Nurses' contributions to health: Perceptions of first-year nursing students in Scandinavia and Indonesia

Abstract

Nursing students need an understanding of how nurses care for people's health from a global perspective. The aim of this study was to explore how nurses can contribute to health from the perspectives of first-year nursing students in Scandinavia (Sweden, Norway) and Indonesia. Data were collected using an open-ended question about nurses’ contribution to health, and analysed using qualitative content analysis. Three common categories emerged: ‘Promoting health and preventing disease’, ‘Performing care and treatment’, ‘Establishing a relationship with patients and being compassionate’. ‘Possessing and implementing knowledge and skills’ was common to Norway and Indonesia. ‘Being a team member’ was emphasised by the Indonesian participants. The Norwegian participants focused on health promotion, whereas those from Indonesia prioritised disease prevention. The Scandinavian participants emphasised individuality, while those from Indonesia focused on the community. The findings indicate that nursing education should take account of different cultures and include student exchange programmes.

Background

Health is a central concern for nurses as well as for many other health professionals. The traditional view of healthcare has been anchored in the medical perspective where health is seen as the absence of disease and symptoms. ¹ This is also called the biomedical perspective, which differs from the humanistic perspective that places health and illness on a continuum. ² The World Health Organization's (WHO) extended definition of health, which is not merely the absence of illness, but a ‘state of complete physical, mental and social well-being’, ³ has been criticised as utopic and for presenting a passive view of people. ⁴ About 40 years later, the Ottawa Charter stated that health is a resource for everyday life, emphasising social and personal resources, as well as physical capacities. ⁵ Ideas about health are also described as culturally related and vary across societies. ⁶ A Scandinavian study of health awareness ‘in the general population’ shows that health is viewed as holistic, woven into all parts of life and society. Furthermore, the study revealed that health is individualistic, pragmatic and relative as it is experienced and evaluated according to people's expectations. ⁷ Similar perspectives have been supported by Baxter. ⁸

Florence Nightingale described nursing as supporting people's health and wellbeing by putting ‘the patient in the best possible position for Nature to act upon him’.^9(p.75) Her view on nursing and health included the interaction between the patient's condition and the internal and external environment. Furthermore, Nightingale understood health as the absence of disease and use of the patient's personal healing powers. She described sufficient nursing knowledge and skills as a prerequisite for improving health, and nurses’ behaviour as having a great impact on patients’ health. ¹⁰ More recently, health professionals including nurses have described health as multi-facetted and a subjective experience, depending on context and culture. ¹¹ A study among Swedish nursing students shows that they also had a wide perception of the concept of health, based on holistic and positive attitudes. ¹² These studies did not show the connection between nurses’ work and health. The International Council of Nurses (ICN) has defined nursing as assisting individuals in activities that contribute to health, recovery or a dignified death. ¹³ The WHO and the ICN have described nursing as autonomous and collaborative care of healthy, sick or dying individuals of all ages as well as families, groups and communities. Nurses’ special concern is responding to health problems, preventing illness, promoting health and performing care.^13,14

Research has found that nurses are directly involved in achieving health objectives ¹⁵ and are good at patient-related care, but less skilled when it comes to developing nursing practice. ¹⁶ It seems necessary to strengthen nurses' critical thinking and their use of research in practice, ¹⁷ as well as improving nursing in the area of disease prevention and health promotion. ¹⁸

It may be difficult to draw a clear line between nurses' contributions to health and those of other health professionals. There may also be variations between countries because of differences in the environment, economy, culture, religion, health status, and working conditions of health personnel. In particular, there might be significant differences between developed countries, such as wealthy Scandinavian nations with relatively predictable environments, and developing countries, such as Indonesia with more unpredictable tropical environments and the challenges of poverty.

Compared to the Indonesian archipelago with about 257 million inhabitants, Norway with around 5 million people and Sweden with approximately 10 million are relatively small countries. ¹⁹ There are also other differences between the countries. People in the Scandinavian countries are mainly Christian, although society has become more secular and multicultural during recent decades. ²⁰ About 87% of Indonesian people are Muslim and in Aceh Province the figure is 98%. In 2015, the average life expectancy at birth differed between Norway/Sweden (about 82 years) and Indonesia (about 69 years) by approximately 13 years. ¹⁹ The mortality of children under five years of age was about 24 times higher per 1000 live births in Indonesia (27.2) compared to Norway (2.6) and Sweden (3.0). In Scandinavia, cardiovascular disorders, Alzheimer's disease and cancer are the main causes of death among the population. In Indonesia, the most common causes of death are also cardiovascular disorders and other so-called lifestyle diseases, but in contrast to Scandinavia, tuberculosis and endemic diseases frequently occur as well. ²¹

The number of physicians and nurses also differs between Scandinavia and Indonesia. There were 4.4 physicians per 1000 inhabitants in Norway in 2014, 4.1 in Sweden in 2013, and 0.3 in Indonesia in 2013. The corresponding figures for nurses in the same years were 16.9 in Norway, 11.2 in Sweden and 1.2 in Indonesia. ²² The availability of nurses is crucial, as studies show that health services and health outcomes suffer when nursing staff are scarce ²³ and that nurses with a higher level of competence reduce the workload and patient mortality in hospitals.^24,25

It has been stated that in the future nurses will need competence in global issues and the influence of the environment on health. ²⁶ Researchers in Scandinavia (Norway and Sweden) and Indonesia (Aceh Province) participated in a collaborative research project involving a questionnaire about life circumstances, health status and professional development among nursing students in the three countries. As part of this project, a study about nursing students' understanding of being a healthy person revealed more similarities than differences between the countries. ²⁷ Based on our literature search and to the best of our knowledge, there is a lack of studies about nursing students' perceptions of how nurses can contribute to health in these three countries. Therefore, another part of this project was to conduct a study with the aim of exploring how nurses can contribute to health from the perspectives of first-year nursing students in Scandinavia and Indonesia. The following research questions have guided the study:

• What are nursing students' perceptions of nurses' contributions to health in Norway, Sweden and Indonesia?

 ^ If there are any similarities or differences in nursing students' perceptions between the countries, what are they?

Method

The study design was qualitative and exploratory.

The context

Nursing education in Scandinavia and Indonesia comprises bachelor's, master's and doctoral degrees. In Sweden and Norway, bachelor's-level nursing education takes place at public university colleges and universities. In Indonesia, nurses are educated at either private or public nursing schools, university colleges, or universities, and although most obtain a Diploma of Nursing, there is an increase in the number obtaining a Bachelor of Nursing degree.^28,29 The Nursing Act of 2014 states that in order to remain registered, all nurses in Indonesia must undergo a competency examination five years after completing their education. They are also required to serve their community and participate in healthcare services, education, training and/or scientific activities. ³⁰

Sample and participants

All first-year nursing students from the bachelor's programme at a university college in Norway (n = 117), a university in Sweden (n = 61) and a university in Indonesia (n = 108), as well as from a Diploma III programme at two nursing schools in Indonesia (n = 111) who started their education in the autumn of 2011 were asked to participate. Diploma III is a three-year vocational education programme aimed at educating nurses to work effectively and efficiently in different healthcare settings.^28,29 Of the 438 eligible students, 397 (89%) participated in the study. About 85% of the participants in Scandinavia and around 75% in Indonesia were women. Approximately half of the Scandinavian students were married or cohabiting, while the Indonesian students were not. The Indonesian students were younger (mean age 18.4 years) than the students from Norway (mean age 25.1 years) and Sweden (mean age 24.3 years). The Norwegian students had completed a health promotion course (10 credits) at the time of the data collection, whereas the other student cohorts had not attended such a course.

Data collection

Data were collected between March and May 2012. An open-ended question: ‘How can nurses contribute to health?’ was included at the end of the questionnaire survey. Results from the survey are presented elsewere. ³¹ Teachers who were not involved in the study informed the students about it and handed out envelopes containing the coded questionnaires. After responding/not responding, each student placed the envelope containing the questionnaire in a sealed box. In accordance with the Eurostat procedure, ³² professional interpreters translated the open-ended question from Norwegian to Swedish, from Norwegian to Bahasa Indonesia and vice versa.

In Sweden and Indonesia, the data were collected on one occasion, whereas in Norway data collection took place on two occasions as the class was divided into two groups. In all countries the students were allocated time in their school/university/college timetable to answer the questionnaires.

Data analysis

Data from the Scandinavian students were analysed in their original language. The data from Indonesia were translated from Bahasa Indonesia into Norwegian before analysis. An Indonesian nurse whose first language is Bahasa Indonesia, but who also speaks Norwegian performed the translations. The data were analysed in accordance with Graneheim and Lundman's description of manifest content analysis from condensed meaning units, codes and categories, ³³ emphasising the research questions. The aim of content analysis is to describe the phenomenon in a conceptual form. The students mostly answered the open-ended question with short statements containing some examples, understood by the researchers as condensed meaning units. These condensed meaning units were in turn translated into English. During the analysis process the researchers identified patterns of the phenomenon from the condensed meaning units, which were then formulated into codes and categories.

After preliminary data analysis by the Scandinavian researchers, a workshop was arranged for the Indonesian and Scandinavian researchers and Indonesian nursing teachers in Banda Aceh, Indonesia (January 2014). During the workshop, similarities and differences between Scandinavian and Indonesian culture were discussed in the light of the preliminary findings. This gave the researchers a deeper understanding of the data and the preliminary findings.

Ethical considerations

The students were informed about the project both verbally and in writing. The project followed national guidelines for ethical principles in medical research based on the Declaration of Helsinki. ³⁴ Anonymity and integrity were safeguarded by the use of coded questionnaires, which were delivered and returned in sealed envelopes. Furthermore, the findings were presented on an overall level, making it impossible to identify participants, places or situations. The students gave their consent to participate by answering the questionnaire after having read the information. The Norwegian Social Science Data Services (NSD; No. 29212) approved the study. Furthermore, the Regional Ethical Review Board in Uppsala, Sweden (Dnr. 2010/462) and the Ethics Committee of the Nursing Faculty of Syiah Kuala University, Indonesia (Dnr. 160811301) also approved the study.

Findings

The findings regarding nursing students’ perceptions of how nurses can contribute to health show both similarities and differences between the three countries. Three common categories emerged: ‘Promoting health and preventing disease’, ‘Performing care and treatment’ and ‘Establishing a relationship with patients and being compassionate’. A fourth category, ‘Possessing and implementing knowledge and skills’, was common to Norway and Indonesia, while a fifth category, ‘Being a team member’, was strongly emphasised by the Indonesian participants.

In the following, the three common categories will first be presented and complemented by examples from Norway (N), Sweden (S) and Indonesia (I), followed by the content identified in the fourth (N, I) and the fifth categories (I).

Promoting health and preventing disease

Promoting health was described as ‘a way of thinking that promoting health is better than cure’, and should include people of all ages (N). The participants also emphasised the importance of working with disease prevention. Health promotion and disease prevention could be accomplished by dissemination of knowledge such as by teaching, providing information, giving advice and explaining how to stay healthy and maintain a healthy lifestyle (N, S, I). It was emphasised that the information should be guided by research and nurses’ experiences (N, I), but also by adhering to national strategies, which was especially stressed by the Indonesian participants. Examples of such information from the respective countries included paying attention to personal and dental hygiene, having sufficient sleep, recognising the positive influence of physical activity on mental health (N), eating healthy food and exercising (S). The participants in Indonesia stressed the importance of drinking enough water and keeping the environment clean, focusing especially on people in the villages (I). The Scandinavian participants mainly focused on the individual, whereas the participants in Indonesia emphasised both the individual and the community, which they expressed as supporting ‘health programmes to improve the quality of the healthcare services both for the individual and society as a whole’ (I).

Participants from the three countries focused on supporting and mobilising people's resources and coping abilities as a means of helping each person to value the positive aspects of life, ‘manage problems’ (N) and ‘find solutions to their problems’ (I). The Scandinavian students also described motivating dialogues and supervision, as well as the need to support a person's self-confidence and optimism (N, S). None of the Scandinavian participants mentioned religious authorities, whereas one participant from Indonesia stated that ‘the nurse must always remind the patient that health comes from Allah, therefore we have a duty to maintain our health’ (I).

Participants from Scandinavia described the nurse as a role model for health promotion, ‘at work as well as in private life’ (N) by ‘appearing as an ideal and an example of good health’ (N, S), ‘being healthy and practicing good lifestyle habits’ (N, S) and ‘sharing personal experiences and own life habits with others’ (N). The importance of personally feeling well was also considered necessary for helping other people (S).

Health promotion and the importance of the individual's resources appeared to be emphasised more by the Norwegian participants, whereas disease prevention received greater attention from the participants in Indonesia.

Performing care and treatment

Although the participants from the three countries stated that nurses could contribute to health through care and treatment, their descriptions highlighted different aspects. The Scandinavian participants stressed relieving pain, providing careful rehabilitation for those who are ill and injured, supporting patients by means of technical equipment (N), promoting wellbeing and caring for the sick body (S). The Indonesian participants mentioned caring, but did not give examples to illustrate their understanding of the word.

The participants from the Scandinavian countries highlighted the importance of caring for the patient as a whole person, encompassing physical, mental, social and spiritual dimensions. The Swedish participants emphasised the mental dimensions and existential aspects of nursing, as well as the importance of strengthening hope and meaning in life.

Participants from two countries described nurses’ contribution to health as ‘meeting a person's fundamental needs and providing medical treatment’ (N, I). In Indonesia, treatment for people in the community and treatment of disease were emphasised.

Establishing a relationship with patients and being compassionate

The importance of safe and trustful relationships established by means of good communication with patients was emphasised by participants from all three countries. The Scandinavian participants described such relationships as ‘cooperating with, listening to, understanding and confirming patients’ (N, S).

Relationships with patients and compassionate care were found to be interwoven. The importance of nurses being engaged, concerned and showing empathy was described by participants from the three countries. This was expressed as ‘being careful’, ‘available’ and ‘showing genuine interest in the patient’ (N), ‘meeting the patient in an altruistic and positive way’ (S) and ‘working with heart, hands and brain’ (I).

Showing respect for the individual was described as being important by participants from all three countries. This was expressed as tolerance, an understanding that ‘each person is unique and different from others’ (N), ‘being free from prejudices’ (S) and ‘treating all people equally, irrespective of their opinion or financial and social status’ (I). The importance of health services being available to all and free of charge was also stressed (I).

The nurse's personal qualities were highlighted, such as behaving in a confident manner and encountering patients, relatives and colleagues in a positive way. Behaving as a positive and optimistic person, spreading energy and being humorous (N, S) were stressed as well as ‘behaving properly when treating the patient’ (I).

Possessing and implementing knowledge and skills

This category only emerged from data provided by participants from Norway and Indonesia. The Norwegian participants referred to ‘knowledge about the individual patient as a whole person’ and ‘in-depth knowledge of the nursing discipline, health, health promotion, fundamental needs and diseases’. The importance of nurses possessing the knowledge to underpin their decisions and interventions and being able to ‘explain their actions to patients’ was also stressed (N). The importance of nurses keeping themselves updated about research was emphasised (N, I) and some Indonesian participants even suggested that nurses should ‘perform research in collaboration with others’.

Nurses’ skills were emphasised, such as good practical skills based on acceptable procedures and norms (N, I), ‘in patients’ best interests’, and ‘in accordance with their wishes’ (N). Working systematically (N, I), ‘searching for concealed needs’ and ‘improving public health’ were also highlighted (I).

Being a team member

Only a few of the Norwegian participants mentioned collaboration with the healthcare team, but this category was highly emphasised by the participants from Indonesia. Many of the Indonesian participants described it as ‘necessary to cooperate to improve the healthcare service to achieve the goals’. Collaboration between nurses and physicians was especially valued: ‘they must work side by side’, ‘listen to each other’, ‘respect each other's opinions’ and ‘avoid conflicts’. A large number of the Indonesian participants also stressed that there should be no hierarchy between nurses and physicians and that they should not suppress each other. This was seen as a condition for successfully ‘meeting the needs of the community’ and ‘promoting health in Indonesian society’.

Discussion

This qualitative study was carried out in Norway, Sweden and Indonesia to gain knowledge about first-year nursing students’ perceptions of how nurses can contribute to health. The Norwegian participants expressed their perceptions in more professional terms than those from the other two countries. One explanation could be that they had completed a course (10 credits) on public health at the time of data collection. The Swedish participants presented only a few brief descriptions. The Indonesian participants expressed their perceptions in more normative ways than the others, such as ‘must’ and ‘should’. Moreover, the categories that emerged revealed both differences and similarities.

Of the five categories identified, three included all three countries, which might indicate that people in different cultures have very similar perceptions of nursing. This is not strange, as nursing worldwide is guided by definitions and directives from the WHO and the ICN. The Norwegian and Indonesian participants stated that nurses should meet patients' fundamental needs, which is in accordance with the classic understanding of nurses' independent function. ³⁵ This finding is not surprising, as both Scandinavian and Indonesian nursing education is influenced by US nursing curricula. ³⁶ However, a country's distinctive culture and conditions, level of education, social systems and traditions also influence what people expect from nurses and how they work. More studies about nurses' autonomous contribution to health in different cultures would be valuable.

In contrast to those from Norway and Sweden, the participants from Indonesia strongly emphasised that nurses should provide medical treatment. Traditionally, nurses have an important role in delivering medical treatment ordered by physicians. Considering the low physician-to-population ratios in Indonesia, nurses might have to perform physicians’ tasks to a greater degree. It is likely that nurses in Indonesia have little independence in terms of providing nursing care and are obliged to function as assistants to the physician because of the historically low level of education of most nurses in the country. ³⁷ Some years ago, Scandinavian nurses were also strongly dependent on physicians, and nursing was termed ‘practical medicine’. ³⁸ During recent decades, nurses’ autonomy has developed, but a challenge remains around how to take care of necessary medical tasks without ignoring nursing. Dewi and colleagues have suggested that the introduction of patient-centred care to the Indonesian healthcare system could improve cooperation among healthcare practitioners and enhance nurses’ autonomous approach to nursing. ³⁹

The participants from the three countries emphasised care as being an aspect of nursing, although the Indonesian participants only mentioned the word without explaining what it represented. However, this does not necessarily mean that care is underestimated, as a study among nurses in the province of Aceh found that they rated care as one of the most important aspects of nursing. ⁴⁰ ‘Nurses’ use of hands, heart and mind’, which was expressed by the Indonesian participants, has been described as caring action ⁴¹ and as the core of nursing. ⁹

Participants from Scandinavia stressed caring for the whole person. Caring for the patient represents an important contribution to wellbeing and the healing process, but only those from Sweden focused on caring for the body. This was surprising because nursing has traditionally been concerned with embodiment and caring for the bodies of those who are ill. ⁴² Caring for the body does not appear to have an explicit place when describing nurses’ competencies^43,44 and caring for patients’ bodies has been perceived as ‘dirty work’ in South Asia. ⁴⁵ Family ties are traditionally strong in Indonesia, which gives the family a significant role in providing hands-on care for the sick and dying. ⁴⁶ In addition, the principles of Islam emphasise that people should help each other. ⁴⁷ Altruistic values also influence families in the Scandinavian countries, but there is a tendency to place the main responsibility on the state and community services. ⁴⁸ According to Sandelowski, ⁴⁹ a timely question is: Are there tendencies that nurses are ceasing to care for patients’ bodies?

Promoting health and preventing disease was one of the common categories found among the Scandinavian and Indonesian participants. Traditionally, disease prevention has been and is still focused on in healthcare. However, during recent years health promotion has received more attention. Health promotion refers to enabling people to improve their health and supporting health-promoting resources. ⁵ The theory of salutogenesis ⁵⁰ and studies^51,52 have shown that health promotion can lead to positive health outcomes, such as adherence, quality of life and increased knowledge about illness and self-care on the part of patients. Empowering people to utilise their resources can reduce many of the health problems experienced in the countries included in the present study. The Ottawa Charter states that health promotion should be strengthened in all countries to enhance healthy behaviours among people. ⁵ Incorporating health promotion courses into nursing education could be a way of changing the focus, although to date research has shown that this is challenging.^53,54 The participants from Norway focused on health promotion, which raises the question of whether the health promotion course in the Norwegian nursing programme contributed to this stance. More studies are needed to investigate this question.

In the present study, the nurses described their health-promotion and disease-prevention strategies as health education, comprising information, advice, motivation, supervision and support. Health education takes a traditional form, where the nurse plays a leading role and the patient a passive one. ⁵⁵ A study from Indonesia revealed a tendency for patients to be compliant and follow instructions in accordance with valid norms rather than their own preferences. ³⁹ In Scandinavia, patient autonomy and user involvement are fundamental to the modern health services, and viewed as a natural part of evidence-based nursing practice. ⁵⁶ Autonomy and user involvement are in line with health promotion, which perceive health as a starting point and resource for everyday life. The present study shows that there is still some way to go to achieve these goals and that more studies about the issues involved are necessary.

The health education content differed, as only the Indonesian participants strongly stressed working with environmental aspects to enhance health. This might be explained by the various health problems in the province of Aceh connected to environmental issues, personal hygiene and access to clean water, which have arisen after years of civil war and the tsunami in 2004. ⁵⁷

Scandinavia, in common with other Western cultures, is more individualistically oriented than many Asian cultures, a tendency which was found in a study about healthy people in Scandinavia and Indonesia. ²⁷ In the present study, the Scandinavian participants mainly described individualistic concerns of nurses, whereas the Indonesian participants emphasised the collective by focusing on communities and the achievement of government health programmes. When considering the geographical location of services and the low number of nurses, it is perhaps necessary for nurses to work at group level. Whitehead has argued that the nursing literature focuses strongly on individualistic forms of health promotion and that socio-political activity is largely theoretical and not applied in practice. ⁵⁵ It has also been stated that nurses have not yet assumed a clear political role in implementing health-promotion activities. ¹⁸ None of the participants from Scandinavia or Indonesia mentioned how nurses could provide information to politicians for the development of future health strategies.

One of the core competencies for nurses is that of being a team member. ⁵⁸ This was strongly stressed by most of the Indonesian participants. Maybe this is because of the special challenges in Indonesia, where it is reported that in terms of status, physicians tower over nurses and the two professional categories have little confidence in each other's competencies. ⁵⁹ Physicians' distrust of nurses' knowledge and skills has been found to be negatively associated with collaboration. ⁶⁰ However, nurses can also be seen as a resource and complement to physicians, thus recognising the nurse as a peer of the physician with whom to engage in shared care. ⁶¹ Cooperation between health professionals and teamwork have been found to be key elements in delivering cost-effective healthcare, positive patient outcomes, enhanced patient and professional satisfaction and high-quality treatment and care. ⁶² In contrast, lack of interprofessional collaboration might result in a higher risk of errors and omissions in patient care, ⁶³ conflicts and poor team outcomes. ⁶²

Trustworthiness and study limitations

The challenges of this qualitative study were linked to cultural and linguistic differences. To enhance trustworthiness several actions have been taken. To strengthen the credibility and confirmability of the study, ⁶⁴ all researchers collaborated throughout the entire research process by means of face-to-face-meetings and discussions, telephone contact and email correspondence, in addition to attendance at an international research conference in Banda Aceh. Furthermore, the preliminary findings were discussed in the light of religion, economy, nature, culture and collaboration in the health team, nurses' positions and the nursing education curriculum at the workshop in January 2014 where nurses, nursing teachers and researchers from the three countries participated. A workshop for the researchers from Norway and Sweden also took place in September 2015 where the results were scrutinised and discussed. Furthermore, one of the Indonesian researchers had completed a master's degree in Norway and contributed knowledge about Scandinavian and Indonesian culture, healthcare systems and nursing education.

The data mostly contained short statements. The researchers were aware of the risk posed by their own pre-understandings, thus they scrutinised and discussed the data together to identify codes and categories. The data collection provided a wide range of data. However, it is possible that a further study based on interviews could deepen the knowledge of the research topic. The open-ended question was positioned at the end of a relatively comprehensive questionnaire. The participants might have been worn out by the time they came to the open-ended question, which could have weakened credibility.

To ensure the dependability of the study, the translation of the open-ended question followed the Eurostat procedure. ³² An Indonesian master's student, whose first language is Bahasa Indonesia and who also speaks Norwegian fluently, translated all the Indonesian empirical data from the open-ended question into Norwegian. Furthermore, all steps in the analysis process, from the participants' statements via codes to categories, were followed as recommended by Graneheim and Lundman. ³³

The Scandinavian participants were recruited from courses at the same educational level, whereas the Indonesian students came from both bachelor's and diploma degree programmes. However, as the students were at the start of their nursing education, different educational programmes and levels should not have had a major impact on the credibility of the study.

The participants and the contexts are described as precisely as possible, which might increase the readers' ability to assess transferability. The findings cannot be generalised, but they can be discussed in the light of nursing curricula and maybe contribute to developing nursing education programmes in the three countries.

Conclusions

The findings in this study show that the participants perceived that nurses' contributions to health are extensive and important. The findings also reveal both differences and similarities between the countries. Participants from all three countries emphasised promoting health and preventing disease using traditional methods, although the Norwegian participants seemed to focus more on health promotion than disease prevention. The Scandinavian participants emphasised caring for the individual, whereas the Indonesian students focused on the community, society and the importance of the environment for health promotion. Participants from all three countries mentioned care, but the medical perspective seemed more apparent among those from Indonesia. The Indonesian participants strongly stressed the need for cooperation with healthcare professionals, especially physicians, maybe because they experience challenges in this area.

As the participants in this study were first-year nursing students, the findings can be of benefit to nursing education as they emphasise the environment, user involvement, individuals as well as the community and society and highlight nurses' core competencies. A curriculum that takes account of different cultures and student exchange programmes could contribute to global nursing.

Further research could explore nursing students' perceptions of the phenomenon at the final stage of their nursing education. It might also be interesting to investigate how health promotion courses during nursing education can strengthen this aspect of nurses' work as well as how nurses' autonomous function can contribute to health in different cultures.