMS have since then, implemented the program to the present. Paramount to its effective and efficient implementation is the data that speak of the status as to whether the implementation is in accord with their mandate. In 2007, the researcher conducted a study at the BRTTH to determine the implementation of the National Policy on Health Emergencies and Disasters in relation to its policies. This research, however, looked into the status of its implementation in BRTTH and BMC with emphasis on strategies and interventions for the problems encountered during its implementation. The necessity to conduct an inquiry becomes imperative, so that whatever deviation from the established intention there is, can be out rightly corrected. The Problem This study determined the implementation of the National Policy on Health Emergencies and Disasters in the Bicol Region with emphasis on strategies and interventions. Specifically, it sought answers to the following questions: 1. What is the status of implementation of the National Policy on Health Emergencies and Disasters along the following strategies: a. Capacity Building and Facilities Enhancement, b. Service Delivery, c. Health Information and Advocacy, d. Health Policy, e. Networking and Social Mobilization, f. Research and Development, g. Resource Mobilization, h. Information Management and Surveillance, i. Standards and Regulation, and j. Monitoring and Evaluation? 2. What are the problems encountered in the strategy implementation of the National Policy on Health Emergencies and Disasters? 3. What interventions may be developed to enhance the strategy implementation of the National Policy on Health Emergencies and Disasters?
Conceptual Framework The DOH through the HEMS is the lead agency in managing health emergencies and disasters. Pursuant to this, the Secretary of Health issued the National Policy on Health Emergencies and Disasters under AO 168 series of 2004. DOH offices, hospitals and their attached agencies are mandated to implement this. It shall likewise apply to all disciplines and institutions, whether government, non-government or private entities whose functions and activities contribute to health, emergency preparedness and response. Figure 1 shows the conceptual framework.
BRTTH and BMC National Policy on Health Emergencies and Disasters (NPHED)
Status of Strategy Implementation Problems Encountered
Interventions - Daguno Cornerstone Theory of Interconnectivity - Implementing Rules and Regulations (IRR) of AO 168
Enhanced Level of Implementation of NPHED
Figure 1. The Conceptual Framework Model
The BRTTH and the BMC are government service hospitals mandated to implement the National Policy on Health Emergencies and Disasters. The former is a 250-bed capacity hospital in Legazpi City catering the provinces of Albay, Sorsogon, Catanduanes and Masbate while the latter is a 500-bed capacity in Naga City considered as the catchment area for Camarines Sur and Camarines Norte. Both are service, training and teaching, and research hospitals. But, BRTTH and BMC cannot effectively and efficiently respond by themselves in times of crisis. Hence, there is a need to involve the community which is considered the front liner in disaster preparedness. Involvement is important in providing a culture of prevention. NGOs and other health related sectors such as the PNRC and PDCC could help in facilitating capacity building through trainings, search and rescue and other services. These agencies are important to carry out the four (4) phases of disaster management which are mitigation, preparedness, response and recovery. For its full implementation, strategies of the National Policy on Health Emergencies and Disasters were carried out. These include capacity building and facilities enhancement; service delivery; health information and advocacy; health policy; networking and social mobilization; research and development; resource mobilization; information management and surveillance; standards and regulation; and monitoring and evaluation. Along its assessment, problems were identified which served as the bases for the interventions using the Daguno Cornerstone Theory of Interconnectivity and the Implementing Rules and Regulations (IRR) of AO 168 that would help enhance the implementation of the National Policy on He alth Emergencies and Disasters in relation to the strategy used. Daguno Cornerstone Theory of Interconnectivity This theory was formulated for the purpose of this study and it could be labeled as Daguno Cornerstone Theory of Interconnectivity. It is based on a firm belief that leadership, human instinct, commitment and love and respect are four pillars which drive a person to achieve a goal even without remuneration. This is shown in Figure 2. The first pillar is leadership. A good leader uses the heart not only the mind when managing people. A good leader is someone who is looking for a person who can replace him anytime. Credit for success is a group rather than an achievement. He/She acknowledges that members are important, competent and effective. He/She does not leave his/her flock and his/her
flock never leaves him/her as well. Working with a good leader is fun, different and meaningful. This kind of leader motivates followers to accomplish a certain goal. Human instinct is the second pillar. Everyone possesses an armory of instinct to protect oneself and others. No matter how bad a person is, he/ she has a certain degree of desire to help those who are in need. Unlike many animals, humans have the willingness to risk lives for people who are not related to them. This is particularly true during emergencies and disasters. A desire to help others reveals a strength of character that can never be explained. Outstanding among these factors in individual and group success is commitment. This is the third pillar which drives a person to work hard not only for oneself but also for others. Commitment ignites action. Commitment has no question about time and effort. It is based on a firm determination to accomplish goals within the group or organization. Genuine commitment stands the test of time. It calls for a leader who leads by example. It is a two-way street. One only gets it if one is willing to give it.
Figure 2. Daguno Cornerstone Theory of Interconnectivity
No amount of hardship can take people apart if they have established a relationship based on love and respect, and this is the final pillar. Love and respect motivate a person to strive and work hard to accomplish tasks. Focus is not on oneself but on others. But love alone is not enough, each one needs respect which is valuing a person as an important being. These four (4) pillars drive a person to act even without remuneration. This will enhance the interconnectivity of human beings leading to improved health emergency and disaster management.
Methodology This study utilized the descriptive design. The descriptive method was used to describe the nature of a situation as it exists at the time of the study and to explore the causes of a particular phenomenon (Travers, 1992). Gay (1992) defines descriptive research as involving the collection of data in order to test hypothesis or to answer questions concerning the status of the phenomenon under study. The descriptive design was employed in this study to gather information about the present status of implementation of the National Policy on Health Emergencies and Disasters along the following strategies, namely: capacity building and facilities enhancement; service delivery; health information and advocacy; health policy; networking and social mobilization; research and development; resource mobilization; information management and surveillance; standards and regulation; and monitoring and evaluation. Further, the focus group discussion (FGD) with key personnel in-charge in the implementation of the National Policy on Health Emergencies and Disasters was conducted to identify problems faced by implementers and possible solutions on how to mitigate the identified problems. As such, the descriptive research design was appropriate for this study as it attempted to determine the status of strategy implementation and identify problems faced by implementers. From these, interventions on how to mitigate them were forwarded. In both cases, qualitative and quantitative data and their analysis was employed. The study utilized primary and secondary data. Primary data were taken from the respondents of the study, such as the members of the executive committee, division heads of medical and administrative departments, training officers, assistant chief nurses, supervising nurses, head nurses
and Health Emergency Management Staff (HEMS) officers. The secondary data were taken from published and unpublished sources such as journals, pamphlets, theses and dissertations, reports, administrative orders, and electronic information from the Internet. The study employed purposive sampling. The selection was based on the position held in the organization and/or committee. They are members of the executive committee, division heads of medical and administrative departments, training officers, assistant chief nurses, supervising nurses, head nurses and HEMS officers of the Bicol Regional Training and Teaching Hospital (BRTTH) in Legazpi City and Bicol Medical Center (BMC) at Naga City. In the BRTTH, the executive committee members and supervising nurses should have been four and six, respectively. But, because one of the executive committee members was the researchers adviser and one of the supervising nurses is the researcher herself and an officer of HEMS, they were excluded as respondents of the study. The assistant chief nurses were either for services or training and research. At the BMC, all personnel directly involved in the implementation of the National Policy on Health Emergencies and Disasters were included. There was a total of 127 respondents. The researcher prepared a questionnaire based on Administrative Order 168, series of 2004 issued by the Office of the Secretary of Health as basis. The survey questionnaire was about the status of strategy implementation of the National Policy on Health Emergencies and Disasters along capacity building and facilities enhancement; service delivery; health information and advocacy; health policy; networking and social mobilization; research and development; resource mobilization; information management and surveillance; standards and regulation; and monitoring and evaluation. Statements for each variable are written for the respondents to determine the status of strategy implementation. The statements that determine the level of strategy implementation for each variable are culled from Administrative Order 168, series of 2004. At the end of every statement is a free option for the respondents to fill in if they had additional information to present. The level of strategy implementation had five scales (Bailey, 1994), namely: very extensive strategy implementation (VE), extensive strategy implementation (E), moderately extensive strategy implementation (ME), fairly extensive strategy implementation (FE) and not extensive strategy implementation (NE), repre-
sented by a concomitant interpretation. Aside from the questionnaire, the researcher also prepared an interview guide, which was utilized to gather further data using the FGD). FGD according to Bailey (1994) is a qualitative method of gathering data consisting of a guided discussion, led by a trained moderator, and designed to provide information on certain topics from a certain population. The results of the trial run served as the basis for preparing the interview guide. The FGD was done at BRTTH and BMC on August 19 and 28, respectively with 30 participants with an objective to identify the problems encountered by implementers and the interventions in order to enhance the strategy implementation of the National Policy on Health Emergencies and Disasters. After retrieving the questionnaire, the quantitative data was collated in a master data sheet. The statistical summaries such as frequency distribution and weighted mean were computed. For the qualitative data taken from the FGD, a write-up of the problems and solutions in the strategy implementation of the National Policy on Health Emergencies and Disasters were written using the words of the members and was translated by the researcher. Analysis, interpretation, inferences and implications were discussed in relation to the level of strategy implementation. To address the problems encountered during the implementation of the program, interventions were forwarded using the Daguno Theory of Interconnectivity which is leadership, human instinct, commitment and love and respect. Discussion of Results Status of Strategy Implementation On Capacity Building and Facilities Enhancement. The data on capacity building and facilities enhancement is shown in Table 1 with all five indicators in moderately extensive level of strategy implementation (ME) and with a weighted mean of 3.17. Among the indicators, availability of ambulance designated for emergencies with equipment, supplies and communications got the highest mean of 3.34. This means that there is an available ambulance for emergencies and disasters; however, the moderately extensive rating (ME) still shows the need to exclusively use the ambulance for health emergencies and disasters purposes and the need to complete such in terms of equipment, supplies and communications.
Table 1 Status of Strategy Implementation Along Capacity Building and Facilities Enhancement
Strategies Weighted Mean 3.29 2.73 3.23 3.34 3.17 3.25 Adjectival Interpretation
Provision of training on health emergency preparedness to all personnel.
Involvement of community in terms of training on health emergency preparedness. Availability of 24/7 (24 hours a day/7 days a week) operation center. Availability of training and radio communication equipment Average Mean Availability of ambulance designated for emergencies with equipment, supplies and communications.
Legend: VE: 4.20 5:00
Moderately Extensive (ME) Moderately Extensive (ME) Moderately Extensive (ME) Moderately Extensive (ME) Moderately Extensive (ME) Moderately Extensive (ME)
ME: 2.60 3.39
One of the respondents elaborated on the importance of a dedicated wellequipped ambulance. He said: If the ambulance is not exclusive for emergencies and disasters pano kun naghatod ki pasiente an driver dara an ambulance tapos bang, bang, pumutok pala an Mt. Mayon na walang warning gaya nong 1993 ( what if the driver transported using the ambulance, then bang, bang, Mt. Mayon erupts without warning just like in 1993.) Another respondent said: Whats the use of an ambulance if it is not wellequipped? Communication equipment must, of course be included aside from those for diagnosis and treatment. Both these observations are relevant. Memorandum no. 120, series of 20031, emphasized the importance of an ambulance for easy dispatch of teams. The ambulance shall be provided with the necessary equipment, medicines, supplies and communication for proper coordination. Authority shall be given to the Health Emergency Management Staff (HEMS) coordinator in the dispatch of these ambulances to prevent delays of response and to authorize any member of the team to drive in case there is no available driver. The lowest among the moderately extensive ratings (ME) with a mean of 2.73 was involvement of community in terms of training on health emer-
FE: 1.80 2.59 E: 3.40 4.19 NE: 1.00 1.79
gency preparedness. It could be deduced from this data that trainings on health emergency preparedness should not only focus on hospital personnel but should also include the community. This should be given priority because during emergencies and disasters, the community is usually the first to be affected and the first to provide emergency assistance as well. Hence, training particularly on first aid and or first responses is vital. Therefore, both first responders which may include the community and hospital staff must be trained in the care of victims in order to minimize loss of lives or extensive disabilities. In the previous research conducted entitled The Implementation of the National Policy on Health Emergencies and Disasters in relation to its policy, coordination with community in all phases of disaster management and programs along program development also got a low level of implementation. Today, the fast turnover of HEMS coordinator at the Bicol Medical Center (BMC) affected many of the activities, particularly on community involvement. This is understandable, for an organization must first of all attend to the needs within its grounds before anywhere. Moreover, the Bicol Regional Training and Teaching Hospital (BRTTH) HEMS, though there has been no change in the organizational structure and its strength is in its active members, has not opened its bin to the community. In other words, the seed has not yet been planted by the BRTTH HEMS with regard to promoting disaster preparedness in the community. When some of the respondents were asked about this seemingly weakpoint along capacity building, these were some of their answers: Seguro, eh, di lang nasisiguro ng team kung mag-spill over ng capability training ang hospital para sa community o duty na ito kan Provincial Health Office (PHO). (Perhaps the hospital team is not sure whether they would spill over the capability training of the hospital for the community or this is already the duty of the PHO.) Kailangan talaga ang capability building ng community dahil sila ang unang tinatamaan ng calamity or disaster; sila rin ang makaka assess ng pangangailangan nila for their own protection and safety. added another from BMC. (There is really a need for capability building of the community because they are the ones affected by calamity or disaster; they can also assess their own need for protection and safety.) However, about 80% of the community who were within the danger zones of Mayon Volcano are now trained. This is a good sign that people had been aware of the need for health emergency and disaster preparedness. Further, this also means that the Provincial Disaster Coordinating Council (PDCC) had been doing its job well.
Moreover, it can be mentioned that the media, especially the radio has been active and effective in the dissemination of warnings or alert levels of disasters. In a way, the Bicolanos have learned to listen and follow directives from government authorities aired by media practitioners. Such could be considered as training for the community.
On Service Delivery. The data on service delivery are shown in Table 2 and the level of implementation was 3.51 or extensive (E). Four out of five variables were rated extensive (E): direct services available (promotive, preventive, curative and rehabilitative) with a mean of 3.69; availability of backup power supply in case of power failure, 3.70; completeness of diagnostic laboratory examinations, 3.46 and response services provided by competent, compassionate and dedicated personnel, 3.47. Table 2 Status of Strategy Implementation Along Service Delivery
Strategies Weighted Mean 3.69 3.70 3.46 3.23 3.47
Direct services available (promotive, preventive curative and rehabilitative). Completeness of diagnostic laboratory examinations. Response services provided by competent, compassionate and dedicated personnel. Average Mean
Adjectival Interpretation E E E ME E
ME: 2.60 3.39
Availability of back-up power supply in case of power failure.
Presence of emergency dispatch and response team with proper scheduling.
Legend: VE: 4.20 5:00
Based on the data, availability of back-up power supply in case of power failure with a mean of 3.70 got the highest rating among the variables rated as extensive level of implementation (E). This is because BMC and BRTTH have large generators that could illumine the hospital in less than a minute particularly some special areas such as the intensive care, critical care, and
FE: 1.80 2.59 E: 3.40 4.19 NE: 1.00 1.79
3.51
neonatal intensive care units and the delivery, emergency and operating rooms. The lowest rating among the extensive ratings (E) with a mean of 3.46 was completeness of diagnostic laboratory examinations. This means that there were times when reagents were not available. As pointed out in literatures, a safe hospital can still continue to provide services even when disaster strikes. Hence, there is a need for the management to look into the preparedness and protective measures before disaster happens. Indeed, an ounce of prevention is better than a pound of cure. Findings also showed that the lowest among the variables along service delivery with a mean of 3.23 was the presence of emergency dispatch and response team with proper scheduling. Response team is vital because nobody knows when disaster would happen. Identification of the team members and proper scheduling are in order for their dispatch anytime. The team should, likewise, be sent for trainings to equip them with the necessary knowledge, attitude and skills with the aim of minimizing loss of lives among victims. BMC has an operation center with an emergency dispatch team manned by volunteers but is only available during the morning shift. The BRTTH, on the other hand, is still working toward composing an emergency dispatch team. Recently, the HEMS central office, allotted the amount of P535,000.00 to selected government hospitals of which BMC and BRTTH are recipients. The former will use the amount to improve the operation center and to purchase necessary equipment, supplies and medicines for health emergency and disaster use. The latter, on the other hand, will create a fully equipped 24/7 (24 hours a day/7 days a week) operation center with necessary supplies and materials. This can be achieved through leadership, commitment and prioritization of people involved. By and large, there were problems on emergency dispatch. One member said: Ma identify kaya kita if something happened to us? (Will we be identified if something happened to us?) The HEMS is working on a voluntary basis and work is largely a sacrifice on their part. The position of an officer or a member is an additional load. They are called whenever needed, risking their lives nonetheless with a feeling of fulfillment whenever the group contributed to save lives and limbs of victims brought about by disasters. On Health Information and Advocacy. Table 3 presents the status of strategy implementation along health information and advocacy. Gleaned from the data celebration of National Disaster Consciousness Month (July)
and Disaster Prevention Week (December) observed got a mean of 3.57, meaning, there was an extensive level of implementation (E) among the two government retained hospitals of the Department of Health (DOH) such as the BRTTH of Legazpi City and the BMC of Naga City. The rest of the variables had moderately extensive level of implementation (ME). The average mean was 3.16 or a moderately extensive level of implementation (ME). The extensive rating was expected because the observance of such activity had been implemented since the creation of HEMS. Activities include poster making and essay writing contests and lectures on health emergencies and disasters participated in by different schools. The Philippine National Red Cross (PNRC), Albay Chapter had a participant who subsequently won the first prize in poster making contest. Table 3 Status of Strategy Implementation Along Health Information And Advocacy
Weighted Mean 3.22 3.08 2.93 3.57 3.16 3.00
Activities informing the public on prevention and preparedness for emergencies and disasters done. Basic First Aid in managing emergencies at home, schools, work place, public places, etc. conducted. Celebration of National Disaster Consciousness Month (July) and Disaster Prevention Week (Dec.) observed.
Legend: VE: 4.20 5:00
Strategies
Adjectival Interpretation ME
Activities empowering the community through health education and promotion done. Distribution of health emergency related posters, flyers and advisories. Average Mean
ME
ME
E ME
ME: 2.60 3.39
FE: 1.80 2.59 E: 3.40 4.19 NE: 1.00 1.79
ME
Minsan nagkakasabay-sabay an mga actibidades sa ospital lalo na kun Disaster Consciousness Month. If there are conflicts of schedule, ang nasasakripisyo iyo an HEMS program. says one member of BRTTH-HEMS. (There
are times when other hospital activities, aside from HEMS are also scheduled during the Disaster Consciousness Month. If there are conflicts of schedule, the HEMS program is sacrificed.) This shows the need for the proper scheduling of all activities so that schedule and preparation of all hospital activities will not be disrupted. Another problem is when some community participants are not available in the conduct of health education. On July 23, 2008, a Nationwide Earthquake Preparedness Drill was conducted simultaneously among hospitals for which BRTTH and BMC were participants. A post-earthquake preparedness drill evaluation was done to test existing preparedness plans of the DOH hospitals to the possible occurrence of an earthquake. In the BRTTH, some of the recommendations were availability of 24/7 operation center with back up supplies and equipment; presence of emergency dispatch and response team; and availability of a radio communication equipment for the senior house officer, the response team, the guard on duty, the driver and the staff of the emergency room (ER) and maintenance unit. Lessons learned were readiness of the ER in times of disaster especially during an earthquake because such occurrence can never be predicted. Under the moderately extensive level of implementation (ME), the highest item which got a mean of 3.22 was activities informing the public on prevention and preparedness for emergencies and disasters done. This is due to the activities done during the month of July and December observing the Celebration of the National Disaster Consciousness Month and Disaster Prevention Week, respectively participated in by some members of the community and government and non-government agencies. The lowest rating with a mean of 2.93 among the moderately extensive (ME) rating was activities empowering the community through health education and promotion done. This implies the need to involve the community in terms of disaster preparedness. Shaeffer2 said: Education and knowledge have the power to save lives. Moreover, the Health Promotion Sub-cluster3 emphasized the need to conduct health education and promotion using basic health messages and compilation of information, education and communication materials. During the process, health and non-health response workers should always remember to use language and techniques that are appropriate to the psycho-socio cultural orientation of the audience. Empowering the community is the key to success of disaster preparedness. This study strongly believes that saving lives is in the hands of the people themselves. Although the need for knowledge through education is imperative,
learning is still a personal matter. Power comes not only from the external but more so from the internal source. It cannot be discounted, however, that people get knowledge from those who have them. Thus, the latter, like the HEMS must share these to those in need: the community. They are the first implementers of the knowledge on prevention and preparedness for emergencies and disasters. In addition, a separate budget exclusively for health education and advocacy would help in the continuity and sustainability of the activities. This would enhance the implementation of the program. On Health Policy. The data on the level of strategy implementation along health policy is presented in Table 4 showing that among the five indicators, three of which were in extensive level of implementation (E): support the DOH- Health Emergency Management programs had a weighted mean of 3.57; establishment of health emergency management systems had a weighted mean of 3.55; and development of policies, procedures, guidelines and protocols had 3.46. On the other hand, support lawmakers regarding laws related to disaster preparedness and advocates researches on health emergencies for policy development were rated moderately extensive (ME) with a weighted mean of 3.20 and 3.10, respectively. Table 4 Status of Strategy Implementation Along Health Policy
Strategies Weighted Mean 3.20 3.57 3.55 3.46 3.38 3.10
Support lawmakers regarding laws related to disaster preparedness.
Adjectival Interpretation ME E E E ME
ME: 2.60 3.39
Support the DOH-Health Emergency Management programs. Establishment of health emergency management systems.
Development of policies, procedures, guidelines and protocols.

Legend: VE: 4.20 5:00
Advocates researches on health emergencies for policy development. Average Mean
FE: 1.80 2.59 E: 3.40 4.19 NE: 1.00 1.79
ME
Based on the above data, implementation along health policy was moderately extensive (ME) only, with a weighted mean of 3.38. On the extensive level of implementation (E), it should be noted that the rating for development policies, procedures, guidelines and protocols was lower than establishment of health emergency management systems. True enough policies should be polished before systems can be established. The highest rating was support the DOH-Health Emergency Management programs which means that the two hospitals, the BRTTH and the BMC had complied with the mandate that health is a basic human right only that its implementation was 61-80%. Looking at the history of emergency management programs, the DOH has established this in the nineties (90s). This was called STOP DEATH (Strategic Tactical Option for the Prevention of Disasters, Epidemics, Accidents and Trauma for Health). The program skyrocketed for the first five (5) years or so then dissipated. It was only thought of and utilized when disasters and or emergencies occurred. Preparation was not continuous and thorough; it was clouded by other health programs. Until recently when health emergencies and disasters occur more often and in great intensity, the government through the DOH revisited the program, its policies, procedures and guidelines. There were too much to attend to: threats of pandemics and epidemics, threats to ultra rightists and terrorists, volcanic eruptions, strong typhoons, flash floods, air, water and road mishaps, and the like. Too much to do with too little time, people, money and other resources. There was a need to prepare to contain all these even with too little. Much could be done if everyone could join hands. Together work can be lot easier. The 61 to 80% implementation of the program is good enough for a program that has just gained momentum again. Perfection or excellence can be attained later for as long as there are committed people, even with little resources to make it soar to its highest. Advocates researches on health emergencies for policy development with a weighted mean of 3.10, got the lowest rating among the five variables with moderately extensive level of implementation (ME). This is due to the fact that research is perceived to be difficult, time consuming and a waste of money. This study proposes that research be included in disaster planning as a way to determine strengths and weaknesses of the services provided to all clients. Management support is, likewise, solicited in order that researchers would have the enthusiasm to pursue such endeavor.
On Networking and Social Mobilization. The data in Table 5 on networking and social mobilization show that coordination with the DOH-HEMS central office and other government and non-government agencies done during the disaster got extensive level of implementation (E) with a mean of 3.73. The rating is a result of the coordination done during the Typhoon Reming experience last November 30, 2006. DOH-HEMS central office and other government and non-government institutions offered help in the form of supplies, equipment and medicines. Augmentation team composed of doctors and nurses from the different hospitals in Metro Manila was deployed at the BRTTH. The BMC staff, on the other hand, helped manning the tent city established by international organizations to decongest hospitals where victims of Typhoon Reming were confined. Table 5 Status of Strategy Implementation Along Networking And Social Mobilization
Representative from the community involved during the disaster planning. Multi-sectoral activities participated. Establishment of Memorandum of Agreement (MOA) with other health sector.
Adjectival Interpretation ME ME ME ME
Community participation are encourage in all phases of the disaster. Coordination with the DOH-HEMS Central Office and other government and non-government agencies done during the disaster. Average Mean
E
ME: 2.60 3.39
Legend: VE: 4.20 5:00
The highest rating among the moderately extensive level of implementation (ME) was multi-sectoral activities participated with a mean of 3.18. This means that the BRTTH and the BMC have networked with other government and non-government organizations whenever needed. Such activities included Magayon Festival, Our Lady of Peafrancia Celebration, intramurals and parade
FE: 1.80 2.59 E: 3.40 4.19 NE: 1.00 1.79
ME
during occasions and many others. Recently, the BRTTH HEMS coordinator and at the same time the designated ER Head provided assistance by assessing the situation in Masbate where several cadavers were found after the Princess of the Stars capsized in Romblon. The lowest rating with a weighted mean of 3.09 was establishment of memorandum of agreement (MOA) with other health sector. MOAs are considered part and parcel of networking for disasters so that when time comes everything are in place in terms of what the agency can offer. It is said that no man is an island. When others take part in any difficult situation it becomes easy. Problems are readily solved when several others discuss and help in their resolution. One man cannot claim to have all the solution to all problems at all times. He would certainly need others to help him. Such is the beauty of networking. Some of the members of the HEMS said: Dapat humingi talaga ng tulong sa ibang tao o ahensiya. Mahirap gawin mag-isa ang lahat ng bagay lalonglalo na pag-emergency or disaster ang pinag-uusapan. (Theres really a need to ask help from other people or agency because its difficult for a person to solve problems especially during emergencies and disasters.) According to HEMS coordinator: Even within the hospital there is a need for coordination, collaboration and cooperation. Outside much less. Take the case of the Mt. Mayon eruption in 1993. The hospital put to full force its networking and social mobilization. With the aid of the broadcast media, Albayanos, in particular, displayed its social force by calling on people to help in search and rescue; to give or share their resources, money or goods; to assist in providing correct information and health education in treatment, care and rehabilitation; to provide transport to those in need, and other similar accounts. Help poured in. People were mobilized. There was a show of compassion, sympathy and unity; the fruits of which were peace and charity in its truest sense. So mga tao sararo talaga. Patarabang-tabang. Nahiling su pagmakulog sa kapwa. Iyo ini an tunay na cumonidad na Kristiyano, quoted by an old member of STOP DEATH. (The people were one in helping each other. You can see their concern. This is a true community of Christians.) On Research and Development. As shown in Table 6, all the variables along research and development got moderately extensive level of implementation (ME). However, from among them, the highest was support researches
related to emergencies and disasters and the lowest was conduct research related to health emergencies and disasters with a mean of 3.14 and 2.91, respectively. The data revealed that to support research is easier than to conduct it. Support extended to the researcher during the previous research conducted gave the highest rating among the indicators. In addition, research is perceived to be difficult, time consuming and is a waste of money. But, there is a need for research in order to improve disaster management and implement policy change. In line with this, the Evidencebased Practice Program, an Agency for Healthcare Research and Quality (AHRQ)4 developed scientific information for agencies and organizations on which to base clinical guidelines, performance measures and other quality improvement tools. Table 6 Status of Strategy Implementation Along Research And Development
Conduct research related to heath emergencies and disasters.
Adjectival Interpretation ME ME ME ME ME
ME: 2.60 3.39
Coordinate with nursing schools regarding participation in research. Submit case reports or other paper presentations.
Legend: VE: 4.20 5:00
Participate in research related to health emergencies and disasters.
Support researches related to emergencies and disasters. Average Mean
Hopefully this study could pave the way for other researches. Research may not be as complex or expensive for as long as it is valid and reliable, and provides conclusions and pertinent recommendations. Deficil kaya baga an research. Dakul an kinukunsumong oras asin tao. (Research is difficult. Lots of time is needed including people who are going to help.)
FE: 1.80 2.59 E: 3.40 4.19 NE: 1.00 1.79
ME
Another said: Minsan dai pa pipaniwalaan; dakul pang hapot. Nakakatakot lugod. (At times no one believes. A lot of questions are asked. It becomes scary.) This is a general perception of many people who have not done any research. But research is very fulfilling. If more researches are done in connection with health emergencies and disasters, many lives could be saved in the future. The extensive study of Al Gore, former Vice President of the United States of America, caused many countries to heed his call or recommendation to help prevent global warming. Moreover, one good result of his study is peoples awareness of the worlds situation about emergencies and calamities and how it could be stopped.
On Resource Mobilization. The data on resource mobilization is shown in Table 7. Out of five strategies implemented along resource mobilization, the highest among the variables with extensive level of implementation (E) was persons responsible during health emergencies and disasters identified with corresponding responsibilities with a mean of 3.59. This means that the organizational structure in terms of persons responsible whenever there is an emergency and disaster is already in place. This supports the findings of the previous research conducted on Implementation of the National Policy on Health Emergencies and Disasters in BRTTH. Along organizational structure, the variable availability of health emergency management coordinator got the highest rating with a mean of 4.05. In addition, members of BRTTH HEMS have been identified and have corresponding designations signed by the Chief of Hospital (COH). A copy of which had been forwarded to DOH. Moreover, the members had been furnished a written copy of their responsibilities. Aside from this, discussions on their job description along health emergency management and disaster preparedness were done on several occasions, with or without calamities or emergencies. Ideally, resource management include assessment of availability of resources namely, staff, supplies, medicines, food, water and power. Without these, a facility might be unable to care for patients and might be evacuated. Abrenica5 pointed out in his study that search and rescue operations could be hampered due to lack of these resources. The latest catastrophe in 2006, Typhoon Reming, what was observed was kulang su tao sa ER na masalida sa mga duty na nagserbisyo na ki 24-36 hours. Paragalon na talaga pero su adrenaline halangkawon pa kaya dai man
na errors na naginibo. (There was lack of personnel to relieve the ER staff who already worked for 24-36 hours. They were very tired but the adrenaline was high so there were no errors committed.) Table7 Status of Strategy Implementation Along Resource Mobilization
Weighted Mean 3.46 3.59 3.13 3.48 3.41 3.41
Availability of updated lists of personnel to recall during emergencies and disasters with cellular and phone numbers. Persons responsible during health emergencies and disasters identified with corresponding responsibilities. Orientation of new employees regarding expectations during health emergencies and disasters done.
Strategies
Adjectival Interpretation E
Response team mobilized when needed.

Legend: VE: 4.20 5:00
ME E E
ME: 2.60 3.39
Availability of supplies within 72 hours post-disaster. Average Mean
An nagkulang pa iyo su tubig pero naremedyohan man tulos. (There was lack of water but the problem was resolved immediately.) Power was easily restored because of the available generator and crude oil. Availability of supplies within 72 hours post-disaster with a mean of 3.41 got the lowest rating among the variables rated extensive (E). This is due to the experience during Typhoon Reming at the BRTTH when supplies became scarce. There was money but there were no suppliers because they were victims themselves. Transportation was hampered due to toppled trees and lahar flow from the Mayon Volcano. The variable which garnered a moderately extensive level of implementation (ME) or 3.13 response was orientation of new employees regarding expectations during health emergencies and disasters done. As usual some employees were difficult to convince. Orientations like this are not given
FE: 1.80 2.59 E: 3.40 4.19 NE: 1.00 1.79
priority in the schedule, especially among doctors and some support group. There is a need to sanction those who fail to attend important orientations such as expectations in times of health emergencies and disasters. It has been an observation that despite a special order from the COH, many still disregard the order. Some say: Eh dai man ika maano kun dai ka mag attend, di ba? (Anyway nothing is going to happen to you if you will not attend, isnt it?) Ulang-ulang yan sa hanapbuhay ko. (It hampers my job.) Ngata man ako mag attend? Sinda na sana. Baco man ako member kan HEMS. (Why should I attend? Let them. Anyway, Im not a member of HEMS.)
On Information Management and Surveillance. Table 8 shows the data on information management and surveillance. Along this variable, the average mean was 3.28 or ME. The highest among them, however, was availability of person in-charge of statistics during health emergencies and disasters with 3.33 and the lowest was availability of computer back-up files where information stored with 3.22 mean. This means that persons in charge had been identified supporting the availability of statistics during Typhoon Reming in November 2006. However, the data submitted did not have a computer back-up of its own. Table 8 Status of Strategy Implementation Along Information Management And Surveillance
Availability of person in-charge of statistics during health emergencies and disasters. Daily submission of 24 hours report during emergencies and disasters. Presence of surveillance team. Availability of computer back-up files where information stored.
Legend: VE: 4.20 5:00
Adjectival Interpretation ME ME ME ME ME
ME: 2.60 3.39
Information disseminated to all concerned by the hospital spokesperson. Average Mean
FE: 1.80 2.59 E: 3.40 4.19 NE: 1.00 1.79
ME
As observed, statistics of victims are readily available for HEMS, COH, DOH and media consumption. Families of victims are likewise kept abreast of necessary information. Statistics are also shown on the board outside the hospital for access to public. However, for confidentiality, names of victims are not published nor revealed to anybody.Some of these experiences were related thus: Minsan kasi lalo na ang media, gusto kunin lahat ng statistics kasama ang pangalan at tirahan ng biktima. Sabi namin hindi puwede. Eh ang iba di makaintindi. (Sometimes, especially the media, they like to get all statistics including names and addresses of victims. We told them, we cannot give all information but some of them cannot understand.) Our information management is that there is only one person responsible for information dissemination. Surveillance is done by another person. Copies of which is provided to COH, HEMS coordinator, DOH and the Public Information Officer (PIO). The latter is then tasked to disseminate the information to those concerned, like the family. It should be noted that three indicators got the same weighted mean of 3.28. These are: daily submission of 24 hours report during emergencies and disasters; presence of surveillance team and information disseminated to all concerned by the hospital spokesperson. This clearly shows the importance of a statistician, a surveillance team and a spokesperson during a disaster. The absence of one may hinder good disaster response; hence, the institution must see to it that these persons are clearly identified and officially designated to assume the task whenever needed. On Standards and Regulation. The data on standards and regulation are shown in Table 9 and the level of implementation was 3.32 or moderately extensive (ME). Among the five indicators, two got extensive ratings namely organization of disaster planning committee and proper representation from the medical (particularly from the emergency department and surgery), nursing, various support services and administration with a mean of 3.47 and 3.44, respectively. It should be noted that organization of disaster planning committee got the highest rating. This is because of the presence of the HEMS who facilitates plans for disaster situation. The rating which was extensive level of strategy implementation (61-80%) could probably become very extensive (81-100%) if management support was solicited or extended. Further, Richter6 emphasized that the responsibility to develop a plan is a task of a disaster preparedness committee. The committee includes representa-
tives from every department of the hospital such as medical staff who could be either an emergency room physician or trauma surgeon, administrative officer, operating room manager, nursing staff, staff from the emergency department, security, communications, public relations, medical records and admissions, engineering and maintenance, laboratory, radiology and respiratory therapy. Table 9 Status of Strategy Implementation Along Standards And Regulation
Weighted Mean 3.47 3.44 3.28 3.25 3.17
Organization of disaster planning committee.
Strategies
Adjectival Interpretation E
Proper representation from the medical (particularly from the emergency department and surgery), nursing, various support services and administration. Disaster planning committee is responsible for overseeing the development of the disaster manual. Hospital Emergency Preparedness and Response Plan (HEPRP) written, disseminated and drilled. Average Mean Disaster planning committee review and critique disaster drills and evaluate if changes be made.
ME
ME
ME
ME: 2.60 3.39
Legend: VE: 4.20 5:00
Among the moderately extensive (ME), disaster planning committee is responsible for overseeing the development of the disaster manual got the highest rating with a mean of 3.28 and the lowest was hospital emergency preparedness and response plan (HEPRP) written, disseminated and drilled got a mean of 3.17. The result means that there is a disaster plan but is not yet complete with all types of disasters. It also means that not all personnel knew about the plan or had not experienced how the plan was practiced or drilled. Hence, this study felt that there is a need to review and critique disaster drills as shown in its moderately extensive level of implementation (3.25).
FE: 1.80 2.59 E: 3.40 4.19 NE: 1.00 1.79
3.32
ME
Here are some quotes from the BRTTH respondents along implementation of standards and regulation: HEMS regularly meet but there is no specific disaster planning committee organized. Plans are in order. An problema kun minsan baco gabos na members nakaka attend. (The problem is sometimes not all members are able to attend.) Implementation of the plans like drills are not also well-attended because of duties in the clinical areas, according to a nurse-member of HEMS. Another revealed that The disaster plan is not yet complete. There is still the need to finalize it. On Monitoring and Evaluation. As shown in Table 10, all the variables along monitoring and evaluation got moderately extensive level of implementation (ME). However, from among them, the highest was final reports of the events that happened submitted with a mean of 3.37. The findings were such because BRTTH and BMC have complied in submitting reports of unusual events. These reports were sent to HEMS central office consolidated and submitted to the Secretary of Health. Table 10 Status of Strategy Implementation Along Monitoring And Evaluation
Weighted Mean 3.20 3.23 3.37 3.17 3.19
Events and lesson learned after the disaster documented.
Strategies
Adjectival Interpretation ME ME ME ME
Post-disaster evaluation performed. Final reports of the events that happened submitted.
Drills or simulation exercises evaluated using criteria set by the disaster planning committee. Disaster planning committee around during the drills or simulation exercises. Average Mean
ME
ME: 2.60 3.39
Legend: VE: 4.20 5:00
FE: 1.80 2.59 E: 3.40 4.19 NE: 1.00 1.79
3.23
ME
The lowest was drills and simulation exercises evaluated using criteria set by the disaster planning committee with a mean of 3.17. This data clearly supports the findings that drills conducted did not have a formal evaluation tool to identify strengths and weaknesses. Likewise, there was no written documentation which served as a basis for the succeeding drills. One participant commented: Its about time we make a standard evaluation tool for our drills. As stated in the literatures, drills train employees and test aspects of hospital response. Drills simulate what employees will do during actual unforeseen events. Hence, there is a need for continuous monitoring and evaluation before, during and after a drill, which should be done by the disaster planning committee, the drill organizer. In addition, hospitals are mandated to have their own Hospital Emergency Preparedness and Response Plan (HEPRP), which should be written, disseminated and drilled. Lack of any of these factors does not make it a good plan. Moreover, drills are considered costly and complex to organize.
Summary of the Status of Strategy Implementation of the National Policy on Health Emergencies and Disasters The data in Table 11 show the summary of the status of strategy implementation of the National Policy on Health Emergencies and Disasters. Of the ten (10) variables, only two got extensive level of implementation (E): service delivery got a mean of 3.51 and resource mobilization, 3.41. This shows that service delivery at the BRTTH and the BMC are already in place and that resources are available in terms of people, supplies and equipment. The rest got a moderately extensive level of implementation (ME). These were: capacity building and facilities enhancement (3.17); health information and advocacy (3.16); health policy (3.38); networking and social mobilization (3.25); research and development (3.05); information management and surveillance (3.28); standards and regulation (3.32); and monitoring and evaluation with a mean of 3.23. Health policy with a mean of 3.38 got the highest rating among those which got moderately extensive level of implementation (ME). This is attributed to the on-going development of health emergency management systems. In fact, series of training workshops were attended by the HEMS coordinators to finalize systems. The support given to the DOH health emergency management programs also contributed to the result.
Table 11 Summary of the Status of Strategy Implementation of the National Policy on Health Emergencies and Disasters
Strategies Weighted Mean
3.17 3.51 3.16 3.38 3.25 3.05 3.41 3.28 3.32 3.28 3.23
Capacity Building and Facilities Enhancement Service Delivery Health Policy Health Information and Advocacy Research and Development Resource Mobilization Standards and Regulation
Legend: VE: 4.20 5:00
Adjectival Interpretation
ME E ME ME ME ME E ME ME ME
ME: 2.60 3.39
Networking and Social Mobilization
Information Management and Surveillance Monitoring and Evaluation Over- all Mean
As usual, research took the back seat because research and development among the ten variables got the lowest rating with a mean of 3.05. As perceived, research is costly, time consuming and a waste of effort. That is why, management support for research is still needed for policy improvement and for identification of strengths and weaknesses. In general, the over-all mean was 3.28 or moderately extensive level of implementation (ME). The result clearly shows that only 41-60% of the parameters are implemented. Hence, the need for management support.
FE: 1.80 2.59 E: 3.40 4.19 NE: 1.00 1.79
ME
Problems Encountered in the Strategy Implementation of the National Policy on Health Emergencies and Disasters. A focus group discussion was conducted at the BRTTH and the BMC on August 19 and 28, 2008, primarily to validate the perceptions on the problems affecting the strategy implementation of the National Policy on Health Emergencies and Disasters. The discussions were focused on some problems along the areas of capacity building and facilities enhancement; service delivery; health information and advocacy; health policy; networking and social
mobilization; research and development; resource mobilization; information management and surveillance; standards and regulation; and monitoring and evaluation. Among the problems which surfaced during the inquiry were those that are discussed below.
On Capacity Building and Facilities Enhancement. Under this strategy are the provisions of training on health emergency preparedness to all personnel including the community, availability of 24/7 operation center, presence of radio communication equipment, and availability of ambulance with equipment, supplies and communications designated solely for emergencies and disasters. Luckily, the BRTTH and the BMC have trainers for BLS-CPR and Emergency Medical Responder (EMR). Despite this, not all personnel were interested to attend underscoring responders who are not trained. There is a need for management to support training programs as important as this to the point of issuing a memorandum to those listed in the special order who fail to attend. The spirit of leadership should truly emerge if all these institutions would be fully prepared to respond to emergencies and disasters of all kinds. There are 400 and 394 personnel at the BMC and the BRTTH, respectively. Of these, there were only 1007 and 318 personnel with updated trainings on BLS-CPR in both hospitals for the year 2008. All responders for these hospitals were BLS-CPR trained. But, only few had trainings on Standard First Aid (SFA) and Medical First Responders (MFR) which are basic for response. When asked why, four of the responders had the same answer which was: I was not able to attend the training because of a conflict between my schedule as regular employee and the training schedule. Training equipment like a mannequin is necessary. At the BRTTH there is no available mannequin while at the BMC only one set of mannequin is available. Borrowing from an NGO is sometimes difficult especially if it is being used. The HEMS had placed an order for a mannequin in the annual procurement plan for the past three years. However, the chairman claimed: Yaon na iyan sa procurement plan, dai pa man pigbabakal (It is already included in the procurement plan but until now it is not yet procured). Also, basic to response is an ambulance with communication facilities which solely to be used during emergencies and disasters. There were six (6) ambulances at the BMC, one of which was exclusively for HEMS use. The BRTTH however, had three (3) ambulances but not one was solely for such use. With regard to the presence of 24/7 operation center, the BRTTH is still
working on attaining this dream while the BMC operation center is available only in the morning shift. The HEMS central office allotted the amount of P535,000.00 for the creation or improvement of a fully equipped operation center. However, creation or improvement of such seems to be a matter of priority and commitment on the part of the management.
On Service Delivery. This variable contains the following: direct services in terms of promotive, preventive curative and rehabilitative aspect offered by the BRTTH and the BMC, backup power supply, laboratory examinations and presence of competent, compassionate and dedicated response team with proper scheduling. Even before the implementation of AO 168, direct services provided by both institutions had been in place. In addition, the four pillars of the Daguno Cornerstone Theory of Interconnectivity among HEMS officers and members which are leadership, human instinct, commitment and love and respect contributed to the extensive level of implementation on this particular strategy. This area however, is confronted with problems brought about by many factors. One management committee member emphasized: Unless people are empowered to appreciate the program, there will always be loopholes in its implementation. Service is hampered because members could attend to HEMS activities only after their duty hours. Priority would still be the work in the hospital. But, this does not deter the HEMS from providing response services. Their commitment drives them to respond to the call of duty even beyond duty hours. This entails a lot of sacrifice. But, love and respect for one another strengthened them to work hard. No amount of hardship could move them away from the bond that they have established at the very start. Service in both hospitals is not always as expedient as expected. First, there is no ready dispatch team because schedule of assignment done is for service in the hospital not for HEMS activities. Dispatch of personnel is done only when there is an urgent need leading to pulling out of members staff who are expected to provide service to in patients. Along this line, a protocol should be established in order to facilitate response and at the same time not compromising patients under the staffs care. On Health Information and Advocacy. The contents of this variable are the activities informing and empowering the public on prevention and preparedness for emergencies and disasters, conduct of basic first aid in managing emergen-
cies and celebration of National Disaster Consciousness Month and Disaster Prevention Week during the months of July and December. The BRTTH and the BMC have designated health educators who are incharge of health information and advocacy to the public. However, information and advocacy on disaster and emergency management were not included among the topics. HEMS takes the cudgel of providing information to the public on what to do and what not to do before, during and after any emergency and disaster. Probably, this topic has never been considered to be part of information and advocacy of health educators. It is earnestly hoped that this topic would be part of health education in the future as their commitment and for the sake of love for life which is prevention of loss of lives and limbs. DOH-HEMS central office issued a memorandum to all retained hospitals to conduct advocacy programs related to emergencies and disasters. This however has a limited time frame, that is, such is carried out only during the observance of the National Disaster Consciousness Month and Disaster Prevention Week which is in the months of July and December, respectively. The BRTTH and the BMC support this particular endeavor through lectures, poster and essay writing contests. Another supporting health information and advocacy is the use of information, education and communication materials such as posters, flyers and advisories. These, however, are not extensively implemented because of monetary constraints.
On Health Policy. Hospital Emergency Preparedness and Response Plan (HEPRP) which contains health emergency management systems, policies, procedures, guidelines and protocols are some of the contents of the health policy. This would serve as a guide when responding to emergencies and disasters which should be written, disseminated and drilled. Fortunately, some BRTTH and BMC officers were trained by HEMS central office on this. The problem, however, is that policies, procedures, guidelines and protocols had been started but has not been finalized. In that case, problems such as guidelines on manpower pull out, for example, has not been taken into serious consideration. The second point is that activities outside the institution have been started without the full implementation of those within the hospital. This meant that leadership should be strengthened by firming up the finalization of the HEPRP or else this seed that has been planted might not grow.
On Networking and Social Mobilization. The BRTTH and the BMC work closely with NGOs and GOs during emergencies and disasters. The human instinct to help those who are in need drove the HEMS to act and respond to the call of duty. However, this strategy did not involve the community down to the barangay level. This affects social mobilization resulting to failure in identifying contact persons in cases of accidents and disasters. Take for example, the vehicular accident that happened at Pamplona, Camarines Sur. Response was delayed due to problems in communication. In this particular case, the victims were the ones who informed the hospital authorities when they themselves were already at the ER of the Bicol Medical Center. Time is of vital importance in any emergency. Delayed response resulted to considerable casualties. This could have been prevented if there was proper communication from the barangay level to the institution. If networking has been established, the barangay captain or any member of the barangay council could have served as the contact person. Likewise, networking and social mobilization was found to have been affected by verbal memorandum of agreement between and among agencies concerned. There was no written and formal agreement. This is one reason commonly observed why private hospitals are hesitant to accommodate victims coming from government hospitals.
On Research and Development. One of the components of this strategy is the submission of case reports and other presentations in which the BRTTH and the BMC are active participants. The presentations were attended by people committed to respond to unforeseen events both locally and internationally with emphasis on best practices. However, no research has been conducted in both institutions except the previous study conducted by this researcher to determine the implementation of the National Policy on Health Emergencies Disasters in relation to policy. Factors which served as hindrances were lack of management support, lack of skills on the part of personnel to undertake researches, non-allocation of budget and some respondents attitude towards research. Hanap ka na lang ki respondent mo. Busy ako (Look for other respondent. Im busy): said one personnel with a higher position. This reality would dampen any researchers enthusiasm to pursue a research the fact that research is believed to be hard, difficult and expensive. If institutions like the BRTTH and the BMC could not support research then collaboration with other agencies, such as nursing and medical schools could be done.
Research is associated with development because all facets of the program could be assisted in terms of research. Program direction and implementation could be best aided with research. Hence, this important part of management and leadership should not be set aside.
On Resource Mobilization. Resource mobilization includes the updated lists of personnel with cellular and phone numbers to recall, persons responsible with organizational structure, orientation of new employees regarding expectations during emergencies and disasters, availability of supplies and response team to be mobilized when needed. HEMS organizational structures in both institutions are in place. Again, leadership, human instinct, commitment and love for and respect of people accountable could not be underscored. However, one of the problems found was the delayed response whenever needed because HEMS can only attend activities related to emergencies and disasters after duty hours. But, their commitment drove them to sacrifice their free time even to the point of risking their lives. In the theory espoused by the researcher, this is called human instinct. This is the result of lack of manpower, in general. Moreover, HEMS needs an updated list of personnel to recall anytime. This includes the name, address and contact number. This is however, found to be incomplete in personnel office of both hospitals. Only the nursing service department of the BRTTH has a complete data of its staff. In this regard, when disasters and emergencies occur only a few could be recalled or pulled out from duty. Adding up to the problem was that there was no orientation among new personnel regarding expectations during emergencies and disasters conducted. On Information Management and Surveillance. Availability of a spokesperson, statistician, surveillance team to include computer back-up files of important HEMS documents and submission of 24-hour report during emergencies and disasters are the contents of information management and surveillance. Both hospitals have a spokesperson, statistician and surveillance team but emergency and disaster responsibilities are not included in their job descriptions. For example, casualties and other related events were recorded accordingly by a hospital staff because there is no one to do it from HEMS. Again, the problem of coming up with a personnel exclusively for HEMS or at least including the tasks for health emergencies and disasters in their job descriptions is firmly addressed to management and leadership. In addition, another problem was that important HEMS documents did not have any back-up files.
On Standards and Regulation. Included under this variable are organization of properly represented disaster planning committee responsible for overseeing the development of a disaster manual and HEPRP to include reviewing, critiquing and evaluating disaster drills and simulation exercises. Meeting the standards relative to training of personnel, only the Fire Safety Training and Management was acted upon by both institutions. Although, essential to disaster management is the organization of a disaster planning committee, the BRTTH has not organized but there is a plan to organize in 2009. The BMC on the other hand had their initial organization. Likewise, Hospital Emergency Preparedness and Response Plan (HEPRP) were found to be incomplete. As revealed during the FGD, there were personnel who were identified to be members of HEMS committee because of their inherent function in the hospital organization. However, they have not been informed nor was there a written office order to that effect. This is a concern that should be addressed by HEMS leadership and should be given priority. In other words, the identified people should be notified and be called upon by the HEMS coordinator. Once this is done, orientation, training and drills could be done, initially for all members of the committee and eventually for all personnel. On Monitoring and Evaluation. The contents of this strategy are the following: documentation of events and lesson learned, post-disaster evaluation, submission of final reports of the events that happened and availability and evaluation of a disaster planning committee during the conduct of drills and simulation exercises. Monitoring and evaluation as a mechanism were implemented for purposes of identifying some deviations that might surface during the implementation of the program. During the Typhoon Reming, HEMS officers and members initiated a documentation of events and lessons learned. It also submitted final reports of the events on time which gave the national office the true picture of the incident. It also facilitated the conduct of a post-disaster evaluation to trace out problems related to disaster management. Among the constraints found by this study was the absence of the disaster planning committee during disaster drills and simulation exercises. Non-participation of management resulted to hospital personnels dampened enthusiasm during the conduct of training and other related activities. Further, monitoring and evaluation were also affected by unavailability of tool for the evaluation of drills and simulation exercises.
General Comments on the Problems Encountered in the Strategy Implementation of the National Policy on Health Emergencies and Disasters Guided by the parameters considered under this inquiry, the focus group discussion generated a general comment contending that the DOH through the HEMS was tasked to lead the Philippine government in the implementation of AO 168. Generally, the program does not have a plantilla position of its own. HEMS officers and members have their own regular jobs as employees of the BRTTH or the BMC. However, they are working for HEMS voluntarily. The dual functions created a conflict between HEMS and their superiors. The BRTTH management claim that HEMS failed to perform what is expected of them as hospital employees. To them HEMS are but additional tasks and the glory is not on the hospital but on the people doing the job. This shows that the roles and functions are not clear to both the management and the HEMS officers and members. Because HEMS is working for free, the institution could not hold people to leave resulting to a fast turnover of HEMS coordinator at the BMC. This situation greatly affects the implementation of the program. Momentum does not reach its peak. There is no continuity of the program. This study therefore, believes that if there are plantilla positions for HEMS particularly for HEMS coordinator, at least somebody is given the responsibility to carry out the mandate. Moreover, the moderately extensive strategy implementation (ME) might also be raised to very extensive strategy implementation (VE). There will always be room for improvement. Considering all the perceived problems relative to disaster management, the level of strategy implementation by the BRTTH and the BMC of Administrative Order 168, series of 2004 was moderately extensive (ME) which implies that a lot more effort, particularly, that of the management must be critically and immediately addressed.
Interventions to Enhance the Strategy Implementation of the National Policy on Health Emergencies and Disasters Based on the problems presented by the respondents, this study deemed it wise to present some interventions to enhance the strategy implementation of the National Policy on Health Emergencies and Disasters using the Daguno Cornerstone Theory of Interconnectivity which involves leadership, human instinct, commitment and love and respect.
1. Capacity Building and Facilities Enhancement. a) Review the training needs of hospital personnel particularly the response team and staff assigned at the Emergency Room. Hospital leadership should prioritize training for identified hospital staff to enhance capacity of the hospital to respond health emergencies and disasters. Likewise, hospital staff should also remember that training would equip them with knowledge, attitude and skills needed not only to save others but maybe themselves and their families. Education is a luxury but training is a necessity; b) Management support for training programs. Monitoring and evaluation of training conducted could be best achieved if hospital leaders would participate. This would also highly motivate personnel to participate in trainings and would also improve future ones; c)Issue a memorandum to the personnel who fails to attend the training despite a special order. A memorandum as a form of discipline to hospital personnel who failed to attend the training should be issued by the hospital chief to make them aware of their responsibility in preparing for possible eventualities; d) Create a functional 24/7 (24 hours a day/7 days a week) operation center. With the available separate budget coming from the DOH central office, creation and improvement of 24/7 operation center is a matter of priority and commitment on the part of the management. Immediate response could be generated if this unit is manned by trained personnel coupled with the state-of-the-art technology to answer emergency calls. This would, likewise, serve as the office for HEMS where officers and members meet, a place to answer queries and entertain visitors, media people and others; e) Identify a dedicated ambulance used solely for emergencies and disasters with necessary communication equipment. Emergencies and disasters happen anytime and anywhere. Hence, an ambulance with medicines, supplies and equipment dedicated solely for this cause is vital for easy dispatch of response team. This entails a firm resolve of the management to make this happen; and f) Purchase equipment and other tools particularly mannequin. Hospital leadership must commit the purchase of training equipment such as mannequins, LCD, laptop, radio communication and overhead projector to facilitate trainings. Commitment to take care of this equipment particularly by the HEMS quartermaster and love and respect for the next user is necessary. 2. Service Delivery. a) Revisit policies relative to the functions of HEMS officers and members. A clear delineation of tasks by HEMS leadership should be done in order to avoid conflicts between HEMS and their superiors; b) Commend personnel with exemplary performance. External motivation by
hospital leaders through simple appreciation or commendation or reward that would boost the personnels morale is in order. They should recognize that commitment of HEMS volunteers goes beyond time and effort. The accomplishment of HEMS is the accomplishment of the hospital as well; c) Systematize the schedule of the response team. Ideally, the response team should be assigned at the emergency room for immediate dispatch. In case transfer could not be avoided due to lack of manpower, a system should be done so that a member could be pulled-out anytime, if needed. Commitment and leadership are required; and d) Establish a protocol for response. A set of rules to follow should be written and well disseminated. 3. Health Information and Advocacy. a) Discuss emergencies and disasters during the conduct of health education/promotion activities. Participation of watchers would provide awareness of emergencies and disasters including their devastating impact. Knowledge would reduce and mitigate tragic human loss for it is believed that education and knowledge have the power to save lives. Commitment of health educators not only the HEMS are, hereby, enjoined; b) Allocate a budget for health emergency related posters, flyers and advisories. This is particularly important to those who are unable to attend lectures and discussions. Such would provide the needed awareness to the public; c) Management support during the observance of the National Disaster Consciousness Month and Disaster Prevention Week. Commitment of management in support of the plan could facilitate its implementation; d) Conduct Basic First Aid in managing emergencies. Though this activity is not a priority, at least, this should also be included in the plan for future implementation. The training includes basic first aid at home, schools, workplace and public places. 4. Health Policy. a) Establish health emergency management systems and develop policies, procedures, guidelines and protocols. Basic to disaster management are well developed, properly and widely disseminated and drilled policies, procedures and guidelines. Prioritization and commitment is important. 5. Networking and Social Mobilization. a) Involve community during the finalization of the disaster plan. During emergencies and disasters the community is the first to suffer and is the initial responder. Involvement would provide them adequate information and knowledge on what to do when unusual events happen. Participation would enhance implementation; b) Network with local government units (LGUs). Meeting the barangay captains is important in order to identify people and to solicit contact numbers. In so doing, any one of them
can inform HEMS to immediately respond in order to save lives; c) Participate in multi-sectoral activities. No man is an island. No man can stand alone during disasters. Attending multi-sectoral activities would enhance a better networking relationship; d) Establish a written Memorandum of Agreement (MOA) with other agencies including radio and television stations. Written documents would formalize agreement. This should be reviewed and renewed as necessary; e) Purchase updated and modern communication equipment. This is basic to facilitate coordination and response. Concern for this equipment is essential. These interventions require leadership and commitment not only among hospital leaders but also among the members of the community, government and non-government organizations. Human instinct to help those who are in need and love and respect for one another would develop a better networking relationship, an element basic to disaster management. 6. Research and Development. a) Support/Participate in research. Attitude is very important. A positive response when somebody is doing research would help. Showing a negative attitude decreases the enthusiasm of the researcher to finish the task. Love and respect should be endowed to those who do a tedious job like research; b) Send interested personnel to attend trainings on research. There is a big probability that some personnel do not have skills and interest in conducting research. Training along this line would, therefore, enhance their skills and enthusiasm. Including this as part of capacity building would help improve implementation of the program; c) Coordinate with nursing and medical schools. If HEMS officers and members are unable to conduct research due to their dual functions as regular employees and as volunteers, nursing and medical students should be encouraged to conduct researches instead; d) Allocate a budget for research. Financial resource is vital in research. An allocated budget would encourage more researchers. But, research could never be achieved without committed leaders who would initiate, support and participate in this endeavor. 7. Resource Mobilization. a) Create a plantilla position exclusively for HEMS. Delayed response could be avoided if there are committed persons with permanent plantilla positions. This could be initiated by the hospital chief with the help and support of HEMS coordinators. Volunteers could also be utilized; b) Require all personnel to submit their personal data sheet including their contact numbers. Personal data with contact numbers must be updated regularly for personnel recall. This should be made available at the emergency room, person in-charge of communication, HEMS operation
center and the office of the Chief of Hospital. In the theory, this is expressed as a human instinct, meaning the data could be easily sourced when needed. c) Orient new employees regarding expectations during emergencies and disasters. An orientation would serve as a baseline knowledge on what employees know and do not know about emergencies and disasters. Skills on what to do during unusual events would contribute to an efficient and effective response and correct attitude would improve networking relationship among stakeholders. A training program would serve as a guide. 8. Information Management and Surveillance. a) Include tasks for health emergencies and disasters in the job descriptions of spokesperson, statistician and surveillance team. Accurate dissemination of information, recording and reporting of casualties and post-disaster illnesses should be included in the job descriptions of concerned personnel. This should be initiated by hospital leadership. Commitment by those concerned to do the task is in order. b) Provide back-up files for important HEMS documents. The necessity to have another file for important documents is recommended. With back-up files, documents would never be lost. Keeping all important documents is a show of love and respect with commitment not only to the HEMS but to the organization and to the victims of health emergencies and disasters, in particular. 9. Standards and Regulation. a) Identify personnel for Disaster Planning Committee. Policies, procedures and guidelines could not be accomplished if there are no people to do it. While nobody should be forced to join the disaster planning committee, there are personnel, who because of their inherent position in the organization, are mandated to become members. Commitment is necessary; b) Organize disaster planning committee. The organization should be represented by all sectors of the hospital namely the medical particularly from the emergency and surgery departments, nursing service, administration and various support service of the BRTTH and the BMC. The responsibility includes overseeing the development of a disaster manual; finalization of Hospital Emergency Preparedness and Response Plan (HEPRP); and critiquing and evaluation of disaster drills and simulation exercises; c) Finalize and implement the HEPRP. The plan should be looked into to ensure that it includes the following components: emergency planning committee; hazard vulnerability assessment; identification of resources and gaps; response to respective hazards; organizational and implementing structure; training and drills; information dissemination and advocacy; networking and coordination; and research and development. The plan would, likewise, cover
all types of disasters, natural, man-made and technological in all phases of the disaster: pre, during and post disaster phase including community risk reduction strategy. Finishing the output is a matter of priority and leadership. Putting them in place would help the BRTTH and the BMC cope with disasters; d) Recommend adoption of the Implementing Rules and Regulations (IRR) of AO 168 series of 2004. The IRR could serve as a guide to effectively and efficiently implement provisions of the law which would further enhance the implementation of the program. In addition, outstanding among the four pillars of the Daguno Cornerstone Theory of Interconnectivity is commitment of people responsible to finish and implement the HEPRP including adoption of IRR. Leadership, love and respect for the organization and for the victims of emergencies and disasters coupled with human instinct to help those who are in need would lead to the finalization and implementation of the output. 10. Monitoring and Evaluation; a) Develop an evaluation tool. The tool would serve as a guide for evaluation of drills and simulation exercises. The evaluation output could improve the strategy implementation of the National Policy on Health Emergencies and Disasters; b) Schedule activity ahead of time. Emergency and disaster drill trains employees and tests aspects for proper response. Documentation of events before, during and after a drill would help in identifying strengths and weaknesses and could act as a basis for improving succeeding drills. The task rests on the disaster planning committee, responsible in evaluating and monitoring the conduct of disaster drills and simulation exercises. Hence, scheduling of activity ahead of time is necessary to ensure participation; c) Participate in the conduct of disaster drills and simulation exercises. The activity should be initiated by personnel occupying higher positions. If superiors are supportive, the rank and file would follow suit. Developing, scheduling and participating in monitoring and evaluation activities depend largely on leadership commitment and love and respect by the rank and file for the job they committed to do for the people they professed to serve. Implications of the Findings of the study in the strategy implementation of the National Policy on Health Emergencies and Disasters to Development Education While the study is on health emergencies and disasters the findings, recommendations and interventions could have strong impact on development education. They have, for example some implications to environmental education.
Emphasis should be made on how to become good stewards of Gods creations not only in the classrooms but in the communities. Students could be assigned to lecture on strategies to safeguard the environment and their effects to health emergencies and disasters. Schools should have outreach programs that would permit a one month immersion of students in communities to implement these strategies. It may not only be teaching households about waste management, sanitation, trees conservation and others but may go as far as having disaster drills. It could pose some difficulties at first but could eventually be surpassed through planning and constancy, consistency and cooperation. From this practice, peoples capacity on health emergencies and disasters are built resulting to good surveillance and better information management because communities will mobilize themselves. It is inverting the pyramid by organizing and mobilizing the base to become self-reliant, that allows them to identify their strengths, strategizing in order to prevent their weaknesses, eliminating threats and utilizing opportunities. Only those which the community could not handle are passed on to those at the top. Educational planning and governance might as well consider health policy and standards, hereto, thoroughly discussed and the strategy implementation forwarded. Since the study found that research got the least among all the strategies with moderate implementation, such could be made as a priority activity. The results of these various researches could be put into one presented to those concerned. A program could, in fact, be developed for the purpose of its implementation. Once done, evaluation could be made yearly, setting aside the common values system of Filipinos which is ningas cogon. Finally, educational success can only be demonstrated through change. Educational leaders and managers could consider the use of strategies, policies and implementing rules and regulations for better quality of education. Accordingly, the Daguno Cornerstone Theory of Interconnectivity which includes leadership, human instinct, commitment and love and respect could be used as a guide for a transformation of those on top as well as those below the hierarchy in the organizational structure. This transformation could redound to the peoples behavioral change. Conclusions and Recommendations Based on the findings, the following conclusions were drawn: 1. Status of Strategy Implementation. The status of strategy implementation of the National Policy on Health Emergencies and Disasters (NPHED) in
the Bicol Regional Training and Teaching Hospital and Bicol Medical Center needs improvement in all aspects. 2. Problems Encountered. Strategy implementation of the NPHED was hampered by problems. 3. Interventions. The offered interventions might strongly enhance the strategy implementation of the NPHED from moderately extensive to very extensive.
On the basis of the findings generated by the present study and the conclusions drawn based on the findings, the following recommendations are hereby offered: 1. Status of Strategy Implementation. The recommendations were addressed largely to the management of the BRTTH and the BMC with the HEMS as the specific target. Total management support in terms of training; manpower, equipment and supplies; advocacy; networking and research would greatly help the implementation of the program. In addition, the creation of a plantilla position for about four to six personnel with a separate budget allocation is essential. With this scheme, the needs of the program could be given full attention. A permanent plantilla position for HEMS Coordinator should be a priority. This is anchored on a certain management principle such as the specific accountability and responsibility of the person holding the position. In this case, the person holding the position could execute his functions authoritatively and explicitly. He could also command leadership and would be accountable for the failure of the program. The HEMS coordinator could also act as Emergency Room Head that would altogether avoid conflict of functions and misdirection. In addition, the sudden turnover of HEMS coordinator affects the implementation of the program. This could have been resolved if there were a permanent plantilla position. 2. Problems Encountered. The problems identified by the study should be presented to the BRTTH and the BMC management and/ or to the whole the BRTTH and the BMC personnel during a general meeting. This would enable all personnel to be oriented on Administrative Order 168, series of 2004. This would also make them support the program as mandated leading to the improvement in the status of implementation particularly on the strategy used. The BRTTH and the BMC management should demand full cooperation from all concerned in order to enhance the implementation of the program from
moderately extensive to very extensive level of strategy implementation. 3. Interventions. With regard to the interventions enumerated, this study proposes that all of them should be done including the proposed implementing rules and regulations of AO 168 with the main purpose of improving preparedness and response. The BRTTH and the BMC management should realize that in doing so they could save lives and limbs of people they profess to protect. The value of the recommendations enumerated is important in the sustainability of the program. By adopting these recommendations the landscape of its implementation would result to the more responsive actions benefiting both the implementers and the beneficiaries. This would result to the attainment of the vision and mission of Administrative Order 168 series of 2004. Areas for Further Study This study would like to suggest some areas for further studies. These are: 1. A Replication of this study in Selected Government Hospitals in the Philippines; 2. The Preparedness Level of Emergency Rooms in Government Hospitals in the Bicol Region; 3. The Preparedness Level of Frequently Stricken Disaster Communities in the Bicol Region; 4. A Post-Disaster Evaluation among Frequently Stricken Disaster Communities; and 5. The Collaborative Roles of Community and Media Practitioners. BIBLIOGRAPHY A. BOOKS Bailey, Kenneth D. Methods of Social Research, 4th ed. The Free Press, Division of MacMillan, Inc., New York, 1994. Freedy JR., HS Resnick and DG Kilpatrick. Conceptual Framework for Evaluating Disaster Impact: Implication for Clinical Intervention. In: Austin LS, Responding to Disaster: A Guide for Mental Health Professionals, 1st edition, Washington, D.C.: American Psychiatric Press, 1992.
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DIABETES MANAGEMENT, CARE AND CONTROL AT BRTTH

Mizel D. Guapo
Introduction Diabetes has changed the health scenario of countries the world over. The Asian Diabetic Association(ADA) (http:/www.diabetescontrol.com/anodyne/ index.ph) and the European Association for the Study of Diabetes (EASD) (Lilly, http://www.asiandiabetes.org/) revealed that by year 2030, 7 out of 10 countries with the most diabetic patients will be in Asia, with India and China topping the list with 79.4 million and 42 million respectively. A recent report by the American Diabetes Association (Berns, Viewpointshttp://www.medscape. come/viewprogram/4517.pnt) shows that more than 48 million Americans have the beginning sign of diabetes. Full blown diabetes affects over 19 million people; another 5 million are undiagnosed as having the affliction. The experts acknowledged the effects of the globalization of the western lifestyle for making diabetes a major and progressive health care problem around the world. The burden of the disease is greatest in countries where there is rapid population growth like China, India and even the Philippines. ADA and EASD said that the Philippines will catapult to rank 9 with 7.8 million by year 2030. Currently 3.36 million Filipinos are diabetic making diabetes as the ninth leading cause of death affecting 1 out of 25 Filipinos (Hantly, http://www.diabetes. org/aboutdiabetes.jsp). People can get diabetes at any age. The term diabetes (Greek: diabts) was coined by Aretaeus of Cappadocia. It was derived from the Greek verb, diabainein, formed from the prefix dia-, across apart, and the verb bainein, to walk, stand. The verb diabeinein meant to stride, walk, or stand with legs asunder; hence, its derivative diabts meant one that straddles, or specifically a compass, siphon. The sense siphon gave rise to the use of diabts as the for a disease involving the discharge of excessive amounts of urine. Diabetes is first recorded in English,
in the form diabete, in a medical text written around 1425. In 1675, Thomas Willis added the word mellitus, from the Latin meaning honey, a reference to the sweet taste of the urine. This sweet taste had been noticed in urine by the ancient Greeks, Chinese, Egyptians, Indians, and Persians. In 1776, Mathew Dobson confirmed that the sweet taste was because of an excess of a kind of sugar in the urine and blood of people with diabetes (Dobson,1976). Diabetes is a disease in which the body does not produce or properly use insulin, a hormone that is needed to convert sugar, starches and other food into energy essential for daily life. The gravity of the disease cannot be overemphasized. Diabetes can come to anyones life from infancy to the elderly. Behind many cardiovascular diseases, the culprit is diabetes. It is also the leading cause of amputation, strokes, blindness, impotence to name just a few. Type 1 Diabetes, an insulin-dependent diabetes, is usually first diagnosed in children, teenagers, or young adults. With this form of diabetes, the beta cells of the pancreas no longer make insulin because the bodys immune system has attacked and destroyed them. Type I tends to run in families. Type 2 Diabetes, formerly called adult onset diabetes or non-insulin dependent diabetes, is the most common form of diabetes. People can develop Type 2 Diabetes at any age even during childhood. Being overweight and inactive increases the chances of developing Type 2 Diabetes. According to Dr. Dalisay Vice Chairman and Vice President of the Philippine Diabetes Association, apart from genetics, the biggest factor that leads to Type 2 Diabetes in the Philippines is the changing lifestyle of the Filipinos from the active lifestyle to the remote control lifestyle brought about by television or computer denying people much needed exercises (http status 404-|page|goodlife). Globalization plays a bigger influence in the prevalence of diabetes in the developing countries like the Philippines, too. There is a growing number of fast-food chains offering quick burgers, fries, and upsized drinks full of calories substituting for the traditional rice meals, thus threatened to increase the number of people with diabetes. The onset of diabetes can be postponed by taking sufficient precautionary measures. The advent of diabetes can be discovered much in advance by analyzing various parameters that are said to be leading to the disease. A regimen of proper diet, strict exercise and discipline helps delay the onset of Type 2 Diabetes. It is in this light that the researcher wanted to determine the management, care and control of diabetes through the patients seen at the Bicol Regional Training and Teaching Hospital (BRTTH).
BRTTH, located between Legazpi City and Daraga, Albay, is the only tertiary government hospital in Albay Province. It has a well developed and well implemented diabetes program since the 1980s. There are dedicated and committed personnel who manage the program and the patients have been organized so that they could help strengthen and encourage each other in management, care and control of the disease. Regular consultations, blood sugar testing, group exercises and health education exclusively for diabetic patients are done every Saturday. As many as 50 patients every Saturday are seen. During outreaches in municipalities of Albay and Sorsogon, more patients are also seen. All these activities regarded BRTTH as one of the best in terms of services, which put it in the limelight when it garnered an award given by the Philippine Diabetes Association. It was for these reasons that the setting of the study was BRTTH. The Problem This study attempted to determine the management, care and control of diabetes patients at Bicol Regional Training and Teaching Hospital. Specifically , the study answered the following sub-problems: 1. What are the services provided in the management, care and control of diabetes? 2. What is the level of implementation of the management, care and control of diabetes? 3. What are the issues encountered by diabetic patients regarding management, care and control of the disease? 4. What compliance measures may be recommended to enhance the management, care and control of diabetes?
Conceptual Framework As indicated, the study determined the management, care and control current programs for diabetes at Bicol Regional Training and Teaching Hospital. Specifically, it answered questions regarding the services provided by the hospital and the level of implementation in the management, care and control of diabetes. This inquiry likewise looked into the services provided by the professional health team and availed by the patients. These services were categorized into: medical management, care and control. Medical management refers to services rendered by the diabetologist and/or any other physician in establishing diagnosis and providing treatment to diabetic patient. Care
pertains to the holistic care physical, emotional, psychological, and spiritual rendered by the nurses. Control on the other hand is the measure that prevents the progress of the disease. The level of implementation of these services and the issues related to their implementation were determined to guide the program implementers assess the strengths, weaknesses, threats, and opportunities of the program. The assessment would then improve the compliance of the patients to the management, care and control regimen. Likewise, measures to enhance the three factors would eventually lead to the diabetic patients wellness and, ultimately to the improvement of the diabetic care program of BRTTH.
BRTTH Programs
Issues Services Compliance Measures enhancing management, care and control High level of wellness of diabetic patients
Level of implementation
Figure 1. Conceptual Framework Model of Guapo
Methodology The study employed the descriptive type of research which uses qualitative and quantitative data. Descriptive research describes the nature of a situation as it exists at the time of the study and explores the causes of a particular phenomenon (Travers, 1992). In addition, Gay defines descriptive research as involving collection of data in order to test hypothesis or to answer questions concerning the status of the phenomenon under study (Gray, 1992). Textual and tabular presentations of the collected data were done. Specifically, the services, level of implementation, problems, and interventions are presented in tables. The bulk of the data analyses and interpretation are descriptive in form and style. The primary sources of data were the answers of the respondents to the queries and issues raised in the Focus Group Discussion, survey, and interviews. The secondary sources were the hospital records and the reports of patients afflicted with diabetes. Likewise, the program plan for the year 2007 and the report on its implementation were reviewed. The respondents of the study were 30 patients who have been regularly treated and cared for and have been actively participating in the control program of the hospital. Likewise, the entire professional team, composed of 2 medical doctors, 2 staff nurses and 2 dietitians were the key informants in the Focus Group Discussion and in the interviews. The Focus Group Discussion (FGD) was conducted to the entire professional team to extract answers to queries as regards the different services for diabetic patients of the hospital. The issues encountered in the implementation of the program and the suggestions to enhance the control program were also tackled. FGD according to Bailey (1994) is a qualitative method of gathering data consisting of a guided discussion, led by a trained moderator, and designed to provide information on certain topics from a certain population. From the output of the FGD, the questionnaire was finalized, especially with regard to the different service options. The questionnaire was another instrument in the study. Two sets of questionnaires were prepared for data gathering. One for the program professionals and the other for the diabetes afflicted patients of the hospital. These questionnaires were designed to elicit information about the services, their level of implementation, issues encountered, and compliance measures to enhance management care and control. As to the level of implementation, Likert Scale was used in this study. The Likert Scale was named after its developer, Rensis
Likert. This scale usually contains five or seven responses for each item, ranging from strongly agree to strongly disagree (Nieswiadomy,2002). However, in this study, the researcher changed the scales. The levels of implementation were scaled as: very high, high, moderate, low, and very low level. Scale 5 4.50-5.00 3.50-4.49 2.50-3.49 1.50-2.49 1.00-1.49 Range Very High Level of Implementation (VHL) This means 81-100% of the services are implemented. Adjectival Interpretation
High Level of Implementation (HL) This means that 61-80% of the services are implemented.
Moderate Level of Implementation (ML) This means 41-60% of the services are implemented. Low Level of Implementation (LL) This means 21-40% of the services are implemented. Very Low Level of Implementation (VLL) This means 0-20% of the services are implemented.
An interview was also conducted with the professional team to validate the answers provided by the patients. Likewise, the patients were also interviewed to add more credence to their answers in the questionnaire. The interview was written in Bikol dialect and was translated in English language. After retrieving the questionnaire from the respondents, the researcher collated the quantitative data in the master data sheet. In order for the researcher to organize and interpret the tabulated and numerical information, statistical procedures were done. Frequency count, percentage, ranking, and mean were the statistical tools utilized. Frequency count was used in tallying the responses of respondents from the collected questionnaires. It helped to determine the number of responses from each sample category from a specific data. Percentage was used to express the relative participation of a set response compared to the totality. A percentage is the number of parts per hundred that a certain portion of the whole represents (Nieswiadomy,2002). Ranking was also used to arrange the data from the highest to the lowest. Finally, mean was used to measure
the level of implementation of the services availed by patients. Mean is the average sum of a set of values found by adding all values and dividing by the total number of values (Nieswiadomy,2002). For the qualitative data taken from the FGD, a write-up of the problems and solutions in the implementation of the services offered to diabetes patients are written in the researchers translation of the patients own words. Analysis, interpretation, and inferences with regard to the level of implementation of services, problems and solutions were done. Implications of the results were also taken into account.
Discussion of Results Services. Table 1 presents the results as regards the BRTTH services availed by Diabetes Mellitus patients. The services herein discussed are of three parts. These are medical management, care and control. Five services were availed by 100% of the respondents. These services included consultation, blood pressure monitoring, blood sugar monitoring, weight taking and control. The two lowest medical managements availed of were free medication, 63.33%; and alternative medicine, 50%. Consultation every Saturday afternoon for known diabetic patients has been established by Bicol Regional Training and Teaching Hospital. It should be noted, however, that consultation in the Out Patient Department of this hospital is done everyday with or without the presence of signs and symptoms. It is only after laboratory examinations that the diagnosis of Diabetes Mellitus is confirmed. Once done, treatment, care and support begin. Moreover, there is only a specific day which BRTTH has set for Diabetes Mellitus (DM) patients. Four of these medical managements were provided for free. Blood sugar monitoring, if needed badly, however, has to be done at the laboratory with a minimal fee. Some of the patients were encouraged to buy their own glucometer, a simple equipment which could be used at home to monitor blood sugar level. The glucose strips and lancet to be used for every test done, however, have to be procured by the patients themselves. As mentioned in the review of literature, a diabetic patient may have circulatory, neurologic or cardiac complications. These are debilitating to some patients and may lead to stagnation, behavioral changes, and body image problems which might lead to depression. Some complications may be too severe that these may lead to death. Some of these are acute complications
Table 1 BRTTH Services Availed by Diabetes Mellitus Patients

1. Medical Management a. Consultation b. Free medication c. BP monitoring f. Eye assessment b. Foot care c. Skin care Services Frequency (F) 30 19 30 30 30 29 15 30 24 22 20 27 28 29 19 30 30 20 21 22
Percent (%) 63.3 96.6 100 80 50 100 100 100 100
d. Blood sugar monitoring 2. Care e. Weight taking/control g. Alternative Medicine
a. Administration of medications d. Dietary counseling e. Wound care
3. Control
f. Psycho-emotional care g. Spiritual care a. Sensible exercise b. Health education
73.3 66.6 96.6 93.3 96.6 63.3 66.6 70.0 73.3 100 100
c. Family counseling f. Alcohol reduction
d. Lecture on compliance to diet e. Lecture on smoking cessation
such as ketoacidosis (DKA), nonketotic hyperosmolar coma, hypoglycemia and diabetic coma (http://en.wikipedia.org/). Other complications that might lead a diabetic patient to death are diabetic foot, carotid artery stenosis and diabetic encephalopathy (Gispen, et. al., http://en.wikipedia.org/). Another complication is diabetic retinopathy which is rarely encountered in the first five years of insulin-dependent diabetes mellitus. Retinopathy is the growth of friable and poor-quality new blood vessels in the retina as well as the macular edema (swelling of the macula), which can lead to severe vision loss or blindness. Up
to 20% may develop retinopathy at the time of first diagnosis of diabetes and most develop some degree of retinopathy over subsequent decades. Since retinopathy is not the only manifestation of diabetic eye disease, attention should also be given to glaucoma and cataract (Berger & Mhlhauser, http:// www.diabetes-mellitus.org/berger.htm.) The lowest among the variables under this category was alternative medicine, which got 50% only. Alternative medicines are those which a patient may resort to as a supplement or a replacement to the medicines prescribed by the physician. One patient articulated: Pag dae na akong ibabakal ki bulong, ampalaya plus na sana an iinom ko. (When there is no money to buy medicines prescribed by the physician, I drink ampalaya plus.) Some others would resort to weeds like kangkong-kangkong or miracle plant, believed to lower blood sugar level and to prevent hypertension. What is emphasized though is consistency in taking them. Moreover, there are herbal medicines in tablet and liquid forms, which are sold in the market although there is a label which says: There are no approved therapeutic claims. This means that such do not have approved scientific basis for their efficacy. However, these medicines though also expensive, are also rightfully well disseminated and largely bought by many. Advertisements run fast through word of mouth. They are sold by way of direct selling and owners and distributors profit from them. But do these medicines really cure? This is the foremost concern that the respondents of the study should consider. Care. Table 1 also shows the care availed by the patients with Diabetes Mellitus. Among the seven variables, only one got a 100% response, that is, administration of medication. As previously mentioned, patients after consultation with a doctor are prescribed some medications which normally would be anti-diabetes. Other times, though, wherein the blood sugar level is higher than 100 milligrams per deciliter, the patient is admitted to the hospital for insulin injections (Vinik, et. al. , http://en.wikipedia.org/). Admission is done to monitor the blood sugar level since hypoglycemia might occur leading to alterations in consciousness that might bring about coma, seizures, or even brain damage and death. Once this is ordered, the nurse has to implement it and medication hasto be given on time, following the 10 Rights (10 Rs) as prescribed by the Association of Nursing Service
Administrators of the Philippines based on McGoverns 10 Golden Rules for administering drugs safely (Vinik, et. al. , http://en.wikipedia.org/). If the patient, however, is not admitted and would require oral medications only, the nurse then would provide him with instructions. One patient said: An importante iyo an pigtaram kang nars na bantayan ko pag ako nag inom ki bulong. An bulong daw may karahayan igua man na karatan. (The important aspect which the nurse said was I should watch out for the medicines that I drink. Medicines according to her have good effects as well as adverse ones.) Another patient uttered: Para sa akin, takot ako uminom ng gamot dahil sa posibleng maramdaman ko lalo na kung bumaba ng husto ang sugar at blood pressure ko. Baka iyon na ang ikamatay ko. (As for me, I am afraid to take medicines for some possible reaction which I may feel especially if the sugar and blood pressure would go to a very low level. It might cause my death.)
Moreover, one patient who had been taking anti-diabetes mellitus, antihypertension and anti-cholesterol medicines for some time already assured her nothing like that would happen if she would just be observant and if she would come to the doctor for a regular check-up. Dai man iyan. (Thats nothing), assured one patient. Ako ngani 10 taon na ki inom kan bulong. An deficil sana ta mahal na an mga bulong. Kun minsan dai ako nakakainom pano daeng bulong na maiinom. (Ive been taking my medicine for 10 years. What is difficult is the high price of medicines. Sometimes, I do not take medicines because I do not have any.) Other patients said too much medicines are hard to comply with such that: Other times I forgot I had a medication to take at 1:00 oclock in the afternoon. Another time I forgot to take my medicine before breakfast. So I had to ask my doctor or the nurse that in times like this could I drink it after breakfast? As revealed, patients generally would take their medicines although they cited some problems related to it. They, moreover, declared that nurses were very supportive of their plight. Nurses, according to them, would instruct them about what to watch out when taking medicines, would give them reassurance, and would demonstrate on how to administer insulin, if needed. The nurses
would tell them what to do in case drug adverse reaction occurs. They would also advise the patients on how to go about in case the latter needed help in sourcing money for medicines. The nurses would also answer the patients questions in the simplest and understandable manner, would erase their doubts, and would provide them with reassurance. Dietary counseling ranked the lowest among the care availed by the patients, 66.6%. It could be so because this is mainly the work of a dietician. The nurses responsibility here is to convey the diet as ordered by the doctor; the details of which are explained by the dietician. It should be noted, however, that although dietary counseling is the responsibility of a dietician, the nurses have a big role to play which is to check whether the patient follows the dietary regimen. According to doctors and nurses, many patients do not really strictly follow their diet. It is said that a diabetic who misses to follows his dietary regimen fails in managing his disease and in preventing possible complications. Most often, complications are preventable through rigid dietary support which should not only come from the patient himself but also from the members of his family. The health care provider, therefore, should see to it that the importance of such should be explained thoroughly to the patient and to his family (Berger & Ingrid Mhlhauser, http://www.diabetes-mellitus.org/berger.htm). The patient usually would experience great craving for food and drinks. These cravings are termed polyphagia and polydipsia, respectively. These are commonly called hunger or thirst in the midst of plenty. This is because there is plenty of sugar in plasma, food and drinks cannot enter the cells anymore making them hungry and dehydrated. These are then sensed by the brain leading the person to eat voraciously and drink aplenty, according to the diabetologist. The nurses agreed to the declaration of the physician saying, Ay talaga! Sabi ng mga pasyente hindi daw nila macontrol ang kumain. (Oh yes! According to the patients they cannot control eating.) Another nurse observed: The family and visitors are contributory to the non-compliance of patients. They bring food and drinks for the patient when they visit. Our responsibility then is to see and instruct the patient on what to eat and what to avoid among those brought in by their rela-
tives and visitors. Similarly, the nurses should encourage family members to join the patient in his dietary regimen so he will not feel isolated, discriminated, or deprived.
Control. As shown in Table 1, health education and family counseling both got 100%, meaning these two were availed by all the respondents. The two least availed of were sensible exercise, 63.3% and compliance with diet, 66.6%, respectively. Health education is an important aspect in any persons wellness, much more of a patient whose goal is to go back to his normal being. A patient, like those with diabetes mellitus, should strive to be able to help himself to maintain health and to prevent himself from getting complications. His goal should be self-care. Self-care means a persons ability to tend to himself the best way he can without being dependent on others. Care here would mean physical, psycho-social, economic, emotional and spiritual. On the other hand, health education according to the Department of Health is the giving of information and instructions of standardized key messages, disseminate them to promote and maintain health and prevent illness to the public (Berger & Ingrid Mhlhauser, http://www. diabetes-mellitus.org/berger.htm). Health education contains all the aspects of care for man. Strategies could be different for every person. Prior to conducting health education, the speaker or the professional health team should identify their learners or participants based on their educational attainment, age, cultural beliefs and knowledge about the disease. This will ensure the speaker the effectiveness of his lecture. The speaker can speak in a dialect or language that the participants or patients could understand. Presence of elderly and weak patients
Another reason according to the dietician was: Sa isang tao na nagdidieta, kinokontrol niya ang kanyang sarili sa pagkain ng marami. Pero pag dumating ang oras na kumain siya at nakalimutan ang pagdiet nya, may tendency siyang kumain ng mas marami. Binabawi nila iyong oras na di sila kumain ng marami; same with diabetic patients. (For a person trying to lose weight, he controls some food cravings which he thinks will not be good for him. But once he has a chance he eats too much and tends to eat up everything that he missed eating during his diet regimen; same with diabetic patients.)
should be considered. They usually are accompanied by a family member or a relative because sometimes they can no longer comprehend due to altered level of sensorium. The companion may listen and bring out questions in behalf of their patients. To guarantee a full understanding of the lecture, an IEC material can be distributed to the participants so that if they fail to remember some information they can browse or scan the provided handout for them. Health education should be part of the service rendered by the health care providers. The old adage, an ounce of prevention is better than a pound of cure, is still very significant in the prevention of any disease. Creating consciousness among diabetic patients regarding the disease lessens the occurrence of further complications. Health education gives clients an understanding about a certain illness, thereby making them aware of the possible outcomes if medical consultation is not made. Also, it motivates the clients to comply with the treatment, diet and exercise, smoking cessation, and alcohol and stress reductions. Here are some declarations of diabetes mellitus patients on health education: Marhay baga ta pigturuan kami kan mga doctor, nars asin parapakaon. Nasabutan mi an bawal asin baco bawal samo. Deficil baga an helang na ini. Makasawa kun minsan. (It is good that doctors, nurses and dietician-nutritionists teach us. We are able to understand what is allowed and not allowed. This disease is hard. We are fed up with it sometimes.) For me, I am able to understand fully the disease process. Why I feel this way, why I should do some exercise, why I should follow the diet as required, why I have to drink medicine and others. I believe this is the key to my wellness. Saco, mas gusto ko kairiba an familia ko na mag dangog kan leccion. Maluya na ako kaya sinda na lang. (For me, I want my family to listen to the lessons. I am weak already that is why I let them.) Among the carers, here are some of their sharings: The family should really be around when we do health education because sometimes the patient could not focus on the teachings due to pain or whatever. Yes, I agree. Most of the time, we teach members of the family on how to care for the patient. They are the ones who could help the patient most.
Both the patients and health care providers perceived family counseling as part of health education. They said that it is perfectly right to counsel the whole family rather than the patient only. Anyway, according to them, the members of their family accompany them in consultations or admissions, during laboratory tests, surgical interventions and rehabilitation. Their families are the ones who take care of them at home, too. They believe that their support to the patient provides the strength and hope to live. Sensible exercise yielded the lowest percentage (63.3%) of service availed of under the control category. As mentioned in the related literature, a sedentary lifestyle is damaging to health and is bearing responsibility for the growing obesity problems. Inactivity and being overweight go hand in hand towards a diagnosis of Type 2 Diabetes. Muscle cells have more insulin receptors, so a person can decrease insulin resistance by exercising. Being more active also lowers blood sugar levels by helping insulin to be more effective.8 But it should be noted that it is not just how much people weigh, but also where they carry the weight, that put them at a greater risk for health problems. Lifestyle plays an important part in determining who gets diabetes. It is recommended that a patient must have at least 2 1/2 hours per week of exercise (Pradran et. al., 2007). The recommendation is a simple brisk walking on a regular basis. Others would do some forms of dancing. The key here is regularity, not necessarily the activity. Hence, this should be the emphasis of the diabetic team in its quest to encourage the patients to perform sensible exercise. The major reason why patients do not exercise is work. Sa dami ng trabaho sa office, paano ka pa mag-exercise? (With lots of work at the office, how can you exercise?) Another said: I consider my chores at home as my exercise. Sa dami ng trabaho sa bahay eh, iyon na. (With plenty of work at home, oh, thats it.) In addition, a patients watcher related:
As a physician, I usually tell the patient as well as the family. It is the family who could be of great help. Support from the family of the patient is necessary in terms of financial and physical. Most of the time they really help.
Nurses, physicians and dietitians would remind them, however, that exercise could be as simple as walking around the house or around the garden. The family could encourage him/her to do what he/she likes to do the most. This is the meaning of sensible exercise. Kun gusto mag gardening or maglakaw pasimbahan pasigihon sana. Kun saen siya interesado di duman siya. (If he likes to do gardening or walk to church let him. Whatever interests him, then let him be.) The diabetic team had this to say: We have regular exercise here for all the patients every consultation day. The exercise is sensible in that it is only simple dancing, marching, swaying of hands and other similar ones. What is good is all of us team members participate in the exercise, added the nutritionist. We dance with the patients or do some hataw or some simple ones such as marching, raising of hands and feet, and the like. What is important is that patients and all of us have fun together. Again it can be seen that the role of the family in helping the patient towards achievement of self-care is tremendous. The family can work out for some help in order that a patient would not be too burdened with household chores or help the patient through reminders in managing time in the office in order to do sensible exercise or serve as a companion during the exercise of the patient. Level of Implementation A 5 point Likert Scale was used to assess the programs level of implementation. The results are shown in Table 2.
Ang tatay ko, gusto rin mag-exercise. Ang problema niya ay kasama. Takot siya sa maaaring mangyari sa paglalakad niya kung wala siyang kasama. Baka daw matumba siya o magutom o mauhaw. Marami siyang agam-agam ba. (My father wants to exercise. His problem though is having a companion. He is afraid of whatever could happen when he walks without a companion. He might collapse or might go hungry or thirsty. He has doubts, you know.) An Mama ko talagang habo mag-exercise. Nalilibong daw siya. Pigpipirit mi ngani pero nadadagit samo, kaya dae man kaming nagiginibo kaysa naman magiriwal kami, di ba? (My mother does not want to exercise. She said she feels dizzy. If we force her she gets angry that is why we just give up instead of us quarrelling, you know?)
Table 2 Level of Implementation of Services for Diabetes Mellitus

1. Medical Management a. Consultation b. Free medication c. BP monitoring f. Eye assessment Services Mean 4.10 3.69 5.00 4.30 5.00 4.26 4.37 4.92 4.62 4.68 4.20 4.32 4.62 4.55 4.23 5.00 5.00 4.26 4.23 4.55 4.48 4.42 4.50 4.23
Adjectival Interpretation High Level (HL) High Level (HL) Very High Level (VHL) High Level (HL) Very High Level (VHL) High Level (HL) High Level (HL) High Level (HL) Very High Level (VHL) Very High Level (VHL) Very High Level (VHL) High Level (HL) High Level (HL) Very High Level (VHL) Very High Level (VHL) Very High Level (VHL) High Level (HL) Very High Level (VHL) Very High Level (VHL) High Level (HL) High Level (HL) High Level (HL) Very High Level (VHL) High Level (HL)
d. Blood sugar monitoring e. Weight taking/control 2. Care g. Alternative Medicine b. Foot care c. Skin care
Overall Mean
a. Administration of medications d. Dietary counseling e. Wound care g. Spiritual care
3. Control
f. Psycho-emotional care Overall Mean a. Sensible exercise
b. Health education
c. Family counseling f. Alcohol reduction
d. Lecture on compliance to diet e. Lecture on smoking cessation Overall Mean General Average
Legend: * VHL 4.50-5.00 (81-100% of the services are implemented) * LL 1.50-2.49 (21-40% of the services are implemented) * HL 3.50-4.49 (61-80% of the services are implemented) * VLL 1.00-1.49 (0-20% of the services are implemented) * ML 2.50-3.49 (41-60% of the services are implemented)
Medical Management. Under medical management, blood pressure monitoring and weight taking obtained the highest results (5.00 each), meaning the level of implementation is very high. This further means that 81-100% of these services were implemented. Free medication which garnered a mean of 3.69 yielded the lowest result. This, however, still means a high level (HL) of implementation, or 61-80% of this service was implemented. According to the 30 respondents, blood pressure and weight taking would be taken every time they consulted. For those who had been admitted to the hospital, especially those with hypertension (HTN) and those who were obese, weight reduction was also encouraged through dieting. Obesity is the number one risk factor for Type 2 Diabetes. The National Center for Health Statistics states that 30% of adults are obese, that is 60 million people. Greater weight means a higher risk of insulin resistance because fat interferes with the bodys ability to use insulin. According to the same study, the number of overweight children has tripled since 1980 (Margeirsdotter, et. al., n.d.). The number of children being diagnosed with Type 2 Diabetes has also risen. On the other hand, keeping track of blood pressure is important because people who have diabetes tend to have more trouble with high blood pressure than people who do not have the disease. Having both diabetes and high blood pressure can pack a damaging one-two punch as far as increasing the risk of heart disease, stroke, and eye, kidney, and nerve complications. High blood pressure (HTN) is known as the silent killer. Therefore, those with HTN Stage 1 have to be admitted and monitored. Monitoring of BP is done every 30 minutes to every 1 hour. The patients are concomitantly given anti-hypertensive drugs until the BP goes down to a normal level, which is 120 systolic over 80 diastolic millimeter mercury. For the obese, the diabetologist usually refers the patient to the dietician. According to the dietician-nutritionist, all patients undergo dietary counseling. The dietician said: I tell the patient and his relatives na dae man na bawal na pagkakan sainda, kundi sunudon sana su number of exchanges kan pagkaon para makontrol an timbang. (There is no food that one is not allowed to eat, but he must follow the number of exchanges in eating to control his weight.) According to one nurse, she would also augment diet counseling especially when the patient is admitted. She would usually emphasize:
The researcher asked the dietician about the importance of utterances of the nurse, and this was the dieticians reply: Tama an sinabi kan nars. Idagdag ko lang na kun halangkaw an carbohydrate sa lawas ini maaccumulate sana sa dugo na pag dae nacounteract ki insulin mahalangkaw an blood sugar level. An fat dangan sodium intake dapat tama sana para dae mag edema na pwedeng idagos sa hypertension o helang sa puso o kidney. (The nurse is right. I will just add that if intake of carbohydrate is increased it might just be accumulated in the blood and if it is not countered by insulin, this will bring about increase in blood sugar level. Fat and sodium intake must be just right in order that edema would no set in that it might lead to hypertension or heart or kidney disease.)
Na magcontrol kang sodium and fat intake kun sinda may hypertension o kaya matabaon na pagkakan pero generally, carbohydrate intake. (They should control sodium and fat intake, if they have HTN and if they are obese but generally, carbohydrate intake.)
Literature reviewed says that greater weight means a higher risk of insulin resistance because fat interferes with the bodys ability to use insulin (Pradran et. al., 2007). Free medication yielded the lowest result as BRTTH does not provide medicines for diabetes and its co-morbidities for free. Many patients said: Iyo ngani, dae lamang na libre. Bata mga marahalon ang bulong sa diabetes, sa cholesterol tapos sa high blood. Sana magtao man an ospital ki libre. (Its true; there are no free medicines for diabetes, also for cholesterol and hypertension. Drugs are so expensive these days. We hope that the hospital would give medicines for free.) Care. Table 2 shows that administration of medication and dietary counseling got the highest and lowest level of implementation, respectively. Administration of medication got 4.92, meaning Very High Level (VHL) of implementation or 81-100% of this service was implemented. On the other hand, dietary counseling got the lowest with 4.20, meaning the level of implementation was high or 61-80% of this service was implemented. Next to this was wound care, which garnered 4.32 interpreted as HL of implementation. There are medicines especially prescribed for diabetic patients. These medi-
cines are not offered for free by BRTTH; they are usually bought by patients in pharmacies outside the hospital. But still, this service of care got the highest. Perhaps this was interpreted as administration of available medication to patients admitted in the hospital that is why it got the highest rating. Nurses are supposed to be giving prescribed medications regularly and on time. Regularity and frequency of medication are essential in the improvement of the patients conditions. The efficacy of medicine is dependent upon the regularity and frequency of administration, hence, nurses must be efficient in providing this service. As stressed by another respondent: An problema lang kun daeng bulong ta dae man akong ikabakal. (The problem when the medicines are unavailable is that I do not have money to buy them.)
The nurses, however, said that they seldom find a case like this. Most of the time patients could buy medicines even if they are bought few at a time. Oftentimes relatives help. Iyan an culturang Pilipino maski na sana ipabakal an sadiring rugaring basta madogtungan an buhay kan saiyang namomutan gigibuhon niya. (That is Filipino culture. Even if it means that one would sell his properties as long as he could extend the life of a loved one, he will do it). Dietary counseling with 4.20 got the lowest rating among the seven factors under care. This means that the level of implementation was high or 61-80% of this service was done. As mentioned, es this job is not for nurses but for dietitians-nutritionists. The latter also mentioned that most of the patients and their relatives would seek dietary counseling. Perhaps the patients really would like to improve their condition and prevent complications if the disease would not be cured anymore. Para baga nagmadali na mawara tulos an namatean (It seems that they are in a hurry to cure immediately what they feel), said one of the members of the team. Pero sa sakuya, ok man iyan. (As for me that is okay.) Why? Because at least the patient is interested to get well and we would not have a hard time in caring for him, di ba? (Isnt it?)
According to a dietician, As for me I am always available for dietary counseling, said the dietitian. The nurse added: I too. I am also here to add
inputs and to answer queries about diet, the best way I can because I believe diet is important in the recovery from the disease and in the prevention of co-morbidities which could be detrimental to them.
Control. As can be gleaned from Table 2, family counseling and health education both got a mean of 5.00, while sensible exercise and smoking cessation also both got a mean of 4.23. This means that the former yielded very high level of implementation or 80-100% implemented while the latter were both highly implemented. Control, in this study, means prevention of complications to major organs such as the heart, kidneys, liver, skin, eyes, lungs and other vital organ. It also means encouragement for behavioral changes on the part of the patient and, possibly, on the part of his family. Hence, compliance to diet, medication, and sensible exercise must always go together. In other words, one should comply with these three or the effect would not be exemplary. The problem, perhaps, is on the patients will power and discipline and on the support of the members of the family as well. Health education and family counseling have always been rendered by the team, both in the Out Patient Department and in the ward. However, the team would not always be around to monitor compliance especially when the patient is at home. In health education and family counseling, emphasis has been on behavioral change. Behavioral change is difficult to achieve. Probably this was the reason why smoking cessation did not hold much water among the respondents although this has always been emphasized in health education and counseling. Habits are difficult to kick until such had caused much on the life of a person. Cigarette smoking is said to be dangerous to health. It is also dangerous to the health of the family who are considered as passive smokers. Moreover, it cannot be denied that smokers also spend much money on this vice. But many people still continue to smoke. When the respondents were asked about the issue, some of their answers were: I have stopped smoking right after I learned that I had diabetes. I was afraid of its consequences. But I had been smoking for 20 years. I had been consuming 1-2 packs of cigarette a day. Masarap kasi lalo na pagkatapos kumain. Wow! Sarap talaga. (It really feels good especially after eating. Wow! Really good.) Ako di talaga ako tumigil kahit na alam ko na hindi ito tama. Ngayon nga naninigarilyo pa rin ako pero konti na kaysa noon. (I
The diabetologist had this to say: Diabetic patients really had to stop smoking. The nicotine in the cigarette can stay in the blood vessels that can cause their constriction and eventually would clog them. This could lead to arteriosclerosis. And you know what? This brings about diseases of the heart and kidney or may lead to stroke. Sensible exercise was one of the major issues brought about in the focus group discussion. This topic has been discussed thoroughly already. As to the level of implementation of the services offered by BRTTH, it can be deduced that medical management and care were rated with high level of implementation while control had very high level rating. The overall mean was 4.47 which mean that the services yielded a high level of implementation. Issues Encountered in the Implementation of the Services A focus group discussion (FGD) was done to elicit answers to questions regarding the issues encountered in the implementation of the services. From the diabetes care teams point of view, the following were enumerated: (1) misconceptions about the illness illness, (2) poor compliance with treatment due to financial problem, (3) late consultation, (4) lack of follow-up at OPD Clinic, and (4) poor compliance to diet therapy and sensible exercise. Three of these were the same problems expressed by the patients, hence, the discussion was imbedded within that of the patients. On the part of the patients, the answers were ranked accordingly. These are shown in Table 3. Understanding of ones disease is vital to acceptance vis--vis cooperation to treatment, care and control. The concern here is the patients time with the doctor and the quantity of time the latter can spend with the patient in order to explain the pathophysiology of the disease. It also concerns about the patients age, level of understanding, severity of illness, and capability of the professional team to relate with and teach the patient. The findings showed that out of answers of the 30 respondents, poor understanding of illness ranked first among the problems that they encountered. Take, for instance, this misconception of one respondent:
did not stop even if I know that this is not right. As of the moment I still smoke although I smoke less now than I did before.)
Table 3 Issues Encountered Regarding Management, Care and Control

Poor understanding of the illness Services Mean 26 24 21 20 20 18 17 14 10 10 1 2 3 6 7 8
Adjectival Interpretation
Poor compliance with treatment due to financial difficulty Inability to comply with check ups Pain Inability to comply with prescribed diet Fear to do self injections Fear of death Inability to cope Inability to comply with sensible exercise Lack of awareness on possible complications
4.5 4.5 9.5 9.5
Noong nalaman ko na may diabetes ako, naisip ko agad na bawasan ang pagkain ko ng matatamis. Hindi ko alam na hindi lang pala asukal o matatamis na pagkain ang dapat kong bawasan, marami ding pagkain na nakapagpapataas ng blood sugar ko. (When I was diagnosed with diabetes, the first thing that came into my mind was that I should cut down my intake of sugar and other sweets. I did not know that there are other foods that can elevate blood sugar levels.) According to the dietician, the fact is that there are some foods that can cause hyperglycemia without a patient knowing it. It does not mean that if a food is not sweet, it does not contain sugar, she further stated. Some of the patients beliefs are misconceptions and such should be addressed properly. Diabetic patients should be able to understand the entirety of the disease. This means they should have full understanding of the pathophysiology, risk factors, complications, prevention and treatment regimen provided for him. It would be difficult for them to follow the treatment routine if they do not know the reason behind the procedures, diet, sensible exercise, and the like. Some of them might intentionally forget to follow some instructions because they might think that these are not necessary or they feel alright anyway. Upon a patients consultation, the physician should initiate counseling to include diet, sensible exercise, smoking and alcohol cessation, and stress reduction.
The fact that poor compliance with treatment due to financial difficulty ranked second was understandable inasmuch as medicines for diabetes, especially with complications, are expensive. These medicines have to be taken everyday on a regular basis notwithstanding the expenses for consultation, laboratory examinations, and surgical interventions, when needed. Nowadays, getting sick is the last thing on ones mind that he would want to happen. A respondent complained about the expensive prices of commodities these days. She added: Tapos magkakahelang ka pa. Nayku! Sobrang pahirap an magkaigwang helang. (Then youll get sick. Oh mother! Being ill is such a burden.) Another one added: Bata mga mahalon an bulong sa diabetes, maray sana kun may delihensya si agom, eh minsan man sana magkaigwa nin sobra. Tama lang pirmi sa oroaldaw na gastuson. (Anti-diabetes medicines are very expensive, its good if my husband gets extra income, but he seldom gets one. His income is just enough for our daily consumption.) Perhaps the financial crisis all over the world is also affecting medical services. As the prices of basic commodities are becoming high, the prices of medical consultation and treatment, medicines and drugs, medical supplies and the like are also skyrocketing. Many people are left without medical attention and they could hardly afford to buy medicines. These are some of the problems of patients suffering from diabetes, more so those with co-morbidities. And if they could not comply with the maintenance of prescribed medicines, the full efficacy of such would not be attained. Moreover, there are some patients who would try their best to buy the medicines prescribed to them. Those who can afford would have no problem; those who cannot would recourse to asking others to help. The significant others include members of the family, friends and benefactors, politicians, priests, broadcasters, doctors, nurses and social workers, and others. Agencies such as the Department of Social Work and Development, Department of Health, and privately owned foundations are also tapped to help. Along this line, the professional team could verily help by sourcing for some medicines and reagents from drug companies and from generous people and private agencies. Inability to comply with follow-up check up ranked third among the problems identified. Again this could be connected to the second problem which was financial difficulty. Perhaps the patients did not have money for transportation. Or as some said: Marhay pang ibakal ko na sana ki pagkaon o bulong kaysa iduman ko
sa doctor. (I would rather buy food or medicine rather than to see a doctor.) Some of them claimed that they live far from BRTTH and they have to come with a companion or else they could not come for consultation at all. Others would claim that anyway they do not feel anything wrong with their bodies so, Ngata ta maduman ako sa doctor? Sayang kan oras asin kuarta. (Why will I go to the doctor? It is just a waste of money and time.) But the professional team would not buy the reasons. They still believe that patients should regularly have their check up whether the latter feel well or not. Through regular consultations impending complications could be detected and corrected at once. Besides according to them, An kuarta nakukua, nasusubli asin naiuuli pero an buhay dai baga. (One can get, borrow and return money but not life.) With a frequency of 10 each, fear of death and inability to cope ranked the least among all the issues noted. This can be explained by Filipinos strong personality and belief in God. As mentioned by one patient: An helang kong ini, ipinagpapa sa Dios ko na sana. Tigsusunod ko man an doktor asin an taramon kang nars, pero sa boot ko, iaako ko na mapagal an helang na ini. Aram ko man na dae Niya ako papabayaan na solohon an problemang ini. Dae man ako natatakot na magadan ta gabos man kita maabot sa oras na ito, asin bayaan an kinaban. (I leave my illness to God. I follow the doctors and nurses orders, although in my heart, I already accepted that having diabetes is hard. But I know that He will never let me struggle with this problem alone. Im not even afraid to die, for I know that all of us, at one point in our life, will leave this world and die.) The other patient whispered: Para sako, nakakaya ko na sana an helang na ini, por dahil sa suporta kan mga aki ko asin iba pang kapamilya. Maski ako naghehelang, dae nanggad ninda ako pipabayaan. Sinda an kusog ko. (For me, I am able to cope with this illness because of my familys support. Even if I am ill, they never leave me, they are my strength.)
The support given by the patients loved ones is really essential in helping them deal with their current condition. Even if they are sick, they are able to go through their everyday lives because of the love and care provided for them. It is very inspiring to take care of patients who are also being taken care of by their relatives. The support given by their loved ones is radiated
by the patients to us in terms of cooperation and compliance with treatment regimen, a nurse emphasized. Gleaned from the findings, the problems were mostly those of the patients. The problems identified by the professional team were still connected to the patients compliance not related to the services of BRTTH.
Measures to Enhance the Services During the FGD and the interviews, the researcher asked the health team and the patients as well to cite some solutions that they think would address the issues forwarded. Regarding the first issue which is poor compliance to treatment due to financial difficulty, one strategy presented was health education. Once the patient understood that non-compliance with treatment would mean onset of complications he might, by all means, comply. Health education, however, must be provided with sufficient quality time. The health team should not only lecture on the topic assigned to them but must ask for feedback from patients and their companions. It is through this that the professional team could best gauge whether the patient fully understands the entirety of his disease and all the treatment instructions. A Health Education Program for Diabetes Type 2 is appended as Appendix B. The program was designed particularly for those who registered in the diabetes care program of BRTTH including those who registered in its outreach activities. The purpose of which is to promote awareness of the public regarding the prevention and control of diabetes, how it is acquired, its manifestations and when to seek medical help. The Health Education Program aims to promote awareness about the disease; identification of its signs and symptoms; explanation of the pathophysiology of the disease; importance of compliance with the dietary regimen; determination of the right and proper activities appropriate for patients; avoidance of aggravating factors that contribute to the provocation of diabetes; recognition of complication early; and demonstration of proper administration of medications. The participants of this program are the clients seen in the Diabetes Clinic of Bicol Regional Training and Teaching Hospital as well as those seen in the outreach activities. The duration of the program is only good for 30 minutes and should be done every Saturday at the Diabetes Clinic of BRTTH and as scheduled in outreach communities. An open forum for another 15 minutes is set at the end of the lecture to allow the participants to ventilate their doubts, inquiries and fears about the disease, its management, care and complications.
The contents of the program include lecture on the pathophysiology, the signs and symptoms, diet, sensible exercise, smoking cessation, alcohol and stress reduction, foot care, and proper administration of medications. Information Education Campaign (IEC) materials were developed by the researcher in vernacular language for the diabetic patients to gain on-hand information regarding the disease, its management, prevention, care and control. At the end of the session, the diabetic patients will be evaluated by the professional health team by asking the patients questions pertaining to the information given by the speakers. A post-test may also be administered to determine the effectiveness of health education. On the other hand, if the patient really does not have the means, then a second strategy could be done, which is referral. The nurse could refer him to the Philippine Charity Sweepstakes Office or to a congressman for the use of Philippine Development Assistance Funds (PDAF). The former, a government agency, assists poor patients with medical needs like drugs and medicines, medical supplies, payment for procedures such as surgery, X-ray, hemodialysis, and the like. Similarly, PDAF are intended for poor patients as well. There are other means to help. These are some government and non-government agencies or groups of individuals, and/ or generous individuals, the business sector, the church and the media. Accordingly, this study recommends that the government through the Department of Health should come up with a program which is similar to that of Short Course Chemotherapy for Tuberculosis. This program provides free consultation, laboratory examinations, and free medicines for six months to those who pass the standard treatment protocol. The proposal is that one who has diabetes without complications could be assured of regular free sugar level monitoring, BP and weight taking, and free medicines for 6 months or until the blood sugar level becomes normal. Added to this program would be instructions on how to prevent complications, diet therapy, and sensible exercise. Due to increasing number of diabetics in the community, it is deemed necessary that they should purchase the medicine sold in the Botika ng Bayan (Public Drugstore) such as metformin, acarbose, rosiglitazone or valsartan and insulin injections. These drugs are sold at a lesser cost and are available at all times. When a patient could not really afford the medicines cited, the professional health team would encourage them to shift to alternative medicines. The problem on inability to comply with check-ups could probably be solved through referral and networking system. BRTTH, through the health team, can make a referral tool to Barangay or Municipal Health Centers where a patient could
have his regular blood sugar, BP and weight monitoring. During home visits, the public health nurse could check on the patients compliance with medications, diet, exercise activities, smoking and alcohol intake control, foot and skin care, and stress reduction schemes. This could be done every week for three weeks; on the fourth week the patient brings the accomplished tool to BRTTH. Fear of death is most likely in any person who is ill, more so to somebody who has chronic disease like diabetes. One best way to help the patient deal with such fear, perhaps, is counseling. The patient can be referred to a psychologist and a church presbyter. The reason for fear is most often unknown to the person. Fear can be influenced by culture. Filipinos, for example, would shun talking about death. Some would even abhor personal will or presence of presbyter or priest because it connotes death. But fear can be reduced if confronted head on. Moving out in the face of fear needs courage and the health team could help build this. Talking about it objectively is one way. The other way is by listening to the feelings of the patient about fear leading to acceptance of his condition and ultimately to his spiritual growth. Listening well is an exercise of attention and this is what matters to chronically ill patients who have all sorts of uncertainties such as death. Listening well means absorbing through the mind and empathizing with the heart. Directly looking at the patients eyes could exemplify this meaning. Spiritual preparedness can help but this should be done with caution as this is a very personal matter. The patient, however, should be allowed to express his spiritual needs and not forced to just receive spiritual care. This is one way of permitting him to understand his own spiritual needs and to address them himself as a strategy to self-care. But if this is not immediately possible, the health team can refer the matter to the spiritual director of the patient, if he has one. Otherwise the nurse can call for the hospital chaplain or the head of the spiritual affairs committee. Spiritual care could be in the form of praying with the patient, providing inspirational books or more advanced ones such as providing for the sacraments of reconciliation, Holy Eucharist and anointing of the sick through the presbyter. It should be noted, however, that the health team should respect the patients religious beliefs and practices. For inability to cope, the study emphasizes relaxation technique as one of the solutions to the problems. This technique needs full and active participation of the patient. It was for this reason that they were asked to contribute to what they could do to help themselves. Here are some of their utterings: Pag napapahingaluan an isip mo, gari iba sa pagmate. Gari baga nawawara
an mga makulog na namamatean ko asin an problema na nasa isip ko. Pag naiisip ko na may helang ako, mas lalong nagraraot an pagmate ko. Dakulang tabang kun magkaigwa man arog kaining aktibidades. (When your mind is relaxed, the feeling is very different. Its as if the pain that you feel and the problems that bother you were gone. When I think of my illness, it makes me more ill. It would be a great help to us if there is an activity such as this.) This implies that most patients regard stress as contributory to severity and onset of complications of diabetes. This was agreed upon by the diabetes health team that is why they said that patients who regularly attend diabetes activities and consultations were more at ease and took things as they come. Relaxation technique could be used in diverting a persons negative thoughts to positive ones. Such could also form as strategies for self care. These strategies could be in the form of art therapies, music therapies, yoga classes, occupational therapies, breathing exercises, gardening, and others which interest the patient. During these relaxation techniques, the patient can be joined by their families and the health care providers. Again the role of the family along this line cannot be overemphasized. Support from them is most wanted. This support could be in terms of simple encouragement and reassurance of love and attention. It could also be along money for treatment, laboratory tests, and medication or just mere presence. It could also be in the form of accompanying the patient to the hospital, joining the patient in exercise activities, in dieting or in general changing lifestyle. Work can help divert a patients attention. So if the patient is working, he could be told that he can still go on with it. Children with diabetes can go to school just the same. Couples should be encouraged to have normal sexual activities. These and more can help the patient cope with his illness. Conclusions and Recommendations From the findings, the following conclusions were drawn: 1. Diabetic patients availed of most of BRTTH services relative to medical management, care and control of diabetes. 2. There was a high level of implementation of the services for diabetic patients at BRTTH. 3. There were few issues encountered by diabetic patients along management, care and control. 4. There are measures that could be offered to enhance management, care and control.
The study recommends the following: 1. The Department of Health through the BRTTH management should provide free medicines and regular blood sugar test for diabetes patients especially for those who cannot afford such. It should also provide for permanent plantilla positions for the diabetes care team who can thoroughly attend to all activities of the diabetes program. The program should include advocacies and outreach activities to communities for early consultation. 2. The professional health team in charge of the diabetes care program in BRTTH should strive to improve the level of implementation of the services from high to very high level. The quality assurance program of the hospital should, therefore, consider this as a priority. 3. The Department of Health might consider bridging the gaps or utilizing the recommendations for issues identified by this research. For example, a program similar to that of the Short Course Chemotherapy could be implemented. The professional team should set aside enough time for health education, advocacy, counseling, stress reduction, and relaxation schemes. The family should be encouraged to support the patient at all levels of management, care and control regimen. Agencies, whether government or non-government, should also help in order that this disease, which is becoming a worldwide phenomenon, will no longer spread widely. 4. The BRTTH management and the diabetic professional health team should consider the measures offered to solve the issues identified The health education for Type 2 Diabetes mellitus patients should be implemented by the professional health team every Saturday and as scheduled in outreach activities to ensure consistency and compliance. A copy of the program could also be provided to the health educator of the hospital. 5. Patients must also be encouraged to help themselves especially in terms of compliance with management, care and control regimen. The professional team, whether in hospitals, municipal health offices, or in the barangay should endeavor to help the diabetic patients. The family of the patients should play their role as a support system to the patient especially in terms of compliance with medication, sensible exercise, stress reduction technique, and diet. The physicians and nurses should also help in all aspects of treatment and care including spiritual, psychosocial and emotional.
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VIOLENCE AGAINST WOMEN: THEIR IMPLICATIONS TO NURSING PRACTICE

Bernardita C. Descalzo-Patacsil
Introduction Violence against women has become a pandemic. This means that all over the world women are violated at home, in the street, in the workplace or in schools. The forms of violence are varied. They could be physical, sexual, emotional, psychological, economic, or verbal. This year, 2008, on International Womens day, women all over the world had an opportunity to break new ground in the struggle for womens rights and gender equality, including the urgent need to end violence against women I all of its forms. Why was this so? It is because on February 25, 2008, the United Nations (UN) Secretary-General announced the UN campaign; UNITE to End Violence against Women. The Secretary-General had personally pledged to bring in men and world leaders to campaign in combating gender-based violence and sending the message that ending violence against women stands on par with other critical development goals. In line with the UNs campaign, governments, womens and other civil society organizations, UN donor partners had been expanding its advocacy and fund raising efforts. They had also been promoting a way for people everywhere to speak out and demand an end to violence against women. For example, United Nations development Fund for Violence Against Women (UNIFEM) had initiated an Internet based advocacy effort, Say No to Violence Against Women with (UNIFEM) Goodwill Ambassador Nicole Kidman in the lead. Likewise, worlds leaders had renewed their commitment to financing gender equality. According to UN Population Division, 49.7% or 3,132,342,000 are women. But at least 60 million girls who would otherwise be expected to be alive are missing from various populations as a result of sex-selective abortions or
inadequate care as they are seen less important than boys. Statistics show that at least one in every three women is abused sexually or physically in their lifetimes, and some studies show that 40-70% of female murder victims are killed by their husbands or boyfriends. Virtually every culture in the world contains forms of violence against women that are merely invisible because they are seen as normal or customary. Some of the violence against women is recognized as a major public concern because they can affect womans reproductive health as well as other aspects of her physical and mental well being. Sexual violence could lead to higher infection rates of Human Immunologic Virus / Acute Immuno-Deficiency Syndrome (HIV / AIDS) The Philippines is one of the various countries that answered the call of the UN and the WHO. It has been active in line with Gender and Development Programs (GAD), which contain the call to end violence against women. Republic Act No. 7192, an Act Promoting the Integration of Women as Full and Equal Partners of Men in Development and Nation Building and for Other Purposes, was approved on February 12, 1992. The Policy cited in Section 2 states that The State recognizes the role of women in nation building and shall ensure the fundamental equality before the law of women and men. The state shall provide women rights and opportunities equal to that of men.
In addition, Executive Order (EO) No. 273, s. 1995, An Order Approving and Adopting the Philippine Plan for Gender Responsive Development; where all government agencies, departments, bureaus, offices and instrumentalities, including government-owned and controlled corporations, at the national and local levels are directed to take appropriate steps to ensure the full implementation of the policies/strategies and programs/projects outlined in the Plan and to institutionalize gender and Development (GAD) efforts in government by incorporating GAD concerns, as spelled out in the Plan; in their planning, programming and budgeting processes. In the province of Albay this EO has been implemented and continuously monitored. Violence against women in Albay province has eighteen (18) reported cases as of 2007 both from Police and Department of Social Work and Development (DSWD) records. Bicol Regional Training and Teaching hospital (BRTTH), one of the tertiary hospital in this province where GAD Program is
at its forefront, has recorded 104 cases of violence against women ranging from physical, emotional, psychological to economic and sexual. These were commonly done in the home. It is at this context that this study was conducted.
The Problem This study was conducted to determine the implications of VAW to nursing practice. Specially, it answered the following sub-problems: 1) What is the profile of the violence along the following categories: Physical, Psycho-emotional, Socio-economic, Verbal, and Sexual?; 2) What circumstances precede violence against women?; 3) What are the effects of violence on the woman victim along the factors such as physical, psycho-emotional, socio-economic, verbal and sexual?; 4) What are the measures done by the woman victim of violence in order to protect herself? and 5) What implications can be deducted to improve nursing care for women victims of violence in all aspects of clinical practice?
Conceptual Framework The Conceptual Framework is depicted in Figure 2. Violence Against Women (VAW) has become a normal issue in the society these days. This means that all over the world women found themselves violated at home, in the street, in the workplace or in schools. The profiles of violence are varied. They could be physical, psychological, emotional, social, economic, verbal and sexual. They could be brought into play alone or in combination. For example, a woman could be abused physically first and end up in sexual, Moreover, there are events that precede violence. Such could be substance abuse, growing up in a cycle of violence and abuse, distorted concept of manhood, poverty and unemployment, economic disequilibrium, hopelessness and despair. The researcher found out that there are two ways to adapt in an environment where there has been a of violence and abuse. These are to become abusive or to restrain himself from being one. Violence has effects on the victim which could be physical, psycho-emotional, socio-economic, verbal and sexual. These could even lead to distorted personality and behavior. It has also observable effects on the other members of the family especially the children. However despite these effects, a victim could still adapt to the situation where she is in. Thus she learns to create measures to protect her from the perpetrator. All these data eventually bring to fore implications to improve nursing practices which are to the nurses, other health professionals, Likewise, the
implications were also directed to police enforcers, lawyers, social workers, barangay officials who in one way or the other serve as support system of the victim. In addition, the implications were also focused on victims of violence, their families and friends who could serve as comforter, protector and guide on how the victim would cope. Lastly, the church, the academe, government and non-government institutions were also addressed.
Victim of VAW
Profile of Violence Physical Psychoemotional Socioeconomic Verbal Sexual
Events that precede violence
Figure 1. Conceptual Framework
Effects of Violence on Victim Physical Psychoemotional Socioeconomic Verbal Sexual Children
Measures to protect against violence
Implications to improve nursing practice
Methodology Qualitative research was used; this made use particularly of a story telling method. Such story was that of one person who had been physically, psychologically, emotionally, socio-economically, verbally and sexually violate by her husband. An in-depth study of her from childhood to the present was presented to find out what made her accept and suffer violence. The primary source of data was the victim of violence. This utilized the minuet approach. Words were quoted verbatim. The quotes made in Bikol were translated to English language and significant behaviors were noted. This led to the improvisation approach, meaning that the researcher was led to ask members of her family such as her parents, her siblings and her children. Further, medical records, police and barangay (village) blotters, social worker intake sheets and the like were also looked into as part of the second approach. However, these records were not available.
The data gathered were not solely from the researcher but also from the views and opinion of the counselor and psychologist / psychiatrist. Internet sources, journals, magazines, unpublished theses, newspapers were taken as secondary data. Furthermore, testimonials from a mother victim were used for comparison. The researcher prepared an interview guide which contained three important stages of the subjects life. These were her childhood, adolescence and adult life. Moreover, the past, the present and the future were tackled. The past talked about her life as a child to find out whether she lived in a violent environment; the present were about her life as wife and mother and the future dealt with the plans of the victim on what to do with her life.
Discussion of Results Violence against women (VAW) has become a pandemic, which means that all over the world women are violated at home, in the street, in the workplace or in schools. The forms of violence are varied. They could be physical, sexual, emotional, psychological economic, or verbal. Just what are the implications of VAW to nurses and their practice is what will be discussed in this chapter. The discussion centers on one woman victim of domestic violence, all forms, and the effects on her as a person, a wife and a mother; the effects on her family and the effects on her work and social life. Furthermore, it also discusses the measures she has done to protect herself from her perpetrator. The behavior and actions of the subject are included in the write-up plus the feelings of the researcher herself. In as much as this study deals with some psychological aspects, the researcher deemed it wise to consult a psychologistpsychiatrist for some in-depth interpretation of the events of the victims life and some of her behavior now. Personal Data of Bigit Bigit is 42 years old, a native of a Visayan Region, married to a soldier. They have four children, two boys and two girls. Their eldest is now 24 years old and a graduate of Bachelor of Science in Secondary Education (BSE) but is presently on training as a soldier. The second is 23 years old and presently a third nursing student in one of the colleges of nursing in Legazpi City. The third and fourth children are 22 and 20 years old, both graduates of BSE and are still looking for work. The eldest is now married with a son while the three are single and all of them stay with the couple including her daughter-in-law.
They are nominal Roman Catholics. They comply with their Sunday obligations but never prayed together as family. They reside in an urban barangay (village) here Legazpi City. The bungalow house was built by her husband. There is no extended family member present in the house. Bigit is a nurse by profession and is presently working in one of the tertiary hospitals in Albay. She has been in the institution for eight years. Moreover, she also had a dream of working overseas. Unfortunately however, this dream might never come true because of certain unforeseen circumstances in her life. Bigits Family Bigit comes from a middle class family of twelve. She is the eighth among 4 girls and 8 boys. Her father is a fisherman and her mother was a home maker who died a few years back. It was her father who taught her how to read and write. Except for one, all of them are married and three have died already. Eight of them finished college but only Bigit and a brother who finished Bachelor of Laws are employed; the rest have their own businesses. Bigit said she is closer to her father. She considers him as her protector, guide, counselor, consoler, director, teacher and friend. He is her inspiration up to now. He calls her Digit, meaning small. She feels so loved by him before and up to now. She related: When I was small, he used to cany me in his arms. Whenever I cry, he would stroke my hair and console me with a song or words of endearment. And now that she has her own family he would still continue to do these things to her such that: Kurt kaipuhan ko nanggad siya dali-daling minapasiring digdi, (If I need him he will come immediately). At this juncture, Bigit would cross her hands as if simulating her fathers arms embracing her and at the same time tears would roll down her cheeks unceasingly. Then she would stop for a long time. The researcher could not do anything but to be silent and to observe her behavior. The silence of the victim seems to be deafening except for the sound of two deep breaths she would take before she starts talking again. To the researcher, these were believed to be gestures reminiscent of her closeness to her father, the love and compassion she had experienced while she was still with him, Baco set agom ko, (Not with my husband). Bigits husband is 56 years old from another province in Bicol Region. He
is the youngest of a brood of four. He has two sisters and a brother. Only one of them finished college. Bigits husband finished first Year College. He is presently a soldier who is about to retire. He claims to be a close friend of just one of his siblings, a brother and an enemy of his two sisters. According to Bigit, the quarrel stems from repartition of farm 74 lots. Love is not experienced among the siblings and probably between her in laws. Asked to clarify this, she said: Saraditpa daw sina agom bulag na sa harong an dua. Si Papa nageestar sa payag; si Mama sa tugang niyang babae na may sadiri nang familia pero harani man sana sa payag ni Papa. Sinda naheheling man daa kan agom ko na naghuhuron. (According to my husband, they were still kids when their parents started living in separate houses. Father stays in a hut; mother stays with her sister who was already with her own family but the house was near the hut. My husband said, he also saw his parents talking to each other.) Bigit said her mother-in-law is kind, understanding and so quiet. Whenever there are problems in the family all she does is go inside a room and cry. In addition, she and her mother-in-law had never quarreled. On the other hand, her father-in-law, a farmer who has his own land was very strict and violent with his children. With her, however, Marhay an tratamiento saco dahil sabi niya harayo daa an henalean ko, balyo ki dagat; masuerte daa yan. May ugali sana an father-in-law ko na habo magpasirbe ki anuman na kakanon, tubig o bulong. Sa saiya udong ini. (He treats me well because he said I come from far away place, from the other side of the sea; he believes it is lucky. However, my father-in-law has the attitude of refusing to be served any food, water or medicine. To him these are poison.)
To the researcher, this is a form of paranoia. One of the remarkable signs of paranoia is suspiciousness. And this was demonstrated by the father-in law of Bigit. This was confirmed by the psychologist-psychiatrist.
Family History of Violence Victim. For Bigit, she denied any family history of violence. She said her father is industrious, good and kind to his children. Her mother was soft-spoken, gentle and industrious too. She saw in them an ideal couple. She never saw nor heard them quarrel. They were prayerful and all the siblings were required
to go to mass with them every Sunday. Every night all of them would gather a family to pray the rosary. Her parents believe in the saying that, The family that prays together stays together. Her parents instilled in them the values of respect and courtesy. They were not allowed to join in adult conversations. For example, they were not also permitted to face and converse with the couples visitors. The values of industry, righteousness and harmony were also emphasized. All of them were expected, for example, to be at home before 6:00 oclock in the evening, not to quarrel among themselves and to help in household chores whenever they are not busy with their lessons. Nobody at home was violent. There was peace and harmony and most of all love. There was continuous happiness demonstrated by sharing and bonding together. Bigit smiles with a glow in her eyes when she reminisces. She said: Kami nagtatarabangan; dai kami nakaexperience ki urorihan. Pakatapos kan trabaho, hurontahan na, karantahan asin erestoryahan. Pagnagkarawat ngani kami ki basketball, kaentra pa si Tatay samantala si Mama nagmamasid sana pero sige man an ulok. Maogmahon kami sa harong. (We help each other; we never experienced envy. After work we proceed to teasing, singing and sharing stories. Whenever we play basketball, Tatay (father) plays with us while Mama (mother) was just an on-looker laughing joyously. We were very happy at home.) Meantime recalling her childhood days with her siblings, she remembers her parents happily preparing meals for them. They saw to it that everybody was around to pray and share meals together. She related: We were made to consume all the food on the table and they would clap and would praise us once it happens. Our mother was always willing to wash the dishes so that we could get a good nap for about an hour; after which she would wake us up with a loud music played over the radio.
During Sundays and holidays, when everybody was around, her parents would serve snacks. Food was served according to the childrens preference. The family lived happily inside and outside the house. They were happy together as well as with their neighbors. They never had any enemies in their community. They knew how to relate and communicate with all types of
people. She said: Wala talaga kaming problema; ang gusto long ng aming Tatay ay lahat kami makatapos ng pag-aaral kasi para sa kanya ito lang ang kanyang maibibigay sa amin na mana. Ito dapat ang priority namin. (We really had no problem; what our father really wanted was for all of us to finish our studies because for him this was the only inheritance which he could give us. That it should be our priority.) She added that her father believes that education brings one to have wider understanding and perspective of things. Hence, all of them really followed his advices,
Perpetrator. Little has been related by the victim about her husband because they talk less at home about their respective families. However, she shared with the researcher some midget stories she gathered and her observations when she stayed with her husbands family for one month. Here are some of them. Her father-in-law, who is now deceased, was very strict and violent. He wanted all of his children to follow everything that he desires. If they do not, he turns to them with violence. This violence was in the form of physical, emotional, psychological and verbal. Some of the incidents related were:
Physical Violence. Bigit shared, Isang araw noong 15 years old ang asawa ko, nagpapastol daw siya ng kalabaw, eh, nakatulog siya. Ang nangyari ang kalabaw ay nakawala at nagdestroy ng mga pananim ng mga kalapit na palayan. Galit na galit daw ang Tatay niya. Pinatawag siya dahil nagsumbong na ang may ari ng napinsalang palayan. Pagdating na pagdating niya sa bahay sinalubong siya ng taga. (One day when my husband was 15 years old he was tending a carabao, eh, he fell asleep. The carabao went astray and destroyed the neighboring farm. His father was enraged. He was called upon because the owner reported the destruction of the farm. Upon returning home he was met by hacking blows of a bolo.) To save himself, he jumped off the window and ran as fast as he could. Hindi na siya bumalik. (He never went back.)
He stowed away. Then he found himself enrolled in the military training. The other siblings also experienced similar physical violence from their father.
Citing what she actually saw when she was two months pregnant for her first baby, she related thus: Dumating ako at ang asawa ko sa bahay nila mga alas 4 ng madaling araw. Gating kami sa Maynila noon. Ang Tatay ay sumisigaw, galit na galit sa ate ng asawa ko dahil nabuntisan. Kitang-kita ko ang paglalatigo sa kanya. Napangiwi ako; gusto ko nang umalis pero grabe talaga ang feeling ko. Takot na takot din ako ngunit wala akong magawa kundi magstay at magmano. (My husband and I arrived in their house at 4 oclock in the morning. We came from Manila. Tatay was shouting angrily at the sister of my husband who was impregnated. I saw her being whipped. I grimaced at the sight; I wanted to leave but .... I could not decipher what I felt. I was so scared yet I could not do anything but stay and bless his hand.)
Verbal Violence. Bigit also related that her father-in-law often would shout at his children. His words were constantly harsh and bitter: Malanit at saka doon tares sa tulang magtaram (Painfal and piercing to the bones when he talks).
Verbal abuse like emotional abuse also lingers longer than physical violence. It also brings about change in the character of a person, that is he becomes like the abuser or tries his best to fight being like him. Psycho-Emotional Violence. The psychological violence was a result of the physical abuse meted on him by his father. Stowing away was a form of withdrawal from his painful experience. Sabi niya namondo man siya kan paghale. Dai niya man gustong bayaan an sadiri niyang magurang asin pagrogaring kundi dai siyang maginibo. Natakot sana daa talaga siya na magpawalat. lyo baga, Madam, siisay man an gustong magadan? Siisay man an gustong magadan kan sadiri niyan ama? Kaya gayod siring kaiyan an sakuyang agom, dai ko aram. (He said he was sad when he went away. He did not like to leave his parents or his abode but he could not do anything. He was just too afraid to stay. It is really true. Madam, who would want to die? Who wants to die in the hands of your own father? I think that could be the reason why my husband is like that; I do not know.)
Another form of escape as coping mechanism towards abuse is denying pain, forgetting the incidents and or refraining from talking about them. The other type of coping was fright. It could be glorifying cruelty and be able to justify it without remorse. Noting all of these, it could be noted that the perpetrator had experienced all sorts of abuse, the basic of which was physical. Miller2 said that it is never right to hit a child. She claims that abuse runs in the family; that a slapped child of one generation becomes the abuser of the next and that violence towards a Tmd child may create a bad adult and eventually foster the creation of a bad society. Most often, parents want the best of their children. This is done through what they term discipline oftentimes physical. However, parents do not probably have the slightest idea of childrens need for attachment, loving contact, respect and orientation. For example, a mother who had been emotionally neglected during her childhood may not have any recollection of what it meant to be loved and cared for. Her only concern probably be herself. Present Story of Violence Sexual Violence. Bigit related openly that the violence started when she was raped by her husband. The nightmare happened when she was only fifteen years old. She said: It was near my birthday. May ... yes, my birthday is May. Her real birthday is September. To the psychologist, this was a form of conscious forgetting as a form of Post Trauma Stress Management. It was about 6 pm on May 14, 1982. I recall then that I had just borrowed a notebook from my classmate, our neighbor. While on my way back home, at a distance, I saw him, the one who would do a bad thing to me. I did not suspect him as potential danger. I never thought that I would be harassed or whatever at that time. However, when I was about to pass along the terrain and exactly near the place where he stood, he approached and grabbed me by the shoulder.
At this moment, she began sobbing. There was a long silence. The researcher had to wait for some time. When she continued, she was still crying, tears rolled down her cheeks continuously.
The researcher asked her to describe the house just to test her if she could still remember. Remembering, in terms of psychology, means that the incident is deeply rooted to the subconscious of a post trauma victim. After a while, she continued ogling me suspiciously, in which I assured her of confidentiality. She mentioned: The house was his friends. I felt so distressed and ashamed upon seeing my underwear stripped away from my private parts. I was bottomless kumbaga (seemingly). What were left were only my top garments. The researcher clarified by asking what really were left. Again taking her some time to answer and crying, she said, Tapes na anopa, (it is finished what else?). At that moment she felt worthless. To her everything seemed to end. Wala nang purpose ang buhay; bakit pa, para ano pa? (There is no purpose in living; why else, what for?) Someone had touched, kissed and raped me). Again she cried bitterly. She did not want to continue relating her story. She begged to continue some other time. After the first encounter, she did not appear on the scheduled date of the interview for three times. The researcher surmised that she really did not want to recall that traumatic incident again. The researcher then asked the one in charge of the Violence Against Women (VAW) of the hospital about the meaning of the behavior of Bigit. This was her answer: A rape victim should not really be asked to repeat her story again because this means that as if she is being raped again. For example, if the rape victim was interviewed and seen by doctor and she is referred to apoliceman, the latter should no longer interview her again.
I attempted some struggle to free me from his arms, but the effort was futile, I was given a strong punch on my shoulder which made me unconscious. The next thing I knew was I was alone inside a room with the devil, sa impiemo (in hell).
After three days, she allowed herself to be interviewed in a small and quiet room. Asked what she meant by being worthless, this was what she said: I thought I would no longer find someone to like me after what happened, especially within our locality where everyone knew the incident. I felt
beheaded, as I would recall it. The devil that time was there inside the room so that I felt so enraged seeing him consoling me. Again she became teary eyed. She started trembling. To the researcher this was tremendous fear. I felt too helpless and hopeless to return home, I tried to be calm yet persevere to make ways despite coercion to stay and beautiful promises were made. Until finally, he left me in that house and headed to his office for a work order. Seeing the door open and knowing to be alone in the house, I right away sneaked through the door and left the place to go home. What I wanted was only to go home.
According to her, at that time, her family was already relentless in looking for her and no one could figure out what really happened overnight. The big news came upon her arrival at home, barefooted and aimless. Everybody was shocked upon seeing her. Her father held her in his arms and hid her immediately in a hole in the ceiling. Deafening silence apparently infringed her parents and the entire house momentarily. While there at the ceiling, she related that it was the only time she felt the aches all over her body. It was the time when she saw the multiple hematomas, a big one on her arms and several ones on both legs. Her perineum was too painful and she could feel makusog na bulos kan dugo hale sa puerta ko (Heavy flow of blood oozing from my vagina). Confused she thought it was just her menstrual period. She was innocent to realize it was due to rape. She groped for significant answers to her questions until she fell asleep. She was kept in the ceiling by her parents until night time then was transferred to her uncles house first then to his fathers cousin. Transferring from one place to another was adding agony to the torture she went through. By then, she related, I had fever. My body would constantly tremble. I could hardly bear the feeling of severe pains over my body as especially when I walked. I could not also understand why I was being transferred from one place to another pag banggi (during the night time). The least that I did was to become subservient to my father. The relatives of her father were all living within the village where they stayed. Her parents thought the transfer would keep her hidden from the guy and it would also save her from the perpetrator. The scheme though was only
short lived. After three days of hiding, the perpetrator went to their house together with his commanding officer and the members of the troop. When they were in the house, the commanding officer initiated the negotiation with her parents and made a compromise which was, tapuson na daa an gabos, ipakasal na daa ako sa demonyo (settle everything for good by marriage to the devil). She expressed apathy to the promises made to her parents by her wouldbe husband quoting the famous saying that, Promises are really meant to be broken, no. dai man sana nasunod gabos sagkod ngonian( everything were not followed until now). When asked to clarify, this was what the victim said: Today patuloy akong nagsasafer (I continue to suffer). It is really ridiculous to continue to suffer despite the promises he made to my father and my mother especially his promise to love me and not hurt me, ever which have all been forsaken. My hurt is not only doubled but...
Her voice trembled, tears unceasingly rolled down her cheeks again. Then she covered her face entirely simulating shame, hurt and hopelessness. It was during this time when the researcher remembered what the hospital counselor shared when she had a similar client with the same feelings of helplessness and hopelessness: You know, it is when one feels helpless and hopeless that she clings to another for strength. Most often it is when she turns to Jesus that she becomes strong and whole; for it is in brokenness that one becomes whole and it is in weakness that one becomes strong.
According to Bigit she was not around during the compromise because she was still in hiding in her uncles house. The perpetrator and his companions were persistent in the seeking for a compromised deal. Because of fear and shame brought about by the experience, her father accepted the offer with humility in his heart and the belief that this would save her favorite daughter and the entire family from humiliation and scandal. The perpetrator and the officer even went to the point of kneeling in front of her parents just to have her.
After the compromised agreement tundra pa rin ako sa amin (I still stayed with my family). This was for three months; then she stayed with the family, of the perpetrator for another 3 months. While she was with her family he visited her seldom and briefly. He would just sneak a look at me and leave after. He stayed at the barracks which he called his home. She added: My three months stay in their house resulted to a lot of turmoil not only to me but to my family, totoo (true). Sobbing again, she continued: Our livelihood, which mainly originated from fishing was entirely stopped because of fear.
Kaya kinuha nila ako sa tiyo ko at iprinisenta nila ako sa kinamumuhian kong tao sa mundo (That was why I was taken from my uncle and presented to the person I hate most in the world).
The researcher asked her to explain further. This was what she said: My father thought that he would be harassed by the New Peoples Army (NPA) rebels should he be seen along the sea coasts or fishing. There was fear of repression among us all in the family after the incident; considering that the culprit was a military man. All of us were very anxious to be labeled pro-military. On the other hand, we were also afraid to be labeled pro-military by the NPA rebels.
Whispering and looking around as if afraid someone would hear her say: My father was said to have relatives in the vigilant side. And... and... Stammering, which could mean fear, she continued: Either of the party may harass us any time; ah, you know if labeled as such. So what happened was all the members of our family had to go home. Certainly, everybody feared getting out of the house. Silence. Then she continued: It was during the time of the late President Marcos, where the perpetrator and his troop members called themselves 69ers or the destroyers, thus their presence created an ambiance of fear amongst the constituents within the locality.
According to stories taken by Bigit from the neighbors of the perpetrator, these soldiers had been labeled as such for they were thought to have been tough rebels in Mindanao, Jolo, Sulu, and others. They were boastful, abusive and always fully armed when present around the place. Undecided for the next steps to take, her father opted to bring her to Manila. The family was optimistic for a better living condition in Manila. As earlier related, she was so subservient to her fathers decisions. They went to her cousin in Manila and stayed there for 5 months. Her father patiently transferred her from one relative to another for 5 months, keeping in mind the real intention to hide her from the person she called devil. The hiding however ended when her father returned back to their hometown. It was a sort of coincidence because when her father was enroute for home, the perpetrator found her in her cousins condominium. She never thought that they would be found in their hideout. Her cousin was hesitant to present her yet fearing the consequence of her decision, voluntarily submitted her to the man who later became her husband. They were married; then she was brought to one of her brothers- in-law. Her calvary was said to have started there. Today Digits frustration is that the love and the attention which were promised to her have never been felt by her. Instead she is continuously battered physically, verbally, psychologically and economically. Profile of Violence Physical. Recalling the physical abuses she experienced from her husband, her face certainly turned gloomy, perceptible grief and aggression followed by tears. The physical abuses were numerous and varied ranging from slight, moderate to severe. She apologized for the intricacy recalling the chronology of events. She found it difficult to recall the exact dates they happened. She said that possibly it was because they were recurrent. These abuses escalated in both frequency and severity, so much so that she bargained to him several times that she be killed, to end her sufferings. She even fought him just to provoke him to kill her. She is certain that her death would simply put an end to all her sufferings. She would rather be dead than to live in this horrible condition. The only thing that propels her is her children. The scenario of violence is always unpredictable every time her husband returns from the camp. In addition to the physical abuse, he also used threat and intimidation to kill her and their children should she violates any of his rules, his dos and donts. One of his donts is contemplating divorce and the
use of personalized cellular phone. Eventually she related one by one these physical abuses. These physical abuses often proceed to sexual. One which she dreaded most was when she fought her husband for the rescue of her eldest son who was physically assaulted by his father until he laid helplessly on the floor, apparently looking pale and dying. Later, she found from the culprit that the physical assault was done as a disciplinary action. The story goes: My son went to a friends birthday celebration and stayed there overnight. Upon his return, he was asked by his father where he went and why he did not ask permission. He wanted to explain why he did so. He also asked for apology. But his father instead of listening, started to slap, whip, kick, and box him all over his body. I couldnt support nor could go near him. I was so afraid. I was shaking and crying endlessly. I thought I would die first when I saw my son lying on the floor, unconscious. I had to gain strength for my son...I had to do it or else my son would surely die. I went near my husband and grabbed his hand. That was the only time he stopped. This time, the researcher shed tears upon hearing the story and a heavy heart for the victim. The intense fear seeing a son tortured to death is agonizing to the spirit. The victim further narrated that she was like a candle melting, overshadowed by helplessness as she pleaded for the life of her son. The assault was very tough, comparable to a torture. It was as if her son was under arrest and he was being tortured by a soldier. She claimed that she could feel the pains her eldest son suffered. She repeated the story in a whisper with tears in her eyes: He was beaten, slapped, kicked on his stomach, chest and other parts of his body, punched, thrown to the comer of the living room. From repeated punches, he stumbled. So parang (just like) the things in the house thrown elsewhere when he got angry. I saw him stumbled in a corner almost unconscious agonizing from the torture. He was so helpless despite my presence. I could hardly bear the thoughts that I was on his side yet I could not help him. Finally while my son was lying helplessly on the floor, looking pale and dying, I felt a renewed physical strength that I was able to grab my husbands arm when he was about to give him another strike. He was so strong that my force was so weak, comparatively. Never-
Asking the victim for reasons, she said that the precedent of the anguish was when her son rationalized for staying overnight with his peers for a birthday celebration. Her husband disliked justification when one of them in the family is confronted. He simply prefers them to remain silent. Contrary to her notion of authority, on the other hand, her husband equates discipline with physical and verbal violence. And she is not spared from these. He considered rationalizing a form of disrespect. This form of discipline was used before when parent were traditionally rigid. They view the world as a big place for subjects to follow completely their master. Authority means control and there was no way for anyone to go against the master. In the domestic abode, the master is the husband and all the rest are subjects, hence should follow without question. If they are subjected to punishment it is because they committed a mistake and they deserve it. The perpetrator has been subjected to this form of abuse when he was under the authority of his father. Now that he is the head of the family he too does what he himself experience, probably thinking that this was the correct way, and the right kind to discipline that will make children good and straightforward and wife loyal. The physical abuse was described this way: the physical battering starts with threats. Then he would start punching the wall; once done, he would turn to her. He would punch, shove, pinch, throw objects at her. He would berate her and then clearly enumerate his dos and donts for her. Eventually this escalates by restraining her to let her realize that she should not leave the house; that her place is only inside the house. The pushing would result to cuts and bruises; the slapping and hitting with his fist result to hematomas on her face; the kicking, grabbing, pulling of hair, punching, kicking, dragging would eventually result to sexual assault. He would tear her under wears and undress her forcibly.
theless, I felt gratified seeing my son is freed from the subsequent assault. I sighed relief when my husband fled. He left them for 6 months. In the meantime, my son was then brought to a nearby hospital. He was appropriately evaluated and managed from the physical injuries he suffered. As a result, he was forced to rest and be absent from classes for a week. He was in his secondary school that time. He was really traumatized that until now, he would not dare bless his fathers hands upon coming home.
Two dreadful situations which the victim related to the researcher were when she was choked while lying on the bed. Wrapped tightly in his arms, she could hardly breathe. She was given a series of stabs using a blunt knife. She remembered she fought her husband but he became more brutal. The provocation to fight him ended her being choked until she was asphyxiated. She thought she was dead, she hoped so. This caused her to miscarriage which at first was unnoticed until she regained a little physical strength to remove the hands of her husband from her neck. She got off the bed. Her vaginal bleeding became profuse hours later that made her feel light-headed. Initially, she was undecided to seek any medical assistance for fear of reprisal. What she opted was leaving things to fate-succumbing to death, which to her was the better option. Realizing the potential threat from undue bleeding and thinking about her childrens fate, she calmed down and sought for help from a neighbor. No one from among her children was around at that time. Enough blood was must have been lost. In the meantime she was left by her husband in bed struggling from asphyxiation and from profuse bleeding. She had an emergency dilatation and curettage. The sedation did her well as she was able to rest but when she woke up she was surprised to see her husband at her side taking care of her. She felt enraged by his presence. She felt depressed knowing that her baby was lost because of his brutality. At that moment she considered him an assassin and a devil. In another situation he had his gun poked to all her family members. And another horrifying incident was when they were splashed of kerosene gas and got them lighted. Her husband then was drunk and had an altercation with a neighbor. Luckily, the fire did not ignite, and no one from among her children was hurt. Once she was about to be ironed by her husband had it not for her mother who begged that she be ironed instead. Her mothers plea made him stop. Like her, her mother was also helpless to the deplorable situation where she was into. And because her mother could not bear it, she left for their hometown right away. Again, after this incident, he left them for about six months. She claimed that the more violent the abuse is, the longer he would not come home. When he returns though, he would just sneak into the house unnoticed by anyone. There upon he would cook breakfast for the family and wait for them. This was the usual pattern of his violence. As in the normal cycle of violence, once the perpetrator is fully satisfied he would feel well. He is not the kind of man who is sweet after the violence. His reason for his violence was
the family members provocation. All he wanted was for all of them to follow his rules and regulations, one of which is for all of them to keep silent and to be subservient at all times. On the other hand, his being away from the family was a form of rejuvenation for all of them in the house; a form of transient democracy or liberty from chaos. Everyone would sigh, a sigh of relief. Every one would have peace. During all those times of violence, the victim would not budge a finger. She would just allow him to do everything he wanted to do to her, saying nothing, doing nothing; not fighting back, fearing that he would become more brutal but silently praying that he would stop. To her, her body is already numb. It does not feel anything anymore-not the punches, slaps, kicks, neither the rape, nothing. According to the psychologist-psychiatrist this is a form of defense mechanism called suppression. The victim puts everything to her unconscious mind in order to escape the pain or the entire experience.
Verbal. Her husband form of verbal abuse was shouting. He never uttered defamatory remarks towards her or her children. On the other hand, for the victim, she dreams that one day she would become assertive or simply have guts to rationalize her actions and to be able to talk him out from his violent acts. She just could not do it, out of fear, she said. One time, she related, she came home late. She started to explain hoping that she would be heard. Her husband was provoked and he went into fits of anger and then violence ensued. He berated her and accused her for infidelity. This was unfounded, of course. Every time she opened her mouth, he would threaten her. Her husband wants her to be just an active listener. And because the children were included in the violence, she thought of poisoning them and herself as well. The normal scenario in the house was for them not to talk to each other. She normally makes herself pre-occupied with the household chores than converse with him fearing she might provoke him again even from her honest answers. Silence is deafening too, she says. It creates psychological and emotional imbalance. Psycho-emotional. To her. family, she remains to be the most stupid daughter/sister they have. She related of being advised to separate from her abusive husband yet she continues to refuse to do such because of fear of her death and those of her children. She knew that she and her children would be found wherever they go however hard they hide.
However, she had promised her family that one day she would find a way to finally free herself from him. But since she could not do it now, she believes that she has deceived them; that she has become a liar making alibis for not attending family affairs. She related of being stalked by someone she does not know. She suspects it was the making of her husband who probably would pay a sizable amount just to report to him her whereabouts including the color of her dress, where she went, who she was with and the time she left, the time she came home. This was proven by the fact that upon interrogation, her husband would know everything about her whereabouts and so forth. To Bigit this was amazing and it created a psychological turbulence in her life. Wala na talaga akong kawala. (I will never really get out of this.) The stalking made her feel as if she is inside a cell closely monitored. It seems that she is a prisoner without walls, always under surveillance. The reason behind why she is reluctant to socialize is her fear to be confronted again and be physically and sexually abused once more. Likewise, her husband just contends himself cooking, preparing the table for meals and washing the utensils later, does light repairs in the house or view television shows. Her fear would start, however, when she hears a neighbor invite him for a drinking spree. She is certain that upon his return to their home, violence in any form may happen again. However, her children have learned some strategies preventing the outburst of the ill temperament of their father. One of his favorite sons normally would accompany him as chaperon in his drinking spree and would stop him when he seemed tipsy. His peers knew his mood swings when drunk so that they conform to the strategy of her son. What is ironical is his awareness of the intention of his son. There were also a few instances of intimidation. These were shown by sarcastic looks and gritty smiles, unremarkable and unexplained actions. All of a sudden, even with slightest or no provocation, he would burst into anger and irritability smashing things, destroying some of their fixtures, abusing their pets, displaying his weapon, followed by silence. These intimidations normally happen when he is drunk and during confrontation of her and her childrens whereabouts. Thus, his presence alone normally creates intimidation to the unpredictable scenario of domestic violence. Socially, she has been shamed and humiliated, a gesture which she just shrugged off and accepted for fear of reprisal. She sometimes blames herself
for not following his rules which eventually result to violence. She admitted that she knows he is suspicious of everything to the point of being obsessively possessive, and so she should be very careful, if it would mean domestic peace. To date, the scenario of domestic violence has become constant in their abode and the only way out is for all of them to submit to his will and to pray that he be freed from the evil of drunkenness. According to a psychologist-psychiatrist, these are symptoms of paranoid and antisocial personality disorder. The thought that her husband is inflicting violence to them plays a major psychological burden on her, playing her diversified roles and responsibilities as a wife, mother, nurse, a Christian and a citizen of the society. Distinct in her roles is her versatility of handling the situations with facade and admirable coping mechanisms that despite the chaos, she remains to be a friendly person, effective and efficient nurse, as proven by her performance rating. She loves to gallivant if circumstances permit and be with friends and colleagues whenever her husband is away. During all these times when she was relating her stories of violence, she would resort to crying incessantly. Tears would flow down to her cheeks and would only bring to a standstill after she could uncover some moral fiber to say a word while wiping her face with a handkerchief. All of a sudden, she would utter, nauuyam talaga ako kan nangyari sako (I am really annoyed with what happened to me). Thereafter, she would start relating her feelings of hatred and despair. Her hatred to her husband is so extreme that all her life, she said, she would never learn to love him, to the point that she could not even heed to his plea to encircle her arms around him whenever they had sex.. She has learned to put a facade of subservience and love all for the sake of harmonious relationship in the family. To date, the scenario of domestic violence has become constant. The researcher saw in the respondents face disgust, anguish, monotony, and sarcastic smile. Her silence was a perceptible form of hatred and submission. Other times she would assume the fetal position and situate her both hands on her right chest, while gazing far for more insights. She would even mumble incomprehensible words. The researcher saw in her desperation and at the same time acceptance of her fate. Likewise, compassion crept in when she attributed the ill-timed death of her mother as a result of her inability to accept her domestic situation coupled by the fact that her husband did not give her a chance to attend to
her mother when she was sick and to go home during her wake. This elicited a grave guilt feeling considering that she is a nurse. She said: Napakatanga ko talaga. Hindi ko man long naipaglaban na pumunta sa amin gayong pinaalam ako ng kapatid ko na may sakit noon si Nanay. (I am really so stupid. I even failed to fight in order for me to go home the fact that I was told by my sister that my mother was sick.)
Fear engulfed her tremendously that made her fail to ask permission. To her this was a product of time. Nasanay na ako.(l got used to it.) This is, according to a psychiatric nurse, allowing oneself to bring into her the personality of the powerful, as she considers herself as powerless. For now she is optimistic for the day when these miseries would come to an end by the death of her husband possibly through an encounter or illness. She displayed a wistful look and a sarcastic smile, saying this. Later, she pleaded guilty for her inner intentions of committing suicide just to end all her sufferings or a similar one which was to kill her husband. Once confronted with this thought, she would think of her childrens future and her inner feeling that this is a grave sin. She herself could not find means to forgive him. She wants vengeance but she seems to be hopeless; she has become apathetic to the situation she is in; she wants to fight but is afraid of reprisal and she wants to trust but feels that it is wrong to do so. She attributes this attitude and behavior from the unreasonable repression of her husband. Bewildered in her coping mechanisms adopted with versatility in varied unexpected scenarios of domestic violence, she remains cognizant of her varied roles and responsibilities as: an individual, a friend, nurse, mother, wife, constituent of the society and a Christian. According to her, there are two things she is not good at, a real Christian by soul, heart and deeds; and second is that she is not good as a neighbor. She has been a great pretender, trying to socialize but withdrawing from neighbor and friends, again because of fear of violence. There was always repression. This made her feel like an object not as a person. She likened herself to a doll which had to be keyed in order to move. She had to come home on schedule and leave the house on schedule as well. She always was afraid to come home late. She was afraid to be seen with other people. She was aware of the imposed restrictions such as the use of personalized cellular phones.
Despite these traumatic experiences, by mere looking at her, one would surmise that she is a jolly good fellow. Apparently, she bears a sweet smile in her face when dealing with her patients, conversant and maintains good interpersonal relations with her colleagues and co workers. One would conclude that her pleasing personality masks all her traumatic experiences. Socio-Economic. She claimed to the adequacy of the financial budget given to her by the husband. The automated transfer machine (ATM) card of her husband is entrusted to her and his salary is regularly deposited in it from which she is allowed to withdraw anytime. For now she said nothing against the financial support given her by her husband. Moreover, the only thing she could relate for economic abuse was during their initial years of marriage. She was then pursuing nursing through the encouragement of her eldest sister working overseas, her husband forbade her from receiving financial support for her tuition fees. Fear overcame her again so she contacted her sister not to send her financial support anymore. Her husband supported her with all her needs though. Her sister wrote her stating that, Para maiwasan an problema, aho daw ang tao na dai ko na aram kun nata sige na sana and sunod, (To avoid a problem, I am, according to her, the person who no longer knows why I just keep on obeying.) She accepted her being extraordinarily submissive to the wills of her husband just to have domestic peace and because he has been a good provider. According to her she has never been asked by him where she spent the money he regularly sends her. Rather, whenever he comes home, he would submit to her all the receipts of his actual expenditures taken from his salary. However, she knew not about his fringe benefits, and she dares not ask.
Circumstances Preceding Violence The circumstances that precede violence were mainly attributed to the provocations from rationalizing a concern from any member of the family and especially the victim, and also from drunkenness. The victim was consistent and made it clear about this during the entire process of interview.
Effects of Violence Victim. Despite the traumatic experiences she remains to be a jolly good fellow. She maintains a sweet smile in her face when dealing with her patients. She is a compassionate, a responsible employee, conversant and has a good interpersonal relations with colleagues and other co-workers. She was never reported for any misconduct but has been praised for her very satisfactory performance. To the researcher, this is a form of compensatory mechanism to hide her disgust, hopelessness, dilemma and tribulations from the different violence she suffered. The researcher was so amazed by her ability to cope and her versatility to display a different personality at work and at home. However, during the interview process, the researcher noticed a display of some sort of depersonalization or dissociation behavior. She even told the researcher of feeling numbed and detached, like being in a daze or a dream. She also related that sometimes she felt the world strange, unreal and unfair to her. It was also noticed that there were lapses and difficulty remembering the important information of the sexual assault that the researcher had to make several clarifications before she could find the final and true answer. Apparently she would like to forget everything about it. Probably, she never got over it because in psychology and psychiatry, the more one talks about a post traumatic experience the better is her debriefing and her ability to unlearn the past would come easy. There were periods where she cried first before she could relate the violence although the researcher noticed that she was selective in relating events. She claimed of difficulty remembering the chronology of events. There were many instances when she would just remain silent for a long time while staring blankly. Hence the process of interview took some months to complete and the researcher had to assure and reassure her of strict confidentiality particularly about her identity. Through all her marriage years, fear and hatred for her husband never left her. Almost always she had nightmares. She attributed her fear to her sexual and physical abuses which up to the present she continues to experience. The enormous fear from each violent attack made her bear it with apathy, complacency and submissiveness despite temptations to escape. Her great fears were severe physical abuse on her and her children if she attempts to leave him; of being hunted down and once found suffer its consequences which could be a worse beating than before; of being killed; losing custody of her children; or
the children being killed. She was always on the guard of her speech, behavior and ways lest might cause provocation. It is as if she was always walking in a tight rope. To her, there is no escape; the only way out is submission. And she used work as a form of escape from his claws, his power and authority, and from his abuse. As his forthcoming retirement comes near, tremendous fear and apprehension again engulfs her whole being. For now she does not know what to do when he comes home, saying: ah basta, bahala no. (oh, whatever). Hatred towards herself and her husband has crept into her whole self: body, mind and spirit. She said she could never bequeath forgiveness and has never felt love towards him. Not a tinge, she said. Her form of escape is to mask it with smiles and silence. Based on her personal observations, she voluntarily admitted that she had learned the conscious acts of deceit and lying. As an effect, her conscience disturbs her because she knows that this is a conscious act but she does this as a means to protect herself from harm. She remembered several instances where she lied. One instance was when she lied to her friend when she asked why she had linear lacerations, abrasions and hematoma on her arms. She claimed that she accidentally fell on the floor while fixing some things inside the house. Actually they were results of trauma from the physical violence she incurred. She preferred to hide these incidents rather than ventilating or reporting them to authorities. She has never gone to the hospital or to the police to report the matter. She has kept mum about her physical and emotional pains as a result of the battering especially if her children have witnessed them. She sans ridicule and possible provocation for another set of battering. Ostensibly no traces of violence are discernible of her. She knows how to mask her sufferings. The researcher even expressed to her congratulations for coping well by not compromising her well being and that of her family. Socially, she had learned to withdraw from society. She had refrained from seeing and joining friends, neighbors and co-workers. She admitted that this is an antisocial attitude. She considers herself under spell of something she herself call her bad fate. She resents her situation now for she claims of being not at fault of anything, analyzing what happened. There had no untoward effects of these traumatic experiences to her in relation to her work as a professional nurse. She remained to be a good employee whose performance rating had always been very satisfactory. She had never posed trouble to her superiors. She was always willing to work anytime
and anywhere. She in fact considered herself lucky to have a permanent work. This, to her is a transient break in the monotony of cycle of happiness and despair. She is proud of her accomplishment in her work and in the salary that she receives because it allowed her to help in the collegiate education of her children. This, at least, increased her self-esteem. She is very optimistic about her children finishing college, landing a job and having families of their own, and possibly had a chance of getting rid of her husbands abuses. The effect of deprivation of her to use cellular phone was difficulty to contact people especially in the workplace. She disclosed that her continuous experiences of rape shame her. After each experience she feels dirty and feels as if she is not herself. This is a form of depersonalization and she abhors the act. She never experienced sexual satisfaction while she believed that her husband felt self gratification every time this is done to her. She finds it unfair.
Children. The effects of violence to her eldest son, according to the victim, were hatred and disrespect. He left their abode without asking permission after he suffered physical injuries from his father. At present he is likened to his father in terms of violating his wife although at a lesser degree. His behavior is also the same as that of his father: temperamental, impulsive and magian an kamot sa agom (easily inflicts physical battering to his wife). On the contrary, the other son remained to be gentle, patient, cool, jolly and respectful. As to her two daughters, she hardly could say that they were physically, verbally, psychologically and emotionally violated. They are so loved by their father. Only that the two girls seemed to inherit her antisocial attitude. They always stay inside the house and seemed not to entertain suitors. It is apparent that the two girls show loss of interest in social activities, low self-concept, and difficulty of interacting and relating with others. They are not self- motivated taking the board examinations neither seeking jobs. They also showed disrespect to their father, hiding themselves in their room when their father arrived from work. They do not also dare bless his hand. They seemed not to love their father at all. While before she was a regular attendee of Sunday mass with her family in Samar, her experiences with domestic violence made her sometimes doubt the presence of God in her life. She has suffered so much and yet she felt that God is far away from her. She claimed that she has not been a prayerful person but she believes in the saying that, The family that prays together
stays together. Thus, she tried her best to instill in her children love and fear of God. Altogether, they go to Sunday mass sometimes without her husband. She knows that one of the commandments of God is, Thou shall not kill. But in her hopelessness she had been tempted to kill her husband on several occasions. She, however, confessed everything to a priest. She said to be undecided to surrender everything to the hands of God and had never thought of ever forgiving her husband for all the miseries and sufferings she had experienced.
Measures to Protect Against Violence The victim was found to employ several measures in order to end the domestic violence. One of these was her continuous adaptation to the situation or the varied violent experiences she has had. She had put to mind the rules or the dos and donts set by her husband in order not to provoke him. She had also helped her children to adapt to the behavior of their father. One of the ways she did was to silently suffer. She cries a lot just to vent the emotional turbulence she continues to feel especially during and after physical and sexual abuse. She had become ultra submissive by not answering, asserting nor rationalizing. The only assertive action she pushed was in relation to her duties at the hospital whereby she never allowed him to interfere with it. She really emphasized to him that her work is her priority although she recalled three instances when she was disturbed by her husband while at work after they had a quarrel at home. Her husband went to the workplace bringing along all her clothes for unknown reasons. He shouted asking her to come out of the unit. Nevertheless, she stayed calm and continued to perform her duty. She has become a workaholic because she found happiness and peace when she is at work. At least when she is working she is out of reach to her husbands abuses. She has been asking her superiors to put her on the night shifts in order for her husband not to sexually abuse her. Besides, being in the workplace allows her to mingle with other people and to have someone to talk to outside the prying eyes of her abusive husband. And so, she only files privilege leaves of absences and she reports for duty way ahead of time. For his physical battering, sometimes she would also do something mainly out of impulse for self-defense. But there were times that she just waited for whatever he would do to her feeling the powerlessness from within. She related several instances when she wrestled with him even if knew she would never win. All she wanted was to let him end her life or that she be given strength
and power to kill him. Another measure she does is staying home after duty or when she has nothing to do; she attends and serves her children. Self pity is another thing she does. She claimed of helping herself accept the fact of her fate. She hopes that everything would turn her bitterness into peace. She constantly asks forgiveness from God for such a thought. She also asks mercy for her endless hatred and unforgiving stance towards her husband and for not keeping her faith and hope in the Almighty power of God. Even if she is not a very spiritual person, she said she meditates and prays to Jesus to strengthen her guts and help her carry her cross. She prays for her husband not to return home or be dead from all sorts. She has prepared a strategic plan now that her husband is going to retire. The victim claimed of optimism in her views of the future, though very much ironical to her present situations, she still hope that everything will change for the better. She finds her present life scenario demoralizing to her dreams, especially to her children. She dreams of giving them the best despite the struggle from the misery. Should she be given a break, she looks forward to leaving the family for a moment and go away to a very silent place, a place where she could have the chance to meditate and possibly ask God why these had happened. From there, she could deliberately outpour everything privately without inhibitions or what. Another is to set her inner self free by shouting. This might release her from being enraged, desperate, apprehensive, frustrated, guilty, anxious, intimidated, hate, agony, self pity, and all similar feelings. These might make her feel renewed and refreshed. The researcher saw a chance to give a bit of advice which was evangelization and reconciliation with God. She even quoted the words of Christ from Proverbs 16:9 A mans heart plans his way, but the Lord directs his steps. Simplified further, Where Gods finger points, His hand will make the way. The researcher also added the passage in Psalm 46:1 that God is our refuge and strength, a very present help in trouble. Despite being undecided of her answers, the respondent showed interest in the covenant.
Discussion About Ningning Supposedly, the subject of this study was Ningning. She was very willing to submit herself for the interview when assured of confidentiality. However, she begged to do it within the duty hours only. She did not come other than her
preferred schedule. She was restless heading for home while being interviewed should it lapsed an hour after her duty fearing the unfounded accusations of her husband. It was observed that there were flaws, inconsistency, and irrelevance as she related the violence inflicted on her so that the researcher opted for another subject in this study. Personal Data of Ningning Ningning is 52 years old with four children ages 22, 20, 18, and 16 years old. Three are girls while one is a boy. All of them are single and they are presently in college. Ningning is a midwife who pursued a Bachelors Degree in Nursing but is not a registered nurse. She works in a government hospital as a Nurse Aide. The researcher decided to discuss a little about Ningning and her family being the first case. She was called by her father as Ningning, associated with the beauty of the rising sun. She has a pleasing personality with medium-built body, which she claimed to be inherited from her beautiful mother. She related that she was chosen as one of the beauty contestants in their locality. She also had a big family but denied of violence in the family; they were eight siblings. Her father and the three siblings died from ailments. She related being close to her siblings until the present day. One helps if someone needs, their motto in the family. The virtue has long been observed in their family. Ningning neither experienced nor seen violence at home when she was growing up. She was loved by her parents and her other siblings. All she remembered was that her father was a soldier who fought during the war leaving them for eight years with their mother. Her mother sought him and prayed for his return. Eventually, when he came back, he told them that he had another family because he thought that he would not be able to comeback to them anymore. Ningning also related that she felt sorry about her mothers actions selling their properties and her jewelry without their knowledge. She said that she never got her share from the proceeds of the sale. Family History of Violence Ningning denied any instance where she could call it violence in their home. She related that her father was such a very wonderful and loving person. He would engage in fun with us while he sang songs and played the guitar.
Their family owned a combo, which is presently called a musical band. This was one of their sources of living. Her father was the guitarist. He knew also how to play other instruments like violin and drum and knew how to sing. Her father related that the other members of the band were his brothers and sisters. When the band was very much sought during those times in festivities or social gatherings, her parents would be seen sharing moments too with peace and joy, to their brothers and sisters, in-laws, relatives and acquaintances. They were never seen quarreling; instead she saw courtesy and respect. Industry, righteousness, good relationship and integrity were their values. Furthermore, she related that her father was a government employee. He was not contented with his wages and stocks in a band. So, he used his free time by selling some merchandise items in their locality. Despite his varied roles and hectic schedules, he remained to be a very responsible and loving father to them. He sent all of them to school until his death when she was only 15 years old. Her mother told her that the cause was heart attack. Her mother was a homemaker. She attended to all of us, she said. She denied any instance being a subject of violence perpetrated by her father. She also could not remember an occasion where they were battered.
Perpetrator The perpetrator suffered from physical, psychological and verbal violence from his own father. This was the victims realization when her husband started to be her own batterer. She described him as similar to his father-inlaw: irresponsible, apathetic, and insensitive. He preferred his friends over his family. He also had vices which he could not do away with. She related that he gambles, smokes and womanize. He is also into substance abuse. Despite the knowledge of his parents, he never was ever corrected. The Filipino culture of Walong pakialam (Do not meddle) or Huwag manghimasok sa buhay ng mag-asawa, (Do not intervene in the life of married couples) has been cultivated in the family. Another value that was observed by Ningning in the family of her husband was favoritism. Unluckily, her husband was not his parents pet. This implied no financial support to him. In fact, it was Ningning who financed his marine engineering course. She therefore accounted the violence by her husband to what psychologists claim that abuse runs in the family; that a slapped child of one generation becomes the abuser of the next and that violence towards a bad child may
create a bad adult and eventually foster the creation of a bad society. She also believes that his vices contribute to his impulsive violence.
Present Story of Violence Ningnings story of violence started after their first child; one year after their marriage. Unexpectedly, she was struck by a comb at her back when her husband was asking him of something which she was not able to answer. Later, she said, he apologized claiming that it was just a joke. The initial gesture of physical violence was repeated but in severe forms. There was pulling of hair, slapping, kicking, punching, and poking of sharp objects or a gun. The forms of violence meted by her husband were socio-economic, verbal, psycho-emotional and sexual. For example, the husband does not provide financial support for the education and domestic needs of his family. When asked to look for work, he would turn violent to her and his children. This results to psycho-emotional turmoil which had been observable in her attitude and behavior. The researcher observed that she was irrelevant and inconsistent in her answers to questions asked. Money and education were always mentioned in conversations. Circumstances Preceding Violence Ningning mentioned that violence was usually preceded by his drunkenness, gambling defeat and when she would not agree to his going out with his friends. Another precedence was when verified about rumors that he was womanizing and had a child with another woman, The verbal dispute normally resulted to other abuses such as marital rape. Effects of Violence Victim. The researcher noticed that during the series of interviews, she answered some of the questions with inconsistency and irrelevance. There were even times that the researcher had to repeat some questions because she seemed not to comprehend. Most of them were out of context and she seemed to be obsessed of financial needs. She was preoccupied mainly about finances and education of her children the fact that she claimed her husband to be irresponsible and lazy. She was observed to mumble incomprehensible words. When asked about it, she would not be able to remember what she was talking about. She would tend to be indirect when relating her stories. She would cry and laugh
at the same time when she related the violent experiences she has had with her husband. These behaviors are symptoms of transient psychosis which could be the effect of continuous cyclical violence, Children. Ningning related that their children turned cold in dealing with their father after they became witnesses to the violence he continuously inflicted on her. Courtesy and respect had to be reminded constantly while they were at home. It was also noticed that they were not close to their father. They would not even dare ask money from him for their transportation, food and education. They tend to be ashamed of their family for the public misdemeanor of their father. It was also apparent that they tend not to believe in the lies of Ningning; that what they were spending came from their fathers earnings.
Measures to Protect Against Violence Ningning related that the strategies she adapted were to live with the varied traumas. She tried to fight him, defended herself and ducked from physical assaults. The other measures were simply remaining silent, crying and just waited for whatever he inflicted to her. She also became subservient to his rules and his power and control to subdue her hostility and freedom. She also became a workaholic just to refrain from talking to him. Spirituality was another measure she treads. She said that she learned to surrender her unlucky and bad fate to God. She continuously added pray that everything would end well for her husband and her family. She hoped for a better future for her children. She wishes that all of them would become successfully employed. Finally, the scenarios of violence were single or combined, recurrent and cyclical. Such had made her adapt, callous and immune. Implications of the Study to improve nursing care for victims of VAW in all aspects of Clinical Practice. The study in general implies that nurses in practice of their profession, whether they are in education or clinical area must know the law specifically RA 7192. They must have knowledge on the rights of women and children to be able to assist anyone who has been violated of these rights. They must also know the process of networking with individuals or groups of individuals, government and non-government agencies who/which can help the victim as well as the perpetrator. They must also possess the character and the competence of a true-blooded nurse espoused by the mother of nursing, Florence
Nightingale, one who can give a real tender loving care. Nurses, for example, must know the law and the rights of women in order to be able to assist them if they so decide to bring their case to court. It is also important for the nurse to note that victims of violence are women and therefore are sensitive to investigations, especially done by men. Likewise when investigations are done repeatedly, such could be traumatic to the victim. If an abused woman comes to the clinical unit of the hospital, the nurse should rightfully attend to her since they are emotionally and psychologically unstable. They may not feel the physical pains at that moment of consultation and so a thorough assessment of them must be made. The nurse must refer her immediately to the physician for treatment. The intensive interview should be done after assessment and treatment. If it is possible, only a few health professionals should examine, treat and care for the patient. And no video taping or photography must be taken or allowed even if the injuries were evident. Oftentimes, nurses fail to be compassionate to victims of violence. Whenever they are confronted with a sexually abused woman, for example, they would get her data and would ask questions that would make the victim feel that she is being violated again. Along this line, the nurses should be cautious about what they should ask. They should find out first whether the victim had already been from another agency like the police or the social worker. In this case then, they should make use of the report that is passed on to them. In other words, what was asked should not be asked again. A female nurse should handle a woman victimized by abuse in order to allow her to relate her story. Most often, a woman can best relate to another woman. Sensitivity to the victims feelings must be taken into consideration. She should understand that most victims are afraid to reveal the experiences they have gone through. The nurse therefore must be very patient to be able to wait for the time when the victim would start talking. The nurses should make her understand that her story as well as her identity will be made confidential. The nurse must establish trust in order for the victim to tell the whole story. And the nurse must do active listening. It is important, therefore, for professionals to know all about violence against women understand why women stay in abusive relations and make sure that their response is not shaped by their own attitudes. Professionals are being called upon to be aware of their own attitudes, experiences and reactions to violence and being non-judgemental and objective when dealing with victims. Doctors and other medical personnel who come into contact with
victims of violence are especially being called upon to exercise sensitivity when examining such victims and to ensure that notes taken during the examination are clear and detailed enough to support prosecution. Privacy must be maintained at all times. If the victim had companions, she should be asked whether she wants them around during physical examinations. If she wants a companion during vaginal internal examination, then she should be permitted to have one. Counseling could be recommended but most often this should be voluntary. If she wants, then, this should be scheduled on a short term basis. The nurse or any of the health team must be competent in counseling or if not she should refer her to a more competent one, a professional counselor or a psychologist for that matter. If the violence is too much that it endangers the life of the victim, the nurse could refer her to agencies which have shelter homes. Hence, the nurse should have knowledge of these agencies which has Women and Child Protection Unit (WCPU). Furthermore, she could ask her to go to the barangay captain so he could order the perpetrator to stay away from her within 100 meters, a part of the law that protects women and children from harm. The nurse could also help her facilitate issuance of certifications and keep records of violence which could be needed for litigation. She could also refer her to womens desk at the Philippine National Police as well as to a lawyer tasked by the government to help women victims of violence. Physical care for hematomas, abrasions, lacerations, sprains, fractures and the like should be done and recorded immediately. Special procedures such as X-ray, ultrasonography, CT Scan for severe cases of physical abuse might also be needed, hence the nurse could serve as support and giver of care. Her presence and consoling words would make a lot of difference. For emotional violence, the nurse could give emotional support by active listening. She should be allowed to cry or shout if there is a need in order to vent her feelings of hopelessness, despair and frustrations over her traumatic experiences. Psychological violence which is often difficult to erase could be helped as well. The nurse could refer her to a psychologist or in severe cases, to a psychiatrist. Encouragement to do so could very well be done by the nurse. She could also be a moral support to the victim by providing her time, asking her to come for follow up, giving her contact number and allowing her to call her anytime she needs help or someone or talk to, keeping her company, to
name a few. When sexual abuse is the complaint of the client, the nurse could help her with the examination, referral to Philippine National Police Crime Laboratory and social worker. She can help her get into counseling and post trauma debriefing sessions. She can also be her support in explaining the experience to her family especially when they fail to understand the circumstances the woman has been. The nurse can also be an avid advocate to stop violence against women. She can join womens groups and share her knowledge on the law, strategies to prevent abuse and how to fight an abuser. In addition, she can also provide the victim with spiritual support. Some ways could be praying with the victim; encouraging her to cling to Gods mercy and grace; reconciling with God through various sacraments; asking for spiritual counseling or encouraging her to attend spiritual activities and to become a member of a religious organization who could help uplift her powerlessness and hopelessness into the power of love and optimism.
Strategies to Help the Victim The following are suggested strategies to help women victims of violence: 1. To believe in her and be sympathetic to her plight. Affirmation for the measures she does to protect her from further violence committed by her husband is important. She should be told that she should not feel guilty about her thoughts that they are causes of her husbands violent actions. 2. To actively listen to the victims ventilation of her feelings about the violence and the sufferings she experiences. She should be assured, however, of the confidentiality for whatever information she relates to safeguard her dignity and integrity. 3. To give clear and reliable insights and messages that show compassionate and non-judgmental attitude. A message like violence is never acceptable and is not a result of bad fate; that married couple should love and respect each other, for better or for worst, in sickness or in health, till death do they part. Another message could be about the rights of a woman and the ways to get out of a violent domestic abode. 4. To inquire about her plans for the future and help her attain her goals. Counseling may help; if it could not be done by the researcher herself, then she may refer her to a professional counselor. The researcher may also befriend her, comfort her, protect her and be her constant companion, a soul mate and
a prayer warrior. 5. To invite her or to encourage tier to join evangelization programs. This will enable her to bequeath forgiveness and mercy to her husband and herself as well. To be with God who is most merciful and loving would allow her to love others as herself, For whatever you do to the least of My brethren you do it unto Me and to encourage her to believe in the words of God and cling to Gods promises as written in the Bible. Conclusions and Recommendations Based on the findings, the study concludes that: 1. Every type of violence has its own profile in terms of physical, psychoemotional, socio-economic, verbal and sexual. A victim or her perpetrator may have a family history of domestic violence. 2. Studies have shown that violence is cyclical and is triggered by several preceding circumstances such as intake of drugs or alcohol, domestic conflicts, economic disequilibrium and growing up in a family where violence is a norm of disciplining children. This was proven by the study. 3. Violence has effects on the victim which can be physical, psychoemotional, socio-economic, verbal and sexual in nature. This study concurs with previous ones which prove that the effects of violence on woman victim are on a long-term basis, can destroy family relationships and values, and can have negative effects on children. 4. Women victims of violence can institute measures to protect themselves. Strategies could either be done on personal basis or through support system. 5. The findings of the study have varied implications to improve nursing care in all aspects of clinical practice for women victims of violence. They are addressed primarily to nurses, hospital and nursing administrators, the department of health and the academe.
Recommendations The study recommends strategies which would generally help prevent and control domestic violence and strategies means to treat and care for women victims of violence. 1. Profile of violence: The following recommendations are based on the profile of violence, along the categories of physical, psycho-emotional, socio-economic, verbal
and sexual respectively; they are as follows: a. As one of the front liners in the community, barangay officials need to be trained along strategies in assisting, referring and networking. b. Women victims may be helped to consult a psychologist, psychiatrist or a counselor for evaluation and management. c. She could be helped to become aware of her rights so she could be accorded to the equal chance to socialize and purchase personal necessities. d. Allow the victim ventilate varied feelings during Nurse-PatientInteraction (NPI) e. The victim must be submitted for laboratory examinations to determine the chance of acquiring dreaded sexually transmitted infections (STIs)/ unplanned pregnancies. Instructors of nursing should discuss thoroughly womens sexuality and reproductive health in lectures. 2. Circumstances Preceding Violence: a. The victim and the family must identify the provoking circumstances that may lead to abuse, thus preventing serious outcomes. b. The health workers in government need to provide rehabilitative counseling and treatment to perpetrators. c. The church, prior to marriage must look into a scheme integrating relevant seminar and dialogue with the soon to be married couple providing awareness on mutual obligations, recognizing the family as the basic unit of institution. Strengthen evangelization programs geared towards unity of the family at the barangay level and other religious organizations. 3. Effects of violence: a. A Women and Children Protection Unit (WCPU) must be available and accessible in all sectors, both government and non-government, and private institutions for reporting, rescue and first-aid management, and referral of physical violence of the VAW victim according to protocol. Strengthening community mobilization through active participation among constituents for reporting potential VAW victims to the barangay need to be executed. b. Spearheading a tri-media campaign and feminist movement among women province-wide emanating from the different sectors of society towards Stop Violence Against Women advocacy, which would pave the way for women empowerment to seek justice and equality to men. c. Other government agencies and LGUs should establish programs such as, but not limited to, education and information campaign and seminars or symposia on the nature, causes, incidence and consequences of violence
particularly towards educating the public on its social impacts. d. There must be an open line of communication among the members of the family on domestic problems, issues and concerns significantly to foster camaraderie and unity of them all. Further, parents shall not use derogatory remarks in front of the children resulting to fear and intimidation thus demoralizing them. e. Sex education for children should be started within the home first. 4. Measures Done to Protect Herself: a. Conduct a similar study on the profile if the perpetrators in order to implement a more realistic approach in altering the values and perspectives of men towards women, and enable men to be actively engaged in promoting the rights of women against any form of abuse and violence. b. A VAW victim and her family members must be availed of legal assistance from the Public Attorneys (PAO) of the Department of Justice (DOJ) or any public legal assistance office. 5. Implications of VAW to Improve Nursing Care: a. The continuing In-Service Training Program for hospital nurses and community nurses must include VAWC Management and Care for Abused Women and Children subjects in their plan in order to assist the victims in their healing and rehabilitation process. Nurses need to realize that they are not just providers of cure but also of care. Likewise, integration of programs addressing same in the Public Health Component of Bicol Regional Training and Teaching Hospital (BRTTH) particularly through Gender And Development (GAD) activities thereby would inculcate knowledge, attitude and skills (KAS) on the part of the general public. b. The health professionals must be trained to properly document any of the victims emotional or psychological injuries.
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DUNONG

REDUCING RISK THROUGH DISASTER AWARENESS AND PREPAREDNESS

AQUINAS UNIVERSITY PROFESSIONAL SCHOOLS Graduate School

Philippine Copyright 2009 by Aquinas University of Legazpi

ALL RIGHTS RESERVED

Vita Veritatis et Amoris ex Gratitudine

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UNIVERSAL BANKS IN LEGAZPI CITY

ENHANCED OPERATIONAL RISK MANAGEMENT ACTIVITIES; CLIENTS SATISFACTION

Figure 3. Conceptual Framework Model

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The banks services exceeded clients expectations. (Delighted.)

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The banks services did not match clients expectations. (Dissatisfied)

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Table 1 Strategic Planning

Very High Very High High

Very High High High High

12. Establishes clear performance expectations for its MIS to be effective.

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Weighted mean 1.90 2.19 1.88 1.88 1.83 2.10 1.88

High High High High High

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Figure 5. Summary of Banks Operational Risk Management Activities

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3. Gathers information concerning consumer dissatisfaction.

4.91 4.88 4.85 4.91 4.82 4.94 4.97

4.64 4.85 3.94 4.27 4.64 4.69 4.87

4.84 4.87 4.69 4.65 4.77 4.72 4.82

4.83 4.92 4.55 4.69 4.76 4.89 4.91

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