Nursing Strategies and Beliefs in Norway

Transcription

1 Public Health Nursing / 2013 Wiley Periodicals, Inc. doi: /phn SPECIAL FEATURES: THEORY A Comparison of the Cornerstones of Public Health Nursing in Norway and in the United States Kari Glavin, Ph.D., P.H.N., R.N., 1 Marjorie A. Schaffer, Ph.D., R.N., 2 Liv Halvorsrud, Ph.D., R.N., 1 and Lisbeth Gravdal Kvarme, Ph.D., P.H.N., R.N. 1 1 Department of Nursing, Diakonova University College, Oslo, Norway; and 2 University Professor of Nursing, Bethel University, St. Paul, Minnesota Correspondence to: Kari Glavin, Department of Nursing, Diakonova University College, Fredensborgveien 24 Q, 0177 Oslo, Norway. kag@diakonova.no ABSTRACT Objectives: This study describes a comparison of the values and beliefs foundational to community nursing practice in Norway with the Cornerstones of Public Health Nursing based on public health nursing practice in the United States. Design and Sample: Methods included a review of the literature and focus groups to determine primary beliefs and values foundational to nursing practice in family, school, and home care settings in Norway. Measures: Authors reviewed documents written in English and Norwegian for content on values and beliefs represented in public health nursing. Data were gathered from two focus group meetings each with school, home care, and family health nurses in Norway (n = 19; n = 11). Method: Focus group questions addressed aspects of the values and beliefs of public health that are foundational to public health nursing. The researchers synthesized content themes of literature and focus groups. Results: Nine Norwegian cornerstones emerged from literature and focus groups. Six of the cornerstones were the same as the cornerstones from the United States, two were modified, and one new cornerstone emerged from the data. Conclusions: The values and beliefs represented in the different modified cornerstones based on Norwegian community nursing practice capture the essence of public health nursing in Norway. The similarities between the two countries show that nurses have much in common, despite different health and governmental systems and laws. Key words: public health nurse, school nurse, family nurse, home care nurse, values, beliefs, cornerstones. Public health nursing traces its roots to England where Florence Nightingale assisted in organizing district public health nursing. Nightingale articulated two missions of the nurse s profession: sick nursing and health nursing, which focused on keeping people well (Green, 1993). In the United States, modern public health nursing was defined by pioneering nurse, Lillian Wald, in the late 1800s. Public health nursing was primarily concerned with taking care of the sick poor in their homes. Wald came to realize that sickness in the home had its origin in larger societal problems. She set about directing nursing efforts toward improving the environment through better sanitation and increasing opportunities for employment, education, and recreation. It was Wald who coined the term public health nurse (Green, 1993). In Norway, parish nurses and male deacons provided nursing care in the community in the beginning of the 19th century. Later on, nursing care in the community expanded to provide public health nurses (PHNs) who functioned as family and school nurses (1947) and home care nurses (HCNs) in community settings (1972). In 1947, Norwegian 1

2 2 Public Health Nursing education for PHNs began using models for public health nursing from the United States and Canada. A Norwegian nurse, Borghild Kessel, funded by the Rockefeller Foundation, studied public health nursing in the United States and Canada, and subsequently, established Norwegian public health nursing education (Hvalvik, 2002). PHNs in United States work with the whole population (Green, 1993). In contrast to the United States, public health nursing in Norway focuses on families, children, and adolescents (Norwegian Directorate of Health, 2004). Norwegian PHNs complete a certificate in public health nursing after finishing their baccalaureate nursing program. Home care services in Norway are operated by the municipality as part of primary health care. Home care nurses, registered nurses with a baccalaureate degree, provide nursing care for patients in their own homes. In recent years it has become common to discharge patients from the hospital earlier so home nurses are often responsible for advanced nursing care in the patient s home. For this article, the term PHN encompasses school nurses, family nurses, and HCNs. The Cornerstones of Public Health Nursing, developed through an initiative led by the Minnesota Department of Health in the United States, describe the values and beliefs that are foundational to public health nursing (Keller, Strohschein, & Schaffer, 2011). Value is a core guide to action, and belief is a statement or sense, declared or implied, intellectually and/or emotionally accepted as true by a person or group as defined by Keller and Strohschein (2001, p. 121). There are eight cornerstones of public health nursing. They have been disseminated across the United States and are used in public health nursing education and practice. The list of the synthesized cornerstones described by Keller et al. (2011, p. 252) is shown in the left-hand column of Table 5. The Cornerstones of Public Health Nursing explain why PHNs are motivated to do the work of public health nursing. The values and beliefs represented in the cornerstones present a framework that captures the essence of public health nursing. Public health nursing is universal to all nurses globally based on client or patient needs. Public health nursing traces its roots to England where Florence Nightingale assisted in organizing district public health nursing (Green, 1993). Knowledge of PHN s values and belief is important as it represents a core guide to action in practice. PHNs become more aware of what is meaningful and important in their work. Knowledge of important values represents a framework or guideline for good clinical practice and makes evident the core values in nursing. As the Cornerstones of Public Health Nursing were developed in the United States, it is important to explore the applicability of the cornerstones to public health practice in international settings to examine their consistency with the values and beliefs of PHNs outside of the United States. Background The prescription for a healthier Norway addresses factors that contribute to creating health problems and help to prevent disease. The statement, by preventing more we can repair less (Ministry of Health and Care Services, 2002, p. 24) captures the strategy for a healthier Norway. The government recommended provision of services for all children, including child health clinics, day nurseries, schools, and school health services, which should be given priority to improve health and living conditions. The reduction in inequalities in health is a primary goal for the government (Ministry of Health and Care Services, 2011; Norwegian Directorate of Health, 2009). Dahl (2009) found that key values that supported the goal of reducing inequalities were social justice and the view that it was a community responsibility to ensure fair distribution of health services. Norwegian health policy emphasizes health promotion through improved living conditions, universal services that are not tied to one s position in the labor market, and fair distribution of resources through reducing the social inequalities that contribute to health inequalities (Fosse, 2009). In addition, Vallgarda (2007) compared Scandinavian public health policies and found emphases in Norwegian health care policy on governmental responsibility for the health of the population; the belief that individuals are capable of self-determination and should be empowered to make good choices; the contribution of living conditions and social networks to good health; and the need for partnership among individuals, communities, and the private and public sectors to initiate and implement public health measures. The Norwegian government has emphasized the idea that everyone has legal and ethical rights

3 Glavin et al.: Cornerstones of Public Health Nursing 3 to both hospital- and community-based health care. Collaboration between the public, family, and volunteers is emphasized based on self-determination and respect for patient. Future community health care should focus more on health prevention for all ages and all groups of patients, including emphasis on nutrition, activity, well-being/quality of life, coping strategies, different leisure activities, and early identification of disability, with a focus on dementia care and less hospital and more community care (Ministry of Health and Care Services, 2009, 2011). Health statistics in Norway in 2010 showed that receiving care at home was increased fivefold from 1992 to 2009 (Norwegian Directorate of Health, 2010). The purpose of public health nursing education is to educate nurses for health promotion and prevention with children, adolescents, and their families (Ministry of Education and Research, 2005). Norwegian nursing education emphasizes the development of a holistic view of human beings, showing respect for human integrity and rights, and safeguarding the client autonomy, involvement, and self-determination (Ministry of Education and Research, 2008). Family health nurses working in well-baby clinics offer comprehensive preventive and health-promoting services for children, youth, and families. School nurses focus on the provision of support and health promotion. They use individual consultation to address health issues (Norwegian Directorate of Health, 2004). Researchers identified the following values in PHN descriptions of their work: a focus on health promotion and illness prevention, a focus on empowerment (as opposed to a medical model), a professional caring approach, working independently, and collaboration (Clancy, 2007; Clancy & Svensson, 2007; Clancy & Svensson, 2009). In a study by Tveiten and Severinsson (2004), PHNs focused on being responsible for health promotion and disease prevention in children, parents, adolescents, and young adults; empowering clients through giving information that enhances client assertiveness and independence; and building relationships to establish trust. In another study, Andrews (2006) found similar beliefs and values for PHNs: using a health promotion approach (vs. a traditional health education approach), establishing a caring and trusting relationship with families to promote using the maternal and child health service, working in a nondirective partnership (collaboration), and creating a positive atmosphere with parents. Key values and beliefs in home nursing include: (1) supporting the patient s coping strategies to live at home as long as possible and (2) contributing to quality of life among the patients. To fulfill these goals the home nurse focuses on helping patients to feel safe in their daily life, supporting the patient s overall quality of life and self-care (Birkeland & Flovik, 2011; Fjørtoft, 2011). In two studies of home care, Vabø (2007) found that HCNs believed that they are advocates for the frailest patients in society. Vabø suggested that nurses encounter a professional and ethical challenge with the expectation to help all who have need and also meet the needs of the frailest patients. In an analysis of physician and nurse perspectives of prioritizing community care for older patients, Pedersen et al. (2011) recommended that justice and patients perspectives should be given more attention in planning for health care services. Research question How do the values and beliefs foundational to community nursing practice in Norway, compare with the values and beliefs represented in the Cornerstones of Public Health Nursing that were developed based on public health nursing practice in the United States? Methods Design and sample The research design incorporated two phases. A review of the literature was the first step in determining primary beliefs and values foundational to nursing practice in family, school, and home care settings in Norway. Second, focus groups were conducted with three groups of Norwegian nurses who practiced in community settings: family health nurses, school nurses, and HCNs. Focus groups were chosen as the method as they provide data on the meaning behind group assessments (Bloor, 2001). Measures Identification of key beliefs and values in the literature Authors reviewed documents written in

4 4 Public Health Nursing English and Norwegian for content on values and beliefs represented in public health nursing. Documents reviewed included: articles on public health nursing, guidelines for well-baby clinics and school health services, Norwegian government reports, Norwegian nursing practice articles, and articles written in English about Norwegian nursing practice and health policy. Search terms used to locate relevant articles in English were combinations of: Norway public health, values, beliefs, nursing, and policy. The search for articles in Norwegian used similar terms with the addition of home nursing. The search for articles written in English yielded 10 articles; the review of Norwegian government papers, literature, and articles written in Norwegian resulted in 19 government papers, two books, one research report, two doctoral theses, and six articles, which addressed values and beliefs foundational to public health nursing in Norway. The review of literature included government perspectives, family health and school nursing, and home care nursing. The author proficient in English conducted a review of key beliefs and values found in literature applicable to nursing practice in community settings in Norway. The authors proficient in the Norwegian language represented expertise in nursing practice in family health, school health, and home health care settings; they conducted a review of Norwegian literature that addressed key values and beliefs foundational to their expertise in nursing practice. Focus groups. Focus groups were conducted in three practice settings in the Bærum municipality in the east of Norway with family health nurses, school nurses, and HCNs. The Bærum municipality is located in the county of Akershus, proximal to Oslo. Bærum is Norway s largest local authority outside the cities. The population is approximately 110,000, with 106 different nationalities and an average household of 2.4 persons (Bærum municipality, 2011). Three nursing leaders representing family health, school health, and home care nursing identified nurses who volunteered for participation in the study. Inclusion criteria included working as a nurse in the identified practice setting. Home care nurses had a baccalaureate nursing degree; PHNs had completed a public health nursing certificate in addition to the baccalaureate nursing degree. The study was reported to the Norwegian Social Science Data Services (NSD). Nurses were informed through a letter about the methods, assumptions, and intentions of the study. The letter specified that participation in the study was voluntary, they could withdraw from the study at any time, and confidentiality would be maintained. Each participant signed an informed consent statement at the time the interview was conducted. Analytic strategy Focus group data collection and analysis. Each of the three groups met two times, for a total of six focus groups. The first focus group explored values and beliefs that guided the nurses practice. The focus group questions (see Table 1), which were translated into Norwegian, were based on questions used in the development of the U.S. cornerstones. In the second focus group meeting, participants were asked to reflect on the meaning of the U.S. cornerstones for their practice. Five of the six focus groups were conducted by two researchers; the sixth was conducted by one researcher. The focus groups took place at a public health office in the municipality and ranged from 30 min to 1 hr and 20 min. The focus groups were tape-recorded and one researcher recorded notes. The data were transcribed verbatim from the recordings. The transcriptions were cross-checked with the taped interviews to ensure accuracy. Initially, the transcripts were read thoroughly several times to obtain an overview. A qualitative content analysis process was used to analyze and describe TABLE 1. Focus Group Questions 1. What is your passion for public health nursing? 2. What is its source and how do you keep it renewed? 3. Why do you stay in public health nursing? 4. What does public health nursing give to you? 5. How important is the concept of social justice and respecting the worth of all people in your practice? 6. Describe an important professional relationship you have had with an individual, family, community, or other health professional in your PHN practice. 7. Can you describe any long-term changes in your community influenced by public health? 8. What comments do you have about the connection between health and mind, body, sprit, and/or physical, social, or environment? 9. How do you maintain caring and compassion for others and not burn out? 10. What do you see as the largest health threat to your user group? How would you like to use energy in your work?

5 Glavin et al.: Cornerstones of Public Health Nursing 5 the interview texts (Polit & Beck, 2012; Sandelowski, 2000). According to Kvale (2001), the analysis process starts in the interview as the respondents answers are based on their interpretation of what the researcher communicates. However, the scrutiny of the text data represents the analysis phase. The meaning of concepts and the words that are used influence the interpretation and the understanding (Kvale, 2001; Polit & Beck, 2012). Following scrutiny of the data, the researchers identified data patterns relevant to the aims of the study as category schemes. Data were organized by category scheme on computer files and then coded, followed by identification of themes, which are units of similar information. In the data analysis process, the researchers condensed the initially identified themes into major themes. The researchers summarized focus group responses, giving participants the opportunity to comment if they did not agree with the researchers summary. The transcripts were reread to ensure that no major topics had been missed (Polit & Beck, 2012). An example of the analysis process is shown in Table 2. The three researchers who were proficient in Norwegian cross-checked the identification of themes based on identified meaning units. Synthesis of literature and focus group data. The researchers synthesized key values and beliefs from the literature and focus group data from the first and second focus groups in the three settings in a collaborative process to identify the Norwegian cornerstones for public health nursing practice. The researchers developed tables separately for each focus group that included: examples of comments from family health nurses, school nurses, and HCNs; related subthemes; and finally, a condensed major theme. The major themes identified for focus group #1 and focus group #2 analyses were then compared to key values and beliefs found in the literature to identify similarities and differences between key values and beliefs underlying public health nursing practice in the United States and Norway. Results Analysis of literature Analysis of the literature resulted in seven key themes of values and beliefs for the English articles and seven key themes for the Norwegian articles. The synthesis of these identified values and beliefs resulted in nine key values and beliefs that are foundational for the practice of family health, school, and HCNs in Norway. Four themes were very similar: (1) a focus on health promotion and disease prevention; (2) holistic care; (3) collaboration; and (4) empowerment of individuals and families. The English literature emphasized a key belief/value as governmental responsibility for reducing health inequality through fair distribution of resources, whereas Norwegian literature emphasized universal access to health services. Although these are related concepts, both were included because universal access is a key value for Norwegian society. One additional theme from the English literature on the independent nature of the work of PHNs was also included. Although the emphasis on independence did not emerge as clearly from the Norwegian literature, Norwegian studies did address the concept of autonomy in public health nursing practice. Focus group findings A total of 19 nurses participated in the first interview and 11 of the same nurses participated in the second interview. For the first focus group, participants included 5 family health nurses, 7 school nurses, and 7 home care nurses. There were fewer participants for the second focus group because some of the participants had left for summer vacation; 4 family health nurses (FHN), 5 school nurses (SN), and 2 HCN participated. Eighteen of the 19 participants were female. The age range for the sample was years with a mean of 50.1 years. Years of experience ranged from 3 months to 39 years with a mean of 12.0 years. Selected participant comments for focus groups at Time 1 and Time 2 with summarized themes both times are listed in Table 3. Examples of comments from school, home health, and family health nurses are included. All groups said their work promoted health for the population they served; however, the three groups worked with different populations. Family health and school nurses focused on child and adolescent populations, whereas HCNs focused on the entire family. All three groups focused on all aspects of health (holistic thinking), but some nurses expressed having uncertainty about spiritual health. Collaboration emerged as an important topic at both focus group times. The nurses

6 6 Public Health Nursing TABLE 2. Meaning Unit, Subtheme, and Theme Examples from Focus Group Analysis of Group 1 and Group 2 Meaning unit examples Subtheme Theme Cornerstone Example Focus Group 1 SN: Help the parents to see the positive part of their children HCN: there to see the patient at home often to see the patient in a different manner. You somehow make other observations than you do other places. FHN: We have to get in contact then to meet the needs then we can help the parents to be good parents. We think very holistic we see the whole picture in a way Example Focus Group 2 SN: (1) We don t talk much about spiritual things. I think this is exciting. In a multicultural society I think the spiritual issues will be more important. (2) We have much focus on psychological health. HCN: (1) You will not only see the wound, you should see the whole person. (2) These preventive visits that we have a lot of then it is to prevent poor nutrition, loneliness. FHN: (1) Yes we focus on the whole aspect but, I don t focus on the spiritual health, I ask about it, but I do not have much focus on the spiritual health. I am more aware of it now when we have a lot of immigrants. (2) And the environmental health, like living conditions, as mold in the apartment. Some families are living in industrial areas, where families with children not are supposed to live Focus on positive Client interacting with the environment Seeing the whole picture Spiritual issues See the whole person Spiritual and environmental health Holistic thinking All aspects of health Encompasses mental, physical, emotional, social, spiritual, and environmental aspects of health collaborated at many levels, but did work alone in some settings. Professional autonomy and independent practice also emerged as themes in focus group discussions. In addition, participants spoke about building trusting relationships and relationships with systems to accomplish their work. All three groups of nurses spoke about the importance of respect for all. Norwegian nurses elaborated on

7 TABLE 3. Participant Comments Representative of Cornerstone Themes Meaning unit examples focus group 1 Meaning unit examples focus group 2 Cornerstone SN: I am thinking of how to help the youth to live as best as they can and to cope with their lives. HCN: It is best to promote health by living at home. I think at the visit that they find that there is a person who did something good you promote at least quality of life FHN: The intention is that children should have optimum growth conditions under the assumptions that surround them SN: We have to prioritize but in the frame of the law and guidelines from the government. FHN: I am often concerned about government priorities and I try to give more than the guidelines frame. HCN: It will be a new big challenge when we get the collaboration reform in the fall and they are going to stay less days at hospital and they shall home and we are going to set up infusions and pain pumps at home that will be a challenge. That will be exciting SN: I think that group is a good way to build relationships between children in the same situation and with us. HCN: But how to build relationships. I think at least it is easier at home because you have different things to talk about FHN: I like to go at home visit to the families myself, because precisely, we get a good start in a home visit SN: You shall meet everybody equal with dignity whatever social class they belong to. HCN: Yet it is like many who are very modest and need as much help FHN: I think we have a responsibility for the families with fewer resources Glavin et al.: Cornerstones of Public Health Nursing 7 SN: community had a pilot project with increased resources to school health service in high schools that were successful. When the school nurse was available the youth used the service much more. HCN: We are very much in the decision so it narrows the things a bit. If I get an assignment (task) that I should look at the mother s disease If it is a cancer mom it may be a child you need to take care of. We think a little bigger. FHN: What we do according to the little ones does also matter for the older ones, so in that manner we are focusing on the health of the entire population. We are thinking in a life circle perspective in a way, but we don t work directly with the elderly SN: We have to be critical of the government s priorities, because it may not be the best for children and adolescents according to a public health perspective. HCN: I think it is difficult with the predecisions. Sometimes I have to do something more. FHN: The public health nursing service reflects the community s priorities and needs, but the recourses are too small so we can t cover all the needs, but it s better for children and adolescents than for elderly SN: I think we establish caring relationships with all the levels by trying to be visible at school. HCN: We often see that we are the one that pulls together everyone s efforts for the entire system and family support. FHN: Yes, but I feel that we have most relationships with individual and families. The leaders represent our service on the system level. So in a way it is the nursing service who establishes relations SN: I think it is important to have the right attitude and values, with respect and empathy and sensitivity. HCN: Well, we have a lot of drug abuse and this with medical treatment and then the nurse will perform care and then follow-up. FHN: The hospital calls and tell that this family needs something extra, or you just see it in the medical record, or they are new in the neighborhood, they are immigrants and don t speak Norwegian.The most important with the well-baby clinics is that we catch up those who are vulnerable of any reason Health promotion [1] Focuses on health of entire population [2] Provision of services based on client need and government priorities and guidelines [1] Concern about identification of priorities [2] Building relationships [1] Having caring relationships at all levels [2] Social justice [1] Respect for all, sensitivity to diversity, and care for the vulnerable [2]

8 8 Public Health Nursing TABLE 3. (Continued) Meaning unit examples focus group 1 Meaning unit examples focus group 2 Cornerstone SN: Help the parents to see the positive part of their children HCN: there to see the patient at home often to see the patient in a different manner. You somehow make other observations than you do other places. FHN: We have to get in contact then to meet the needs then we can help the parents to be good parents. We think very holistic we see the whole picture in a way FHN: We have to have knowledge at a lot of topics, for example the child motor development and psychical development and attachment. Because our work is a special sphere, we have to be updated. SN: Yes, it s important to have possibility to attend conferences and projects. To keep updated and learn something new. HCN: Professional development and building competence is important SN: I like the responses you get from colleagues and other people you cooperate with. HCN: It is a coordinating work you are such a link between doctors and everybody. FHN: We have great doctors to collaborate with, and we have good professional discussions in the lunchtime SN: I think independent is on the top. Independence has always been a relief for me. HCN: Important to visit to the same patient That it is the right person at the right place. Is important for the patient s health. FHN: being able to respond properly to a question from parents, and that I feel that I am confident is important SN: (1) We don t talk much about spiritual things. I think this is exciting. In a multicultural society I think the spiritual issues will be more important. (2) We have much focus on psychological health. HCN: (1) You will not only see the wound, you should see the whole person. (2) These preventive visits that we have a lot of then it is to prevent poor nutrition, loneliness. FHN: (1) Yes we focus on the whole aspect but, I don t focus on the spiritual health, I ask about it, but I do not have much focus on the spiritual health. I am more aware of it now when we have a lot of immigrants. (2) And the environmental health, like living conditions, as mold in the apartment. Some families are living in industrial areas, where families with children not are supposed to live SN: (1) We should be critical of research if it is evidence-based and who has said how it should be. (2) We promote health based on knowledge; otherwise, it would be a disaster. HCN: It is essential that you seek knowledge and then share it. FHN: Overweight, everything from overweight to immunization, to gastric flu in the kindergartens. Now the focus is on overweight and we act according to that SN: (1) At school we work very much alone. (2) Multidisciplinary collaboration is important. (3) We do collaborate with second and third level with the government and the counties. HCN: Sometimes we need to contact the diabetes clinic because they have just the knowledge in this field. FHN: We have multidisciplinary collaboration in team We collaborate with the kindergartens to focus on food SN: (1) We do work very independent. (2) I think we practice out work independent according to the law for health professional. I have to take my own decisions according to the law and guidelines for the service. HCN: When you see a patient that must be visited four times instead of one then I ll do it. Then you take the responsibility and report this. FHN: Yes we work independently, we are very independent. And we do our work according to the laws Holistic thinking [1] All aspects of health [2] Updating knowledge and competence [1] Using evidence-based practice [2] Collaboration [1 and 2] Professional autonomy [1] Independent practice specified in national law [2]

9 Glavin et al.: Cornerstones of Public Health Nursing 9 TABLE 3. (Continued) Meaning unit examples focus group 1 Meaning unit examples focus group 2 Cornerstone HCN: Fair distribution of the care SN: All the things we do are grounded in ethics. You shall meet all people with respect, empathy, and sensitivity; it is not enough with knowledge. FHN: It is something that all gets, all gets the same. It s in the system in a way; yes it s in the system FHN: In Norway all children have the right to health check which takes care of the vulnerable in the community. HCN: The right to health care. SN: When I think of preventive health our task is to provide health care for all children and families Universal health care with respect for the individual and social justice [1] Universal health care provides care for the vulnerable [2] the concept of respect for all and expanded it to address the value of universal health care. All groups were concerned about knowledge and competence, which led to the theme of evidence-based practice. Participants discussed governmental priorities for health that they needed to address in their nursing roles. Synthesis of data sources When comparing the major themes identified for focus group #1 and focus group #2 analyses to key values and beliefs found in the literature, the researchers identified similarities and differences between key values and beliefs underlying public health nursing practice in the United States and Norway. Nine Norwegian cornerstones emerged from literature and focus groups. Six of the cornerstones were the same as the cornerstones from the United States, two were changed to reflect differences in Norway, and one new cornerstone emerged from the data. The results of this comparison of key values and beliefs in literature, and themes from both focus groups are shown in Table 4. Table 5 shows the final list of Norwegian cornerstones compared with the U.S. cornerstones. Discussion The analysis resulted in both similarities and differences in the comparison of Norwegian and U.S. cornerstones. This discussion will highlight some of the differences that were noted. For the cornerstone focuses on the health of entire populations, PHNs in Norway focus on the promotion of health and prevention of disease for children, parents, teenagers, and young adults through well-child clinics and school health services. PHNs assist individuals and families to take action to improve their health behavior choices in their everyday lives to improve their health status. Often their work takes the form of teaching and counseling about healthy lifestyle choices for these populations. However, HCNs also focus on the health of persons receiving services at home and consider the entire family in their delivery of services. Thus, the three groups together focus on the health of the entire population, which is consistent with the U.S. cornerstones. Although the cornerstone reflects community priorities and needs is acknowledged by Norwegian nurses in the sample, the concern about priorities did not emerge in the first focus group discussion. They referred to the priorities for care identified in government guidelines and indicated that they sometimes needed to provide more than what the guidelines suggested. As previous research suggests (Clancy & Svensson, 2007), we also found that PHNs showed respect and loyalty toward their clients. Although Norwegian nursing care is guided by the national laws and the priorities in municipalities, nurses reported the importance of giving patient needs priority. For example, HCNs sometimes expanded what they believe should be included in nursing care despite the guidelines that are provided by the municipality. Nurses in all groups were concerned about holistic thinking and all aspects of health, which emerged in the cornerstone encompasses mental, physical, emotional, social, spiritual, and environmental aspects of health. Although participants viewed spiritual health as important, evidenced by the comment on relevance to immigrant populations, they did not necessarily provide interventions that focused on spiritual health. Nursing education in Norway does address the importance of spiritual health (Kristoffersen, Nortvedt, & Skaug, 2011) as Florence Nightingale did in the 1850s (Nightingale,

10 10 Public Health Nursing TABLE 4. Analysis of Similarities and Differences in Norwegian Values and Beliefs with U.S. Cornerstones Key values and beliefs in literature The focus is on the promotion of health and prevention of disease children, parents, teenagers, and young adults through wellchild clinics and school health services Focused on reducing inequalities in health; the key values that supported the goal were social justice and the view that it was a municipal responsibility to make sure fair distribution of health services occurs. Still the municipality has to prioritize what services to emphasize according to the community s needs Individuals and families are empowered through: (a) increasing coping ability, knowledge, decision-making competence, and self-management practices; and (b) focusing on human strengths and optimal function, rather than on weakness and negative function The government is responsible for influencing the health of populations and reducing health inequality through fair distribution of resources Health involves the well-being of the whole person (holistic care): (a) promotion of psychological and physical health; (b) improvement of social environment and factors that benefit population health; and (c) emphasis on nutrition, activity, wellbeing/quality of life, coping strategies, and leisure activities Future increased demand for community health care should be met with knowledge and competence in health care; increased autonomy; increased health prevention, including a focus on dementia care; and increased physical activity for residents in the municipalities A partnership of individual, community, and private and public sectors is needed to carry out public health measures. This involves collaboration: (a) with family/ relatives and the local society such as committees, local clubs, and churches; (b) and between the different levels in the health care system to improve treatment and care Focus group #1 analysis Health promotion Provision of services based on client need and government priorities and guidelines Building relationships Social justice Focus group #2 analysis Focuses on children and adolescent populations (family health and school nurses) Focus on entire family (home care nurses) Concern about identification of priorities Caring relationships at all levels Respect for all, sensitivity to diversity, and care for the vulnerable Cornerstone Focuses on the health of entire populations [same] Reflects community priorities and needs [same] Establishes caring relationships with communities, systems, individuals, and families [same] Grounded in social justice, compassion, sensitivity to diversity, and respect for worth of all people, especially the vulnerable [same] Holistic thinking All aspects of health Encompasses mental, physical, emotional, social, spiritual, and environmental aspects of health [same] Updating knowledge and competence Collaboration Use evidence-based practice Collaborate at many levels, but work alone in some settings Use evidence-based practice to promote health in the community [different] Collaborates with community resources to achieve those strategies, but can and will work alone if necessary [same]

11 Glavin et al.: Cornerstones of Public Health Nursing 11 TABLE 4. (Continued) Key values and beliefs in literature Public health nurses often work independently Universal access to health services includes: (a) the right to health services for all by promoting healthy living conditions and strengthening health systems; (b) respect for human rights, democracy, and gender equality; and (c) reduction in inequalities in health and living conditions Focus group #1 analysis Professional autonomy Universal health care with respect for the individual and social justice Focus group #2 analysis Independent practice specified in national law Universal health care provides care for the vulnerable Cornerstone Derives its authority for independent action from national law [different] Promotes equality for all through offering universal health care services [new] TABLE 5. Comparison of Cornerstones for Public Health Nursing Practice in the United States and Norway U.S. cornerstone a Focuses on the health of entire populations Reflects community priorities and needs Established caring relationships with communities, systems, individuals, and families Grounded in social justice, compassion, sensitivity to diversity, and respect for worth of all people, especially the vulnerable Encompasses mental, physical, emotional, social, spiritual, and environmental aspects of health Promotes health through strategies driven by epidemiological evidence Collaborates with community resources to achieve those strategies, but can and will work alone if necessary Derives its authority for independent action from the Nurse Practice Act Norwegian cornerstone Focuses on the health of entire populations [same] Reflects community priorities and needs [same] Establishes caring relationships with communities, systems, individuals, and families [same] Grounded in social justice, compassion, sensitivity to diversity, and respect for worth of all people, especially the vulnerable [same] Encompasses mental, physical, emotional, social, spiritual, and environmental aspects of health [same] Use evidence-based practice to promote health in the community [different] Collaborates with community resources to achieve those strategies, but can and will work alone if necessary [same] Derives its authority for independent action from national laws [different] Promotes equality for all through offering universal health care services [new] a Source: Keller et al., 2011, p ). However, previous Norwegian research also shows that nurses provide few interventions that focus on spiritual health (Sæteren, 2006). The resulting Norwegian cornerstone use evidence-based practice to promote health in the community was changed to focus on evidence rather than epidemiology, which is the focus of the U.S. cornerstone. The Norwegian nurses used the term evidence rather than epidemiology. In focus groups 1 and 2, participants were concerned about having the newest knowledge and using evidence-based practice. However, they did not use the term epidemiology before it was presented as a cornerstone in the second focus group. School nurses mentioned providing vaccinations in response to the term epidemiology. Home nurses talked about the importance of having the latest knowledge in home care nursing and sharing this knowledge with their nursing colleagues. FHNs said that they used epidemiology knowledge to prevent diseases and problems. They mentioned vaccination, working with mental health, and responding to overweight and obesity. Evidence-based practice is emphasized in education, continuing education courses, and in the literature, and the nurses indicated that epidemiology is a part of evidence-based knowledge. The Ministry of Health and Care Services (2006) highlights that future increased demand for community

12 12 Public Health Nursing health care should be met with knowledge and competence in health care. This message from the government was reflected in the comments of focus group participants. Promotes equality for all through offering universal health care services emerged as a new Cornerstone. The differences in cultural and political contexts between United States and Norway influence this outcome. The cornerstone reflects the cultural and political contexts of Norway, which impact how health care is delivered. The Norwegian health care system has universal health care, meaning that all residents and all persons present in the municipality are entitled to health care (Ministry of Health and Care Services, 2011). Political historical traditions of each country have contributed to the organization of health care and also have likely contributed to the identification of this cornerstone by Norwegian nurses. As evidenced in the literature review, the Norwegian government has a strong social justice perspective and holds the view that it is the responsibility of the community to achieve a fair distribution of health services. This view contrasts with the market justice perspective predominant in the United States, which emphasizes the rights of individuals (Schaffer, Garcia, & Schoon, 2011). One interesting finding was that there were similarities among the three groups in values and beliefs, even with their different educational preparation. In Norway, family health nursing and school nursing are a specialized form of registered nursing that combines nursing and public health principles. Family health nurses and SNs in Norway must have at least 1 year of practice as registered nurses, followed by a year of postgraduate education related to public health, children, and families in the municipality. The aim of the education is to provide nurses with knowledge and skills for work in the municipal public health services (Ministry of Education and Research, 2005). Typically, FHNs and SNs are responsible for preventive services provided to infants, children, adolescents, and their families in a geographically defined area, including work in well-baby clinics, school health services, and youth health clinics (Andersson, Ose, & Norvoll, 2006). Home care nurses are registered nurses and are not required to have any postgraduate education. Considering the similarities among the groups in values and beliefs, it is likely that the Norwegian undergraduate education facilitates development of these important values and beliefs. The process of identifying and translating meaning units and subthemes to English was challenging; it is possible that errors were made in the translation process. However, all four researchers discussed the meaning of each theme to work toward consensus. The sample is from one area of Norway. It is possible that priorities in this municipality were different from other parts of Norway. The focus groups were completed by three different researchers and were carried out over the summer when recruitment for participation is more difficult. All groups had fewer participants in the second focus group as some had gone on vacation. The lack of male participants could be a limitation, but there are only few men in public health nursing in Norway. The U.S. cornerstones were derived from PHNs practicing in the upper Midwestern area of the United States. As nearly 17% of Minnesotans claim a Norwegian heritage, there may be overlapping worldviews that lead to similar beliefs and values of PHNs in Norway and in Minnesota. To test their universality further, the cornerstones also should be tested in other countries. Findings from this study will contribute to increasing PHN awareness and understanding of their values and beliefs. Knowledge of important values represents a framework or guideline for good clinical practice and makes evident the core values in nursing. Results from this study also may strengthen the recognition that Norwegian nurses and nursing students give to the values and beliefs in community nursing in other parts of the world. Furthermore, the study may improve the collaboration between all the three groups of the Norwegian community health care nurses. We will translate the Norwegian cornerstones back into Norwegian to disseminate this to nurses in Norway and to make it available for use in education and for reflection on practice. The purpose of this study was to compare the values and beliefs foundational to community nursing practice in Norway with the values and beliefs represented in the Cornerstones of Public Health Nursing developed in the United States. The values and beliefs represented in the cornerstones based on Norwegian community nursing practice present a framework that captures the essence of public health nursing in Norway. The similarities between the two countries show that nurses have much in

13 Glavin et al.: Cornerstones of Public Health Nursing 13 common, despite different health and governmental systems and laws. Acknowledgements We are grateful to the public health nurses who made this research possible by participating in the focus groups. We also want to thank associate professor Berit Sæteren for valuable comments. Conflict of interest: No conflict of interest has been declared by the authors. Funding: This research was funded from Diakonova University College, Norway. References Andersson, H. W., Ose, S. O., & Norvoll, R. (2006). Public health nurses competence. Oslo (in Norwegian): SINTEF Helse. Andrews, T. (2006). Conflicting public health discourses Tensions and dilemmas in practice: The case of the Norwegian mother and child health service. Critical Public Health, 16(3), Bærum municipality. (2011). Retrieved from Barum-in-English1/About-Barum/ Birkeland, A., & Flovik, A. M. (2011). Nursing in home. Oslo (in Norwegian): Akribe. Bloor, M. (2001). Focus groups in social research. London: Sage. Clancy, A. (2007). A profession under threat? An exploratory case study of changes in Norwegian public health nursing. International Nursing Review, 54, Clancy, A., & Svensson, T. (2007). Faced with responsibility: Levinasian ethics and the challenges of responsibility in Norwegian public health nursing. Nursing Philosophy, 8, Clancy, A., & Svensson, T. (2009). Perceptions of public health nursing practice by municipal health officials in Norway. Public Health Nursing, 26(5), Dahl, E. (2009). Policies to tackle health inequalities in Norway: From laggard to pioneer? International Journal of Health Services, 39 (5), Fjørtoft, A. K.. (2011). Home nursing. Responsibilities, challenges and opportunities. Bergen (in Norwegian): Fagbokforlaget. Fosse, E. (2009). Norwegian public health policy; Revitalization of the social democratic welfare state. International Journal of Health Services, 39(2), Green, E. B. (1993). Legacy of leadership: The public health nursing program at the University of Minnesota. Minneapolis, MN: School of Public Health Alumni Society, University of Minnesota. Hvalvik, S. (2002). Bergljot Larsson and modern nursing. Dissertation for the Dr. Polit. degree. Faculty of Social Sciences. Department of Nursing Science. Oslo (in Norwegian): University of Oslo. Keller, L. O., & Strohschein, S. (2001). Public health interventions applications for public health nursing practice. St. Paul, MN: Public Health Nursing Section, Minnesota Department of Health. Keller, L. O., Strohschein, S., & Schaffer, M. A. (2011). Cornerstones of public health nursing. Public Health Nursing, 28(3), Kristoffersen, N. J., Nortvedt, F., & Skaug, E. A. (2011). Basic nursing. Oslo (in Norwegian): Gyldendal akademisk. Kvale, S. (2001). The qualitative research interview. Oslo (in Norwegian): Ad Notam Gyldendal. Ministry of Education and Research. (2005). Regulation for public health nurses education. FOR Oslo (in Norwegian): Ministry of Education and Research. Retrieved from wift/ldles?doc=/sf/sf/sf html Ministry of Education and Research (2008). The regulation for nursing education: Set 25 January Oslo (in Norwegian): Ministry of Education and Research. Ministry of Health and Care Services. (2002). St.meld. nr. 16 ( ) The prescription for a healthier Norway. Oslo (in Norwegian): Ministry of Health and Care Services. Ministry of Health and Care Services. (2006). St.meld.nr. 25. Coping opportunity and meaning. The future challenges in care( ). Oslo (in Norwegian): Ministry of Health and Care Services. Ministry of Health and Care Services. (2009). St.meld.nr. 47. Coordination Reform: the right treatment The right place Right time ( ). Oslo (in Norwegian): Ministry of Health and Care Services. Ministry of Health and Care Services. (2011). St.meld.nr. 16. National health care plan Oslo (in Norwegian): Ministry of Health and Care Services.

14 14 Public Health Nursing Nightingale, F. (2009). Notes on nursing: A guide for today s caregivers. Edinburgh: Balliere Tindall Elsevier. Norwegian Directorate of Health. (2004). The municipalities work for health promotion and prevention in well baby clinics and school health services. Veileder til forskrift av 3. April 2003 nr Oslo (in Norwegian): Norwegian Directorate of Health. Norwegian Directorate of Health. (2009). The Norwegian Directorate of Health s annual report on measures to reduce social inequalities in health. Norwegian Public Health Policy report Oslo (in Norwegian): Norwegian Directorate of Health. Norwegian Directorate of Health (2010). What can government statistics tell us about the priorities in nursing and care services? An article based on the published nursing and care statistics in Oslo (in Norwegian): Norwegian Directorate of Health. Pedersen, R., Nortvedt, P., Nordhaug, M., Slettebø, A., Grøthe, K. H., Kirkevold, M., et al. (2011). In quest of justice? Clinical prioritizations in healthcare for the aged. Clinical Ethics, 30, Polit, D. F., & Beck, C. T. (2012). Nursing research: Generating and assessing evidence for nursing practice. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins. Sæteren, B. (2006). Struggling for life in the veil of pensiveness. A life between the pressure created by the possibility of life and the necessity of death. Abo, Finland: Abo Akademis f orlag. Sandelowski, M. (2000). Whatever happened to qualitative description? Research in Nursing and Health, 23, Schaffer, M. A., Garcia, C. M., & Schoon, P. M. (2011). Population-based public health clinical manual: The Henry Street model for nurses. Indianapolis, IN: Sigma Theta Tau International Society of Nursing. Tveiten, S., & Severinsson, E. (2004). Client supervision: Meaning and experiences from the perspective of Norwegian public health nurses. Nursing and Health Sciences, 6, Vabø, M. (2007). Organisation for welfare: The community home care in light of changed organizational ideology. Oslo (in Norwegian): Norwegian Institute for research on welfare and aging, (NOVA). Vallgarda, S. (2007). Public health policies: A Scandinavian model? Scandinavian Journal of Public Health, 35,