Från substantiv till formell teori

Den genererade teorin är en substantiv teori och gäller för det avgrän- sade området distriktssköterskors hälsovägledning i barnhälsovården. Den är tämligen generell och är inte snävt avgränsad till en specifik barnhälsovård, utan berör en övergripande problematik i barnhälsovår- den. Troligtvis skulle den därför kunna gälla både för distriktssköters- kor och fö r barnsjuksköterskor inom alla typer av barnhälsovård, även om de är organiserade på olika sätt.

Även andra yrkesgrupper har samma dubbelsidiga hälsofrämjande och pedagogiska uppdrag som barnhälsovårdens distriktssköterskor, med att samtidigt både följa riktlinjer för befolkningsinriktat hälsoarbe- te och arbeta utifrån den enskilde individens bästa under en längre av- gränsad tidsperiod. Skolsköterskor har också ett nationellt program att följa, samtidigt som de har som uppgift att arbeta med de enskilda ele- vernas hälsa ur ett individperspektiv under den tid som barnen går i skolan. Företagssköterskor har samma situation som distriktssköterskor i barnhälsovården. De arbetar både med hälsoprogram som är fastställt för befolkningen inom en arbetsplats, samtidigt som de skall uppmärk- samma den enskilde arbetstagarens hälso- och arbetssituation i ett tids- perspektiv. Den genererade teorin är på så sätt troligtvis tillämpbar både i skolhälsovård och i företagshälsovård. Den är troligtvis också

tillämpbar inom flera andra verksamheter med en liknande dubbelsi- dighet inbyggd, t.ex. pedagogiskt arbete i skola och omsorg.

Genom att använda teorin som ett inslag i forskning på andra områ- den än det som varit aktuellt i denna studie, kan det komma att visa sig, att teorins giltighet sträcker sig utanför det substantiva området och att den kan utvecklas till en formell teori kring det hittills dåligt genomlys- ta problemområdet hur motstående uppdrag kan syntetiseras.

Summary

Introduction

Child Health Services (CHS) in Sweden have a long tradition as a health promotion activity. It is well established and most families with children up to seven years of age use the opportunity to visit ”their” Child Health Centres (CHC) and ”their” nurses, in accordance with the Swedish nationa l CHS programme and the families’ own need for con- sultation. Thereby, CHS at CHC form a strategic arena for Swedish health promotion, from a societal as well as an individual perspective.

Nurses at CHC are important actors in CHS. Besides health exami- nations and child development assessments, the nurses have educa- tional tasks, including general health information for all parents, paren- tal education and individual health counselling based on parents’ re- quests.

CHS nurses meet families from various contexts and cultures with different prerequisites, experiences and values, which are of importance to their feelings, thoughts, and behaviour. Their individual needs differ, and their requests for health promotion therefore vary. In this way, dis- trict nurses in CHS face a daily educational challenge, i.e. suiting health promotion to each family and supporting their learning proc- esses.

My earlier studies of child health promotion (Olander, 1993, 1994, 1998) demonstrated health counselling in CHS to be multi- faceted work, consisting of several areas demanding integrated approaches and methods. Health counselling can thus be seen as an educational process aimed at strengthening parenthood, increasing empowerment and creat- ing awareness of health and society. In fact, the health counselling process consists of two processes. One is an educational process start- ing from aims and policies, moving via district nurses health counsel- ling to parent participation, activity and learning. The other process is a learning process, starting from parent’s participation, activity and learn- ing and moving via district nurses to health counselling.

The study also pointed to the difficulties district nurses working with health counselling experienced, due to negative influences from differ- ent factors such as unclear aims and policies, lack of time for reflection and discussions, lack of competence, and organisations and environ- ments that do not support counselling. Thereby health counselling in practice cannot be improved only by implementing a new counselling method. All of the factors mentioned above - important for accomplish- ing health counselling - also have to be improved. District nurses’ edu- cational task in health promotion has not been given much attention, neither from district nurses themselves, nor in nursing training pro- grammes or policies. Research focusing on interacting factors and their relationships for health promotion and especially health counselling in CHS is not widespread. Researchers and evaluations consider there to be a need for didactic research in health promotion in CHS, focused on the whole educational context, the process, and their interaction.

Purpose

The present study focuses on district nurses’ health counselling in CHS. The purpose is to improve understand ing of what is important in shap- ing and accomplishing health promotion, and to generate theory, useful in a CHS context. The study can hereby be an effort to extend theory building for health counselling in CHS. The study builds on a widely framed question: What do district nurses experience as their main con- cern in their meetings with parents and children at CHC open consulta- tions?

Point of departure

The present study has its base in my experience of daily practices and my long felt need for scientific elaboration. This laid the foundations for an inductive research approach, using the method of Grounded Theory (Glaser & Strauss, 1967), with roots in pragmatism and sym- bolic interaction. The study is based on a holistic view on health and on the assumption of health promotion as an enabling process, following Health 21 (WHO, 1998). This approach is not so widely used in health care, since a ”traditional” approach (preventing diseases, not promoting health), has dominated health care including CHS.

An essential part of CHS is health education. Different concepts such as health information, giving advice, etc. are used for these educa- tional activities. They do not relate to education as a learning process in

which professionals and parents take an active part. Therefore the con- cept of health counselling is used in my studies of CHS as a means of coming closer to a modern approach centered on health promotion and learning processes.

Child Health Services

CHS is voluntary and free of charge. The national Child Health Promo- tion programme comprises health surveillance, health examinations, immunisation and health education. The programme embraces general activities for all children as well as specific activities intended for vul- nerable groups or individual families. The child health promotion pro- gramme consists of frequent meetings with parents and their children during the child’s first one and half years, and after that, consultations each year. In addition to these consultations, parents can go to CHS open consultations whenever they wish, to control their children’s health and discuss health problems. All consultations in CHS are re- corded in a national standardised child health record. The case record consists of defined fields noting each child’s development, medical examinations and interventions. The case record also has fields for cur- rent notes about the content in consultation and health counselling. In several county councils in Sweden, district nurses, not paediatric nurses, have the responsibility for CHS alongside primary health care for adults and elderly people in a clearly defined geographical area. General practitioners or paediatricians are involved in CHS to a lesser extent.

Method

Grounded Theory (Glaser & Strauss, 1967), the method used in the present study, is an inductive method with deductive elements. It is aimed at generating a theory containing an integrating set of conceptual hypotheses based on data from a substantive field. This is made possi- ble by constant comparison of data, concepts, categories and properties of categories/concepts. The methodology comprises methods of data collecting, substantive and theoretical coding, theoretical sampling fol- lowed by repeated coding, while constantly comparing, further sorting of memos written throughout the multivariate process and finally ha v- ing a theory emerge, based on how the people in the substantive field manage their main concern.

Data were mainly collected at CHS in one primary health care area. Data sources consist of video-observations with recalled interviews, field notes, notes from group discussions and individual interviews. Seven district nurses meetings with parents and children at open con- sultations were video recorded three times each and the nurses were interviewed after the recorded visits. Field notes were collected from participatory observations and brief discussions during the time I spent at the centre, approximately one day a week during two years. Notes taken of group discussions and group interviews were based on sched- uled monthly group meetings. Individual interviews with district nurses were selective interviews, as comparison required more data for the saturation of concepts. Data were also collected from the findings of my earlier study of health counselling in CHS (Olander, 1998). This data-source reflects CHS policies and other district nurses opinions of child health promotion and health counselling.

Data analysis followed the classic Grounded Theory method de- scribed by Glaser (1978, 1992, 1998). Following this method, concepts were created, allowing an emerging framework of categories and sub- categories through constant comparative analysis. A core category emerged and the other categories become sub-categories, all connected to the core category and to each other. Central to theoretical analysis process is memo writing. These written notes with reflections and ideas of concepts, relationships and hypotheses, are essential to the final the- oretical sorting for generating theory.

Results

Core category and sub-categories

At an early stage, empirical data indicated two aspects of district nur- ses’ health promotion in CHS. One derived from data where health promotion focuses on the population through general health surveil- lance, screening, general health information and advice-giving follo w- ing the CHS Health Promotion programme. The other was derived from data where health promotion focuses on the individual child and family, using the family situation as a starting point for discussions and advice. These concepts were labelled the population approach and the individ-

ual approach. District nurses thus have two missions: a public health mission (a government demand based on families as parts of the popu-

District nurses’ main concern in CHS is to synthesise these two ap- proaches in their practical work at the CHC’s open consultations. The category Population-individualisation evolved as the core category. Sub-categories related to the core category are Two-facedness, Indi-

vidualisation efforts, Normality focus, Case-record concern, Communi- cation staging and Action scope promoting. These all relate to the core

category and to each other. The concept of two-facedness refers to the nurses' awareness that the dual mission is, in fact a coin with two faces. The missions are contrasting but not contrary. District nurses make strong efforts to bring about individualisation in their meetings with parents and children and want to be able to live up to the family's wi- shes, needs and requests both in level of ambition and practice. The category has four main properties: identifying, confidence building,

participation inviting and obliging.

The next category is Normality focus. In CHS, development and behaviour is continually discussed and controlled in relation to borders and norms for what is accepted and no rmal, as expressed in guidelines and diagrams and by nurses and parents. District nurses in CHS have a considerable Case-record concern. In accordance with other health professionals, district nurses in CHS feel a strong need for recording facts and data and the child’s case record is given a lot of attention dur- ing the families’ visits to the CHC.

In district nurses’ meetings with parents and children Communica-

tion staging consists of making a choice between different types and

dimensions of conversation. The evolved types are prelude-talk, check-

up talk, chat, closing talk and dialogue. The evolved dimensions are separate or mixed conversation, discussing advice or giving advice and finished or unfinished conversation.

The last category is Action scope promoting. District nurses use strategies such as shutting off, taking needed time, keeping to routines and keep moving, which provides scope for individualization of health promotion in relation to the open consultations’ unpredictable envi- ronment and circumstances.

The categories form a theoretical construction for the emerging the- ory with the concept population-individualisation as the core category. The two missions, the public health mission and the family health mis- sion, are interrelated, which constitutes a complex dynamic context for CHS health promotion.

Patterns and movements

Four dynamic fields evolved in the analysis. The first field is the popu-

lation-individualisation field in which general concerns for public

health are combined with considering the needs of the specific family. This field has a strong population approach and a strong individual ap- proach. The second field represents a strong individual approach and a weak population approach. This is labelled individual support. The third has a strong population approach and a weak individual approach. This is labelled population-inspection. In the fourth field both ap- proaches are weak. This field is labelled routine check-up.

The next analysis focused on how district nurses accomplish health promotion to fulfil their main concern for synthesis, i.e. working from two missions with different approaches and keeping health promotion in the population-individualisation dimension. Analysis showed four patterns for synthesising. One is a hypothetical ideal proceeding. This is a synthesis where both approaches are equally strong. This cannot be seen in praxis. In empirical data three patterns with oscillatory move- ments are evident. One is a sig-sagging pattern with small oscillating movements, another is a pendulating pattern with longer movements and the third is a compensating pattern in which defective balancing on one occasion is compensated by alterations on the next visit.

Through the generating analysis the following substantive theory could be formulated:

District nurses in CHS manage a double-sided mission commissioned them by society (public health demands) and individuals (family health care) through synthesising these two approaches using oscillatory pat- terns within the dimension of population-individualisation.

Discussion

In order to integrate generated theory with existing knowledge, relevant literature and previous research were taken into account. Literature concerning the double mission in CHS and district nurses’ health pro- motion in CHS is sparse. Lipsky (1980) and Johansson (1992) describe dilemmas for individuals in public health services in virtually the same way as the present study does. According to Lipsky’s theory, district nurses in CHS can be counted among the group of official workers that is called ”street level bureaucrats”. These workers are the government’s outermost phalanx, and perform public policies required by high- level

administrators. It is these street level bureaucrats who give the final shape to these policies through their decisions and their routines, in which they constantly have to consider individual clients interests, be- sides the government’s. Lipsky points to the role of a bureaucratic con- troller counteracting the helping and advocating role. The present study shows another aspect of the double-sided role, in that district nurses in CHS subscribe to synthesizing the roles.

In a lot of the literature, the concept of health promotion is discussed from different perspectives: as levels, arenas, different approaches and theoretical models. The dual mission of a public health approach and an individual approach is noted in some of the literature, but the meaning, effects and problems are not discussed to any large extent.

The generated theory grounded in empirical data within the context of CHS provides us with knowledge that can help district nurses under- stand and manage their main concern for synthesising these two mis- sions. This theory may also contribute to increased awareness among administrators, decision makers and nurse- and health promotion edu- cators with regard to the dual mission in health promotion and the strategies for coping with it. In this way, generated theory should be able to contribute to the improvement of health promotion and health counselling in CHS.

The generated theory fulfils the four criteria for grounded theory trustworthiness: fitness, relevance, workability and modifiability. Fit- ness means that the received concepts are solidly grounded in the data. Relevance means that the theory is about real concerns of the partici- pants in the substantive area. Workability refers to the concepts and their theoretical coding being functioning in generating the theory. A grounded theory bears being modified if new data appear out of the substantive field, the literature or from elsewhere. In this way it can be modified by new data coming in, or by changes in the CHS context.

The generated theory is a substantive theory valid for district nurses’ health promotion in CHS. As it is rather general and concerned with the overarching problem in CHS, it is probably of relevance to all varieties of CHS. Other professionals, such as school nurses and occupational nurses have the same double-sided mission as the district nurses. Other professionals such as schools teachers have a double-sided mission, affording opportunities for all pupils to learn as well as supporting the individual pupil’s learning process. The generated substantive theory

can probably evolve into a formal theory for use in future research, valid for all professionals in public service with double-sided missions.

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