Critical Discourse Analysis Perspective on Norwegian Public Health Nursing Curriculum in a Time of Transition

Discourse analysis is an area of social linguistics, which can advance social theory in the direction of language. Public health nurses are to perform health promotion and disease prevention work on an individual and population level. By identifying how features of different discourses are constructed and maintained, combining linguistics tools and social science perspectives, the purpose was to provide an understanding of the health promotion and disease prevention discourse in the public health nursing curriculum to reveal governmental strategies for public health nursing education in a time of transition. Fairclough’s three‐dimensional model of critical discourse analysis that consists of the analytical dimensions social events, social practices, and social structures was carried out. There is a linguistic‐discursive dialectic between the dimensions. The analysis revealed four discourses in the curriculum text: a contradictory health promotion and disease prevention discourse; a paternalistic meta‐discourse; a hegemonic individual discourse; and a hegemonic discourse for interdisciplinary collaboration. The results indicate a hegemonic disease prevention discourse, while the health promotion discourse being more disguised. The analysis revealed how language functions ideologically, and in line with the sociolinguistics, how the role of the language in the curriculum text can have consequences for the social work of public health nurses

Meanings of knowledge and Identity in public health nursing in a time of transition : interpretations of public health nurses' narratives.

Background: A changing healthcare system affects the professional identity of nursing groups. Public health nursing has experienced challenges in balancing the paternalistic expert ideology and the empowerment participation ideology. A strong professional identity can legitimate nursing, and possibly influence the quality of nursing work. Narrations from practice can illuminate the nurses’ theoretical and practical knowledge and help illustrate their collective professional identity. Aim: To illuminate the meaning of public health nursing knowledge and professional identity in a continuously changing public health nursing practice. Method: A qualitative interview study with a purposeful sample of 23 Norwegian public health nurses was carried out. Data were analysed using phenomenological hermeneutics, a descriptive method inspired by Ricoeur’s philosophy of interpretation. Findings: Three themes emerged (i) Being a generalist: emphasising the need for generalised knowledge and using clinical judgement, (ii) Being one who empowers: focusing on resources and coping strategies, (iii) Being occupied with individual problem solving: focusing on individuals with special needs, using standardised techniques and protocols, and lacking specialised knowledge. Conclusion: Interpretation of the nurses’ stories illuminated their need for generalised evidence-based knowledge, but also the importance of using sound clinical judgement in a diverse complex practice, where service users need encouragement, support and expert advice. Time pressures can limit the nurses‘ involvement. Many had an individual problem-focus more than a primary prevention focus, in contrast to governmental regulations stating that Norwegian public health nurses should focus on health promotion and primary prevention. Public health nurses have a broad generalised knowledge of their special target group giving them a ‘specialist generalist’ role. Clarification of this role, in relation to jurisdictional borders, can create a strong identity at a time when healthcare policy promotes economic values, professional neutrality and increased collaboration

Discursive construction of the patient in online clinical cancer pathways information

Aim: To explore how the patient is constructed and socially positioned in discourses of web-based pathways information available to cancer patients in Norway.Design: Mixed qualitative and quantitative design, using Corpus-Assisted Critical Discourse Analysis.Methods: The study, conducted in January 2020, examined the language of one general and six specific web-based cancer pathways information brochures. The approach combines analysis of word frequencies and concordance lines using corpus analysis software to identify the ‘linguistic fingerprint’ or ‘aboutness’ of the text prior to further qualitative critical discourse analysis.Results: The analysis identified three core discourses which constructed the patient differently: 1) a participating active person, in a brief, inclusive discourse; 2) a passive person lacking knowledge or perception of their situation within dominant, medical and interprofessional expert discourse; and 3) reduced to a disease and a code in the pathways discourse.Conclusion: This study offers insight into the construction of patients in online clinical pathways information for cancer treatment. The analysis revealed how governance systems such as New Public Management and its demands on efficiency and productivity influence the cancer pathways. The World Health Organization has promoted a person-centered approach, emphasizing the importance of participation and a partnership of equals. A person-centered approach to care was not evident in the discourse of the online documents. The dominant ideology of these pathways was paternalistic with patients constructed as passive persons who get standardized treatment.Impact:This study gives new insight that can be valuable for nurses, other healthcare professionals and the government. The lack of a person-centred focus in the cancer pathway information could have a negative impact on the patient`s health outcomes by promoting a culture of inattention to the patients’ needs and wishes among practitioners. The results may provide a stimulus for discussion about the role of patients in cancer treatment.Keywords

Students’ approaches to scientific essay writing as an educational method in higher education : a mixed methods study

Purpose: To describe students' approaches to essay writing as part of their academic studies. As a theoretical framework Lavelle's five approaches was used. Methods: A descriptive study with a mixed methods design. Two questionnaires to the same student group, early (n = 39) and at the end (n = 37) of their studies, and three focus group interviews (n = 19) were conducted. The participants were nurses, physiotherapists, occupational therapists, social workers, and teachers who were part of a master's degree programme at an institute of health sciences at a university in Norway. Results: Mostly, the students took an impulsive and unplanned approach to essay writing. However, the students affirmed that essays were a method in which they could combine their theoretical knowledge and clinical experiences. When writing essays in groups, the students developed more reflective and critical thinking than when they wrote alone. The teacher's role was more of a supervisor than a traditional teacher. Four categories of Lavelle's writing approaches were found namely, spontaneous-impulsive, elaborative, reflective revisionist, and procedural, of which the spontaneous-impulsive and elaborative categories were most prominent. Conclusions: Approaches to essay writing can be developed in a more reflective and critical way among students in higher education and the teacher's role can be developed into more of a supervisor than a traditional teacher. Higher education is an arena for building a relationship between theory and practice and using academic essay writing as a method can promote this process.publishedVersio

Mapping interaction quality for nursing and medical students in primary care placement in municipal emergency care units: a systematic observational study

IntroductionPrimary care placement for nursing and medical students is vital for developing the competence to accommodate the increasing number of patients with multimorbid and complex conditions. Prior studies have suggested that interaction quality in primary care placement empowers learning. However, research mapping interaction quality in primary care placements in municipal emergency care units is lacking. This study aimed to systematically map interaction quality for nursing and medical students in primary care placement in two municipal emergency care units.Materials and methodsThis study adopted a systematic descriptive observational design. Systematic observations (n = 201 cycles) of eight nursing students (n = 103 cycles) and six medical students (n = 98 cycles) were used to map interaction quality across six learning situations between March and May 2019. Observations were coded using the Classroom Assessment Scoring System-Secondary (CLASS-S). Data were analyzed using descriptive statistics and Spearman correlations.ResultsInteraction quality is described in three domains: (I) emotional support, (II) framework for learning, and (III) instructional support, and the overall measure, student engagement. The results indicated middle-quality interactions in the emotional and instructional support domains and high quality in the framework for learning domain and student engagement. Correlations exhibited similar patterns and ranged from non-significant to strong correlations.ConclusionThe interaction qualities indicated a generally positive and supportive learning environment contributing to nursing and medical students’ learning and active participation in work tasks related to their professional roles. Thus, this new form for primary care placement for nursing and medical students in the municipal emergency care units was found to be a positive learning arena. These results may enhance nursing and medical education programs in countries with similar health services and education. Health education, supervisors, peers, and others contributing to students’ learning should recognize which interaction qualities may affect learning and how to improve quality, thus affecting supervisors’ approach to training students. While the CLASS-S showed potential for mapping interaction qualities for nursing and medical students in primary care placement in municipal emergency care units, further studies are needed to validate the CLASS-S for use in clinical placement settings

Norwegian public health nurses’ competence areas

Objective: To explore the competence areas of public health nurses in Norway. Design: A qualitative and comparative design was employed. Sample: A purposive sample of 41 public health nurses participated. Measurements: Data were gathered from focus groups and individual interviews. The interviews centered around an open question about public health nurses’ knowledge. They also discussed 10 proposed competence areas for public health nursing, developed from the literature. A qualitative content analysis was conducted on the interview transcripts, followed by a synthesis of the data from the interviews and earlier developed competencies. The 10 competence areas for Norwegian public health nursing were then refined. Finally, we compared the affirmed competence areas with earlier developed cornerstones and the new educational guidelines. Results: The interviews revealed 10 competence areas. These 10 competence areas were synthesized with the 10 proposed competencies from literature. Ten affirmed competence areas, which mostly corresponded with the competences from literature, were developed. The affirmed competencies were supported by the previously developed cornerstones and new educational guidelines. Conclusions: The affirmed competencies will help promote and explain the content and focus of PHNs’ work in Norway and may have implications for education and international research.publishedVersio

Perceptions of experiences with interprofessional collaboration in public health nursing: a qualitative analysis

In public health nursing interprofessional collaboration has become a goal, however, there is little clarity on the distribution of responsibility or approach to cooperation between the professional groups. The aim of the study was to explore public health nurses’ perceptions of their experiences related to interprofessional collaboration. A qualitative content analysis was carried out. An interview study with a purposeful sample of 23 Norwegian public health nurses (PHNs) was conducted. Data were analyzed using semi-structured interviews to identify categories and themes of PHNs’ working lives. The data were classified into three major themes: institutionality: the institutional understanding of the professional roles; competence: clarifying jurisdictional borders, and recognition: professionals` recognition of different roles. There needs to be a robust strategy in collaborative working that involves public health nurses among other professionals to avoid role overlap, interpersonal and interprofessional conflict and reduce the damaging threat or stress that comes with informal or ad hoc rules of engagement and status claiming by one profession over another

The meaning of professional identity in public health nursing

Because health care is constantly changing, public health nursing is experiencing new and demanding challenges, which can have consequences for the identity of the profession. The overall aims of this dissertation are to help generate knowledge and understanding of professional identity in public health nursing, in order to increase knowledge of how public onal identity in public health nursing by (a) identifying the underlying governmental principles in the curriculum of public health nursing, (b) illuminating the experiences of PHNs in ethically charged work encounters and their influence on professional identity and (c) investigating knowledge and identity in the narratives of PHNs. Methods: Two methods of analysis were applied: Fairclough’s critical discourse analysis on the educational curriculum of Norwegian public health nursing (paper I) and the phenomenological hermeneutic method, inspired by the philosophy of Ricoeur, on individual interviews with 23 PHNs working at health clinics for children and young people and in school health services (papers II and III). Findings: Paper I, the analysis of the curriculum, revealed conflicting discourses: (a) a competing social scientific and biomedical knowledge discourse, (b) a paternalistic metadiscourse and (c) a hegemonic individual discourse. The analysis suggests the existence of a dominant disease prevention discourse in the curriculum, thereby pushing the health promotion discourse to the background. Although recent policies concerning public health nursing focus more on health promotion, the analysis revealed that this is not sufficiently explicit in the curriculum text. One interpretation of this finding is that the curriculum is not in line with the policies, which state that PHNs are to implement health promotion and primary prevention strategies. Paper II, about being in ethically charged encounters, revealed PHNs as follows: (a) feeling responsible and being engaged; (b) being committed and willing to stand up to fight; (c) feeling confident, courageous and trusted; and (d) feeling inadequate and unimportant. The action choices of PHNs had a moral basis, where the responsibility for service users was a deciding factor that could overshadow institutional demands. It seemed as though value conflicts mobilised courage, which is essential in maintaining moral strength. This in turn is important for a strong professional identity. In paper III, narratives about knowledge and identity, the following themes emerged: (a) being a generalist and using clinical judgement, (b) being one who empowers and (c) being one who is occupied with individual problem-solving and adherence to guidelines. Time was a deciding factor for the involvement of PHNs and displaced the primary prevention focus. The PHNs had a broad generalised knowledge of their special target group, thereby giving them a ‘specialised-generalist’ identity. Clarification of this position, in relation to jurisdictional borders, can create a strong public health nursing identity. Conclusion: Discourses in society can influence the constitution of PHNs` identity, and the way in which PHNs describe their practice. How values and knowledge are used and integrated into clinical practice can be indications of how PHNs understand themselves and their identity. This study shows a complex and diverse public health nursing mandate and practice, which can pose a challenge to the constitution of a public health nursing identity. At the macro level, the limited focus on population in both the curriculum text and the practice experiences of PHNs suggests that the government directives stating that PHNs are to promote mental and physical health, good social and environmental conditions (healthy schools and healthy local environments), and to prevent disease and injury on individual and population level were not fulfilled. At the micro level PHNs worked from a moral basis, they were proud of their work, viewed their work as valuable and considered responsibility and trust to be core values. However they were challenged by constraints, such as time, which influence the execution of both macro-level directives and micro-level initiatives. The PHNs could be described as having a stronger identity in relation to personal and professional values (e.g., following up individuals in need) than in relation to institutional values of efficiency and loyalty to policy directives. A clarification of public health nursing as an exclusive working field and an elucidation of public health nursing as a specialisedgeneralist profession could secure the role of PHNs in relation to jurisdictional borders and strengthen the identity and legitimacy of the profession in their work towards improving the quality of life in the population

Meanings of knowledge and identity in public health nursing in a time of transition: interpretations of public health nurses’ narratives

Background: A changing healthcare system affects the professional identity of nursing groups. Public health nursing has experienced challenges in balancing the paternalistic expert ideology and the empowerment participation ideology. A strong professional identity can legitimate nursing, and possibly influence the quality of nursing work. Narrations from practice can illuminate the nurses’ theoretical and practical knowledge and help illustrate their collective professional identity. Aim: To illuminate the meaning of public health nursing knowledge and professional identity in a continuously changing public health nursing practice. Method: A qualitative interview study with a purposeful sample of 23 Norwegian public health nurses was carried out. Data were analysed using phenomenological hermeneutics, a descriptive method inspired by Ricoeur's philosophy of interpretation. Findings: Three themes emerged (i) Being a generalist: emphasising the need for generalised knowledge and using clinical judgement, (ii) Being one who empowers: focusing on resources and coping strategies, (iii) Being occupied with individual problem solving: focusing on individuals with special needs, using standardised techniques and protocols, and lacking specialised knowledge. Conclusion: Interpretation of the nurses' stories illuminated their need for generalised evidence-based knowledge, but also the importance of using sound clinical judgement in a diverse complex practice, where service users need encouragement, support and expert advice. Time pressures can limit the nurses' involvement. Many had an individual problem-focus more than a primary prevention focus, in contrast to governmental regulations stating that Norwegian public health nurses should focus on health promotion and primary prevention. Public health nurses have a broad generalised knowledge of their special target group giving them a ‘specialist generalist’ role. Clarification of this role, in relation to jurisdictional borders, can create a strong identity at a time when healthcare policy promotes economic values, professional neutrality and increased collaboration

The meaning of ethically charged encounters and their possible influence on professional identity in Norwegian public health nursing: a phenomenological hermeneutic study

Background: In today’s health care, new health reforms focus on market values and demands of efficiency influence health workers’ professional practice. Norwegian public health nurses work mainly with healthy populations, but the children, families and young people they meet can be in vulnerable and even dependent situations. Strategies in coping with ethically challenging encounters can be important for the identity of the profession. Aim: The aim of the study was to illuminate public health nurses’ experiences of being in ethically charged encounters and to reflect upon how these experiences can influence their professional identity. Method: A purposive sample of 23 Norwegian public health nurses with experience ranging from 0.5 to 25 years narrated about their work-related experiences. The interviews were interpreted with a phenomenological hermeneutic method inspired by the philosophy of Paul Ricoeur. Findings: Four themes were identified: feeling responsible, being committed, feeling confident and feeling inadequate. These experiences were related to both work and private life and involved an emotional commitment to the well-being of children, young people and families. Conclusion: On the basis of the findings, it can be estimated that PHNs are committed to their work, and defending children’s rights is a strong driving force. Responsibility for service users is a deciding factor that can overshadow institutional demands. It seems as if value conflicts mobilised courage which is essential in maintaining moral strength. This is in turn important for a strong professional identity and can have positive implications for the quality of public health nursing work