In recent years, health needs have become more complex and serious in Japan, and technologies that enhance local strengths to solve problems are essential. It is essential to develop a learning programme for public health nurses to acquire public health nursing skills that enhance community strengths and a self-assessment scale for achievement.
Aim
This study developed a self-assessment scale for the Public Health Nursing Art to Enhance “Strength of Community” (PASC).
Design
This study was designed as confirmatory.
Methods
A draft of the scale was developed using the framework of Public Health Nursing Art to Enhance “Strength of Community,” and a self-administered questionnaire was mailed to full-time public health nurses working at 1245 sites, including the government offices of the prefectures and ordinance-designated cities/designated mid-level cities across Japan. Subsequently, item, confirmatory factor, and correlation analyses were conducted to verify the scale’s reliability and validity.
Findings
Content, construct, and criterion-related validities and reliability were confirmed.
Conclusions
This scale can measure public health nursing art to enhance public health nurses’ “strength of community.” Furthermore, reflecting on their daily activities will improve public health nurses’ skills, contributing to the community's optimal health outcomes.
Clinical evidence
This study developed a self-assessment scale of Public Health Nursing Art to enhance “Strength of Community.” Regarding reliability, no significant bias in the data distribution or correlations was observed and confirmed internal consistency. Regarding construct validity, the GFI, AGFI, and CFI were considered statistically acceptable.
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Abkürzungen
PHNs
Public health nurses
PASC
Self-assessment scale of Public health nursing Art to enhance “Strengths of Community”
HCs
Health centers
CFA
Confirmatory factor analysis
CMIN/DF
Degree of freedom
GFI
Goodness-of-fit index
AGFI
Adjusted goodness-of-fit index
CFI
Comparative fit index
RMSEA
Root mean square error of approximation
PDS
Professional Development Scale
SCAT
Steps for Coding and Theorization
Introduction
Public health nursing, characterized by the norm of social justice in its activities, targets all individuals, families, and communities (e.g., groups, organizations, and regions). Furthermore, it aims to improve self-care and community care, which enhances the strength of every family and region. These activities aim to extend people’s lives and social well-being, which is the health of the community. In the United Kingdom, the seven beliefs supporting the public health nursing practice of health visitors have included “positive health,” “empowerment,” and “community partnership and participation” [1]. Further, in the United States, the eight skill areas of public health nursing core competencies that have been identified by the United Council of Major Community Nursing Organizations include “community dimensions of practice skills” [2]. In Japan, the “Guidelines for Public Health Nurses’ Health Activities in Local Communities” developed by the Director General of the Health Service Bureau of the Ministry of Health, Labour and Welfare in 2013 indicated that “strengthening activities based on district activities” and “promoting healthy community development in accordance with local characteristics” were essential. In this context, community health workers must first assess the current state of the community to determine how to promote community health [3]. Therefore, in public health nursing, strengthening the community in a positive and healthy direction is essential along with enhancing its abilities and resources, making skills to enhance the strengths of the community necessary.
In Japan, health needs are becoming increasingly complex and serious, such as parenting support and older adult care issues, owing to declining birthrates and the rising aging population, respectively. Furthermore, the prevalence of cancer and heart diseases is increasing due to changes in the living environment and lifestyle. Furthermore, Japan is prone to natural disasters, and people’s health needs may increase owing to unexpected disruptions caused by earthquakes and torrential rains.
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In 2022, in the “Report of Local Communities,” the Ministry of Internal Affairs and Communications revealed that the percentage of residents joining residents’ associations were decreasing, neighborhoods were becoming less friendly, and a limited number of people participated in community activities. Therefore, enhancing community strength in terms of both the environment and manpower has become increasingly difficult. Under these circumstances, Japanese public health nurses (PHNs) are engaging in public health activities with the aim of enhancing community strength; thus, establishing public health nursing arts is an urgent issue.
However, public health nursing activities are challenging to visualize [4], and PHNs themselves were unclear regarding who they were working for and what results they were achieving, based on the analysis of actual activities, public health nursing arts to enhance “Strengths of Community” have been identified in previous studies to provide a framework and key skills [5]. In addition, a reference book was published to disseminate the arts [6]. However, no self-assessment scale exists for assessing this knowledge. Furthermore, the acquisition of the arts, learning, and reflection were left to an individual’s discretion. Therefore, developing an evaluation scale to establish a systematic learning support system for acquiring arts is necessary. Enabling appropriate evaluation of these skills will enhance the competence of PHNs through opportunities such as human resource development and improve their professionalism, which in turn will contribute to the health and well-being of residents. Hence, this study aimed to develop a public health nursing art scale to enhance “Strengths of Community” (PASC).
Methods
Design
This study was designed as confirmatory.
Participants
The survey included 1,745 PHNs. To calculate a sufficient sample size, we considered 35,000 PHNs from the 2018 Survey on Public Health Nurses’ Activity by the Ministry of Health, Labor and Welfare, a confidence level of 95%, an error margin of 5%, and a response rate of 30% based on the response rate to a recent national survey [7, 8]. The sample size was determined to be 320.
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A survey was conducted between December 2019 to February 2020. Since a sufficient sample size was not obtained, an additional survey was sent to 500 Health Centers (HCs) between December 2020 and February 2021. The questionnaire was mailed to the representatives of the HCs. They distributed it to PHNs who worked in comprehensive support centers for families with children and community comprehensive support centers involved in fostering community strength.
The survey included a draft of the PASC, questions regarding participants’ demographic characteristics, such as sex, age, years of experience, affiliation, and position, and items related to the competencies of PHNs.
Data analysis
IBM SPSS Statistics version 27 and Amos version 27 were used for data analysis. Confirmatory factor analysis (CFA) was used to test reliability and validity. The analysis was divided into “norm” and “skills” respectively.
Draft scale
The draft of the PASC was newly created using a framework that consisted of seven domains based on the Public Health Nursing Art to Enhance the “Strength of Community” [5]. The scale was designed with “Norm” and “Skills”. In “Norm” a total of 3 items were created, including Social Justice. In “Skills” a total of 26 items were created, including Searching (six items), Stimulating (four items), Facilitating (four items), Cooperation (four items), Continuing Quality Improvement (four items), and Policy/Resource Development (four items). Responses regarding the degree of implementation were rated on a 6-point scale from 5 (always) to 0 (never). We refer to the subsequent domains of the PASC using [square brackets].
Content validity
Public Health Nursing Art to Enhance “Strength of Community” was conceptualized after the validation of its contenting previous studies; however, we checked that each category had been extracted using the appropriate procedures. We conducted a paper critique to confirm that consulted more than two experts familiar with public health nursing and generated comprehensive categories to accurately reflect the semantic content.
Item analysis
To determine whether there was any bias in the composition of the scale, we examined the frequency distribution and ceiling, and floor effects. In addition, to determine whether each item was relevant, item-test correlations were conducted. We examine whether there was a positive correlation of 0.5 or greater for each item and the total score [9].
Reliability
A Cronbach’s alpha coefficient, a measure of internal consistency, of > 0.8 was used to determine reliability [9].
Construct validity
Since the concepts already examined for content validity were used, confirmatory factor analysis via structural equation modeling (SEM) was used to determine construct validity. Furthermore, factor validity was examined for "Skills," a 26-item, six-factor structure. Discrepancy divided by degree of freedom (CMIN/DF), goodness-of-fit index (GFI), adjusted goodness-of-fit index (AGFI), comparative fit index (CFI), and root mean square error of approximation (RMSEA) were used as indices. Values of CMIN/DF < 3, GFI > 0.90, AGFI > 0.90, CFI > 0.95, and RMSEA < 0.08 were considered to indicate good fit, referring to Schermelleh-Engel’s goodness-of-fit indices [10]. In addition, based on previous studies [11, 12] that used the known group method to accurately assess the actual state of health professional skills, we examined the known group validity via three career-level groups, which were the number of years of PHN experience and duties by position. The three career level groups were those with five or less years of experience as a PHN (< 5 years), six or more years’ experience without a position above the chief level (≥ 6 years without position), and a position above the chief level (with position).
Criterion-related validity
We used the Professional Development Scale (PDS) [13], which measured the competencies of PHNs, to determine whether the total PDS score was positively correlated with the total score of each domain of the PASC with a value of r = 0.3 or more [9].
Scale translation
Although the survey was conducted in Japan and the draft scale was written in Japanese, we referred to the report by the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Task Force [14] and translated the scale using five steps to make appropriate for use internationally. First, two translators, who were native English speakers, completed a forward translation of the scales. Second, we compared and examined the draft and forward-translated scales to create the first scale. Third, two translators, whose native language was Japanese, completed back-translations of the first scale. Fourth, we compared and examined the draft and back-translated scales to create a second scale. Finally, two native English speakers confirmed the English expressions, grammar, and translation of the second scale.
Results
Participants
A total of 318 responses were collected (18.2% response rate), of which 312 were valid (17.9% valid response rate). Of the participants, 97.4% were female and 2.2% were male. Participants’ mean age was 45.8 ± 9.5 years, and the mean number of years of experience was 20.8 ± 10.3 years (min 0, max 41) (Table 1).
Public Health Nursing Art to Enhance “Strength of Community” (PASC) Score
range
Mean ± SD
Norm
Norm Total Score
0–15
12.3 ± 1.8
Social Justice
1
Trust and partnership
I act in accordance with the norm of trusting in people’s abilities and of building sustainable partnerships
0–5
4.1 ± 0.6
2
Equality and equity
I act in accordance with the norm of eliminating health inequalities in the community and fairly distributing available resources within the community
0–5
4.0 ± 0.7
3
Protection of everyone’s lives
I act in accordance with the norm of protecting everyone's lives, livelihoods, and right to life
0–5
4.1 ± 0.7
Skills
Skill total score
0–130
80.7 ± 17.0
Searching
Searching Total Score
0–30
18.0 ± 4.1
4
Identification of potential
I identify all potential within the community to promote positive health
0–5
3.5 ± 0.8
5
Needs identification
I comprehensively identify realities that threaten everyone’s lives, livelihoods, and right to life
0–5
3.5 ± 0.8
6
Resource exploration
I explore all available social resources within and outside the community and assess their realities
0–5
3.6 ± 0.7
7
Visualization
I use documents and charts to illustrate the realities of issues and strengths in the community
0–5
2.8 ± 1.0
8
Substance presentation
I use the live voices of the people involved and plot mapping to show the real existence of the issues and strengths
0–5
2.2 ± 1.1
9
Factor presentation
I analyze the various factors and circumstances behind the realities and create a visualization of the relationship among them
0–5
2.5 ± 1.1
Stimulating
Stimulating Total Score
0–20
14.0 ± 2.9
10
Collective responsibility sharing
I nurture people's commitment to taking ownership of the issues at hand and address them at their own initiative
0–5
3.4 ± 0.8
11
Collective voluntary Involvement
I nurture everyone's commitment to working together and having fun to achieve more positive conditions
0–5
3.5 ± 0.9
12
Initiation assistance
I encourage and buoy everyone to take the initiative in voluntary efforts
0–5
3.5 ± 0.8
13
Motivation boosting
I bolster people's confidence and encourage them to continue their energetic efforts
0–5
3.6 ± 0.8
Facilitating
Facilitating Total Score
0–20
12.1 ± 3.5
14
Player amplification
I empower people to enlist more players to mobilize the community's full potential
0–5
3.1 ± 0.9
15
Mutual contribution presentation
I empower people to share their contributions as players
0–5
3.0 ± 1.0
16
Local dissemination
I empower people to disseminate their efforts throughout their neighborhood and other neighborhoods
0–5
3.0 ± 1.0
17
Initiative support
I take steps to empower people in establishing their initiative as a model so they may take root in the whole community
0–5
3.0 ± 1.0
Cooperation
Cooperation Total Score
0–20
12.8 ± 3.3
18
Collaboration for growth
I collaborate with stakeholders by sharing goals while ensuring outcomes and mutual growth
0–5
3.4 ± 0.9
19
Adjustment for development
I work with stakeholders for comprehensive coordination to ensure constructive outcomes
0–5
3.4 ± 0.9
20
Positive Health transformation
I create opportunities and platforms to transform from reluctant to constructive collaborations
0–5
3.0 ± 1.0
21
Outcome consolidation
I create opportunities and platforms to ensure the required decisions are made, and reforms are implemented
0–5
3.0 ± 1.0
Continuing Quality Improvement
Continuing Quality Improvement Total Score
0–20
11.7 ± 3.4
22
Key people development
I identify key individuals in promoting positive health and develop their capabilities
0–5
3.1 ± 1.0
23
Collaborative knowledge development
I build stakeholders' capacity through discussions to find the best possible solution(s)
0–5
2.9 ± 1.0
24
Overhaul
I continuously check the overall quality of relevant social resources and identify matters for improvement
0–5
2.8 ± 1.0
25
Bottom-up improvement
I promote bottom-up improvements in response to pressing issues
0–5
2.9 ± 0.9
Policy/Resource
Development
Policy/Resource Development Total Score
0–20
12.0 ± 3.1
26
Resource generation
I make preparations and adjustments for the development of the required social resources and guide their realization
0–5
2.9 ± 0.9
27
Use promotion
I promote the utilization of social resources so they may be available to more people
0–5
3.3 ± 0.9
28
Priority identification
I identify priorities on issues that require planning and systematization
0–5
2.9 ± 1.0
29
Decision/Building/Infrastructure
I build and continuously develop policies and systems after the decision-making stage
0–5
2.8 ± 1.0
For “Norm”, the average total score (range 0–15) for Social Justice was 12.3 ± 1.8. The average scores for the sub-items (range 0–5) were 4.1 ± 0.6 for “Trust and partnership”,”Equality and equity”4.0 ± 0.7, and “Protection of everyone's lives”4.1 ± 0.7.
For “Skills”, the average total score (range 0–130) for public health nursing skills that enhance regional strengths was 80.7 ± 17.0 points. For the six areas of “Skills”, the average total score (range 0–30) for the [Searching] was 18.0 ± 4.1. The average scores for the sub-domains (range 0–5) were as follows: [Identification of potential”3.5 ± 0.8,”Needs identification”3.5 ± 0.8,”Resource exploration”3.6 ± 0.7″Visualization”2.8 ± 1.0,”Substance presentation”2.2 ± 1.1,”Factor presentation”2.5 ± 1.1.The average total score (range 0–20) for [Stimulating] was 18.0 ± 4.1. The average scores for the sub-items (score range 0–5) were 3.4 ± 0.8 for [Collective responsibility sharing], 3.5 ± 0.9 for [Collective voluntary Involvement], 3.5 ± 0.8 for [Initiation assistance], and 3.6 ± 0.8 for [Motivation boosting].
The average total score (range 0–20) for [Facilitating] was 12.1 ± 3.5. The average scores for the sub-items (range 0–5) were 3.1 ± 0.9 for Player amplification, 3.0 ± 1.0 for Mutual contribution presentation, 3.0 ± 1.0 for Local dissemination, and 3.0 ± 1.0 for Initiative support.The average total score (range 0–20) for [Cooperation] was 12.8 ± 3.3. The average scores for the sub-items (score range 0–5) were 3.4 ± 0.9 for “Collaboration for growth”, 3.4 ± 0.9 for “Adjustment for development”, 3.0 ± 1.0 for “Positive Health transformation”, and 3.0 ± 1.0 for “Outcome consolidation”.[Continuing Quality Improvement]The average total score (range 0–20) was 11.7 ± 3.4. The average scores for the sub-items (range 0–5) were 3.1 ± 1.0 for “Key people development”, 2.9 ± 1.0 for “Collaborative knowledge development”, 2.8 ± 1.0 for “Overhaul”, and 2.9 ± 0.9 for “Bottom-up improvement”.[Policy/Resource Development]The average total score (range 0–20) was 12.0 ± 3.1. The average scores for the sub-items (range 0–5) were 2.9 ± 0.9 for “Resource generation”, 3.3 ± 0.9 for “Use promotion”, 2.9 ± 1.0 for “Priority identification”, and 2.8 ± 1.0 for “Decision/Building/Infrastructure”.
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Verification of reliability and validity
Content validity
The Public Health Nursing Art to Enhance the “Strength of Community” was selected using the Steps for Coding and Theorization(SCAT), qualitative research method [15], which was highly reflective and refutable. The concept was comprehensive and appropriately generated through consultation with multiple experts familiar with public health nursing [5].
Item analysis
For both the "Norm" and "Skills,” the histograms confirmed no significant bias in the distribution of scores for the responses to the subscales. The mean scores for the 29 items of the subscale (range 0–5) had a range of 2.2–4.1. with standard deviations ranged 0.6–1.1. Furthermore, no ceiling and floor effects were observed (Table 2). Regarding the item-test correlations, for "Norm" (three items) and 26 items, the correlation coefficients between each item and the total score ranged 0.820–0.898 and 0.588–0.807, respectively.
Reliability
Regarding internal consistency, the Cronbach’s alpha coefficient for [Social Justice] was 0.833. For “Skills,” the Cronbach’s alpha coefficient for all 26 items was 0.959, and it was 0.837 for [Searching], 0.903 for [Stimulating], 0.929 for [Facilitating], 0.907 for [Cooperation], 0.899 for [Continuing Quality Improvement], and 0.861 for [Policy/Resource Development].
Construct validity
Confirmatory factor analysis of the 26-item, six-domain structure revealed a goodness-of-fit of CMIN/DF = 2.191 (p < 0.001), GFI = 0.868, AGFI = 0.829, CFI = 0.949, and RMSEA = 0.062 (Fig. 1).
Fig. 1
Confirmatory Factor Analysis of the “Skills”
×
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Regarding the known groups, by the three career level groups, the mean values for each factor for both “Norms” and “Skills” were lower for the group with no position and five years or less compared to the other groups. The total scores for [Social Justice] in "Norm" and total score of “Skills,” [Searching], [Stimulating], [Facilitating], [Continuing Quality Improvement], and [Policy/Resource Development] were significantly higher in the other groups than in the group without a position for ≤ 5 years. No significant differences were observed for [Cooperation] (Table 3).
Table 3
Association between the three career level groups and total PASC scores
≤ 5 years
≥ 6 years
without position
With position
n = 37
n = 108
n = 167
range
M
SD
M
SD
M
SD
p
Norm
Social Justice
0–15
11.4
±
1.9
12.4
±
1.9
12.4
±
1.7
0.008
*
Skills
Skill total
0–130
72.7
±
17.8
80.5
±
17.5
82.6
±
16.1
0.005
*
Searching
0–30
15.8
±
3.4
18.3
±
4.2
18.4
±
4.1
0.002
*
Stimulating
0–20
13.1
±
3.1
14.0
±
2.9
14.3
±
2.8
0.067
±
Facilitating
0–20
10.8
±
3.5
11.8
±
4.0
12.6
±
3.1
0.011
*
Cooperation
0–20
12.1
±
4.1
12.9
±
3.6
13.0
±
3.0
0.362
Continuing quality Improvement
0–20
10.1
±
4.0
11.5
±
3.4
12.1
±
3.2
0.003
*
Policy/Resource Development
0–20
10.8
±
3.1
12.0
±
3.2
12.2
±
3.0
0.050
±
One-Way Analysis of Variance
*p < 0.05, ± 0.05 ≦p < 0.1
Criterion-related validity
The correlation coefficients between the total PDS scores and overall and total scores for each factor of “Norms " and "Skills” were > 0.3, demonstrating a positive correlation.
Discussion
Adequacy of data
Although the response rate was low, the number of valid responses was 312, a sufficient sample size (number of items × 7 and number of respondents × 100 or more), as indicated by the COnsensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) [16].
Reliability and validity of the scale
A self-assessment scale of PASC that consisted of 3-item and 1-domain “Norm” and 26-item, and 6-domain "Skills" was developed. Regarding reliability, no significant bias in the data distribution or correlations was observed. Furthermore, the Cronbach’s alpha coefficient was 0.8 or higher for the total score of “Norms” and "Skills" and for all the factors, confirming internal consistency. Regarding construct validity, the GFI, AGFI, and CFI all fell short of Schermelleh–Engel et al.’s accepted fit; however, they were considered statistically acceptable. Regarding the relationship with known groups, the results that were separated according to the three career level groups for both “Norms” and “Skills” supported previous findings [11] indicating that as the years of experience or position increased, the professional competence also increased. Furthermore, significant differences were observed in the total score of [Social Justice] for “Norms” and “Skills,” [Searching], [Stimulating], [Facilitating], [Continuing Quality Improvement], and [Policy/Resource Development], indicating known group validity. However, no significant differences were observed for [Cooperation]. Therefore, evaluating this factor alone was difficult. Regarding criterion-related validity, a positive correlation between the total PDS score for each domain of the “Norm” and “Skills” was observed, indicating comorbid validity between the concepts. In summary, the PASC had a certain degree of reliability and validity.
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Implications for practice
The originality of this study was that it measured the skills of PHNs demonstrated toward the outcome of the best population health in the community. In other words, quantitatively determining the degree of one’s own performance of activities5 such as “actuation to make reality visible,” “motivational support,” and “promotion to disseminate activities throughout the community” was possible [5], even among public health nursing activities that are said to be difficult to visualize.
For PHNs who have under 6-year work experience, the scale's dissemination will allow to recognize public health nursing skills that enhance community strengths based on the scale’s items and verbalize how they are deploying their skills in their public health activities, helping PHNs to make sense of their activities. For PHNs who have under 6-year work experience, by using the scale regularly before and after providing community support, PHNs can confirm the acquisition of art and clarify the areas they need to strengthen through the activities they are developing in the community they oversee. In this way, the self-assessment of each public health nurse in human resource development can clarify the necessary learning support, possibly leading to establishing a systematic learning system.
The ability of public health nurses to clarify and verbalize the issues in their own activities will help reduce barriers to their purposeful actions, communication of professional information among PHNs, and collaboration between public health nurses, residents, and stakeholders and will facilitate the Plan-Do-Check-Act cycle in their activities.
Therefore, we believe that we can expect improvements in public health nursing art to enhance “Strength of Community” of the PHNs, and PHNs can contribute to the roles and responsibilities of administrative agencies as general coordinators of the community and that their activities can impact the community, enhancing long-term sustainability and fostering community strengths.
Limitations
First, to increase the response rate, a reminder was sent once in this survey. As a result, the sample size was sufficiently large for statistical processing, but the response rate did not reach 30%, which is the same as in previous studies. Thus, the possibility of sampling errors cannot be ruled out owing to the low response rate(17.9%). Second, the confirmatory factor analysis could not confirm sufficient goodness-of-fit in some areas and fully confirm concomitant validity in some domains. Therefore, future studies should increase the sample size and conduct further scale validations both as a whole and by domain.
Conclusions
This scale can measure public health nursing art to enhance public health nurses’ “Strength of Community.” Furthermore, reflection on their daily activities will improve their skills, which will contribute to the optimal health outcomes for the community.
Acknowledgements
We would like to thank all the PHNs who cooperated in the development of the scale and in the survey.
Clinical trial number
Not applicable.
Declarations
Ethics approval and consent to participate
This study was approved by the Ethics Committee for the Intervention Study of Osaka University Hospital (No. 19322 and 12/18/2019), and all the procedures were followed in accordance with the Declaration of Helsinki. A letter of request was enclosed with the survey, which included the survey objectives and ethical considerations, and consent was deemed to have been given by ticking the consent box on the upper left of the questionnaire cover. Informed consent was obtained from all the participants. The ethical considerations included freedom to cooperate in the survey, management of personal information and guarantee of anonymity, scope of use and management method of data, and time required for the survey.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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