Construction of a practice model of evidence-based health service development for public health nursing in Japan: a Delphi survey

Abstract

Background

An effective and efficient response to health needs requires the development of an evidence-based health service. Public health nurses are considered to be key practitioners of health service development in Japanese health administration, increasing the importance of the role of health service development. The purpose of this study is to build a practice model for evidence-based health service development adapted to the context of public health nursing in Japan (“Practice Model”).

Methods

The draft Practice Model consisted of 17 items grouped into three stages, was developed through literature research and regular consultations by the study team and feedback at two public gatherings. The framework and item-pool of the initial draft were built on implementation science models meeting one or more of the criteria set by the study team. The survey was conducted using the Delphi method, a consensus formation technique, and consisted of three rounds of self-administered questionnaires. The expert panel was formed by sending a request letter to supervising PHNs and PHN training course professors nationwide, and selecting those who expressed their willingness to cooperate and met the selection criteria.

Results

99 expert panel joined in Round 1 (52 practitioners and 47 faculty), of whom 81 cooperated in all three surveys. As a result of three rounds of opinion gathering and revision, high percentages of agreement of 80% or over were obtained in all rounds for all items. In particular, in Round 3, the percentages of agreement of 95% or over were achieved for all items.

Conclusions

The results of the Delphi survey showed that the Practice Model, which underwent revisions after each round, achieved a high level of consensus and was modified. The Practice Model clearly outlined the structure of evidence-based health service development. The novelty of this model lies in its structure, which includes three stages—the preparation stage (Type 1 evidence focus), the implementation stage (Type 2 evidence focus), and the dissemination stage (Type 3 evidence focus)—and incorporates important processes such as the Plan‑Do‑Check‑Act cycle and implementation science, while also positioning continuing professional development as the foundation for practice. In the future, the utilization of this Practice Model will serve as on-the-job training to enhance the health service development capabilities of public health nurses, which in turn is expected to improve the quality of evidence-based public health in the field.

Clinical trial number

Not applicable.

Supplementary information

The online version contains supplementary material available at 10.1186/s12912-025-03820-4.

Contributions to the literature’ statement
1. In this study, a “practice model of evidence-based health service development for public health nursing in Japan” was constructed.
2. This practice model was confirmed by the Delphi survey, which identified a consensus among the panel of experts.
3. The practice model could serve as a guide for local government public health nurses to properly promote health service development.
4. This practice model could provide implementation strategies in developing evidence-based public health nurse activities.

Introduction

An effective and efficient response to health needs requires the development of an evidence-based health service. As the World Health Organization (WHO) endorses “health in all policies” (Adelaide Declaration, 2010) [1], the promotion of health service development, such as programs, projects and activities that lead to help meet health needs is a critical mission for health professionals.

In Japan, public health nurses (“PHNs”) are defined under the Act on Public Health Nurses, Midwives, and Nurses as professionals licensed exclusively to use that title in providing health guidance [2], and are specified as one of the minor groups of the “professionals” major group under the Japan Standard Occupational Classification [3]. Since almost 70% of PHNs are affiliated to an administrative agency [4], they are considered to be key practitioners of health service development in Japanese health administration.

Traditionally, PHNs have been conducting personal health activities on a population basis focused on individuals and local communities, including health visiting, health teaching and community organizing. With the growth of health needs in recent years, however, emphasis has been shifting to more system-focused activities, increasing the importance of the role of health service development. The inclusion of “preparation/implementation of plans” and “building of a community care system” in the roles to be played by PHNs under the Guidelines on PHN Activities (Ministry of Health, Labour and Welfare), as revised in 2013 [5], reflects this trend. Moreover, “promotion of science-based community health” was added to the overarching goals specified in the Basic Guidelines for Promoting Community Health Measures in 2012 [6], effectively imposing the duty of evidence-based public health (EBPH) on PHNs.

Nonetheless, it has been pointed out that PHNs’ EBPH practices are not evidence-based and that education to this end is insufficient. Specifically, a national survey of PHNs found that they do not usually examine, apply or evaluate research results in making use of evidence [7]. Although PHNs “regularly” perform the PDCA cycle in implementing health programs, they adopt EBPH only “sometimes” [8], pointing to some issues in EBPH for health service development among PHNs. On the education agenda, according to the Basic Survey on the Foundation of PHN Activities [9] a regular large-scale survey of the Japanese Nursing Association, commissioned by the government, “service development and policy recommendation capacity” (39.2%) heads the list of the essential capacities that PHNs lack opportunities to learn These findings clearly indicate the low level of EBPH practice among PHNs and the lack of opportunities for capacity development in terms of health service development. Therefore, it was considered urgent to develop practical models that would contribute to addressing these issues.

The purpose of this study is to build a practice model for evidence-based health service development that can be used by PHNs in Japanese public health administration adapted to the context of public health nursing in Japan. The significance of this is that if there are guidelines on how to develop programs and projects, anyone will be able to implement EBPH practices above a certain level, and it can be expected that this will be useful for education. Ultimately, this will contribute to solving the issues of low EBPH practice capacity among PHNs and the lack of opportunities for capacity building.

In this paper, health service development (HSD) is defined as the practice of PHNs in Japanese administrative agency to improve and develop new or existing programs, policies, activities, and systems related to health. In reference to the concept of the nursing model [10], “practice model” is defined as “a framework in which components of practice with specific objectives are structured and serve as a bridge to practice,” and “evidence” is some form of data or information used in making judgments and decisions [11]. Types of evidence are defined with reference to Brownson et al.‘s “Evidence-Based Public Health” [11] as follows: Type 1 is evidence regarding the magnitude, severity, distribution, and priority of health issues; Type 2 is evidence demonstrating that a specific intervention is effective; and Type 3 is evidence regarding the context (optimal solution or feasible solution) of intervention implementation and implementation methods.

Methodology

Study design

The design of this study was Consensus Study Design using a Delphi Method.

Drafting of a practice model

The draft practice model for evidence-based HSD for public health nursing (“Practice Model”) was developed in May 2023 – June 2024 through literature research and regular consultations (three in-person and five online meetings and frequent e-mail exchanges between sessions) by the study team and feedback at two public gatherings (Supplementary file 1). The study team is the authors of this paper and all have at least 5 years of public health nursing practice and 15 years of teaching and research experience.

In discussing the draft, we considered it appropriate to adopt implementation science, i.e. an approach to promote the provision of health service tailored to the population with health needs by closing the gap between research and practice based on evidence [12], and we proceeded as follows.

The framework and item-pool of the initial draft were built on implementation science models meeting one of the following criteria set by the study team: (1) adopted following consultation with experts on applicability to the field of administration; (2) explainable or verifiable with actual cases; (3) often cited by researchers in a number of articles; (4) presented as guidance by the expert team of an international organization; or (5) developed by integrating multiple frameworks.

The 14 referenced models [12–25] include the health service implementation model (eight items) in a previous study of the author and coworkers (JSPS Scientific Research Fund: JP19H03961), Consolidated Framework for Implementation Research (CFIR), RE-AIM framework, Model for Adaptation Design and Impact (MADI), EPIS (Exploration, Preparation, Implementation, Sustainment) model, Intervention Mapping (IM), and Framework for the dissemination and utilization of research for health-care policy and practice, among others.

Specifically, based on references 10, 14, 15, and 16, the study team devised a model that focused on the “partial” aspect of PHNs searching for and adopting evidence-based projects. These were mainly contents corresponding to the preparation stage of this Practice Model. However, in practice, it was decided that a model covering the “entirety” of EBPH actually implemented was necessary, and it was decided to collect more comprehensive items based on the following direction. The direction was that the models should be developed in the fields of public health, health care, and policy, and should include contents related to overall implementation, implementation strategies for evidence, and transfer and dissemination to practice. From the 17–23 additional literature references, components corresponding mainly to the implementation and dissemination stages were extracted. The items in each model used different terminology and had different ranges of meaning, even for similar practices. Therefore, while interpreting the meanings of each term among the study team members, the wording was developed with an emphasis on simplicity and understandable, and well-adapted to the context of PHN activities, without deviating from the guidelines of the Japanese public health administration. After repeated discussions, 16 items consisting of three stages and one item covering all stages, for a total of 17 items, were generated. The three stages were grouped into three types based on the evidence that was the focus of the EBPH process. The “preparation stage” involved using Type 1 evidence, which clarifies health issues, to initiate planning; the “implementation stage” involved using Type 2 evidence, which is effective for solving and improving health issues, to plan and implement the program; and the “dissemination stage” involved creating Type 3 evidence, which clearly shows how results were achieved in a specific context. One item across all stages was related to continuing professional development (CPD).

Delphi survey

Survey method

The survey was designed as a cross-sectional observation using the Delphi consensus method. This structured survey method [26] was adopted with the aim of reaching an appropriate consensus by seeking comments on the initial draft from the expert panel and modifying it as necessary. At the stage of study planning, we set criteria for the selection of the expert panel, three rounds of exercise to ensure ample discussion, and a clear definition of consensus, followed by an anonymous, self-administered questionnaire via e-mail.

Selection of the expert panel and confirmation of consent to participate in the survey

The expert panel was potentially composed of 608 practitioners and faculty in public health nursing, meeting the selection criteria (314 practitioners, including two supervising PHN or managers working for each of the 157 prefectures and government-designated cities/wards with health centers, requested to be selected from different department/teams; and the PHN training course managers of the 294 faculty institutions). Selection criteria concerned: (A) expertise (affiliation, position); (B) heterogeneity (job category); and (C) interest (expressed willingness to participate, attendance at relevant training courses) [27]. An explanation of the survey and a request for cooperation were made in mailed documents, and the willingness to participate was confirmed via e-mail messages directly sent to the survey secretariat by the respondents.

Survey content

The questionnaire included questions on the demographics of the expert panel, the 17 items of the draft Practice Model, and the composition of the three stages of the Practice Model.

The questions on demographics concerned the duration of experience as PHN, academic qualifications, covered geographical area and the items used as selection criteria.

The draft contained a total of 17 items including six on the preparation stage, six on the implementation stage, four on the dissemination stage and one covering all of the stages. We adopted a five-point Likert scale, with 1 indicating “Do not agree at all,” 2 “Do not agree,” 3 “Do not know,” 4 “Agree” and 5 “Completely agree” and provided the following instruction: “For each item, please choose the level of agreement you feel from the five choices in the answer box.” We also asked the respondents to indicate their views about proposed modifications on each item and any additional comments in the free description box.

The survey was conducted from June to November 2024 (first questionnaire: June 24 – August 1; second questionnaire: August 30 – October 7; and third questionnaire: October 11– November 8).

Method of analysis

We adopted two criteria for determination on consensus formation with reference to a previous study [26–29]. The percentage of agreement was judged as high where scores of 4 and 5 on the rating scale combined accounted for 80% or over of the total responses, and medium when the share was 70% or over. The degree of consensus was judged from the median value and the interquartile range (IQR), indicating the distance between the first and third quartiles, either as high (median of 5, IQR of 0 or 1) or medium (median of 4, IQR of 1). We employed IBM SPSS Ver. 28 for the analysis.

In the modification process for the second and third rounds after recovering the questionnaire forms, the secretariat aggregated the responses, made a list of comments expressed and sorted out similar ones. Then, the survey leader interpreted the results and developed a draft answer to each of the comments expressed, which was modified through consultation at the plenary meetings of the study team. The modified draft continued to be discussed via e-mail, and was included in the next questionnaire after confirmation.

The methodological soundness of the survey was validated in line with the checklist in Guidance on Conducting and REporting DElphi Studies (CREDES) [29], namely transparency and the quality of reporting, selection criteria for the expert panel, purpose and number of rounds, feedback and design of the next round.

Ethical considerations

The research program was implemented with the approval of the Ethics Committee for Observational Study, Osaka University Hospital (Approval No. 23484(T3–2) dated 18 April 2024). The request and ethical consideration, as well as the questionnaire form were downloaded by individual expert panel members from the URL for the external file transfer service specified by the secretariat to prevent exceeding the quota and wrong transmission. The document told the respondents not to sign their name in the e-mail message when returning the questionnaire form, in the questionnaire itself or in the file name, explained that the respondents would be deemed to have confirmed their consent to participate in the survey by ticking the appropriate box in the questionnaire form, and also explained the publication, the voluntary nature of participating in or leaving the survey, and data processing with ID numbers unrelated to personal information, among others.

Results

Demographics of the expert panel (Table 1)

Table 1.

Demographics of the expert panel (Round 1:N=99)

Attributes and Selection Criteria				n	%
Attributes	Experience as PHN		Less than 10 years	19	19.2
			10-19 years	9	9.1
	Mean 25.5   ± SD 12.8		20-29 years	16	16.2
			30 years or more	55	55.6
	Academic qualification		Postgraduate degree (Master・Doctorate)	53	53.5
			Others	46	46.5
	Geographical area		Hokkaido/Tohoku	12	12.1
			Kanto/Koshinetsu	17	17.2
			Tokai/Hokuriku	16	16.2
			Kinki	26	26.3
			Chugoku/Shikoku	13	13.1
			Kyushu/Okinawa	15	15.2
Selection Criteria	Affiliation		Local governments (prefectures)	24	24.2
			Local governments (Government-designated cities with health centers)	28	28.3
			Faculty institutions	47	47.5
Criterion A: Expertise	Position	Practitioner	Section chief or above	52	100.0
		n=52	None	0	0.0
		Faculty	Professor	33	70.2
			Associate Professor/Lecturer	14	29.8
		n=47	Assistant professor or below	0	0.0
Criterion B: Heterogeneity	Job category		Practitioner	52	52.5
			Faculty (Educator/Researcher)	47	47.5
	Details	Practitioner	Supervising PHN	31	59.6
		n=52	None	21	40.4
Criterion C: Interest	Willingness to cooperate	Number of people who responded to the request for cooperation in writing: 608
		→ Of these, the number of people who responded to the request for cooperation by email: 118 (19.4%)
		→ Of these, the number of people who actually cooperated in the survey: 99 (16.4%)
	Training history related to health service development	Yes (multiple times or several-day course training)		32	32.3
		Yes (one-off, one time)		20	20.2
		No		47	47.5

Selection criteria concerned (Those who fulfill any three of the following requirements: ①② in A, ①② in B, and ①② in C):

A Expertise: ① Different Professional Affiliations; Whether the affiliation is a local government (prefecture), local government (Government-designated cities with health centers), or faculty institution

② Position requiring specialization; Whether or not the practitioner is a section chief or above, whether or not the faculty is a lecturer or above

B Heterogeneity: ① Whether or not the practitioner or faculty is in a different occupation, ② Whether or not the practitioner has a supervisory role (supervising public health nurse)

C Interest: ① Whether or not the panel expressed a willingness to cooperate with the survey and cooperated with it, ② Whether or not the panel has attended related training courses

Of the 608 candidates requested to participate, 99 (16.3%) joined the expert panel in Round 1 (52 practitioners and 47 faculty, all of whom met the selection criteria). The number of participants declined to 91 (91.9%, dropout rate of 8.1%) in Round 2, and to 81 in Round 3 (complete participation rate of 81.8%, dropout rate of 18.2%).

The duration of experience as PHN averaged 25.5 years (33.0 for practitioners, 17.1 for faculty); by 10-year bracket, over 70% of the panel had 20 years or more experience. By academic qualification, 53 had a postgraduate degree (including all of the faculty). By geographical area, all six regional blocs each accounted for at least 10%, although Kinki represented as much as a quarter of the panel. By selection criterion, responses on expertise (Criterion A) indicated a 50:50 distribution in affiliation, between local governments and faculty institutions, and for local governments, between prefectures on the one hand, and government-designated cities with health centers and other municipalities, on the other. As regards job title, the practitioners were invariably section chief or above, whereas 70% of the faculty were professors and none were assistant professor or below. Concerning heterogeneity (Criterion B), responses on job category showed a 50:50 distribution between practitioners and faculty, while 60% of the practitioners were supervising PHN, with other PHNs accounting for the remaining 40%. With regard to interest (Criterion C), all panel members participated in the survey after expressing their willingness to cooperate, with more than half having participated in a training course on HSD.

Consensus formation in the Delphi survey (Table 2)

Table 2.

Consensus formation in the Delphi survey

The [minimum – maximum] percentage of agreement on the 17 items was 81.8–98.0% in Round 1, 86.8–98.9% in Round 2, and 95.1–98.8% in Round 3. By item, the percentage of agreement in Round 1/2/3 reached 83.8/91.2/96.3% on the three-stage structure of the Practice Model, and 80.8/82.4/98.8% on designating a single item, namely “continuing professional development” as the foundation of practice. High percentages of agreement of 80% or over were obtained in all rounds for all items. In particular, all items gained even higher percentages of agreement in Round 3, reaching 95% or over. The degree of consensus remained medium on six items in Rounds 1 and 2, then reached high levels on all items in Round 3, including seven items on which complete consensus was formed with an IQR of zero.

Modified draft after the three rounds of survey (Table 3)

Table 3.

Practice model of evidence-based health service development, and Foundation of practice

	Stages		Modified draft	Draft
Practice model of evidence-based health service development	Preparation stage	1	Clarify the issues requiring the development/improvement of the project/program.	Clarify the issues requiring the development/improvement of the project/program.
	Type 1 Evidence Utilization leading to the best decision and Plan	2	Identify issues and set targets among the stakeholders.	Identify issues and set targets to be achieved among the stakeholders.
		3	Explore best practices* to achieve the target.	Select possible options for the best practices to achieve the target (or for an existing project, validate continuation through evaluation and improvement).
		4	Examine evidence of the best practice/existing project and select possible options.	Examine evidence of possible options for the best practice/existing project.
		5	Validate the applicability of possible options for the project/program.	Validate the applicability of possible options.
		6	Clarify the incentives and disincentives for planning, execution and evaluation.	Identify the incentives and disincentives for planning, execution and evaluation.
	Implementation stage	7	Make decisions on the start/continuation of the project/program.	Make decisions on the start/continuation of the project/program.
	Type 2 Evidence Utilization leading from Plan and Do to result	8	Prepare execution and evaluation plans for the project/action.	Prepare execution and evaluation plans for the project/action.
		9	Include in the execution plan measures to leverage incentives and address disincentives.	Include in the execution plan how to leverage incentives and address disincentives.
		10	Include in the evaluation plan how to evaluate the result of addressing incentives and disincentives.	Include in the evaluation plan how to evaluate the outcome of addressing incentives/disincentives.
		11	Execute/replicate the project/action.	Execute/replicate the project/action.
		12	Monitor the execution/replication of the project/program.	Monitor/optimize the replication process of the plan.
	Dissemination stage	13	Evaluate the outcome of the project/program.	Evaluate the outcome of the project/program after execution.
	Type 3 Evidence Creation leading from Check and Act to utilization of results	14	Clarify required improvements based on the evaluation of the project/program.	Clarify required improvements based on the evaluation of the project/program.
		15	Consider improvement measures for, or upscaling and downscaling of the project/program.	Replicate quality improvement/upscaling measures.
		16	Make public the outcomes/evidence of the project/program and promote measures for dissemination.	Make public the outcomes/evidence and promote measures for dissemination.
Foundation of practice	Continuing Professional Development leading to society’s trust in PHNs	17	Continue competency* development as professionals	Continue competency development as professionals.

In practice, the initial draft was modified after Round 1, the first modified draft was further modified after Round 2, and the second modified draft was turned into the final draft following the validation of consensus after Round 3

The underlines in the table indicate modified parts. Forward slash (/) means “and/or.”

The item numbers are for convenience and do not indicate any order or priority

In the Japanese version, words marked with an asterisk* are followed by a Japanese translation in parentheses for the benefit of Japanese readers

Despite the good results in terms of both the percentage of agreement and the degree of consensus, there were quite a few comments on the terms and expressions used in the draft. In response, we left the draft as it was where the text was considered to contain or supersede what was expressed in the comments, but decided to modify the text to clarify the meaning where a comment pointed out that the passage was hard to understand. In addition, we highlighted those parts of the draft which contained some uncertainties so that everyone could give a comment for modification after consultations. (See the underlined parts of Table 3 for the modified parts.) In this modification process, the item “continuing professional development (CPD),” which was to be included in all stages in the draft, was repositioned as the “foundation of practice” as multiple comments expressed disagreement about making it a cross-cutting item.

The following are the main revisions made. Regarding items 3 and 4, the Japanese term “best practices” is unfamiliar to Japanese speakers and difficult to understand. There was a suggestion that it may not be necessary to use this term, so we added in Japanese “Saishin Sairyou no Jissen” in parentheses, which is familiar in the definition of evidence. Item 15 originally included “Replicate upscaling measures” in addition to quality improvement, but following feedback from the expert panel that downscaling or discontinuation may also be possible, it was revised to “Consider upscaling and downscaling of the project/program” to reflect both possibilities. Additionally, to clarify the relationship between the evidence focused on at each stage and the Plan-Do-Check-Act cycle, we added “Focused evidence types and PDCA cycle” below each stage name. Specifically, the Preparation stage is “Type 1 Evidence Utilization leading to the best decision and Plan,” the Implementation stage is “Type 2 Evidence Utilization leading from Plan and Do to result,” and the Dissemination stage is “Type 3 Evidence Creation leading from Check and Act to utilization of results.” During the revision process, several opinions were raised that one item of CPD, which was described as “across all stages” in the draft, would be incongruous if placed alongside the other stages, and it was therefore decided to position it as a “foundation of practice.”

The number of comments expressed on each item is shown in Table 2. By stage, the number of comments in Round 1/2/3 totaled 25/14/5 on the preparation stage of the Practice Model, 13/11/4 on the implementation stage, 8/7/2 on the dissemination stage, 9/9/2 on the foundation of practice, 11/9/0 on the three-stage structure, and 22/17/0 on defining CPD as the foundation of practice. The decline in the number of comments as the survey progressed may be inevitable.

Thus, the initial draft of the Practice Model, shown on the right side of Table 3, was modified through three rounds of survey into the final draft shown on the left side of the table.

Discussion

Determination on consensus formation and methodological soundness

We carefully reviewed and revised the numerous opinions obtained from the expert panel in the three rounds of the survey, one by one for each round. As a result, the final draft of the Practice Model enjoyed a high percentage of agreement and a high degree of consensus on every item. We consider it highly significant that a practice model in line with the context of public health nursing in Japan was built by applying the knowledge of implementation science, which will promote evidence-based HSD by PHNs going forward.

Also, the evaluation of the Delphi survey process in line with the CREDES checklist validated its methodological soundness, in terms of well-defined purpose, method and expert panel selection criteria, clear definition of consensus formation, and transparent reporting of results and the modified document.

We recruited 608 participants nationwide under the expert panel selection criteria for expertise and diversity, obtaining cooperation from 16.3% of the candidates (99 participants) meeting the criterion of “interest.” This number reflects the methodological soundness of our Delphi survey, as it has a different meaning from the collection rate in a field survey, confirming that the expert panel was a selection of highly motivated persons. The role of managers in the career ladder for PHNs in Japan clearly includes “policy formulation and evaluation,” and the fact that all members of the expert panel were section chiefs or above, who perform such roles, indicates that they fully met the “expertise” criteria used in the Delphi survey. In addition, all faculty members were at least lecturers, which indicates that they were qualified to teach “Health, Medical Care, and Welfare Administration,” a subject included in the PHN education curriculum, and thus fully met the “expertise” requirement. It is believed that the survey collected high-quality data with the cooperation of this expert panel. In addition, the characteristics of this expert panel enabled them to thoroughly understand the significance of the practical model and evaluate its content, which is thought to have contributed to the large number of specific comments and high level of agreement.

Characteristics of the practice model

The 10 Guidelines on PHN Activities (Ministry of Health, Labour and Welfare, 2013) [5] include “implementation of the PDCA cycle based on community diagnosis” regarding the concrete practice replication process as the first guideline, in addition to the two guidelines referred to in the introduction to this paper. Among the 16 items in the three stages of the Practice Model built under the present project, a total of eight items may be considered to form the mainstay of the PDCA (“PDCA Items”) including two at the preparation stage, four at the implementation stage and two at the dissemination stage. The finding that all those items have an IQR of 1, not zero, showing a high degree of consensus, implies that PDCA has become deeply rooted in the activities of PHNs. Specifically, the eight items include: two on the preparation stage, ranging from community diagnosis to planning [namely “1. Clarify the issues requiring the development/improvement of the project/program” and “2. Identify issues and set targets among the stakeholders”]; four on the implementation stage, ranging from planning/execution to evaluation [namely “7. Make decisions on the start/continuation of the project/program,” “8. Prepare execution and evaluation plans for the project/action,” “11. Execute/replicate the project/action,” and “12. Monitor the execution/replication of the project/program”]; and two on the dissemination stage, ranging from evaluation/improvement to next planning [namely “13. Evaluate the outcome of the project/program” and “14. Clarify required improvements based on the evaluation of the project/program”].

As for the other eight items, on the other hand, IQR was zero for two items and 1 elsewhere. Although the degree of consensus was also deemed high for those items, the data reveal a lower level of convergence as compared with the PDCA Items. This result suggests that even the critical EBPH items extracted from multiple implementation science models may not have been recognized by PHNs unless the relevant practice is specified in the government’s guidelines. In addition, 30 years ago, the curriculum consisted of only two credits for health and welfare administration, compared to the current four credits [30], which may have resulted in insufficient basic education on HSD at that time. Specifically, such items include: two essential processes prior to incorporating evidence-based interventions into a plan for “EBPH” [namely “3. Explore best practices to achieve the target,” and “4. Examine evidence of the best practice/existing project and select possible options”]; four items comprising the key pillars of “adaptation [12, 17]” [namely “5. Validate the applicability of possible options for the project/program,” “6. Clarify the incentives and disincentives for planning, execution and evaluation,” “9. Include in the execution plan measures to leverage incentives and address disincentives,” and “10. Include in the evaluation plan how to evaluate the result of addressing incentives and disincentives”]; and one item each corresponding to “scale-up and dissemination [12]” [namely “15. Consider improvement measures for, or upscaling and downscaling of the project/program,” and “16. Make public the outcomes/evidence of the project/program and promote measures for dissemination.”]

The sole item corresponding to continuing professional development, which forms the foundation of practice in the Practice Model [namely “17. Continue competency development as professionals”] may be considered to have links to professionalism and human resource development specified in a number of standards on education and practice both inside and outside Japan [31–34]. Activities in line with the Practice Model entail the acquisition of corresponding competencies. Inclusion of this item as the foundation of practice is believed to have a significant meaning in that sense.

Thus, it is concluded that the Practice Model agreed upon in this survey comprises three stages (preparation, implementation, dissemination) that each focus on the three types of evidence identified in EBPH, integrating PDCA and key implementation science processes, with CPD positioned as the foundation of practice to support the whole model (Fig. 1).

Fig. 1.

Evidence based practice model for health service development in public health nursing

By utilizing this practical model, it may be possible to modify the practices of PHNs in the field as follows. For example, in local governments where measures to address specific health issues (Type 1 evidence) are lagging behind, if items 3 and 4 are implemented, several advanced examples of effective practices (Type 2 evidence) are searched for, and the most appropriate ones are selected and adopted, it may be possible to promote the improvement of health issues among the target population in the local government more effectively than before. Furthermore, if the capacity of PHNs can be developed and facilities can be renovated so that evidence-based nursing interventions can be faithfully implemented in the processes of items 5, 6, 9, and 10, there is potential for the creation of secondary outcomes in the form of improved service quality in addition to improvements in health issues. These organizational efforts in the local government will lead to the creation of Type 3 evidence, which can be published and disseminated to fulfill accountability to residents and stakeholders. In this way, the utilization of a practical model that integrates EBPH and PDCA has the potential to be effective as on-the-job training and is expected to contribute to improving the quality of PHNs’ activities in the field.

Limitations of this study and future prospects

The Practice Model built in this study potentially serves as practice guidelines in the field, as content for education including basic and mid-career training, and as a framework for a field survey or practice evaluation in research. Despite the consensus formed on the outline of the Practice Model, limitations to this study include insufficient consideration of how to disseminate it, including for the development and practice of concrete substructures to the model. In addition, it will be necessary to confirm the feasibility and acceptability of the Practice Model in the field, which is also considered a limitation at this point. Going forward, a program should be developed to prepare a guidebook that describes the content of the Practice Model with illustrations of concrete actions and cases, develop evaluation indicators to check the level of proficiency and effectively learn the skills to conduct activities in conformity to the Practice Model. This will require further research. In particular, initiatives are urgently required to develop personal competencies pertaining to EBPH, adaptation, scale-up and dissemination and to clarify and address the challenges for the organizations that promote those initiatives.

Conclusion

As a result of the Delphi survey, the practical model revised from the draft was finalized with a high degree of consensus. The practical model explicitly outlines the evidence-based structure of HSD, featuring three stages (preparation, implementation, and dissemination) that each focus on the three types of evidence identified in EBPH, with the important processes of PDCA and implementation science integrated into these stages. Additionally, the model incorporates CPD as the foundational framework for its implementation, representing a novel aspect of its design.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

Each named author has substantially contributed to conducting the underlying research and drafting this manuscript. All authors read and approved the final manuscript. Conceptualization, Methodology: R.O.; Formal analysis, Investigation, Resources, Data Curation: R.O., K.K., H.I., M.H., S.I.; Writing - Original Draft: R.O.; Writing - Review & Editing: K.K., H.I., M.H., S.I.; Supervision: H.I. Project administration, Funding acquisition: R.O., K.K. Elsevier, CRediT author statement: https://www.elsevier.com/authors/policies-and-guide lines/credit- author-statement.

Funding

This work was supported by JSPS KAKENHI Grant Numbers JP23K27915.

Data availability

The datasets analyzed during the current study are not publicly available due to needing further analysis but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was conducted with the approval of the Ethics Committee for Observational Study, Osaka University Hospital (Approval No. 23484(T3–2) dated 18 April 2024). All the procedures were followed in accordance with the Declaration of Helsinki. As informed consent, we confirmed all expert panel/participants gave consent to participation in the survey by ticking the appropriate box in the questionnaire form and returning it. All authors have read and approved the submission of the manuscript.

Consent for publication

In the document on ethical considerations, we clearly stated that we would anonymize the data and protect personal information in the analysis and publication of the data, and obtained consent from the research participants. All authors have agreed for the publication of the manuscript.

Competing interests

There are no companies with which all authors have a COI relationship that should be disclosed in relation to the contents of this paper. All authors have declared no conflicts of interest associated with this research.