What are the new threats to health in the United States that community health nurses deal with?

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Areas of public health responsibility
The roles of local, state, and federal governments
Accreditation and national public health standards
Key resources

Public health is one of the greatest things in which a government can invest. Early prevention, which is relatively inexpensive, can prevent dire and expensive health care problems later in life.

Early in their development, both Minnesota and the United States recognized the role of the government in protecting the public's health, and each entity makes reference to this in their constitutions as part of a "general welfare" clause. Public health promotes the welfare of the entire population, ensures its security and protects it from the spread of infectious disease and environmental hazards, and helps to ensure access to safe and quality care to benefit the population.

Governmental responsibilities for public health extend beyond voluntary activities and services to include additional authorities such as quarantine, mandatory immunization laws, and regulatory authorities. The state's partnership functions by encouraging residents to do things that benefit their health (e.g., physical activity) or create conditions to promote good health, and requiring certain actions (e.g., food safety).

Areas of public health responsibility

Minnesota's areas of public health responsibility within the Local Public Health Act follow. They describe what people in Minnesota should expect to receive from their local health department no matter where they live, and are used by community health boards for assessment and planning purposes.

The areas of public health responsibility include (1) assuring an adequate local public health infrastructure, (2) promoting healthy communities and healthy behaviors, (3) preventing the spread of communicable disease, (4) protecting against environmental health hazards, (5) preparing for and responding to emergencies, and (6) assuring health services. You can find more information on public health activities relating to these areas online.

Assure an adequate local public health infrastructure

Assuring an adequate local public health infrastructure means maintaining the basic capacities foundational to a well-functioning public health system such as data analysis and utilization; health planning; partnership development and community mobilization; policy development, analysis and decision support; communication; and public health research, evaluation and quality improvement.

Promote healthy communities and healthy behavior

Promoting healthy communities and healthy behaviors means activities that improve health in a population, such as investing in healthy families; engaging communities to change policy, systems or environments to promote positive health or prevent adverse health; providing information and education about healthy communities or population health status; and addressing issues of health equity, health disparities, and the social determinants of health.

Prevent the spread of communicable disease

Preventing the spread of infectious disease means preventing diseases that are caused by infectious agents, such as by detecting acute infectious diseases, assuring the reporting of infectious diseases, preventing the transmission of disease, and implementing control measures during infectious disease outbreaks.  

Protect against environmental health hazards

Protecting against environmental health hazards means addressing aspects of the environment that pose risks to human health, such as monitoring air and water quality, developing policies and programs to reduce exposure to environmental health risks and promote healthy environments, and identifying and mitigating environmental risks such as foodborne and waterborne diseases, radiation, occupational health hazards, and public health nuisances.

Prepare and respond to emergencies

Preparing and responding to emergencies means engaging in activities that prepare public health departments to respond to events and incidents and assist communities in recovery, such as providing leadership for public health preparedness activities within a community; developing, exercising and periodically reviewing response plans for public health threats; and developing and maintaining a system of public health workforce readiness, deployment, and response.

Assure health services

Assuring health services means engaging in activities such as assessing the availability of health-related services and health care providers in local communities; identifying gaps and barriers; convening community partners to improve community health systems; and providing services identified as priorities by the local assessment and planning process.

The roles of local, state, and federal governments

Public health is population-based. Although local health departments and community health boards provide services to individuals, the goal of a population-based approach is very different from that of a patient-based or client-based approach that addresses the needs or concerns of an individual. Since public health activities are based on community needs, resources, funding, and support, services vary among local public health departments.

Minnesota's commissioner of health has the general authority for the development and maintenance of an organized system of programs and services for protecting, maintaining, and improving the health of the citizens (Minn. Stat. § 144.05). Such programs and services are related, but not limited to, maternal/child health, environmental health, public health emergency preparedness, disease prevention, control and epidemiology, public health administration, healthy communities and behaviors, licensing and inspection, and health care access.

The Minnesota Department of Health (MDH) is also responsible for monitoring, detecting, and investigating disease outbreaks; researching causes of illness and operating prevention programs; providing laboratory services; safeguarding the quality of health care, working to contain health care costs and assure that all Minnesotans have access to health care; safeguarding the quality of food, drinking water, and indoor air; developing strategies to improve the health of vulnerable populations; and working to eliminate health disparities.

In partnership with local public health entities, MDH helps with everything from developing guidelines, to providing technical assistance and support, to funneling state and federal funds to community health boards. Its specialists and scientists collect and analyze data that are used for research, resource development, and program development throughout the state. Public health system consultants provide specialized assistance on local and tribal public health to regions around the state.

MDH also has staff in seven district offices that provide assistance to local health departments (and others) regarding epidemiological investigations and consultation, emergency preparedness, environmental health, public and nonpublic water supplies, maternal/child health, public health nursing, and the practice of public health, as well as other areas. The MDH district offices are located in Duluth, St. Cloud, Bemidji, Fergus Falls, Marshall, Mankato, and Rochester.

Federal influences

State and local health departments work with a number of federal agencies, primarily those within the U.S. Department of Health and Human Services. For example, the Centers for Disease Control and Prevention (CDC) leads efforts to control communicable disease outbreaks and promote mass immunization. The federal government also assists states with funding (when state resources are not available) and guidance for work such as emergency preparedness. At both the state and local level, Minnesota relies on these offices for grant funding and expertise.

Accreditation and national public health standards

Related: PHAB standards and measures

In recent years, there has been recognition at the national level of the lack of standardization between health departments, and a need to identify what state and local health departments should do to deliver quality public health programs and services. This led to the development of a set of standards that health departments can put into practice to ensure that they are providing the best services possible to keep their communities safe and healthy.

The Public Health Accreditation Board (PHAB) has developed a national voluntary accreditation program for state, local, territorial, and tribal public health departments. The accreditation process will drive public health departments to continuously improve the quality of the services they deliver to the community, as well as offering the following benefits:

• Accountability and credibility
• Leverage for funding
• Visibility
• Increased efficiency and effectiveness

The State Community Health Services Advisory Committee, or SCHSAC, which is comprised of representatives from across the state, has recommended that Minnesota's local public health annual reporting align with national standards, and that community health boards interested in applying for accreditation will be ready to apply by 2020.

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1Department of Nursing, Chung Shan Medical University, Taichung City 40201, Taiwan; wt.ude.umsc@gnyp (C.-P.K.); moc.liamg@molnujanoif (H.-M.C.)

2Department of Nursing, Chung Shan Medical University Hospital, Taichung City 40201, Taiwan

Find articles by Ching-Pyng Kuo

3Department of Nursing, College of Health, National Taichung University of Science and Technology, Taichung City 40343, Taiwan; wt.ude.ctun@enihs

Find articles by Pei-Lun Hsieh

1Department of Nursing, Chung Shan Medical University, Taichung City 40201, Taiwan; wt.ude.umsc@gnyp (C.-P.K.); moc.liamg@molnujanoif (H.-M.C.)

2Department of Nursing, Chung Shan Medical University Hospital, Taichung City 40201, Taiwan

Find articles by Hsiao-Mei Chen

3Department of Nursing, College of Health, National Taichung University of Science and Technology, Taichung City 40343, Taiwan; wt.ude.ctun@enihs

Find articles by Shu-Liang Wang

Munjae Lee, Academic Editor, Kyu-sung Lee, Academic Editor, and Jitendra Singh, Academic Editor

Received 2021 Jun 11; Accepted 2021 Jul 22.

Aim: This study explored the effect of public health nurses’ current community care nursing competency on the psychological and organizational empowerment of public health services in Taiwan. Design: A cross-sectional nationwide survey design was used. Methods: A self-developed structured questionnaire was administered to public health nurses. They were recruited using a purposive sampling technique, and they participated in community healthcare workshops. Results: The mean score of Community Care Nursing Competence (CCNC) was 3.92 ± 0.83. The mean score in Community Empowerment (CE) was 3.66 ± 0.90. The study revealed that age and communication competence were crucial factors in public health nurses working in the community. With age and through the accumulation of practical experience, public health nurses’ communication competence may also improve, which can further enhance their psychological and organizational empowerment in the nursing workplace.

Keywords: public health nurse, nursing competence, community empowerment

Promoting community care has been adopted as a policy goal because of the aging population and advancements in medical technology. Community care emphasizes the need to integrate health concepts and healthy lifestyles to achieve a high quality of life, which includes independence, social participation, and dignity [1]. The outbreak of new infectious diseases (such as COVID-19), complications caused by chronic diseases, and decreasing medical budgets have affected global public health [2].

The set of core competencies for public health was devised, comprising seven categories: public health sciences; assessment and analysis; policy and program planning; implementation and evaluation; partnerships, collaboration, and advocacy; diversity and inclusiveness; and communication and leadership [3]. Public healthcare nurses no longer serve as an auxiliary in traditional community healthcare or medical care. Instead, nurses should form partnerships with residents, fully cooperate with the community, perform health assessments and management in the community, and plan health improvement programs and health promotion plans, playing the role of the integrator and coordinator in the community healthcare team [4,5].

The importance of encouraging healthcare professionals to be involved in the entire community was emphasized by the COVID-19 epidemic. Educational institutions should adapt their curricula in response to the increasing value attached to global health and community, and public health to address these changes and to cultivate a health workforce with vital competencies and capabilities [2]. Public health nurses’ (PHNs) main responsibility is to implement national public health policies, especially concerning national healthcare, medical care, and disease prevention, which are all within the scope of the major responsibilities of PHNs [6]. Public health nursing practitioners principally work in health centers. The primary services of health centers are associated with the promotion and maintenance of health, disease prevention, and early detection and treatment of diseases, with the aim of ensuring health for all.

Community care competencies include health promotion and illness prevention, the provision of health education to community residents, and promotion of behavioral changes to enable persons to take control of their health [4,5,7]. Communication competencies include effective written, oral, and electronic communication with clients and interprofessional teams. The development of consultation and advisory skills, and knowledge of languages are also crucial communication competencies [8]. Management competence comprises several facets: employing skills in policy development and program planning; designing, implementing, evaluating, managing, and performing quality assurance on interventions based on the needs of the population; employing problem-solving, critical thinking, and decision-making skills; and performing health assessments of individuals and families during home visits [9].

The definition of empowerment in the literature on community psychology indicates that it can enhance individuals’ competence and self-esteem and can therefore enhance their perception of personal control, which directly affects their health condition. This theory of empowerment can be extended to include forging connections with other people and the community, hoping to obtain more power through the changes in the external environment. Empowerment has a positive impact on productivity in the healthcare. When analyzing nursing productivity in a challenging situation (such as pandemic disease), nurses’ critical thinking, psychological status, and workplace support should be considered as key factors. Studies have demonstrated that empowered nurses more effectively complete their work, display higher organizational productivity, and display more favorable performance in nursing practice [8,10].

The purpose of the study was to identify the current status of the PHNs providing health services in the community and to access the self-perceived community nursing competence, and psychological and organizational empowerment of the PHNs. PHNs’ community nursing competence and empowerment were measured to guide healthcare institution managers in creating a productive and innovative work environment that fosters a sense of empowerment to foster higher-quality outcomes. Specifically, this study addressed the following two research hypothesis: (1) the competencies of care, communication, and management affects CE among PHNs; (2) psychological and organizational empowerment in public health service is related to clinical community health nursing competencies.

This study adopted a cross-sectional nationwide survey design.

The target population of this study was Taiwanese PHNs. PHNs were enrolled from public health centers situated in Taiwan. The nurses worked in public health service-related settings (such as a community healthcare center, public health bureau, or community service center). Nurses working in local medical clinics or hospitals were excluded.

Two instruments were self-developed by authors and referenced from the study [11], a community care nursing competence (CCNC) scale, and a community empowerment (CE) scale. A survey was developed by the author to assess factors related to CCNC and CE.

The three sections of the CCNC scale were CC, communication, and management. The first section of the scale consisted of 15 items rated using a five-point Likert scale. The second and third sections of the scale measured communication competence and management competence, each section included eight items rated on a five-point Likert scale, with the responses ranging from strongly disagree to strongly agree. Higher scores indicated higher care competence in providing community health services.

The two sections of the CE scale were psychological CE (PCE) and organizational CE (OCE). The first section of the scale comprised 10 items to assess psychological empowerment in PHNs and was rated using a five-point Likert scale. The second section of the scale measured empowerment in the working organization and comprised 15 items rated on a five-point Likert scale. Higher scores indicated higher community empowerment for providing community health services.

This study has been approved by the Ethical Committee of China Medical University, Taichung, Taiwan, for Research Data on 11 November 2019 (decision number CRREC-108-125). The researchers explained the research purpose, process, and protection of personal rights to the participants, and informed consent forms were provided before data collection. Written information about the study, including the participants’ legal rights regarding participation and confidentiality, was provided. The participants were assured that it was voluntary to participate in the study and that they were free to withdraw from the study at any time.

Between December 2019 and March 2020, 244 paper questionnaires were distributed to public health nurses. These public nurses had completed community care related on-the-job training, and the questionnaire survey was conducted. A total of 197 valid questionnaires were returned. Therefore, the response rate of 80.74%.

Descriptive statistics were used to describe the major study variables and sample demographics. A one-way analysis of variance and t tests were used to analyze the variance among the demographic data, CCNC, and CE. The bivariate Pearson correlation measures were used to direction of linear relationships between pairs of continuous variables. Fisher’s least significant difference (LSD) method was used in ANOVA to create confidence intervals for all pairwise differences between factor level means. Furthermore, stepwise regression was used to test two of the hypotheses and to predict the significant factors affecting the CE of PHNs.

Most research subjects were female, aged between 40 and 49 years (n = 83, 42.10%), and 72.60% were married (n = 143). Most participants (n = 133, 67.50%) had a baccalaureate degree, and 13.70% had a master’s degree or higher. The occupation title of most of the participants was “registered nurse” (n = 137, 69.60%). Most subjects worked in public health centers (n = 176, 89.30%). Most respondents had over 10 years of experience in public health nursing (n = 61, 31.0%) (Table 1).

Demographic characteristics of the subjects (n = 197).

The content validity index values for the CCNC scale was 0.90. CCNC involves the aspects of CC, communication, and management (shown in Figure 1). The total scale of this study displayed acceptable internal consistency (Cronbach’s α = 0.98). The average score on the overall CCNC was 3.92 ± 0.83, which is between neutral and agree. Among the dimensions, “Communication” (mean = 4.05 ± 0.78) displayed the highest score, followed by “CC” (mean = 4.03 ± 0.90) and “Management” (mean = 3.98 ± 0.81). In the “CC” dimension, “Provide health check and early screening services for related chronic diseases” scored the highest (mean = 4.59 ± 0.63), followed by “Provide blood pressure, blood glucose, and cholesterol measurement services” (mean = 4.4 ± 0.86). In the dimension of “Communication”, “Maintain effective communication with the client and listen and accept client concerns” scored the highest (mean = 4.15 ± 0.80), followed by “Provide the clients with proper explanations and descriptions when implementing related measures or care plans” (mean = 4.12 ± 0.80) and “Observe and use nonverbal communication skills to establish high-quality nurse–patient relationships” (mean = 4.12 ± 0.80). In “Management”, “Cooperate with central government policies to implement chronic disease–related care” scored the highest (mean = 4.19 ± 0.76), followed by “Cooperate with the organizational departments (such as long-term care and social welfare)” (mean = 4.10 ± 0.75).

The content validity index values for the CE scale was 0.92. The mean overall CE score was 3.66 ± 0.90. The “Psychological Empowerment Scale” dimension scored the highest (mean = 3.91 ± 0.74), followed by “The work performed is crucial for health promotion” (mean = 4.20 ± 0.67) and “The work performed is critical for promoting community health” (mean = 4.19 ± 0.70); the items with the lowest scores were “I am highly proficient in the skills required at work” (mean = 3.74 ± 0.70) and “I can influence what happens within the work unit” (mean = 3.74 ± 0.75). The mean score on the subscale “Organizational Empowerment” was 3.79 ± 0.75, and among the items, “I can satisfy the work requirements and complete the work as scheduled” scored the highest (mean = 3.95 ± 0.64), followed by “The budget is sufficient for the work that must be performed” (mean = 3.91 ± 0.71); the items scoring the lowest were “The human resources (both inside and outside the organization) required to perform the work are provided” (mean = 3.63 ± 0.90) and “I receive sufficient positive encouragement from the supervisor” (mean = 3.65 ± 0.89).

The analysis of the correlation between personal attributes and CCNC revealed that the service unit (F = 1.936, p = 0.001) was correlated with the CCNC. The CCNC of nurses working in health centers was higher than that of those working in health bureaus and other CC locations. The correlation analysis of the personal attributes and CE of the PHNs demonstrated that age (F = 2.179, p = 0.015) was correlated with CE. Pearson’s correlation coefficient was used to analyze the correlation between the CC competence and the CE of the nurses (see Table 2 for details).

Correlation between community care nursing competence and community empowerment (n = 197).

Multiple regression analysis was used to determine factors affecting the community empowerment by including variables with statistical significance. The results (Table 3) revealed that the major predictors were “Age” (B = 0.18, p = 0.021) and “Communication Competence” (B = 0.17, p = 0.002), and the explanatory power of the community empowerment was 28 per cent.

Factors affecting community empowerment (n = 197).

The research results showed that “Age” was one of the factors affecting community empowerment. The largest proportion of participants 31% had more than 10 years of service in public health units, 23.4% had between 5 and 10 years, and 28.4% had less than 5 years. Approximately 60% of participants had a bachelor’s degree. These findings indicate that nursing staff in public health services should be equipped with sufficient field experience to be familiar with conditions in the local community and to establish partnerships [12]. Approximately 40% of the participants did not have a bachelor’s degree, which may result in a relatively weak perception of empowerment among the PHNs, both psychologically and concerning the working environment [6,11].

A significant positive correlation was observed between the degree of chronic disease care implementation and the perception of empowerment, indicating that more frequently performing CC was associated with a higher score on relative empowerment perception, which is in accordance with the results from numerous studies, including a study on empowering PHNs in the care of clients and improving PHNs’ self-efficacy [1,5,13], a study on the effect of psychological empowerment on CC competence [11], and a study on the positive effects of self-efficacy on work performance [6,9]. The results of the present study indicated that PHNs’ competence in the implementation of CC management and the degree of implementation increased when their perception of psychological empowerment and empowerment in the workplace was enhanced.

The CC results indicated that health checks and early screenings of related chronic diseases were the services most commonly provided by PHNs, suggesting that the PHNs’ care services were primarily focused on preventive health services. Studies have reported that PHNs provide services for community health promotion and preventive care services and that the frequency of providing chronic disease care services is the highest [1,4,7]. However, the participants reported that their competencies were insufficient when providing individual care plans based on client needs and preventing comorbidities, which may be related to PHNs’ experience in the care of disease [5,8]. When the COVID-19 pandemic occurred in 2020, communities faced a tremendous public health threat. Therefore, PHNs should exercise caution when visiting clients in the community and should increase their relevant knowledge of emerging infectious disease and prevention measures. Furthermore, PHNs should also instruct the public on disease prevention and should provide referrals to competent professionals to control hazardous public health situations [1,7].

“Communication” items displayed the highest scores of CCNC, indicating that PHNs should be equipped with strong communication competencies because these enable them to establish nurse–patient relationships and to understand clients concerns when providing care plans; this finding accorded with results reported in the literature [4,5,14]. PHNs could “Maintain effective communication with the client and listen and accept client concerns”, “Provide the clients with proper explanations and descriptions when implementing related measures or care plans”, and “Observe and use nonverbal communication skills to establish high-quality nurse–patient relationships”, indicating that communication plays a crucial role in CC services. The results of this study demonstrated that communication competence affects nurses’ perception of empowerment, a finding that is in accordance with the findings in the literature [5,7]. However, the nurses perceived personal insufficiencies in the items of “Make decisions concerning treatment and care plans with community clients” and “Use community resources to achieve various treatments or health promotion”, demonstrating that nurses must improve communication with the clients regarding their needs when discussing care plans [4,11].

The CE results indicated that the PHNs believed that “The work that is performed is critical for health promotion” and “The work that is performed is crucial in promoting community health”, and these beliefs were associated with psychological empowerment. Regarding organizational empowerment, the participants with a self-perception of “I can meet the work requirements and complete the work as scheduled” could also perceive that they were empowered in the workplace, which improved their work efficiency [15]. Certain aspects of psychological empowerment, such as the sense of self-meaning of work, care management competence, and decision-making related participation, can be enhanced with related resources, such as more work-related information, specific suggestions for information, addressing problems, and positive encouragement, all of which can enable PHNs to be independent and to leverage all community resources to manage chronic diseases. PHNs would thus be able to provide patients and their family members with relevant chronic disease care information to address their concerns and to implement strategies with partner organizations to improve the quality of care for clients with chronic disease in the community.

Professional competence is crucial in providing quality healthcare services. Quality of care requires that nursing staff members possess the competencies needed to satisfy complex healthcare demands. Internationally, studies have indicated that higher staffing a higher number of nurses in general healthcare are associated with a higher quality of care, improved patient outcomes, and fewer adverse events.

This study adopted a cross-sectional correlation design; thus, the results depended on the condition and status of the respondents at the time of completing the questionnaire. The respondents completed their statements subjectively, making it difficult to assess their actual intention. Moreover, this study was a quantitative study, which made it difficult to understand the PHNs’ CCNC and empowerment in community.

This study determined that, in addition to basic competencies in general chronic disease care management, PHNs in the community should gain experience with clients with chronic diseases or residents in the community so that the PHNs’ communication capabilities can be improved for them to share their experiences. PHNs are poised to lead advancements in public health and healthcare, especially in terms of solving health inequities. PHNs with a bachelor’s degree or higher are equipped to handle numerous determinants of health and to fully participate in the challenges of achieving and maintaining public health. The scope of their responsibilities include community-building, health promotion, policy reform, and implementing system-level changes to promote and protect public health. PHNs, as the leaders in the improvement of health and the promotion of health equality, play a crucial role in the future of healthcare.

We sincerely express our appreciation to the experts in the community health nursing fields and their academic, policy, and workforce knowledge for helping us adapt the questionnaire to the context and for assessing the content validity of the questionnaire.

C.-P.K. was responsible for the study idea and design. H.-M.C., S.-L.W. and Y.-L.H. performed the data collection. S.-Y.Y. performed the data analysis. C.-P.K. and P.-L.H. were responsible for drafting the manuscript. P.-L.H. made critical revisions to the paper for important intellectual content. All authors have read and agreed to the published version of the manuscript.

None of the study sponsors or funding sources had a role in the design of the study.

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethics Committee of China Medical University, Taichung, Taiwan (protocol code CRREC-108-125 and date of approval on 11 November 2019).

Informed consent was obtained from all subjects involved in the study.

The data presented in this study are available on request from the corresponding author.

The authors declare that there are no competing interests.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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