The meaning of professional identity in public health nursing

Abstract

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.