Community Health Nursing Competency and Psychological and Organizational Empowerment of Public Health Nurses in Taiwan: A Cross-Sectional Survey


 Background: 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.Method: A cross-sectional survey design and a self-developed structured questionnaire were administered to Taiwanese public health nurses, recruited using a purposive sampling technique, who participated in community health care workshops offered by Ministry of Health and Welfare in 2019.Results: The majority of subjects were aged between 40 and 49 years and reported working in public health for over 10 years. Furthermore, 89.30% of the subjects worked in a Public Health Center. The mean score of Community Care Nursing Competence (CCNC) was 3.92 ± 0.83 (measured using a five-point Likert scale). The mean score in Community Empowerment (CE) was 3.66 ± 0.90, between “Neutral” and “Agree.” The CCNC was positively correlated with the workplace. The CE was positively correlated with age. The CCNC was positively correlated with psychological and organizational empowerment. The stepwise regression revealed that age (B = 0.18, p = .021) and communication competence (B = 0.17, p = .002) positively predicted community empowerment. Conclusions: 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, Taiwanese public health nurses’ communication competence may also improve, which can further enhance their psychological and organizational empowerment in the nursing workplace.

The importance of encouraging health care professionals to be involved in the global village 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 cultivate a health workforce with vital competencies and capabilities (Grootjans & Newman, 2013).
Public health nurses' (PHNs) main responsibility is to implement national public health policies, especially concerning national health care, medical care, and disease prevention, which are all within the scope of the major responsibilities of PHNs (Bigbee et al., 2010;Clark et al., 2016). 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.
In the workplace, conditions such as leadership, organizational resources, organizational manpower, and time distribution play important roles in nursing productivity, as suggested in nursing-related studies (Royer, 2011;Uner & Turan, 2010). Assessment of such conditions involves consideration of numerous personal factors, such as experience, knowledge, attitude, mental and physical preparation, and feelings.
However, when analyzing nursing in a challenging situation, key factors that must be considered include 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 (Piper, 2011).
The de nition of empowerment in the literature on community psychology indicates that it can enhance individuals' competence and self-esteem, and thereby 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. Studies have demonstrated that empowered nurses more effectively complete their work, display higher organizational productivity, and display more favorable performance in nursing practice (Shapir a-Lishchinsky, & Benoliel, 2019; Edmonds, 2017).
The purpose of the study was to understand the current status of the PHNs providing health services in the community and explore the self-perceived community nursing competence and the psychological and organizational empowerment of the PHNs. PHNs' community nursing competence and empowerment were measured to guide health care institution managers in creating a productive and innovative work environment that fosters a sense of empowerment to foster higher-quality outcomes.

Study design
This study adopted a cross-sectional survey design to investigate the current state of community health nursing competence and psychological and organizational empowerment among PHNs. In uential factors were also investigated.

Setting and samples
The target population of this study was Taiwanese PHNs. PHNs were enrolled from public health centers situated in Taiwan. Nurses working in a public health service-related setting (such as a community health care center, public health bureau, or community service center). Nurses working in local medical clinics or hospitals were excluded. G power 3.0 analysis was performed to estimate the minimum samples needed to obtain statistically signi cant results and the most reasonable sample size to secure a reliable interpretation of the study results and prevent excessive data collection. Using constants that were most suitable for multiple regression analysis (effect size of .15, a signi cance level of .05, and a power of .95), a minimum sample of 155 participants was required. A 20% data wastage rate was adopted, and data from 244 PHNs were collected.

Measures
Two instruments were self-developed by authors and referenced from the study conducted by , 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 content validity index values for the CCNC and CE scale were 0.90 and 0.92, respectively.

Community care nursing competence
The three sections of the CCNC scale were CC, communication, and management. The rst section of the scale consisted of 15 items rated using a 5-point Likert scale, with the responses ranging from strongly disagree to strongly agree (Cronbach's α = .96). Higher scores indicated higher care competence in providing community health services. The second section of the scale measured communication competence and included eight items rated on a 5-point Likert scale, with the responses ranging from strongly disagree to strongly agree (Cronbach's α = .97). The third section of the scale measured management competence and included eight items rated on a 5-point Likert scale, ranging from strongly disagree to strongly agree (Cronbach's α = .94). The total scale of this study displayed acceptable internal consistency (Cronbach's α = .98)

Community empowerment
The two sections of the CE scale were psychological CE (PCE) and organizational CE (OCE). The rst section of the scale comprised 10 items to assess psychological empowerment in PHNs and was rated using a 5-point Likert scale, with the responses ranging from strongly disagree to strongly agree (Cronbach's α = .93). Higher scores indicated higher psychological empowerment for providing community health services. The second section of the scale measured empowerment in the working organization and comprised 15 items rated on a 5-point Likert scale, ranging from strongly disagree to strongly agree (Cronbach's α = .96). The total scale of this study was determined to have acceptable internal consistency (Cronbach's α = .96).

Data collection
Between December 2019 and March 2020, 244 questionnaires were distributed to nal-year nursing students, and 197 valid questionnaires were returned. Therefore, the response rate of 80.74%.

Data analysis
Descriptive statistics were used to describe the major study variables and sample demographics. A oneway analysis of variance, t tests, and Pearson's correlation coe cients were used to analyze the variance and correlations among the demographic data, CCNC, and CE. Furthermore, a stepwise regression was employed to predict the signi cant factors affecting the CE of PHNs.

Research subject demographic information
Most research subjects were 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).  "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). The items that scored the lowest were "Provide individual care plans based on the needs of individual clients" (mean = 3.75 ± 0.93) and "Prevent comorbidities in clients" (mean = 3.77 ± 0.93). 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); the items that scored the lowest were "Make decisions concerning treatment and care plans with community clients" (mean = 3.96 ± 0.83) and "Use community resources to achieve various treatments or health promotion" (mean = 4.00 ± 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 items with the lowest scores were "Effectively allocate time for the case management and application of clients with chronic diseases" (mean = 3.76 ± 0.84) and "Implement the evaluation and modi cation of case care" (mean = 3.82 ± 0.84).
Community empowerment of public health nurses The CE of PHNs was investigated to understand the mental state and the perceived CE in the working environment during the prior 6 months. The mean overall CE score was 3.66 ± 0.90, which was between neutral and agree. The "Psychological Empowerment Scale" dimension scored the highest (mean = 3.91 ± 0.74), in which the item "The work performed is crucial for health promotion" (mean = 4.20 ± 0.67), followed by "The work performed is critical for promoting community health" (mean = 4.19 ± 0.70); the items with the lowest scores were "I am highly pro cient in the skills required at work" (mean = 3.74 ± 0.70) and "I can in uence 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 su cient 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 su cient positive encouragement from the supervisor" (mean = 3.65 ± 0.89).
The correlation between the personal attributes, community care competence, and community empowerment of public health nurses Analysis of the correlation between personal attributes and CCNC revealed that the service unit (F = 1.936, p = .001) was correlated with the CCNC. Fisher's least signi cant difference (LSD) indicated that 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 = .015) was correlated with CE. Fisher's LSD further revealed that older and senior nurses displayed higher CE than younger nurses. Pearson's correlation coe cient was used to analyze the Factors affecting community empowerment Based on these analyses of the factors affecting CE, a multiple regression analysis was performed using statistically signi cant variables. The results demonstrated that the major predictors were "Age" (B = 0.18, p = .021) and "Communication Competence" (B = 0.17, p = .002). Table 4 displays a summary of the multiple regression analysis of all the variables of the CE.

Discussion
The largest proportion of participants were aged 40 to 49 years. Furthermore, 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 ndings indicate that nursing staff in public health services should be equipped with su cient eld experience to be familiar with conditions in the local community and able to establish partnerships (Polivka et al., 2008). Approximately correlation between the CC competence and the CE of the nurses. The analysis revealed a signi cant positive correlation (see Table 3 for details). Table 3  For "Management" in the community, "Cooperate with central government policies to implement chronic disease-related care" and "Cooperate with the organizational departments (such as long-term care and social welfare)" were the most critical, demonstrating that nurses must adhere to health care policies when promoting public health by professional contacts and discussion of CC services among chronic disease care businesses and relevant units of long-term care and social welfare institutions. However, most participants reported that "Implementing the evaluation and modi cation of case care" was di cult in managing chronic disease cases, which could be related to the accumulation of practical experience in the community or work overload. PHNs understood that developing community ability by using community-oriented programs is the most important core concept (meaning). However, such effort requires more time than individual public health services (MacDonald & Schoenfeld, 2003).
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 e ciency (Flowers et al., 2020).
The results of this study indicated that access to organizational information had a positive impact on community competence. These results accorded with previous studies. PHNs are better equipped to understand the needs and the goals of the organization when they have more information, which can improve work e ciency. This result supported the premise of the cognitive model of empowerment and accorded with studies that stated that employees with stronger self-e cacy would make more efforts to cope with the challenges of client outcomes and would feel more effective in their work (Piper, 2011;Royer, 2011;Flowers et al., 2020).
A signi cant 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 accords with results from numerous studies, including a study on empowering PHNs in the care of clients and improving PHNs' self-e cacy (Royer, 2011;Cole, 2011;Clark et al., 2016), a study on the effect of psychological empowerment on CC competence , and a study on the positive effects of self-e cacy on work performance Piper, 2011). 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.  suggested that psychological empowerment could be encouraged and promoted through education and training and by sharing work experience within groups. They further suggested that supervisors could have active discussions with nurses to provide them the opportunity to participate in the decision-making process, which could enhance their in uence at work. Furthermore, the World Health Organization (WHO) mentioned that for the innovative care of chronic diseases, communityrelated care management and innovative measures are being developed in the world and include education, self-management training, and the provision of services by community volunteers and nonprofessional personnel in the community (WHO, 2020). Empowering PHNs can enable them to use this experience to empower clients with chronic diseases to achieve the ultimate ideal state of CC.
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, speci c suggestions for information, addressing problems, and positive encouragement, all of which can enable PHNs to be independent and able 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 implement strategies with partner organizations to improve the quality of care for clients with chronic disease in the community.
CE re ects the continuous shifts in power relations between different individuals and social groups, whereas empowerment, in the broadest sense, refers to the process by which people with less power work together to increase control over events that could determine their lives and health. Furthermore, 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 to improve their communication and to enable them to share their experiences. Relevant courses should be included in the in-service education courses for PHNs. PHNs should be instructed in policy awareness and the basic business of the relevant government health agencies and parallel units during their formative education. Furthermore, PHNs should be provided with relevant resources, and encouraged to use them, to enable them to integrate resources from parallel units and medical networks.
PHNs are poised to lead advancements in public health and health care, especially in terms of solving health inequities. PHNs with a bachelor's degree or higher are equipped to handle numerous determinants of health and 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 health care.  -108-125). 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 con dentiality, was provided. 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. The PHNs agreed to complete the questionnaire surveys after the end of the educational workshop training.

Consent for publication
Not applicable.
Availability of data and material The dataset and analyses are not currently publicly available as further articles based on the dataset are planned. However, the materials could be available from the corresponding author upon reasonable requests.