The components of the [Norm (Social Justice)] included {Trust and Partnership}, {Equality and Equity} and {Protection of Everyone’s “Living”}.

(Referring to the monitoring of a community café launched with the support of the PHN and led by local inhabitants) As we put unwavering trust in local inhabitants and went to see how it was going from time to time, even without being invited, they were always waiting there, ready to empower me. (2-21)

The PHNs embodied {Trust and Partnership} in a constant way, respecting inhabitants-led decision-making in the belief that they can change. The data described above indicate the story told by a PHN who went to observe the community café whose launch she had supported in Activity #2. The remarks will express the attitude of the PHN toward this norm.

I make it a rule to provide information to the whole community in response to any request from a specific neighborhood. (2-5)

Keeping in mind the need to ensure {Equality and Equity} for the whole community, the PHNs acted not to create any health-affecting gap. The data described above, also taken from Activity #2, tells the story of a PHN seeking to provide information to the whole neighborhood in an equitable manner.

Only PHNs can seamlessly observe and monitor the situation of all individuals and families from the perspective of their family members and neighbors in the community. (5-38)

As professionals in ensuring health for all, the PHNs continued activities in {Protection of Everyone’s “Living”}, or activities to protect the lives, livelihood, and right to life of all inhabitants. The data described above is a story about Activity #5, where the PHN sought to support individuals, recognizing them as full members of the community, or people who will remain in the community for the rest of their lives.

In [Searching], two categories were identified: {Reality Searching} to identify the realities and {Reality Actualization} to communicate the realities.

The realities of the community are marked by the ongoing population aging. Many people are still able to move, but the government can no longer lead singlehandedly the effort to prevent long-term care needs. We feel that the ownership of community members is required going forward. (3-3, 3-7)

For the purpose of {Reality Searching}, the PHNs practiced <Potentials Identification> in the community, <Needs Identification> to understand the current crisis and limits, and <Resource Exploration> to explore a wide variety of resources and the possibility of transferring, introducing, utilizing or disseminating them, lest SC should be undermined. The data described above, a story told at the beginning of Activity #3, depicts the attitude of a PHN exploring the possibility of resource development by identifying the needs for preventing ailments that require long-term care in the community, and focusing on the availability of people for such activities.

(Referring to the implementation rate of effective treatment of a given disease) This chart shows the situation of Prefecture A as a whole. In this period, the rate in City B remained at 8% against the national average of 30%. (The case, as well as) The data indicate that the inhabitants were not in a position to select the treatment. (4-36)

For the purpose of {Reality Actualization}, the PHNs practiced <Visualization> to illustrate the realities in documents or charts, <Substance Presentation> to show the realities through mapping or the live voices of stakeholders, and <Factor Presentation> to show the obstructing or promoting factors behind the realities. The data described above, which concerns Activity #4, tells the story of a PHN who has succeeded in individual-focused and community-focused visualization of the realities of traditional treatment practiced in the community.

In [Stimulating], two categories were identified: {Ownership Fostering} to encourage stakeholders to take the initiative; and {Motivation Support} to launch and sustain activities.

We focused our effort on ensuring that both the inhabitants and staff members enjoy (the implementation of the project for) disease prevention and health promotion. (5-28)

For the purpose of {Ownership Fostering}, the PHNs practiced <Collective Responsibility Sharing> to raise awareness of the necessity of efforts by the whole community, and not individuals, and <Collective Voluntary Involvement> to ensure that the value of “full involvement,” “interaction/ participation” and “positive and proactive attitude” take root in the whole community. The data described above, regarding Activity #5, shows how the PHN designed the project to ensure the voluntary involvement of everyone, and shared with community inhabitants, including the disabled, the elderly and young children and their parents, awareness of the need to promote better health together.

We launched a planning committee for exchange events to raise the essential motivation for continuing (the voluntary activities of inhabitants) when the going gets tough. (3-28)

For the purpose of {Motivation Support}, the PHNs practiced <Initiation Assistance> for inhabitants to take the initiative, and <Motivation Boosting> to continue the initiative with confidence. The data described above, concerning Activity #3, reveals how the PHN acted to revive a inhabitants’ initiative facing a viability crisis and boosted motivation.

In [Facilitating], two categories were identified: {Collective Effort Promotion} to ensure that community members share roles in making progress by leveraging their skills; and {Full Retention Promotion} to ensure that the whole community maintains the effort.

We organized a Leadership Training Course for Care Needs Prevention on a local scale to invite one or two candidates from each community to serve as leaders. (3-20)

For the purpose of {Collective Effort Promotion}, the PHNs practiced <Player Amplification> to augment the agents of change, and <Mutual Contribution Presentation> to ensure that the players recognize each other’s contribution and maintain their morale. The data described above, which concerns Activity #3, expresses how the PHN engaged with the whole community to recruit potential community leaders to promote prevention activities.

We often say to the participants: “Tell everybody how much fun you have had today on your way back home, and all your neighbors will feel rejuvenated. (2-15)

For the purpose of {Full Retention Promotion}, the PHNs practiced <Local Dissemination> to scale the results of the Prevention Class, etc. to all neighborhoods through word of mouth and itinerancy, and <Initiative Support> to guide the inhabitants toward self-reliance by providing different support at different stages. The data described above, a story from Activity #2, describes how the PHN called on participants in the Prevention Class held in various neighborhoods to disseminate their learnings throughout their neighborhood.

In [Cooperation], two categories were identified: {Collaborative Piloting} to promote collaboration in an effective way; and {Opportunity/Platform Provision} to set opportunities and platforms fit for the purpose.

Relevant organs with limited relationships created a horizontal network through the conference, and this tool (developed over two years through collaboration) has helped everyone to provide information on services to be provided in the next period. (1-56)

For the purpose of {Collaborative Piloting}, the PHNs practiced <Collaboration for Growth> to create results by building organic relationships for mutual growth, and <Adjustment for Development> to achieve the objective through comprehensive adjustments among a wide range of community members. The data described above, a story from Activity #1, shows how the PHN facilitated growth and development among the stakeholders through a multi-year process of developing a support pathway for 0-15 year olds, for joint use by the stakeholders and various professionals.

Conducting a survey in Year 1, holding joint study groups in Year 2, and visualizing a draft (for Year 3) for feedback from relevant organs and further refinement – this process was crucial (in building the system). (4-66)

For the purpose of {Opportunity/Platform Provision}, the PHNs practiced <Positive Health Transformation> to direct community members toward positive, and not negative health, and <Outcome Consolidation> to ensure the consolidation of cases such as decision-making in stages and the transformation of the community. The data described above, regarding Activity #4, tells how the PHN continued to provide opportunities/platforms for learning and consultation to change the recognition of the related institutions in stages and build a system to ensure positive health among the stakeholders.

In [Continuing Quality Improvement], two categories were identified: {Capacity Building} to raise the capacity of the community; and {Quality Management} to ensure qualitative management of social resources in the community.

It was not about making the tool (for collaborative support) per se. What mattered was the process of making the tool, which enabled all six members to say the same thing to the relevant organizations. (1-68)

For the purpose of {Capacity Building}, the PHNs practiced <Key People Development> to discover high-caliber talented individuals for skills development, and <Collaborative Knowledge Development> to ensure that the inhabitants and stakeholders specialized in different areas co-create knowledge and gain capacity through joint activities. The data described above, which concerns Activity #1, demonstrates the fact that the members gained the capacity to explain on their own the knowledge learned through several years of collaboration for the development of the support pathway.

In evaluating the results of network development (over the three years), the PHNs took ultimate responsibility for final verification, as any increase (in resources) has no meaning unless they are utilized for the benefit of patients. We were aware that the evaluation of health activities would revert to the inhabitants. (4-82)

For the purpose of {Quality Management}, the PHNs practiced <Overhaul> to check overall quality and identify the matters that required maintenance/upgrading or improvement, and <Bottom-up Improvement> to plan, implement and evaluate to ensure the actual improvement of field practice. The data described above, which concerns Activity #4, indicates how the bottom-up activity facilitated by the PHN brought benefit to the whole community.

In [Policy/Resource Development], two categories were identified: {Resource Development} to develop social resources for meeting the needs of the community; and {Planning/Systematization} to develop the policies and mechanisms required therefor.

The survey helped us measure the capacity of clinics involved (in-home pediatric care) and identify the medical institutions that could become involved if given adequate conditions. (1-18)

For the purpose of {Resource Development}, the PHNs practiced <Resource Generation> to make preparations and adjustments for social resource development, and <Use Promotion> to operationalize and promote the use of social resources. The data described above, taken from Activity #1, depicts how the PHN recognized that the existing resources might be useful for finding better solutions to future challenges and promoted their usability as resources.

At that time, participants in the functional training class were limited to those aged 40 or over under the law. We changed the municipal guidelines to allow the participation of young disabled persons. (5-35)

For the purpose of {Planning/Systematization}, the PHNs practiced <Priority Identification> to identify priorities in planning/systematization, and <Decision/Building/Infrastructure> to build and continuously develop policies and systems following the decision-making stage. The data described above, taken from Activity #5, tells the story of a PHN who developed measures to address high-priority health issues even if it entailed a decision to modify the system.

{Reality Searching} for relevant events to promote public health entails population-based <Needs Identification> to focus on both individuals and the community, as well as <Potentials Identification> and <Resource Exploration>. It is the PHNA supported by a sense of purpose, in combination with the subsequent process of {Reality Actualization} to ensure that the realities are visible to the inhabitants and related institutions, and to set the direction of activities for positive health promotion, in close relation with {Protection of Everyone’s “Living”}, which represents the norm of social justice.

Some point to the persistence of a culture that focuses on negative aspects, emanating from the traditional problem-focused/deficiency-based approach to healthcare that prevailed when disease structure was still simple [17]. In advocating theory and practice in nursing with “community as partner,” however, Anderson et al. [18] stress that “a nursing model should encompass all aspects of health care needs,” calling for “health promotion and the holistic focus that is central to nursing.” In line with the norm of social justice, the PHNA identified in this study sets the direction of positive health promotion by integrating health care needs from various aspects, including strengths, challenges, and resources.

{Ownership Fostering} and {Motivation Support} for promoting population-based positive health are the PHNA to increase the independence of community members and ensure the initiation and continuation of activities. They may be considered as closely related to “solidarity and mutual aid” and “organizational dynamics to drive decision-making” in [SC: state of inhabitants] and the development of “neighborhood organization” in [SC: the surrounding situation of inhabitants]. Also, {Collective Effort Promotion} and {Full Retention Promotion} are the PHNA to ensure results by mobilizing the whole population to improve performance. They may be considered as closely related to the promotion of “skills of exploring and leveraging resources” and “balance and control over impact” in [SC: state of inhabitants].

Cowley [19] notes that “public health cannot function at a single, individual level,” and that it can only make progress by “involving those people who make up the population.” In the [Stimulating] and [Facilitating] art identified in our study would empower the population to contribute to the betterment of positive health, by encouraging local people to take ownership, make dedicated collective efforts, and establish and expand the activities in the whole community.

Fig. (1). Public Health Nursing Art to enhance “Strength of Community (potential of the community to promote positive health)”.

{Collaborative Piloting} and {Opportunity/Platform Provision} for promoting population-based positive health are the PHNA to ensure that diverse community members get together to positively integrate their functions. They may be considered as closely related to “partnership building” in [SC: state of inhabitants] and “network” building in [SC: the surrounding situation of inhabitants]. Also, {Capacity Building} and {Quality Management} are the PHNA to ensure the quality of the whole population. They may be considered as closely related to “capacity building” in [SC: state of inhabitants], as well as {Trust and Partnership} and {Equality and Equity}, which comprise the norm of social justice.

Cowley and Frost [14] include Positive Health in the seven public health values in practice, adding that “health is a positive concept, encompassing social and personal resources, as well as physical capacities,” and that “health promotion, therefore, involves finding ways to create resources for health.” Indeed, the PHNA of [Cooperation] and [Continuing Quality Improvement] identified in our study may be considered as the PHNA to contribute to the process of promoting positive health, as they highlight essential requirements for realizing Policy/Resource Development, such as opportunity/platform provision and capacity building.

{Resource Development} and {Planning/Systematization} for promoting positive health are the PHNA to create systems by working on the environment surrounding the population. They may be considered as closely related to the betterment of “network” and “support system” in [SC: surrounding situation of inhabitants].

Noting that “health promotion is a process,” WHO’s Ottawa Charter [20] provides that “to reach a state of complete well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment.” In this connection, the [Policy/ Resource Development] art identified in our study would help change the environment, including systems and resources through the process of [Cooperation] to upgrade the PHNA of the inhabitants and stakeholders, and thus may be considered to contribute to health promotion by enhancing Positive Health.

Although each art was classified into a specific framework, the data revealed the actual interaction of deployed art in various ways. For example, [Searching <Needs Identification>] led to [Cooperation <Positive Health Transformation>] in some cases (3-7), while [Stimulating <Collective Voluntary Involvement>] developed into [Policy/Resource Development <Resource Generation>] in others (5-28). Also, population-based PHN activities changed their target depending on the time and situation, focusing on individuals, the community, or the whole system. Hence, it was found that each art was structurally positioned around the core of the Norm. In deployment, they interacted with each other, focusing on the individual and/or the community and/or the system, aiming for the best positive health (or improvement in public health) among the population. Fig. (1) illustrates this dynamic: the PHNA positioned at and around the core and linked with each other like a rotating globe, evolves in the direction of the ultimate goal while changing their focus as needed.

In the final analysis, this study succeeded in demonstrating that the PHNA was collected, refined and structured in a multidisciplinary and comprehensive manner, within the context of promoting Positive Health among the population. This is an original feature of our study.

It is said that public health nursing activities are difficult to visualize [21] even PHNs themselves cannot clearly express what results they are working to produce and for whom [22]. This implies obstacles in the transfer of professional information among PHNs and the clarification of roles in cooperation with inhabitants and stakeholders. It has been considered natural to implement the PDCA cycle in conducting activities. However, PDCA only represents a framework of knowledge regarding the order of the process, as the “Plan” stage does not indicate what should be planned and for what purpose. In contrast, the PHNA identified in this study clearly indicates what should be done and for what purpose: actualizing to visualize the realities; supporting to boost motivation; and promoting to disseminate the activities in the whole community. This characteristic should help learners and practitioners understand and acquire the PHNA. We believe that the identification of the PHNA as acts with sense of purpose will improve the ability of PHNs to explain their work as professionals, thus helping to solve the above-mentioned obstacles, and eventually to develop confidence and pride among PHNs.

As mentioned earlier, most PHNs in Japan are working for administrative agencies. The PHNA identified in this study include the characteristics of PHNs working in accordance with the legal division of duties and of nurses providing care to specific communities, and hence reflect the expertise of PHNs, which is different from other professions. It is widely understood that hierarchical relationships exist in administrative agencies in particular, as seen in the auditing of hospitals and restaurants. However, the findings indicate that PHNs, or public health nursing professionals, are involved in [Cooperation <Adjustment for Development>] and [Continuing Quality Improvement <Collaborative Knowledge Development>] on an equal footing with inhabitants and stakeholders when they engage with the community to promote Positive Health. Thus, the identification of the PHNA in the context of developing various potentials to enhance SC effectively demonstrates that PHNs contribute to the roles and responsibilities of administrative agencies by acting as general coordinators, and that their activities have an impact on the whole community, enhancing sustainability in the long term.