Background: According to the diversification of the health needs and the expansion of health disparities, it is necessary to raise their reflective practice skills so that PHNs present more appropriate activities. The purpose of this study was to elucidate the realities of reflective practice skills among public health nurses in Japan and identify related factors. Methods: This study covered 1725 public health nurses in the Chugoku/Shikoku area. We conducted an anonymous self-completed questionnaire survey. As reflective practice skills (RPS), we adopted the six components of the six cycles of the Gibbs reflective model. We used the 20 criteria of the Scale for Practical Competence (SPC). We set 25 learning history/daily lifestyle items. The study plan was approved by the Ethics Committee of Okayama University. Results: We analyzed the 962 (55.8%) valid responses. Although years of experience as a public health nurse was highly correlated with practical skills as measured by SPC, with a correlation coefficient of 0.627, it was not closely related with RPS, with a correlation coefficient as low as 0.129. A logistic regression analysis of the eight learning history items and six daily lifestyle items associated with RPS, with the introduction of the high/low RPS groups as dependent variables, showed a convergence to five factors (odds ratio of 1.38 - 2.29). Conclusions: Going forward, we will need to consider how to accumulate learning on a daily basis and how to include positive health practice in PHN education, in connection with exploring the curriculum and method of training.
Reflective practice is a forward-looking exercise for practitioners to review their own way of working and find out about the best practice expected of them [
Public health nurses are working to find solutions or improvements to community health issues. Health issues, however, change with the times, constantly influenced by area characteristics and the social landscape. Thus, there is no correct answer in the activities of public health nurses, who are always required to find the best possible solution to each specific case. This means that public health nurses have to upgrade their reflective practice skill if they are to ensure quality services. This is particularly important because of the realities of society today, characterized by the diversification of health issues, widening health gaps and frequent health crises including natural disasters and emerging infections.
Although reflection has been integrated into nursing education in Japan [
The purpose of this study was to elucidate the realities of reflective practice skill among public health nurses in Japan and identify related factors. Since it is said that reflection stems from experience and that any learning should be built upon daily first-hand experiences [
The present study was designed as a cross-sectional field survey and relation exploration research.
This study covered 1725 public health nurses, or half of the Japanese public health nurses affiliated with the nine prefectures in the Chugoku/Shikoku area and all municipalities located in the prefectures.
We conducted an anonymous self-completed questionnaire survey. We sent a set of request letters, ethical consideration statements, questionnaire forms and reply envelopes to the lead public health nurse of each municipality, who was asked to distribute the survey kits to half of the full-time public health nurses selected to represent all age groups without bias. The survey was conducted from December 2013 to January 2014 in Chugoku, and from December 2014 to January 2015 in Shikoku.
(1) Basic attributes
Basic attributes included gender, age, years of PHN experience and place of work.
(2) Realities of reflective practice skill
We defined reflective practice skill as comprising the six components of the six cycles of the Gibbs reflective model [
1) I always write down, and check what I did and why I did it.
2) I always write down, and recall what I thought and felt about what I did.
3) I always write down, and evaluate what was good and bad about what I did.
4) I always write down, and analyze what sense I could make of what I did.
5) I always write down what things I could have done better to help improve my performance.
6) I always write down what I would do if the same situation arose gain.
Regarding each of those statements, the respondents were asked to reply on a scale of 1 to 6: “Does not apply at all” (1); “Does not apply” (2); “Somewhat does not apply” (3); “Somewhat applies” (4); “Applies” (5); and “Applies very much” (6). Before analyzing the result, we calculated Cronbach’s alpha for the six reflective practice skill (hereafter “RPS”) components. The coefficient turned out to be 0.935, indicating a high internal consistency that warrants using the aggregate score for analysis.
Since it has been verified that the practical skills of public health nurses improve with experience [
(3) Learning history and daily lifestyle items
We set nine items in total for learning history: PHN training institution; level of education; place of work (overlap with attributes); experience in presentation at academic meetings; average amount of annual out-of-pocket investment in self-development; out-of-pocket subscription to any journal for the current year; experience in reading any specialized book over the past year; membership of any professional association for the current year; and participation in any training or study session over the past year.
We set a total of 16 items regarding daily lifestyle: 10 daily health practice items integrating Breslow’s seven items [
(1) Realities of reflective practice skills
We calculated the total RPS score, and mean and standard deviation of the six components. We also conducted a correlation analysis between the years of PHN experience on one hand, and SPC and RPS on the other for comparison purposes.
(2) Learning and lifestyle factors related to reflective practice skill
Using the mean value as borderline, we classified the respondents into the high RPS and low RPS groups for cross tabulation with learning and lifestyle items, followed by a statistical test (χ2 test) at the significance level of 5%. Afterwards we performed a logistic-regression analysis of the learning and lifestyle items associated with RPS as independent variables, with the introduction of the high/low RPS groups as dependent variables.
We used SPSS Statistics 22 for the analysis.
We provided to the lead PHNs and potential participants written explanations on ethical considerations, including the freedom (not) to participate in the survey, the protection of personal information, the method of data storage, the publication of the findings and the cost of participating in the survey, among others. Individual participants were asked to mail the completed questionnaire form for collection, and the return of the questionnaire form was regarded as indicating consent on the part of the participant. The study plan was approved by the Ethics Committee for Nursing Study, Graduate School of Health Sciences, Okayama University (approval no. M13-02, 29 October 2013).
Of the 982 (56.9%) questionnaire forms returned, we analyzed the 962 (55.8%) valid responses. The attributes of the respondents are shown in
Items | N | % | |
---|---|---|---|
Sex | Male | 16 | 1.7 |
Female | 937 | 97.4 | |
Blank | 9 | 0.9 | |
41.8 ± 10.41 (22 - 60) | |||
Age | Twenties | 164 | 17.0 |
Thirties | 236 | 24.5 | |
Forties | 268 | 27.9 | |
Fifties or more | 284 | 29.5 | |
Blank | 10 | 1.0 | |
17.9 ± 10.58 (1 - 38) | |||
Years of PHN experience | 5 years or less | 179 | 18.6 |
6 - 15 years | 235 | 24.4 | |
16 - 25 years | 268 | 27.9 | |
26 years or more | 280 | 29.1 | |
Place of work | Prefectures | 237 | 24.6 |
Government-ordinance-designated cities | 144 | 15.0 | |
Cities | 421 | 43.8 | |
Towns and Villages | 160 | 16.6 |
Mean value ± standard deviation (range) for age and years of PHN experience (except where data are not available).
respondents were mostly females, aged 41.8 on average, ranging from 22 to 60, but each age bracket had over 100 respondents.
The mean value ± standard deviation (median, range) of RPS was 20.8 ± 5.81 (21, 6 - 36). As regards the six components, the value stood at 3.8 ± 1.15 (4, 1 - 6), 3.5 ± 1.12 (4, 1 - 6), 3.4 ± 1.10 (4, 1 - 6), 3.3 ± 1.08 (3, 1 - 6), 3.4 ± 1.13 (3, 1 - 6) and 3.3 ± 1.12 (3, 1 - 6), respectively.
Although years of PHN experience was highly correlated with practical skills as measured by SPC, with a correlation coefficient of 0.627, it was not closely related with RPS, with a correlation coefficient as low as 0.129 (
Eight learning history items had a significant relationship with the two RPS groups (p < 0.05), including PHN training institution, level of education, place of work, experience in presentation at academic meetings, average amount of annual out-of-pocket investment in self-development, out-of-pocket subscrip-
Correlation coefficient with SPC score | Correlation coefficient with RPS score | ||
---|---|---|---|
Years of PHN experience | 0.627** | 0.129** | |
Correlation coefficient represents spearman’s rho (two-tailed). | |||
P < 0.01** |
tion to any journal for the current year, experience in reading any specialized book over the past year and membership of any professional association for the current year. For each of those items, the share of the high RPS group exceeded that of the low RSP group by at least one percentage point among those who gave the following answers to the questions, respectively: One-year vocational school or specialized junior college course; Vocational school or specialized junior college; Prefectures; Yes; Yes; Yes; Yes; and Yes (
Likewise, some daily lifestyle items had a significant relationship with the two RPS groups, including one daily health practice item (i.e. “Balanced diet”) and five positive health practice items (i.e. “Active in adopting useful health information in daily lifestyle”, “Usually cook food for myself and my family”, “Try consciously to walk and use stairs”, “Always take care not to catch a cold” and “Remain sociable with enjoyment”). The respondents giving those answers were likely to be included in the high RPS group (
Further, a logistic regression analysis (step-up procedures, stepwise, likelihood ratio) of the eight learning history items and six daily lifestyle items associated with RPS, with the introduction of the high/low RPS groups as dependent variables and years of PHN experience as moderator variable, showed a convergence to the five items listed in
There is no problem in the representation of the population, about a quarter of which was covered by the survey without any bias in age or place of work.
(1) Difficulties in process leading to action plan
The mean score for each of the six RPS components stood at over 3, just between “4. Somewhat applies” and “3. Somewhat does not apply”. The median score was 4 for “description”, “feelings”, and “evaluation”, but only reached 3 for “analysis”, “conclusion” and “action plan”, thus pointing to a lower skill level in the latter half of reflection, i.e. skill to make sense out of experience for forward-looking purposes. This indicates that the practice of running the whole reflection cycle to action planning, as per the Gibbs reflective model, has not been established among Japanese public health nurses.
(2) RPS without any correlation with experience as PHN
Although our correlation analysis indicated a strong correlation between the practical skills of public health nurses in general and the years of PHN experience, as with previous studies, we found that RPS had little to do with the years
Learning and lifestyle factors | Total | Reflective practice skill score | χ2 test P value | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
Persons | % | High RPS group Persons % | Low RPS group Persons % | ||||||||
Learning history | PHN training institution | 1-year vocational school course | 547 | 56.9 | 323 | 59.8 | 224 | 53.1 | |||
Specialized junior college course | 77 | 8.0 | 47 | 8.7 | 30 | 7.1 | 0.026 | * | |||
College | 302 | 31.4 | 148 | 27.4 | 154 | 36.5 | |||||
Vocational school integrated curriculum | 36 | 3.7 | 22 | 4.1 | 14 | 3.3 | |||||
Educational level | Vocational school | 457 | 47.5 | 269 | 49.8 | 188 | 44.5 | ||||
Specialized junior college | 153 | 15.9 | 92 | 17.0 | 61 | 14.5 | 0.038 | * | |||
College | 329 | 34.2 | 164 | 30.4 | 165 | 39.1 | |||||
Graduate school | 23 | 2.4 | 15 | 2.8 | 8 | 1.9 | |||||
Place of work | Prefectures | 237 | 24.6 | 157 | 29.1 | 80 | 19.0 | ||||
Government-ordinance-designated cities | 144 | 15.0 | 80 | 14.8 | 64 | 15.2 | 0.003 | * | |||
Cities | 421 | 43.8 | 221 | 40.9 | 200 | 47.4 | |||||
Towns and villages | 160 | 16.6 | 82 | 15.2 | 78 | 18.5 | |||||
Experience in presentation at academic meetings | Yes | 476 | 49.5 | 302 | 55.9 | 174 | 41.2 | 0.000 | * | ||
No | 486 | 50.5 | 238 | 44.1 | 248 | 58.8 | |||||
Average annual investment in self-development amounting to \30 k or over | Yes | 281 | 29.2 | 177 | 32.8 | 104 | 24.6 | 0.006 | * | ||
No | 681 | 70.8 | 363 | 67.2 | 318 | 75.4 | |||||
Out-of-pocket subscription to any journal over the past year | Yes | 236 | 24.5 | 153 | 28.3 | 83 | 19.7 | 0.002 | * | ||
No | 726 | 75.5 | 387 | 71.7 | 339 | 80.3 | |||||
Experience in reading any specialized book over the past year | Yes | 583 | 60.6 | 352 | 65.2 | 231 | 54.7 | 0.001 | * | ||
No | 379 | 39.4 | 188 | 34.8 | 191 | 45.3 | |||||
Membership of any professional association for the current year | Yes | 600 | 62.4 | 361 | 66.9 | 239 | 56.6 | 0.001 | * | ||
No | 362 | 37.6 | 179 | 33.1 | 183 | 43.4 | |||||
Participation in any training or study session over the past year | Yes | 835 | 86.8 | 473 | 87.6 | 362 | 85.8 | 0.410 | |||
No | 127 | 13.2 | 67 | 12.4 | 60 | 14.2 | |||||
Daily lifestyle | 10 daily health practice items (integration of Breslow’s 7 items and Morimoto’s 8 items) | (n = 961 as one missing value) | |||||||||
1. Maintain desirable weight (BMI 18.5 - 24.9) | Yes | 832 | 86.6 | 464 | 85.9 | 368 | 87.4 | 0.503 | |||
No | 129 | 13.4 | 76 | 14.1 | 53 | 12.6 | |||||
2. Moderate or no alcohol consumption | Yes | 897 | 93.3 | 510 | 94.4 | 387 | 91.9 | 0.120 | |||
No | 64 | 6.7 | 30 | 5.6 | 34 | 8.1 | |||||
3. Do not smoke | Yes | 936 | 97.4 | 528 | 97.8 | 408 | 96.9 | 0.403 | |||
No | 25 | 2.6 | 12 | 2.2 | 13 | 3.1 | |||||
4. Regular exercise | Yes | 383 | 39.9 | 227 | 42.0 | 156 | 37.1 | 0.118 | |||
No | 578 | 60.1 | 313 | 58.0 | 265 | 62.9 | |||||
5. Get enough sleep (7 - 8 hours) | Yes | 619 | 64.4 | 344 | 63.7 | 275 | 65.3 | 0.603 | |||
No | 342 | 35.6 | 196 | 36.3 | 146 | 34.7 |
6. Do not eat between meals | Yes | 177 | 18.4 | 101 | 18.7 | 76 | 18.1 | 0.796 | ||
---|---|---|---|---|---|---|---|---|---|---|
No | 784 | 81.6 | 439 | 81.3 | 345 | 81.9 | ||||
7. Have daily breakfast | Yes | 894 | 93.0 | 507 | 93.9 | 387 | 91.9 | 0.235 | ||
No | 67 | 7.0 | 33 | 6.1 | 34 | 8.1 | ||||
9. Do not work over 9 hours per day | Yes | 468 | 48.7 | 269 | 49.8 | 199 | 47.3 | 0.433 | ||
No | 493 | 51.3 | 271 | 50.2 | 222 | 52.7 | ||||
10. Do not feel much subjective stress | Yes | 409 | 42.6 | 227 | 42.0 | 182 | 43.2 | 0.710 | ||
No | 552 | 57.4 | 313 | 58.0 | 239 | 56.8 | ||||
8. Balanced diet | Yes | 854 | 88.9 | 491 | 90.9 | 363 | 86.2 | 0.021 | * | |
No | 107 | 11.1 | 49 | 9.1 | 58 | 13.8 | ||||
6 positive health practice items (determined by researchers through consultations) | ||||||||||
1. Active in adopting useful health information in daily lifestyle | Yes | 906 | 94.2 | 520 | 96.3 | 386 | 91.5 | 0.002 | * | |
No | 56 | 5.8 | 20 | 3.7 | 36 | 8.5 | ||||
2. Usually cook food for myself and my family | Yes | 827 | 86.0 | 478 | 88.5 | 349 | 82.7 | 0.010 | * | |
No | 135 | 14.0 | 62 | 11.5 | 73 | 17.3 | ||||
3. Try consciously to walk and use stairs | Yes | 769 | 79.9 | 447 | 82.8 | 322 | 76.3 | 0.013 | * | |
No | 193 | 20.1 | 93 | 17.2 | 100 | 23.7 | ||||
4. Always take care not to catch a cold | Yes | 919 | 95.5 | 523 | 96.9 | 396 | 93.8 | 0.025 | * | |
No | 43 | 4.5 | 17 | 3.1 | 26 | 6.2 | ||||
5. Properly regulate life rhythm | Yes | 865 | 89.9 | 491 | 90.9 | 374 | 88.6 | 0.240 | ||
No | 97 | 10.1 | 49 | 9.1 | 48 | 11.4 | ||||
6. Remain sociable with enjoyment | Yes | 856 | 89.0 | 503 | 93.1 | 353 | 83.6 | 0.000 | * | |
No | 11.0 | 37 | 6.9 | 69 | 16.4 |
*The items associated with RPS (P < 0.05) were used logistic regression analysis as dependent variables.
Learning and lifestyle factors | Partial regression coefficient | Significance probability | Odds ratio | 95% Confidence interval | |
---|---|---|---|---|---|
p value | Lower | Upper | |||
Remain sociable with enjoyment No 0/Yes 1 | 0.828 | 0.000 | 2.290 | 1.484 | 3.533 |
Active in adopting useful health information in daily lifestyle No 0/Yes 1 | 0.764 | 0.010 | 2.148 | 1.197 | 3.854 |
Experience in presentation at academic meetings No 0/Yes 1 | 0.491 | 0.000 | 1.634 | 1.251 | 2.135 |
Experience in reading any specialized book over past year No 0/Yes 1 | 0.385 | 0.005 | 1.470 | 1.123 | 1.924 |
PHN training institution College or vocational school integrated curriculum 0/One-year vocational school or junior college course 1 | 0.322 | 0.022 | 1.380 | 1.047 | 1.819 |
Adjusted for years of experience, step-up procedures, stepwise, likelihood ratio.
of experience. This indicates that RPS might not be the kind of skill that simply improves with length of experience in public health nursing activities. In other words, improving RPS might require something other than practical experience as a public health nurse. What might those other factors be?
(1) Commitment to positive health and balanced input/output
The factors that contributed to the higher RPS with an odds ratio of 2 or over were all related to positive health practice, namely those who “Remain sociable” or are “Active in adopting useful health information in daily lifestyle”. Sociable public health nurses who take in useful health information are readily seen as being highly committed to positive health and enjoying interaction with the outside world, in terms of both input and output. Thus, a positive professionalism towards health promotion and affluence in human qualities appear to be closely related to higher RPS levels.
(2) Competency to drive activities for publication of results through continuing professional development
It was found that two learning history factors contributed to higher RPS with an odds ratio of about 1.5 - 1.6: “Experience in presentation at academic meetings” and “Experience in reading any specialized book over the past year”. Thus, higher RPS levels are attained by those who continue their professional development by reading specialized books on a daily basis, run the PDCA cycle in their public health nursing activities, assess the results and present them at academic meetings. Thus, continuing professional development, as well as the competency to drive public health nursing activities based thereon towards the goal of publishing the results, can help improve the level of RPS.
(3) Adequate practical onsite training in a graduate course for PHN education
Other learning history factors contributed to higher RPS with an odds ratio of about 1.4: “PHN education in one-year vocational school or junior college course”. The result indicates that the RPS level is higher among those who have received one-year institutional education with adequate time allocated to lectures, exercise and practical onsite training on public health nursing. In the 14-year period from 1997, when PHN education was integrated with nursing education in all colleges, the development of practical skills among public health nurses was seriously undermined by the double-counting of credits, for example [
Our study found: 1) that RPS among Japanese public health nurses is limited in that it does not help them develop action plans; 2) that RPS is not related to the years of practical experience as PHN; and 3) that higher RPS is related to some learning history and daily lifestyle factors. However, this study only succeeded in considering RPS from a limited number of aspects. Further literature study and research are needed to identify additional factors required for upgrading skills.
Going forward, we will need to consider how to accumulate learning on a daily basis and how to include positive health practice in PHN education, in connection with exploring the curriculum and method of training to improve the practical competence of PHNs.
We sincerely thank all public health nurses who participated in the survey.
This study was subsidized by JSPS Scientific Research Grant #JP25671016.
We have no conflict of interest to report on our relationships with any specific entity.
Okamoto, R., Koide, K., Maura, Y. and Tanaka, M. (2017) Realities of Reflective Practice Skill among Public Health Nurses in Japan and Related Learning and Lifestyle Factors. Open Journal of Nursing, 7, 513-523. https://doi.org/10.4236/ojn.2017.75040