743897

research-article2017
SJP0010.1177/1403494817743897Scandinavian Journal of Public HealthB.M Dahl

Scandinavian Journal of Public Health, 2018; 46(Suppl 20): 53–58

Original Article

Challenges and demands in the population-based work of public health

nurses

Berit Misund Dahl

NTNU-Norwegian University of Science and Technology, Norway

Abstract
Aims: Government programs and the Norwegian Directorate of Health give public health nurses in Norway an explicit role
in population-based health promotion and disease-prevention work. The aim of this paper is to explore Norwegian public
health nurses’ experiences with population-based work. Methods: A phenomenological hermeneutic approach was adopted,
involving face-to-face interviews with a purposeful sample of 23 public health nurses from urban and rural districts in
two counties in Norway. Results: Three themes were identified: the predominance of work at the individual level, a lack of
resources, and adherence to administrative directives. The interviews revealed that the public health nurses were mostly
occupied with individual problem-solving activities. Population-based work was hardly prioritized, mostly because of a lack
of resources and a lack of recognition of the population-based role of public health nurses. Conclusions: The study indicates
contradictions between the public health nursing practice related to population-based work and the direction
outlined by the government and the public health nursing curriculum, which may mean that the public health
nursing role is not sufficiently clarified. The implementation of practice models and administrative directives
and resources, as well as an explicit emphasis on population health in public health nursing education, can
contribute to increased population-based interventions. Greater knowledge of and emphasis on population-
based work in public health nursing are needed.

Key Words: Disease prevention, health promotion, Norway, phenomenological hermeneutics, population-based work, public health
nursing

Introduction
Norwegian public health nurses (PHNs) are a link
between the government and the population con-
cerning public health. With children, young people,
and families as their main target groups, PHNs can
contribute to changing and improving the quality of
life and to reducing inequality in the health of the
population. The concept of public health, which can
be understood as “collective action for sustained
population-wide health improvement” [1], has tradi-
tionally had a narrow view of public health. This bio-
medical disease model is based on a pathogen-risk
focus, with attention given to problem-solving
strategies. The Ottawa Charter for Health Promotion
[2] is widely considered to have sparked a shift in the
societal discourse of public health. The Ottawa
Charter presented a “new public health,” advocating
the importance of local communities as arenas for
health promotion. In 1986, the World Health
Organization [2] defined health promotion as the
process of enabling people to increase control over
the determinants of health and thereby improve their
health. The determinants of health include income
and social status, social support networks, education,
employment and working conditions, the physical

Correspondence: Berit Misund Dahl, Department of Health Sciences in Ålesund, Faculty of Medicine and Health Sciences, Norwegian University of
Science and Technology (NTNU), NO-6025 Ålesund, Norway. E-mail: bd@ntnu.no

Date received: 28 march 2017; reviewed: 7 June 2017; accepted: 26 October 2017

© Author(s) 2018
Reprints and permissions: sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1403494817743897
https://doi.org/10.1177/1403494817743897
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54    B.M Dahl
environment, personal health practices and coping
skills, biology and genetic makeup, and health ser-
vices of the population [3,4]. The population can be
divided into two groups: a population-at-risk group,
with a focus on disease prevention; and a population-
of-interest group, with an emphasis on health-
promotion strategies. This form of thinking was
recognized in the former regulations for public health
nursing [5] and in the successor, a recent national
professional directive for health promotion and dis-
ease-prevention work in Norwegian public health
nursing [6]. It highlights the goals of PHNs’ work in
child health clinics and school health services: to pro-
mote mental and physical health and good social and
environmental conditions, and to prevent disease and
injury. As early as possible, the service shall screen
children and young people, conduct an assessment,
and make a referral if needed. This universal service
shall target both individuals and the population.
PHNs’ social mandate—with an increased emphasis
on population-based work and particularly health-
promotion strategies, such as empowerment stimu-
lated by meeting with service users in an open and
respectful way and engaging in dialogue, thereby
revealing their own resources—has become more
complex. However, a review of the international lit-
erature shows that nurses often misunderstand the
concept of health promotion. Their focus has been
on changing individual behaviors; meanwhile, the
population focus has been somewhat ignored [7–9].
The role of expert as the traditional nursing position
is a view shared not only by patients and service users
but also by PHNs. The more complex PHN role may
still be unclear and, thus, hard to manage and define.
Drawing clear jurisdictional boundaries with other
professions is of importance in establishing an auton-
omous profession; however, these professional bor-
ders can be renegotiated [10], which might be the
current case in public health nursing.
One would expect an emphasis on population
interventions and health-promotion work to be
reflected in the educational curriculum of Norwegian
public health nursing. However, a critical discourse
analysis of the curriculum [11] revealed that the
“new public health” promotion focus and population
initiatives were not sufficiently explicit and expressed
in the text. The curriculum [12] can be described as
reflecting governmental strategies for the profession,
related to underlying knowledge in public health
nursing education, and for the creation of jurisdic-
tional borders with other professions. The study con-
cluded that the curriculum did not meet the political
health-promotion expectations. This finding is some-
what similar to that of a study demonstrating that the
educational curriculum of nursing programs in the
UK has placed greater emphasis on health promo-
tion and disease prevention in recent years; however,
a dichotomy existed between the curriculum text and
what the student nurses experienced in practice [13].
Norwegian political programs in health and social
care have found it necessary to highlight population
work. A recent government document [14] empha-
sized the need for a shift in health and care services,
from a solely individual perspective to an active role
regarding the population for whom they are responsi-
ble. This emphasis on a shift can be interpreted as an
acknowledgment that population initiatives are lim-
ited among health and care workers. Government
directives for Norwegian public health nursing state
that public health nursing’s health promotion and dis-
ease-prevention work shall include population initia-
tives in addition to individual work [15]. International
studies indicate that the reorientation of healthcare
toward a more pronounced health-promotion focus
has been challenging, but that health professionals
largely have a positive attitude and in-depth knowl-
edge about lifestyle intervention methods [13,16].
International studies have also pointed out that
PHN practice shall focus on keeping populations
healthy to alleviate pressure on the healthcare system
[17], but that PHNs’ skills and abilities are underuti-
lized and largely invisible [18]. Theoretical and con-
ceptual models have been developed to help PHNs
focus on population health. Employing the storytell-
ing method [19], a US study on public health inter-
ventions for school nurses found that using the
Intervention Wheel can contribute to achieving
healthcare reform goals and to reaching more stu-
dents at the population level. It offers interventions at
the individual/family, community, and system levels,
and helps explain what PHNs do [20]. Researchers
maintain that school nursing education should
include a public health model to increase nursing
students’ understanding of population health work.
Cusack et  al. [17] presented a participatory action
research design wherein a practice model was devel-
oped to redefine the PHN role to focus on popula-
tion health and equity. The study revealed two critical
needs: the need for clarification of the underlying
goal and value of PHN practice (i.e., the role of a
moral agent whose actions are based on nursing pro-
fessional morals and standards) and the need for
resources and organizational leadership. This need
for resources was also highlighted by Hoekstra et al.
[21]. They found that the role of the English school
nurse is very diverse, that the role has shifted from
the delivery of health education to a more advisory
and supportive role toward schools, and that tailored
public health education resources are needed to sup-
port school nurses.

Despite differences in culture and geography, and
the fact that nurses can have different titles in differ-
ent countries, previous research has shown that simi-
larities exist between Norway and other countries
regarding concerns and issues with the PHN role.
For instance, a study on values and beliefs among
PHNs in Norway and in the US found that they had
much in common [22]. The present study, with its
political focus on population-based interventions,
explores Norwegian PHNs’ experiences with popula-
tion-based health promotion and disease-prevention
work.
Methods
Design
This study is based on data obtained with a phenom-
enological hermeneutic method, inspired by the phi-
losophy of Ricoeur [23]. The method allows the
researcher to reveal the lived experiences of the
informants. Semi-structured face-to-face interviews
with a narrative approach were performed to illumi-
nate the practical experiences of the PHNs in rela-
tion to population-based work. Stories from practice
can reflect public health nursing strategies and
challenges.
Sample
A purposive sample of 23 PHNs working at health
clinics for children and young people and in school
health services participated in this study. They came
from urban and rural districts in two counties in
Norway. Their practice experience varied from less
than one year to 25 years. Access to these partici-
pants was established through oral and written
inquiries to the leaders of the PHNs in the districts.
These leaders in turn informed the PHNs, who then
engaged in direct contact with the researcher for
interviewing. The interviews lasted from 1 to 1.5 h.
Analysis
The analysis began with a description of the lifeworld
of PHNs as it appeared in practice, and this life experi-
ence was then interpreted, taking into consideration
that the experiences were embedded in different prac-
tice contexts. The method involved three steps: a naïve
reading of the transcribed text, resulting in a naïve
understanding; a structural analysis, revealing themes;
and a critical reading, leading to a comprehensive
understanding of the text. The analysis was a dialectic
movement between an explanation and a naïve and
comprehensive understanding. The emphasis was on
Population-based work in public health nursing   55
what the transcribed text illuminated about possibili-
ties of living and acting as a professional [24]—that is,
the interviewed PHNs’ experiences with population
work.
Ethical approval
Approval to conduct the study was obtained from the
Norwegian Social Science Data Services, and ethical
guidelines for research were followed. The study
comprised tape-recorded interviews with profession-
als. The informants signed consent forms prior to
beginning the study and were notified that they could
withdraw at any time.
Results
Naïve understanding
Many of the PHNs were occupied with solving their
service users’ problems at the individual level. They
also experienced a lack of resources for performing
population-based work. In those situations where
leaders focused on population-based work, the
PHNs’ involvement in population interventions was
crucial.
Theme: The predominance of work at the
individual level
The interviews revealed that the PHNs were occu-
pied with problem-solving at the individual level.
Some experienced limited population work in public
health nursing. One PHN described the situation as
follows:
There is little population-based work. We meet some at
parent meetings in school and in the groups at the child
health clinic and parenting courses. So there has not
been anything more aimed at the broad population. We
have talked about having health information in the
newspaper, but it has never been carried out.
The importance of health promotion population
initiatives, such as the dissemination of health infor-
mation in different media, was emphasized by some
PHNs. A few also mentioned that they regularly con-
tributed articles on various health topics to local
newspapers.
One PHN talked about the changing times and,
consequently, the changing PHN role:
It was much easier to work with screenings. There was a
pattern. … If you found something, then you referred.
Now we have much more responsibility ourselves to
help them, to be therapists. Yes, including young people
56    B.M Dahl
with … children and young people with psychosocial
problems. Therefore, there is a big change. Moreover, it
is much more time-consuming.
Some PHNs found that they expended many
resources when working with services users at the
individual level. As a consequence of increased men-
tal health problems among young people, the PHNs
also experienced playing a central role in meeting
with them, often regularly, within school health
services.
Theme: A lack of resources
The PHNs noted that the available resources were
insufficient to carry out their work at both individual
and population levels. Therefore, they prioritized
individual meetings with their service users in child
health clinics and at schools. One PHN described the
situation as follows: “We do not take much initiative
ourselves to [target] the broad population because
we simply do not have the capacity to do that.”
However, the PHNs also expressed that the popula-
tion arena might not be their responsibility. One
PHN made the following comment:
When it comes to general prevention, I think there are
many others besides PHNs who do that, including those
who work with these immigrant groups. … I think we
are important contributors there [general prevention
work], but we must not think that we must do everything.
… We cannot be in all arenas. But we could be if we had
more positions.
On the one hand, the PHN believed that they and
other professions were contributors to population-
based work, but that they themselves could not be
involved in all arenas. On the other hand, she believed
they could be if there were sufficient resources (in the
form of positions) available for population-based
work. This comment suggests that the population-
based role of PHNs was not recognized at the admin-
istrative level and possibly not among PHNs.
Theme: Adherence to administrative directives
Some PHNs were fully aware that their focus was
primary prevention. One PHN acknowledged the
part played by her health manager in gaining this
awareness:
My role has become clearer and clearer and I am fully
aware of where I want to be and where we are going to
be, that is, with primary prevention work. But this you
shall not do [secondary and tertiary prevention, and
treatment]. That my health manager has told me every
year. She has been completely aware of where we
should be.
The leader was seen as an important person in prior-
itizing and implementing population-based work in
public health nursing. For instance, influenza vacci-
nation of the elderly population once a year was the
PHNs’ responsibility in some districts. This disease
prevention population initiative was initiated at the
administrative level, and the participation of the
PHNs involved was positive.
Discussion
Both the results from the interviews with PHNs and
the analysis of the public health nursing curriculum
[11] indicate a principally individual-based strategy
toward service users. This finding is supported by
international research on public health nursing. For
instance, an American study on PHNs found a lack
of population health focus in the practice activities,
management priorities, and educational preparation
of PHNs [25]. However, the finding is contradictory
to government documents [15] emphasizing the
importance of population-based work. Vallgårda
[26], who studied Nordic public health policy docu-
ments, revealed that the Norwegian policy placed the
responsibility for the population’s health at the social
and political levels, which is in line with a social dem-
ocratic view. As a link between the government and
the population concerning health issues, PHNs have
a mission: to play a central role in maintaining and
improving the public’s health and in maintaining a
competent public health workforce [27].
Whitehead [8] found that nursing students can
demonstrate a good theoretical capacity in health
promotion but are not able to implement health pro-
motion strategies in practice. According to Whitehead
[8], nurses need a clearer contextualization of health
promotion in the nursing literature to develop their
health-promotion strategies. A 2014 analysis of the
educational curriculum of Norwegian PHNs also
revealed a lack of focus on both health promotion
and population work [11], suggesting that the educa-
tion of PHNs is one of many possibilities where the
focus becomes lost. Public health nursing students
need skills and tools to implement health-promotion
thinking into practice. Before 1986, both public
health policies and practice had mostly a narrow
population-at-risk focus, centering on mistakes, what
could go wrong, and interventions at the individual
level [28]. The findings of the present study indicate
that the individual disease-prevention approach still
has hegemony. Performing health-promotion strate-
gies at individual, group, and community levels is

broad and demanding; hence, the curriculum needs
new structure and content [11,29]. In line with the
population-of-interest health-promotion thinking,
PHNs must demonstrate a positive attitude toward
the changing processes—that is, by praising and con-
veying hope, respect, trust, and belief in coping strat-
egies both related to universal and targeted
approaches. In addition, PHNs must possess ade-
quate knowledge about the issues at stake. When
PHNs provide relevant knowledge to service users
and the community, the targeted groups can assess
their needs and feel confident about the situation. At
the individual level, this can involve supporting a
mother with a newborn about breastfeeding so that
she can feel that she has mastered the skill and has
faith in her own mastering. At the population level, it
can involve teaching classes in schools about the
health benefits of a good diet and physical activity.
Health-promotion interventions empower a commu-
nity to gain greater control over conditions that affect
health. Lacking the language to articulate population
interventions can be a barrier for PHNs. Practice
models have thus been developed to support public
health nursing work [17,20]. In their validation of the
Intervention Wheel, McDonald et al. [9] stated that
the model contributed to identifying and naming
PHN interventions and thus increased the visibility
and credibility of the PHN role. Identifying PHNs’
population work can help clarify the jurisdictional
boundaries of PHNs. With today’s unclear bounda-
ries and a possible lack of professional interest in
population-based work, implementing interventions
may involve a fight over boundaries that will need to
be clarified so as to develop an autonomous and
authoritative public health nursing profession. Health
promotion is also about collaboration with profes-
sionals and with service users (individuals, groups,
and communities). An example is for a PHN at a
school to be available for all students and to teach
different topics related to health issues in collabora-
tion with the school staff.
The PHNs in this study described lacking the
time to perform population-based interventions.
They recognized the need for health-promotion
strategies—that is, having office hours at schools,
meeting with all pupils, developing skills, and focus-
ing on the positive to increase pupils’ sense of achieve-
ment—but were challenged by constraints, such as
time. This finding is supported by Whitehead [8],
who maintained that lack of time, resources, support,
and training can be barriers to nurses’ health-promo-
tion practice.
Some PHNs in this study did not recognize their
role in population-based work, instead prioritizing
work at the individual level. This finding may be
Population-based work in public health nursing   57
explained by the lack of directives from PHN leaders
about population-based interventions in public
health nursing. Where universally targeted popula-
tion initiatives were instituted, the PHNs had a uni-
versal focus. This finding indicates that administrative
recognition and directives, followed by resources, are
crucial for PHNs’ implementation of universal health
promotion and disease-prevention work.
The public health nursing role is complex and
diverse, and PHNs frequently experience new and
demanding challenges. To strengthen the profession,
PHNs need to clarify their role and work field in rela-
tion to jurisdictional borders. One may maintain that
the responsibility lies with public health nursing edu-
cation to introduce models for population-based
interventions and with the administrative level in
public health nursing practice to make resources
available for population-based health promotion and
disease-prevention work.
Limitations
A relatively small sample of Norwegian female PHNs,
all of whom had been educated in Norway and were
working in a Norwegian context, were interviewed
for this study. The size and composition of the sam-
ple limited the opportunity to examine the context
from a larger perspective. The findings must be inter-
preted in this context and, therefore, cannot be gen-
eralized. However, many of the findings are supported
in the literature. Ricoeur [23] maintained that the
interpretation process can reveal many truths, but
some interpretations are more probable than others.
Representative quotations from the interviewees are
provided in the Results section to illustrate similari-
ties and differences in the transcribed text.
The fact that the interviewer was a PHN and
worked in public health nursing education may have
influenced the interview process. The researcher may
have had a better understanding of the informants
and, consequently, asked follow-up questions of rel-
evance. Thus, it was essential to employ theoretical
perspectives and analyzing tools, together with a
transparent analysis of the data, so as to achieve nec-
essary distance and a critical entrance to the data in
the research process.
Conclusions
The aim was to explore Norwegian PHNs’ experi-
ences with population-based health promotion and
disease-prevention work. The contradictions concern-
ing the public health nursing role from the PHNs’
viewpoint and from the curriculum and governmental
programs suggest that the PHN role is not sufficiently
58    B.M Dahl
clarified. The development of administrative directives
and resources and practice models, and an emphasis
on population health in public health nursing educa-
tion, can contribute to promoting population-based
interventions. PHNs need to develop their population-
based health promotion and disease-prevention role
so that they can contribute to improving the quality of
life and to reducing health inequalities in the popula-
tion. More knowledge about population-based work
in public health nursing is needed. A potential next
step may be to implement the Intervention Wheel to
validate and provide a set of interventions for public
health nursing practice.
Acknowledgements
The author would like to thank the participants of
the study for sharing their experiences with her.
Declaration of conflicting interests
The author declared no potential conflicts of interest
with respect to the research, authorship, and/or pub-
lication of this article.
Funding
This research received no specific grant from any
funding agency in the public, commercial, or not-for-
profit sectors.
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