Identifying Community/Public Health Nursing Competencies in Indonesia: A Modified Delphi Method

Background: Nurses in public health centers, or known as public health nurses (PHNs), have duties in implementing promotive, preventive, curative, and rehabilitative efforts. In Indonesia, there is no basic reference to the competencies that should be performed by PHNs. The provision of health services in the community should cover two areas, namely inside and outside the building (Minister of Health’s Regulation No. 279 Year 2006); it causes nurses in the community to further hone their skills while in the field. Purpose: This study aimed to identify the competencies of the Indonesian PHNs from experts using the C/PHN competencies of the Quad Council Coalition through a Delphi method. Methods: This study was quantitative research with a Delphi method. We employed a purposive sampling technique to recruit the experts of public health nurses. The experts did a Delphi method to identify, analyze, and modify the C/PHN Competencies of the Quad Council Coalition into the Indonesian version of C/PHN Competencies with local cultures. Results: Results showed that from eight domains of the Quad Council Coalition C/PHN competencies, there were changes for priority of the PHN competencies in Indonesia. All priorities were classified into eight groups, namely: (1) Leadership Skills and Thinking Systems; (2) Community Dimensions of Practice; (3) Assessment Analytic; (4) Policy Development and Program Planning; (5) Communication Skills; (6) Financial Planning and Management and Planning; (7) Public Health Sciences Skills; and (8) Cultural Competency. Conclusion: The Quad Council Coalition of C/PHN competencies are appropriate with the Indonesian PHN competencies, although the priority is changed related to local wisdom as stated in the Minister of Health’s Regulation No. 279 Year 2006. Therefore, the Indonesian P/HN competencies should be developed to support the Indonesian health people through family approach.


Research instrument and data collection
The C/PHN of the Quad Council Coalition is a measuring tool that was analyzed by each expert. This measurement tool is used to measure the level of competence of public health nursing and was developed by the Quad Council Coalition. There are 8 domains and 44 items which cover the competencies of public health nursing. Until now, Indonesia does not yet have a measurement tool used to measure the level of competence of public health nursing. The only reference used to guide public health nursing in public health centers in Indonesia is the Minister of Health 's Regulation No. 279 Year 2006 about Perkesmas. However, this regulation does not explain in details about the competencies that public health nurses should have; it only describes two parts of the PHNs' activities: inside and outside the building.

Data analysis
The research consisted of three rounds ( Figure 1). In the first round, each expert was given the C/PHN Competencies of the Quad Council Coalition and the Minister of Health 's Regulation No. 279 Year 2006 about Perkesmas to be examined and analyzed. The experts were requested to evaluate the competencies using Likert scales of 1 to 4 for each competency item in the C/PHN Competencies: 1=not relevant, 2=quite relevant, 3=relevant, and 4=very relevant.
In the second round, the experts were invited to gather to do FGDs (focus group discussion) in one place. In this round, the experts were asked their respective opinions for each competency item in the C/PHN Competencies. The experts were asked for their opinions on each item whether it is in accordance with local cultures in Bondowoso and Jember. Then each expert made a rating for each item as in the first round.
In the third round, all experts were given the results of the study in the first round and the second round. They were also confirmed for approval for each item whether it could be used to test the draft of public health nursing competencies. In this final stage, the experts were requested to sign the agreement for the approved competencies.

Ethical consideration
The ethical approval of this study was obtained from the Research Ethics Committee of the Faculty of Dentistry, Universitas Jember. All participants were informed of the study's purposes and procedures and signed informed consent for their participation.

RESULTS
Eight experts of public health nursing selected based on the inclusion criteria of the study participated in the study. These participants came from three universities in the area of Bondowoso and Jember, Indonesia. The characteristics of eight experts of PHN are presented in Table 1.  Table 1 shows that most community nursing experts in this study were aged in the span of the 40s (50%) and females (75%). Most experts hold master degree education (62.5%). A half of the experts (50%) already attended Perkesmas training. Although not all experts had participated in Perkesmas training, they are experts in the field of the public health nursing, education, profession, and research.
In round I, the experts as participants were asked to analyze and examine the 44 items in QCC which are divided into eight domains by using Likert scales and compared it with the existing legislation (the Minister of Health 's Regulation No. 279 Year 2006 about Perkesmas). Then, the result was analyzed based on the mean value of each item.
In round II, eight nursing experts gathered in a place to give the assessment results that had been done before. In this discussion, group forum of experts was requested to assess the items and determine whether words or sentences in the items should be changed according to local wisdom. Once the data were collected, each expert determined to carry out a validity test for each item (Waltz, Strickland & Lenz, 2010). The validity and the reliability test of this instrument was conducted on eight public health nursing experts in February 2020. Table 2 shows the results of round I and II of the study.   In round III, the experts approved the feasibility of instrument with 44 items by signing a letter. Additionally, the researchers also get the results of domain rankings from Delphi results by experts and presented these results in Table 3.
As shown in Table 3, the highest rated domain is Domain VIII: Leadership Skills and Thinking Systems, while the lowest one is Domain IV: Cultural Competency Skills.  , 2006). According to the authors' observations, Domain VIII became first domain in the Indonesian version of C/PHN Competencies, according to experts, because the critical thinking ability of a nurse in primary health care is very important. Public health nurses are required to have good leadership skills because they are responsible for the success of the promotive and prevention program of a health problem in an area. In addition to being responsible for leading the community in efforts to improve health status, public health nurses must also have the ability to develop good interactions with cross-sectors. Therefore, this is related to the domain that is ranked second in the Indonesian version of C/PHN Competencies, i.e., Community Dimensions of Practice Skills. In Domain V, public health nurses have the ability to manage good relations between stakeholders, business owners, community leaders, religious leaders, and the community themselves in handling all health problems in an area.
The fifth place in this study was Domain III (Communication Skills) and as the sixth rank was Domain VII (Financial Planning and Management Skills and Planning). There are no laws or regulations governing the competency of nurses in the field of communication and finance that are destined for nursing personnel in primary service order. Some experts argue that good communication skills and financial management skills are both programs acquired by the community nurse in the work. It can be concluded that this ability can be improved from work experience; the longer the community nurse experience works, the better the ability of communication and financial management in the community will be. Different from the management and planning skills, although specifically nurses have a branch of nursing management (Cross et al., 2006;Hewitt, Roye, & Gebbie, 2014;Polivka & Chaudry, 2015), but the theory is more appropriate to use by nurses in clinical settings, not in the community. In the public order, in relation to primary service, nurse should carry out the rules and policies that are contained in the Minister of Health' Domain VI (Public Health Sciences Skills) in the C/PHN Competencies of the Quad Council Coalition was ranked seventh in this study. The last rank was Domain IV (Competency Skills with Cultural Aspects). Some experts in the study agreed that the competencies that the nurses have in the community are heavily influenced by the nurses' work experiences. Longer working experience will make nurses increase their expertise in doing their job in the field. In addition, regional cultures also greatly affect the working style as well as the results of working nurses in the community (American