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A changed society

Icelandic society has undergone a radical change since the beginning of the 20^th century, when the country's population was predominantly rural. Today, on the other hand, nearly 90% of all Icelanders live in densely populated areas. Modern-day employment has to a large extent become service-related, while jobs requiring physical exertion have decreased. In recent decades, women have increasingly entered the employment market, and at present an average of 75% of Icelandic women have jobs outside the home. Recent developments in information technology have opened up new venues for communication and the exchange of ideas. Modern society is cosmopolitan and characterised by ethnic multiplicity, which in turn calls for tolerance and understanding of the different backgrounds and outlook of the individuals.

            The family is the institution which most affects the health, well-being and development of the citizens. The social, educational and health care systems must therefore support the family in this important role. The family pattern in Iceland has changed in recent decades and family ties between generations are not the same as they were. This change has, for example, affected the situation of the elderly, who are now more likely to be found living on their own or in specialised institutions than in the homes of their relatives. As a result, the elderly have become increasingly dependent on the assistance of their spouses, friends or public services.

            During the first years of life the foundations are laid for the future of each individual. Therefore, all changes within the social and family structure are bound to have an impact upon the individual in numerous ways. Today, divorces are more common and a growing number of children are being brought up in single parent households. The effects of this have revealed themselves in increased stress, drug abuse, violent behaviour and unhealthy eating habits. Suicides among young males between 15 and 24 years of age have increased considerably. Accidents involving children are more common in Iceland than in the other Nordic countries. This is primarily thought to be the result of a lack of proper supervision. Icelandic parents tend to work longer hours and the availability of adequate day-care facilities has, until recently, been rather scarce. This trend is, however, gradually being reversed as is evidenced by relatively fewer deaths, for instance from road accidents, poisoning, burns and drowning.

            Research has shown that, despite a generally high standard of living, a proportion of the Icelandic nation lives in poverty. Poverty is more common among women than men, and among the elderly and farmers. One of the more serious results of poverty is bad health, which can be traced to poor social conditions and limited possibilities for health improvement. Since the last decade of the 20^th century there has also been constant unemployment, particularly among young people. An increasing number of families are suffering on account of prolonged unemployment and adverse social circumstances. The number of families seeking public financial support is growing and so is the number of families on the brink of desperation due to financial difficulties, a changed self-image and the insecurity that comes with unemployment and difficult circumstances.

            Demographic projections for the Icelandic nation envisage a relative increase in the numbers of elderly citizens over the coming decades. This development is believed to be the result of increased and improved health care services and improvements in socio-economic conditions. Despite longevity, however, research has shown that a large number of the elderly suffer from one or more chronic illnesses, thus making the elderly the group of citizens which most need the assistance and support of the health care system. The elderly are a heterogeneous group and their needs and requirements vary. Their nursing requires a comprehensive knowledge where individual views and conditions are taken into consideration. It is, therefore, of primary importance that the availability of a range of options as regards nursing and social services be ensured in coming years for this age group.

            Recent decades have witnessed a revolutionary progress in the health sciences. Health care professionals have at their command an extensive knowledge of the causes, the nature and the treatment of health problems as well as sophisticated technology to help solve these problems, often with very good results. This does, however, also mean that more individuals survive serious accidents and illnesses than before while at the same time suffering the after-effects of lasting ill health or even disfigurement. Coping with such circumstances and facing the psychological stress involved places a heavy burden on the individuals and their families and relatives. These individuals often require long-term care and support, both in and out of health care institutions, with special emphasis on rehabilitation and the protection of human rights and dignity. The recent revolution in knowledge and technology has thus left health care professionals with an increased responsibility. Difficult ethical questions regarding when and how to apply this technology, the possible outcome and the prioritisation of tasks must be answered.

The philosophy of nursing

The definition of nursing which has shaped the ideas of nurses all over the world in recent decades was formulated by Virginia Henderson and introduced to nurses worldwide by the International Council of Nurses.

                                      The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.

(Basic Principles of Nursing Care)

            This definition is still valid, although new ideas and views have helped to broaden our understanding of nursing even further. Nursing entails a holistic understanding of the human being. All individuals are influenced by a complex interplay of biological and psychological factors that are closely interwoven with their social, religious and moral surroundings. But just as the individuals are moulded by their surroundings, they are also constantly interacting with, and affecting, their own environment. All of this is relevant to the well being and development of the individual and must therefore be taken into consideration in the planning and implementation of nursing. What characterises human society, above all else, is Man's ability to lead a meaningful life. Our understanding of life in general and of our bodies, circumstances and events is shaped by our culture and experience. Tailoring nursing to the individuals' perception of their circumstances as well as their desires and expectations is best way in which to fulfil their requirements.

            Illness and disability or having to deal with events causing stress, such as the loss of a loved one, which may result in considerable personal upheaval, is often a cause of distress for the individual. With the care and support of family and professionals such experiences can, however, lead towards enhanced personal development and a deeper understanding of human values. The close and personal connection that arises from daily care and the presence offered by nursing gives the clients the chance to discuss their experiences and nurses the opportunity to provide counselling and support.

            The increased use of technology, specialisation and cutbacks in modern health care call for a dialogue regarding the ethics of nursing. Nursing means caring for the client, i.e. showing respect for the individual's life, freedom and human dignity. Under no circumstances do nurses show disrespect nor discriminate against individuals on grounds of nationality, race, religion, age, gender, politics, social position, disability, sexual preferences, or the nature of the health problem. Nurses are also the advocates of the clients and their families, both inside and outside the health service.

            Nursing is centred on working closely with clients and their families in times of sadness as well as joy. The relations between the nurse and the client are shaped by their respective moral and ethical views. The nurse should always seek to base this interaction on consultation, which means that any dialogue regarding ways in which to solve a problem is based on trust and should result in the client and the professional taking mutual responsibility. Consultation means respecting the personal freedom of the clients while at the same time assisting them in reaching an informed decision regarding treatment and care. Nurses help the clients to identify their needs, interests and options in such a way that the decisions made are consistent with the individual's values, views and expectations. All individuals have the legal right to access information regarding their health, diseases, tests, treatment and prognosis. They also have the right to any information regarding the potential risk involved in treatments or tests as well as possible side effects and secondary ailments. By the same token, the individual's right to reject such information must also be respected.

            In a hi-tech environment special care must be taken to uphold the tradition within nursing of respecting the views, requests and needs of the clients, their families and other individuals who provide support.

Knowledge in nursing

Nursing practice is based on a range of varied knowledge, both theoretical knowledge gained from research and experiential knowledge from the profession itself. The discipline of nursing seeks to create a comprehensive knowledge of human reaction to illness or disability and of ways in which to assist and support individuals in improving their health and adapting to altered circumstances. In addition to nursing knowledge, nurses also draw on the knowledge of related disciplines, such as the social sciences, the humanities, biology and medicine. Such knowledge gives insight into the biological characteristics and development of human beings and helps nurses towards an understanding of the social relations, culture and personal history which shape and mould the experience and views of individuals and their families.

            The integration of theoretical knowledge and practical experience is a key factor in nursing. Through reflection and continuous assessment of their professional performance, nurses can gain a deeper understanding of their discipline and thus strengthen their practical knowledge, which is a prerequisite to professional competency. Practical knowledge must be respected and every effort must be made to help further its growth and development.

            The creation of knowledge through research is important to the nursing profession as it leads to improved nursing, more successful nursing intervention and increased efficiency. The ability to measure the results of nursing is important, although it may not always be possible. All nurses are in one way or another participants in the process of structuring and conducting research into nursing practice as well as disseminating and utilising knowledge created through research. The academic education of nurses in the field of research must, therefore, be strengthened and necessary conditions created within health care institutions for nurses to carry out research and apply the results obtained in clinical work.

Nursing education

The education of nurses has been a key issue ever since nursing became an independent profession in the 19^th century. Icelandic nurses have been successful in their struggle for improvement and today they are counted among the leaders in Europe as regards the organisation of general nursing studies. The Icelandic School of Nursing was founded in 1931, but in 1986 all nursing education was brought up to university level. Today, nursing is taught at the University of Iceland and at the University in Akureyri.  The degree of BS in nursing is awarded after a four-year general study programme.

            The principal education policy of the Icelandic Nurses' Association is that basic nursing studies should aim at educating a generalist, followed by optional specialisation at the advanced level. Basic nursing education should aim at the adoption of professional work methods among the students, introduce theoretical knowledge, facilitate understanding and knowledge of the ethics of nursing, and provide opportunities for the application of knowledge in practice. The nature of nursing education is theoretical and geared towards training students in scientific work methods, while at the same time broadening the students' insight into clinical nursing and their understanding of the underlying ethics. This gives a broad and general foundation for nursing in urban as well as rural areas, in primary health care centres as well as technologically advanced institutions. Nursing education should take aim of society's needs at each particular time and reflect the latest developments in knowledge.

            Advanced and continuing education is a prerequisite to maintaining professional knowledge and competency. Such educational options should therefore be readily available to nurses at all times. Technological advances and increased complexity at various levels of treatment have resulted in growing specialisation, especially in high technology institutions. In the years to come, we can thus expect an increased demand for specialised nurses with advanced technical skills and for a range of different fields such as geriatric nursing, psychiatric nursing, and primary health care. Simultaneously, work in all aspects of nursing requires a comprehensive ethical knowledge and ability to address morally complex issues. Further education options at the University of Iceland have decreased in recent years - a negative trend which must be reversed by all means available.

            Since nursing has now become a university discipline, it is only natural that specialised postgraduate education should be organised at Master level. Postgraduate studies give nurses the opportunity to advance their theoretical skills, to broaden their knowledge in certain specialised areas and further their research skills. There is a growing need for people with advanced specialised education within the health care system, so today it has become imperative to strengthen nursing education at the Master level.

            During doctoral studies, nurses develop their skills in organising extensive research projects and in conducting independent theoretical inquiries, which require comprehensive knowledge and aptitude for critical analysis. Nursing is rapidly growing as an academic discipline. Doctoral studies are a key factor for the promotion of research and the enhancement of the profession and every effort must be made to support nurses who embark upon such a course of study.

Towards the future

The changes in social structure and general health, which were outlined above, call for new means for preventing detrimental effects on health and improving the well being of the nation. One of the chief characteristics of modern health services is that patients and their families are now expected to be active participants in their own care and decision making processes. The public has become health-conscious and seeks information on how to improve well being, prevent diseases and solve health problems. Recent developments in informatics provide a new venue for disseminating information on healthy living, prevention, self-help, health problems and the health service as a whole.

            An informed public demands information and participation in its treatment and these demands must be met with the full support and understanding of health care professionals. These developments are not only reflected in changed attitudes toward patient participation, but have also affected the modification of services. In most parts of the Western world there is now a general tendency to move services away from hospitals and long-stay institutions towards primary health care centres. This trend is in many ways humanitarian and preferable, but it also calls for improvements in health and social services. The continuity of services for the sick and the disabled between institutions and their homes must be ensured. Responsibility for specific areas must also be clearly defined. Care must be taken not to make unrealistic demands on patients for looking after themselves and for families to provide direct care. Care giving in the home requires a well-organised public support system.

            Ensuring continuity in nursing intervention between hospitals, families, home care nursing and social services is a major task which demands co-operation and an efficient exchange of information. The health and social services must be prepared to offer clients a range of options, be flexible and prepared to meet different needs and requirements. Short-term respite in nursing homes is an important option which facilitates the ability of the elderly to live at home with the help of home care nursing. Others may choose permanent residence in nursing homes, often because of the limited availability of informal assistance at home. Similarly, sheltered housing and day-care facilities are important options for a number of patients. Clients must, above all, have an easy access to appropriate and reliable services whenever needed.

            In order for community nurses to be able to shoulder the increased responsibility inherent in a new kind of health system, they need to have access to specialised services and advice on nursing and related fields. Here, the work of independent specialised nurses is important. As well as looking after patients who require specialised nursing, they also play an important role as consultants in primary health care. In a number of instances, these independent nurses provide individuals who choose to stay at home with the kind of nursing that would normally not be available in hospitals and thus form a kind of a bridge between these institutions and the community.

            In addition to improving the services to those who need care and support in the community, it is also important to strengthen other aspects of community care outside health care institutions, for instance in schools and at work-sites. Special attention should be given to the various ways in which health education, counselling and support could be made available to children and adolescents at all levels of education. Efficient public health care, which focuses on prevention and improved well-being, is an area that needs to be developed in the near future. This calls for changes within the existing health care system as well as in the education of health care professionals. The aim of health promotion is to prevent problems by making the public aware of the benefits of healthy living. At the same time it is important to provide information on the risks of chronic illness, psychiatric problems and accidents while simultaneously drawing attention to ways in which to improve general well-being, both among the chronically ill and disabled and those who are regarded as healthy.

            A psychosocial support system can help people cope in times of stress. Self-help groups give patients and their families the opportunity to meet with others who share their problems or have found themselves in similar situations. Nurses need to have good access to information on self-help groups and patient interest groups and be familiar with the way in which they operate.

Health sector financing

The revolutionary advance in our knowledge of the nature and causes of health-related problems and how to deal with them has resulted in a steady increase in health sector expenditure. Modern technology has made it possible to achieve far more than we as a nation are willing to spend in the area of health care. Therefore, in recent years, the government has constantly sought ways to curb spending and has even resorted to fundamental restructuring of its health care services. It is a vital concern that such reductions do not affect those in need. In addition to cutbacks, service fees have also increased. The overall effects created by charging health service fees need to be surveyed and every effort must be made that such practices do not discriminate against the less affluent. 

            Health service is regarded as a basic human right in Iceland. It is, therefore, natural and imperative that the public authorities ensure that all citizens have access to an efficient health service that is tailored to their needs. Their task is to lay down rules regarding the quality and level of service. Public authorities also serve an important role as regulators. Owing to the nature of the health system, it can only be assumed that it will to a large extent be run by public authorities. The Icelandic Nurses' Association, however, encourages operational flexibility, for example by examining various different structural forms.

Job environment

Public financing and staffing affect the quality of nursing no less than the education, knowledge and experience of nurses. Shorter hospital stays in hi-tech hospitals, often due to cutbacks, demand greater professional skills. A growing demand for well-educated and specialised health care professionals has coincided with increased pressure at work. Numerous indicators of increased stress among nurses require careful consideration. Examples include the results of research into violence suffered at work, increases in sick-leaves and the general discussion on unacceptable working conditions in health care institutions in the wake of cutbacks

Management

The nursing division employs nurses, nursing auxiliaries and unskilled workers under the control of a director of nursing service who is responsible by law for the conduct of the service. It is important to ensure that the director of nursing service is a fully qualified nurse. Directors of nursing service give direction regarding areas of emphasis in nursing care and methods to be employed and motivate their staff to provide high-quality service. A good rapport between management and general nurses is vital and there must always be a general consensus regarding changes and improvements. Middle managers, i.e. head nurses, play an important role in ensuring that all views are heard and taken into account when organising the service.

            According to the current legislation on nursing, it is not permissible to employ others than qualified nurses to take on the responsibilities of nursing in hospitals, retirement homes, primary health care or domestic nursing. Nursing auxiliaries and unskilled workers are employed in nursing divisions under the control and responsibility of qualified nurses.

References:

1        World Health Organization: Alma - Ata 1978: Primary Health Care (Health for All Series, No. 1) Geneva, WHO. 1991

2        Íslensk heilbrigðisáætlun (Icelandic Health Policy). Parliamentary resolution ratified by Althingi, 19 March 1991.

3        Nursing Practice (1996). A report compiled by a specialist committee under the auspices of the World Health Organization. Geneva: World Health Organization.