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Tacit knowledge of public health nurses in identifying community health problems and need for new services: A case study
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International Journal of Nursing Studies 43 (2006) 819–826 www.elsevier.com/locate/ijnurstu
Tacit knowledge of public health nurses in identifying community health problems and need for new services: A case study Kyoko Yoshioka-Maedaa,, Sachiyo Murashimaa, Kiyomi Asaharab a
Department of Community Health Nursing, Division of Health Sciences and Nursing, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan b Department of Community Health Nursing, St Luke’s College of Nursing, 10-1 Akashi-cho, Chuo-ku, Tokyo 104-0044, Japan Received 5 August 2004; received in revised form 9 September 2005; accepted 3 November 2005
Abstract Background: The purpose of this study was to explore the tacit knowledge of public health nurses in identifying community health problems and developing relevant new projects. Previous research only roughly showed those skills for creating new community health services, such as lobbying. Method: Nine Japanese public health nurses who had created new projects in their municipalities were selected by theoretical sampling and interviewed in 2002–2003. Yin’s Case Study Method, especially the multiple-case study design, was used. Results: All 9 public health nurses used similar approaches in identifying community health problems and the need for creating new services, even though their experiences differed and the kinds of projects varied. They identified the difficulties of clients, recognized clients who had the same problems, elucidated the limitations of existing services, and forecasted outcomes from the neglect of the clients’ problems. Then they succeeded in creating a new project by examining individual health problems in the context of their community’s characteristics, societal factors, and using existing policies to support their clients. Conclusion: This is the first study to explore the skills of public health nurses and their intention to use such skills in creating new projects as well as the exact process. They could identify community health problems that will be the basis for developing new services to provide care for individual clients. This is different from the traditional community assessment approach that requires the collection of a huge amount of information to clarify community health problems. The tacit knowledge of public health nurses will help to create needs-oriented new services more smoothly. r 2005 Elsevier Ltd. All rights reserved. Keywords: Tacit knowledge; Public health nurse; Project development; Community health assessment; Difficult clients
What is already known about the topic?
Traditional community assessment, in which identification of the community health problem is considered Corresponding author. Tel.: +81 3 5841 3597;
fax: +81 3 5802 2043. E-mail address: [email protected] (K. Yoshioka-Maeda).
0020-7489/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2005.11.001
to be the first step in developing a new service, is needed to collect sufficient information to clarify the community health problems. Previous research only roughly showed methods for developing new programs, such as lobbying. However, practical approaches by public health nurses in identifying health needs that require new public health projects have not yet been elucidated.
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What this paper adds
This is the first study to explore the skills of public
health nurses and their intention to use such skills in creating new projects as well as the exact process utilized in this effort. Even though their experiences differ and the kind of projects varied, all of the public health nurses used similar approaches. Public health nurses can identify community health problems that will be the basis for developing new services to provide care for individual clients. This is different from the traditional community assessment approach that requires collection of a huge amount of information to clarify community health problems.
is translated into action for the public good. PHNs can perform this role in any setting, but it is mainly performed in the public sector (APHA, 1996). In Japan, most PHNs work in the public sector (The Ministry of Health Labour and Welfare of Japan, 2004). As the first step to gain knowledge about this important area of administration, this study explored the tacit knowledge that PHNs use to identify community health problems and the need for new projects in their everyday practice. Of the various stages in performing a community assessment, we focused particularly on the identification of health problems and community analysis (Anderson and McFarlane, 2000).
2. Methods
1. Introduction and literature review The World Health Organization (1996) mentioned that identifying community health problems and then developing relevant programs or policies are among the functions of public health nurses (PHNs). Recently, this role has gained much attention in Japan (Yuzawa, 1997; Murashima et al., 1999b). Most PHNs discover community health problems in the course of their everyday practice, such as, home visits (Kennedy, 2002). However, practical approaches in identifying health needs that require new public health projects have not yet been elucidated. Such practical approaches are based on the tacit knowledge of PHNs. However, previous research has not clarified this tacit knowledge of PHNs (Houston and Cowley, 2003; Yoshioka et al., 2004). A literature search produced only a single report outlining the method used in creating a health-related project (Murashima et al., 1999a), although the use of lobbying and other measures in developing programs has been reported (Milio, 1998). Traditionally, PHNs use a method known as community health assessment to define community health problems (hereinafter referred to as ‘‘health problems’’), by which an understanding of the local situation is gained through the collection and analysis of information from a broad range of community sources (Muecke, 1984; Kriegler and Harton, 1992). Therefore, a large volume of data must be analyzed (Anderson and McFarlane, 2000; Cassells, 2001). The importance of community involvement in community health assessment has been identified (Flynn, 1998). However, the use of epidemiological or economic approaches (Billings and Cowley, 1995) has been criticized for failing to reflect community opinions (Fuller et al., 2001). PHNs provide a critical link between epidemiological data and the clinical understanding of health and illness as it is experienced in peoples’ lives. This understanding
2.1. Rationale for selection of the case study research method We adopted the case study research method to focus on the individual experience of expert PHNs who have acquired ‘‘tacit knowledge’’ accumulated through everyday practice (Herbig et al., 2001). PHNs apply this ‘‘tacit knowledge’’ when developing new projects, yet this empirical knowledge was unexplained and has not been shared by many PHNs. For this reason, we focused on the individual experience of expert PHNs. This is the principle for adopting the case study design (Cresswell, 1998). In this study, Yin’s case study method and the multiplecase study design are utilized (Yin, 2003). Yin strongly addresses that the evidence from a multiple-case study is considered more robust than that from a single-case study and findings based on this method are considered to have high reliability and validity. In this study, participating PHNs were called ‘‘Case 1’’, ‘‘Case 2’’, etc. 2.2. Data collection To improve reliability and increase validity of findings, Yin stressed three points (Yin, 2003). First, data collection should be based on a case study protocol (hereinafter referred to as the ‘‘protocol’’). Second, researchers must create a case study database to record the information and the data collected for case studies. Third, data can be collected from many sources, such as documentation, records, interviews, etc. Our data met these criteria including data from documentation, notes related to interviews, analyses, and other pertinent information for each case study. The protocol included interview questions and documents to support the interview data such as tables summarizing community information, local demographic statistics, organizational charts, master plans, and community health and welfare plans of the municipality. To develop interview questions, we conducted semi-structured
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interviews (hereinafter referred to as ‘‘interviews’’) with 2 PHNs who met the same criteria as the study participants and 2 officers with experience in auditing project proposals. In the open-ended questions, we included the affiliations and experience of the PHNs and the process of identifying health problems and the need for new projects. Participants in the study were PHNs who had developed a new public health project in their local municipalities between April 1997 and September 2003, based on a written policy of the municipality and a guaranteed budget for each project. In addition to snowball sampling, participants were recruited on the basis of information gathered from five representative Japanese public health nursing journals. The total number of participants was 9 at the end. As for recruiting these 9 PHNs, the first telephone contact was made with 61 PHNs who thought to be suitable for participation, and consent to participate was obtained from 5 of the 10 candidates who met the eligibility criteria. The study was conducted from 10 May to 16 October 2002. These 5 PHNs with 20 years’ experience developed a public health project for either the elderly or mothers and children. For theoretical sampling purposes, the second telephone contact was made with 8 PHNs either with less than 10 years’ experience or who had developed mental health projects. Four of them gave consent to participate in this study. The study was conducted from 16 July to 19 December 2003. Each participant was interviewed three times. With the participants’ consent, interviews were recorded and the researcher transcribed the interview by oneself. At the first interview, information was gathered regarding the process of identifying the health problem and developing a new project. At the second interview, unclear points from the first interview were clarified. At the third interview, the case study report made after the second interview was revised by the participants to confirm the interview data. The first and second interviews lasted an average of 96 min, and the third interview an average of 56 min. To increase an understanding of the participants, the researcher observed the practice of 5 PHNs who provided permission for this activity. 2.3. Data analysis The Yin’s Case Study Method incorporates a method of analysis to improve reliability and validity of findings (Yin, 2003). First, results of each case are compared to find common patterns, and second, the researchers and study participants review the draft of study findings. Longitudinal analysis was selected due to the nature of community assessment involves a series of assessments. After the second interview, the transcripts of the first and second interviews were made. The researchers divided the transcripts into sections according to content, and 2–3 line summaries were compiled. The
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summaries were coded for the questions: ‘‘How did PHNs identify the health problems?’’ and ‘‘Why did PHNs choose these approaches?’’ These codes were organized in chronological order, and a case study report was written for each participant. When the interview data was not sufficient, the researchers added new data to case study reports, such as community characteristics from collected documents. After the participants’ confirmation of the report at the third interview, again, the interview data was transcribed, summarized and coded. Each code was classified according to similarity of content and named to reflect that classification. After identifying the approaches used by each PHN, we compared them to determine commonalities between the 9 participants. We examined the situations and the order in which each PHN approached and supported their clients. We then attempted to create a schematic model of the process. To ensure validity of the results, we enlisted the opinion of the 9 participants as well as an expert in qualitative research methods. After discussion with them, we refined the naming of the approaches and the model developed. 2.4. Ethical considerations Before the beginning of a case study research project, we sent a letter to all the PHNs and their superiors, such as, department managers or the governors of each municipality to protect them from entering into a study without full knowledge of its purposes and procedures (Yin, 2003). This letter included a summary of the study, the purpose and methods to be utilized, an outline of the interview, identification of the researches, and ethical considerations, etc. Prior to commencement, we again explained the aims and methods of this study to the participants both orally and in writing. We also explained that participation was voluntary and that each PHN could opt out of the study at any time, that the information obtained from the interviews would not be used for any purpose other than the study, and that their privacy would be protected. Then we obtained informed consent from all study participants. Tape recordings and transcripts of the interviews and all other material related to this study were kept in strict confidence and anonymous.
3. Results 3.1. Summary of projects developed by the PHNs Tables 1 and 2 show the affiliations of the 9 participants, a little information on their community and the projects they developed. Of the 9 participants, 3 had produced projects for elderly clients, 4 had devised
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projects for mothers and children (2 of these PHNs had less than 10 years of experience) and the remaining 2 had produced mental health projects. 3.2. Approaches used by the PHNs to identify community health problems and the need for new projects In identifying the health needs of their community, regardless of their level of experience and the different nature of their projects, all of the 9 PHNs used the similar seven approaches. These are described in detail. Direct quotes from the participants are shown within quotation marks. Table 1 Characteristics of the public health nurses who participated in the study and of their communities N ¼9 Mean7SD or number Gender (M/F) Age (years) Educational background Three years nursing school and vocational training Nursing college Nursing experience in hospitals (years) Experiences as a municipal public health nurse (years) Community characteristics (urban/rural) Juvenile population ratio (%) Senior citizen population ratio (%) Residents per public health nurse (person)
0/9 40.979.7 8 1 0.971.8 17.878.8 4/5 13.975.9 14.874.6 620072300
Table 2 Summaries of the projects the 9 public health nurses developed Case
The projects
Case 1
Program to prevent the elderly to become bedridden, working with community volunteers Dementia prevention program Program for preventing the need for care, working with community volunteers Consultations with mothers of infants under 4 months old Counseling program for mothers to talk about stress of child rearing Child rearing groups to support mothers whose children have language delay Child rearing support groups for foreign mothers Support program for parents of withdrawal adolescents Support program for schizophrenic patients and their families
Case 2 Case 3 Case 4 Case 5 Case 6 Case 7 Case 8 Case 9
3.2.1. Identification of difficult clients that led to the development of a project In the course of PHNs’ everyday practice, consultations and home visits, they encountered clients who were not getting sufficient assistance through existing projects, such as demented elderly for whom care at home was becoming difficult. They also encountered clients with multiple problems for whom they felt assistance was inadequate. The PHNs were uncertain of the best way of dealing with problems. The mothers repeatedly told me they were concerned about their children’s language delay. However, I did not know how to support these mothers. (Case 6) Through contact with difficult clients, all participants recognized the health problems faced by individuals and came to realize their own limitations for providing support, which led them to think the reason why the existence of these difficult clients. At that time, I supported the foreign mother who neglected her child. Child abuse cases involving foreigners were increasing within a short period. Because of the difference in national character and language, I felt difficulty in supporting them, and wondered why we could not recognize these clients much earlier. In my imagination, there would be some potential problem that would cause a mother to neglect her child. (Case 7)
3.2.2. Recognition of the existence of difficult clients with similar problems and their common points The PHNs identified how many clients in their community had the same problems as their difficult clients; and whether the number of this type of clients was increasing within their community. By using objective evidence, such as ‘consultation records’, ‘child health checkups records’ and ‘surveys’, the PHNs also identified potential difficult clients. I reviewed all consultation records of frail elders who lived in our district. The records showed that we consulted with elderly clients about unsanitary handling of garbage very often. I discovered that the same is true of users of Day Service. Many elders were refused the service because they did not fit the criteria for it. I found that there were many elders who could not use existing services and needed help in the community. (Case 1) In this way, the PHNs specified latent clients with similar problems that would be changed to difficult clients, and transformed individual problems into aggregate problems.
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3.2.3. Elucidation of limitations and problems with existing projects The PHNs reviewed existing projects to identify factors that influenced the occurrence of difficult clients, and considered whether they could use existing services to support their clients. However, all 9 PHNs identified that existing projects did not fully support the needs of their difficult clients. In some cases, reviewing the current methods of caring for existing clients revealed their limitations. Then they thought of what kind of services would support their clients, and recognized the necessity of fundamental solutions. Because of lacking social resources for mental health, I could not find any services for mentally impaired clients. I felt it was difficult to support our clients by visiting the home and listening to their problems individually. If I told them to improve their life style by themselves, they could not do it. However, if a public gathering space would be created and our clients went there, their life style would be better. That was why I considered the need of creating a new social resource. (Case 9) 3.2.4. Forecasting the outcome of neglecting difficult clients The PHNs predicted the outcome of neglecting difficult clients. They concerned that the problems with such difficult clients would only worsen, and predicted that they would have more clients with the same problems in the future. The PHNs also examined the effect of lack of community resources and forecasted the future situation in their communities. Then, all participants confirmed the need for new projects. The number of consultations about demented elders snowballed every year. If this trend continued, I felt we could not support our clients in the future. If things remained as they are, developing services for demented elderly would be too late in this municipality. For these reasons, I believed that we had to create services for them to help maintain their autonomy and quality of life. (Case 2) 3.2.5. Determining whether the problem could be dealt with by PHNs alone and identification of future collaborators Having elucidated the limitations and problems of existing projects, all 9 PHNs considered ‘whether this was a problem that could be supported by PHNs alone,’ and concluded that ‘it was not a problem that only PHNs could deal with themselves.’ Therefore, 9 participants explored and identified the future collaborators that were required to put their new projects into practice.
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I thought seriously as to whether this was a problem that could be supported by PHNs alone. Children move on to the next stage of education, such as nursery school, elementary school, junior high school. It was important to share the way of thinking about care of children with staff of the municipality. That was why I wanted to collaborate with the education board and the school counsellor who understood the importance of the mother–child relationship. (Case 5) In this way, the PHNs recognized the necessity of collaborators and working cooperatively with them. 3.2.6. Identification of community characteristics and societal factors related to difficult clients The PHNs examined factors related to difficult clients that existed in the course of providing care to them. This produced evidence for their contention that the health problems of clients affected not just the client but also the entire community. They recognized demographic changes in their communities, and aware of environmental factors affecting their difficult clients. Because this was a new residential area, there was little communication between residents, and mothers of babies were easily isolated. (Case 6) The PHNs took into account resistance to utilizing services by some members of the community, and also identified the prejudices and lack of understanding of the community toward difficult clients. They also considered societal factors, such as the nationwide trend toward nuclear families. This approach confirmed that the problems recognized by the PHNs were also important for Japanese society as a whole. Lack of a playground for children and of the chance to meet with mothers who have babies had been a problem in this municipality. Because of the national and regional trend toward a decreasing number of children, there were no similarly aged children in their neighbourhood. It was also a problem in my community. If foreign mothers went out in the daytime, some neighbour would say, ‘The mother was going to have fun even in the daylight.’ I thought the mothers were not free to go out and that it was difficult to go to get health check-ups for their babies. (Case 7) 3.2.7. Utilizing policy related to support for difficult clients The PHNs believed in the necessity of developing new services and required evidence to confirm their ideas. They sought out existing policies and regulations related to support for difficult clients, and checked whether they could apply the health policy and regulations to their
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clients. They utilized these policies in such a way as to reinforce their ideas. The participants applied not only national policies such as the ‘Long-Term Care Insurance Law,’ but also policies and regulations of municipalities such as ‘Master plans of the municipality.’ The policies provided important evidence for making sure of ‘the feasibility in the case of putting their ideas into practice’ by the PHNs. At that time, not only the national government but also the municipality adopted a policy to improve welfare for the elderly. Then the Long-Term Care Insurance Law was enforced and the municipality worked out a policy to promote the development of a program to prevent the elderly from becoming bedridden. I could confirm whether the new service that I thought was in need of creating was part of a trend or not, and was necessary or not. (Case 1) 3.3. Correlation of approaches used by PHNs in identifying community health problems and recognizing the need for new projects The seven approaches that the PHNs used were illustrated as creating a model to identify community health problems and the need for new public health projects as shown in Fig. 1. The approach for identification of difficult clients was at the core of the seven approaches because the difficult clients that the PHNs encountered in their daily activities triggered the
creation of new services. By using objective evidence, such as ‘‘consultation records and surveys,’’ the participants identified clients who had similar problems to those of trigger clients. This approach helped to identify the health problems of aggregates as well as just one client. The participants considered the limitations of existing projects and predicted the outcome if difficult clients were neglected. These approaches contributed to revealing factors that influenced the occurrence of difficult clients and the need of creating a new health project. They also considered whether the problem could be dealt with by PHNs alone and identified future collaborators necessary to put their new projects into practice. The 9 participants considered community characteristics and social factors and utilized policies related to support for their difficult clients. These approaches confirmed the need for developing a new service, transforming the individual problem into a community problem. In other words, by using each approach, the PHNs tried to identify community health problems, to recognize the need for new projects, and to gather evidence to confirm their ideas. The horizontal axis shows the purpose of the PHNs in the use of each approach. Each approach also helped to identify the clients who needed support. Coverage of the PHNs’ activities expanded from the individual to aggregates with the same health problems as the difficult clients and then to their community. The vertical axis represents the target of the PHNs’ activities.
Target of the public health nurses' activities
Community
Aggregate
1 Identification of the difficult clients
2 Recognition of the existence of difficult clients with similar problems
3 Elucidation of the limitations and problems of existing projects
4 Forecasting the outcome of neglecting the difficult clients
5 Determining whether the problem could be dealt with by public health nurses alone
6 Identification of community characteristics and societal factors related to the difficult clients
7 Utilizing policy related to support for the difficult clients
Individual
Identification of the ⇒ community health problems
Recognition of the need for new projects
⇒
Confirming public health nurses' ideas with gathering evidences
Purpose of public health nurses
Fig. 1. Correlation of the approaches used by the public health nurses in identifying community health problems and the need for new projects.
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All approaches were both outlined by and connected with broken lines, which indicate invisible connections. The approaches were based on tacit knowledge of the PHNs and the broken lines were used to symbolize that such knowledge is ‘‘invisible.’’
4. Discussion We explored the approaches used by PHNs to identify community health problems in their everyday practices and the need for new public health projects to ameliorate those problems. This study had two principal findings. First, the tacit knowledge of PHNs was described to identify community health problems and the need for new services in concrete terms based on the multiple-case study design. Second, regardless of their varying levels of experience and the different nature of projects, all participating PHNs applied the same approaches. Providing support for difficult clients by the PHNs was the starting point in identifying community health problems and the need for new services in their daily practice. In other words, the results show that the PHNs cared for their difficult clients first and gradually identified the existence of the community health problem. This is different from traditional community assessment, in which identification of the community health problem is considered to be the first step of developing a new service, and is needed to collect sufficient information to understand the community and to clarify community health problems (Anderson and McFarlane, 2000; Clemen-Stone, 2002). In summary, the participants used methods that differed from traditional ones. Using statistical data and results of surveys, they recognized that many people in their community had the same problems as their difficult clients. This approach provided the basis for the development of public health policy and helped to define community health problems (German, 2001). This finding indicates that PHNs can identify community health problems that will be the basis for developing new services through individual care. It also reveals that they look at the community from the perspective of care of the individual. In addition, the results show the importance of face-to-face care for clients because PHNs interact with these clients during their everyday practice. We found that the PHNs considered factors that would influence the occurrence of difficult clients, such as problems and limitations associated with existing projects, and recognized the necessity of creating new services. Evaluation of existing services helps to clarify the gap between the need of support for clients and services provided by existing projects (Smith and BaziniBarakat, 2003). In this context, difficult clients can be considered the embodiment of problems with existing
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projects and are the trigger for the development of new projects by PHNs. The PHNs forecasted outcomes if these clients would be left without support and believed the need for developing the new services. The community assessment method showed the importance of predicting the seriousness of problems (Sharma, 2003). Estimating the future outcome of neglecting the health problem was a concrete way to understanding its severity. This result means that regardless of PHNs’ varying levels of experience, they can easily identify health problems that require the creation of new projects by estimating the future situation in their communities. We also found that the PHNs determined whether the problem could be dealt with by themselves and identified future collaborators in parallel. To solve community health problems, it is important to work on such problems with interdisciplinary staff as a team (Larsson and Butterfierld, 2002). Finding usable resources is necessary to implement a new project (Williams and Yanoshik, 2001). The participants in this study used this approach to enhance the possibility of creating new health projects. The PHNs examined individual health problems in the context of their community’s characteristics and societal factors, which is typical of PHN activities, supporting both populations and individuals (Quad council of public health nursing organizations, 1999). Community health problems are closely related to the values and behavioural patterns of the community’s residents (Porche, 2004), and PHNs undertake the role of addressing them (Anderson, 2002). For this reason, PHNs considered the need for changing community awareness by identifying the fundamental solution for the health problem. The results of this study indicate that the PHNs used policy and regulations related to support for difficult clients. The core functions of public health agencies at all levels of government are assessment, policy development, and assurance (IOM, 2003). PHNs are assumed to be a responsibility (APHA, 1996). However, Bartee et al. (2003) pointed out that PHNs perceived a lack of policy development and program planning skills. Our findings indicate the importance of development of needsoriented programs and projects that can be more smoothly implemented by PHNs. The present study did have two limitations. The first concerns the number of participants. However, numbers were limited by the eligibility criteria and the strict recruitment procedure. The second is that to reduce recall bias we supplemented the interviews with documents. However, we were unable to examine certain internal documents, which raise the possibility that the information gathered was incomplete. In spite of these limitations, this is the first study to explore the skills and exact process of tacit knowledge used by PHNs in creating new projects based on a multiple-case study design.
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Acknowledgements Our heartfelt thanks go to the PHNs and officers who supported the conduct of this study, which was also assisted by a 2002 research grant from the Univers Foundation (Grant No. 02-01-018), and the Sasakawa Scientific Research Grant from The Japan Science Society (Grant No. 16-314).
References American Public Health Association, Public Health Nursing Section, 1996. The Definition and Role of Public Health Nursing: A Statement of the Public Health Nursing Section. APHA, Washington DC. Anderson, E.T., McFarlane, J., 2000. Community assessment. In: Anderson, E.T., McFarlane, J. (Eds.), Community as Partner: Theory and Practice in nursing, third ed. Lippincott Williams & Wilkins, Philadelphia, PA, pp. 165–218. Anderson, D., Guthrie, T., Schirle, R., 2002. A nursing model of community organization for change. Public Health Nursing 19 (1), 40–46. Bartee, R.T., Winnail, S.D., Olsen, S.E., et al., 2003. Assessing competencies of the public health workforce in a frontier state. Journal of Community Health 28 (6), 459–469. Billings, J., Cowley, S., 1995. Approaches to community needs assessment: a literature review. Journal of Advanced Nursing 22 (4), 721–730. Cassells, H., 2001. Community assessment. In: Nies, M.A., McEwen, M. (Eds.), Community Health Nursing, third ed. WB Saunders Company, Philadelphia, PA, pp. 92–108. Clemen-Stone, S., 2002. Community assessment and diagnosis. In: Clemen-Stone, S., McGuire, S.L., Eigsti, D.G. (Eds.), Comprehensive Community Health Nursing, sixth ed. Mosby, Inc, St. Louis, Missouri, pp. 449–480. Cresswell, J.W., 1998. Philosophical and theoretical frameworks. In: Cresswell, J.W. (Ed.), Qualitative Inquiry and Research Design: Choosing Among Five Traditions. Sage Publications, Thousand Oaks, CA, pp. 73–87. Flynn, B.C., 1998. Communicating with the public: community-based nursing research and practice. Public Health Nursing 15 (3), 165–170. Fuller, J., Bentley, M., Shotton, D., 2001. Use of community health needs assessment for regional planning in country South Australia. Australian Journal of Rural Health 9 (1), 12–17. German, R.R., 2001. Lessons learned from the first funding period of the CDC Assessment Initiative. Journal of Public Health Management & Practice 7 (5), 50–57. Herbig, B., Bussing, A., Ewert, T., 2001. The role of tacit knowledge in the work context of nursing. Journal of Advanced Nursing 34 (5), 687–695. Houston, M.A., Cowley, S., 2003. Health needs assessment in the health visiting service and the impact on the ethnic community. International Journal of Nursing Studies 40 (1), 85–94. Institute of Medicine (IOM), 2003. The governmental public health infrastructure. In: The future of the public health 21st
century. The National Academies Press, Washington, DC, pp. 96–101. Kennedy, C.M., 2002. The work of district nurses: first assessment visits. Journal of Advanced Nursing 40 (6), 710–720. Kriegler, N.F., Harton, M.K., 1992. Community health assessment tool: a patterns approach to data collection and diagnosis. Journal of Community Health Nursing 9 (4), 229–234. Larsson, L.S., Butterfierld, P., 2002. Mapping the future of environmental health and nursing: strategies for integrating national competencies into nursing practice. Public Health Nursing 19 (9), 301–308. Milio, N., 1998. Priorities and strategies for promoting community-based prevention policies. Journal of Public Health Management Practice 4 (3), 14–28. Muecke, M.A., 1984. Community health diagnosis in nursing. Public Health Nursing 1 (1), 23–35. Murashima, S., Asahara, K., White, C.M., Ryu, S., 1999a. The meaning of public health nursing: creating 24 h care in a community in Japan. Nursing and Health Sciences 1, 83–92. Murashima, S., Hatono, Y., Whyte, N., Asahara, K., 1999b. Public health nursing in Japan: new opportunities for health promotion. Public Health Nursing 16 (2), 133–139. Porche, D.J., 2004. Cultural competence. In: Proche, D.J. (Ed.), Public & Community Health Nursing Practice. Sage Publications, Thousand Oaks, CA, pp. 129–143. Quad council of public health nursing organizations, 1999. Scope and Standards of Public Health Nursing Practice. American Nurses Association,, Washington, DC. Sharma, R.K., 2003. Putting the community back in community health assessment: a process and outcome approach with a review of some major issues for public health professionals. Journal of Health & Social Policy 16 (3), 19–33. Smith, K., Bazini-Barakat, N., 2003. A public health nursing practice model: melding public health principles with the nursing process. Public Health Nursing 20 (1), 42–48. The Ministry of Health Labour and Welfare of Japan, 2004. Annual report on health, labour and welfare 2002–2003. Gyosei Corporation, Tokyo, pp. 317-318. Williams, R.L., Yanoshik, K., 2001. Can you do a community assessment without talking to the community? Journal of Community Health 26 (4), 233–247. World Health Organization, 1996. Report of a WHO expert committee. Technical report series 860. WHO, Geneva. Yin, R.K., 2003. Case Study Research, third ed. Sage Publications, Thousand Oaks, CA. Yoshioka, K., Asahara, K., Murashima, S., 2004. Processes and strategies for developing public health nurse directed community health projects in municipalities of Japan. Japanese Journal of Public Health 1994 51 (4), 257–271 (in Japanese). Yuzawa, F., 1997. Research on the Future Role of Public Health Nurses who Work for Municipalities: report of the research and investigation on health, medical and welfare programs in the community. Ministry of Health and Welfare, Tokyo (in Japanese).
International Journal of Nursing Studies 43 (2006) 819–826 www.elsevier.com/locate/ijnurstu
Tacit knowledge of public health nurses in identifying community health problems and need for new services: A case study Kyoko Yoshioka-Maedaa,, Sachiyo Murashimaa, Kiyomi Asaharab a
Department of Community Health Nursing, Division of Health Sciences and Nursing, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan b Department of Community Health Nursing, St Luke’s College of Nursing, 10-1 Akashi-cho, Chuo-ku, Tokyo 104-0044, Japan Received 5 August 2004; received in revised form 9 September 2005; accepted 3 November 2005
Abstract Background: The purpose of this study was to explore the tacit knowledge of public health nurses in identifying community health problems and developing relevant new projects. Previous research only roughly showed those skills for creating new community health services, such as lobbying. Method: Nine Japanese public health nurses who had created new projects in their municipalities were selected by theoretical sampling and interviewed in 2002–2003. Yin’s Case Study Method, especially the multiple-case study design, was used. Results: All 9 public health nurses used similar approaches in identifying community health problems and the need for creating new services, even though their experiences differed and the kinds of projects varied. They identified the difficulties of clients, recognized clients who had the same problems, elucidated the limitations of existing services, and forecasted outcomes from the neglect of the clients’ problems. Then they succeeded in creating a new project by examining individual health problems in the context of their community’s characteristics, societal factors, and using existing policies to support their clients. Conclusion: This is the first study to explore the skills of public health nurses and their intention to use such skills in creating new projects as well as the exact process. They could identify community health problems that will be the basis for developing new services to provide care for individual clients. This is different from the traditional community assessment approach that requires the collection of a huge amount of information to clarify community health problems. The tacit knowledge of public health nurses will help to create needs-oriented new services more smoothly. r 2005 Elsevier Ltd. All rights reserved. Keywords: Tacit knowledge; Public health nurse; Project development; Community health assessment; Difficult clients
What is already known about the topic?
Traditional community assessment, in which identification of the community health problem is considered Corresponding author. Tel.: +81 3 5841 3597;
fax: +81 3 5802 2043. E-mail address: [email protected] (K. Yoshioka-Maeda).
0020-7489/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2005.11.001
to be the first step in developing a new service, is needed to collect sufficient information to clarify the community health problems. Previous research only roughly showed methods for developing new programs, such as lobbying. However, practical approaches by public health nurses in identifying health needs that require new public health projects have not yet been elucidated.
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What this paper adds
This is the first study to explore the skills of public
health nurses and their intention to use such skills in creating new projects as well as the exact process utilized in this effort. Even though their experiences differ and the kind of projects varied, all of the public health nurses used similar approaches. Public health nurses can identify community health problems that will be the basis for developing new services to provide care for individual clients. This is different from the traditional community assessment approach that requires collection of a huge amount of information to clarify community health problems.
is translated into action for the public good. PHNs can perform this role in any setting, but it is mainly performed in the public sector (APHA, 1996). In Japan, most PHNs work in the public sector (The Ministry of Health Labour and Welfare of Japan, 2004). As the first step to gain knowledge about this important area of administration, this study explored the tacit knowledge that PHNs use to identify community health problems and the need for new projects in their everyday practice. Of the various stages in performing a community assessment, we focused particularly on the identification of health problems and community analysis (Anderson and McFarlane, 2000).
2. Methods
1. Introduction and literature review The World Health Organization (1996) mentioned that identifying community health problems and then developing relevant programs or policies are among the functions of public health nurses (PHNs). Recently, this role has gained much attention in Japan (Yuzawa, 1997; Murashima et al., 1999b). Most PHNs discover community health problems in the course of their everyday practice, such as, home visits (Kennedy, 2002). However, practical approaches in identifying health needs that require new public health projects have not yet been elucidated. Such practical approaches are based on the tacit knowledge of PHNs. However, previous research has not clarified this tacit knowledge of PHNs (Houston and Cowley, 2003; Yoshioka et al., 2004). A literature search produced only a single report outlining the method used in creating a health-related project (Murashima et al., 1999a), although the use of lobbying and other measures in developing programs has been reported (Milio, 1998). Traditionally, PHNs use a method known as community health assessment to define community health problems (hereinafter referred to as ‘‘health problems’’), by which an understanding of the local situation is gained through the collection and analysis of information from a broad range of community sources (Muecke, 1984; Kriegler and Harton, 1992). Therefore, a large volume of data must be analyzed (Anderson and McFarlane, 2000; Cassells, 2001). The importance of community involvement in community health assessment has been identified (Flynn, 1998). However, the use of epidemiological or economic approaches (Billings and Cowley, 1995) has been criticized for failing to reflect community opinions (Fuller et al., 2001). PHNs provide a critical link between epidemiological data and the clinical understanding of health and illness as it is experienced in peoples’ lives. This understanding
2.1. Rationale for selection of the case study research method We adopted the case study research method to focus on the individual experience of expert PHNs who have acquired ‘‘tacit knowledge’’ accumulated through everyday practice (Herbig et al., 2001). PHNs apply this ‘‘tacit knowledge’’ when developing new projects, yet this empirical knowledge was unexplained and has not been shared by many PHNs. For this reason, we focused on the individual experience of expert PHNs. This is the principle for adopting the case study design (Cresswell, 1998). In this study, Yin’s case study method and the multiplecase study design are utilized (Yin, 2003). Yin strongly addresses that the evidence from a multiple-case study is considered more robust than that from a single-case study and findings based on this method are considered to have high reliability and validity. In this study, participating PHNs were called ‘‘Case 1’’, ‘‘Case 2’’, etc. 2.2. Data collection To improve reliability and increase validity of findings, Yin stressed three points (Yin, 2003). First, data collection should be based on a case study protocol (hereinafter referred to as the ‘‘protocol’’). Second, researchers must create a case study database to record the information and the data collected for case studies. Third, data can be collected from many sources, such as documentation, records, interviews, etc. Our data met these criteria including data from documentation, notes related to interviews, analyses, and other pertinent information for each case study. The protocol included interview questions and documents to support the interview data such as tables summarizing community information, local demographic statistics, organizational charts, master plans, and community health and welfare plans of the municipality. To develop interview questions, we conducted semi-structured
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interviews (hereinafter referred to as ‘‘interviews’’) with 2 PHNs who met the same criteria as the study participants and 2 officers with experience in auditing project proposals. In the open-ended questions, we included the affiliations and experience of the PHNs and the process of identifying health problems and the need for new projects. Participants in the study were PHNs who had developed a new public health project in their local municipalities between April 1997 and September 2003, based on a written policy of the municipality and a guaranteed budget for each project. In addition to snowball sampling, participants were recruited on the basis of information gathered from five representative Japanese public health nursing journals. The total number of participants was 9 at the end. As for recruiting these 9 PHNs, the first telephone contact was made with 61 PHNs who thought to be suitable for participation, and consent to participate was obtained from 5 of the 10 candidates who met the eligibility criteria. The study was conducted from 10 May to 16 October 2002. These 5 PHNs with 20 years’ experience developed a public health project for either the elderly or mothers and children. For theoretical sampling purposes, the second telephone contact was made with 8 PHNs either with less than 10 years’ experience or who had developed mental health projects. Four of them gave consent to participate in this study. The study was conducted from 16 July to 19 December 2003. Each participant was interviewed three times. With the participants’ consent, interviews were recorded and the researcher transcribed the interview by oneself. At the first interview, information was gathered regarding the process of identifying the health problem and developing a new project. At the second interview, unclear points from the first interview were clarified. At the third interview, the case study report made after the second interview was revised by the participants to confirm the interview data. The first and second interviews lasted an average of 96 min, and the third interview an average of 56 min. To increase an understanding of the participants, the researcher observed the practice of 5 PHNs who provided permission for this activity. 2.3. Data analysis The Yin’s Case Study Method incorporates a method of analysis to improve reliability and validity of findings (Yin, 2003). First, results of each case are compared to find common patterns, and second, the researchers and study participants review the draft of study findings. Longitudinal analysis was selected due to the nature of community assessment involves a series of assessments. After the second interview, the transcripts of the first and second interviews were made. The researchers divided the transcripts into sections according to content, and 2–3 line summaries were compiled. The
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summaries were coded for the questions: ‘‘How did PHNs identify the health problems?’’ and ‘‘Why did PHNs choose these approaches?’’ These codes were organized in chronological order, and a case study report was written for each participant. When the interview data was not sufficient, the researchers added new data to case study reports, such as community characteristics from collected documents. After the participants’ confirmation of the report at the third interview, again, the interview data was transcribed, summarized and coded. Each code was classified according to similarity of content and named to reflect that classification. After identifying the approaches used by each PHN, we compared them to determine commonalities between the 9 participants. We examined the situations and the order in which each PHN approached and supported their clients. We then attempted to create a schematic model of the process. To ensure validity of the results, we enlisted the opinion of the 9 participants as well as an expert in qualitative research methods. After discussion with them, we refined the naming of the approaches and the model developed. 2.4. Ethical considerations Before the beginning of a case study research project, we sent a letter to all the PHNs and their superiors, such as, department managers or the governors of each municipality to protect them from entering into a study without full knowledge of its purposes and procedures (Yin, 2003). This letter included a summary of the study, the purpose and methods to be utilized, an outline of the interview, identification of the researches, and ethical considerations, etc. Prior to commencement, we again explained the aims and methods of this study to the participants both orally and in writing. We also explained that participation was voluntary and that each PHN could opt out of the study at any time, that the information obtained from the interviews would not be used for any purpose other than the study, and that their privacy would be protected. Then we obtained informed consent from all study participants. Tape recordings and transcripts of the interviews and all other material related to this study were kept in strict confidence and anonymous.
3. Results 3.1. Summary of projects developed by the PHNs Tables 1 and 2 show the affiliations of the 9 participants, a little information on their community and the projects they developed. Of the 9 participants, 3 had produced projects for elderly clients, 4 had devised
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projects for mothers and children (2 of these PHNs had less than 10 years of experience) and the remaining 2 had produced mental health projects. 3.2. Approaches used by the PHNs to identify community health problems and the need for new projects In identifying the health needs of their community, regardless of their level of experience and the different nature of their projects, all of the 9 PHNs used the similar seven approaches. These are described in detail. Direct quotes from the participants are shown within quotation marks. Table 1 Characteristics of the public health nurses who participated in the study and of their communities N ¼9 Mean7SD or number Gender (M/F) Age (years) Educational background Three years nursing school and vocational training Nursing college Nursing experience in hospitals (years) Experiences as a municipal public health nurse (years) Community characteristics (urban/rural) Juvenile population ratio (%) Senior citizen population ratio (%) Residents per public health nurse (person)
0/9 40.979.7 8 1 0.971.8 17.878.8 4/5 13.975.9 14.874.6 620072300
Table 2 Summaries of the projects the 9 public health nurses developed Case
The projects
Case 1
Program to prevent the elderly to become bedridden, working with community volunteers Dementia prevention program Program for preventing the need for care, working with community volunteers Consultations with mothers of infants under 4 months old Counseling program for mothers to talk about stress of child rearing Child rearing groups to support mothers whose children have language delay Child rearing support groups for foreign mothers Support program for parents of withdrawal adolescents Support program for schizophrenic patients and their families
Case 2 Case 3 Case 4 Case 5 Case 6 Case 7 Case 8 Case 9
3.2.1. Identification of difficult clients that led to the development of a project In the course of PHNs’ everyday practice, consultations and home visits, they encountered clients who were not getting sufficient assistance through existing projects, such as demented elderly for whom care at home was becoming difficult. They also encountered clients with multiple problems for whom they felt assistance was inadequate. The PHNs were uncertain of the best way of dealing with problems. The mothers repeatedly told me they were concerned about their children’s language delay. However, I did not know how to support these mothers. (Case 6) Through contact with difficult clients, all participants recognized the health problems faced by individuals and came to realize their own limitations for providing support, which led them to think the reason why the existence of these difficult clients. At that time, I supported the foreign mother who neglected her child. Child abuse cases involving foreigners were increasing within a short period. Because of the difference in national character and language, I felt difficulty in supporting them, and wondered why we could not recognize these clients much earlier. In my imagination, there would be some potential problem that would cause a mother to neglect her child. (Case 7)
3.2.2. Recognition of the existence of difficult clients with similar problems and their common points The PHNs identified how many clients in their community had the same problems as their difficult clients; and whether the number of this type of clients was increasing within their community. By using objective evidence, such as ‘consultation records’, ‘child health checkups records’ and ‘surveys’, the PHNs also identified potential difficult clients. I reviewed all consultation records of frail elders who lived in our district. The records showed that we consulted with elderly clients about unsanitary handling of garbage very often. I discovered that the same is true of users of Day Service. Many elders were refused the service because they did not fit the criteria for it. I found that there were many elders who could not use existing services and needed help in the community. (Case 1) In this way, the PHNs specified latent clients with similar problems that would be changed to difficult clients, and transformed individual problems into aggregate problems.
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3.2.3. Elucidation of limitations and problems with existing projects The PHNs reviewed existing projects to identify factors that influenced the occurrence of difficult clients, and considered whether they could use existing services to support their clients. However, all 9 PHNs identified that existing projects did not fully support the needs of their difficult clients. In some cases, reviewing the current methods of caring for existing clients revealed their limitations. Then they thought of what kind of services would support their clients, and recognized the necessity of fundamental solutions. Because of lacking social resources for mental health, I could not find any services for mentally impaired clients. I felt it was difficult to support our clients by visiting the home and listening to their problems individually. If I told them to improve their life style by themselves, they could not do it. However, if a public gathering space would be created and our clients went there, their life style would be better. That was why I considered the need of creating a new social resource. (Case 9) 3.2.4. Forecasting the outcome of neglecting difficult clients The PHNs predicted the outcome of neglecting difficult clients. They concerned that the problems with such difficult clients would only worsen, and predicted that they would have more clients with the same problems in the future. The PHNs also examined the effect of lack of community resources and forecasted the future situation in their communities. Then, all participants confirmed the need for new projects. The number of consultations about demented elders snowballed every year. If this trend continued, I felt we could not support our clients in the future. If things remained as they are, developing services for demented elderly would be too late in this municipality. For these reasons, I believed that we had to create services for them to help maintain their autonomy and quality of life. (Case 2) 3.2.5. Determining whether the problem could be dealt with by PHNs alone and identification of future collaborators Having elucidated the limitations and problems of existing projects, all 9 PHNs considered ‘whether this was a problem that could be supported by PHNs alone,’ and concluded that ‘it was not a problem that only PHNs could deal with themselves.’ Therefore, 9 participants explored and identified the future collaborators that were required to put their new projects into practice.
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I thought seriously as to whether this was a problem that could be supported by PHNs alone. Children move on to the next stage of education, such as nursery school, elementary school, junior high school. It was important to share the way of thinking about care of children with staff of the municipality. That was why I wanted to collaborate with the education board and the school counsellor who understood the importance of the mother–child relationship. (Case 5) In this way, the PHNs recognized the necessity of collaborators and working cooperatively with them. 3.2.6. Identification of community characteristics and societal factors related to difficult clients The PHNs examined factors related to difficult clients that existed in the course of providing care to them. This produced evidence for their contention that the health problems of clients affected not just the client but also the entire community. They recognized demographic changes in their communities, and aware of environmental factors affecting their difficult clients. Because this was a new residential area, there was little communication between residents, and mothers of babies were easily isolated. (Case 6) The PHNs took into account resistance to utilizing services by some members of the community, and also identified the prejudices and lack of understanding of the community toward difficult clients. They also considered societal factors, such as the nationwide trend toward nuclear families. This approach confirmed that the problems recognized by the PHNs were also important for Japanese society as a whole. Lack of a playground for children and of the chance to meet with mothers who have babies had been a problem in this municipality. Because of the national and regional trend toward a decreasing number of children, there were no similarly aged children in their neighbourhood. It was also a problem in my community. If foreign mothers went out in the daytime, some neighbour would say, ‘The mother was going to have fun even in the daylight.’ I thought the mothers were not free to go out and that it was difficult to go to get health check-ups for their babies. (Case 7) 3.2.7. Utilizing policy related to support for difficult clients The PHNs believed in the necessity of developing new services and required evidence to confirm their ideas. They sought out existing policies and regulations related to support for difficult clients, and checked whether they could apply the health policy and regulations to their
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clients. They utilized these policies in such a way as to reinforce their ideas. The participants applied not only national policies such as the ‘Long-Term Care Insurance Law,’ but also policies and regulations of municipalities such as ‘Master plans of the municipality.’ The policies provided important evidence for making sure of ‘the feasibility in the case of putting their ideas into practice’ by the PHNs. At that time, not only the national government but also the municipality adopted a policy to improve welfare for the elderly. Then the Long-Term Care Insurance Law was enforced and the municipality worked out a policy to promote the development of a program to prevent the elderly from becoming bedridden. I could confirm whether the new service that I thought was in need of creating was part of a trend or not, and was necessary or not. (Case 1) 3.3. Correlation of approaches used by PHNs in identifying community health problems and recognizing the need for new projects The seven approaches that the PHNs used were illustrated as creating a model to identify community health problems and the need for new public health projects as shown in Fig. 1. The approach for identification of difficult clients was at the core of the seven approaches because the difficult clients that the PHNs encountered in their daily activities triggered the
creation of new services. By using objective evidence, such as ‘‘consultation records and surveys,’’ the participants identified clients who had similar problems to those of trigger clients. This approach helped to identify the health problems of aggregates as well as just one client. The participants considered the limitations of existing projects and predicted the outcome if difficult clients were neglected. These approaches contributed to revealing factors that influenced the occurrence of difficult clients and the need of creating a new health project. They also considered whether the problem could be dealt with by PHNs alone and identified future collaborators necessary to put their new projects into practice. The 9 participants considered community characteristics and social factors and utilized policies related to support for their difficult clients. These approaches confirmed the need for developing a new service, transforming the individual problem into a community problem. In other words, by using each approach, the PHNs tried to identify community health problems, to recognize the need for new projects, and to gather evidence to confirm their ideas. The horizontal axis shows the purpose of the PHNs in the use of each approach. Each approach also helped to identify the clients who needed support. Coverage of the PHNs’ activities expanded from the individual to aggregates with the same health problems as the difficult clients and then to their community. The vertical axis represents the target of the PHNs’ activities.
Target of the public health nurses' activities
Community
Aggregate
1 Identification of the difficult clients
2 Recognition of the existence of difficult clients with similar problems
3 Elucidation of the limitations and problems of existing projects
4 Forecasting the outcome of neglecting the difficult clients
5 Determining whether the problem could be dealt with by public health nurses alone
6 Identification of community characteristics and societal factors related to the difficult clients
7 Utilizing policy related to support for the difficult clients
Individual
Identification of the ⇒ community health problems
Recognition of the need for new projects
⇒
Confirming public health nurses' ideas with gathering evidences
Purpose of public health nurses
Fig. 1. Correlation of the approaches used by the public health nurses in identifying community health problems and the need for new projects.
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All approaches were both outlined by and connected with broken lines, which indicate invisible connections. The approaches were based on tacit knowledge of the PHNs and the broken lines were used to symbolize that such knowledge is ‘‘invisible.’’
4. Discussion We explored the approaches used by PHNs to identify community health problems in their everyday practices and the need for new public health projects to ameliorate those problems. This study had two principal findings. First, the tacit knowledge of PHNs was described to identify community health problems and the need for new services in concrete terms based on the multiple-case study design. Second, regardless of their varying levels of experience and the different nature of projects, all participating PHNs applied the same approaches. Providing support for difficult clients by the PHNs was the starting point in identifying community health problems and the need for new services in their daily practice. In other words, the results show that the PHNs cared for their difficult clients first and gradually identified the existence of the community health problem. This is different from traditional community assessment, in which identification of the community health problem is considered to be the first step of developing a new service, and is needed to collect sufficient information to understand the community and to clarify community health problems (Anderson and McFarlane, 2000; Clemen-Stone, 2002). In summary, the participants used methods that differed from traditional ones. Using statistical data and results of surveys, they recognized that many people in their community had the same problems as their difficult clients. This approach provided the basis for the development of public health policy and helped to define community health problems (German, 2001). This finding indicates that PHNs can identify community health problems that will be the basis for developing new services through individual care. It also reveals that they look at the community from the perspective of care of the individual. In addition, the results show the importance of face-to-face care for clients because PHNs interact with these clients during their everyday practice. We found that the PHNs considered factors that would influence the occurrence of difficult clients, such as problems and limitations associated with existing projects, and recognized the necessity of creating new services. Evaluation of existing services helps to clarify the gap between the need of support for clients and services provided by existing projects (Smith and BaziniBarakat, 2003). In this context, difficult clients can be considered the embodiment of problems with existing
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projects and are the trigger for the development of new projects by PHNs. The PHNs forecasted outcomes if these clients would be left without support and believed the need for developing the new services. The community assessment method showed the importance of predicting the seriousness of problems (Sharma, 2003). Estimating the future outcome of neglecting the health problem was a concrete way to understanding its severity. This result means that regardless of PHNs’ varying levels of experience, they can easily identify health problems that require the creation of new projects by estimating the future situation in their communities. We also found that the PHNs determined whether the problem could be dealt with by themselves and identified future collaborators in parallel. To solve community health problems, it is important to work on such problems with interdisciplinary staff as a team (Larsson and Butterfierld, 2002). Finding usable resources is necessary to implement a new project (Williams and Yanoshik, 2001). The participants in this study used this approach to enhance the possibility of creating new health projects. The PHNs examined individual health problems in the context of their community’s characteristics and societal factors, which is typical of PHN activities, supporting both populations and individuals (Quad council of public health nursing organizations, 1999). Community health problems are closely related to the values and behavioural patterns of the community’s residents (Porche, 2004), and PHNs undertake the role of addressing them (Anderson, 2002). For this reason, PHNs considered the need for changing community awareness by identifying the fundamental solution for the health problem. The results of this study indicate that the PHNs used policy and regulations related to support for difficult clients. The core functions of public health agencies at all levels of government are assessment, policy development, and assurance (IOM, 2003). PHNs are assumed to be a responsibility (APHA, 1996). However, Bartee et al. (2003) pointed out that PHNs perceived a lack of policy development and program planning skills. Our findings indicate the importance of development of needsoriented programs and projects that can be more smoothly implemented by PHNs. The present study did have two limitations. The first concerns the number of participants. However, numbers were limited by the eligibility criteria and the strict recruitment procedure. The second is that to reduce recall bias we supplemented the interviews with documents. However, we were unable to examine certain internal documents, which raise the possibility that the information gathered was incomplete. In spite of these limitations, this is the first study to explore the skills and exact process of tacit knowledge used by PHNs in creating new projects based on a multiple-case study design.
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Acknowledgements Our heartfelt thanks go to the PHNs and officers who supported the conduct of this study, which was also assisted by a 2002 research grant from the Univers Foundation (Grant No. 02-01-018), and the Sasakawa Scientific Research Grant from The Japan Science Society (Grant No. 16-314).
References American Public Health Association, Public Health Nursing Section, 1996. The Definition and Role of Public Health Nursing: A Statement of the Public Health Nursing Section. APHA, Washington DC. Anderson, E.T., McFarlane, J., 2000. Community assessment. In: Anderson, E.T., McFarlane, J. (Eds.), Community as Partner: Theory and Practice in nursing, third ed. Lippincott Williams & Wilkins, Philadelphia, PA, pp. 165–218. Anderson, D., Guthrie, T., Schirle, R., 2002. A nursing model of community organization for change. Public Health Nursing 19 (1), 40–46. Bartee, R.T., Winnail, S.D., Olsen, S.E., et al., 2003. Assessing competencies of the public health workforce in a frontier state. Journal of Community Health 28 (6), 459–469. Billings, J., Cowley, S., 1995. Approaches to community needs assessment: a literature review. Journal of Advanced Nursing 22 (4), 721–730. Cassells, H., 2001. Community assessment. In: Nies, M.A., McEwen, M. (Eds.), Community Health Nursing, third ed. WB Saunders Company, Philadelphia, PA, pp. 92–108. Clemen-Stone, S., 2002. Community assessment and diagnosis. In: Clemen-Stone, S., McGuire, S.L., Eigsti, D.G. (Eds.), Comprehensive Community Health Nursing, sixth ed. Mosby, Inc, St. Louis, Missouri, pp. 449–480. Cresswell, J.W., 1998. Philosophical and theoretical frameworks. In: Cresswell, J.W. (Ed.), Qualitative Inquiry and Research Design: Choosing Among Five Traditions. Sage Publications, Thousand Oaks, CA, pp. 73–87. Flynn, B.C., 1998. Communicating with the public: community-based nursing research and practice. Public Health Nursing 15 (3), 165–170. Fuller, J., Bentley, M., Shotton, D., 2001. Use of community health needs assessment for regional planning in country South Australia. Australian Journal of Rural Health 9 (1), 12–17. German, R.R., 2001. Lessons learned from the first funding period of the CDC Assessment Initiative. Journal of Public Health Management & Practice 7 (5), 50–57. Herbig, B., Bussing, A., Ewert, T., 2001. The role of tacit knowledge in the work context of nursing. Journal of Advanced Nursing 34 (5), 687–695. Houston, M.A., Cowley, S., 2003. Health needs assessment in the health visiting service and the impact on the ethnic community. International Journal of Nursing Studies 40 (1), 85–94. Institute of Medicine (IOM), 2003. The governmental public health infrastructure. In: The future of the public health 21st
century. The National Academies Press, Washington, DC, pp. 96–101. Kennedy, C.M., 2002. The work of district nurses: first assessment visits. Journal of Advanced Nursing 40 (6), 710–720. Kriegler, N.F., Harton, M.K., 1992. Community health assessment tool: a patterns approach to data collection and diagnosis. Journal of Community Health Nursing 9 (4), 229–234. Larsson, L.S., Butterfierld, P., 2002. Mapping the future of environmental health and nursing: strategies for integrating national competencies into nursing practice. Public Health Nursing 19 (9), 301–308. Milio, N., 1998. Priorities and strategies for promoting community-based prevention policies. Journal of Public Health Management Practice 4 (3), 14–28. Muecke, M.A., 1984. Community health diagnosis in nursing. Public Health Nursing 1 (1), 23–35. Murashima, S., Asahara, K., White, C.M., Ryu, S., 1999a. The meaning of public health nursing: creating 24 h care in a community in Japan. Nursing and Health Sciences 1, 83–92. Murashima, S., Hatono, Y., Whyte, N., Asahara, K., 1999b. Public health nursing in Japan: new opportunities for health promotion. Public Health Nursing 16 (2), 133–139. Porche, D.J., 2004. Cultural competence. In: Proche, D.J. (Ed.), Public & Community Health Nursing Practice. Sage Publications, Thousand Oaks, CA, pp. 129–143. Quad council of public health nursing organizations, 1999. Scope and Standards of Public Health Nursing Practice. American Nurses Association,, Washington, DC. Sharma, R.K., 2003. Putting the community back in community health assessment: a process and outcome approach with a review of some major issues for public health professionals. Journal of Health & Social Policy 16 (3), 19–33. Smith, K., Bazini-Barakat, N., 2003. A public health nursing practice model: melding public health principles with the nursing process. Public Health Nursing 20 (1), 42–48. The Ministry of Health Labour and Welfare of Japan, 2004. Annual report on health, labour and welfare 2002–2003. Gyosei Corporation, Tokyo, pp. 317-318. Williams, R.L., Yanoshik, K., 2001. Can you do a community assessment without talking to the community? Journal of Community Health 26 (4), 233–247. World Health Organization, 1996. Report of a WHO expert committee. Technical report series 860. WHO, Geneva. Yin, R.K., 2003. Case Study Research, third ed. Sage Publications, Thousand Oaks, CA. Yoshioka, K., Asahara, K., Murashima, S., 2004. Processes and strategies for developing public health nurse directed community health projects in municipalities of Japan. Japanese Journal of Public Health 1994 51 (4), 257–271 (in Japanese). Yuzawa, F., 1997. Research on the Future Role of Public Health Nurses who Work for Municipalities: report of the research and investigation on health, medical and welfare programs in the community. Ministry of Health and Welfare, Tokyo (in Japanese).