State of Nursing Science in Finland
6.3 Characteristics of the Discipline of Nursing Science
programmes but also for the development of research and nursing as a scientific discipline. The national collaboration has provided the opportunity to invite interna- tional experts to Finland, made research collaboration easier, and guaranteed high- level national education for PhD students. In summing up the establishment and the first steps in the development of nursing science in Finland, which was character- ized by strong enthusiastic attitude of the people working at the universities and in the field, it is important to note that the universities offering these programmes have been working together, have made collaborative decisions and have supported each other. This collaborative approach has been a characteristic of Finnish nursing aca- deme, in addition to the collaboration with other health sciences.
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statistics available). Approximately 200 nurses finish a Master’s degree and approx- imately 20 nurses finish a PhD degree from universities every year. This means that we have nurses with university nursing degrees in all areas of society: in health care, in education, in the third sector, in politics, in the business sector and in research.
Universities have provided Master’s education within nursing and health-care education. Internationally, there are many differences between countries in health- care education and the required competence of educators [10]. In Finland, nursing and health-care educators are needed in two levels: in universities of applied sci- ences (UAS) and in universities. All educators in UAS have a minimum of Master’s degree, with nursing science as the main discipline and minors in educational sci- ences. Some nursing educators in leading positions and in the UAS Master’s pro- grammes also have a PhD qualification. In the universities, a PhD degree is the main competence criterion of faculty members. Nursing educators with Master’s or PhD qualification also work in health-care organizations, mainly in the coordination of clinical teaching but also in management positions. This means that both in the field of clinical practice and education, the level of teachers and their knowledge about nursing research is rather high. This gives more potential for evidence-based nurs- ing in the country.
As for nurse leaders and managers, their educational background is not quite as clear as that of teachers, even though the programme for nurse managers was the first one to be established in the University of Kuopio in 1979 [11]. Nurse leaders and managers in health districts and primary health care have a Master’s degree from university; some leading directors also have a PhD degree—either in nursing science or health-care administration. Thus, compared with many other European countries, the leaders and managers have a rather high level of education, allowing them to implement evidence-based nursing and to support the implementation of nursing research in health-care organizations. In recent years, however, the number of nursing administrator positions has decreased due to the financial situation in the health-care organizations.
In Finnish clinical practice, there are also clinical nurse specialists educated at universities and nurse practitioners educated at either universities or universities of applied sciences. The positions, however, are concentrated in university hospitals, mostly in Helsinki and Turku. In the University Hospital of Oulu, the most northern university hospital, they have had one of the very first clinical specialists in nursing science. However, the work role of these clinical specialists varies, and their role is not strictly defined in Finland. The same goes for advanced nurse practitioners (APN) in general: there is a variation in their education and the nature of their posi- tions. They do, however, have a national Finnish network that enables collaboration and future development. In Finnish health-care organizations, nurses have a major role: in 2009, Finland had 9.6 nurses per every 1.000 inhabitants—at the time a larger proportion compared to the other Nordic nations, whereas we had 2.7 practis- ing physicians per every 1000 people, which is very low compared to the other Nordic countries. This can partly be explained by the importance placed on the changing role of nurses taking on more responsibilities from physicians and which greatly reduces the need for practising physicians.
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6.3.2 Nursing Research Within the Finnish Health-Care System The Finnish health-care system is organized around primary health care and 21 health-care districts owned by the municipalities [12]. Finnish health care can be considered a success based on several indicators. Over the past few decades, there has been a remarkable improvement in life expectancy, and infant mortality and maternal mortality are among the lowest in the world. Particular success can also be seen in regards to specialized medical care and the coverage of screening, like breast cancer screening, and vaccination programmes. According to the Euro Health Consumer Index (2017) [13], Finland placed fourth in its 2015 survey, being a leader in value-for-money health care. In the future, lower fertility rates and multi- dimensional health issues of older population bring new challenges to the Finnish health-care system. As there will be fewer people to pay for health and social care, it is predicted that many of the ageing population will be affected and the old age dependency ratio in Finland will be the highest among all EU countries in 2025.
Therefore, in the coming years, a large reform of the social and health-care sector is planned to be implemented.
In health-care districts, especially in university districts, research strategies are important instruments for the development of evidence-based practice. For exam- ple, in the Health District of South-West Finland, in the area of Turku University Hospital, the strategy of nursing research [14] emphasizes research in the field of patient-centred services and patient resources, nursing professionals’ resources and health-care service systems. In the Kuopio [15], the corresponding fields are func- tionality of the health-care service systems, leadership in health-care and development- related interventions. In all the health districts, the Ministry of Social Affairs and Health distributes annual research funding (referred to as state research funding, VTR). This funding is also aimed at nursing research in the area, based on competition with all other clinical fields. In different health districts, nursing researchers have succeeded rather well in competing for funding, mainly because nursing concentrates more than other disciplines on the development of the organi- zation of health care, also implementing health service research. Development of the organization of health care has for many years been the focus of funding allo- cated by the Ministry of Social Affairs and Health.
From the very early years of nursing research, patient orientation has been fundamental in nursing research in Finland. To strengthen nursing research for patients, all universities have established cross-appointments of nursing profes- sors in the university hospitals, health-care districts and primary care: in Kuopio, where three professorships were established (1990, 2000, 2011); in Turku, where four professorships were established (1991, 2006, 2007, 2012); and in Oulu (1994), Tampere (1995), Åbo Akademi (1996) and Helsinki (2011), where one professorship was established at each of the universities. In these cross-appoint- ments, there is variation and the work profile of the professors depends on the district. In some of the districts, also other collaborative positions have been established. They all, however, conduct their own research in the hospitals of the health districts and primary health care, which provide the professors with an
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effective research environment, close connections with nurses in working in clini- cal practice and supporting the implementation of research results or evidence into the clinical practice.
The implementation of the results of nursing research, or evidence-based prac- tice, has been rather successful in many parts of health-care organization.
Implementation, however, seems to be a challenge both nationally [16] and interna- tionally [17]. An organization, Hoitotyön tutkimussäätiö (Nursing Research Foundation, NRF) [18], was established (in the year 2005) aimed to improve the implementation and is responsible for the nursing recommendations and their implementation and also for improving the utilization of nursing research. The results, however, are not yet very consistent, and there is a continuous need to develop systematically evidence-based nursing. In health districts and primary health care—based on law—this is the duty of nurse directors [19]. The factors inhibiting the use of research findings in nursing practice are mainly dependent on the organizations, not so much on the nurses. Studies have shown that nurses lack the time to familiarize themselves with nursing research, they lack opportunities to read about research during working hours, and an organizational culture is not facil- itating them to provide evidence-based nursing care [16]. Similar challenges have been identified in nursing education [20].
6.3.3 Quality of Nursing Research
Every university in Finland is responsible for the evaluation of their programmes, outcomes and the arrangements needed for improving the quality and effectiveness of education and research. Approximately 25 years after the launch of academic nursing education (1979), nursing research was evaluated in 2003, by the Academy of Finland (2003) [21]. The main task of the Academy is to support high-level research with funding. In the committee for research related to health, nursing sci- ence is described as one of the disciplines of health sciences, which guarantees the formal position of nursing science. An international evaluative expert committee was invited in 2003, and all five universities produced material for the evaluative analysis. As a summary, the evaluative committee stated that:
… there have been many very positive developments and achievements in nursing science in Finland over its relatively short history. Finland was fortunate in having had visionary nurse scholars who led the first all-important developments in the early years that resulted in the introduction of research into Finnish nursing, and the introduction of nursing into Finland’s university system. ([21], p. 58)
Despite these positive comments, the evaluative committee, however, made the following recommendations: to move away from small-scale studies to larger-scale national and international research and international multicentre research and to create more research focusing on clinical outcomes and measuring the effectiveness of nursing interventions. Also, they recommended a stronger leadership of research programmes and pointed out the heavy teaching demands on staff in the nursing
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science departments. Furthermore, they recommended to strengthen the group iden- tity of PhD students as well as emphasizing the need for post-doctoral training fel- lowships. Based on these recommendations, many outcomes can be identified. At the University of Turku, a professorship in clinical nursing science was established in 2008, and the Finnish national doctoral network was strengthened. However, set- ting up a post-doctoral training programme, as recommended, took a while and was established in Turku in 2013. Other universities have since followed suit. In conclu- sion, the international evaluation conducted in 2003 by the Academy of Finland was extremely useful for the discipline of nursing science in Finland.
After that, evaluations have been performed at the universities as part of their general evaluation [22, 23]. Generally, the level of nursing research has been valued as high. In 2016 the nursing science department at the University of Turku, for example, scored very high or “excellent” in all 14 areas of the evaluation.
Furthermore, nursing research at the University of Turku has ranked high in the International QS ranking [24] and the Shanghai ranking [25]. Also, the University of Eastern Finland ranked high, coming in the second position in Finland. Units of nursing/caring science in all Finnish universities, however, have been very success- ful and productive.