State of Leadership in Nursing Science in Iceland
10.2 Reforms in Nursing Education as the Ground for Nursing Science
Quality nursing education was an important topic for Icelandic nurses for most of the twentieth century. In the beginning, women went abroad for their nursing education, mainly to Denmark but also to the other Nordic countries, often with a support of individual nurses who at the time were mainly from abroad. The Icelandic Nurses’
Association (ice. Félag íslenskra hjúkrunarkvenna), when established in 1919, became paramount in promoting nursing education. The association worked dili- gently toward having sufficient and well-educated nurses when the first national hos- pital in the country, Landspitali the National Hospital, would open in the year 1930 [7]. Formal nursing education, provided in a 3-year hospital-based diploma school, the School of Nursing, was first offered at Landspitali the National Hospital in Reykjavik in 1931 shortly after its opening. That school was transferred to become the Icelandic School of Nursing (ISN) in the year 1948. The ISN was the only hospi- tal-based nursing school in the country from its establishment until its closure in 1986. After the establishment of formal nursing education, Icelandic nurses contin- ued to seek education abroad, mainly for specialty education. The majority of nurses went to the Nordic countries. Concurrently Icelandic nurses enjoyed advise and sup- port on education from their colleagues in the Nordic countries through an indispens- able collaboration within the Northern Nurses’ Federation [2, 7, 8].
In the 1960s nurses had identified needs for changes in their education in order to be able to sufficiently run the ISN where there was a shortage of nurse educators.
To become hired as teachers at the ISN, nurses had to go abroad to specialize in teaching. Even more importantly, there was an ever greater need to enlarge the nurs- ing work force concurrent with advances in health sciences and more complicated health care with consequently new tasks for nurses. New healthcare institutions were built, and primary health care was gaining momentum. Many issues came together: There was a great demand for enlarging the nursing work force, and there was shortage of nurses who had specialty education, particularly in nursing educa- tion, administration, and management [8].
As a part of an international trend, there was a big influx of students generally, and women particularly, to the University of Iceland (UI), the only university in the country at the time. New disciplines needed to be established, and nursing became one of them [3]. Postwar economic growth and a general increase in emphasis on science and education put forward by the government also paved the way for
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university education in nursing [3]. There were fresh winds blowing in the Icelandic society. Higher education was gaining significance among the general public.
Influences from the “hippi” uprising in 1968 were dominant, with strong claims for gender equality between men and women particularly regarding education and work opportunities [3]. The position of women in the Icelandic society was strong, e.g., with the first woman became president of the nation in 1981 when Madame Vigdís Finnbogadóttir was elected to the Icelandic parliament. The Women’s Party had become a powerful voice in politics with several seats in the parliament, both of which contributed to the leeway that nursing education received in the early days.
There were as well powerful nurse leaders of the time; nurses who had strong ties to key persons in public administration and politics, for whom it became easier to get across the notion of the significance of university education in nursing. In this con- text, the small size of the Icelandic society played a significant role as well; there were short lines of communication, one existing nursing school in the country and few health care organizations with which to consult.
The Icelandic governmental officials, particularly within the ministry of edu- cation, administrators at the University of Iceland, and leaders within the Faculty of Medicine, responded positively to a proposal for university education for nurses composed by the Icelandic Nurses’ Association in 1969 [3, 8]. Like the other Nordic nurses’ associations, Icelandic nurses envisioned advanced educa- tion at the university for nurses with diploma education. They also wanted more students with matriculation degree to enter into nursing. Different, however, from the initial idea, the University of Iceland launched an undergraduate univer- sity education in nursing. The Icelandic Nurses Association proofed the proposal but reiterated the need for advanced education at the university level for nurses with diploma education [8].
In 1973, a generic 4-year baccalaureate nursing program was launched in the Department of Nursing (DoN) which was located within the Faculty of Medicine at the University of Iceland. Advanced education in specialty areas started in the newly formed New School for Nurses (not a university education) in 1972, first in psychi- atric nursing, and later in several other specialties. That continued until advanced education for nurses with diploma education was incorporated into the University of Iceland in 1990 [8]. Since, continuing education at the university level has been provided there in various specialty areas in nursing.
10.2.1 University Education in Nursing
University of Iceland took the lead in Europe to be one of the first universities to offer baccalaureate education in nursing when the nursing program started in 1973.
Undergraduate education in nursing had already begun at the University of Edinburgh some years earlier [9]. This foresight caught quite an attention interna- tionally [10]. University education was meant to raise the educational level of nurses so that they would be better equipped to meet more complex healthcare demands, equally to alleviating long-standing shortage of nurses. The importance of having
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students with a stronger educational background, or a matriculation examination, on entry into the nursing education was valued [8].
The establishment of the Department of Nursing had a short preparation. At the time there was no nurse with graduate education available in the country to take on a faculty position. To a large extent, teaching was sought elsewhere in the UI, par- ticularly the Faculty of Medicine, as well as outside the UI, among nurses especially at the Landspitali the National University Hospital (LSH). Temporary faculty was also sought internationally to strengthen the teaching and curriculum development.
Guidance and financial support was provided from the World Health Organization (WHO), which, some years earlier, had proposed a universal university education for nurses. Over less than a decade, WHO supported six nurses for up to a semester to teach and council the faculty at the DoN. The WHO also granted funding for Icelandic nurses seeking graduate education in the UK and USA. The Fulbright Institute supported guest professors from the USA, and there were some faculties from Canadian universities who contributed substantially to the DoN [8]. The Icelandic Red Cross also provided financial support (MagnúsdÓttir, 2018, Personal communication). The university education was, right from its beginning, highly influenced by nursing educational systems in the USA and Canada. Those influ- ences have remained ever since, augmented by bilateral contracts of collaboration with some institutions, among them the University of Minnesota, Twin Cities, and the University of Wisconsin, Madison.
A strong focus on research skills has been in the curriculum right from the outset.
One of the five main goals of the education was that upon graduation students could plan and conduct nursing research. This goal was considered particularly ambitious.
Twenty years later the president of the university maintained that with perseverance and courage of the leaders of the department, the original goals had mainly materi- alized [11]. Students learned methodology and practiced research skills when work- ing on their BS thesis. A primary care nurse who graduated from the Icelandic School of Nursing in the 1970s reflecting on her education said that at that time there was hardly any mention of nursing research. If so, students could only envi- sion research that was to be conducted on the students/nurses themselves. Twenty years later, however, there was hardly any nurse who did not realize that nursing research was the foundation for progress in nursing and that research findings were the basis for good nursing care [12].
A quarter of century after the establishment of the undergraduate education at the UI, Icelandic nurses got the opportunity to study toward a master’s degree in their own country. In the meantime, most nurses had gone to the USA and some to Sweden and the UK for master’s education. With master’s degrees in a variety of specialty areas, some nurses continued for their PhDs in these same countries. For an example of this trend, six out of eight graduates of the undergraduate program the year 1981 hold a master’s degree; four of them took their degree in the USA and two in Iceland. Three of them continued and took a doctoral degree, two in the USA and one in Sweden. Later on, with the master’s education in nursing established at UI in 1998 and the PhD program in 2004, nurses have more or less stopped seeking
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graduate education abroad. Despite the availability of student loans, financial cost of graduate education has become of increasing hindrance, although family issues are barriers as well.
Going abroad to seek formal nursing education and to widen the horizon was highly important for Icelandic nurses for the whole of the twentieth century [7].
This has in fact been so for Icelanders, more generally, for centuries. The University of Iceland was founded in the year 1911. For several decades before the establish- ment of the University of Iceland, education in the professions of theology, medi- cine, and later the laws had been offered in separate schools. The first one was the School of Theology, which was established in the year 1847. Prior to the establish- ment of the UI, university education was primarily only for a selected group of the social elite who could afford living abroad. Around the middle of the twentieth century, the Icelandic Student Loan Fund was founded and became essential in providing the vast number of young people to seek university education at both undergraduate and graduate levels [3]. The fund has the main role to secure that, with some restrictions, Icelandic people “have the opportunity to pursue studies irrespective of their financial standing” [13].
In the beginning years of the Department of Nursing, all effort was dedicated to running the school and admitting a growing number of students. The first faculty member, Marga Thome, a master’s prepared nurse, was hired in the year 1977. In 1983 there were 3.5 full-time positions and just about 300 students. In 1988 the positions had grown to 8.5 and the number of students 335 [14]. Nurses who had finished their master’s education abroad were gradually hired as faculty members.
However, the emphasis on faculty research endeavors lagged behind and was less than expected in comparison with other faculties. This was due to the heavy teach- ing load of the young and immature department [14]. Slowly the faculty and other master’s prepared nurses sought doctoral degrees from abroad. The first nurse com- pleted her doctoral work in 1992. In the beginning of the year 2018, about 50 Icelandic nurses hold a doctoral degree. From around the middle of the 1990s, due to a generally more stringent recruitment policy [15], nurses with a doctoral degree were the only nurses to be hired in academic positions in nursing to the DoN.
For the first 13 years, the baccalaureate program at the University of Iceland ran parallel with the diploma education provided by the Icelandic School of Nursing.
The baccalaureate education was met with some resistance in the beginning years from nurses with diploma education. Some felt deceived when they realized that only undergraduate education was to be offered at the UI. Of particular concern was that teachers of the ISN had lost their positions as nursing teachers. A special BS program was designed for them and run once [8]. More was however needed to make smother this big transformation in nursing education. In the year 1991, a for- mal diploma-baccalaureate program specially designed for nurses with diploma education primarily from the Icelandic Nursing School was initiated. Its goal was to provide courses that were an extension of the diploma nursing education, emphasiz- ing nursing knowledge as well as research methods and training of scientific skills [16]. In the beginning the program was 120 ECTS [17], but was gradually reduced
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and was 60 ECTS in the year 1998 when the last group of students was admitted. A considerable part of nurses with diploma education finished that program or about 200 nurses [18]. In retrospect this program contributed substantially to alleviate the tension between nurses with diploma and baccalaureate education. More impor- tantly though in this context was the unification of the two nursing organizations, the Association of University Graduate Nurses (ice. Félag háskólamenntaðra hjúk- runarfræðinga) established in 1978, with the Icelandic Nurses’ Association (ice.
Félag íslenskra hjúkrunarkvenna established in 1919, which was renamed Hjúkrunarfélag Íslands in 1960). This event took place in 1994, and the new asso- ciation was named the Icelandic Nurses’ Association (ice. Félag íslenskra hjúk- runarfræðinga) [8].
One year after the diploma nursing school was closed, or in 1987, an undergradu- ate nursing education program started at University of Akureyri (UnAK). Located on the north site of Iceland, this school aimed to educate nurses for work in most areas within the healthcare system as staff nurses, managers, and educators [19]. At the outset the educational curriculum mirrored the one at the UI, later to develop toward its own. Blended learning with distant education is the main mode of the education. The faculty of nursing at the UnAk is positioned within the School of Health Sciences at UnAk. The School of Health Sciences runs a master’s program in health sciences. In the year 2017, UnAk was licensed to offer doctoral education in five disciplines, one of which is nursing [20].
10.3 Autonomy Over Nursing Practice and of Nursing