1 BACKGROUND

Public health nursing (PHNing) is central to promoting primary health care services (PHCS) in communities. Most western European countries offer additional educational program for registered nurses (RNs) to become a public health nurse (PHN) (Salvage & Heijnen, 1997). In the Nordic countries, institutions of higher education (HE) offer educational program/courses in PHNing, often founded on national guidelines describing learning objectives and the profession's expected practice (Danish Ministry of Health, 2019; Finnish Ministry of Education & Culture, 2014; Norwegian Ministry of Education & Research, 2021; Swedish Ministry of Education & Research, 1993, 2020). HE should motivate students to become open-minded, critically reflective and grounded in evidence-based knowledge and proven experience, as well as develop the profession according to the needs of users and society (European Commission [EC], 2002; Frenk et al., 2010; GUNI, 2017). International exchange and mobility for students and academic staff are ways to stimulate reflection, innovation, and an international perspective, addressing both the local and global demands of society. In Europe, the Bologna Declaration describes a common system for HE institutions to compare curricula and harmonize degrees across countries, including the cycle of degrees, workload, and credits (EC, 2008; European Ministers in charge of HE, 1999, EC 2020).

In Europe the education and practice of PHNs have developed along with the public health movement that started more than 100 years ago, focusing on preventing illness and promoting the health of individuals and families in communities. The first qualified PHNs were examined in England in the late 19th century by Nightingale (Monteiro, 1985). The praxis of the PHN in the Nordic countries started in the first decades of the nineteenth century and developed concurrently over the following decades. In Sweden, PHNs were introduced by the county councils in the early 1900s, but not until 1920 was a formal education in place (Jakobsson, 2017). Iceland started the PHN practice back in 1915 (Pétursdóttir, 1969); however, the first Icelandic PHNs were educated abroad (Guðmundsdóttir, 2010). Until recently, PHN education program have been sporadic in Iceland (Líndal, 2016; Pétursdóttir, 1969). Even today basic nursing registration is the only requirement for employment in PHCS (Guðmundsdóttir, 2010). In Norway and Finland, courses in PHNing started in the 1920s–1930s (Clancy, 2007; Simoila, 1994). Finland implemented the Act of mother-child health clinics in 1944, and PHNs became statutory for municipalities in 1972 (Finnish Ministry of Social Affairs & Health, 1972; Simoila, 1994). In Norway, the education of PHNs was established in 1947, and the act regulating PHNs in all municipalities passed in 1957 (Schiøtz, 2017). In Denmark, the education of PHNs was established in 1937, and stipulated by law for all municipals in 1973 (Samberg & Rasmussen, 2012).

PHNs have worked within PHCS focusing on areas important for the health of the population since the establishment of the profession. From the beginning, there has been a focus on reducing poverty, inequity, infectious diseases, and environmental pollution. This later turned toward a focus on lifestyle and psychosocial related illnesses and, in recent times, promoting people's well-being (Edgecombe, 2001; Schiøtz, 2017). The services and areas of services differ between countries with some offering support to parents and children and others to school children, the elderly, and persons with disabilities, often with the practice located near people's everyday environment (Edgecombe, 2001). Although the term “public health nurse” is not internationally consistent in literature or practice, The EU established in 2001 an initiative to develop a common education program in PHNing (Danielson et al., 2005). Thirteen EU countries developed a program describing the knowledge, skills and attitudes structured in three parts: compulsory and optional modules, and clinical placements. The competencies of PHNs are described in the following: identify and assess the health needs of individuals, families, and communities (I/F/C), and/or prioritize them in accordance with health needs, nursing standards and relevant policies; initiate or contribute to the delivery of public health actions or program from different care settings; facilitate and empower I/F/C to increase control of health determinates; work collaboratively with other professions and sectors; act as an advocate for I/F/C to improve health, and; evaluate the outcome of their own actions/program and/ participate in the evaluation of other health program (Danielson et al., 2005, p34). To facilitate the international exchange of students a section of 30 ECTS is recommended to be equal for all countries. However, in 2021, the education of PHNs still seems to be multifaceted.

Hence the aim of this paper is twofold: to give an overview of PHN education and service in the Nordic countries and thereby discuss opportunities for collaboration between the Nordic educational program.

2 DATA SOURCES AND COMPILATION OF DATA

Since all the Nordic countries have National legislations for PHN education and services, and national PHN competence descriptions these were used as data. We also used the educational structure and curricula of one PHN program in each country as data. All data are publicly available. Regarding education, each one of the authors extracted data about admission criteria, ECTS/ EQF, amount of clinical education, courses in the elected programs and teaching criteria from each country respectively. Data about services were population to serve as PHN and types of services. Since all sources were written in the language of each country, all the authors wrote the parts that described each countries conditions in English. Thereafter, all authors contributed equally to the compilation of data.

4 DISCUSSION

The fundament for achieving a degree in PHNing in all Nordic countries is a BSN. Finland is the only country where experience as RN is not a prerequisite for admission to a PHN programme. Instead, the PHNing courses are parallel to the BN courses (Finnish Ministry of Education & Culture, 2014). In Iceland, Sweden, and Norway, the PHN educational programmes are on level 7 (Artic Council, 2020; Norwegian Ministry of Education & Research, 2021; Swedish Council for HE, 2021), whereas the programmes in Finland and Denmark are at level 6 (Danish Ministry of Health, 2019). The extent of the education is between 60 to 75 ECTS, and for Norwegian PHNs this extends to 90 ECTS (Norwegian Ministry of Education & Research, 2021). In all countries, except Iceland, ministries of education or health establish guidelines for PHN educations.

The dimension of theoretical courses within the programmes varies from 2- 20 ECTS, and to arrive at a more uniform education and practice in the Nordic countries, a minimum ECTS for theoretical courses should be considered. Between the countries, there are similarities in the PHN courses, such as the PHNing framework and the development of children and adolescents. The programmes in Denmark and Sweden offer compulsory courses focusing on children, families, and other groups with special needs, in addition to advanced home nursing. Subjects within pharmacology and prescriptions for certain medication are part of mandatory education in Sweden, Norway, and Iceland (Icelanic Ministry of Health, 2020; Norwegian Health Directorate, 2015; Swedish National Board of Health & Welfare, 2018). PHNs in Finland can start contraception for girls in school or student health care, and PHNs with special education can prescribe certain medications and vaccinations (Finnish Ministry of Social Affairs & Health, 2010a).

PHNs in Finland, Sweden, and Iceland (Finnish Ministry of Social Affairs & Health, 2010b; Icelandic Ministry of Health, 2007; Swedish District Nurses Association, 2019) promote the health of citizens throughout their lifespan and offer consultations with the target population at health care centres/clinics. PHNs in Denmark and Norway offer services to parents, children, and adolescents (Danish Ministry of Health, 2019; Norwegian Ministry of Health & Care, 2018). PHNs in Denmark mostly carry out their services by home visit, and in Norway most of the PHNs’ practice is carried out at family- child health clinics, which is also the case in Finland and Sweden. In all Nordic countries, children access free school health care run by PHNs. In Swedish and Icelandic PHN programmes, students can choose whether to focus on the health care of the elderly, or on children, adolescents, and their families. In Finland, PHN students have mandatory theoretical studies in all areas of PHNing, whereas in Denmark and Norway, courses related to PHNs for adults are not part of the programme (Danish Ministry of Health, 2019; Norwegian Ministry of Health & Care, 2018).

Clinical placements differ between the countries as well as within programmes in one country, like Sweden and Finland. The PHN programmes in Iceland and Finland consist of larger parts of clinical practice than in Norway and some of the programmes in Sweden. Students in Sweden, Denmark, Iceland, and Norway are experienced nurses when entering the programme. For all countries, clinical placement is supervised by experienced, practicing PHNs and evaluated by academic staff. In Denmark, Finland and Norway, clinical placement is offered as separate courses, but in Iceland, clinical placement and theoretical education is mainly combined. Clinical practice in Denmark consists of 30 ECTS, and one of the courses is related to children and young persons with special needs. In Norway, clinical training in services for children and school children are mandatory.

Interestingly, the structure, content, and level of PHN programmes within and across Nordic countries differs somewhat, but a focus on preventing illness and promoting health among children, adolescents, and families is integral to all programmes and services. The social structures in the Nordic countries have much in common, and all PHNs’ practices are based on the Nordic model with a welfare state promoting the well- being of its citizens (Iqbal & Todi, 2015). Even though this provides all citizens equal and free or low-cost care, PHNs face challenges such as an increasing elderly population and more multi-cultural citizens (Brandenberger et al., 2019). However, PHNs in Norway and Denmark have no authority to offer services to the adult population (Danish Ministry of Health, 2019; Norwegian Ministry of Health & Care, 2018). More than ever, PHN students need to develop competence to meet the population from different perspectives, perform care that is meaningful to the population and support healthy living. One way to develop critical reflection and cultural competence among PHN students is to challenge their ‘taken for granted standpoints’ and allow them encounter different education and health care systems and ways of performing PHNing (Crithley et al., 2009; Sloand et al., 2008). This might enhance their reflection on conditions in society as well as ways of promoting health and preventing illness. A way to start international collaboration is to develop PHNing courses that students in the cooperating institutions can take part in, although one of the first premises for the exchange of students is the willingness of academic staff. A first step may be to agree on subjects that are possible to cooperate on and adjust courses in the programmes in a way that creates opportunities for exchange. The different levels of educational programmes can, however, be challenging in cooperation. Subjects like strategies, tasks, population of PHNs, and knowledge of children and families’ development can be of mutual interest regarding learning outcomes, while scientific methods and work will have different learning objectives depending on the level of the programme. However, despite the programme level, cooperation across borders will give the students international perspectives on the services, their profession, and society. Courses act as an advocate for I/F/C to improve health, as the EU programme proposed by Danielson et al. (2005) is not described in any of the Nordic PHN programmes offered by the institutions represented within this paper. This might be something to develop in international collaboration. To succeed with cooperation, planning and organisation is a premise, besides good support from information technology solutions. The ongoing pandemic shows that it is possible to cooperate across borders with the help of technology and that exchange does not have to include travels. In collaboration, language might be a hinder; however, most students in the Nordic countries manage English as working language.

Since all the programmes collaborate with health care organisations on clinical placements, these may also take part in the collaboration. Other possibilities are collaboration in research projects and academic staff giving lectures across borders. To succeed in collaboration, one should have in mind that implementation takes time and calls for flexibility by those involved (Danielson et al., 2005).

5 CONCLUSION

This paper describes similarities and differences with a focus on education, level of EQF, amount of ECTS, as well as the services of PHNs. The educational programmes of PHNs in Norway, Finland and Sweden are largely guided by national guidelines. Finland is the only country that has PHN education as part of a BN. The PHN programme in Finland and Denmark are at level 6 while the programme in Norway, Sweden, Iceland is at level 7. PHN education in Finland, Iceland and Sweden has a lifespan focus while the education in Denmark and Norway places focus on children and youth. Clinical practice is great part of education in Iceland, while home care visits are used to a greater extent in Denmark than in the other countries. Differences within the programmes and within the services might stimulate critical reflection. On the other hand, a proportion of similarities might be a premise for collaboration to give credits for courses students have on exchange. Critical reflection by students within PHN education programmes in collaboration projects, practice exchange, joint master projects and academic staff collaboration in education and research have the potential to enhance quality both within PHN education and in the development of the PHNing profession.

ACKNOWLEDGMENT

The authors wish to express their sincere thanks to Ulrika Bengtsson taking part in the early draft of the manuscript.